How to do the Medical coding - Basic tips

The following guidelines are to be followed when reporting diagnoses in ADM.  The ICD-9-CM diagnostic codes are used for professional services furnished in both the inpatient and ambulatory setting.  ICD-9-CM procedure codes are only used for inpatient institutional DoD coding and not professional services DoD coding.  

Prioritized Diagnoses

All conditions that are documented in the medical record and require or affect patient care, treatment, or management during the encounter are to be coded. 

The primary diagnosis will be the reason for the encounter, as determined by the documentation.  When a diagnosis has a codable manifestation, comorbid condition, or etiology, the linked codes should be sequenced together whenever possible (e.g., diabetic skin ulcer of the ankle, coded with 250.8x and 707.13).  For some
cases, ICD-9-CM conventions indicate that the underlying cause should be coded first, before a manifestation.  In these instances, manifestations cannot be coded as a primary diagnosis.

Conditions/diseases that exist at the time of the encounter, but do not impact the current encounter are not coded.  Conditions/diseases that impact the current encounter are coded.  Conditions that always impact the encounter and will be coded if space is available are:

    Hypertension
    Diabetes Mellitus
    Asthma
    Congestive heart failure
    Parkinson’s disease
    Chronic obstructive pulmonary disease
    Emphysema.

If space is not available for all conditions/diseases treated and impacting treatment, and the seven chronic conditions that are always coded are present, code the reason the patient presented for care, conditions/diseases treated and the chronic condition that most impacts care.

Specificity in the Coding Classification

Specificity in coding is assigning all the available digits for a code.  Diagnostic codes should be assigned at the highest level of specificity.  If a code has five digits, all five digits must be used.
•    Assign three-digit codes only if there are no four-digit codes within that code category.
•    Assign four-digit codes only if there is no fifth-digit sub classification for that category. 
•    Assign the fifth-digit sub classification code for those categories where it exists.
•    Assign a DoD Extender code if one exists (refer to the DoD Extender Code Section).

Example:  A patient is seen for abdominal pain in the upper right quadrant and no specific cause has been determined.  The appropriate diagnostic code would be the five-digit code of 789.01, Other symptoms involving abdomen and pelvis, right upper quadrant, as opposed to the four-digit code of 789.0 (Other symptoms involving abdomen and pelvis, unspecified site).

Select the Most Explicit Code

Coding should be as explicit as the documentation permits.  For instance, when the provider documents “Acute serous OM,” code 381.01 Acute serous otitis media, not 382.9 Unspecified OM.


Unconfirmed Diagnosis

When a provider is not certain of a diagnosis, capture the known manifestations, signs, symptoms, or abnormal test results.

Example:  The diagnosis documented, as “rule out malignant neoplasm of the pancreas” cannot be coded, as the diagnosis is unconfirmed.  The documentation indicates a “mass on the pancreas.”  The terms “mass” and “neoplasm” are not synonymous.  Therefore, the most appropriate code would be 577.9, unspecified disease of pancreas. 

Although ADM permits designation of uncertain (unconfirmed) diagnoses with a “u” instead of a number, unconfirmed diagnoses are not traditionally coded.  If a “u” designator is used for a diagnosis in ADM, then that data is only available at the local server.  The “u” designated diagnosis cannot be the only diagnosis captured (there must be a primary diagnosis other than the “u” diagnosis).  Currently, Air Force is the only Service that permits use of a “u” designator in ADM.

Example:  A patient comes in with chest pain, and the provider wants to rule out myocardial infarction.  The provider would document the specific symptom of chest pain as the primary diagnosis and document the myocardial infarction code as an unconfirmed diagnosis.  The provider could document the myocardial infarction code as an unconfirmed (u) diagnosis if that Service permits the designation.

1 comment:

Nancy said...

Hello,
Thanks for the coding info. I am a medical coder for an outpatient radiology service and I like your list of conditions/diseases that exist at time of encounter. I do use some of them, thanks for the others listed. I am always looking for coding info and your blog is great.

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