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Medical Billing Chapter 2 Study Notes

by: Megan

Medical Billing Chapter 2 Study Notes MA 1032

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About this Document

These notes cover what is going to be on the next exam.
Medical Coding
Judy Kronenberger
Class Notes
medical, Billing, coding
25 ?




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This 4 page Class Notes was uploaded by Megan on Saturday September 10, 2016. The Class Notes belongs to MA 1032 at University of Cincinnati taught by Judy Kronenberger in Fall 2016. Since its upload, it has received 15 views. For similar materials see Medical Coding in Medical Assisting at University of Cincinnati.


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Date Created: 09/10/16
Megan Willis MA 1032  OF M EDICAL   B ILLING & C ODING Chapter 2 study notes Always reference Index first, then located code identified in the Index in the Tabular. MA 1032 of Medical  ~ You can never code directly from Index Billing & Coding Chapter 2 study notes  ICD – International Classification of Diseases.  10  revision of ICD­CM issued in 1993 by  the WHO.  CM – Clinical Modification. WHO – World Health Organization.  Responsible for maintaining ICD­10­CM. NCHS – National Center for Health Statistics.  Responsible for the disease classification  system entitled ICD­10­CM. Medicare Catastrophic Coverage Act 1988 – Required submission of appropriate  diagnoses codes. Coding Reasons – Facilitate payment of health services; study health care costs; research  quality of health care; predict health care trends; plan for future health care needs. Improvements of ICD­10­CM –  1. Addition of information relevant to ambulatory and managed care encounters. 2. Expansion of injury codes. 3. Extensive expansion of the injury codes, allowing for greater specificity. 4. Creation of cothination diagnoses codes. 5. Addition of a 6  character. CDI – Clinical Documentation Improvement to ensure documentation is specific enough to  support the level of detail required from ICD­10. GEM’s – General Equivalence Mappings.  Type of crosswalk to find corresponding diagnoses  codes between the two codes sets.  GEM’s files do NOT have decimals. Approximate (flag 0) – Direct match between the two coding systems & GEM’s file directs  coder to a SINGLE entry. Approximate (flag 1) – Assists in the process of conversion by identifying when more than  th one code in I­10 is available to replace an I­9 code.  7  character is also reported to indicate  episode of care. No Map – There is NO similar code from one coding system to the other.  There will be a 1  as the second character in Flag 2. (11000) 1  Combination (flag 3) – Contains a 1 when a code from the source system must be linked to  more than one code in the target system to be valid. th Scenario Field – 4  field.  # of variations of diagnosis combinations included in the source  system code. (only one combination code). th Choice List – 5  field.  Indicates possible target system codes that when combined are one  valid scenario.  ~ a 2 scenario field indicates this combination is a second combination  possibility. 1­10 Alphabetic Index and Tabular – Used to assign diagnostic codes. ICD­10­PCS – For surgical, therapeutic, and diagnostic procedures and is used primarily by  hospitals. Dealers of Coding Principals/practices – CMS, National Center for Health Statistics,  American Health Information Management Association, American Hospital Association. Alphabetic Index contains 3 sections – Index to Diseases & Injuries; Table of Drugs &  Chemicals; External Cause of Injuries Index. Main Terms – Identified by bold print. Sub Terms – Under main terms, indented to right (lowercase, NOT bolded). Essential Modifiers – Modified main terms. Connecting Words – Certain sub terms that define a relationship between main term or  sub term & associated condition of etiology. (With, without, associated with, due to, with  mention of, in…) Carry over line – Used when there is not enough space one a single line for an entry. In order – Chapter; section; category – 3 characters; subcategory – 4 characters, sub  classification – 5­7 characters. Italicized – For ALL exclusion notes & to identify those codes that are not sequenced as the  first­listed diagnoses. National Center for Health Statistics & CMS – Maintaining ICD­10­CM. NEC – Not Elsewhere Classifiable.  In Index, means “Other specified”. NOC – Not Otherwise Classified.  Meaning, “Unspecified”.  These codes are not advised  unless there is no other option.  Contact physician for more info. Colon – In Tabular list after an incomplete term. 2  And & With – “And” means and/or; “With” means that two conditions are included in the  code and BOTH conditions MUST be present to report the code. Includes – Under categories to further define or give examples of the content of category. Excludes 1 – Means “Not coded here!”.  Code excluded should NOT be assigned at the same  time as the code above it.   Excludes 2 – Means “Not included here.” Patient may have both conditions at same time, so it is acceptable to use both the code and the excludes 2 code together. Code First/Use Additional Code – Indicate etiology & manifestation paired codes.   Etiology then manifestation. Code Also – Instructs that two codes may be required to fully describe a condition. Default Code – listed next to main term in ICD­10­CM Index.  Represents unspecified code  for the condition. th th X – In order for the A to be a 7  character, an X is added as a 6  character to S43.50XA. Cross­references – Provide the coder with possible alternatives or synonyms for a term.   (see, see also, see category).  In other words, “look elsewhere”. 3 


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