To code accurately, it is necessary to have a working knowledge of medical terminology and to understand the characteristics, terminology and conventions of ICD-9-CM. Transforming descriptions of diseases, injuries, conditions and procedures into numerical designations (coding) is a complex activity and should not be undertaken without proper training.
Originally, coding allowed retrieval of medical information by diagnoses and operations for medical research, education and administration. Coding today is used to describe the medical necessity of a procedure and facilitate payment of health services, to evaluate utilization patterns and to study the appropriateness of health care costs. Coding provides the basis for epidemiological studies and research into the quality of health care. Incorrect or inaccurate coding can lead to investigations of fraud and abuse. Therefore, coding must be performed correctly and consistently to produce meaningful statistics to aid in planning for the health needs of the nation.
Follow the steps below to code correctly:
1. Identify the reason for the visit. (e.g., sign, symptom, diagnosis, conditions to be coded). Physicians describe patient’s condition using terminology that includes specific diagnoses, as well as symptoms, problems or reasons for the encounter. If symptoms are present but a definitive diagnosis has not yet been determined, code the symptoms. Do not code conditions that are referred to as “rule-out”, “suspected”, “probable”, or “questionable”.
2. Always consult the Alphabetic Index, Volume 2, before turning to the Tabular List. The most critical rule is to begin a code search in the index. Never turn first to the Tabular List (Vol. 1), as this will lead to coding errors and less specificity in code assignments. To prevent coding errors, use both the Alphabetic Index and the Tabular List when locating and assigning a code.
3. Locate the main entry term. The Alphabetic Index is arranged by condition. Conditions may be express as nouns, adjectives and eponyms.
4. Read and interpret any notes listed with the main term.
Notes are identified using the italicized type.
5. Review entries for modifiers.
Nonessential modifiers are in parentheses. The parenthetical terms are supplementary words or explanatory information that may either be present or absent in the diagnostic statement and do not effect code assignment.
6. Interpret abbreviations, cross-references, symbols and brackets.
Cross-references used are “see”, “see category”, or “see also.” The abbreviation NEC may follow main terms or sub-terms. NEC may follow main terms or sub-terms. NEC (not elsewhere classified) indicates that there is no specific code for the condition even though the medical documentation may be very specific. The check box indicates the code requires an additional digit. If the appropriate digits are not found in the index, in a box beneath the main term, you
MUST refer to the Tabular List. Italicized brackets [ ], are used to enclose a second code number that must be used with the code immediately preceding it and in that sequence.
7. Choose a tentative code and locate it in the Tabular List.
Be guided by any inclusion or exclusion terms, notes or other instructions, such as “code first” and “use additional code,” that would direct the use of a different or additional code from that selected in the index for a particular diagnosis, condition or disease.
8. Determine whether the code is at the highest level of specificity.
Assign codes using 4th or 5th digits, when available, in order to code to the highest level of specificity.
9. Consult the color coding and reimbursement prompts, including the age and sex edits.
Consult the official ICD-9-CM guidelines for coding and reporting, and refer to the AHA’s Coding Clinic for ICD-9-CM for coding guidelines governing the use of specific codes.
10. Assign the code. .
Its hold good for ICD -10 too but the codes are different.
