Intro to ICD-9-CM Flashcards
V-Codes
V-Codes are used when the patient presents for treatment with no compliants. Common resadons to report V codes are for screening tests, routine physicals and when a patient has a person history or family history of a disease or disorder.
E-Codes
E-codes are used to report how an injury occured and where the injury occured.
NEC
Not Elsewhere Classifiable - used when the ICD-9-CM system does not provide a code specific for the patient’s condition.
NOS
Not otherwise specified - this is the equivalent of ‘unspecified’ and is used only when the coder lacks the information necessary to code to a more specific fourth or fifth digit category.
What do brackets [ ] mean?
used to enclose synonyms, alternate working, or explanatory phrases.
What do slanted brackets mean?
used to indicate multiple codes are required.
What do Prentheses ( ) mean?
Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assisgned.
Eponym
Disease or syndrome named after a person.
Coding Signs and Symptoms
Outpatient = Do no code unless it is certain Inpatient = Report suspected or rule out diagnoses as if the condition does exist. This is true for all inpatient services except HIV. HIV is the only condition that must be confirmed if it is to be reported in the inpatient setting.
Combination Code
Used to identify fully and instance in which two diagnoses, or a diagnosis with an associated secondary process (manifestation) or complication, are included in the description of a single code number. Assign only a combination code when that code fully identifies the diagnostic conditions involved, or when instructed in the Alphabetic Index.
Acute and Chronic Conditions
When there is a separate code for each, the acute code is sequenced first.
Late Effects
The residual condidtion is coded first, and the code(s) for the cause of the late effect are coded as secondary. The coder may have to reference the External Causes in the Index to determine the appropriate E Code.
Impending or Threatened Condition
review the Alphabetic Index for the sub term “impending” or “threatened” under the main term of the conidition. If a subterm does not exist, reference “impending” or “threatened” as the main term, with the condition as a subterm. If a suitable code does not exist, report the signs and symptoms that led the provider to suspect an impending or threatened condition.
Reporting the Same Diagnosis Code More than Once
Do not report the same diagnosis code more than once. Ex. a patient complains of pain in right and left leg. Because there is not a code to distinguish between the right and left leg, 729.5 “pain in limb” is reported once.
Admissions/Encournters for Rehabilitation
When the purpose of the encounter is rehabilitation, the first listed code is a V code from category V57 Care invoving use of rehabilitation procedures. The second listed code is the condition for which th patient requires the rehabilitation services.
Syndrome
if the syndrome is not located in the Alphabetic Index, code the patient’s signs and symptoms.
Documentation of Complications of Care
there must be a cuase-and-effect relationship between the care provided and the condition. THe provider must also specifically document that the condition is a complication.
Codes that Describe Symptoms and Signs
are acceptable for reporting purposes when a physician has not esablished (confirmed) the diagnosis. Chapter 16 of ICD-9-CM contains many, but not all, codes for symptoms.
Uncertain Diagnosis
Do not code diagnoses documentated as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis.”Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Conditions that Coexist
Do not code conditions that were treated previously and no longer exist. History codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
Pt. Receives Diagnostic Services Only
Sequence a code from category V72.8, other specified examinations, to describe the preoperative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the properative evaluation.
Ambulatory Surgery
code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time of diagnosis is confirmed, select the postoperative diagnosis for cidng because it is the most definitive.
Routine Outpatient Prenatal Visits
When no complications are present, coded V22.0 Supervision of normal first pregnancy and V22.1 Supervision of other normal pregnancy should be used a principal diagnoses. These codes should not be used with chapter 11 codes. It would be inappropriate to code V22.1 for supervision of other normal pregnancy if the patient is diagnosed with a condition that complicated the pregnancy.
