MEDICAL CODING ICD-10-CM GUIDELINES LESSON - 1.A - Coder explanation and examples for 2021
TLDRIn this informative video, Victoria, a medical coder auditor educator, addresses her audience's request for an overview of the ICD-10-CM coding guidelines. She emphasizes that while memorizing the entire 126-page document is impractical, familiarity with the guidelines is crucial. Victoria plans to break down the guidelines into a series, starting with the 2021 edition, and explains the importance of understanding where to find specific coding answers. She also touches on the structure of ICD-10-CM, including categories, sub-categories, and codes, and discusses the use of the alphabetic index and tabular list for code lookup. Victoria's approach is to make the complex guidelines more accessible through examples and practical advice, highlighting the challenges and rewards of a career in medical coding.
Takeaways
- 📚 Victoria, a medical coding educator, responds to viewer requests to cover ICD-10-CM guidelines.
- 🚀 The ICD-10-CM guidelines are extensive, running 126 pages, and Victoria plans to cover them in a series of videos.
- 🔍 Medical coding is not about memorizing everything but knowing where to find the answers.
- 📈 The ICD-10-CM guidelines are updated annually; Victoria will focus on the 2021 edition.
- 💻 The entire ICD-10-CM book can be downloaded for free from the CDC or CMS websites.
- 📝 Victoria emphasizes the importance of reading the guidelines thoroughly for a deeper understanding.
- 📊 ICD-10-CM uses an indented format for easy reference and includes a tabular list and an alphabetic index.
- 🔑 The guidelines explain the use of the alphabetic index, tabular list, and the importance of verifying codes.
- 📌 Specific conventions like NEC (Not Elsewhere Classifiable) and NOS (Not Otherwise Specified) are discussed.
- 🔄 The use of 'excludes' notes to determine whether conditions should be coded together or separately.
- 🔄 Sequencing guidelines for conditions with underlying etiology and multiple body system manifestations.
- 🎯 The importance of provider documentation in assigning codes, as clinical criteria alone cannot establish a diagnosis.
Q & A
What is the primary focus of Victoria's content on her channel?
-Victoria's primary focus is on providing tips, tricks, and tutorials related to medical coding, specifically to help her viewers succeed in their medical coding careers.
What does Victoria emphasize about learning the ICD-10-CM guidelines?
-Victoria emphasizes that medical coding is not about memorizing every detail but knowing where to find the answers. She encourages familiarity with the ICD-10-CM guidelines for effective coding.
What is the significance of the alphabetic index and tabular list in ICD-10-CM?
-The alphabetic index is used to look up medical codes by key terms, while the tabular list is used for verification. The alphabetic index includes various indexes such as diseases, injuries, neoplasms, and drugs/chemicals.
How does ICD-10-CM handle codes that require a seventh character?
-If a code requires a seventh character but only has four, a placeholder 'X' is used to fill in the additional characters to ensure the code is fully extended.
What do the abbreviations NEC and NOS stand for in ICD-10-CM?
-NEC stands for 'Not Elsewhere Classifiable' and NOS stands for 'Not Otherwise Specified'. NEC is used when there's a definitive diagnosis but no specific ICD-10 code, while NOS is used when the provider hasn't given enough specifics about the code.
How are synonyms and alternative wordings indicated in the ICD-10-CM?
-Synonyms and alternative wordings are indicated using brackets in both the tabular list and the alphabetic index.
What is the purpose of 'includes notes' in ICD-10-CM?
-Includes notes provide further definition or examples of the context of the category. They list terms that are included under some codes and may be synonyms or a list of various conditions that could be assigned that code.
What are the two types of 'excludes notes' and when are they used?
-Excludes one notes indicate that two conditions cannot occur together and should not be coded together, while excludes two notes indicate that the conditions are independent and can be coded together if they both exist.
How does ICD-10-CM handle conditions with both an underlying etiology and manifestations?
-ICD-10-CM has a coding convention that requires the underlying condition to be sequenced first, followed by the manifestation, with specific use additional code notes at both the etiology and manifestation codes.
What does the term 'end' mean in ICD-10-CM code titles?
-In ICD-10-CM code titles, the term 'end' does not just mean the end but could also mean 'or so'. It should be interpreted as 'end or when it appears in a code title'.
How does Victoria suggest her viewers engage with her content?
-Victoria encourages her viewers to engage by giving a thumbs up, subscribing to her channel, hitting the notification bell, and considering joining her channel membership for exclusive content.
Outlines
📚 Introduction to Medical Coding Guidelines
The speaker, Victoria, introduces herself as a medical coding auditor educator and content creator. She acknowledges the frequent requests from her audience to cover medical coding guidelines. Victoria emphasizes that medical coding is about knowing where to find answers rather than memorizing everything. She plans to cover the 2021 ICD-10-CM guidelines, which are extensive at 126 pages, in a series of videos. Victoria also discusses the importance of familiarizing oneself with the guidelines and the availability of the ICD-10-CM book online as a free resource.
📈 Understanding ICD-10-CM Structure and Coding Basics
Victoria delves into the structure of ICD-10-CM, explaining the categorization of codes into categories, sub-categories, and specific codes. She discusses the use of the alphabetic index and the tabular list for code lookup, the significance of the seventh character extension, and the use of placeholders for incomplete codes. Victoria also addresses the use of abbreviations like NEC (Not Elsewhere Classifiable) and NOS (Not Otherwise Specified), and the importance of understanding punctuation and notes in the guidelines for accurate coding.
🔍 In-Depth Look at Coding Conventions and Sequencing
In this segment, Victoria explores the coding conventions and sequencing rules in ICD-10-CM. She explains the etiology and manifestation conventions, the use of additional codes, and the importance of proper sequencing. Victoria clarifies the meaning of 'end' in code titles and the presumed causal relationship between conditions listed under 'with.' She also discusses chapter-specific guidelines and the necessity of explicit documentation to link conditions that are not explicitly connected by relational terms in the classification.
📖 Applying Coding Guidelines and Documentation
Victoria concludes the video by discussing the application of coding guidelines in relation to provider documentation. She explains the use of 'see' and 'see also' instructions in the alphabetic index, the meaning of default codes, and the importance of provider statements in code assignment. Victoria stresses that clinical criteria alone cannot establish a diagnosis; it must be documented by the provider. She encourages viewers to engage with her content, subscribe to her channel, and join her channel membership for exclusive content.
Mindmap
Keywords
💡Medical Coding
💡ICD-10-CM Guidelines
💡CPT Guidelines
💡Coding Conventions
💡Sequence of Coding
💡Inclusion Terms
💡Exclusion Notes
💡Medical Coder Auditor Educator
💡Content Creator
💡Community Feedback
💡Educational Series
Highlights
The video discusses the importance of understanding medical coding guidelines, specifically the ICD-10-CM guidelines.
The ICD-10-CM guidelines are extensive, running 126 pages long, and are updated annually.
The goal of learning the guidelines is not to memorize every detail but to know where to find the answers when needed.
Medical coding is not solely about memorization but also about understanding where to locate specific information.
The ICD-10-CM guidelines can be downloaded for free from the CDC or CMS websites.
The video will cover the ICD-10-CM guidelines in a series of segments due to their length.
Reading the entire guidelines is recommended for medical coders to become familiar with the content.
Medical coding is a complex field and cannot be simplified entirely, which is why medical coders are well-compensated.
The video will use a webcam style format to go through the guidelines and provide examples for better understanding.
ICD-10-CM is required for reporting and billing purposes in the United States.
The guidelines discuss the structure of ICD-10-CM, including categories, sub-categories, and codes.
The use of the seventh character extension in coding is explained, along with the use of placeholders.
The video explains the use of abbreviations such as NEC (Not Elsewhere Classifiable) and NOS (Not Otherwise Specified).
The importance of understanding the use of brackets, parentheses, and colons in the ICD-10-CM is highlighted.
Inclusion and exclusion notes are discussed, explaining how they guide code assignment.
The video touches on the sequencing guidelines for conditions with underlying etiologies and manifestations.
The use of the term 'end' in code titles is clarified, indicating a presumed causal relationship.
The video emphasizes that code assignment must be based on provider documentation, not just clinical criteria.
The video concludes by encouraging viewers to subscribe for the next parts of the ICD-10-CM guidelines series.
Transcripts
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