Within the medical field, there is a specific way to code the current list of codes is IC-D-10-CM coding. The billing staff at Sugar Land Chiropractors know the importance of accuracy when coding. There are always 3 to 7 characters within this coding system period 3 characters are located for the decimal and up to 4 characters are located after the decimal. The first character is always an alpha character. All the letters of the alphabet are used except for “u”. The second character is numeric. Characters 3 through 7 are alpha or numeric. Within the code alpha characters are not case sensitive. Before ICD-10-CM coding began there was ICD-9-CM coding. There are many similarities between these two coding systems. First is the tabular list. The tabular list is in a chronological list of codes divided into chapters based on body system or condition. The same hierarchical structure is in both ICD-9-CM and ICD-10- CM. Chapters in tabular are structured similarly to ICD-9-CM with minor exceptions which are where few chapters have been restructured. The staff at Sugar Land Chiropractors are careful to ensure accurate coding. The biller at Sugar Land Chiropractors makes sure that the ICD-10-CM coding system is used instead of the ICD-9-CM system. Since organs such as the ears and eyes are separated from the nervous system chapter and moved to their own chapter. Other similarities between ICD-9-CM and ICD-10-CM is the index. The index is an alphabetical list of terms and their corresponding codes. It also is indented sub terms appear under main terms. Also, the same structure as ICD-9-CM such as the alphabetic index of diseases and injuries, alphabetic index of external causes, table of neoplasms, in the table of drugs and chemicals.
Many conventions have the same meaning within the two systems such as abbreviations, punctuation, symbols, note such as code firs and use additional code. Nonspecific codes are available to use when detailed occupation to support more specific codes is not available; although Sugar Land Chiropractors do their best to always code effectively it is deemed necessary to use the nonspecific codes on occasions. Codes are looked up the same way in both systems such as when looking up diagnostic terms they are in the alphabetic index then when you verified code number in the tabular list. Codes are invalid if they are missing an applicable character. ICD-10-CM official guidelines for coding and reporting a company and compliment ICD-10-CM conventions an instruction. Adherence to the official coding guidelines in all health care settings is required under the health insurance portability and accountability act which is also known as HIPAA.
Some examples of combination codes that are used at Sugar Land Chiropractors are as follows. I25.110 atherosclerotic heart disease of native coronary artery with unstable angina pectoris E11.311 type two diabetes Meletus with unspecified diabetic retinopathy with macular edema K71.51 toxic liver disease with chronic active hepatitis with facilities K50.012 Crohn’s disease of small intestine with intestinal obstruction these are just a few of the codes that are combination codes.
Differences from ICD-9-CM to ICD-10-CM in the tabular format. Injuries grouped by a map of the anatomical site rather than type of injury and ICD-9-CM fractures are coded 800-829, dislocations are coded 830-839, and sprains and strains are coded 840-848. ICD-10-CM injuries to the head are coded S00 dash S 09, injuries to the neck S10 dash S 19 comma and injuries to the thorax S20- S29. The addition of the servant character encoding is used in certain chapters such as musculoskeletal, abstract, injuries or external causes. Different meanings depend on section where it is being used. The code must always be used in the 7th character position period and when the 7th character applies, codes missing 7th character are invalid. Describing the encounter with the 7th character such as is done at Sugar Land Chiropractors is as follows: initial encounter as long as a patient is receiving active treatment for the condition examples of active treatment are surgical treatment emergency Department encounter and evaluation and treatment by a new physician. Subsequent encounters: once a patient has received active treatment of a condition and is receiving routine care for the condition during the healing process the 7th character would be describing the encounter. Sequala complications or conditions that arise as a direct result of a condition such as scar formation after a burn. Aftercare of an injury is assigned acute injury code with 7th character for subsequent follows.
Placeholder X is an addition of a dummy placeholder and is used in certain codes too allow for future expansion or fill in empty characters when code contains fewer than 6 characters and a 7th character applies. X is not case sensitive. When the placeholder character implies it must be used in order for the code to be valid. ICD specify examples RS72.04G which is the nondisplaced fracture of base of neck of right femur, I-69.351 sequelae of cerebral infarction, following cerebral infarction affecting right dominant side, and encounter for orthopedic aftercare following surgical amputation which is Z47.81.
The staff at Sugar Land Chiropractors follow ICD-10-CM coding examples are as follows: type one diabetes myelitis with diabetic neuropathy step one looks up perm in an alphabetic index the term would be diabetes, diabetic myelitis sugar an 11.9 type one would be E10.9 with neuropathy. Step two is to verify code in the tabular so E1021 code assignments would be type one diabetes mellites with diabetic neuropathy.
Next example would be acute cystic with the material step one would be to look it up in the alphabetic index look under cystitis in 30.90 acute in 30.00 with the material in 30.01 so our beginning code would be in 30.01. The next step is to verify this in the tube tabular section, and it verifies that the N30.01 is the correct code. As one can see coding for health records is a very complex system. It is imperative that the coder codes everything correctly. Mistakes can be very detrimental not only to the patient but also to the doctor and his facility such as Sugar Land Chiropractors when submitting billing for a patient. If a person takes the time to learn the correct way to code, then they can be an asset two the entities that they work for. It is also important that the coder always used the latest coding system which to date is ICD-10-CM.