Step 1: Identify the reason for the visit (e.g.. sign, symptom, diagnosis, condition to be coded).
Physicians describe the patient's condition using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter. If symptoms are present but a definitive diagnosis has not yet been determined, code the systems. Do not code conditions that are referred to as "rule out," "suspected," "probable" or "questionable."
Step 2: Always consult the Alphabetic Index, Volume 2, before turning to the Tabular List.
The most critical rule is to begin a code search in the index. Never turn first to the Tabular list (Volume 1), as this will lead to coding errors and less specificity in code assignments. To prevent coding errors, use both the Alphabetical Index and the Tabular List when locating and assigning a code.
Step 3: Locate the main entry term.
The Alphabetic Index is arranged by condition. Conditions may be expressed as nouns, adjectives and eponyms. Some conditions have multiple entries under their synonyms. Main terms are identified using boldface type.
Step 4: Read and interpret any notes listed with the main term.
Notes are identified using italicized type.
Step 5: Review entries for modifiers.
Nonessential modifiers are in parentheses. These parenthetical terms are supplementary words or explanatory information that may ether be present or absent in the diagnostic statement and do not affect ode assignment. |
Step 6: Interpret abbreviations, cross-references, symbols and brackets.
Cross-references used are "see," "see category" or "see also". The abbreviation NEC may follow main terms or sub terms. NEC (not elsewhere classified) indicates that there is no specific code for the condition even though the medical documentation may be very specific. The check box indicates the code requires and additional digit. If the appropriate digits are not found in the index, in a box beneath the main term, you MUST refer to the tabular list. Italicized brackets [ ], are used to enclose a second code number that must be used with code immediately preceding it and in that sequence.
Step 7: Choose a tentative code and locate it in the tabular list.
Be guided by any inclusion or exclusion terms, notes or other instructions, such as "code first" and "use additional code," that would direct the use of a different or additional code from that selected in the index for a particular diagnosis, condition or disease.
Step 8: Determine whether the code is at the highest level of specificity.
Assign three-digit codes (category codes) if there are no four-digit codes within the code category. Assign four-digit codes (subcategory codes) if there are no five-digit codes for that category. Assign five-digit codes (fifth-digit sub classification codes) for those categories where they are available.
Step 9: Consult the color coding and reimbursement prompts, including the age, sex, and Medicare as secondary payer edits.
Step 10: Assign the code.
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