Medical Coding and Billing ICD-10 Training From Learning247

Medical Coding and Billing ICD-10 Intro

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welcome to icd-10-cm coating
your training course my name is Robyn
and I will be instructing
on how to code in the icd-10-cm coding
manual
icd-10-cm
stands for international classification
of diseases
tenth revision clinical modification it
represents a coating update
from the current manual icd-9-cm
which is one that includes both DX and
hospital
in patient procedure codes who which
stands for
World Health Organization has separated
the code sets into two
coating manuals one in title icd-10-cm
for the DX codes and the other icd-10
PCS for the hospital inpatient coder PCS
stands for
procedure coding system the
icd-10-cm is used to present
and improve mortality reporting by
monitoring certain categories
and causes of death the implementation
date
be icd-10 has been rescheduled for
October 1st
2014 at which time all health care
facility should be utilizing the
icd-10-cm coding manual
in place ABI icd-9 after successful
completion of this course
you should be able to know what's new in
icd-10-cm coding
and recognize general coding guidelines
understand chapter specific coding
guidelines
use the alphabetic index to locate
conditions that will lead to correct
coding
in the tabular section what's new
and icd-10-cm letter reality
is now included in code selections their
are additional ambulatory and managed
care encounters to select from
there are more injury codes
that are grouped by anatomical site more
combination diagnosis
that include manifest
nations poisonings and external causes
more codes with the seventh character
that determines encounter or sick well a
there are now full code titles without
the need for
the fourth or fifth notation indicator
complications during the postoperative
period
are now included in the PX specific body
system chapters
they now have a placeholder
letter act that is used for future
expansion
and to hold a place to remind the coder
to append
a mandatory seven character diabetes
malai discos include greater specificity
volume 1 now has 21 chapters instead of
nineteen
which includes V codes and decode
general coding guidelines
the two new chapters are I and adnexa
which are your accessory structures such
as the eyeball
I muscles lacrimal apparatus and
ear and mastoid process which plays a
part in conditions affecting the hearing
in balance in volume 1 all 21 chapters
begin with a letter
and are in alphabetical order omitting
the letter you
the external causes and factors
influencing health status in contact
with health services codes
are no longer supplemental the tabular
section
but now I have been incorporated into
volume 1
those codes are now in chapters 20 and
21
respectfully the structure for volume 2
is the same you still have your main
term
and indicated some terms situation under
ni
your neoplasm table table and drugs and
chemicals
an external cause individual sections
are still located in volume 2
after the alphabetical index
instructional notations are clues
that helped lead you to the best code
selection be
includes notation appears under certain
categories for more instructions
or to supply eggs
samples for clarity be 02
herpes Ulster directly underneath is
your notation includes
followed by conditions shingles and zona
which means that the doctor uses the
word shingles
in the medical record instead of herpes
auster we can still code in the B 02
category
excludes one into both means not coded
here
the code above and after the exclude one
notation
should not be assigned at the same time
because they cannot
occur together the code above
and after the exclude to notation
indicate
separate conditions they can appear at
the same time
and therefore can be billed as to
separate codes
please refer to your coding resource
page
entry number one ep 17 nicotine
dependence
look at the exclude one notation H
X up tobacco dependency the 87
point 891 the exclude one notation
tells us that the 8 seven-point 81
and F 17.00 cannot be coated together
and two only code1 or the other look at
exclude to tobacco use during pregnancy
09 9.33 the exclude to notation tells us
that
at seventeen point 200 and
0 99.3 3 are conditions that
can't happen simultaneously in a patient
and therefore
can be coated together using two
separate codes
cohn also is used when two codes
are needed to fully describe the
condition
however correct sequencing is necessary
code first and use additional codes
indicate ideology and manifestation pair
code
and they are still reported separately
in
icd-10 the tables that were sporadically
located throughout the tabular section
icd-9-cm
to determine fourth and fifth digit
placement
are now used to identify the seventh
character
in icd-10 if the code has less than six
characters
X serves as a place holder to alert the
coder
to select the seventh character when a
check mark
is placed in front the code please refer
to your coding resource page
entry number two s
01 point 81 ac laceration without
foreign body
other part ahead X at the end is the
placeholder
that holds the sixth position and the
check mark
at the beginning indicates 7 character
is needed
always search the area prior to the code
for your table a table is located actor
category s
01 that list three possible choices for
the seventh character
ADRs choice selection is based
on the medical record and the patience
circumstance please refer to your coding
resource
page entry number three let's
take a look at category J 68 which
states
code first 251 3065
go to category 8051 and in the notes
you'll see
being used additional code notation for
manifestations
punctuation also helps guide you
to the correct code all the punctuation
have the same meaning as they had in
icd-9-cm
brackets represent synonyms
alternate words an explanatory phrases
parenthesis
represent supplementary words can be
absent
and not affect the code selection a
colon after an incomplete term is used
to connect one
or more modifiers to make it complete
a colon after an incomplete term
is used to connect one or more modifiers
to make it complete a hyphen is found
in both the index and the tabular
sections at the into the code
it represents more digits to follow in
the tab
Miller section n EC which stands for
not elsewhere classified cable ended AKA
otherwise specified indicates that there
is not a specific code that exist
in OS which stands for not otherwise
specified
is AK a unspecified indicate the code up
higher specification
is available if you query the position
for more
information in OS which stands for
not otherwise specified and is AKA
unspecified indicate the code higher
specification
and is available if you query the
position for more information
the word and is equivalent to the words
and or or for example if the code
description states
to anatomical sites such as the owner
and radius
the medical record only need one or the
other
above the sites in order for you to make
that code selection
steps to accurate coding identify main
terms from the physicians documentation
locate main terms in the alphabetical
index volume 2 locate any
some terms if Apple couple follow the
directional instructions
verify selected codes in a tabular
section
volume 1 follow the instructional
notations and punctuation
assign the codes to the highest
specification
coding practice
we have abstracted the condition
hyperglycemia from the physicians notes
this is the condition
up overproduction glucose sugar in the
bloodstream
alphabetical index volume 2
please refer to your coding resource
page
injury number four hyperglycemia
hyperglycemic transient are 7-3
.9 the word transit
inside the parenthesis lets us know that
it is a non-essential
if the documentation states transit or
not
it will not affect our code selection
are seven 3-point now
9 in volume 1 we see are seven 3.9
hyperglycemia unspecified since the
doctor
only stated hyperglycemia we have to
choose the
unspecified as the type therefore
confirming that
are seven 3.9 is the correct code
official guidelines level of specificity
always report to the highest
specification
which are the codes with the most
characters if a7 character code is
available
it should be in your code selection
integral conditions
signs and symptoms can be reported
when there is not a definitive DX
available however
once the DX is established the sentence
then become integrated
and can not be coded separately examples
shortness of breath and ammonia non
integral conditions signs and symptoms
that are not
part %uh a definitive DX and are not
treated in
some form by the physician are reported
separately
pneumonia and dehydration j1
8.9 new Monia E 8
6.0 dehydration not all patients with
pneumonia
have dehydration dehydration not stated
as due to pneumonia many any allergy and
manifestation codes are now combination
code such as
type 1 diabetic retinopathy
E 10 point 319
diabetes the ideology is a fall systemic
condition that can cause right now but
the
the manifestation which is a disease ABI
innermost
sensitive layer the eyeball a cutie and
chronic conditions
when conditions are described as both
acute and chronic
and have separate sub injuries in the
index
volume 2 sequence the acute first
acute conditions are quick onset
conditions
while chronic our long-term pancreas
Titus acute K aid 5.9
chronic K 8 6.1
combination code if a combination code
exist
we must code that instead of coding
acute and chronic
s separate codes a combination code
includes either to diagnosis
already axed and its manifestation or DX
with
a complication any sample is K 80.0 one
which is calculus up the gallbladder
with acute cholecystitis with
obstruction
this is an example of the Deacs and its
manifestation
K 8 0.01 calculus
up gallbladder acute cholecystitis with
obstruction residual and cause
the words aquella is used in place a
blade effect
but all three words sequelae late effect
and residual are interchangeable
they represent a condition that arises
after an acute phase
up an illness or injury is terminated
there is no time limit as to when to
code a residual condition
two codes are required and sequencing is
important
code first the cause of the condition
then the late effect
which is the reason why the patient has
come to see the doctor today
so Kuala late effect residual residual
and cause in the alphabetical index
under the main terms the Kuala find your
condition in the
invented some terms lateral means
the side in bilateral means to or both
sides
and examples up mir image anatomical
sites are
your to eyes your to years
X cetera laterality is now included in
the code description
and the last character the code
determines which side is involved
H 40 dot 21 code
H 40 dot 21 is acute angle
closure glaucoma and the last digit 1
represents the right II to is the left
eye
and if we coated with 3 as the last
digit
it is both or bilateral I've please
refer to your coding resource page
injury number five
in pending or threatened conditions are
ones that have not been confirmed as a
DX and have not occurred
but are only suspect when we see
either words in a medical record look
in the alphabetical index under
impending or threatened
if there is a some term for the
condition we can coded
after it has been confirmed in a tabular
section
if the condition is not listed under
either
amis main terms in the index Colby
underlying condition reporting
same diagnosis more than one a patient
can have more than one DX per encounter
but each can have only in a patient can
have more than one DX per encounter
but each can only be reported once if
the description includes lead a rally
use the single code if no bilateral code
exist
we can assign separate codes for both
right and left side