How to look up an ICD-10-CM code. Medical Coding Demonstration - Beginner Level Practice

Contempo Coding

14 Jul 202213:06

EducationalLearning

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TLDRIn this informative video, Victoria, a medical coder auditor educator, guides viewers on how to perform basic code lookups using the ICD-10-CM manual. She explains the importance of medical coding in health information management and provides step-by-step examples for coding conditions like keloid scars, urinary tract infections, lower back pain, and an encounter for insulin pump titration. The video is designed to help newcomers understand the fundamentals of medical coding and offers resources for further learning.

Takeaways

📚 Introduction to ICD-10-CM: Victoria, a medical coder auditor educator, provides a tutorial on using the ICD-10-CM manual for basic code lookup.
🔍 Medical Coding Importance: The process of translating medical records into code sets is crucial for billing, insurance claims, and health care cost management.
📈 Career Guidance: Victoria offers a master class for those interested in medical coding, covering salary expectations, certifications, job outlook, and training programs.
📖 ICD-10-CM Manual: Different versions are available from various publishers, each with slight variations in guidelines, illustrations, and organization.
🔎 Basic Lookup Process: Start with the alphabetic index to find the main term, then verify in the tabular list for the specific code.
👎 Not Directly from Index: Never code directly from the alphabetic index; always cross-reference with the tabular list.
📊 Example 1 - Keloid Scar: The code for a keloid scar is found under 'L' for scar, then specified as 'L91.0' in the tabular list.
🚽 Example 2 - UTI: For urinary tract infection (UTI), the main term is 'infection', with the code 'N39.0' for UTI site not specified.
🏥 Example 3 - Lower Back Pain: The term 'pain' leads to the code 'M54.50' for low back pain, with updates indicated by a black dot and yellow highlighting in the manual.
🤕 Bilateral Pain Coding: For conditions like bilateral hip pain, use multiple codes (e.g., M25.0.551 and M25.0.552) when a specific code for 'bilateral' does not exist.
💉 Special Encounters: ICD-10-CM also covers codes for encounters, such as 'Z46.81' for an encounter for insulin pump titration.
💌 Stay Updated: Victoria encourages viewers to check her masterclass for more comprehensive medical coding training and to stay updated with new codes.

Q & A

What is the primary purpose of medical coding?
-The primary purpose of medical coding is to review medical records and translate the different diseases, disorders, procedures, services, equipment, etc., into code sets. This process is critical for health information management and impacts billing, insurance claims, research, and budgeting for health care costs.
How does Victoria describe the ICD-10-CM manual's role in medical coding?
-Victoria describes the ICD-10-CM manual as a crucial tool for basic code lookup in medical coding. It helps in translating medical conditions and procedures into standardized codes that are used for various administrative and analytical purposes in the healthcare industry.
What is the first step in looking up a medical code according to Victoria?
-The first step in looking up a medical code, as per Victoria, is to start in the alphabetic index, which is usually found in the front of the ICD-10-CM manual.
How does Victoria verify the code found in the alphabetic index?
-Victoria verifies the code found in the alphabetic index by checking it against the tabular list in the ICD-10-CM manual. The tabular list is also in alphabetical order and provides more specific codes and guidelines.
What is the ICD-10-CM code for a keloid scar?
-The ICD-10-CM code for a keloid scar is L91.0. Victoria explains that after finding 'keloid scar' in the alphabetic index under 'scar,' one should verify this code in the tabular list to confirm.
What is the ICD-10-CM code for a urinary tract infection (UTI) with an unspecified site?
-The ICD-10-CM code for a urinary tract infection (UTI) with an unspecified site is N39.0. Victoria notes that an additional code is required to identify the infectious agent, but in the absence of specific information, N39.0 is used for a general UTI.
How does Victoria handle a code for lower back pain in the ICD-10-CM?
-For lower back pain, Victoria looks up 'pain' in the alphabetic index and finds the specific code for low back pain, which is M54.50. She mentions that this code is new for 2022 and is an unspecified code, as indicated by the black dot and the yellow highlighting in the manual.
What is the process for coding bilateral hip pain in the ICD-10-CM?
-For bilateral hip pain, since there isn't a specific code for 'bilateral,' Victoria uses two codes: M25.0.551 for right hip pain and M25.0.552 for left hip pain. She explains that this is necessary because the patient has pain in both hips, and the code M25.55 requires a sixth character to specify the side.
How does Victoria find a code for an encounter related to an insulin pump titration?
-Victoria looks up 'encounter' in the alphabetic index and then searches for 'insulin pump.' She finds the code Z46.81, which is used for encounters for fitting and adjustment of an insulin pump, including titration, instruction, and training.
What advice does Victoria give for navigating the ICD-10-CM manual?
-Victoria suggests keeping scrap paper nearby to jot down page numbers and codes while navigating the manual, as it can be helpful for remembering what has been looked up, especially when first learning to use the ICD-10-CM.
What does Victoria recommend for those interested in learning more about medical coding?
-Victoria recommends her masterclass for those who want to learn more about medical coding. She suggests that the class covers various aspects of medical coding, including salary expectations, certifications, job outlook, and training programs, providing a comprehensive roadmap for individuals to become job-ready in the field.

Outlines

00:00

📚 Introduction to Medical Coding with ICD-10-CM

Victoria, a medical coder, auditor, and educator, introduces viewers to the basics of medical coding using the ICD-10-CM manual. She emphasizes the importance of coding in health information management and its impact on billing, insurance claims, and healthcare budgeting. Victoria offers a comprehensive master class for those interested in advancing their medical coding skills and staying job-ready without incurring student loan debt. The video will cover five examples of medical code lookups, starting with 'keloid scar' as the first example.

05:01

🔍 Looking Up Keloid Scar and UTI Codes

The video continues with a detailed walkthrough on how to look up medical codes for a keloid scar (L91.0) and urinary tract infection (UTI). Victoria explains the process of using the alphabetic index to find the main term, then verifying and refining the code in the tabular list. She highlights the importance of following guidelines and understanding the category of the code. The example of UTI emphasizes looking up 'infection' rather than 'urinary tract' and the need to add an additional code for the infectious agent, although in this case, a general code (N39.0) is used due to lack of specific information.

10:02

🏥 Coding for Lower Back Pain and Bilateral Hip Pain

In this section, Victoria demonstrates how to code for lower back pain (M54.50) and bilateral hip pain (M25.0.551 and M25.0.552). She clarifies that 'lower back pain' is often referred to as 'lumbago' and that the code for hip pain is found under 'joint hip.' Victoria also explains the need for additional characters to specify the laterality of the pain. The video emphasizes the importance of understanding the anatomy and the specific terms used in medical coding to accurately capture the condition being coded.

🩺 Encounter Coding: Insulin Pump Titration

Victoria concludes the video with an example of coding for an encounter related to insulin pump titration (Z46.81). She advises viewers to familiarize themselves with the alphabetic index for encounters and explains the process of finding the specific code for insulin pump titration. The video serves as a basic introduction to medical coding, encouraging viewers to explore further learning opportunities and to consider Victoria's master class for in-depth training.

Mindmap

Keywords

💡Medical Coding

Medical coding is the process of reviewing medical records and translating the information about diseases, disorders, procedures, and services into a set of codes. These codes are crucial for health information management, impacting billing, insurance claims, research, and healthcare budgeting. In the video, Victoria educates viewers on how to perform basic code lookups using the ICD-10-CM manual, which is a fundamental skill in a medical coding career.

💡ICD-10-CM Manual

The ICD-10-CM manual is a comprehensive guide used for medical coding, detailing the classification of diseases and conditions into codes. It includes an alphabetic index for quick lookup and a tabular list for more detailed classification. Victoria uses this manual to demonstrate how to find codes for various medical conditions, such as keloid scars and urinary tract infections.

💡Code Lookup

Code lookup is the process of finding the appropriate ICD-10-CM code for a specific medical condition or procedure. It involves using the alphabetic index to find a starting point and then verifying and refining the code in the tabular list of the ICD-10-CM manual. This is a fundamental skill for medical coders and is demonstrated throughout the video.

💡Keloid Scar

A keloid scar is a type of overgrown scar tissue that can be wide, thick, bulge out, or be hardened. In the context of medical coding, it is important to identify and use the correct code for a keloid scar, which is L91.0 according to the ICD-10-CM manual. This specificity is crucial for accurate medical record documentation and subsequent billing and insurance claims.

💡Urinary Tract Infection (UTI)

Urinary tract infection (UTI) is a condition where the urinary tract is infected, which can include various parts such as the kidneys, bladder, or urethra. In medical coding, it is important to identify the correct code for a UTI, which is N39.0 for an unspecified site of infection. Additional codes may be required to specify the infectious agent, but this information may not always be available.

💡Lower Back Pain

Lower back pain refers to discomfort or pain in the lower region of the back. In medical coding, it is important to specify the type of pain, such as 'low back pain,' and its unspecified nature, which is coded as M54.50. This specificity helps in accurately documenting the patient's condition for medical records and insurance purposes.

💡Bilateral Hip Pain

Bilateral hip pain indicates pain in both hips. In medical coding, this requires the use of two codes to fully describe the condition since there isn't a specific code for bilateral hip pain. The codes used would be M25.0.551 for right hip pain and M25.0.552 for left hip pain, indicating that the pain is present in both hips.

💡Encounter Codes

Encounter codes in the ICD-10-CM classification system are used to describe the reason for a patient's visit to a healthcare provider. These codes do not relate to a specific disease or treatment but rather the context of the healthcare encounter, such as a routine check-up, a follow-up after surgery, or an adjustment of a medical device like an insulin pump.

💡Medical Coder Auditor Educator

A medical coder auditor educator is a professional who not only performs medical coding but also audits coded records for accuracy and provides education and training to others in the field of medical coding. Victoria identifies herself as a medical coder auditor educator, indicating her expertise and role in teaching others about medical coding.

💡Health Information Management

Health information management refers to the collection, analysis, and management of patient data for the purpose of improving patient care, managing health services, and complying with legal and regulatory requirements. Medical coding is a critical component of health information management, as it ensures that healthcare data is accurately recorded and can be used for various administrative and research purposes.

💡Masterclass

A masterclass is an advanced educational course or training program that provides in-depth knowledge and skills in a specific field. In the context of the video, Victoria offers a masterclass for those interested in furthering their medical coding education, covering topics such as salary expectations, certifications, job outlook, and comprehensive training to prepare individuals for a career in medical coding.

Highlights

Victoria is a medical coder auditor educator and content creator, providing tips and tutorials for success in medical coding.

Medical coding involves translating medical records into code sets, impacting billing, insurance claims, and health care budgeting.

The ICD-10-CM manual is used for basic code lookup in medical coding.

Different versions of the ICD-10-CM manual may have guidelines and illustrations in different locations.

The first step in looking up a medical code is to start in the alphabetic index.

Keloid scar is coded as L91.0 in the ICD-10-CM manual.

The tabular list in the ICD-10-CM manual is mostly in alphabetical order, with some exceptions like chapter 22.

UTI (urinary tract infection) is coded as N39.0 when the site is not specified, and an additional code is needed for the infectious agent.

Lower back pain is often referred to as lumbago and is coded as M54.50.

Bilateral hip pain requires two codes (M25.0.551 and M25.0.552) since there isn't a specific code for bilateral.

Encounter for insulin pump titration is coded as Z46.81.

The ICD-10-CM manual also includes codes for reasons for encounters and impacts on health care services.

Familiarity with the ICD-10-CM manual's contents can jog memory and improve coding efficiency.

Victoria offers a master class for those interested in learning more about medical coding.

The video provides a basic level introduction to medical coding, with more complex concepts available for further learning.

The importance of using the correct main term when looking up medical codes is emphasized, such as using 'infection' for UTI, not 'urinary tract'.

For conditions like homelessness, there are specific ICD-10-CM codes that can be looked up.

Victoria's video aims to help viewers understand the process of basic code lookup in medical coding, suitable for beginners.

Transcripts

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Takeaways

Q & A

What is the primary purpose of medical coding?

How does Victoria describe the ICD-10-CM manual's role in medical coding?

What is the first step in looking up a medical code according to Victoria?

How does Victoria verify the code found in the alphabetic index?

What is the ICD-10-CM code for a keloid scar?

What is the ICD-10-CM code for a urinary tract infection (UTI) with an unspecified site?

How does Victoria handle a code for lower back pain in the ICD-10-CM?

What is the process for coding bilateral hip pain in the ICD-10-CM?

How does Victoria find a code for an encounter related to an insulin pump titration?

What advice does Victoria give for navigating the ICD-10-CM manual?

What does Victoria recommend for those interested in learning more about medical coding?