Coding Guidelines

To ensure knowledge of Coding Guidelines, we will be focusing on them on a weekly basis. Remember, ICD-10-CM Coding Guidelines are located in the front of your book. This week, we will focus on Conventions and general coding guidelines. It is imperative that you begin committing coding guidelines to memory. Please read the following scenarios and find the coding guidelines and state the ENTIRE coding guideline that provides coding directions on how to code the scenario. Task(s): Example: When locating a code in the ICD-10-CM book, is it correct to look up the code in the alphabetic index only? Yes or No? State the Coding Guideline instructing you how to look up (locate)codes in the ICD-10-CM book. 1. Locating a code in the ICD-10-CM To select a code in the classification that corresponds to a diagnosis or reason for a visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included in the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required. Your Questions: 1. The Physician (patient’s provider states that the patient is obese, but never stated the patient’s body mass index of 45; however, the Registered Dietician states the BMI of 45. Are we able to code the BMI (body mass index) from the Registered Dietician’s documentation? Yes or No? Please state the entire coding guideline that supports your response. 2. Parentheses (), Brackets [}, and colons: are used in our coding books. Please document the entire Coding convention which explains what both mean. 3. What’s the maximum number of characters an ICD-10-CM code may have? If after looking the code up, you find that the code if in a certain ICD-10-CM category in which the applicable 7th character is required, what should you do? Please state the coding convention that applies. 4. Patients to the hospital with a severe headache, and after having an MRI of the brain done, it is found that the patient has a malignant brain tumor. The doctor documents, “Headache due to malignant brain tumor”. Should you code signs and symptoms if a definitive has been established?