General Inpatient Coding Guidelines

 A.   Use Of Both Alphabetic Index Tabular List

 

                  Use both the alphabetic and the index list when locating and assigning a code. Reliance on only the alphabetic index or the tabular list leads to errors in code assignments and less specificity in code selection.

 

                               Locate each term in the alphabetic index and verify the code selected in the tabular list. Read and be guided by instructional notations that appear in both the alphabetic index and the tabular list.

 

 B.   Level Of Specifying In Coding

 

Diagnostic and procedure codes are to be used at their highest level of specificity : 

 Assign three - digit codes only if there are no four - digit codes within that code category.

 Assign four - digit codes only if there is no fifth - digit sub classification for that category. 

 Assign four-digit codes only if there is no fifth-digit sub classification for that category.

 Assign the fifth-digit sub classification code for those categories where it exists. 

 

C.   Other (NEC) And unspecified (NOS) Code Titles

 

                                   Codes labeled "other specified (NEC not elsewhere classified) or "unspecified (NOS not otherwise specified) are used only when neither the diagnostic statement nor a through review of the medical record provides adequate information to permit assignment of a more specific code. 

                                   Use the code assignment for "Other" or NEC when the information at hand specifies a condition but no separate code for that condition is provided.

                                   Use "Unspecified" (NOS) when the information at hands odes not permit either a more specific or "Other" code assignment.  

                                    when the alphabetic index assigns a code to a labeled "Other(NEC)" or to a category labeled "Unspecified(NOS)", refer to the tabular list and review the titles and inclusion terms in the subdivisions under that particular three - digit category (or subdivision under the four - digit code) to determine if the information at hand can be appropriately assigned to a more specific code.

   

D.   Acute & chronic Conditions 

                                       If the same condition is described is as both acute (subacute) and chronic and separate subenteries exit in the alphabetical index at the  same indentation level, code  both and sequence the acute (Sub acute) code first. 

 

 E.   Combination Code 

                         1    A single code used to classify two diagnoses or a diagnosis with an associated secondary process (Manifestation) or an associated complication code. combination codes are identified by referring to sub term entries in the alphabetic index and by reading the inclusion and exclusion noted in the tabular list.

                          2     Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the alphabetic index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. when the combination code lacks necessary specificity in describing  the manifestation or combination, an addition code may be used as a secondary code.

 

F.   Multiple Coding Of  Diagnoses

 

                  Multiple coding is required for certain condition not subject to the rules for combination codes.

                                 Instruction for conditions that require multiple coding appear in the alphabetic index and the tabular list.

 

                   1. Alphabetic Index :

                                  Code for both etiology and manifestation of a disease appear following the     sub entry term, with the second code in brackets.

                            Assign both code in the same sequence in which they appear in the alphabetic index .

                  2. Tabular List:

                                 Instructional terms, Such as"Code first", Use Additional Code for any", and " Note", indicate when to use more than one code.  " Code First Underlying Disease."

                           Assign the codes for both manifestation and underlying cause. The codes for manifestations cannot be used (Designated) as principal diagnosis.

                         "Use additional code, to identify manifestation, as" Assign also the code that identifies the manifestation, such as, but not limited to, the example listed. the codes for manifestations cannot be used (Designated) as principal diagnosis. 

  

                 3. Apply Multiple Coding Instructions Throughout The Classification:

                              Where appropriate, whether or not multiple coding appear in the alphabetic index or the tabular list. Avoid indiscriminate multiple coding or irrelevant information,such as symptoms or sign characteristic of the diagnosis.

G.   Late Effect

 

                                         A late effect is the residual effect (condition produced) after the acute the acute phase on an illness or injury has terminated. There is no time limit on when a late effect code can be used.

                                The residual may be apparent early, such as in cardiovascular accident cases, or it may occur month or years later, such as that due to a previous injury.

   Coding of late effects requires two codes:  

1. The residual condition or nature of the late effect

2. The cause of the late effect 

 

                                   The residual condition or nature of the late effect is sequenced  first, followed by the cause of the late effect,except in those few instances where the code for the late effect is followed by a manifestation code identified in the tabular list and title or the late effect has been expanded( at the fourth and fifth digit levels) to include the manifestation(s). 

                             1. Late Effects Of Cardiovascular Disease

                                  Category 438 is used to indicate conditions classifiable to categories 430-437 as the causes of late effects (neurologic deficits), they classified elsewhere.

                                    These "Late Effect" include neurologic deficits that persist after initial onset of conditions classifiable to 430-437.

                                    The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to 430-437.

                                 Codes from category 438 may be assigned on a health care record with codes from 430-437 if the patient has a current CVA and deficits from an old CVA.

                                    Assign code V12.59 ( and not a code from category 438) as an additional code for history of cardiovascular disease when no neurologic deficits are present.

 

H.  Uncertain Diagnosis

 

                                    If the diagnosis documented at the time of discharge is qualified as"probable","suspected", "likely","questionable", possible", or "still to role out ", code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. 

  

I.   Impending or Threatened Condition

 

Code any condition described at the time of discharge as "Impending" "Threatened" as follows:

                                   If it did not occur, reference the alphabetic index to determine if the condition has a subentery term of "impending" or "threatened" and also reference main term entries for Impending and for Threatened.

                                   If the subterms are not listed,code the existing forerunner condition(s) and not the condition described as Impending or Threatened.