As the condition established after study to be chiefly responsible for admission of the patient to the hospital.
Why is the designation of the correct principal diagnosis so important?
Is is important because the information is used in cost comparisons, in care analysis, and in utilization review. It is also crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily on principal diagnosis.
Name and explain the official guidelines for designating the principal diagnosis.
Two or more diagnoses that equally meet the definition for principal diagnosis. - A symptom followed by contrasting/comparative diagnoses. - Original treatment plan not carried out. - Two or more comparable or contrasting conditions.
What conditions must be met in order for a diagnosis to be listed as an “other” diagnosis? Conditions that affect the episode of hospital care in terms of any of the following may be listed as “other” diagnoses
Clinical evaluation - Therapeutic treatment - Further evaluation by diagnostic studies, procedures or consultation - Extended length of hospital stay - Increased nursing care and/or monitoring
What does the word “and” mean when it appears in a code title, such as “Unspecified anomalies of face and neck”?
The condition may be present in either both the face and neck, or in the face or neck.
Why is it important to review the entire medical record before assigning diagnosis codes?
Some diagnoses, operations and procedures are frequently not listed on the face sheet or are not described in sufficient detail, making a review of operative reports, pathology reports, and other special reports imperative. Reviewing the entire medical record will ensure complete and accurate coding.
What type of instructional note is used in the Tabular List of Diseases to identify a code for a condition that is a manifestation of an underlying disease?
Code first underlying condition note.
Label lines as either main terms or subterms, or carryover lines.Absence (organ or part) (complete or partial), This next line is Indented 2 spaces - acoustic nerve 72.8, This next line is also indented 2 spaces - adrenal (gland) (congenital) 759.1
Main term - subterm - subterm
Where does a physician list the final diagnoses?
Admission record (face sheet) - Progress notes - Discharge summary
What are the steps in locating codes in ICD-9-CM? Explain.
Locate the main term in the Alphabetic Index. Review subterms and nonessential modifiers related to the main term. Follow any cross-reference instructions. Refer to any notes in the Alphabetic Index. - Verify the code number in the Tabular List. Read the code title. Read and be guided by any instructional notes. Refer to other codes as instructed. - Determine whether a fifth digit must be added.
Identify the main term - Respiratory failure
Identify the main term - Orthostatic hypotension
Identify the main term - Recurrent seizure. - Identify the main term - Abscess, right breast.
Seizure - Abscess
Coagulation defect are characterize by?
Prolonged clotting time. Some are congenital in origin, other are acquired. Bleeding PT who is being treated with Coumadin, heparin or another anticoagulant does not indicate that a hemorrhagic disorder due to instrinsic circulating anticoagulant present.
If a main term cannot be located in the Alphabetic Index, what should the coder do?
Consider a synonym, eponym, or other alternative term.
What are two basic coding principles?
Both the Alphabetic Index and the Tabular Lists must be used to locate and assign appropriate code. - Assign codes to the highest level of detail.
How is the term “dual classification” used in ICD-9-CM?
Dual classification is used to describe the required assignment of two codes to provide information about both a manifestation and the associated underlying disease.
What is the meaning of the abbreviations NOS?
Not otherwise specified - is the equivalent of “unspecified” and is used only in the tabular lists. NOS codes are to be used only when neither the diagnostic statement nor the medical record provides information that permits classification to a more specific code. Ordinarily classified to the final digit “9.”
What is the meaning of the abbreviations NEC?
Not elsewhere classified - is used in the Alphabetic Index to indicate that there is no separate code for the condition even though the diagnostic statement may be very specific. Ordinarily classified to the final digit “8.”
What is the difference between the terms “rule out” and “ruled out?”
Rule out indicates that a diagnosis is still considered to be possible. Ruled out indicates that a diagnosis originally considered as likely is no longer a possibility.
What is the meaning of the term “late effect” in ICD-9-CM?
A late effect is a residual condition that remains after the termination of the acute phase of an illness or injury.
What is a significant procedure?
A significant procedure is one that is: surgical in nature; carries an anesthetic risk; carries a procedural risk and requires specialized training.
How is a planned procedure coded that is begun but cannot be completed?
The procedure is coded to the extent to which it was actually performed.
Name the three volumes of ICD-9-CM
Tabular List of Diseases and Injuries (Volume 1) - Alphabetic Index of Diseases and Injuries (Volume 2) - Tabular List and Alphabetic Index of Procedures (Volume 3)
When a symptom is followed by contrasting/comparative diagnoses, How is it coded?
The symptom code is sequenced first. The contrasting/comparative diagnoses are coded as additional diagnoses
Anemia can be due to what?
Acute or chronic blood loss, chronic disease, inadequate intake of dietary iron.
Most hearing loss is classified as what?
Conductive, sensorineural and mixed conductive and sensorineural hearing loss
Gram negative pneumonia Usually appear as/or from
A complication of surgery, trauma, or chronic illness such as advance carcinoma, cardiac failure or alcoholism. It also common complication of COPD and frequently follow treatment with immunosuppressive drugs or use inhalation therapy.
Coagulation that is not true
Bleeding in PT who is treated w. Coumadin, heparin or another anticoagulant indicate that a hemorrhagic disorder due to instrinsic circulating anticoagulant