Chapter 2 -Lesson 5, 6, 7,

Diagnostic Coding

Note: If you want faster and more efficient coding, you will not need to learn the organization of the ICD-9-CM books. Instead you will be accessing codes via a computer database. If your not going to purchase the 3.5 diskette of codes and wish to manually look up codes, continue with this portion of the lesson.

The history of the International Classification of Diseases (ICD) dates back to seventeenth century England. The system came to the United States in the second half of the eighteenth century. The original reason the ICD was used was to track mortality statistics -- doctors and governments wanted to know how many people were dying of different diseases.

Currently, the ninth edition of the ICD is in widespread use. Most physicians also use a clinical modification (CM) of ICD. Thus, the current diagnostic coding system of reference is called ICD-9-CM, which stands for International Classification of Diseases, Ninth Edition, Clinical Modification.

Understanding how the ICD-9-CM is organized:

There are three volumes in the ICD-9-CM. Volume 2 is presented first and is called the alphabetical index. It is divided into three sections. See below...

ICD-9-CM - Volume 2 (Alphabetical Index)

Section Title Description

Section 1 Index to Diseases A-Z An alphabetical list of diseases with the corresponding

diagnostic codes.

Section 2 Table of Drugs and Chemicals An alphabetical table listing substances to identify poisoning and external causes of injury.

Section 3 Index to External Causes An alphabetical list of E codes with definitions and (E codes) examples

Volume 1 of the ICD-9-CM, known as the tabular list, is presented second. It uses a numerical index cross-referenced with diseases and injuries according to the anatomic system affected and/or etiology (the cause of the disorder). Volume 1 is into eight sections. Section 1 contains 17 chapters, shown in the table below. Each chapter contains a range of codes.

Volume 3 is presented third, and not all publications of ICD-9-CM even include Volume 3. It consists of two sections of codes that define procedures instead of diagnoses. Volume 3 is intended for use by hospitals only. See below.

Using the ICD-9-CM

In order to become an effective diagnostic coder using the book, you must become familiar with the introductions to each section. Read all the information at the beginning of both Volume 1 and Volume 2. These sections will tell you the meanings of important abbreviations, signs, punctuation and symbols. For example, in the ICD-9-CM, the following abbreviations are used:

NEC This means not elsewhere classifiable in coding books. This is only to be used when there is not enough information available to code the term more specifically.

NOS This means not otherwise specified by the physician.

In addition to abbreviations, the ICD-9-CM also contains signs or punctuation that mean different things. Look at the following table:

Coding ICD-9

Once you know the organization of the ICD-9-CM book, you can now learn how to code. This lesson will give you a chance to code first hand using sample forms taken from the ICD-9-CM Volumes. When these exercises are completed, you will be more familiar with the process of coding. As a result, you'll be more prepared as you start your new career.

Remember that the concepts covered in Lesson 6 will not be automatic, they will take time to master. This lesson is the cornerstone of all future coding. In order to code using ICD-9-CM, remember these 5 steps: See below..

The Five Steps to Diagnostic Coding

Step 1 Locate the written diagnosis on the patient's chart or encounter form. The encounter form is the same thing as a superbill -- a term used in some code books. You will need to find the doctor's diagnosis for the bill you are preparing. When more than one diagnosis is listed, work on one at a time.

An important note: You need to code the Primary Diagnosis first. The Primary Diagnosis is the reason the patient is seeking care today.

Step 2 Look in the Alphabetical Index in the ICD-9-CM (Volume 2) and find the diagnosis. First, look for the condition, then find descriptive words in the listing that narrow down the diagnosis until you have located the exact condition. Note all possible modifiers and synonyms and pay attention to cross references.

Step 3 Look in the Tabular List (numerical index) in the ICD-9-CM (Volume 1) and find the code you found in the Alphabetical Index. Be sure you locate the exact code that you found in the alphabetical index. Look for the number in bold type.

Step 4 Read all sub-classifications to find the code that corresponds to the patient's exact condition or disease. Make sure you obey all instructions and notations (such as exclusion notices).

Step 5 Record the diagnostic code on the insurance form and proofread the numbers. When you have found the correct diagnostic code, then fill that number in on the insurance form. Be Sure to double-check your accuracy.

Instruction on E & V Codes

Many insurance companies use E & V codes, found in separate indexes in both Volume 1 and Volume 2 of ICD-9-CM. E codes refer to insurance claims for automobile accidents and injuries or illnesses covered by school insurance companies.

E Codes: E codes for Volume 1 have their own section. Not all insurance carriers use E codes, however, we will show you how they are correctly used. E codes are used to code external causes of injury. They are also used to code adverse reactions to medication.

See the table below. It shows how the Table of Drugs and Chemicals is organized in Volume 2 of ICD-9-CM.

External Cause (E - Code)

Substance Poisoning Accident Therapeutic Suicide Assault Undetermined Use Attempt

Acetylsalicylic Acid 965.1 / E850.3 / E935. / E950.0 / E962.0 / E980.0

To use and E code, you first read the Forward in Volume 2. Each of the drugs and poisons listed in the table is assigned a code between 960 and 989. You use these codes in the case of an overdose, intoxication or poisoning or if the patient has taken the wrong drug. These situations can cause and adverse effect.

An adverse effect is a pathologic response by the patient to a normal dose of a drug or agent. This is different from poisoning. Poisoning occurs when the patient takes or receives an overdose of a drug or agent, or takes the wrong drug or agent for his/her condition.

To assign an E code, follow the steps below:

Steps to Assigning an E Code

Step 1. Look in the Table of Drugs and Chemicals in Volume 2 and find the substance affecting the patient. Then look at the diagnosis to find out what effects (heart fibrillation, a rash or some other condition) the drug had.

Step 2. Determine the cause (look at the columns -- if the patient attempted suicide, then code that number, and so on).

Step 3. Next follow your steps to code the effect of the drug.

Step 4. Fill in both the E code and the diagnosis code on the insurance form.

Coding Concepts

When you use certain concepts during the coding process, you will not only code with greater accuracy, but also with more concepts such as unconfirmed diagnosis, acute vs. chronic conditions, late effects coding and how it effects the reimbursement by insurance companies.

Unconfirmed Diagnoses

Do not code on uncertain conditions. You will never code a condition until it is determined to be the diagnosis. Suspected conditions, ones that use words like suspicion or probable or even likely, are not "confirmed diagnoses". Conditions like these are known as "unconfirmed diagnoses" and they require a different code other than a "confirmed diagnosis".

When coding unconfirmed diagnoses, you code the chief complaint and document the confirmed diagnosis even if none of the diagnoses are the principal diagnoses. Be as thorough as possible, but never play doctor and narrow down the choices of categories for that diagnosis. If the term ruled out is used beside a diagnosis, then DO NOT code that diagnosis. Ruled Out means the doctor once considered that diagnosis, but then found it was not the case; therefore, it should not be coded.

Acute vs. Chronic & Congenital vs. Acquired Conditions

When looking through the ICD-9-CM book, you will notice that some entries have choices. Like, Chronic Conditions or Acute Conditions. These 2 terms can determine how insurance companies reimburse, and because of this, you need to use the correct code. Chronic means lingering or lasting. It refers to a condition that has affected the patient before and continues to affect the patient. Acute means short and severe - a new injury or disease for example.

Congenital and Acquired have differences as well. Congenital means present at birth. The person was either born with the condition or born with the cause of the condition. Acquired means the condition or cause of the condition showed up after birth. The process of finding a code that is chronic, acute, congenital or acquired are always the same.

Find the condition, then look for the specific code for the description you are looking for. If coding a chronic condition, for example, find the code listed next to the word acute, always be careful to write the correct code, sometimes they are written close together.

Late Effects Coding

When an acute injury or disease leaves permanent damage, this damage is called Late Effects. Late Effects means the residual effects after the termination of an acute injury or disease. The length of time such effects remain is indefinite. If the diagnosis contains any words or phrases similar to (or exactly like): due to an old injury, late, due to previous illness or injury, or due to an injury or illness that occurred on a year or more before current encounter, then the effect is considered late.

You should code both the residual late effect and its causes.

Coding for Burns

When you code for burns, you always use 2 separate codes. The first code tells the exact location of the burns, while the second says the percentage of the body burned. Add a 5th digit to the second code to tell how much of the body was burned by 3rd degree burns. For coding, the body is divided into regions. Each region is assigned a percentage. The head is 9%, the arms are 9% each, the trunk is 18% for the front and 18% for the back, the legs are 18% each, and the perineum is 1% each.

Burn codes should be put in order with the highest degree, most serious, burns first.

Specific Coding Situations

As a medical claims and billing specialist, you will come across several different coding situations. Regardless of how much or how little of the coding you handle for a client, you will likely run into coding circumstances that require special rules for coding. Neoplasm’s, Pregnancy and Complications are 3 great scenarios of specific coding situations.

Neoplasm’s are new growths in the body. They can be either malignant or benign. You code them by looking under neoplasm and locating the anatomic site of the growth. Then you look at the diagnosis and figure whether the growth is "primary" (the original tumor site) or secondary (a metastasis).

If there is no mention of metastasis, you usually code the neoplasm as primary (except with lymph and liver - codes 200-202). If the anatomic site is the lymph of liver, you code it as secondary, unless it is noted as primary. Anatomic sites that are listed with an asterisk are considered to be a part of the skin.

Pregnancy

There are six sections of codes for pregnancy. The codes range from 630-676 and cover everything from C - Sections to Abortions to Normal Delivery. If you're coding the diagnosis, then you must find the proper code for the diagnosis you are looking for. Is the pregnancy normal? How far along is the mother? The time factor is extremely important. When was the examination done? That has a code.

To code pregnancy correctly, you must know 3 things:

1.the term of the pregnancy

2.the diagnosis reached

3.were there any complications?

You would look up the diagnosis, the condition, then you must look for a time line and code according to how far along the mother is. When delivery time comes, you have several choices. If the delivery is completely normal with no complications, you code 650. This covers a full term fetus delivered. With or without an episiotomy, with no manipulation needed and no laceration performed. Also if complications do arise, you must code these complications accordingly. You must first code a principal diagnosis, and then code each complication accordingly.

Home / Lessons / Chapter 1 / Chapter 2 / Chapter 3 / Chapter 4 / Chapter 5 / Practice Tests / Answer Keys
How to use ElectroniClaim

Send mail to sales@electroniclaim.com with questions or comments about this web site.
(Last modified: July 5, 1999)
Copyright © 2000 Electroniclaim