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ICD-9-CM

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International Classification of Diseases, Ninth Revision, Clinical Modification

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Main terms

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represents diseases, injuries, problems, complaints, drugs, and external causes of diseases or conditions

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Subterms

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words that are identified under main term

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Sub-subterms

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indented 3 character spaces from the term above it

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V-codes

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reports circumstances other than disease or injury

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Tabular List (3) divisions

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diagnoses codes, supplementary classification, appendixes

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E- codes

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Supplementary Classification of External Causes of Injury and Poisoning. These codes classify the causes of injury, poisoning, and adverse events and are used to gather statistics relating to these occurences.

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ICD-9-CM codes range

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3 to 5 digits

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Tabular List Format

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Chapter, Section, Category, Subcategory, Subclassification,

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Alphabetic Index is

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Vol. 2, contains medical terms and is used first

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Tabular List is

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Vol. 1

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Alphabetic Index lists words describing

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pneumonia, bronchitis, infection, and fracture

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External causes of diseases

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fall, accident, burn, and cut

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Category codes are

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3 digits

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Subcategory codes are

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4 digits

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Subclassification codes re

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5 digits

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Classifies procedures used in hospitals only

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Vol. 3

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Basic coding

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Review complete medical documentation and Abstract the medical conditions and procedures that should be coded

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Modifiers

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parenthetical or nonessential modiers, terms surrounded by parentheses

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cross-references

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terms see, see also, and see category. Coder must look elsewhere

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HIPPA Final Rule

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in addition to mandating the ICD-9-CM code set, also requires the use of ICD-9-CM Official Guidelines for Coding and Reporting, when codes are selected

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brackets

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are used to enclose synonyms, alternative wordings, ans explanatory phrases in the tabular list of diseases and injury

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Parentheses

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used in Alphabetic Index and Tabular Lists to enclose terms that are supplementary, that may or may not be present in the disease statement, and that do not affect code assignment. They are always used to enclose nonessential terms

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section mark

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precedes a code to indicate there is a footnote with special instructions. Found in all 3 volumes

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Bold

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used to identify main terms and titles in the Alphabetic Indexes. Depicts each code and code title in Tabular List

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Code first underlying disease

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located only in Tabular List with codes that are not intended to be selected as a primary disease because they are manifestations of other underlying disease. Sometimes in italics

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HIPPA legislation

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requires the use of ICD-9-CM for reporting diagnoses in all patient care settings and also stipulates the Official Guidelines

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Current Procedural Terminology

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CPT

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CPT is maintained by

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American Medical Association (AMA)

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CPT was designated

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by Federal Dept of Health and Human Services(HHS) as nationally accepted HIPPA standard code set for physician and other health care professional services

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Category 1 codes

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are permanent CPT codes

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6 sections of category 1 codes

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Evaluation and Management, Anesthesia, Radiology, Surgery, Pathology and Lab, and Medicine

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Surgery section

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Largest procedure code section, with codes ranging from 10021-69990

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separate procedure

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CPT explains that it can be reported if it was performed alone, for a specific purpose, and independent of any other related service provided. If it was performed as a component part of a larger procedure it is not billed separately.

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Appendix A

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List of Modifers

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Appendix C

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Clinical Examples

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Appendix E

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Summary of CPT codes exempt from Modifer -51

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fee-for-service

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if a physician bills and is paid the full amount on the fee schedule

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Always list

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the modifer that affects payment first, where there are multiple modifiers

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Modifier -21

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Not a facility modifier

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837P

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Physicians bill medical services and procedures on

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Never make a code

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fit

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HCPCS code set

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if a code cannot be found that matches what was done

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Category 3 code section

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If HCPCS does not include a code that fits or if the payer does not accept HCPCS codes

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