CHAPTER 2 After completing this chapter you should be able to 1. Demonstrate ability to utilize the Alphabetic Index and Tabular List. 2. Understand the steps to accurate coding. 3. Comprehend the organization of the Guidelines. 4. Use both the Alphabetic Index and Tabular List. 5. Outline the need for level of specificity in diagnosis coding. 6. Identify conditions integral to a disease process. 7. Assign multiple codes to a single condition. 8. Report acute and chronic conditions. 9. Demonstrate application of combination codes. 10. Differentiate between residual and late effects. 11. Abstract information that determines if a condition is impending or threatened. 12. Outline the rules when reporting the same diagnosis code more than once. 13. Assign codes based on laterality. The complete 2012 ICD-10-CM Official Guidelines for Coding and Reporting are posted on the web at www.cdc.gov/nchs/icd/icd10cm.htm. The Guidelines are organized into sections. Section I of the Guidelines includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient (hospital) settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting. Outpatient coders, however, use guidance from throughout the Official Guidelines for Coding and Reporting because not all of the coding circumstances are fully explained in Section IV of the Guidelines. Within your learning activities, the number that appears to the left of the guideline is the number of the guideline as listed in the Official Guidelines for Coding and Reporting. 1. Identify the main term(s) in the diagnostic statement. 2. Locate the main term(s) in the Alphabetic Index (referred to in this material as the Index). 3. Review any subterms under the main term in the Index. 4. Follow any cross-reference instructions, such as see. 5. Verify the code(s) selected from the Index in the Tabular List (referred to in this material as the Tabular). 6. Refer to any instructional notations in the Tabular. 7. Assign codes to the highest level of specificity. 8. Code the diagnosis until all elements are completely identified. Examples
Using ICD-10-CM
Organization of the guidelines
Accurate coding
Steps to accurate coding
Alphabetic index and tabular list
Level of specificity
Diagnosis:
Infectious colitis
Index:
Index:
Tabular:
A09 Infectious gastroenteritis and colitis, unspecified
Code:
A09 Infectious colitis
Diagnosis:
Subarachnoid hemorrhage, nontraumatic
Index:
Tabular:
I60.9 Nontraumatic subarachnoid hemorrhage, unspecified
Code:
I60.9 Subarachnoid hemorrhage
Diagnosis:
Aseptic meningitis in leptospirosis
Index:
Leptospirosis A27.9
Tabular:
Code:
A27.81 Aseptic meningitis in leptospirosis
Tabular:
Code:
D81.810 Biotinidase deficiency
Diagnosis:
Initial encounter for fatigue fracture of vertebra
Index:
Tabular:
Code:
M48.40XA Initial encounter for fatigue fracture of vertebra
Integral conditions
Using ICD-10-CM
“ICD-10-CM requires an advanced knowledge of medical terminology and anatomy. Even though we are comfortable in our respective specialty; the level of specificity is tremendous. It’s imperative that we dig deep in learning far more than we ever thought we needed to know.”
Exercise 2-1
