Comprehensive Health Insurance Billing, Coding, and Reimbursement

1. Comprehensive Health InsuranceBilling, Coding, and Reimbursement Chapter 4 ICD-9-CM Medical Coding

2. Definition of Diagnosis Coding • Describes services and procedures diagnoses • ICD-9-CM: • Volumes are now used for coding the appropriate medical conditions

3. Coding History • Bills of mortality 1665: some of the earliest uses of coding • Warnings of plague epidemics • Diagnoses were often wrong or vague • 18th century: Cause of death was noted

4. Purpose of the ICD-9-CM • Establishes medical necessity • Translates written terminology into common language • Provides data for statistical analysis

5. The Yearly Addenda • Includes the addition of new codes • Deletes old codes • Includes descriptor revisions

6. The Three Volumes of the ICD-9-CM • Volume 1: Tabular/numerical list of diseases • Volume 2: Alphabetic index of disease • Volume 3: Tabular and alphabetic index of procedures

7. ICD-10-CM • Replaces volumes 1 and 2 of the ICD-9-CM • Uses alphanumeric codes • Is much more detailed than ICD-9-CM • Includes ambulatory and managed care encounters • Contains injury codes

8. ICD-10-CM • Combines many codes to give a more detailed description of the injury or illness • No implementation date has been set yet for the ICD-10-CM. Implementation will be based on the process for adoption of standards under HIPAA.

9. Common Terminology • Encounter: Refers to all healthcare settings • Provider: Physician or qualified healthcare provider • Diagnostic statement: The main reason for encounter • Primary diagnosis: The main reason for visit or encounter

10. Common Terminology • Principal diagnosis: The final diagnosis • Manifestation: The sign or symptom of a disease • NEC: Not elsewhere classified • NOS: Not otherwise specified

11. Symbols and Typeface and Terms • Boldface: Main term • Subterms: Indented two spaces to the right • Supplementary term: Assists coder in finding correct term • ( ): Parentheses enclose supplementary words

12. Symbols and Typeface and Terms • Colon (:) is used after incomplete phrase or term requiring indented term(s) • [ ]: used to enclose synonyms, alternate wordings, or explanatory phrases • Instructional terms: Assists coder in finding most specific term

13. Volume 2, The Alphabetical Index • Use this volume first to search for the correct code or condition. • After you find the code, use Volume 1 (tabular list) to research the specific code.

14. Volume 1, The Tabular List • Used to research the specific code • Punctuation has various meanings. • A colon : is used after an incomplete phrase or when a modifier is needed. • Square brackets, [], are used to enclose synonyms, alternate wordings, or explanations.

15. Volume 1, The Tabular List • Punctuation has various meanings. • Parentheses () are used to enclose supplementary words that may be present or absent in a statement of disease without affecting the code assignment

16. Three Steps for Accurate Coding • Determine the reason for the encounter. • Locate the term in alphabetic index Volume 2. • Verify the code in the tabular list (Volume 1).

17. Key Coding Guidelines • Code the primary diagnosis first, followed by current coexisting conditions. • Code to the highest level of certainty. • Code to the highest level of specificity.

18. Code to the Highest Level of Certainty • Code condition of encounter. • Sign: Objective • Symptom: Subjective • Signs, symptoms, ill-defined conditions • Use Volume 2, alphabetic index, for sign or symptom • Use Volume 1, Chapter 16, to verify

19. Code to Highest Degree of Specificity • Assign three-digit codes if there are no four-digit codes in the category. • Assign four-digit codes if there are no five-digit codes in the category. • Claims submitted with three- or four-digit codes will be returned if four- to five-digit codes are available.

20. Proper Order for Coding • Main reason for encounter • Any current coexisting condition • Do not code conditions that were previously treated and no longer exist.

21. Subsequent Coding • Surgical coding: Diagnosis for which surgery is performed • Late effects/residual effects: Condition that remains after an acute illness or injury • Acute and chronic conditions • Combination codes

22. Subsequent Coding • V codes: Supplemental code that describes problems, services, or facts • E codes: Supplemental classifications of external causes of injuries and poisonings

23. Nine Steps of Accurate ICD-9-CM Coding • Locate main term in the diagnostic statement. • Locate the main term in Volume 2, the alphabetic index. • Refer to all notes under the main term. Use instructions in any notes appearing in a box after the main term.

24. Nine Steps of Accurate ICD-9-CM Coding • Examine any modifiers. • Note any subterms that provide greater specificity.

25. Nine Steps of Accurate ICD-9-CM Coding • Follow any cross-reference instructions. • Confirm the code selection in the tabular list (Volume 1). • Follow the instructional terms in Volume 1. • Assign the correct code number.