Medical Coding

a QuickStudy Laminated Reference Guide

Shelley C Safian

• Publisher: QuickStudy Reference Guides
• Year: 2018
• ISBN:
  9781423240693
• Topic: Médecine
• Subtopic: Théorie, pratique et référence de la médecine

Updated for 2018 ICD-10 guidelines, this 6 page laminated guide covers core essentials of coding clearly and succinctly. Author Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer used her knowledge and experience to provide the largest number of valuable facts you can find in 6 pages, designed so that answers can be found fast with color coded sections, and bulleted lists. A must for students seeking coding certification and a great desktop refresher for professionals.
6-page laminated guide includes:

• General Coding & Legal Guidelines
• Coding Tips
• Conditions & Diagnoses
• Diagnosis Coding
• Pathology & Laboratory
• Reimbursement & Billing Tips
• Coding Evaluation & Management Services
• ICD-10 Terms, Notations & Symbols
• Wounds & Injuries
• Important Resources
• Anesthesia, Surgery & Radiology
• Diagnostic Coding
  

Conditions & Diagnoses

Hypertension

• Elevated Blood Pressure: an isolated or infrequent reading of over 140/90
• Benign Hypertension: chronic high blood pressure typically controlled with medication and diet
• Hypertension: a chronic condition of blood pressure over 140/90
• Malignant Hypertension: chronic, extremely high blood pressure accompanied by swelling of the optic nerve, often associated with other organ damage
• Unspecified Hypertension: even though 95% of hypertension cases are benign, you cannot assume; only code Benign or Malignant when the physician specifically uses these words in the notes; if the physician does not use either of those words, you must code the hypertension as Unspecified
• CVA: CardioVascular Accident

Neoplasms

• Neoplasm: a tumor; an abnormal tissue growth
• Benign Neoplasm: a nonmalignant character of a neoplasm, having no threat to health
• Malignant Neoplasm: an invasive and destructive growth
• Carcinoma: a malignant neoplasm NOTE: A carcinoma is always a malignant neoplasm, but every malignant neoplasm is not necessarily a carcinoma
• CA IN SITU (carcinoma in situ) Malignant: a malignant neoplasm with no indication of metastasizing at this time
• Primary Malignant: first anatomical site of the body where the malignant neoplasm was identified
• Secondary Malignant: anatomical site to which a malignancy has spread, or metastasized, from the primary site or another secondary site
• Histology: the microscopic composition of tissues
• Morphology: the study of the configuration of living organisms
• Uncertain Behavior: a classification from the pathologist indicating that the tissue cannot be specially determined as benign or malignant

Coding Sequencing of Neoplasms

• Code primary site first, then code the secondary, unless no treatment is being provided for the primary at all
• Code secondary site first, followed by personal history of neoplasm code if the primary site has been removed
• Code dehydration or anemia first, followed by neoplasm code(s) if patient is admitted to hospital for treatment of either resulting from chemotherapy or radiation therapy for the malignancy

Poisonings & Adverse Effects

• Poisoning: a condition produced by a substance that harms or causes death
• Adverse Effect: an unexpected, bad result
• Toxic: poisonous

P.E.E. FOR POISON

When coding a poisoning (sometimes termed a toxic effect), you should have at least three diagnosis codes, in order: Poison, Effect, External Cause

P = Poison: What drug or chemical caused the adverse reaction?

E = Effect: What effect did the poison have on the patient (coma, nau­sea, rash, etc.)?

E = Explanation (External cause code): Was it an accidental poisoning, an attempted suicide, or assault?

Coding Adverse Effects

• If the drug was prescribed by a physician and:
  • Correct drug was taken
  • Correct dosage was given
  • Correct patient
  • Right time
  • Correct route of administration (i.e., orally, IV, IM, etc.)
  • Still had an adverse reaction
• Do not include a poisoning code; only code the effect and External Cause code
  • E = Effect: What effect did the prescribed drug have on the patient (coma, nausea, rash, etc.)?
  • E = External cause code: Identify this drug as being given for therapeutic use

Burns

Third-degree burns can be described as necrosis
Second-degree burns will show blistering
First-degree burns will show redness

• When coding burns, you will need at least three codes:
  • S/S.E.E. the burn S/S = Site & Severity: one code to indicate where on the body (the anatomical site) the burn is located and to what extent (first, second, or third degree—i.e., how severe the burn is)
  NOTE: Code with the highest degree of burns first
  • E = Extent: What percentage of the body has been burned? (Use the rule of nines if the provider doesn’t specify)
  • E = External cause code: How and/or where did the burn happen?

NOTE: Sunburns are not coded the same way as other kinds of burns)

• To calculate the percentage of the body affected use the Rule of Nines

Adults—Rule of Nines
Head and neck	9%	Lower back, buttocks	9%
Chest	9%	Leg, right, front	9%
Arm, right	9%	Leg, right, back	9%
Arm, left	9%	Leg, left, front	9%
Abdomen	9%	Leg, left, back	9%
Upper back	9%	Genitals	1%

• Infected Burn Site: add the code for posttraumatic wound infection, NEC, to the other codes for the case
• Nonhealing Burn: code as a current burn
• Scar (identified as the lasting effect of a burn): code as a late effect of that burn

Fractures

• Fracture: the break of cartilage or bone
• When coding fractures: S.O/C.S.E. will cover it!
• S = Site: anatomical site of the fracture
• O/C = Open/Closed: Is the fracture open or closed? If not specified by the provider as open, the default is closed
• S = Seg...