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adverse effect

answer

Appearance of a pathologic condition due to ingestion or exposure to a chemical substance properly administered or taken. Also called an adverse reaction.

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Appendices ICD-9-CM Appendices -

answer

serve as a resource in coding neoplasms, adverse effects of drugs and chemicals and external disease and injury. in addition the 3 digit disease category codes are listed as an appendix Appendix A: Morphology of Neoplasms -the volume 1 appendix that contains a nomenclature of the morphology of neoplasms adapted from the International Classification of Diseases (ICD) of Oncology; used with codes from chapter 2 depending on the setting of the encounter. B was deleted in 2004 Appendix C: Classification of Drugs by the American Hospital Formulary Service (AHFS) List Appendix D - Classification of Industrial Accidents According to Agency the volume 1 appendix that lists industrial accidents as defined by the Tenth International Conference of Labor Statisticians. Appendix E: List of Three-Digit Categories

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appendix A Morphology of Neoplasms

answer

contains a reference to WHO. The appendix also interprets the meaning of each digit of the morphology code number. (Morphology indicates the tissue type of a neoplasm.) Reported to state cancer regeetries coding should be delayed until pathology

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Appendix C Classification of Drugs by the American Hospital Formulary Service (AHFS) List

answer

organized in numerical order according to AHFS list number by the (American society of hospital pharmacist)

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Appendix D - Classification of Industrial Accidents

answer

According to Agency the volume 1 appendix that lists industrial accidents as defined by the Tenth International Conference of Labor Statisticians. based on employment injury statistics adopted by TICLS. Because it may be difficult to locate the E code entry in the icd index to external causes, coders may find the Appendix more helpful in identifying the category of equipment and so on

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adverse reaction

answer

Appearance of a pathologic condition due to ingestion or exposure to a chemical substance properly administered or taken. Also called an adverse effect.

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axis of classification

answer

System that organizes entities, diseases, and other conditions according to etiology, anatomy, or severity.

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benign

answer

Not cancerous.

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carcinoma (CA) in situ

answer

Malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).

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Classification of Drugs by AHFS List

answer

Appendix C of the ICD-9-CM, which contains the American Hospital Formulary Services (AHFS) List number and its ICD-9-CM equivalent code number. Organized numerically according to AHFS List number.

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Classification of Industrial Accidents According to Agency

answer

Appendix D of the ICD-9-CM, which is based on employment injury statistics adopted by the Tenth International Conference of Labor Statisticians.

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coding conventions

answer

Rules that apply to the assignment of ICD-9-CM codes.

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coding tips

answer

Observation Stay. When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. Outpatient surgery that requires observation stay. When a patient presents for outpatient surgery and develops complications reqiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses. Outpatient surgery, when a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contrindication. Coding tip An inpatient is a person admitted to a hospital or long-term care facility (LTCF) for treatment (or residential care, if LTCF) with the expectation that the patient will remain in the hospital for a period of 24 hours or more.

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comorbidity (concurrent condition)

answer

Secondary diagnosis or concurrent condition that coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient must be treated or monitored.

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complication

answer

Condition that develops subsequent to inpatient admission block 21 of cms-1500 form locator 67A-67Q of the UB-04

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computer-assisted coding (CAC)

answer

Uses a natural language processing engine to read patient records and generate ICD-9-CM and HCPCS/CPT codes. can be compared to speech recognition technology.

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congenital anomaly

answer

Disorder diagnosed in an infant at birth.

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contiguous site (or overlapping site)

answer

Sites that occur when the origin of a tumor (primary site) involves two adjacent sites. Also called overlapping sites.

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Diagnostic Coding and Reporting Guidelines for Outpatient Services: Hospital-Based and Physician Office

answer

Guidelines developed by the federal government for use in reporting diagnoses for claims submission.

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E code (E is for external)

answer

Codes in the ICD-9-CM Tabular List that describe external causes of injury, poisoning, or other adverse reactions affecting patients' health. They are reported for ENVIRONMENTAL events, industrial accidents, injuries inflicted by criminal activity.

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encoder

answer

Tool that automates the coding process using computerized or Web-based software. Instead of manually looking up conditions or procedures in the coding manual's index, the coder uses the software's search feature to locate and verify diagnosis and procedure codes.

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first-listed diagnosis (for outpatient claims)

answer

(reported on Block 21 of CMS 1500 claim form) Remember: the outpatient settings first listed diagnosis code is not the principal diagnosis because: principal diagnosis: Condition determined after study that resulted in the patient's admission to the hospital. (form locator 67 of the UB-04 CMS-1450 claim

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general equivalency mapping (GEM)

answer

Translation dictionaries or crosswalks of codes that can be used to roughly identify ICD-10-CM/PCS codes for their ICD-9-CM equivalent codes and vice versa.

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iatrongenic illness

answer

Illness that results from medical intervention (e.g., adverse reaction to contrast material injected before a scan).

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Index to Diseases (ICD-9-CM)

answer

Include "codes in slanted brackets," eponyms, essential modifiers, main terms, NEC and NOS, nonessential modifiers, notes, qualifiers, instructions (e.g., See , See also, See also condition ), and subterms.

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ICD-9-CM, Characteristics of

answer

Single codebook, 3 volumes Volume 1 Diseases: Tabular List Volume 2 Diseases: Alphabetic Index Volume 3 Procedures: Tabular List and Alphabetic Index "Official" version available only on CD-ROM from U.S. Government Printing Office

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ICD-9-CM Chapter Format

answer

Each chapter is structured into the following subdivisions Sections Categories Subcategories 5th-digit subclassifications

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ICD-9-CM Sections

answer

group of 3-digit categories Represent a single disease entity or a group of similar or closely related conditions Example: Disorders of Thyroid Gland (240-246)

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ICD-9-CM Categories

answer

Consist of 3 digits Represent a single disease entity or a group of similar or closely related conditions Example: 520 Disorders of tooth development and eruption

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ICD-9-CM Subcategories

answer

Represented by 4th digit Provide more specificity or information regarding the condition's Etiology Site Manifestation 4th-digit subcategories are collapsible to the 3-digit level Example: 476.0 Chronic laryngitis

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ICD-9-CM Fifth-Digit Subclassifications

answer

The 5th digit adds greater specificity to certain 4th-digit codes 5th-digit assignments and instructions appear at the beginning of a: Chapter For example, in Chapter 13, Diseases of Musculoskeletal System, certain categories must be assigned a fifth digit to describe the affected body site

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Index to Diseases (ICD-9-CM) Coding Conventions code in slanted brackets

answer

...

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Index to Diseases (ICD-9-CM) Coding Conventions eponym

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Index to Diseases (ICD-9-CM) Coding Conventions essential modifier

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Index to Diseases (ICD-9-CM) Coding Conventions main term

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Index to Diseases (ICD-9-CM) Coding Conventions NEC (not elsewhere defined)

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...

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Index to Diseases (ICD-9-CM) Coding Conventions nonessential modifier

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...

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Index to Diseases (ICD-9-CM) Coding Conventions notes

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Index to Diseases (ICD-9-CM) Coding Conventions qualifier

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Index to Diseases (ICD-9-CM) Coding Conventions see

answer

...

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Index to Diseases (ICD-9-CM) Coding Conventions see also

answer

...

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Index to Diseases (ICD-9-CM) Coding Conventions see also condition

answer

...

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Index to Diseases (ICD-9-CM) Coding Conventions see category

answer

...

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Index to Diseases (ICD-9-CM) Coding Conventions subterm

answer

...

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Index to Diseases (Volumn 2)

answer

Volume of the ICD-9-CM coding manual that contains the Alphabetical Index of Diseases and Injuries, which is referred to first when assigning code numbers, Table of Drugs and Volume of the ICD-9-CM coding manual that contains the Alphabetical Index of Diseases and Injuries, which is referred to first when assigning code numbers, Table of Drugs and Chemicals, and Index to External Causes of Injury and Poisoning.

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Index to Procedures (ICD-9-CM) Coding Conventions code also as synchronous procedures

answer

...

question

Index to Procedures (ICD-9-CM) Coding Conventions omit code

answer

Omit code: Term that identifies procedures or services that may be components of other procedures. This instruction means that the procedure or service is not coded. Code also any synchronous procedures: Refers to operative procedures that are to be coded to classify a procedure completely.

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Index to Procedures and Tabular List of Procedures (Volumn 3)

answer

Included only in the hospital version of the commercial ICD-9-CM. Is a combined alphabetical index and numerical listing of inpatient procedures.

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indexing

answer

Process of cataloging diseases and procedures by code number.

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injury

answer

Traumatic wound or some other damage to an organ.

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Inpatient

answer

admitted for long term care to a hospital or facility for at least 24 hours

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Internationala Classification of Diseases, 10th Edition, Clinical Modification/Porcedure Coding System (ICD-10-CM/PCS)

answer

...

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late effect

answer

Residual effect or sequela of a previous acute illness, injury, or surgery.

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lesion

answer

Any discontinuity of tissue (e.g., skin or organ) that may or may not be malignant.

question

List of Three-Digit Categories

answer

Found in Appendix E of the ICD-9-CM. Contains a breakdown of three-digit category codes organized beneath section headings.

question

malignant

answer

Cancerous.

question

Mandatory reporting of ICD-9-CM codes

answer

Requirirng diagnosis codes to be reported on submitted claims establishes the medical necessity of procedures and services rendered to patients (e.g., inpatient care, office visit, outpatient visit, or emergency department visit). Medical necessity is difined by Medicare as "the determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury. Medicare the patient must sign an advance beneficiary notice (ABN) which acknowledges patient responsibility for payment is Medicare denies the claim

question

Medical necessity

answer

Purpose: the procedure or service is performed to treat a medical condition Scope: the most appropriate level of service is provided, taking into consideration potential benifit and harm to the patient. Evidence: the treatment is known to be effective in improving health outcomes Value: the treatment is cost-effective for this condition when compared to alternative treatments including no treatment

question

metastasize

answer

Spread of cancer from primary to secondary sites.

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metastatic

answer

Term that indicates a primary cancer has spread to another part of the body.

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morbididty

answer

disease

question

morphology

answer

Indicates the tissue type of a neoplasm. While M codes are not reported on provider office claims, they are reported to state cancer registries.

question

Morphology of Neoplasams (M codes)

answer

Appendix A of the ICD-9-CM. Contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology (ICD-O).

question

mortality

answer

death

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National Center of Health Statistics (NCHS)

answer

One of the U.S. Department of Health and Human Services (DHHS) agencies responsible for overseeing all ICD-9-CM changes.

question

neoplasm

answer

New growths, or tumors, in which cell reproduction is out of control.

question

outpatient

answer

Person treated in one of three settings: (1) health care provider's office; (2) hospital clinic, emergency department, hospital same-day surgery unit, or ambulatory surgical center (ASC) from which the patient is released within 23 hours; or (3) hospital admission solely for observation and from which the patient is released after a short stay.

question

overlapping site (or contiguous)

answer

Sites that occur when the origin of a tumor (primary site) involves two adjacent sites. Also called contiguous.

question

perinatal condition

answer

Condition that occurs before birth, during birth, or within the perinatal period.

question

perinatal period

answer

First 28 days of life.

question

poisoning

answer

Situation that occurs as the result of an overdose, wrong substance administered or taken, or intoxication (e.g., combining prescribed drugs with nonprescribed drugs or alcohol).

question

preadmission testing (PAT)

answer

Completed before an inpatient admission or outpatient surgery to facilitate the patient's treatment and reduce the length of stay.

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primary malignancy

answer

Original cancer site.

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principal diagnosis (used for inpatient)

answer

Condition determined after study that resulted in the patient's admission to the hospital. (form locator 67 of the UB-04 CMS-1450 claim

question

principal procedure

answer

Procedure performed for definitive treatment rather than diagnostic purposes, or performed to treat a complication, or that which is most closely related to the principal diagnosis.

question

qualified diagnosis

answer

Working diagnosis that is not yet proven or established.

question

qualifiers

answer

...

question

re-excision

answer

State that occurs when the pathology report recommends that the surgeon perform a second excision to widen the original tumor site.

question

secondary diagnosis

answer

Includes cormorbidities and complications. Condition that coexists with the primary condition, can affect treatment of the primary condition, and is an active condition for which the patient must be treated or monitored. also referred as: concurrent condition or comorbidity. Comorabidity: Secondary diagnosis or concurrent condition that coexists with the primary condition, has the potential to affect treatment of the primary condition, and is an active condition for which the patient must be treated or monitored.

question

secondary malignancy

answer

Tumor that has metastasized to a secondary site, either adjacent to the primary site or to a remote region of the body.

question

secondary procedure

answer

Additional procedure performed during the same encounter as the principal one.

question

sequelae

answer

Late effects of injury or illness.

question

Tabular List of Diseases (ICD-9-CM) Coding Convensitons

answer

Include format and punctuation (e.g., bold type, braces, brackets, colon, parentheses), instructions (e.g., code first underlying disease, excludes, includes, use additional code) , terms and phrases (e.g., and, category, chapter headings, major topic headings, not otherwise specified (NOS), subcategory, subclassification, with). Classification of diseases and injuries Classify conditions according to etiology (cause of disease) or by specific anatomical (body) system Supplementary classifications V Codes E Codes Appendices

question

selection of first -listed condition

answer

used and determined in accordance with icd coding convection's (or rules) as well as general and disease-specific coding guidelines. because diagnosis are often not established at the time of the patients initial encounter or visit, two or more visits may be required before the diagnosis is confirmed

question

Tabular List of Diseases (ICD-9-CM) Coding Convensitons and

answer

...

question

Tabular List of Diseases (ICD-9-CM)

answer

-These codes must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reasons for the encounter

question

Accurate reporting of ICD-9-Cm diagnosis codes

answer

C. Accurate reporting of ICD-9-Cm diagnosis codes For accurate reporting of ICD-9-Cm diagnoses codes, the documentation should describe the patient's condition, using terminaology which includes specific diagnoses as well as sysmptoms , problems, or reasons for the encounter.

question

Codes that describe signs & symptoms

answer

Codes that describe symptoms and signs, as opposed to definite diagnoses, are acceptable for reporting purposes when a diagnosis has not been established by provider (780.0-799.9) I.B.6 . some codes are in other ICD chapters

question

Encounter for other circumstances other than diseases or injury

answer

V codes are for encounters for circumstances other than a disease or injury Supplementary classification of Factors Influencing Health Status and Contact Health Services (V01.0-V91.99) I.C.18 is provided to deal with occasions when circumstances other than disease or injury are recorded as diagnoses or problems

question

Selection of codes 001.0 through V91.99

answer

These codes must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reasons for the encounter

question

Code all documents conditions that Coexist

answer

Code all documents conditions that Coexist Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management.Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be reported as secondary codes if the historical condition or family history has an impact on current care or influence treatment.

question

Outpatient coding guidelines

answer

The diagnostic coding and reporting guidelines for outpatient services Hospital-Based and Physician Office were developed by the federal government for use in reporting diagnoses for claims submission. Four cooperating parties are involved in the continued development and approval of the guidelines. 1. American Hospital Association (AHA). 2. American Health Information Management Association (AHIMA). 3. Centers for Medicare and Medicaid Services (CMS, formerly HCFA). 4. National Center for Health Statistics (NCHS).

question

Chronic diseases

answer

Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition.

question

Preadmission Testing

answer

Preadmission Testing (PAT) is routinely completed prior to an inpatient admission or outpatient surgery to facilitate the patient's treatment and reduce the length of stay. Some payers provide higher reimbursement for PAT, making it important to properly assign codes (e.g. V72.6 Laboratory examination).

question

DIAGNOSTIC SERVICES?

answer

only during an encounter/visit sequence first the diagnosis condition problem or other reasons for encounter

question

THERAPEUTIC SERVICES?

answer

Therapeutic Service is one which some type of treatment is performed to treat a specific disease. Therapeutic services can range from a medicaition to a surgical procedure Therapeutic Services only Sequence diagnosis, condition, problem or other reason for visit/encounter first, then code other diagnoses, (chronic) as additional diagnoses. Exception to rule, is when primary reason for admission is chemotherapy, radiation therapy, or rehabilitation. Appropriate V code is listed first, then the diagnoses or problem for which services is being performed is listed second

question

Surgery Pre-Op Eval

answer

Surgery Pre-Op Eval Receieving preopevals only code from category V72.8, other specified exams to describe the preop consult, code condition for surgery as second. Also code any findings related to preop eval

question

Preoperative Clearance Code

answer

first the encounter for preop clearance, then reason for surgery, then condition requiring clearance V72.81 Preoperative Cardiovascular Exam V72.82 Preoperative respitory Exam V72.83 Other specifified preoperative exam V72.84 Peroperative exam unspecified

question

PRENATAL SERVICES?

answer

what are guidelines for PRENATAL SERVICES? outpatient prenatal visits with no complications code v22.0 normal first pregnancy v22.1

question

Code diagnoses for surgery.

answer

Code diagnoses for surgery. If postoperative diagnosis is known to be different from perop diagnosis at the time siagnosis is confirmed, select postoperative diagnosis for coding, since it is most definitive

question

Routine Lab/radiology testing

answer

Routine Lab/radiology testing In absence of signs, symptoms, or associated diagnosis assign v72.5 and/or code from subcategory v72.6. If routine testing is performed during same encounter as a test to evaluate sign, symptom it is appropriate to assign both vcode and code to describe reason for the non-routine test

question

Uncertain Diagnosis

answer

Uncertain Diagnosis Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other terms indicating uncertainty. Code condition to highest degree of certainty in outpatient setting. This may mean coding symptoms, signs, abnormal test results, or another reason for encounter

question

Observation Code V71.0-71.9 series

answer

Observation Code V71.0-71.9 series - Observation and evaluation for suspected conditions, are as signed as first listed diagnoses for encounters or admissions to evaluate the patients condition when there is evidence to suggest existence of abnormal condition or following an accident or other incident that results in health issue

question

Level of coding detail

answer

icd-9-cm disease codes contain 3,4,or 5 digits. codes with three digits are insluded as a catagory of disease codes that may further subdivided by the assignment of 4, or 4 & 5 digits which provide greater specifity

question

Tabular List of Diseases (ICD-9-CM) Coding Convensitons bold type

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons braces

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons brackets

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons catagories

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons code first underlying disease

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons colon

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons excludes

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons format

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons fourth and fifth digits

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons includes

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons major topic heading

answer

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons not otherwise specified (NOS)

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons parentheses

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons subcategory

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons subclassification

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...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons use additional code

answer

...

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Tabular List of Diseases (ICD-9-CM) Coding Convensitons with

answer

...

question

Tabular List of Diseases (Volume 1)

answer

Contains 17 chapters that classify diseases and injuries, 2 supplemental classifications, and 5 appendices.

question

uncertain behavior

answer

Indicates it is impossible to predict subsequent morphology or behavior from the submitted specimen.

question

unspecified nature

answer

Neoplasm is identified, but there is no further indication of the histology or nature of the tumor reflected in the documented diagnosis.

question

V code

answer

Codes in the Tabular List. Assigned for patient encounters when circumstances other than diseases or injuries are present. Examples: 1.) Removal of a CAST applied by another physician (V54.89) 2.) Exposure to tuberculosis (V01.1) 3.) Personal history of breast cancer (V10.30 4.) Well-baby checkup (V20.2) 5.) Annual physical examination (V70.0

question

who developed the ICD-9-CD

answer

American hospital association (AHA) American Health Information Management association (AHIMA) Centers for Medicare & medicaid services (CMS) National Center for health Statistics (NCHS)

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