Introduction to Medical Coding | ICD-10-CM for Beginners (CPC, CCS-P, CCS) - Part FOUR

Welcome to Introduction to ICD10

CM part 4. I'm Mrs. Jay, one of the

curriculum developers here at AMCI and

one of your ICD10

instructors.

Now, let's begin.

Previously

we discussed in part three ICD10 CM

categories

and we learned AMCI's technique to

identify these categories on site. Yes,

that was fun. And hopefully we brought

you one step closer to ICD10 CM coding

mastery.

And the goals for today are we are going

to discuss

section 4 guidelines ICD10 CM section 4

guidelines. We are going to learn about

sequencing that first listed code and

we're also going to learn how to

identify the first listed code. And

finally we are going to learn how to

identify codable diagnosis in

documentation. So all codable diagnosis

in documentation.

And before we go any further let's go

ahead and read the copyright. CPT is a

registered trademark of the AMA. Keyword

concept FTR, Chun, AMCI, FAB 7, AMCI

Flip, TAP, and MCG are all registered

trademarks of AMCI. The credentials CPC,

CRC, COC, CPMA, CPB, CPPM, CPCO are

owned by AAPC

and the credentials CCA, CCS, CCSP,

RHIA, RHIT are owned by AHEA and AMCI

does not own the rights to these

credentials.

Now let's begin our discussion on

section 4 guidelines diagnostic coding

and reporting guidelines for outpatient

services. Let's do it.

All right coders section 4 guidelines

are the guidelines for diagnostic coding

and reporting guidelines for outpatient

services. This is key coders. You know

what this means? This means that the

section 4 guidelines are not for use for

inpatient

encounters. So again, these are

outpatient guidelines. And here is where

you're told or directed to use a

different type of guidelines. for

inpatient encounters. Just so you know,

for inpatient encounters, we use the

uniform hospital discharge data set

guidelines. And those guidelines are in

sections um two and three. All right.

So, let's quickly review the section 4

guidelines.

number one or a um section 4 a these are

the guidelines for selection of the

first listed condition

and under that category you've got

outpatient surgery observation stay then

we're we go to B and the guidelines at

the B level tell us to use codes from

A00 00 through Z99.

We have C guidelines that discuss

accurate reporting of your ICD10 CM

diagnosis codes. D codes that describe

signs and symptoms. E encounters for

circumstances other than a disease or

injury. F level detail and coding. And

underneath F, you've got um your ICD10

CM codes with 3, four, five, six or

seven characters.

Two, you it instructs you to use the

full number of characters required for a

code. G

ICD10 CM codes for diagnosis, condition,

problem, or other reason for the

encounter or visit.

H. uncertain diagnosis and what to do. I

chronic diseases.

J. Coding all documented conditions that

exist. K. Patients receiving diagnostic

services only.

L. Patients receiving therapeutic

services only. M. Patients receiving

pre-operative evaluations only. N

ambulatory surgery.

O routine outpatient prenatal visits. P

encounters for general medical

examinations with abnormal findings. And

Q encounters for routine health

screenings. All right, coders. It is

time.

We're going to review all of these

section 4 guidelines

line by line and I'm going to give you a

brief overview of each of the

guidelines.

We are almost ready to begin. If you

have your MCG manual, that is perfect

because you probably should follow along

in your MCG manual. If you don't have

it, you may want to pause the

presentation. Now, locate your section

for guidelines

in your MCG manual.

And we'll begin with answering the

question, what are these section 4

guidelines used for? Well, these

guidelines are used for hospital-based

outpatient services. So services that

are not inpatient. What is an outpatient

service? Like the ED facility,

outpatient clinic. Again, anything

that's not inpatient facility.

Also, these guidelines are used for

provider-based office visits. What is

that? Those are doctor visits. So

outpatientbased

hospital and doctor visits. And

remember, do not use these guidelines

for inpatient facility coding. Now, if

you have the MCG manual, you may want to

write in inpatient

facility coding because you do use it

for outpatient facility.

All right. Next, our next topic is first

listed code definition and use. Well,

we use it in the outpatient setting. The

term first listed diagnosis is used in

lie of the principal diagnosis. Yes. So

whenever you hear you hear people say

principal diagnosis very often and

people use first listed diagnosis and

principal diagnosis interchangeably.

That's incorrect because principal

diagnosis is for inpatient facility

encounters. So you should only say

principal when you're talking about

inpatient. Anything else first

and

first listed code

is going to be the chief reason for the

encounter. So this is the the chief

reason the patient is being seen and we

call it the RF reason for encounter

and also specific coding guidelines take

precedence over the section 4

guidelines.

Specific coding guidelines can be found

in section one C. Yes, there's section

section 1 C guidelines. We did not

review them yet, but those are specific

coding guidelines.

Next, uncertain diagnosis. And anytime

you have an a doctor renders an

uncertain diagnosis like probable, the

patient probably has diabetes.

suspected the patient is suspected to

have um osteoarthritis

or rule out we're going to rule out

an acute mioardial infarction. Well, you

know what coders in outpatient coding we

don't code that kind of stuff. We code

what the doctor actually does. Okay? So

do not code inconclusive or uncertain

diagnosis. Code

the most specific, no certain. We code

to the highest level of doctor's

certainty. So if the doctor is only

certain about a sign or a symptom. Let's

say the doctor says, "Oh, the patient,

we're going to bring the patient in to

the ED and we're going to rule out a

heart attack." No, we're not. We're not

going to code for that rule out. We're

going to code for the reason for that

encounter, the chief reason for the

encounter, which may just be chest pain.

Next, selection of the first listed

condition. All right, coders. Now, they

tell you, you know, we've already

learned that you always look up the code

in the alphabetic index first and then

verify the codes in the tabular list. We

know that. But when you have outpatient

surgery,

you're going to always code the chief

reason for the surgery as first listed.

Okay?

If the patient's in observation stay,

there could be two circumstances that

they're there. Number one, they could be

there for a medical reason. Or number

two, they could be in observation due to

maybe a problem that occurred in