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A comprehensive overview of the key concepts and principles of icd-10-cm coding, which is the standard diagnostic coding system used in the united states for reporting medical diagnoses and conditions. Topics such as the structure and organization of icd-10-cm codes, the use of various coding conventions and guidelines, the reporting of present-on-admission (poa) indicators, and the coding of specific scenarios like congenital malformations, diabetes, and malignant neoplasms. It also explains the importance of reading and understanding the beginning of chapter notes, inclusion terms, and coding sequencing rules. This document serves as a valuable resource for healthcare professionals, coders, and students who need to gain a solid understanding of icd-10-cm coding principles and practices.
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Main terms - ANS-Represent diseases, conditions, symptoms, nouns, and adjectives in the Alphabetic Index. are set in boldface and listed in alphabetic order. Nonessential modifiers - ANS-A term or a series of terms that appear in parentheses following a main term or subterm has no effect on the selection of the codes listed for that main term. Default code - ANS-The code listed next to a main term in the Alphabetic Index Placeholder character - ANS-Used when a code has less than six characters and a seventh character is required NOS - ANS-The equivalent of "unspecified" NEC - ANS-The equivalent of "other specified" Square brackets - ANS-Used in the Tabular List to enclose synonyms, abbreviations, alternative wordings, or explanatory phrases. The terms within the brackets are presented for informational purposes. Parentheses - ANS-Used to enclose supplementary words or explanatory information that may or may not be present in the statement of a diagnosis Colon - ANS-Used in the Tabular List after an incomplete term that needs one or more additional terms in order to be assigned to a particular code Excludes1 - ANS-Indicates that the conditions listed after it cannot ever be used at the same time as the code above the code. A patient can't have both conditions at the same time. Exception - ANS-when two conditions are unrelated. Excludes2 - ANS-Indicates that two codes are applied when both conditions are present And - ANS-Means "and" or "or" when it appears in a code title Structure of ICD-10-CM Codes - ANS-Three (3) to seven (7) characters in length, The first character is alpha (all letters except U are used), The second character is numeric, Characters 3-7 are alpha or numeric, Code uses a decimal after the first three characters, Code uses dummy placeholder "x", Alpha characters are not case sensitive, Some examples of codes include: - ANS-P S32.010A
subterm - ANS-Indented beneath the main term, etiology code - ANS-should always be reported first). The ICD-10-CM Tabular List - ANS-divided into 21 chapters. subdivided - ANS-subchapters (blocks) that contain three character categories and form the foundation of the code. categories - ANS-urther subdivided into four- or five-character subcategories ICD-10-CM codes - ANS-must be used to the highest number of characters available or to the highest level of specificity. When the code contains fewer than seven characters, - ANS-the placeholder "X" must be used to fill in the empty character(s). What are the four reporting options for POA? - ANS-A code used to identify the place where an injury occurred. This code describes the physical location or place where the event occurred, not the patient's activity at the time of the event. A data element required on the CMS 1450 claim form or the Uniform Bill-04 to be linked with all ICD-10- CM diagnosis codes according to present on- admission reporting guidelines. The purpose of the POA indicator is to differentiate between conditions that were present in the patient at the time of admission and the conditions that develop during the inpatient stay How would you code a congenital malformation that has been corrected? - ANS- What type of diabetes should be coded if the documentation does not state the type of diabetes? - ANS- What site are malignant neoplasms of ectopic tissue coded to? - ANS- Carryover lines - ANS-are needed on occasion in the Alphabetic Index because the number of words that can fit on a single line of print is limited. They are two indents from the preceding line. Eponyms - ANS-A name for a disease, organ, procedure, or body function that is derived for the name of a person who first identified the condition. See - ANS-provides direction to the coder to look elsewhere in the Index before assigning a code.
See also - ANS-provides direction to the coder to look elsewhere in the index before assigning a code. code also - ANS-meaning that two codes may be required to fully describe a condition. A category - ANS-is composed of three characters that represent a single disease or a group of similar or closely related conditions. A three-character category that has no further subdivision is equivalent to a code. subcategory - ANS-Most three-character categories are further subdivided into four- or five-character subcategories. Each level of subdivision after a category is a subcategory. Slanted brackets - ANS-Are used in the Alphabetic Index to identify manifestation codes. Other and Unspecified Codes - ANS-to be used when the documentation in the health is more specific than any code available to be used. Other and Other Specified Codes - ANS-are used when information in the health record is more descriptive than the available code in ICD-10-CM Unspecified codes - ANS-A code that includes the term unspecified in the title of the code is used when the information in the health record is insufficient to assign a more specific code. Beginning of Chapter Note - ANS-the chapter starts with a "note" introduces the content of the chapter and the intended use of the categories and codes within the chapter. Coders must read the beginning of chapter notes to understand the intent and content of the chapter. Inclusion Terms - ANS-inclusion terms are lists of medical diagnoses under some codes in the Tabular List. These are conditions for which the code is to be used. The terms may be syn- onyms of the code title or the terms are a list of various conditions assigned to "other specified" codes. The inclusion terms are not an exhaustive list of terms. Additional terms found only in the Alphabetic Index may also be assigned to the code Inclusion notes - ANS-Includes or inclusion notes are used throughout the ICD-10-CM, the Tabular List, to further define or provide an example of a three character code. Includes notes are not exhaustive; that is, not every synonym or similar condition may be listed. Includes notes appear at the beginning of a chapter, section or directly below a category or subcategory code etiology - ANS-Coded first
manifestation - ANS-Additional code. appear in italicized fonts. Code first note - ANS-The coding convention used in ICD-10-CM that directs the coder as to which condition is coded first. Sequela or Late Effects - ANS-A condition that is produced by another illness or an injury and remains after the acute phase of the illness or injury. There is not time period as to when the sequel must appear or be present. Two codes are required for coding sequel. The first reported code is the condition that exist at the present or the sequela. The second code is the original condition identified as the cause of the present condition. Impending or Threatened Condition - ANS-The physicians may describe a patient's condition as impending or threatened. The coder needs to determine if the condition actually did or did not occur. Impending or Threatened Condition are coded as follows: - ANS-1. If the condition did occur, code as a confirmed diagnosis.
Syndromes - ANS- 1.Identify all main terms included in the diagnostic statement - ANS- 2.Locate each main term in the Alphabetic Index - ANS- 3.Refer to any subterms indented under the main term. The subterms form individual line entries and describe essential differences by site, etiology, or clinical type - ANS- 4.Follow the instructions (see, see also) provided in the Alphabetic Index if the needed code is not located under the first main entry consulted - ANS- 5.Verify the code selected in the Tabular List - ANS- 6.Read and be guided by any instructional terms in the Tabular List - ANS- .Assign codes to their highest level of specificity, up to a total of seven characters if applicable - ANS- 8.Continue coding the diagnostic statement until all the component elements are fully identified - ANS-