How to Locate the Main Term in ICD-10-CM Code Lookup - Medical Coding Demonstration

Contempo Coding

4 Aug 202212:07

EducationalLearning

32 Likes 10 Comments

TLDRIn this informative video, Victoria, a medical coder and educator, offers valuable tips on efficiently identifying the primary term when searching for a diagnosis code in ICD-10-CM. She explains the importance of understanding the description of medical conditions and demonstrates how to navigate the alphabetic index effectively. Through various examples, including back pain, colon cancer, and post-operative pain, Victoria clarifies common misconceptions and highlights the significance of using the correct terminology for accurate medical coding.

Takeaways

📚 Understand the importance of identifying the main term when looking up ICD-10-CM diagnosis codes for medical coding purposes.
🔍 When coding for back pain, focus on 'pain' as the main term rather than 'back', as the latter directs you to see 'condition' which ultimately points back to 'pain'.
📈 For anatomical locations like 'colon', shift focus to the condition affecting it, such as 'cancer', and use the neoplasm table for precise coding.
🩺 In cases like 'post-operative pain', the adjective 'post-operative' describes the type of pain, but 'pain' remains the main term to look up.
💡 For complex diagnoses like 'open type fracture of the head of the left femur', the main term is 'fracture', and further specification is needed based on the details provided.
🚫 Remember that 'see condition' in the alphabetic index does not mean looking up 'condition', but rather the condition of the specified anatomical part.
🩸 For 'acute kidney failure', 'failure' is the main term, with 'acute' and 'kidney' providing additional context for the specific type of failure.
📊 In combination codes like 'type 2 diabetes mellitus with retinopathy', 'diabetes' is the primary term, and an assumed cause-effect relationship exists between diabetes and related conditions unless stated otherwise.
🍼 For 'feeding problems with newborn', 'problem' is the main term, as it encapsulates the issue at hand, with 'feeding' and 'newborn' providing additional context.
🩹 In the case of 'stage three pressure ulcer of the buttocks', 'ulcer' is the main term, and further specification is required to accurately code the condition.
🧠 Practice and familiarity with the ICD-10-CM coding system will improve efficiency in identifying main terms and accurately coding medical diagnoses.

Q & A

What is the main focus of the video?
-The main focus of the video is to teach viewers how to quickly and easily locate the main term when looking up a diagnosis code in ICD-10-CM.
Who is the speaker in the video?
-The speaker in the video is Victoria, a medical coder, author, educator, and content creator.
What is the first medical diagnosis example discussed in the video?
-The first medical diagnosis example discussed in the video is back pain.
What is the importance of understanding the main term in ICD-10-CM coding?
-Understanding the main term in ICD-10-CM coding is crucial for accurate and efficient medical coding, which is essential for insurance billing and healthcare data analysis.
How does the speaker suggest finding the main term for back pain in the ICD-10-CM?
-The speaker suggests not looking for body area, organ system, or location, but instead focusing on the description of the problem, which in the case of back pain is 'pain'.
What is the process for looking up a term like 'back' in the ICD-10-CM alphabetic index?
-When looking up 'back', the index directs to 'see condition', which means you should look up the condition of the back, leading to 'pain' as the main term to look up.
What is the main term for the diagnosis of colon cancer as discussed in the video?
-The main term for colon cancer is 'neoplasm', as cancer is a type of neoplasm.
How does the speaker handle a diagnosis with multiple descriptors, such as 'open type fracture of the head of the left femur'?
-The speaker identifies 'fracture' as the main term, as it is what is being described by the other terms ('open type', 'head of the left femur', 'type 1').
What is the significance of the 'see also' directive in the ICD-10-CM alphabetic index?
-The 'see also' directive in the ICD-10-CM alphabetic index is used to guide the coder to another term or condition that provides additional specificity or context for the code being looked up.
How does the speaker approach a diagnosis with an assumed cause and effect relationship in ICD-10-CM coding?
-The speaker explains that in cases like diabetes with retinopathy, there is a guideline in ICD-10-CM that assumes a cause and effect relationship unless the provider specifically states otherwise, leading to the use of combination codes.
What advice does the speaker give for coders who are struggling to find the main term?
-The speaker advises coders to practice and to not be discouraged if they don't succeed at first; they can try looking up other terms and remember that 'see condition' means to identify the specific condition being described by the term they are researching.

Outlines

00:00

📚 Introduction to Medical Coding with ICD-10-CM

Victoria, a medical coder, educator, and content creator, introduces the video's purpose: to teach viewers how to quickly and easily locate the main term when looking up a diagnosis code in ICD-10-CM. She emphasizes the importance of understanding medical codes for professionals in the field and provides a brief overview of the video's content, which includes examining various medical diagnoses and explaining how to find the main term in the ICD-10-CM's alphabetic index.

05:00

🔍 Locating Main Terms for Medical Diagnoses

The video delves into the process of identifying the main term for medical diagnoses. Victoria uses the example of back pain to illustrate that the main term is not the body area or organ system but the description of the problem, which is 'pain'. She explains the concept of 'see' references in the ICD-10-CM index, such as 'see condition', and how they direct the coder to the correct term. The video also covers how to handle combination codes, like type 2 diabetes with retinopathy, and the assumed cause-effect relationship in diabetes coding.

10:01

🩺 Case Studies in Medical Coding

Victoria presents several case studies to demonstrate the process of finding the main term in medical coding. These include a patient with an open fracture of the left femur, a patient with acute kidney failure, and a newborn with feeding problems. She explains how to navigate the ICD-10-CM index to find the correct codes, emphasizing the importance of following indentations and understanding the condition being described. The video also touches on the difference between an isolated elevated blood pressure reading and a formal hypertension diagnosis.

📈 Understanding 'See' and 'See Also' in ICD-10-CM

The final part of the video focuses on the nuances of 'see' and 'see also' references in the ICD-10-CM. Victoria clarifies that 'see condition' does not mean looking up the word 'condition' but rather the specific condition of the anatomical part in question. She provides examples of how to interpret these references and how they guide the coder to the appropriate main term. The video concludes with encouragement for viewers to practice and refine their medical coding skills, reassuring them that with persistence, they can become proficient in identifying main terms.

Mindmap

Keywords

💡Medical Coding

Medical coding is the process of converting healthcare procedures, diagnoses, and other medical information into universal alphanumeric codes. In the video, the speaker, Victoria, is a medical coder and aims to educate viewers on how to successfully navigate and understand ICD-10-CM codes, which are crucial for medical billing and record-keeping.

💡ICD-10-CM

ICD-10-CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification. It is a coding system used in the United States for documenting and reporting diagnoses and procedures. The video focuses on teaching viewers how to locate the main term in this coding system for various medical diagnoses, which is essential for accurate medical coding.

💡Main Term

The main term refers to the primary word or concept that describes a medical condition or procedure. Identifying the main term is crucial in the medical coding process because it allows coders to find the appropriate ICD-10-CM code. The video provides strategies for determining the main term from a medical diagnosis, which is key to accurate and efficient coding.

💡Alphabetic Index

The Alphabetic Index is a section of the ICD-10-CM manual that lists terms in alphabetical order, with cross-references to the numerical codes. It is a critical tool for medical coders to find the correct codes by looking up symptoms, diagnoses, or procedures. The video emphasizes the importance of using the Alphabetic Index to locate the main term for coding.

💡Neoplasm Table

The Neoplasm Table is a specific section in the ICD-10-CM manual that categorizes and lists codes for neoplasms, or abnormal growths such as tumors. This table is used when the main term for a diagnosis involves a type of cancer or other growth. The video explains the importance of consulting the Neoplasm Table for certain conditions like 'colon cancer' to find the appropriate code.

💡Encounter

In medical coding, an 'encounter' refers to a face-to-face meeting between a patient and a healthcare provider for the purpose of preventing, evaluating, diagnosing, or treating health conditions. The video explains how to code for different types of encounters, such as an annual examination, which is a specific type of encounter.

💡Condition

In the context of medical coding, 'condition' refers to the specific health issue or problem that a patient is experiencing. It is a term used in the ICD-10-CM Alphabetic Index to direct coders to the appropriate main term for a diagnosis. The video clarifies that 'see condition' in the index means to look up the condition of the specified body part, not the word 'condition' itself.

💡Fracture

A 'fracture' is a medical term for a broken bone. In medical coding, specific codes are assigned to fractures based on the type, location, and other characteristics of the injury. The video provides an example of how to identify the main term for a fracture, such as 'open type fracture of the head of the left femur,' and how to navigate the ICD-10-CM to find the appropriate code.

💡Type 2 Diabetes Mellitus

Type 2 Diabetes Mellitus is a specific form of diabetes characterized by high blood sugar levels due to insulin resistance, where the body does not use insulin properly. In medical coding, combination codes are often used for diabetes-related conditions, assuming a cause and effect relationship between diabetes and the related condition. The video discusses this assumption and how to code for diabetes with additional conditions like retinopathy.

💡Pressure Ulcer

A pressure ulcer, also known as a bedsore, is an injury to the skin and underlying tissue resulting from prolonged pressure on the skin. In medical coding, pressure ulcers are classified into stages based on severity. The video explains how to identify the main term 'ulcer' for coding a stage three pressure ulcer of the buttocks, and how to use the ICD-10-CM to find the specific code.

💡Elevated Blood Pressure Reading

An 'elevated blood pressure reading' refers to a measurement indicating that a person's blood pressure is higher than the normal range. However, a single elevated reading does not necessarily mean a person has hypertension, which is a formal diagnosis. The video clarifies the difference between an isolated elevated reading and a diagnosis of hypertension, emphasizing the importance of provider documentation for coding purposes.

Highlights

The video provides tips on quickly locating the main term when looking up a diagnosis code in ICD-10-CM.

The presenter, Victoria, is a medical coder, author, educator, and content creator offering advice for success in medical coding.

The importance of understanding ICD-10-CM is emphasized for those working with medical codes or wanting to learn more about them.

The example of back pain is used to illustrate the process of finding the main term, which is 'pain' rather than 'back'.

The concept of 'see condition' in the ICD-10-CM index is explained, clarifying that it directs to the specific condition of the anatomical part, not the word 'condition' itself.

The video demonstrates how to find the main term for a diagnosis like annual examination, which is 'encounter'.

For conditions like colon cancer, the video advises looking up 'neoplasm' rather than the anatomical location.

The process of identifying the main term for post-operative pain is discussed, highlighting that 'pain' is the main term.

An example of an open type fracture of the head of the left femur is used to explain not looking up locations but instead focusing on the condition being described.

The video explains the assumed cause and effect relationship in ICD-10-CM for conditions under 'diabetes'.

The coding of type 2 diabetes mellitus with retinopathy is detailed, emphasizing the need for further specification of the code.

Feeding problems with newborns are discussed, with 'problem' being identified as the main term for coding.

The difference between an isolated elevated blood pressure reading and a formal hypertension diagnosis is clarified.

Acute myocardial infarction is used as an example to illustrate looking up the main term 'infarction'.

The video explains the coding process for stage three pressure ulcers, emphasizing the main term 'ulcer' and the importance of additional characters.

The video concludes with encouragement for viewers to practice identifying main terms and reminds them that there are always other terms to try if the first attempt is unsuccessful.

Transcripts

Browse More Related Video

Medical Coding CPT & ICD-10-CM Surgical Case Study - Step-by-Step Walkthrough

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

MEDICAL CODING ICD-10-CM GUIDELINES LESSON - 1.A - Coder explanation and examples for 2021

Complete Guide to the Neoplasm Table in ICD-10-CM for Beginner Medical Coders

Medical Coding for Pressure Ulcers - CPT and ICD-10-CM with case example

MEDICAL CODING ICD-10-CM GUIDELINES LESSON - 1.B - Coder explanation and examples for 2021

How to Locate the Main Term in ICD-10-CM Code Lookup - Medical Coding Demonstration

Takeaways

Q & A

What is the main focus of the video?

Who is the speaker in the video?

What is the first medical diagnosis example discussed in the video?

What is the importance of understanding the main term in ICD-10-CM coding?

How does the speaker suggest finding the main term for back pain in the ICD-10-CM?

What is the process for looking up a term like 'back' in the ICD-10-CM alphabetic index?

What is the main term for the diagnosis of colon cancer as discussed in the video?

How does the speaker handle a diagnosis with multiple descriptors, such as 'open type fracture of the head of the left femur'?

What is the significance of the 'see also' directive in the ICD-10-CM alphabetic index?

How does the speaker approach a diagnosis with an assumed cause and effect relationship in ICD-10-CM coding?

What advice does the speaker give for coders who are struggling to find the main term?