Download Clinical Classification Systems

Clinical
Classification
Systems
©2010 Jones and Bartlett Publishers
Clinical Classification Systems
©2010 Jones and Bartlett Publishers
Documentation and Coding Quality
•
Accurate coding is contingent upon
complete, accurate, legible and timely
documentation
•
ICD-9-CM and CPT coding drives
reimbursement and is a mechanism used
to determine utilization of services and
the quality of care rendered to patients
©2010 Jones and Bartlett Publishers
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Nomenclature and Classification
Systems
Nomenclature
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A list of proper names for diseases and
operations which may include a code
number for each listing
SNDO
SNOMED
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Nomenclature and Classification
Systems
• Classification
– A system of assigning diseases and
operations to code numbers covering groups
of related diseases.
– ICD-9-CM
– ICD-10-CM (will replace ICD-9-CM volumes 1
and 2)
– ICD-10-PCS (will replace ICD-9-CM volume
3)
– ICD-O
– DSM-IV
©2010 Jones and Bartlett Publishers
Why do we code?
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Research
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Reimbursement
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Predict health care trends
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Plan for future health care needs
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Evaluate use of health care facilities
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Study health care costs
©2010 Jones and Bartlett Publishers
ICD-9-CM
©2010 Jones and Bartlett Publishers
ICD-9-CM
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Translate descriptive information into
numerical codes for disease, injuries,
conditions, and procedures.
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Classify morbidity (sickness) and mortality
(death)
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First published by WHO (World Health
Organization) in 1979.
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ICD-9-CM
• Volumes of ICD-9-CM
– Volume 1- Tabular list
– Volume 2- Index
– Volume 3- Procedure Index and Tabular
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ICD-9-CM (cont.)
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Main terms
Sub-terms
Carryover lines
Code number and
modifier
– With
– Due to
Volume 1
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Chapter
Section
Category
Subcategory
Sub-classification
Volume 3
– Index- Procedure
– Tabular-Procedure
Volume 2
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Tables
– Hypertension
– Neoplasms
– Drugs and Chemicals
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ICD-9-CM Conventions
– Abbreviations-NEC, NOS
– Punctuation- [ ], ( ), { }, : Brackets,
parenthesis, braces, and colon
– Symbols- Section Mark, lozenge
– Bold face and Italicized type face
– Includes and excludes notes
– Use additional code, if desired
– Code also underlying disease
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ICD-9-CM Conventions
– Code also
– Omit code
– Eponyms
– Main terms
– Joined main terms
– Non-essential modifiers
– Not elsewhere classifiable (NEC)
– Cross reference notes
– Hypertension table
– Neoplasm
– Etiology and manifestation of diseases
©2010 Jones and Bartlett Publishers
Basic ICD-9-CM Coding Guidelines
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Use both alphabetic indexes and tabular list
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Assign codes to the highest level of detail
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Assign residual codes (NEC and NOS) as
appropriate
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Assign combination codes when available
©2010 Jones and Bartlett Publishers
Basic ICD-9-CM Coding Guidelines (cont.)
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The appropriate code(s) from 001.0 through
V84.8 must be used to identify diagnoses,
symptoms, conditions, problems, complaints
or other reason(s) for the encounter or visit
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Selection of codes 001.0 through 999.9 will
frequently be used to describe the reason
for the admission or encounter. Theses
codes are from the section of ICD-9-CM for
the classification of diseases and injuries
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Basic ICD-9-CM Coding Guidelines (cont.)
• Codes that describe signs and symptoms, as
opposed to diagnoses, are acceptable for
reporting purposes when a related definitive
diagnosis has not been established by the
provider
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Basic ICD-9-CM Coding Guidelines (cont.)
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Signs and symptoms that are integral to the
diseases process should not be assigned as
additional codes unless otherwise instructed
by the classification
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Additional signs and symptoms that may not
be associated routinely with a disease
process should be coded when present
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Basic ICD-9-CM Coding Guidelines (cont.)
• Assign multiple codes as required
• Assign only the combination code when
that code fully identifies the diagnostic
conditions involved or as
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Basic ICD-9-CM Coding Guidelines (cont.)
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Code unconfirmed diagnoses as if
established
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If the same condition is described as
both acute (subacute) and chronic, and
separate subentries exist in the
alphabetic index at the same indentation
level, code both and sequence the acute
(subacute) code first
©2010 Jones and Bartlett Publishers
Basic ICD-9-CM Coding Guidelines (cont.)
• Coding of late effects generally requires
two codes sequenced in the following
order:
– The condition or nature of the late effect is
sequenced first
• The late effect code is sequenced
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Basic ICD-9-CM Coding Guidelines (cont.)
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Code any condition described at the time of
discharge as “impending” or “threatened”
as follows
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If it did occur, code as confirmed diagnosis
If it did not occur, reference the alphabetic
index to determine if the condition has a
subentry term for “impending” or
“threatened” and also reference main term
entries for “impending” and for “threatened”
If subterms are listed, assign the given code
If the subterms are not listed, code the
existing underlying condition(s) and not the
condition described as “impending” or
“threatened”
©2010 Jones and Bartlett Publishers
Basic ICD-9-CM Coding Guidelines (cont.)
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Code any condition described at the time of
discharge as “impending” or “threatened”
as follows
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If it did occur, code as confirmed diagnosis
If it did not occur, reference the alphabetic
index to determine if the condition has a
subentry term for “impending” or
“threatened” and also reference main term
entries for “impending” and for “threatened”
If subterms are listed, assign the given code
If the subterms are not listed, code the
existing underlying condition(s) and not the
condition described as “impending” or
“threatened”
©2010 Jones and Bartlett Publishers
Basic ICD-9-CM Coding Guidelines (cont.)
• Refer to ICD-9-CM Official Guidelines for
Coding and Reporting set forth by the
Centers for Medicare and Medicaid
Services (CMS) and the National Center
for Health Statistics (NCHS), both of the
Department of Health and Human
Services (DHHS)
©2010 Jones and Bartlett Publishers
ICD-9-CM Coding by
Chapters
©2010 Jones and Bartlett Publishers
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Infectious and Parasitic Diseases
Bacteremia is bacteria in the blood, as
confirmed by culture, but may be transient. It
denotes a laboratory finding, not an acute
illness, but can progress to septicemia when
there is a more severe infectious process or
an impaired immune system.
Septicemia or sepsis is a severe infection that
is characterized by release of toxins into the
bloodstream and the presence of bacteria in
the blood. Negative or inconclusive blood
cultures do not preclude a diagnosis of
septicemia in patients with clinical evidence of
©2010 Jones and Bartlett Publishers
the condition.
Infectious and Parasitic Diseases
• Urosepsis NOS is coded to urinary tract
infection. Some physicians use this term
to mean sepsis due to a urinary tract
infection. When documentation isn’t clear,
query the physician.
©2010 Jones and Bartlett Publishers
Infectious and Parasitic Diseases (cont.)
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Neoplasms
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Codes can be located in the Neoplasm
Table.
Categories include malignant, benign,
carcinoma in situ
Invasive means extension of tumor to other
sites (metastatic)
Benign means the tumor is not invasive and
will not spread to other sites. Usually cured
by total excision of tumor.
Carcinoma in situ is undergoing malignant
changes, but still confined to point of origin.
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Infectious and Parasitic Diseases (cont.)
– If the primary malignant tumor has been
previously excised, but patient is still
undergoing treatment, i.e. chemotherapy or
radiation therapy, the primary malignancy
code is used.
– Secondary site (metastatic site) is
sequenced as principal when reason for
admission is based entirely on the
secondary malignancy.
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Infectious and Parasitic Diseases (cont.)
– If the secondary site is specified without
mention of the primary site, or if the primary
site is unknown, code 199.1 (malignant
neoplasm, NOS) for the primary site.
– Contiguous sites are identified by a fourth
digit 8-other specified sites when the
neoplasm overlaps the boundaries of two of
more contiguous sites. Do not use a fourth
digit of 8 to replace fourth digit 9 (unspecified)
to avoid using an unspecified code.
©2010 Jones and Bartlett Publishers
Endocrine, Nutritional, Metabolic Diseases
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Insulin dependent diabetes mellitus (IDDM),
type I.
Non insulin dependent diabetes mellitus
(NIDDM), type II.
The abbreviation IDDM is not enough to code
insulin dependent diabetes mellitus, the
physician must document Type 1.
Fifth digit is needed to specify controlled
versus uncontrolled. When poorly controlled
is documented, query the physician to see if
he/she means uncontrolled.
If a patient is admitted for dehydration due to
acute renal failure, sequence the acute renal
failure as principal even though treating the
dehydration with IV fluids resolves the renal
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failure.
Diseases of Blood and Blood-Forming Organs
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Sickle cell anemia
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Use addition code to specify type of crisis, i.e.
acute chest pain syndrome. Code sickle cell
anemia with crisis as principal followed by
acute chest pain syndrome as secondary
diagnosis.
If patient is admitted for treatment of anemia
due to chronic disease, (i.e. ESRD, neoplastic
disease or other chronic disease), code first
the anemia followed by the chronic disease.
Anemia, thrombocytopenia and neutropenia
documented on same admission should be
coded to pancytopenia (284.8), which is a type
of aplastic anemia which represents deficiency
of all three elements of the blood.
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Diseases of the Respiratory System
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Respiratory failure should be coded as
principal diagnosis when a patient is admitted
in respiratory failure caused by a respiratory
condition such as pneumonia, asthma,
emphysema and COPD or a chronic nonrespiratory condition like myasthenia gravis.
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Respiratory failure should be coded as a
secondary diagnosis when a patient is
admitted in respiratory failure due to a nonrespiratory condition, such as CHF, myocardial
infarction, poisoning/overdose and CVA.
©2010 Jones and Bartlett Publishers
Diseases of the Digestive System
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Gastrointestinal bleeding resulting from an
identified G.I. lesion, such as angiodysplasia,
ulcers, gastritis, diverticulitis, etc., the
combination code should be used. Only
exception is when physician clearly states the
bleeding is unrelated to the G.I lesion
identified, then both the GI lesion and the GI
bleeding are coded.
AVM (arteriovenous malformation) is a term
used interchangeably with angiodysplasia.
Although the alphabetic index leads to
congenital anomaly, do not use this code until
physician has indicated it is congenital.
©2010 Jones and Bartlett Publishers
Complications of Pregnancy,
Childbirth, Puerperium
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Normal delivery (650) can be coded if infant
is single, full-term, born alive; delivered
without instruments or surgery; occiput
(vertex) or head first presentation, and no
complications before of after labor. Can
also be used if physician performed an
episiotomy.
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Complications of Pregnancy,
Childbirth, Puerperium
• Fifth digits 0 should not be used as the
hospital record should have enough data
present to use fifth digits 1-4.
• 1- delivered this admission with/without
antepartum condition
• 2- delivered this admission, but developed
complications after delivery.
• 3- antepartum; discharged undelivered.
• 4- delivered on previous admission, but
admitted with postpartum complication.
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Complications of Pregnancy,
Childbirth, Puerperium (cont.)
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Conditions of pregnancy can be indexed
under the condition, pregnancy or delivery.
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Always assign outcome of delivery as
secondary diagnosis.
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When instrumentation or surgery is used to
deliver the baby, always use the condition
that required the instrumentation or surgery
as your principal diagnosis.
©2010 Jones and Bartlett Publishers
Complications of Pregnancy,
Childbirth, Puerperium (cont.)
• Since ICD-9-CM assumes conditions are
complicating the pregnancy unless the physician
specifically states otherwise. Codes from 630676 should be used as your principal diagnosis.
Often an additional outside of Chapter __will be
needed to fully code a condition affecting the
pregnancy. If the physician states the condition
is not complicating the pregnancy, code the
condition first and V22.2 (incidental pregnancy)
as a secondary diagnosis.
©2010 Jones and Bartlett Publishers
Disease of the Circulatory System
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ICD-9-CM assumes a cause and effect
relationship with hypertension and renal
disease. When both are mentioned, use
combination code. Exception to the rule is
acute renal failure- 584.9 + 401.9
Hypertensive or “due to” indicate a cause
and effect relationship and combination
coding should be used.
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Example
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Hypertensive cardiovascular disease (HCVD)
is coded 402.90
Hypertension and renal failure is coded
403.91
©2010 Jones and Bartlett Publishers
Disease of the Circulatory System (cont.)
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Congestive heart failure has been expanded
to specify the CHF as systolic, diastolic or
both, with an additional code for the CHF.
Cerebrovascular Accident (CVA) should be
coded the highest level of specificity. In some
facilities, use of the radiologist findings can be
used to provide specificity needed to code
“infarction”.
CVA most likely due to cardio embolism should
be coded to cerebral embolism with/without
infarction. The condition is common with
patient with atrial fibrillation.
Residuals (i.e. hemiplegia, dysphagia,
aphasia, etc.) that resolve before discharge
are not coded.
©2010 Jones and Bartlett Publishers
Burns
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Burns should be coded to the highest
degree only at each given site.
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When multiple degrees of burns are
present, use the highest degree burn as
your principal diagnosis.
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2nd and 3rd degree burns of the forearm
should only be coded to the 3rd degree.
1st degree burn of the finger, 2nd degree
burn of the toe, and 3rd degree burn of the
chest. The 3rd degree burn of the chest
should be the principal diagnosis.
Code percentage of body surface as an
additional code, if specified
Non-healing burns are coded to acute
burns.
©2010 Jones and Bartlett Publishers
Poisoning and Adverse Effects of Drugs
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Terms for poisoning include wrong medication
taken or given, overdose, taking prescribed
dose and drinking alcohol, and taking too
much of prescribed dose.
Taking less than prescribed dose does not
constitute a poisoning.
An adverse effect of a drug includes taking
prescribed dose and having a reaction from
the drug.
Always code an E code for the drug causing
the adverse effect.
©2010 Jones and Bartlett Publishers
V Codes
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Key terms include admission for, examination,
history, observation, aftercare, problem and
status.
V codes also show birth status of newborns
and are used as a principal diagnosis.
V codes show outcome of delivery and are
used as a secondary diagnosis.
V codes shows history of and is appropriate to
code if impacting a patient’s care.
©2010 Jones and Bartlett Publishers
ICD-9-CM Procedural coding
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Conventions for volume 3 are essentially the
same as those used in the disease
classification
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The alphabetic index is organized by main
terms which are printed in bold typeface
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Main terms usually identify the type of
procedure performed rather than the anatomic
site involved
©2010 Jones and Bartlett Publishers
ICD-9-CM Procedural coding
• A main term may be followed by a series of
terms in parentheses which are nonessential
modifiers
• A main term may also be followed by a list of
subterms or modifiers which do have an
effect upon the selection of the appropriate
code for a given procedure
©2010 Jones and Bartlett Publishers
ICD-9-CM Procedural coding (cont.)
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NEC is used for two purposes which can
only be determined by referring to the
tabular list
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Used with ill-defined terms as a warning that
specified forms of the procedure are
classified differently
Terms for which a more specific category is
not provided in the tabular list, and no
amount of additional information will alter
the selection of the code
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ICD-9-CM Procedural coding
(cont.)
• Omit code
– Terms which identify incisions are listed as
main terms in the alphabetic index
– If the incision was made only for the purpose
of performing further surgery, the instruction
omit code is given
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ICD-9-CM Procedural coding (cont.)
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Synchronous procedures are coded for
some operative procedures if it is
necessary to record the individual
components of the procedure
Notes are used to list fourth-digit subclassifications for those categories which
used the same fourth-digit subdivisions
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In these cases, only the three-digit code is
given for the individual entry
The user must refer to the note following the
main term to obtain appropriate fourth-digit
sub-classification
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ICD-9-CM Procedural coding
(cont.)
• Eponyms are operations name for persons
– They are listed as main terms in their
appropriate alphabetic sequence and under
the main term “operation”
– A description of the procedure or anatomic
site affected usually follow the eponym
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CPT-4 and HCPCS
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CPT-4
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CPT-4
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The Common Procedural Terminology-4th
Edition was developed in 1960 by American
Medical Association for the main purpose of
reimbursement by all types of health care
providers to classify, report and bill for a
variety of health care services. It describes
medical, surgical and diagnostic services
and is revised and updated annually.
CPT was adopted by CMS as level I of the
Healthcare Common Procedure Coding
System (HCPCS)
©2010 Jones and Bartlett Publishers
Chapters of CPT-4
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Introduction
Evaluation and Management (E &M)
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine
Appendices
Index
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CPT-4 Section Format
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Section- Surgery
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Subsection- Respiratory
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Heading- Trachea and Bronchi
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Subheading- Incision
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CPT-4 Punctuation, Typeface and Symbols
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Semicolon, and Indention
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Boldface type
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Symbols- Triangle, bullet, asterisk or star,
plus sign
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CPT-4 Modifiers
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Used to indicate that a performed service or
procedure has been altered by some
specific circumstance but not changed in its
definition.
– To report only the professional component of
a procedure or service.
– To report a service mandated by a thirdparty payer
– To indicate that a procedure was performed
bilaterally
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CPT-4 Modifiers
– To report multiple procedures performed at
the same session by the same provider
– To report that a portion of a service or
procedure is reduced or eliminated at the
physician’s discretion
– To report assistant surgeon services
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CPT-4 Unlisted Procedures
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Due to advances in medicine, there may be
services or procedures performed by
physicians or other health care professionals
that have not yet been designated with a
specific CPT code. Each section of the CPT
book have been designated an unlisted
procedure code to identify these unlisted
procedures. Use of an unlisted procedure
code requires a special report or
documentation to describe the service.
©2010 Jones and Bartlett Publishers
CPT-4 Add-on Codes
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Codes that describe procedure/services
that must never be reported as a standalone code. They describe
procedures/services that are always
performed in addition to the primary
procedure/service.
– Identified by the “+” symbol
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CPT-4 Unbundling
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Reporting a procedure/service using two
or more codes for each part of the
procedure when one comprehensive
codes covers all the parts
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CPT-4 Separate Procedures
• Identified by the inclusion of the term
(separate procedure) in the code
descriptor. Codes designated as separate
procedure may not be reported
additionally when it is an integral
component of another procedure/service
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CPT-4 Index
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Main Terms
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Sub-terms
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Code Ranges
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Cross-references
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General Rules For CPT Coding
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Identify the procedures and services to be
coded by carefully reviewing the health record
documentation
Consult the index under the main term for the
procedure performed and consult any subterms under the main term.
If the term is not located under the procedure
performed, check the organ or site, condition,
or eponym, synonym or abbreviation
Note the code number(s) found opposite the
selected main term or sub-term
©2010 Jones and Bartlett Publishers
General Rules For CPT Coding (cont.)
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Check the code(s) or code range in the
body of the CPT codebook
– When a single code number is provided,
locate the code in the body of the CPT
codebook
– When two or more codes separated by a
comma are shown, locate each code in the
body of the CPT codebook
– When a range of codes is shown, locate the
range in the body of the CPT codebook
©2010 Jones and Bartlett Publishers
General Rules For CPT Coding (cont.)
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Read and be guided by any coding notes
under the code, at the subheading, heading,
subsection or section level
Never code directly from the index
Assign the appropriate modifier(s) when
necessary to complete the code description
Assign the appropriate code
Continue coding all components of the
procedure or service using the above steps
©2010 Jones and Bartlett Publishers
Healthcare Common Procedure
Coding System (HCPCS)
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Administered by CMS and includes three
levels of codes
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Level 1 Current Procedural Terminology
Level 2 alphanumeric procedure and
modifier codes and represent items,
supplies and non-physician services not
covered by the CPT codes
Level 3 were local procedure and modifier
codes used prior to 2003. They are no
longer used. Additional Level 2 codes are
used to compensate for the loss of the Level
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3 codes.
ICD-10
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ICD-10
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Copyrighted by the World Health
Organization
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Used to code and classify mortality data
from death certificates
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Replaced ICD-9 for this purpose as of
January 1, 1999
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ICD-10-CM
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The codes in ICD-10-CM are not
currently valid for any purpose or use
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Proposed to replace ICD-9-CM volumes
1 and 2 with proposed implementation in
the year 2013 based on the process for
adoption of standard under the Health
Insurance Portability and Accountability
Act of 1996
©2010 Jones and Bartlett Publishers
ICD-10-PCS
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Proposed new procedure coding system
being developed as a replacement for
ICD-9-CM, Volume 3
©2010 Jones and Bartlett Publishers