Medical Billing & Coding
Part II
Intermediate Coding Exercises
ICD-9-CM Coding Instructions: • Sequence the ICD-9-CM principal diagnosis in the first diagnosis position. • Assign all reportable secondary diagnosis codes including V codes and E codes (both cause of injury and place of occurrence). • Sequence the ICD-9-CM principal procedure code in the first procedure position. • Assign all reportable secondary ICD-9-CM procedure codes. ICD-10-CM and ICD-10-PCS Coding Instructions: • Sequence the ICD-10-CM principal diagnosis code in the first diagnosis position. • Assign all reportable secondary ICD-10-CM codes. • Sequence the principal ICD-10-PCS code in the first procedure position. • Assign all reportable secondary ICD-10-PCS codes. The scenarios are based on selected excerpts from health records. In practice, the coding professional should have access to and refer to the/entire health record. Health records are analyzed and codes assigned based on physician documentation. Documentation for coding purposes must be assigned based on medical record documentation. A physician may be queried when documentation is ambiguous, incomplete, or conflicting. The queried documentation must be a permanent part of the medical record. The objective of the cases and scenarios reproduced in this publication is to provide practice in assigning correct codes, not necessarily to emulate complete coding, which can be achieved only with the complete medical record. For example, the reader may be asked to assign codes based on only an operative report when in real practice, a coder has access to the entire medical record. The ICD-9-CM Official Guidelines for Coding and Reporting, published by the National Center for Health Statistics (NCHS), includes Present on Admission (POA) Reporting Guidelines in Appendix I. These guidelines supplement the official conventions and instructions provided within ICD-9-CM. Adherence to these guidelines when assigning ICD-9-CM diagnosis codes is required under the Health
Intermediate Coding Exercises
ICD-9-CM Coding Instructions: • Sequence the ICD-9-CM principal diagnosis in the first diagnosis position. • Assign all reportable secondary diagnosis codes including V codes and E codes (both cause of injury and place of occurrence). • Sequence the ICD-9-CM principal procedure code in the first procedure position. • Assign all reportable secondary ICD-9-CM procedure codes. ICD-10-CM and ICD-10-PCS Coding Instructions: • Sequence the ICD-10-CM principal diagnosis code in the first diagnosis position. • Assign all reportable secondary ICD-10-CM codes. • Sequence the principal ICD-10-PCS code in the first procedure position. • Assign all reportable secondary ICD-10-PCS codes. The scenarios are based on selected excerpts from health records. In practice, the coding professional should have access to and refer to the/entire health record. Health records are analyzed and codes assigned based on physician documentation. Documentation for coding purposes must be assigned based on medical record documentation. A physician may be queried when documentation is ambiguous, incomplete, or conflicting. The queried documentation must be a permanent part of the medical record. The objective of the cases and scenarios reproduced in this publication is to provide practice in assigning correct codes, not necessarily to emulate complete coding, which can be achieved only with the complete medical record. For example, the reader may be asked to assign codes based on only an operative report when in real practice, a coder has access to the entire medical record. The ICD-9-CM Official Guidelines for Coding and Reporting, published by the National Center for Health Statistics (NCHS), includes Present on Admission (POA) Reporting Guidelines in Appendix I. These guidelines supplement the official conventions and instructions provided within ICD-9-CM. Adherence to these guidelines when assigning ICD-9-CM diagnosis codes is required under the Health