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

Welcome back to Introduction to ICD10 CM

part two. I'm Mrs. J. I'm the curriculum

director at AMCI and one of your ICD10

CM instructors.

Previously in part one, we learned the

history of ICD10 CM, the structure of an

ICD10 CM code, how to look up the code,

how to determine ICD10 CM main and

subterms, and finally, how to select a

seventh character extender.

Now let's take a look at the goals for

this presentation.

Goals of the presentation.

Number one, review ICD10 CM conventions,

general coding guidelines, provide

scenarios and quizzes to test your

knowledge, and bring you one step closer

to ICD10 CM coding mastery.

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Association.

Keyword concept FTR Chun AMCI Feb 7 AMCI

ICD10CM flip tap and mcg are registered

trademarks of AMCI. The credentials CPC,

CRC, COC, CPMA, CPB, CPPM,

CPCO are owned by AAPC.

The credentials CCA, CCS, CCSP, RHIA,

and RHIT are owned by AHEA and AMCI does

not own the rights to these credentials.

All right, coders. Now that you've

completed part one, you are ready.

You're ready for Mrs. Jay's adult or

grown folks conversation.

And this is just one of my adult

conversations. So just so you know, when

you hear me say grown folks or adult

conversation, it means that I think you

are ready for it. In this case, you're

ready to understand the difference

between billers and coders.

All right. So, I want to talk very

briefly about medical coders and medical

billers. They are not one and the same.

Let me tell you what is the difference.

A medical coder takes the doctor's

documentation

and they turn that documentation into

medical codes

and after they are finished coding they

give it to the biller

who will put it in the system

for payment.

Both the of these professions

are well they're different and what

makes them different are the guidelines

that they follow.

Coders follow coding guidelines.

Billers follow payer guidelines.

So coders

a biller is not a coder. A coder is not

a biller. They both have two distinct

skill sets

and it is the guidelines that they

follow that makes them different. So

with that said, let's begin our

discussion on the guidelines of ICD10

CM.

All right. So I've spoken about

guidelines in part one. I'm beginning

the discussion on guidelines right now

and I never told you or defined what a

guideline is. So let's just say this, a

guideline is a rule. And you know what

rules are? Rules must be followed. All

right? They're not broken in coding. And

when you understand

the the importance of guidelines, you

understand 50%.

You do. So you'll do very very well. All

right. So in ICD10 CM you have

guidelines in the alphabetic index and

in that index you your guidelines are

set up in three categories and four

sections. You have section one, section

two, section 3, section 4. In section

one, you have conventions.

You have general coding guidelines. You

have specific coding guidelines for

ICD10 CM. And in section four, you've

got guidelines, too. And these

guidelines pertain to diagnostic and

reporting guidelines for outpatient

services.

And ladies and gentlemen, these two uh

sections are the sections that we're

going to review because these two

sections are the sections that pertain

to certified professional coding or

coders. Okay, so let's get started.

Let's look at the section one guidelines

and section 4 guidelines.

Here are the guidelines at a glance.

Your section one

2 3 and four. Now let's turn our

attention on the left hand side. This is

where the section one guidelines begin.

You've got your convention. Yes,

conventions are guidelines. You've got

your general coding guidelines. And you

have your chapter specific coding

guidelines.

And in this presentation, we're going to

talk about section one guidelines. A and

B.

And in our next presentation, we're

going to talk about section four

guidelines. Section two and three will

not be discussed. Section two is pretty

much for inpatient coding. they really

do a comprehensive job talking about

selecting the principal diagnosis and

that really does pertain to inpatient

coding and also reporting of those

additional diagnosis. We will not be

discussing that in our ICD10 CM

um presentation. So section one and

section four it is. But we're going to

start with section one conventions.

What is a convention? Well, a convention

represents the general way things are

done in ICD10 CM. in this section of

guidelines.

These are called section one letter A

guidelines. Again, these are called

conventions. And what are the

conventions? Well, first let me tell you

there are 19 conventions

and I'll read them for you. The first is

the alphabetic and index and tabular

list. This is the guideline surrounding

how to use both of those. Um, oh, look

what I just did. Use both of those

indexes for looking up codes. Number

two, this is the format and structure of

ICD10. Three, this is the use of codes

for reporting purposes.

Four, placeholder character. Five,

seventh characters. Sixth,

abbreviations.

Seven, punctuations. Eight, the use of

the word and. Nine, the use, excuse me,

other and unspecified

codes. 10, includes notes. 11, inclusion

terms. 12, excludes notes, excludes one,

two.

13. Ideology manifestation conventions

14 and 15 with

16 C and C also 17 code also note 18

default codes 19 code assignment and

clinical criteria. All right coders

let's get started and let's look at all

19 of these conventions.

All right. So, if you recall during part

one, we talked about some of these

conventions without me actually saying

they are conventions. The alphabetic

index and tabular list, the guideline

that says, hey, you have to look up the

code in the index first followed by the

tabular list. This is where you find

that guideline. The format and structure

of a code. We did some talk a discussion

in detail about the format and a

discussion of a code. The formal

guidelines can be found here. The use of

codes for reporting purposes. I told you

that we have to use um ICD10 CM codes as

per directed by HIPPA. Your placeholder

character. Remember X marks the spot. We

talked about that. We talked about

seventh characters. And you know what

coders? there's no need to talk about it

again. And we're going to begin our

discussion at number six,

abbreviations.

And that's guideline A six. So section 1

A6. And we're going to talk about A and

B,

N O S

and N E C. These two are our most common

abbreviations in ICD10 CM coding. NOS is

the acronym for not otherwise specified.

In other words, the doctor was not

specific in their diagnosis.

Okay. So, let's say the doctor said,

"Oh, the patient has hypertension."

Well, you will come to know coders that

there are several types of hypertension.

you have hypertensive CKD, hypertensive

heart disease, pulmonary hypertension,

etc. But if your doctor says