icd
10 diagnostic mammogram
on today's episode of coding with Kate we I'm going to be talking about icd-10-cm a diagnosis code book this book is an integral part of or one of the integral parts of coding the medical record this code book literally has any diagnosis and variation of diagnosis you could ever imagine that's why it's so big but to look at the breakdown of this book in the very beginning in the read section they have information of how this code book works what conventions they use meaning what terms like code also code with excludes1 excludes2 these are all things that you will learn in your coding courses but in the read section that is one of the places where you'll find that information along with a breakdown of each chapter and any guidelines that fall within it that will help you learn how to code those sections and those diagnoses the next section the big black section here that is your alphabetic index that is the first place you will look when you start to code within the diagnosis in the OP report you want to look for the main term or the type of illness ailment etc like disease infection or any specific type of illness you need to find that main term look for it in the alphabetic index and also if there are specific names like crohn's disease you can look under Crohn's or you can look under disease either way you will find that from there you can look down under the sub terms to find any other specific information that define that main term for your specific diagnosis you are coding for and it will give you the first three characters of the code
once you go into the tabular list there
are several chapters that cover body
systems and what diseases illnesses and
diagnoses are commonly associated or
found in that body system there are also
chapters that cover the environment in
which the diagnosis happened or just
other information like was it an injury
that happened via gunshot wound is the
woman pregnant and what information
describes her pregnancy gestation period
etc so there's a lot of additional
information that you'll find more
towards the back of the codebook to help
further describe the diagnosis and once
you go into whichever chapter then you
can find more information and more
detailed information about the diagnosis
so then you can fill in your entire code
so the code can be up to seven
characters long the first three is the
category which is essentially the title
of the chapter then we have a decimal
point and then once you're in the
tabular list the rest of this
information is what you need to fill in
to make sure it's complete and remember
we need to code to the highest degree of
specificity in detail so the next three
characters talk about the ideology of
anatomic site or the severity you don't
need to know which numbers are which
they will give you that information but
this describes the next three characters
if all three are needed or given and
then the seventh character that is the
character that provides even more
information for certain diagnoses
it is the first occurrence second or
third occurrence and other things that
help describe at diagnosis if you are
given a code that only has four
characters but it needs a seventh
character icd-10-cm uses a placeholder
or an X so you put the X in the fifth
and sixth character and then add in
whichever seventh character the book
tells you to use and that is how you
complete your code but know that in some
or even most instances a seventh
character is not needed and you're only
given four or five or six characters
that is okay don't freak out it does not
have to be seven characters long but
make sure you look at the guidelines
within each chapter and with that
specific diagnosis you're looking for
because it will give you information of
how to make that code complete now I
have an example of how to navigate the
code book in your courses you will be
given a practice book that gives
instructions and detailed information on
how to code and within there you will be
given exercises on how to search for
certain terms how to pinpoint what is
the main term and then also how to find the code etc so from my exercise book I am choosing one but I think is a good example of how to search from the alphabetic index to the tabular list and this one also requires multiple codes so you can see in the code book where it tells you also code for etc it gives you that notation that you need another code for this and it also helps with sequencing the code which codes need to be first in second and third which is also also helpful because in diagnosis coding the sequencing is very important and you'll learn more about why so this example is acute suppurative peritonitis due to e.coli so the main term we need to figure out what is the type of illness and it says peritonitis that is a main term there can be several different types of peritonitis acute is just describing what level of severity the peritonitis is superlative is the type of peritonitis or another type of and due to e.coli that is what caused the peritonitis
so peritonitis is our main term so in
the alphabetic index we go to P
peritonitis and then we look at the sub
terms below peritonitis and we want to
look for acute or superlative either one
I suggest when you're learning to look
for both and see if it takes you to the
same place or not if it takes you to two
different places then I would suggest
going to both because you want to go to
the highest level of specificity and
detail and having those two codes to
compare which one matches as closely as
possible to the diagnosis in the upper
port it's very important to do that but
since I thought I had when you look
under acute and supportive it brings you
to the same code so under peritonitis
you can see that on the top and then
look for separative and it tells you K
60 5.0 if you also look under a cute it
gives you the same exact code k 60 5.0
so then we go to our tabular list under
K and the tabular list is in alphabetical
order and this section is a dark blue
and the chapter is chapter 11 diseases
of the digestive system so this is a
diagnosis that happens within or is
commonly associated with the digestive
system and then from there the numbers
in that code are in numerical order so
we want to go a little bit halfway
through the K section to find K 65 point
65 point and it is that bottom section right there where it says diseases a peritoneum and retroperitoneum K 65 through Kasich see that it says K 65 peritonitis now it gives us in red letters
note that we need the second coat so it
says right there use additional code be
95 through B 97 to identify infectious
agent we already know that our diagnosis
said due to e.coli which is our
infectious agent so this section already
told us you need to use K 60 5.0 and we
need to get more specific on the rest of
that code and then we also need to refer
to the infectious agent and put that
code as well and since it said use
additional the infectious agent code
will come second if it had to go first
it would have clearly said code first so
here we have our sequencing k 60 5.0
comes first and then our infectious
agent in the B section will come second
so then we read down and it tells you
excludes one which is you cannot use
this diagnosis if anything on this list
it gives is also in the report tells you
you can't put them together you have to
pick one and then you will have to go
and figure out which one it is or find a
new diagnosis that is more detailed and
is the better option but with this one
we don't have that problem so we go to K
60 5.0 it said generalized or acute
peritonitis and then it also lists the
different types like pelvic peritonitis
acute for male subphrenic peritonitis
acute and then separated peritonitis
acute that's what we need and then we'll
also look down the rest of the list to
make sure there is not another code that
is more closely associated or describes
the diagnosis that we have and looking
at the rest of them k60 5.0 is the
closest diagnosis code we can use for
this now as you can see we have case 65
decimal point oh and they didn't give us
anything else for the last three
characters so we don't need to put those
in because there is no other notation
that states you need a seventh character
and there no other subcategory to
give us those extra numbers so we stick
with k60 5.0 and then with the note
saying whose additional code for the
infectious infectious agent we need to
go to section b to be 95 through B 97 to
find our infectious agent or ecoli
the section is in green says chapter
one certain infectious and parasitic diseases P 95 the number 95 is almost to the end of the section it says bacterial and viral infectious agents and from there we'll read through what that note says and then we'll also look for e.coli and figure out what code we need so in that note it says these categories are provided for use as supplementary or additional codes to identify the infectious agents and diseases classified elsewhere keep this in mind that if I'm reading this note correctly learning experience happening right now that is telling me that this range of codes be 95 through B 97 and not be put as your principal diagnosis I think that's correct I will need to go back and check so we look down into the sub terms and these subcategories until we find e.coli so it's not in the be 95 section let's go to the B 96 section other bacterial agents as the cause of diseases classified elsewhere alright I found e.coli I'm going to admit I do not know how to actually correctly pronounce the full term but I found you coli the thing we need to know and it also has in brackets ecoli so just in case you don't know what the full name is or know how to spell it or pronounce it it says 'i coli thankfully so ecole is B 96.2 now once we look at B 96.2 it says e coli as the cause of diseases classified elsewhere there are also even more sometimes below that that we need to look at that will be is a fifth character if it's needed so we must look since none of those match what our diagnosis said we have to sit with be in 96 point to be 96 point to all and as you can see the last two characters are not filled in because they did not give us one it also did not give a note of a seventh character so we leave that blank and then you will look back at your offer port look at your diagnosis make sure there aren't any other pieces of information that need to be coded using diagnosis codes and then since we have to put it in the correct order the correct sequencing our main diagnosis the peritonitis goes first and then our infectious agent code goes second and that is what we will put on our for Mac his diagnosis coding so that was a fairly easy one I will say there are quite a few that I still am not sure about like sepsis HIV diabetes and then some of the diagnoses that deal with the heart those have very specific guidelines that I'm still working on the guidelines do give you a step-by-step of if this is shown or if this is recorded do this look at this put this first so they do give you a step by step but it's still a little confusing sepsis can be very confusing for me so I make a lot of notes and I look at examples to see which sequence they used so it's a lot of getting used to and figuring out what you need to do to make sure you have a sequencing correct because that is very important and you can always talk with your professors and reach out to other coding professionals who can give you more guidance on that and once you are in the field and you are a certified coder you can always talk with other coders or your manager or even go on to one of the health information management associations and look under their forums where you can ask questions if you are unsure about coding something and you can't find the answer at your facility so there's many many resources that can give you guidance so then you can continue
learning and make sure you are coding
correctly hopefully that was interesting
the next video that I'll be making his
own pcs coating which is inpatient
hospital procedure called procedural
coding which is my favorite type of
procedural coding I love it and I can't
wait to do that video so I will see you
then
