AMCI ICD-10-CM Coding for Beginners- Part 1

determine the main term find your main term and solve it you have one minute, time is up coders how did you do it? well, what is your main term? well this might be a little complicated, influenza, I selected influenza as my main term, but gastroenteritis is also a main term, but I'm going to choose influenza as my main term, it's a diagnosis, so is gastroenteritis and this is how when the doctor documented it, so I'm going to look it up. this way, but you can search for it either way, well, you could have searched for gastroenteritis with influenza or influenza with gastroenteritis, but I have a sneaking suspicion, you probably couldn't suspect that you probably wouldn't find it if you searched for gastroenteritis. with influenza I could be wrong, but they are both main terms.

I'm going to use influenza, so I'm going to look up influenza in my alphabetical index, first influenza and I'll move on because I have to search and find my subterm. which is gastroenteritis, then influenza with gastroenteritis takes us to code j11.2. I'm going to check my j11.2 in the tabular list. I'll stop at the boss because I just need to stop. I am new at this. j11 this is influenza due to an unidentified influenza virus. Okay, I don't know any better, but that's what the boss says. I can't code it. He says there are four characters and it's not specific enough for me, so if I go down, I stay. route j11 and I go to 0.2 this is the code for influenza due to unidentified influenza virus with gastrointestinal manifestations in other words influenza gastroenteritis not otherwise specified, that is in fact what we have influenza gastroenteritis and nothing was specified more about it, so if you said 1 1.2 is your answer, you're right, great, but if you learn something about encoders, that's priceless, okay, I'm not ready to start, now we have a few more, so if you want to continue , I do it too, if you want to take a break, go ahead and press pause, take a break, okay, let's get to our diagnosis, acute bleeding peptic ulcer, okay, your time starts now, I think I gave it a few more seconds.

Time is up, well, what is the main term acute bleeding peptic ulcer, if you said ulcer is outstanding? your diagnosis and bleeding acute and peptic all describe the type of ulcer in fact acute describes the severity bleeding is the type and peptic well I think peptic is the type and bleeding is a more specific indicator um okay let's find our main term in the alphabetical index ulcer what peptic type with acute yes acute severity what hemorrhage k 2 7.8 you could say wait a minute madam j how do you know to code bleeding as hemorrhage? Well, I'm going to show you and this will be something that you We're going to need to remember, okay, so we're going to go to k27.0, look for it in the tabular list.

Let's start at the boss. K27 has a red box. We know we are not

coding

it, but Let's read it, this is the category for peptic ulcer, the site is not specified, that is correct, there is no specification of where the peptic ulcer is, this includes a gastroduodenal ulcer or a peptic ulcer , now you have to use an additional code to identify alcohol and dependence, we don't mention any alcohol or alcohol dependence, so we'll let it fly, but we have a note that excludes one that says, hey, if you know you're

coding

for ulcer peptic ulcer of a newborn you don't code it unless you have you know a newborn with a peptic ulcer and a newborn with a peptic um oh excuse me, you just don't code, you don't use this sorry, I'm getting confused Actually, I'm moving on, let me stop, let me back up, but what I do want to bring to your attention is this coding tip.

That's how I knew I could code bleeding as hemorrhage, assign a code with hemorrhage when peptic and gastrointestinal bleeding is documented, we have documented bleeding, the ICD-10-CM classification assumes that the two are related without the provider linking the two conditions with evidence. Bleeding is not necessary during a procedure and then there is another advice for bleeding ulcers resulting from anticoagulant therapy and that is not our situation, but this advice tells us that when you have bleeding you code it as a hemorrhage, so that is why it is important to stop it . in the boss I see that valuable information that we got, yes, okay, so our code is k2 7.0 k2 7.0 we need to check that unspecified acute peptic ulcer site with hemorrhage, I think that's our code and if you said k2 7.0 outstanding, How are you doing, coders? you're okay, hopefully you learned something, we have another scenario, I think we have two more, come on, dementia with aggressive behavior, time starts now, time is up, okay programmers, this might be a little difficult for some people too, okay, which of the two terms?

Its main term is dementia or aggressive behavior. I chose dementia and aggressive behavior could also be a primary term, but dementia is a diagnosis. So is aggressive behavior. Pick one, look for it, but I chose dementia. This is what I suggest you follow in the documentation. If you have two terms that could be the diagnosis, go in the order presented. Yes, let's follow the doctor's documentation. You can't go wrong. OK. If it doesn't work, search for the other term. be our method now let's look for our main term in the alphabetical index aggressive behavior will be our subterms dementia with aggressive behavior takes us to the code f03.91 let's go ahead and check in the tabular list f 03.91 unspecified dementia with behavioral disturbance says aggressive behavior so let's look at our supplemental terms we have unspecified dementia with aggressive behavior this is actually our code now this is not um this is unspecified dementia because the doctor didn't specify the type of dementia so these are our answer coders if you said f 0 3.91 outstanding now coders, if you didn't do well but you learned something, you know what, that's even better because it's priceless, so we have one more to look for, that's it, one more and then you can take the last one. break before

part

two acute cystitis due to e coli infection your time starts now time is up coders I know you didn't have enough time I know you didn't have it but I hope you paused the presentation you figured it out on your own and let me show them what I did what is the main term, well, the main term cystitis, yes, that's a diagnosis, and you know we have another main term, infection, infection.

Well, we have a subterm with cystitis, acute cystitis and e coli is also our subterm and the reason why I know we have two main terms because I tried to search for this and I turned around so I'll show you how I knew so I searched cystitis first, cystitis, then I looked for acute and it took me n30.00, well below, I didn't see any mention of E coli infection, so I knew I had to look for E coli infection as well, and also after I went and I checked my n3 0.00, I went to the boss n30 and told him that this is cystitis, but this is what he actually told me that I had to also code for e coli, it tells you to use an additional code to identify the infectious agent well, if not Did you know, now you know that e coli is an infectious agent, so let me continue with my task, so I'm going down, I need to code cystitis n30.0 acute cystitis and then it takes me to n30.00 acute cystitis without hematuria, so the hematuria is blood in the urine and hematuria is not mentioned so it will always be coded without if it is not mentioned then it does not exist so now if we go back to our instruction note it says to use an additional code to identify the infectious agent , not only tells us to code, but also tells us how to sequence it. new, okay, so it tells us to encode it after cystitis when you see the language code, also, that means encoded after cystitis.

Now let's go ahead and look for E coli infection. Our main term is going to be infection, we're going to look it up in the alphabetical index infection because e coli e coli is the short term for escarchuria oh esker riccia excuse me escarichia coli and if we go down you'll see that escorichia coli is b96, we're going to look in the tabular list for b96. 20 but we are going to stop at the boss and this is the category for other bacterial agents as a cause of diseases classified elsewhere, we are going to go down to b96.2 scoricia coli or e coli as a cause of diseases classified elsewhere.

We know we can't code it because it has a red box, so let's go with one more b96.20. There is no red box. We can code it. Escoricia coli e coli not specified as a cause of diseases classified elsewhere escoriccia coli nos. This is actually our code now again, they told us how to sequence these codes, we're going to have to code cystitis first and additionally code e coli and our code will look like this n30.00 and b96.20 in that order, all good. Programmers, I know we had a learning moment because we didn't discuss how to sequence, but I hope you learned something and we will discuss it in future chapters.

Alright coders, how are you feeling? I want to congratulate you because you have done it. In this session you learned the history of icd-10-cm, the structure of an icd-10-cm code, you learned how to search for icd-10-cm codes, how to determine the main term in subterms, and you learned how to select an extender of the seventh character, you learned a lot, so if you need to continue, take a break and programmers, I'll see you in

part

two, that's when we'll talk about a lot of the guidelines that we'll talk about. about general coding conventions and guidelines, so see you, great job, exceptional coders, thanks for watching an exclusive presentation from

amci

in association with aapc until next time