Discussion week 1 main

Explain three important points about the format of the ICD-10-CM coding manual.All initial responses to the DQs require at least one reference. Reminder: Use your own words when writing your post. The reference at the bottom of your post should appear as follows:ReferenceCarol J. Buck, Saunders. Step-by-Step Medical Coding, by Carol J. Buck, Saunders

CHAPTER 3

ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

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First-Listed Diagnosis

I-10 Guidelines state

Principal Dx = inpatient settings

First-Listed Dx = outpatient settings

The primary reason for encounter

Example: Pt with inguinal hernia presents with shortness of breath

SOB is first-listed

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Assign I-10 codes for outpatient services in accordance with the I-10 Official Guidelines for Coding and Reporting.
In the outpatient setting, the term “first-listed diagnosis [primary]” is used instead of “principal diagnosis.”

Unconfirmed Diagnosis
In outpatient setting, may take several encounters to confirm diagnosis
Signs/Symptoms are reported
Example: Pt presents with complaint of frequent heartburn
Physician prescribes Prilosec for suspected GERD with patient returning in 10 days
Report: frequent heartburn

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Outpatient Surgery
Code the reason for the surgery first
Even if the surgery is not performed
Followed by code to report reason procedure not carried out, such as Z53.09, procedure not carried out due to other contraindication

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Report the reason for the surgery as the first-listed diagnosis (reason for the encounter).

Z Codes
Report circumstances other than disease or injury
Z codes are informative
May be first- or additionally listed
Depending on circumstances
Z23 reports encounters for inoculations and vaccinations
Procedure code identifies administration

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External Cause Index
Located after I-10 Table of Drugs and Chemicals

Figure 3.1
External Cause Index of the I-10. (From Elsevier: 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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External Cause Codes
Never first-listed Dx
Clarify injury or adverse effects

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Code terms describe the external circumstances under which an accident, injury, or act of violence occurred.
External Cause codes have their own Index in I-10.

Observation Stay
Categories Z03 and Z04
Pt admitted to observation status
Report Z code as first-listed for Dx stated as suspected/rule out conditions
If Dx made, report Dx as first-listed

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Other codes may be reported in addition to observation codes.

Coexisting Conditions
If coexisting conditions are present and affect pt care or is treated—report as coexisting condition
Example, pt presents with SOB due to asthma. Physician prescribes nebulizer treatments. Pt is morbidly obese making examination and treatment more complex.
First-listed: (asthma);
Coexisting Condition: (obesity)

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Uncertain Dx
Inpatient report uncertain Dx as if exists
Probable, suspected, questionable, rule out, working Dx, etc.
Outpatient report symptoms, signs, abnormal test results, or other reason for encounter

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Code the condition to the highest degree of certainty, such as symptoms, signs, abnormal results, or reason for encounter.

Chronic Diseases
Chronic conditions are treated on ongoing basis
Report condition as many times as pt receives care or treatment for condition
Do not report conditions that were previously treated and no longer exist
Report history codes (Z80-Z87) as secondary Dx if condition impacts current condition or affects treatment

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Diagnostic Services
Only diagnostic service provided, report first reason for service
Example: Pt presents for routine, periodic gynecological exam, report Z01.419
No signs, symptoms, or associated diagnosis
Example: Pt presents for diagnostic imaging for left breast mass, subareolar. Report N63.42, unspecified lump in left breast, subareolar
Later Dx: Malignant neoplasm, report C50.112

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Therapeutic Services
Pt receiving only therapeutic service, report reason for encounter
Example: Outpatient chemotherapy for right breast cancer, report Z51.11 (chemo) and C50.911 (malignant neoplasm, right breast)

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Preoperative Evaluation
First-listed code is preop exam
Subcategory Z01.81 code (encounter for preprocedural exam)
Z01.810 Preop cardiovascular exam
Z01.811 Preop respiratory exam
Z01.812 Preop lab
Z01.818 Preop exam, NOS exam before chemo
Additional code, reason for surgery

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Also code any additional findings related to the preop evaluation.

Pre/Postoperative Dx
Report most definitive Dx
Usually postoperative Dx

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When the report indicates a different pre- and postoperative diagnosis, which would you report? (Postoperative)

Prenatal Encounters
Routine outpatient prenatal encounters with no complications, report category Z34, supervision of routine pregnancy
Example: 19-year-old female presents for initial prenatal exam, first pregnancy, Z34.00
Prenatal encounters for high-risk patients report as first-listed, O09 (supervision of high-risk pregnancy)
Example: 29-year-old first trimester female patient presents for prenatal encounter with varicose veins of legs, O22.01

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Conclusion
CHAPTER 3
ICD-10-CM OUTPATIENT CODING AND REPORTING GUIDELINES

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CHAPTER 2

AN OVERVIEW OF ICD-10-CM

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An Overview of the ICD-10-CM

Classification System

Morbidity (illness)

Mortality (death)

ICD = International Classification of Diseases

WHO’s ICD-10 used globally

World Health Organization

ICD-10-CM = 10th Revision; CM, Clinical Modification

Continuity of data

(Cont’d…)

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The International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) is designed for the classification of patient morbidity and mortality information for statistical purposes and for the indexing of health records by disease and operation for data storage and retrieval.

Index
Main terms and subterms
Figure 2.2
ICD-10-CM Index (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)
 

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I-10 Index is alphabetic, with the main terms in bold type and subterms indented under the main term.

ICD-10-CM Chapters
Chapter 1 Certain Infectious and Parasitic Diseases (A00–B99)
Chapter 2 Neoplasms (C00–D49)
Chapter 3 Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism
(D50–D89)
Chapter 4 Endocrine, Nutritional, and Metabolic Diseases (E00–E89)
Chapter 5 Mental, Behavioral and Neurodevelopmental Disorders (F01–F99)
Chapter 6 Diseases of the Nervous System (G00–G99)
Chapter 7 Diseases of the Eye and Adnexa (H00-H59)
Chapter 8 Diseases of the Ear and Mastoid Process (H60–H95)
Chapter 9 Diseases of the Circulatory System (I00–I99)
Chapter 10 Diseases of the Respiratory System (J00–J99)
Chapter 11 Diseases of the Digestive System (K00–K95)
Chapter 12 Diseases of the Skin and Subcutaneous Tissue (L00–L99)
Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00–M99)
Chapter 14 Diseases of the Genitourinary System (N00–N99)
Chapter 15 Pregnancy, Childbirth, and the Puerperium (O00–O9A)
Chapter 16 Certain Conditions Originating in the Perinatal Period (P00–P96)
Chapter 17 Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00–Q99)
Chapter 18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00–R99)
Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes (S00–T88)
Chapter 20 External Causes of Morbidity
(V00–Y99)
Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00–Z99)
Chapter 22 Codes for Special Purposes (U00-U85)

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Tabular
Each section begins with unique letter and codes arranged in numerical order
ICD-10-CM Tabular, R codes. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)
Figure 2.5

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All codes in a chapter begin with a letter.

Official Instructional Notations
Includes
Define or give examples of category content
Figure 2.13
Includes notation. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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I-10 has instructional notations providing guidance to the coder.
Since the figures in this chapter are taken directly from Buck’s ICD-10-CM for Hospitals, you may notice extra symbols and notations meant to enhance the user experience in addition to the official notations that are part of the ICD-10-CM release.

Excludes1
Excludes1 = Not Coded Here
Figure 2.14
Excludes1 notation in I-10. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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What Excludes note is a pure excludes? (Excludes1)
Indicates the code excluded should not be assigned at the same time as the code above the Excludes1 note.

Excludes2
Excludes2 = Not Included Here
Figure 2.15
Excludes2 notation. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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Excludes2 note indicates the condition excluded is not part of the condition it is excluded from and a patient may have both conditions at the same time.
When Excludes2 note appears under a code, acceptable to report code and the Excludes2 code together.

Code First/Use Additional Code
Code First/Use Additional = Etiology/Manifestation Paired Codes
Figure 2.16
I-10 Tabular, Code first notation. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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I-10 has a coding conversion that requires the underlying condition to be sequenced first followed by the manifestation.

Code Also
Code Also = More than 1 code required
Figure 2.18
I-10 Tabular, Code also notation (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.)

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Sequencing of the two codes depends on the following:
Severity of the condition.
Reason for the encounter.

7th Character and Placeholder X
Codes <6 characters that have a 7th character requirement, X is placeholder Figure 2.20 X as the placeholder. (From Elsevier: Buck’s 2022 ICD-10-CM for Hospitals, St. Louis, 2022, Elsevier.) Slide ‹#› Copyright © 2022 by Elsevier Inc. Placeholder X is assigned for all characters less than 6 that require a seventh character. Conclusion CHAPTER 2 AN OVERVIEW OF ICD-10-CM Slide ‹#› Copyright © 2022 by Elsevier Inc. Slide ‹#› Copyright © 2022 by Elsevier Inc. 12