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

The video begins with Victoria, a medical coder auditor and educator, welcoming viewers to her series on the ICD-10-CM 2021 coding guidelines. She emphasizes the importance of understanding Section 1b, the general coding guidelines, and encourages viewers to watch the previous video for context. Victoria explains the process of locating a code in ICD-10-CM, starting with the alphabetic index and verifying the diagnosis in the tabular list. She stresses the importance of following additional guidelines and using the full extent of the code, including the seventh character when available. Victoria also discusses the significance of a dash at the end of an alphabetic index entry, indicating the need for additional characters.

In this paragraph, Victoria delves into the level of detail required for encoding diagnosis codes, emphasizing that codes should be reported at the highest number of characters available. She explains the composition of ICD-10-CM diagnosis codes, which can be three to seven characters long, with each additional character providing more detail. Victoria also addresses the coding of signs and symptoms in the absence of a definitive diagnosis, such as using a code for abdominal pain when further testing is needed. She further discusses the conditions under which additional coding is acceptable, including when a patient has a symptom that is not typically associated with their disease process, like a rash in a patient with the flu.

Victoria continues her discussion on coding by addressing the use of additional codes for conditions like bacterial infections and the 'code first' principle for certain diagnoses. She explains the use of secondary codes and the importance of following the correct sequencing. The video also covers coding for acute and chronic conditions, combination codes, and sequelae. Victoria introduces the concept of social determinants of health, highlighting that for the first time, ICD-10-CM 2021 guidelines allow for coding based on medical record documentation from clinicians other than the patient's provider, and even patient self-reported information for certain circumstances.

This paragraph focuses on the guidelines for coding in various healthcare encounters, including the treatment of bilateral conditions, the use of codes based on documentation by non-physician clinicians, and the reporting of the same diagnosis code only once per encounter. Victoria clarifies the use of codes for conditions like BMI, coma scale, and NIH stroke scale, which can be based on documentation from other clinicians. She also discusses the new guidelines for coding social determinants of health, emphasizing that such codes should be reported as secondary diagnoses and are only applicable for certain conditions.

Victoria concludes the video with a discussion on coding for healthcare encounters in the aftermath of a hurricane. She explains the use of external cause of morbidity codes to identify the cause of injuries resulting from a hurricane and how these codes should be sequenced. Victoria emphasizes that these codes are supplemental and should not be used as the principal diagnosis. She provides examples of how to assign codes for injuries resulting from different hurricane-related events, such as building collapse or flooding, and also discusses the use of Z codes to further explain the reasons for healthcare encounters in such situations.

In the final paragraph, Victoria wraps up the video by encouraging viewers to like, share, and subscribe to her channel for more content on ICD-10-CM coding guidelines. She reminds viewers to turn on notifications to stay updated with the series and expresses her hope that the video was helpful. Victoria looks forward to continuing the discussion in the next episode, encouraging viewers to keep learning and improving their coding skills.