Week 2 Chapter 3 - Introduction to ICD-10-CM Questions & Answers

ICD-10 was endorsed by who and when? - ANSWERSThe 43rd WHO (World Health Organization) in May 1990. Came to use in 1994. ICD origins - ANSWERS1850's. First was called the International List of Causes of Death. Adopted by International Statistical Institute in 1893. WHO took over responsibility in 1948 when 6th edition, which now included causes of morbidity, was published. Who developed ICD-10-CM? - ANSWERSNCHS (National Center for Health Statistics) What does ICD-10-CM stand for? - ANSWERSInternational Classification of Diseases, 10th Revision, Clinical Modification ICD-10-CM is published in two sections - ANSWERS1.Alphabetic Index or Index to Diseases and Injuries: Diagnostic terms organized in alphabetic order for the disease descriptions in the Tabular List. In this curriculum, the terms Alphabetic Index and Index to Diseases and Injuries are used interchangeably. 2.Tabular List: Diagnosis codes organized in sequential order and divided into chapters based on body system or condition. Main terms in the Alphabetic Index usually reference the disease, condition, or symptom. Subterms modify the main term to describe differences in site, etiology (cause), or clinical type. Main terms are bold in the Alphabetic Index. Subterms add specificity to the main term. The code listed next to the main term is considered the default code. The default code represents the condition most commonly associated with the main term. As with all code assignment, always verify the default code in the Tabular List to assure proper reporting. - ANSWERS The Tabular List contains 22 chapters and contains categories, subcategories, and codes. Each character for all categories, subcategories, and codes may be either a letter or a number. - ANSWERSCodes can be three, four, five, six, or seven characters. The 1st character of a category is a letter. The 2nd and 3rd characters may be either letters or numbers. Subcategories are either four or five characters and may be either letters or numbers. Codes are three, four, five, or six characters and the final character in a code may be either a letter or number. Certain categories have a 7th character extension Certain ICD-10-CM categories have applicable 7th characters. - ANSWERSThe applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be in the 7th position. If a code is three, four, or five characters, but requires a 7th character extension, a placeholder X must be used to fill the empty characters. Conventions - ANSWERSNEC Not elsewhere classifiable - used when the ICD-10-CM system does not provide a code specific for the patient's condition. Selecting a code with the NEC classification means that the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-10-CM to report the condition accurately. NOS Not otherwise specified - the equivalent of unspecified and is used only when you lack the information necessary to code to a more specific diagnosis. Brackets are used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes in which multiple coding and sequencing rules will apply. Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned. The terms in the parentheses are referred to as nonessential modifiers. The colon is used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category Other codes (usually with an 8 or a 9 as the last character) are used when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate other codes in the Tabular List. These Alphabetic Index entries represent specific diseases for which no specific code exists; therefore, the term is included within the other code. Unspecified codes (usually with a 9 or a 0 as the last character) are used when the information in the medical record is not available for coding more specifically. Unspecified codes should be selected only when there is no other option. Code first - This instructional note, used in the Tab Code Assignment and Clinical Criteria - ANSWERSAccording to the ICD-10-CM guidelines, the assignment of a diagnosis code is based on the provider's documentation that the condition exists. Occasionally, the documentation of the clinical criteria may not support the provider's diagnostic statement. In this case, query the provider. Payers are required by HIPAA to use the Official ICD-10-CM Guidelines; however, the guidelines may have various interpretations by different payers. Understanding the payer interpretation will be imperative to successful coding. IF IT WASN'T DOCUMENTED - IT DOESN'T EXIST Steps to Look Up Diagnosis Code - ANSWERS1. Locate each term in the Alphabetic Index: Locate the main term in the Index to Diseases and Injuries (Alphabetic Index). Refer to any notes under the main term. Read any terms enclosed in parentheses following the main term. Refer to any modifiers of the main term. Do not skip subterms indented under the main term. Follow any cross-reference instructions, such as see also. Use of a medical dictionary can help you to identify main terms and understand the disease process to assist with accurate coding. 2. Verify the code in the Tabular List: Find the code in the Tabular List Review any category notes (located under the three-character category) Review notes for the code including Includes notes, Excludes1 and Excludes2 notes, code first notes, code additional notes, etc Level of Detail in Coding - ANSWERSCode to the highest degree of specificity. A three-character code may be used only when the category is not subdivided further. When a three-character code has subdivisions, the appropriate subdivision must be coded. The three-character category may be further subdivided by the use of 4th, 5th, and 6th characters, which provide greater detail. Codes may also require a 7th character extender. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.