Basics of Diagnosis Coding

March 17th, 2015 - Betsy Nicoletti
Categories:   Diagnosis Coding  
0 Votes - Sign in to vote or comment.

Diagnosis coding is the process of translating narrative medical description into a code.

CMS Coding and Reporting Guidelines for diagnosis coding:

  • Use the ICD-9-CM codes that describe the patient's diagnosis, symptom, complaint, condition, or problem.
  • Use the ICD-9-CM code that is chiefly responsible for the item or service provided.
  • Assign codes to the highest level of specificity. Use the fourth and fifth digits when indicated as necessary in your ICD-9-CM volumes.
  • Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that the services were provided for "rule out" purposes.
  • Code a chronic condition as often as applicable to the patient's treatment.
  • Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions which no longer exist)

ICD-9 Conventions:

Non specific codes

Decimal digits .8 and .9 indicate “other specified” or “non otherwise specified.”  Use only when more specific information is not available, or doesn’t exist, not just “when it is not convenient to get more detailed information.”

NEC (Not elsewhere classified) Used in Volumes 1 and 2

These codes should only be used when a coder lacks precise information necessary to code a term more specifically.

NOS (Not otherwise specified) Used in Volume 1

Etiology codes have "use additional code" notes to indicate when manifestation codes are required and manifestation codes have "code first" notes to indicate when an etiology code is required.

The words "in diseases classified elsewhere" are part of the code title for most ?manifestation codes.

See: Indicates the coder should look up the term specified to find the correct code.

See Also:  Indicates the coder should look up the term specified to find the correct code.

The ICD-9-CM book consists of three volumes.  We use the first two:

Volume 1: Tabular list of Diseases and Injuries

    * Use this volume to select codes

    * Arranged in numerical sequence

    * Contains V codes and E codes

Volume 2 is an Alphabetic Index to Volume 1 and includes:

    *  Alphabetic Index of Diseases and Injuries

    * Table of Drugs and Chemicals

    * Index of External Causes of Injuries and Poisonings

Always begin the initial search for a code with Volume 2, but do not code directly from Volume 2. Coding from Volume 2 can lead to inaccurate codes because:

    *  Not all fifth digits are indicated

    * Include, Exclude, and Notes are not included

V codes are for screening personal history of or family history of.  You are most likely to use them for patients who no longer have active disease or for whom you are doing a screening service. 

E codes are for accidents or incidents, like these.  Motor vehicle accidents are in the range of E-810 to 819; accidental poisonings, E-850 to E-858, and many others. 

    * Code to the highest degree of specificity.  When fourth and fifth digits are available, they must be used.

    * Code the diagnosis, symptom, complaint, condition that is chiefly responsible for the visit

    * If the diagnosis is not known, use symptoms

    * Do not code rule out, probable or possible, use symptoms

    * Code underlying and chronic conditions only if they were considered and documented in today’s visit

    * For multiple injuries: code the most severe first.

    * Limit use of unspecified codes when more specific codes are available and there is definitive information available.

    * For inpatient services, code the reason that lead to admission, then secondary diagnoses.

    * Use acute and chronic conditions when ICD-9 uses those distinctions.

Remember, physician claims are paid based on CPT® code, but denied based on diagnosis code!


Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association