Chapter 3 & 4 Flashcards
Coding Process
the sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between health care professional and patient
Alphabetic Index
the section of a code book showing all codes from A-Z by the short code descriptions
Symbols
marks, similar to emojis that provide additional direction to use codes correctly and accurately
Notations
alerts and warnings that support more accurate use of codes in specific code set
Tabular List of Disease and Injuries
the section of the ICD-10-CM code book listing all of the codes in alphanumeric order
Main Section
the section of the CPT code book listing all of the codes in numeric order
Tables
the section of the ICD-10-PCS codebook listing all of the codes in alphanumeric order,based on the first three character of code
Alphanumeric Section
the section of the HCPCS Level II code book listing all of the codes in alphanumeric order
Alphanumeric
containing both letters and numbers
ICD-10-Tabular List
Official Guidelines
a listing of rules and regulations instructing how to use a specific code set accurately
Linking
confirming medical necessity by pairing at lease one diagnosis code to at least one procedure code
List the 6 Coding Actions in Order
- Abstract Documentation
- Query if Necessary
- Code the diagnosis or diagnoses
- Code the procedure or procedures
- Confirm medical necessity
- Double check your codes
Action 1 in the Coding Process
Abstract Documentation
read carefully through
re read the docs and identify the main terms the diagnosis (WHY) & procedures (WHAT) of the encounter
Action 2 in the Coding Process
Query if Necessary
never assume or guess if something is unclear, missing, contradictory
Action 3 in the Coding Process
Code the diagnosis or diagnoses & signs or symptoms describing why the health care professional treated this patient during encounter
use best most accurate code or codes available based on documentation
Action 4 in the Coding Process
Code the procedure or procedures
-Determine whom / Describing What
physician or out patient facility =CPT
hospital or inpatient facility = ICD-10-CM-PCS
HCPCS Level II= transportation, equiptment, durgs
Action 5 in the Coding Process
Confirm medical necessity
each procedure code matches/is supported by at least one diagnosis code to verify medical necessity
Action 6 in the Coding Process
Double check your codes
slowly, carefully, completely
What does it mean when you see X
a place holder / holds a spot for futre expansion of the diagnosis
may need up to 3 X placeholders
X may not be at the end of a code
ex- S61.250X
Systemic Condition
a condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in his or her medical decision making for any other condition
Principal Diagnosis
the condition after study that is the primary or main reason for the admission of a patient to the hospital for fare the condition that requires the largest amount of hospital resources fore care
First Listed
“first-listed” diagnosis is used when reporting outpatient encounters, instead of the term “principal diagnosis”
acute
sever, serious
chronic
long duration continuing over an extended period of time
unspecified
the absence of additional specifics in the physicians documentation
anatomical site
a specific location within the anatomy (body)
confirmed
found to be true or definite
other specified
additional information the physician specified that isn’t included in any other code description
underlying condition
one disease that affects or encourages another condition
differential diagnosis
when the physician indicates that the patients signs and symptoms may closely lead to two different diagnoses usually written as diagnosis A vs diagnosis B
NEC - not elsewhere classified
used when ICD-10-CM does not provide a specific code for a patients condition
the provider documented more specific info regarding the patients condition but there isn’t a code in ICD-10-Cm that reports the code accurately
NOS- not otherwise specified
equivalent to unspecified and is used only when info lacks the information necessary to report a more specific code (might query Dr for more info in this situation)
Brackets (2 meanings)
used in Tabular List to enclose synonyms alternate wording, or explanatory phrases
used in alphabetic index to indicate multiple codes are required
Parenthesis
used to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code # to which is assigned the terms in the parenthesis are known as Non Essential Modifiers
Bold Face Type
used for all codes and titles in the tabular list and for the main terms in the alphabetical index
Excludes 1
represents that the condition is NOT coded here. this note indicates that the code excluded should NOT be used at the same time as the code about the excludes 1 note, IF THE CONDITIONS ARE RELATED. They indicate when 2 conditions should NOT be reported together
ex a congenital form vs an aquired form of the same condition
in some cases the 2 codes may be used together when the conditions are unrelated to each other
Excludes 2
represents that the condition is NOT included here. indicates that the condition excluded is not part of the represented by the code, but a patient may have both conditions at the same time. when a type 2 excludes note appears under a code, it is acceptable to sue both the code and the excludes code together
Includes
appears immediately after a three character code title to further define or clarify the category
List Etiology/ Manifestation Codes (4)
- uses additional codes
- uses additional code if applicable
- code 1st
- combination code
uses additional code
signals the coder that an additional code should be used if the info is available to provide a more complete picture of the diagnosis
use additional code if applicable
causal condition note indicates that this code may be assigned as the principle diagnosis if the cause is not known, however if the causal condition is know it should be sequenced 1st
Code 1st
used in categories not intended to be the principal diagnosis. requires that the underlying disease be sequenced 1st and its manifestation 2nd
Combination Code
single code is used to classify 2 diagnoses a primary diagnosis with an associated secondary diagnosis or with an associated complication
Italicized or Slanted Brackets
found in the alphabetical index and will surround additional code or codes
ex- secondary codes that must be included with initial code
