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.
