Lesson 2
Introduction to Diagnostic Coding
Objectives
Diagnostic Coding
Diagnostic codes are codes that refer to the physician's diagnosis. These codes are used to record and track statistical health care data.
Diagnostic codes aid in the insurance claims process. The actual amount of payment received from the insurance company is based on the procedure. However, the diagnostic code will indicate why the procedure was performed.
Diagnostic
Coding
Diagnostic Coding
For instance, if a provider bills an insurance carrier for putting an arm in a cast, but the diagnosis does not show a broken arm, the carrier may deny payment for lack of medical necessity. The medical appropriateness of a procedure is based on its relation to the diagnosis.
Accurate diagnostic coding is important to both the financial and the legal status of the medical practice. Improper coding can result in reduced reimbursement from insurance carriers. If improper codes are the result of fraud or abuse, civil or criminal penalties can be assigned.
Primary and Secondary Diagnoses
Many times, patients have more than one diagnosis. The primary diagnosis is the one that required the most resources or was primarily responsible for the services performed.
A secondary diagnosis is one that coexists with the primary condition and may affect its treatment. Up to eleven secondary diagnoses may be entered on a claim. The order of the secondary diagnosis codes is determined by the specialized coding guidelines for each type of diagnosis reported on the claim. A secondary diagnosis should not be reported unless it is relevant to that day's treatment or service.
Volumes of the ICD
The ICD-10-CM manual is divided into two volumes:
There are two different sets of ICD-10 codes: CM and PCS. The PCS coding system is not used in the medical office, as it is used only for reporting inpatient hospital procedures. Outpatient medical coding only requires the use of the first two volumes of ICD-10-CM.
1
2
Volume 2 of the ICD
It depends on the publisher of the manual, but Volume 2 usually comes before �Volume 1 in the ICD manual. When coding from the ICD, the diagnosis must be �referenced in Volume 2 first.
Volume 2 of the ICD-10-CM lists all known diagnoses. It is separated into four sections:
SECTION
1
SECTION
2
SECTION
3
SECTION
4
Organization of Volume 2
Volume 2 is organized alphabetically by main terms. The main term refers to the most general term in a diagnosis. Listed with each main term will be:
2
A code is associated with each diagnosis in Volume 2. However, the code must be cross-referenced in Volume 1. Never code from Volume 2 without verifying the code in the Tabular list (Volume 1).
Main Terms
Main terms in the index are listed in bold. They are not indented. Many conditions can be found in more than one place in Volume 2. Conditions may be searchable by more than one main term.
Main terms are not, however, parts of the body. For instance, if a patient has been diagnosed with a rash on the face, the main term will be rash, not face.
Main terms can be:
Eponyms can also be main terms. An eponym is a disease, procedure, or syndrome named after a person. An example is Parkinson's disease, described by Dr. James Parkinson in 1817. Parkinson's Disease is also known as paralysis agitans. This diagnosis could be found in Volume 2 under Parkinson or under agitans.
Dr. James Parkinson
Modifiers and Qualifiers
The main terms are followed by modifiers.
Nonessential modifiers are found in Volume 2. They appear in parentheses directly after the main terms. These modifiers may give alternate terminology or help to add specificity, but they are not necessary for code selection.
Essential modifiers are found in Volume 2, indented under the main term. They modify the main term by describing the site of a diagnosis, its cause, or its specific type. Essential modifiers are, as the name suggests, required.
Qualifiers will appear indented underneath essential modifiers. Each qualifier increases specificity. They should be used if they more accurately describe the diagnosis. Before assigning a code, assistants should read through all qualifiers.
Nonessential Modifiers
Essential Modifier
Qualifiers
Summary