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.

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