AMCI ICD-10-CM Coding for Beginners- Part 3

welcome to

part

three of icd-10-cm i am mrs j director of curriculum at

amci

and one of your icd-10-cm instructors let's start above we review the general

coding

guidelines of the icd-10-cm conventions We did some scenarios and quizzes to test our knowledge and hopefully brought you one step closer to mastering

coding

. Let's review our goals for today. First, we will learn about the guidelines in section four. Two. Let's learn about code sequencing. Yes, what comes first. What comes next. Third, we will learn to identify the first one. listed code your first listed code is the code that will appear first or sequenced first and fourth we will learn how to identify all other codable diagnoses now we will read our copyright below and then we will begin copyright 2021 copyright mcg ttt keyword concept ftr chun

amci

7 of February amci flip tap amci master 7 mm are all trademarks of amci cpc is a registered trademark of the american academy of professional coders ccs is a registered trademark of the american health information management association the content found in this presentation our Copyright of the aforementioned ICD-10-CM is maintained by the National Center for Health Statistics and ICD-10-PCS is maintained by the Center for Medicare and Medicaid Services. all coders correct, Section 4 guidelines are the guidelines for diagnostic coding and reporting guidelines for outpatient services. these are the key coders so you know what this means, this means that the section 4 guidelines are not for use in patient encounters, so again, these are outpatient guidelines and this is where you are told or told that uses a different type of guidelines for inpatient encounters, so you know Inpatient Encounters we use the guidelines from the uniform hospital discharge data set and those guidelines are in sections um two and three, so let's quickly review the section for know guidelines number one or a section um for these are the guidelines for selecting the first condition listed. and under that category you have day surgery observation stay, then we go to b and the guidelines at level b tell us to use codes a00 to z99.

We have c guidelines that discuss accurate reporting of your icd-10-cm diagnosis. codes d codes that describe signs and symptoms e encounters due to circumstances other than an illness or injury f level of detail coding and below f you have your icd-10-cm codes with three four five six or seven characters two tells you to use the total number of characters required for a code g icd-10-cm codes for diagnosis problem condition or other reason for encounter a visit h uncertain diagnoses and what to do i chronic diseases j code all documented conditions that exist k patients receiving only diagnostic services l patients receiving therapeutic services only m patients receiving preoperative evaluations only n outpatient surgery or routine outpatient prenatal visits p encounters for general medical examinations with abnormal findings and q encounters for routine health examinations very good coders, it's time for us to go a Please review all of these Section 4 guidelines line by line and I will give you a brief overview of each of the guidelines.

We're almost ready to go if you have your mcg manual, that's perfect because you should probably follow it on your mcg. manual, if you don't have it, you may want to pause the presentation. Now look for the guidelines section in your mcg manual and we'll start by answering the question: what are these section 4 guidelines used for? Well, these guidelines are used for hospitals. outpatient services, so non-inpatient services, what is an outpatient service, like the education center outpatient clinic, again, anything that is not an inpatient facility, Also these guidelines are used for provider office visits, what are doctor visits, so are they outpatient doctor visits? visits and remember not to use these guidelines for inpatient facility coding now, if you have the mcg manual you may want to write in inpatient facility coding because you use it for outpatient facilities.

Next, our next topic is the first to list the definition of the code and its correct use. we use it in the outpatient setting, the term first diagnosis on the list is used instead of the main diagnosis. Yeah, whenever you hear people say primary diagnosis a lot and people use the first diagnosis on the list and the primary diagnosis interchangeably, that's incorrect because the primary diagnosis is for inpatient facility encounters, so You should only say main when talking about hospitalized patients. Anything else that comes first and code first will be the primary reason for the encounter, so this is the primary reason the patient is being seen and we call it the reason for the encounter and also the specific coding guidelines take precedence over the guidelines in section 4.

Specific coding guidelines can be found in section 1 c. Yes, there are section 1c guidelines. We haven't reviewed them yet, but they are specific coding guidelines for the next uncertain diagnosis and at any time. you have a doctor makes an uncertain diagnosis like probable the patient probably has diabetes the patient is suspected of having osteoarthritis or we rule out we're going to rule out acute myocardial infarction well, do you know what coders in outpatient coding don't you? We don't code that kind of thing, we code what the doctor actually does, so let's not code an inconclusive or uncertain diagnosis, let's code the most specific one, we're not sure, we code to the doctor's highest level of certainty, so if the doctor is only sure of one sign or symptom.

Let's say that the doctor says that other patients, we are going to take the patient to the emergency room and we are going to rule out a heart attack, no, we will not do it, we are not going to code for that ruling out, we are going to code the reason for that encounter, the main reason for the encounter, which may simply be chest pain, next selection of the first condition listed, okay, coders, now they tell you that you know, we have already learned that you always look up the code in the alphabetical index first and then check the codes in the tabular list, We know this, but when you have outpatient surgery, it will always code the main reason for the surgery as listed first.

Okay, if the patient is on observation, there could be two circumstances where they are there number one, could they be there for a medical reason or number two, could they be an observation due to maybe a problem that occurred in outpatient or as a result of outpatient surgery? Well, if the patient has been admitted from observation for a medical condition. then the medical condition will be the first code on the list, then if the patient was admitted for observation from outpatient surgery for a complication, then the reason for surgery will be the first code on the list and I guess I should have said that this first code in the list means that the code that you are going to sequence first, the code that you are going to assign first also appears first, I think you knew that, but I need to say it also next, we have some more topics, so codes from a00 to z99, guideline b. tells us that we have to use the full set of diagnostic coding guide c accurate reporting of icd-10-cm diagnosis codes tells us that we have to code accurately we have to follow the documentation we have to use the terminology that is specified in the documentation, as well as the symptoms, the problems or the reason for the encounter, we have to consider all that and make an appropriate code, a selection, well, section four, guidelines d, codes that describe the symptoms and signs, we know that the we code in absence.

From a confirmed diagnosis we know that level of detail in coding well, it tells us that we have to use the full length of the code, encoding the characters that are required to the left of the code if it is specified and it tells us that we need five characters. that's what we code, we're going to code to the full level of detail in the coding, we're going to code to the highest level of specificity, that's where we find that guidance, you'll hear people say it all the time, code to the highest level of specificity is guideline f section 4. guideline g icd-10-cm code for the diagnostic condition issue or other reason for the encounter or visit, we will first sequence the primary reason for the encounter followed by any additional coexisting conditions in the diagnostic diagnosis. uncertain this is the pattern h doesn't it look familiar?

Yes, and I know I put it twice in section four, but it's that important. Don't code the documented diagnosis as probable, suspicious, questionable, rule out if it's not, if it's not definitive then don't do it. code it, the doctor has to be sure code it with the highest level of medical certainty guideline h chronic conditions we can report them as many times as the patient is treated now we will not code them multiple times, but in any encounter if the patient is being treated by them , then coded and will also code all documented conditions coexisting at the time of the encounter pattern.

You will code all of them if they are present or if they affect the patient's treatment, you will code those coexisting diagnoses and we will show you some examples of many of these guidelines. They also do not code resolved conditions, do not code them, they do not exist, so do not code them, however, if they exist. relevant to your encounter, you can use history codes to indicate or identify that the patient had a past history and you can only use those history codes if their history of having an illness or disease is relevant to the encounter we are talking about.

Now we are in the pattern k patients who receive diagnostic services, what is a diagnostic service? Well, diagnostic service means that we are trying to diagnose a patient's condition, we don't really know what it is, but we are not trying to diagnose the patient's conditions, let's say. that a patient has an arthroscopy, let's say they have knee pain and they are having an arthroscopy or arthroscopy, they only have knee pain, we are trying to see if there is another condition, okay, so this is what you do, you are going to sequence First, the primary reason for the encounter and then will also code all coexisting diagnoses at the time of the encounter.

Now let's say routine labs were performed. Let's say a patient has a Pap smear and there is no correct diagnosis. a patient may have a lab test or a pop test or something like that and there is no diagnosis to justify it so they will have to use code z01.89 for routine labs or radiology and that could be a bad example because I think that there could be a pap test code, but if there is no code for it and it is a routine lab without a diagnostic, then it will code it as z01.89 and now it will go back to that diagnostic test if there is a diagnostic test done by a doctor and the results.

We've made a diagnosis, let's say we had that arthroscopy and let's say arthropia says we have some internal disorder that will be the diagnosis and then it will replace that pain code or that sign and symptom that we have a diagnosis of and so on. The guidance says that if a diagnostic test performed by a physician and the results have returned a diagnosis of internal disorder, code the confirmed diagnosis as the first diagnosis listed. Okay, don't code those related signs and symptoms. No, we do not code them and why coders if said because the related signs and symptoms are an integral

part

of the outstanding diagnosis, we are reaching the end of the guideline l patients receiving therapeutic services only what does it mean that therapeutic services are well-intentioned means that they are receiving treatment so therapeutic means treatment, so as long as patients receive only therapeutic services.

You will code as the main reason for the encounter is listed first and you will additionally code all co-existing diagnoses. Now the only exception to this rule is if the patient if the encounter is for chemotherapy or radiotherapy. Chemotherapy and radiation therapy have their own encounter codes, so you will not need to code the patient's cancer diagnosis. Your code, the encounter code, patients receiving preoperative evaluations, only you will code as the first in the list, a code from subcategory z01.81 and then, you will sequence the reason for surgery, the next outpatient surgery regimen, when you have an environment where you have two diagnoses, you will have a pre-op diagnosis and a post-op diagnosis, you will sequence thefrom chapter 18, you will review these coma scales um, but just so you know the first subcategory r4 0.21 this is where they measure your eyes whether your eyes open or not and they are for 0.22 this is measuring your verbal response but like the doctor said it was level two so we're going to apply both Well, s06.333 a will be our first code in the list followed by our force r for 0.212 r for 0.222.

These are the manifestations of our first code in the list and also, encoders are our seventh seventh character extender and we reviewed it not too long ago. We didn't have space to look at this gauge, but believe me, I went to the boss, if you want to do it yourself, go to s06, you will see the gauges, very good cutters, I think I want to show you something else too. had some guideline teaching moments meaning we had to apply some guideline knowledge and the first one was code first when you see code first in the red instruction notes that's a manifestation code the instruction is code manifestation, it's not always a manifestation, but read the instructions, okay? and you when you say don't sequence um when it's a manifestation code you don't sequence the manifestation codes first okay so when you see the first language code and you use additional code that tells you the sequencing order and anything that needs to be sequenced after the first one.

The code is a statement and this is the guideline to section 1a13. Now the next guideline that we had a teachable moment with is section b 9, yes, we had a combined code, head laceration and brain hemorrhage, which was a code and the guidelines tell you that when they have a code of combination, do not code them separately, so the combination code was a guiding teaching moment and level 2 coma is a manifestation, so the combination code will be our first diagnosis on the list. Well coders, I hope you had an aha moment because we are moving forward and now you exercise six a 25 year old patient arrives at the surgery center the same day for cartiva implant surgery in the big toe the patient complains of pain in the big toe and cannot wear high-heeled shoes the patient has a history of type 2 diabetes. the doctor diagnosed the patient with hallux rigidus and it is your job, the coders, to identify the first diagnosis listed and all other codable diagnoses .

Now the coders might say, well, wait a minute if the doctor said the patient has hallux rigidus, why not? That's the diagnosis, well it could be, but it's your job as a coder to review the documentation to see if there are any other codable diagnoses and if something was primarily the reason for the encounter, so we have to determine what the primary reason is. for the encounter and if that doesn't work then we check our chart and find out the main reason for the encounter now let's check our keywords big toe pain type 2 diabetes hallux rigidus okay now let's take a look at these diagnoses and you know what I don't expect So you know what they are, so let's take a look at what rigid hallux is.

Well, we have two images, the one on the left is called hallux valgus and the one on the right is hallux rigidus. hallux valgus is a bunion and hallux rigidus is arthritis, that's the difference between the two now the clinical indicators of a hallux bunion well, you can actually see some of those signs and symptoms. These symptoms are pain, the sign is pressure or tender prominence. on the fifth metatarsal, so it's tender there because you can see it's red and it's prominent, it sticks out and the deviation of the big toe is a sign that the big toe is going in the opposite direction.

Well, we don't necessarily have to say the opposite, but it goes to the left with the left foot and if the bunion was on the right foot, it could go very well, so hallux rigidus. Clinical indicators are pain, stiffness, loss of motion, and the patient is unable to stand on tiptoe. It is arthritis in this area where you see these osteophytes. painful, okay, so I think we need to get back to our scenario, we're going to leave the bunion alone and we're going to take the hairy little toes with us, okay, now we're going to take inventory of our pain diagnosis in large toe diabetes type 2 hallux rigidus let's get our chart and we're going to determine the main reason for the encounter and let's start, let's look at our chart, we'll start at 1 because we have some signs and symptoms that pain in the big toe is a symptom and we do not code signs or symptoms that are integral or clinically related to a diagnosis and the pain in the big toe is related to hallux rigidus and remember that that is arthritis, so we are going to understand getting rid of the pain you have to go it is a distraction now we have two two diagnoses we have type two diabetes and hallux rigidus okay so the guideline we're going to follow is can you guess coders if they said let's go? follow guideline 2 outstanding yes other guidelines apply, but guideline 2 is the most relevant this is the guideline for outpatient surgery says to code the main reason for the surgery as the first code on the list, so the main reason for the Surgery is not diabetes. outstanding hallux rigidus yes and remember the patient had same day surgery when you have same day surgery follow the day surgery rules if applicable now you could say well there are other guidelines that apply do you have co-existing conditions do you have chronic diseases absolutely, but always Follow the most relevant guideline and the most relevant guideline is that the patient was on the same day of surgery; you will often find that you will use these chronic diseases in this co-existing condition and it will still lead you to the same answer, but always remember, when you can, try to follow the most relevant guideline and our answer for the six hallux rigidus exercise.

Now you could say Ms. J. Some of these are so obvious that you can easily see that you can, but once you move forward and are Let's move on very soon, you will see that this chart will help you because it will not be so simple and easy that it will keep your brain focused on what you need and you will see what you need to do to determine the The first code on the list, but I didn't want to be too difficult, that wouldn't be right, so we have our last exercise and you all are doing fantastic.

I just know, exercise seven and because this is the last one I want. To reiterate the steps, step one, you will need to take inventory of all possible diagnoses, include your signs and symptoms, number two, identify the first diagnosis listed and three, apply all guidelines, the patient arrives at the doctor's office with complaints of severe abdominal pain, has a history of hypertension, diabetes mellitus, and gastroesophageal reflux disease. I apologize. The patient was sent for upper gastrointestinal studies and it was determined that she had a ruptured appendix. Code the first diagnosis listed and all other codeable diagnoses.

Okay, coders, what are your keywords? It's going to be what you're going to inventory, you're going to inventory your abdominal pain, hypertension, diabetes mellitus, gastroesophageal reflux disease, I use disease and disorder, so that stumped me for a minute, but let's say disease. and broken appendix, okay, let's do what we need to do to find the first code on the list. Step one. Let's inventory everything. All of you with me. Step two. Let's locate or identify our first list of codes. to do this using the code table listed first by amci and we will stop at the signs and symptoms, do we have any signs and symptoms that are integral to a diagnosis?

Well, let's reveal what the diagnoses of diabetes mellitus, gerd and rupture of the appendix are. and we have severe abdominal pain we know it's a sign no it's not a sign it's a symptom so if abdominal pain is a symptom it could be related to GERD or a ruptured appendix so guess What has to happen, you have to go, okay? Now we have four diagnoses here, our job is to determine the main reason for the encounter. Number five says that when you have co-occurring conditions, you code all the documented co-occurring conditions that exist at the time of the encounter, all of them exist or if they impact. the patient's treatment, so they exist and could definitely affect the patient's treatment, so we're going to code them all, but our task is to determine which of the four is the main reason for the encounter now if you were paying attention. would know that the patient was sent well the patient arrived with abdominal pain the patient was sent for upper gastrointestinal studies and it was determined that the patient had a ruptured appendix so ruptured appendix is ​​our first code listed, it was the most discussed and Mainly significant of the five during this encounter, so it's our first code listed and you would code all the others second or later, okay, that's it, how do you feel, coders, how do you feel okay, yeah Do you want to do some exercises on your own? you are in the amci course just go to your movies you have a handout and you can practice now let's go ahead and finish with a summary remember that today we were studying the section 4 guidelines these guidelines only refer to outpatient encounters, facility visits outpatient and doctor, okay and we don't code this is really important, so this is a guide that you should probably keep in mind. does not code inconclusive diagnoses. do not encode them. should code to the physician's highest level of certainty if the physician is unsure not to do so.

Don't code it, it's something else, code with the highest level of specificity and always code the main reason for the encounter first now, if you don't know what it is, use the table and you will be fine, here is the table and it is in your manual mcg. It's not purple, but it's white and you should use it, so again, the main reason for the encounter and encode with the highest level of certainty and specificity. Congratulations coders, you've finished part three, you've learned the guidelines from section four, you've learned how. to select the first code in the list and how to identify all other pending codable diagnoses now you are ready for part four and this will be a short presentation, we are going to demonstrate how to learn the categories by site, yes, we are going to show you know how to do it and I just didn't come up with this on my own.

Many amci students helped me do it. It's a lot of fun, so I hope to see you in part four. Thank you for watching an exclusive Amci presentation. in collaboration with aapc until next time