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PHCC coding guidline
| section coding | guidlines for the coding |
|---|---|
| General Coding Guidelines | Use both the Alphabetic Index and Tabular List |
| General Coding Guidelines | Locate each term in the Alphabetic Index ,then verify in the Tabular List |
| Level of Detail in Coding | Dx and procedure codes are used at there highest digit available. |
| Abbreviation | Index abbreviation:NEC = not elsewhere classifiable:reps. "other specified" the a specific code is not available for a condition the index directs the coder to the "other specified"code in the tabular |
| Abbreviation | Tabular abbreviation: NEC = not elsewhere classified:reps. "other specified" the a specific code is not available for a condition the index directs the coder to the "other specified"code in the tabular. NOS 'not otherwise specified"= unspecified |
| Acute and Chronic Conditions | If the same condition is described as both , and separate sub-entries exist in the Alphabetic Index at the same indention level, code both and sequence the acute (subacute) code first |
| Combination Code | is a single code used classify : 2 Dx, or a Dx w/ an associated secondary process(manifestation)or a Dx w/ an assocaited complication |
| Multiple Coding of a Single Condition | **When coding, code the Dx first followed by the cause |
| Uncertain Dx | **( only for inpatient adm) if Dx is probable,suspected,likely,questionable,possible still to rule out or the uncertainty, code the condition as if it existed or was established |
| Impending or Threatened Condition | code any condition described at the time of discharge as impending or threatened as follows: |
| Impending or Threatened Condition | :If it DID OCCUR, code as confirmed Dx |
| Impending or Threatened Condition | :if it DID NOT OCCUR , reference the Alph.Index to determine if the condition has a sub-entry term for "impending" or "threatened" and also reference main term entries for "impending" and for "threatened" |
| Impending or Threatened Condition | If the Sub-terms ARE listed,assigned the given code |
| Impending or Threatened Condition | if the Sub-terms ARE NOT listed , code the existing underlying condition(s) and NOT the condition described as impending or theratened |
| Selection of Principal Diagnosis | defined in the Uniform Hospital Discharge Data set (UHDDS) as "that condition establish after study to be chiefly responsible for occasioning the admission of the patient to the hospital care" |
| Selection of Principal Diagnosis( ICD-P-CM code for the diagnosis, condition, problem, or other reason for encounter/visit) | list first the ICD-9-Cm code for the Dx,condition,problem,or other reason for encounter shown in the medical recordto be chiefly responsible for the services provided |
| Codes symptoms,signs,and ill-defined conditions | codes for s/s and ill-defined conditions from Cp16 are not used as a principal Dx when a related definitive Dx has been established |
| Codes that describe s/s | these codes as opposed to Dx are accepted for reporting purpose when a Dx has not been established(confirmed) by the provider. |
| Codes in Brackets, etiology/manifestation convention ("code first","use additional code" and "in disease classified elsewhere" notes) | // |
| Two or more interrelated conditions, each potentially meeting the definition for principle Dx | when there are two or more interrelated conditions potentially meeting the definition of principle Dx,either condition may be first, unless the circumstances of the admission,the therapy provided,the Tabular List,or the Alphabetic Index indicate otherwise |
| Two or More Dx that equally meet the definition for principle Dx | and another coding guidelines does not provide sequencing direction, any one of the Dx may be sequenced first |
| Two or More comparative or contrasting conditions: | when documented as "either/or" (or similar terminology)they are coded as if the Dx were confirmed and the dx are sequenced according to circumstance of admission. if no further Dx as principle Dx ,either Dx may be sequenced first |
| A symptom(s) followed by contrasting comparative Dx | The symptom code is sequenced first, and all the contrasting/comparative Dx should be coded as additional Dx. |
| Observation for Suspected Conditions: Classification of factors Influencing Health Status and Contact w/ Health Service (Supplemental V01-V89):::V CODES, the 4 primary circumstances | 1 Person,not currently sick encounters services for some specific reason,2 Person w/a resolving issue encounters health services for aftercare. 3 Circumstance/problems influences a person's status but not in itself a current illness/injury,4 Newborns |
| Observation for Suspected Conditions: Classification of factors Influencing Health Status and Contact w/ Health Service (Supplemental V01-V89):::V CODES, Used in any health-care setting | // |
| Original Tx not carried out | sequence as the principal Dx the condition(after study occasioned the Adm. to the hospital,even though Tx may not have been carried out due to unforeseen circumstances |
| Late effects | a late effect is the residual effect after teh acute phase of an illness or injury has terminated ( The condition or natural of the late effect is sequenced first. the late effect code is sequenced second) |
| Late Effect of Cerebrovascular Disease | category 438 is use to indicate conditions classifiable to cat.430-437 as the cause of late effects (neurologic deficits), themselves classified elsewhere( these Late effects persist after onset of a condition classified in 430-437 |
| Late Effect of cerebrovascular Disease Codes from category 438 w/ codes form 430-437 | codes category 438 may be assigned on a health care record w/ codes form 430-437, if the patient has a current CVA and deficit from an old CVA |
| Late Effect of Cerebrovascular DiseaseV12.54 TIA and cerebral infarction w/out residual effects | assign code V.12.54 ( and not code form cat. 438) as an additional for history disease when no neurologic deficits are present |
| HIV codes 042 a breakdown: | 1) code only confirmed cases |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | a) patient admitted for HIV-related conditionif a patient is admitted for an HIV -related condition , the principal Dx should be 042, followed by additional Dx codes for all reported-related condition |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | b)patient w/ HIV admitted for unrelated condition , the code for hte unrelated condition should be the principal Dx |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | c)whether the patient is newly Dx, or has previous adm/encouters for HIV conditions is irrelevant to teh sequencing decisions |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | d)asymptomatic HIV infection use code V08, if the term AIDs or if the patient is being treated for an HIV-related illness use code 042 |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | e)patients w/ inconclusive HIV serology, but no definitive Dx or manifesation of the illness, may be assigned code 795.71 (inconclusive serologic test for HIV) |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | f)previoulsy Dx HIV-related illness should be coded to 042 ( once a patient developeed an HIV-related illness they should always be assigned 042 on every subsequent adm/encouter |
| HIV codes 042 a breakdown: selection and squenencing of HIV codes | HIV infection in pregnancy ,childbirth and the puerperium, a patient admitted ( or presenting for a health care encounter) |
| Septicemia,Systamtic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock | definition: septicemia = refers to a systemic disease associated w/ the presence of pathologicale microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms |
| Septicemia,Systamtic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock | SIRS, generally refers to the systemic response to infection , trauma/burns, ot other insult (such as cancer) w/ symptoms including fever, tachycardia,tachypnea, and leukocytosis |
| Septicemia,Systamtic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock | Sepsis, generally refers to SIRS due to infection |
| Septicemia,Systamtic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock | Sever Sepsis, gernerally refers to sepsis w/ associated acute organ dysfunction |
| The coding of SIRS, sepsis and severe sepsis ( These coding require a minium of 2 codes ; A code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 (SIRS) | The Coding of SIRS , sepsis and severe sepsis |
| The Coding of SIRS , sepsis and severe sepsis | the code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcatagory 995.9 |
| The Coding of SIRS , sepsis and severe sepsis | Sepsis and sever sepsis require a code for the systemic infection (038.xx,112.5,etc) and either code 995,91,Sepsis, or 995.92 ( if not causal oragnism doc. assign code 038.9 |
| The Coding of SIRS , sepsis and severe sepsis | Servere sepsis requires assitional code(s) for the assoicated acute organ dysfunction(s) |
| The Coding of SIRS , sepsis and severe sepsis | If a patient has sepsis w/ multiple organ dysfunction, follow the instructions for coding severe sepsis |
| The Coding of SIRS , sepsis and severe sepsis | either term sepsis or SIRS must be deoc. to assign a code from subcat. 995.9 |
| The Coding of SIRS , sepsis and severe sepsis ( Sequencing Sepsis and Severe Sepsis) | Sequencing Sepsis and Servere Sepsis |
| Sequencing Sepsis and Servere Sepsis as a Principle Dx | If presented upon adm. and meets def. of primary Dx, the systemic code (038.xx,112.5 etc) should be assigned as the principle Dx followed by code 995.91 or 995.92 |
| Sequencing Sepsis and Servere Sepsis as a Secondary Dx | // |
| Sequencing Sepsis and Servere Sepsis with localized Dx | if reason for Adm is both sepsis and a localized infection , code the systemic infection first, then code 995.91 or 995.92, followed by the code for the localized infection |
| Sequencing Sepsis and Servere Sepsis ( Bacterial Sepsis and Septicemia) | // |
| Sequencing Sepsis and Servere Sepsis (Acute organ function) | patient has sepsis and an acute organ dysfunction,but the medical record doc. indicates that the acute organ dsyf. is relates to a medical condition other than sepsis,do not code 995.92(severe sepsis) |
| Sequencing Sepsis and Servere Sepsis ( sequencing for Septic Shock) | for these caese , the code for the systemic infection should be sequenced first, followed by 995.92 AND 785.82 then any other organ dysfunction ( septic shock CAN NOT be listed as the prime Dx, 1st) |
| Sequencing Sepsis and Servere Sepsis ( sepsis and septic shock complicating abortion and pregnancy) | // |
| Sequencing Sepsis and Servere Sepsis ( negative or inconclusive blood cultures) | these do not preclude a Dx of septicema or sepsis in patients w/ clinical evidence of the condtion |
| Sequencing Sepsis and Servere Sepsis ( Newborn sepsis) | see sectoion I.C. 15.j |
| Sequencing Sepsis and Servere Sepsis (due to a postprocedureal Infection) | // |
| Sequencing Sepsis and Servere Sepsis ( external cause of Injury codes w/ SIRS | // |
| Sequencing Sepsis and Servere Sepsis ( sepsis and servere sepsis associated w/ nopn-infection process, ( sequencing of sepsis/severe sepsisi assocaited w/ non-infectious process) | // |
| Sequencing Sepsis and Servere Sepsis 9 only one SIRS (subcat. cat 995.9) code should be assigned | // |
| NEOPLASMS | // |
Created by:
wgolon
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