icd 10 diagnostic mammogram

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