Presentation on theme: "Basics of Diagnostic Coding"— Presentation transcript: 1 Basics of Diagnostic Coding Show
2 Consider the following while reading this chapter: 3 What Is Diagnostic Coding?
4 Why Use ICD Codes? Standardizing a system of diagnostic coding accepted and understood by all parties in the
reimbursement cycle Creating a more convenient method of data storage and retrieval Assisting in the maximization of reimbursement Shortening the claims-processing time Facilitating and measuring regulatory compliance by use of guidelines and other instructions Assisting in measuring the appropriateness and timeliness of medical care Discuss the ways that ICD Codes have allowed users to save time in the claims process.
Talk about why a maximum reimbursement is important to the physician. 5 The ICD-9-CM Code The ICD-9-CM code is located in Volume
1, the Tabular Index, of the ICD-9-CM coding manual. The code consists of a three-digit category code that represents a specific disease, illness, condition, or injury, within a general disease category. Up to two additional digits can be used, which add further definition and specificity. These two additional digits are the fourth digit, or subcategory; and the fifth digit, or subclassification, respectively. What does ICD-9-CM actually mean?
Understand the format of what the ICD-9-CM code looks like. 6 Structure of the ICD-9-CM 7 Volume 1—Tabular Index Volume 1 of the ICD-9-CM consists of 17 chapters that
classify diseases and injuries: Each chapter can contain the following four subdivisions, each of which provide more detail about the illness, condition, disease, or injury: Section, also called a Chapter Category, also called a Classification Subcategory Subclassification Two sections containing supplementary classification codes V and E; Five appendices Discuss the definitions of each
subdivision. Talk about the difference between V codes and E codes. 8 Volume 1—Tabular Index (cont’d) 9 Volume 1—Tabular Index, Supplemental
Classifications 10 Volume 1—Tabular Index,
Appendixes
11 Conventions Used in Volume 1: the Tabular Index
12 Volume 2—Alphabetic Index 13 Supplementary Sections of the Alphabetic Index 14 Volume 3—Procedures: Tabular Index and Alphabetic Index 15 Beginning the Coding Process 16 Beginning the Coding Process Medical Documentation 17 Beginning the Coding Process Encounter Form 18 Beginning the Coding Process Treatment or Progress Notes
19 Beginning the Coding Process History and Physical Report 20 Beginning the Coding Process
Discharge Summary 21 Beginning the Coding Process Operative Report 22 Beginning the Coding Process Radiology, Laboratory, and Pathology
23 Beginning the Coding Process Extracting Diagnostic Statements
24 Beginning the Coding Process Main and Modifying Terms
25 Diagnostic Coding Decision Tree Which type of document would we find the diagnostic statement?Which documents would the medical assistant search to find the diagnostic statement? Diagnostic statements that are assigned by the provider may be found in operative reports, discharge summaries, history and physical exam reports, and ancillary diagnostic services, such as radiology reports.
When determining the diagnosis code what is the first step quizlet?The correct procedure for assigning accurate diagnosis codes has six steps: (1) Review complete medical documentation; (2) abstract the medical conditions from the visit documentation; (3) identify the main term for each condition; (4) locate the main term in the Alphabetic Index; (5) verify the code in the Tabular ...
What are some of the reports that are found in a diagnostic statement?Diagnostic statements are found in operative reports, discharge summaries, history and physical (H&P) reports, and reports on ancillary diagnostic services that support the patient's diagnosis or diagnoses. Ancillary diagnostic services include radiology, pathology, and laboratory service reports.
What are the first 3 digits in a diagnosis code called?The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease. The category is followed by a decimal point and the subcategory.
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