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Learn the 10 essential steps to proper ICD-9-CM coding, including consultation, interpretation, and specificity. Understand key concepts and best practices for accurate medical coding.
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Chapters 2 - 4 Overview of ICD-9-CM August 23, 2011
10 Steps to Correct Coding 2. Always consult the Alpha Index, Volume 2, before turning to the Tabular List. 1. Identify the reason for the visit 3. Locate the main entry. 4. Read and interpret any notes listed with the main term. 5. Review entries for modifiers.
10 Steps to Correct Coding 6. Interpret abbreviations, cross-references, symbols and brackets. 7. Choose a tentative code and locate it in the Tabular list. 8. Determine whether the code is at the highest level of specificity. 9. Consult the color coding and reimbursement prompts, including the age and sex edits. 10. Assign the code!
Chapter 2 Review Discussion • Which volume of the ICD-9 contains the Alphabetic Index to Diseases? • Which index would you use to locate an E code? • What do you know about a code when it is in italicized type or inside slanted brackets? • What are the 3 cross-references found in the Alphabetic Index that direct you to seek information in another location? • Where in the ICD-9 is the Table of Drugs and Chemicals located? • What organization would report using codes from Volume 3 of the ICD-9?
Chapter 3 Review Discussion • What is the difference between the selection of the first-listed diagnosis for inpatients and outpatients? • What is an unconfirmed diagnosis? • What are V codes used for? • What is the first-listed diagnosis for a patient admitted to observation status? • How do you determine how many diagnoses codes to submit for a patient encounter? • What is the first-listed diagnosis for a patient who is receiving therapeutic treatment? • What type of code would be expected to report for a routine outpatient prenatal visit?
Chapter 4 Review Discussion • What is the name of the document that directs coders how to assign diagnosis codes? • Why can you not code from the ICD-9 Index? • If there is a code of 3 digits, can you assign that code if there is 4th digit available? • When signs and symptoms routinely associated with a disease process, these signs and symptoms are termed what? • What is the name of the code that includes more than one condition reported with that one code?
Chapter 4 Review Discussion cont. • How do you report a condition that is described as both acute and chronic and separate subentries exist in the Index at the same indention level? • When there is a residual condition and a late effect of that condition, which diagnosis is listed first?