Chapter 6 MO 205 – Flashcards

- ICD-10 - ICD-9-CM - ICD-10-CM - ICD-10-PCS - ICD-CM/PCS is how it is abbreviated

- used to archive data - not supported/updated by ICD-9-CM Coordination and Maintenance Committee

crosswalks of corse used to roughly identify ICD-10-CM codes for ICD-9-CM equivalent codes (and vise versa)

- clinical modification of WHO's ICD-10 - used to classify diseases for all health care settings

used to classify inpatient hospital procedures only

- decreases need to attach supporting documentation to claims - enhances ability to conduct public health surveillance - improve ability to measure health services

- conducting research/tracking public health - designing payment systems - identifying fraud and abuse - making clinical decisions - measuring care provided to patient - processing claims

- ensures acurate ICD-10-CMS/PCS coding - process is activated when coder notices problem with documentation quality - coder requests clarification about documentation so accurate code can be assigned

- brand new classification developed by CMS - used for inpatient hospital procedures only - multi axial seven-character alphanumeric codes (e.g., 047K04Z) - provides unique codes for procedures - allows new procedures to be easily incorporated as new codes

- ICD-10-CMS/PCS coordination and maintenance committee oversees changes and modifications - committee is comprised of: CMS, NCHS, AHA, and AHIMA - committee also discusses issues such as creation and update of GEMs

- uses natural language processing engine to "read" patient records and generate codes - coders become coding auditors, responsible for ensuring accuracy of codes

- medicare catastrophic coverage act of 1988 mandated reporting of ICD-9-CM codes on medicare claims - switch to ICD-10-CM (diseases) and ICD-10- PCS (hospital inpatient procedures) mandates their reporting

- determines the extent to which individuals with health conditions receive health care services - reporting diagnosis codes (ICD-10-CM) ensures the medical necessity of procedures and services (CPT/HCPCS level II) provided to patients during an encounter -____= determination that service/procedure rendered is reasonable and necessary for diagnosis or treatment of illness or injury - if scheduled test, services, or procedures might be found medically unnecessary by Medicare, patient must sign advance beneficiary notice (ABN)

- face to face contact between patient and health care provider who assesses and treats patient's condition -thus, medical necessity is the measure of whether a health are procedure or service is appropriate for the diagnosis and/or treatment of a condition

- format and typeface - eponyms - abbreviations - punctuations - tables - includes notes, excludes notes, and inclusion terms - other, other specified, and unspecified codes - etiology and manifestation rules - and - due to - with - cross-references, including, see, see also, see category, and see condition

- ICD-10-CM index uses an indented format for ease in reference - ICD-10-CM index sub terms are indented two spaces - second and third qualifiers associated with the main term further indented by two and four spaces, respectively - if an index entry requires more than one line, additional text is printed on the next line and indented five spaces - in the ICD-10-CM tabular list, additional terms are indented below the term to which they are linked - if a tabular list definition or disease requires more than one line, additional text is printed on next line and indented five spaces - boldface type is used for main term entries in the index - boldface type is usually for all tabular list codes and description of codes - italicized type is used for all tabular list exclusion notes - italicized type is used to identify manifestation codes, which are never reported as the first-listed diagnosis

- disease or syndrome named for a person - listed in alphabetical sequence as main terms in the index - listed as sub terms below main terms such as disease or syndrome - tabular list usually includes this in code description

- means "other" or "other specified" - identifies codes that are assigned when information needed to assign a more specific code cannot be located

- equivalent of unspecified - identifies codes that are to be assigned when information needed to assigned a more specific code cannot be obtained from provider

used after incomplete term or phrase in index and tabular lost when one or more modifiers (additional terms) is needed to assign a code

used in index and tabular list to enclose nonessential modifiers (supplementary words that may be present in or absent from physician statement of disease or procedure without affecting code number assigned)

- used in index to identify manifestation codes - used in index and tabular list to enclose abbreviations, synonyms, alternative wording, or explanatory phrases

-condition that occurs as the result of another condition - these codes are always reported as secondary codes - code and description may or may not appear in italics in tabular list

alphabetical index of anatomic sites that categorize tumors as malignant primary, malignant secondary, malignant in situ, benign, of uncertain behavior, and of unspecified nature

alphabetical index of medicinal, chemical, and biological substances that result in poisoning and adverse effects

appears in tabular lists below certain categories to define, clarify, or give examples of the content of a code category

"pure excludes" - means not coded here - indicates mutually exclusive codes - two conditions that cannot be reported together

- means "not included here" - indicates that, although excluded from, a patient might be diagnosed with all conditions at the same time - when excludes2 note appears under a code, it may be acceptable to assign both the code and the excluded code(s) together if supported by documentation

- located below certain codes in the tabular list - indicate some conditions for which that code number may be assigned - may be synonyms of the code title - for other speficied codes, inclusion terms provide list of conditions included within a classification code - lists of inclusion terms in tabular lists is not exhaustive- refer to index for additional terms

- assigned when documentation provides detail for which specific code does not exist in ICD-10-CM - index entries contain NEC are classified to "other" codes in tabular list - index entries represent specific disease entities for which no specific code exists in the tabular list, so the term is included with an "other" code

- assigned when documentation is insufficient - ask provider to document additional information - when tabular list category does not contain unspecified code, an other specified code may represent both other and unspecified - other and specified category and subcategory codes require assignment of extra character (s) to classify condition

- code first underlying disease - code first underlying disease, such as: - code, if applicable, ant casual condition first - use additional code - in diseases classified elsewhere

- appears in category titles and code descriptions, means and/or - example: subcategory code H61.0, Chondritis and perochondritis of external ear, is interpreted as: - chondrities of external ear - perichondritis of external ear - chondritis and perichondritis of external ear

- located in index, in alphabetical order below main term - indicates presence of cause and effect relationship between tow conditions - when index includes this as sub term, code is assigned only if physician documented causal relationship between two conditions

- located in index, in alphabetical order below main term - indicates presence of cause and effect relationship between two conditions - to assign a code from the list of qualifiers below this word, physician must document both conditions

- located in index, immediately below main term - means associated with or due to - to assign a code from the list of qualifiers below the word with, physician must document both conditions

- located after index main term - directs coder to refer to another index term to locate code - coder must go to the referenced main term to locate correct code

- located after index main term or sub term - directs coder to another main term (or sub term) that may provide additional useful index entries - does not have to be followed if original main term (or sub term) provides correct code

- directs coder to tabular list, where code can be selected rom the options provided

- directs coder to main term for condition - found in disease index

- alphabetical listing of terms and corresponding codes, which include: - specific illnesses - injuries - eponyms - abbreviations - other descriptive diagnostic terms

- boldfaced - listed in alphabetical order - hyphens within main terms are ignored - single space within a main term is not ignored

- supplementary words located in parentheses after main term - do not have to be included in diagnostic statement for code to be assigned

- supplementary terms - further modify sub terms and other qualifiers

- also called essential modifiers - qualify main term by listing alternative sites, etiology, clinical status - indented two spaces under main term - ____= indented two spaces under sub term - ____= indented two spaces under second qualifier -____= indented two spaces under third qualifier - when moving from bottom of one column to top of next, main term will be repeated and followed by ----continued

- tumors in which reproduction is out of control - providers specify whether tumor is: benign (noncancerous), malignant (cancerous), or invasive (spreads to other parts of the body) - refer to pathology report for clarification of diagnosis

-____= discontinuity of tissue, which may or may not be malignant - index entries for this contain sub terms according to anatomic site - this terms is referenced only if diagnostic statement does not confirm malignancy following conditions are examples of benign lesions and are listed as index main terms: - adenosis - cyst - dysplasia - mass - if neoplasm is used in diagnostic statement, refer to Table of Neoplasms (not index entry for mass) - polyp

- malignancy is coded as primary site if diagnosis documents: metastatic from a site, spread from a site, primary neoplasm of a site, malignancy for which no specific classification is documented - recurrent tumor

- described as metastatic - indicated that primary cancer has spread (metastasized) to another part of body - sequencing of neoplasm codes depends on whether primary or secondary cancer is being: managed or treated - cancer described as metastatic from a site is primary of that site - assign one code to primary neoplasm - assign code to: secondary neoplasm of that specified site (if secondary site is known) or unspecified site (if secondary site is unknown) - cancer described as metastatic to a site is considered secondary of that site - assign one code to secondary site - assign second code to: specified primary site (if primary site is known) or unspecified site (if primary site is unknown) - when anatomic sites are documented as metastatic: assign secondary neoplasm code(s) to those sights and assign unspecified site code to primary malignant neoplasm - if diagnostic statement does not specify whether neoplasm site is primary or secondary, code site as primary - unless documented site is bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, or spinal cord - the above site are considered secondary sites unless the physician specific that they are primary

- if cancer diagnosis does not contain documentation of the anatomic site: but the term metastatic is documented assign codes for unspecified site for both primary and secondary sites

- no longer present - do not assign code for "primary of unspecified site" - instead, classify previous primary site by assigning appropriate code from category Z85 (personal history of malignant neoplasm)

also called overlapping sites - occur when origin of tumor (primary site) involves two adjacent sites - neoplasms with overlapping site boundaries are classified to fourth-digit subcategory .8, other

- occurs when pathology report recommends surgeon perform second excision to widen margins of original tumor site - ensures all tumor cells were removed - ensures clear border (margin) of normal tissue surrounding excised specimen - use diagnostic statement found in report of original excision to code reason for re-excision - pathology report for re-excision may not specify malignant, but patient is still under treatment for original neoplasm

- alphabetical index of medicinal, chemical, and biological substances that result in poisonings and adverse effects - first column lists generic names of drugs and chemicals - next six columns classify poisonings adverse effects, and underdosing - poisoning: accidental (unintentional) - poisoning: intentional (self-harm) - poisoning: assault - adverse effect - underdosing

- arranged in alphabetical order by main term to indicate event - secondary codes for use in any health care setting - intended to provide data for injury prevention strategies assigned to capture - cause of injury - activity being performed - place of occurrence - status at the time of injury

1. locate main term in index 2. if instructional phrase- see condition is found after main term, descriptive term or anatomic site has been mistakenly referenced instead of disorder or disease documented in diagnosis statement 3. when condition in diagnostic statement is not easily found in index, use main terms below to locate code 4. sometimes terms found in index are not found in tabular list when code number is reviewed for verification _____- concept that there are more terms listed in index than in tabular list, so do this and go to the code indicated

- chronological list of codes contained within 21 chapters - based on body system or condition - organized within: major topic headings and categories, subcategories, and codes,

- three-character categories - four-, five-, or six-character subcategories - four-, five-, six-, or seven-character codes which contain letters and numbers - each level of subdivision within a category is called a subcategory - final level of subdivision is a code

- only codes are permissible, not categories or subcategories - any applicable seventh character is required - ICD-10-CM utilizes character "x" as fifth-character placeholder for certain six-character codes - allows for future expansion without disturbing six-character structure (e.g., H62.8x1) - when this exists, the x must be entered for the code to be considered a valid code - certain categories contain applicable seventh characters - required for all codes within category (or as instructed by notes in tabular list) - seventh character must always be located in seventh character data field - if code that requires a seventh character is not six characters in length, placeholder x is entered to fill in empty character

- injury, poisoning, and certain other consequences of external causes (chapter 19) (S and T codes) - external causes of morbidity (chapter 20) (V-Y codes) reported for - environmental events - industrial accidents - injuries inflicted by criminal activity - external cause codes do not directly impact reimbursement to provider - however, such codes can expedite insurance claims processing - external cause codes indicate circumstances related to an injury

- incorporated into tabular list - located in chapter 21 (Z codes) (Z00-Z99) - last chapter of the ICD-10-CM tabular list - codes are reported for patient encounters when circumstance other than disease or injury is documented (e.g., well-child visit)

-tissue type of neoplasm examples: adenocarcinoma, sarcoma - not reported on insurance claims - reported to state cancer registries - ICD-O-3 is used to assign these codes - contain five digits, preceded by letter M - range is from M8000/0 to M9989/3 - first four digits (e.g., M8000) indicate specific histologic term - fifth digit, after slash, is behavior code - indicates whether tumor is: malignant, benign, in situ, or uncertain whether malignant or benign - separate one-digit code is assigned for histologic grading to indicate differentiation

- prepared by CMS and NCHS - approved by cooperating parties for ICD-10-Cm and ICD-10-PCS, which include: CMS, NCHS, AMA, and AHIMA - rules that accompany ICD-10-CM/PCS coding conventions and instructions - joint effort between health care provider and the coder is essential for complete accurate: documentation, code assignment, and reporting of diagnoses and procedures -____= indicates all health care settings, including inpatient hospital admissions -____= refers to physicians and qualified health care practitioners who are legally accountable for establishing the patient's diagnosis ICD-10-CM official guidelines organized as: - section 1: conventions, general coding guidelines, and chapter-specific guidelines - section 2: selection of principal diagnosis - section 3: reporting additional diagnoses - section 4: diagnostic coding and reporting guidelines for outpatient services - appendix 1: present on admission reporting guidelines ICD-10-PCS official guidelines are organized according to: conventions, medical and surgical section guidelines, and obstetrics section guidelines

- selection of first-listed condition - IDC-10-CM tabular list of diseases (A00-T88, Z00-Z99) - accurate reporting of ICD-10-CM diagnosis codes - codes that describe signs and symptoms - encounters for circumstances other than a disease or injury (Z codes) - level of detail in coding - ICD-10-CM codes for the diagnosis condition, problem, or other reason for encounter/visit - uncertain diagnoses -____= suspected, questionable, rule out, or working diagnosis, or other similar terms indicating uncertainty - chronic diseases - code all documented conditions that coexist - patients receiving diagnostic services only - patients receiving therapeutic services only - patients receiving preoperative evaluations only - ambulatory surgery (or outpatient surgery) - routine outpatient prenatal vists - encounters for general medical examinations with abnormal findings - encounters for routine health screenings