Ch 4 ICD 9 Flashcards
Updates to the ICD 9 CM
Addenda
What what are the five conventions applied when using the alphabetic index correctly?
- Turnover lines are indented farther to the right then subterms
- See cross-references lead the coder to another main term; see also suggest additional possible key terms
- Notes provide information on code selection
- The abbreviation NEC appears with mean terms for which no specific code exists
- Some conditions may require two codes
Section of the ICD-9-CM listing diagnosis codes numerically
Tabular list
Section of the ICD-9-CM listing diseases and injuries with corresponding diagnosis codes alphabetically. Organized by the condition, not body part.
Alphabetic index
Covers procedures chiefly in hospitals
Tabular list and alphabetic index
What are the five conventions that apply to using the alphabetic index?
- Turnover lines are indented farther to the right then sub terms
- See cross-references leave the coder to another Meanterm see also suggest additional possible key terms
- Notes provide information on coats election
- The abbreviation NEC appears with main terms for which no specific code exists
- Some conditions may require two codes
What are the 10 conventions used in the tabular list?
- Fifth-digit requirement symbol
- Includes and excludes notes
- Colons in notes
- Parentheses around supplementary terms
- Brackets around supplementary synonyms, alternative wording, or explanations
- Braces to group related terms
- Lozenge for nonWHO codes
- The abbreviation NOS and NEC
- (.) Bullet for new codes or entries single triangle or facing triangles for revised descriptions
- Codes that are not used as primary appear in italics and are usually followed by an instruction to code 1st underlying disease or use an additional code
Alphanumeric ICD code for healthy patients to receive routine service, for therapeutic ecounters, for a problem that is not currently affecting the patient’s condition, and for preoperative evaluation’s.
V code
Alpha numeric ICD code for an external cause of injury or poisoning
E code
What are the coding steps? (5)
Step 1- review complete medical documentation
Step 2- abstract the medical conditions from the visit documentation
Step 3- identify the main term for each condition
Step 4- locate the main terms of the alphabetic index
Step 5- verify the code in the tabular list
Patient’s description of the symptoms or reasons for seeking medical care
Chief complaint (cc)
Represents the patients major illness or condition for an encounter
Primary diagnosis
What are the ICD-9-CM official guidelines for coding and reporting? (3)
- Code the primary diagnosis first, followed by current coexisting conditions
- Code to the highest degree of certainty, never coding inconclusive, rule-out diagnosis
- Code to the highest level of specificity, using fifth digits or fourth digits when available
Condition that remains after an acute illness or injury in ICD 9 CM
Late effect
Map of codes for same or similar classifications under two coating systems
Crosswalk
