18. Basic Steps To Coding ICD-10-CM

CodeMaster Coach
21 Aug 201615:06
EducationalLearning
32 Likes 10 Comments

TLDRIn this educational video from Code Master, Coach, viewers are guided through the foundational steps of medical coding with ICD-10-CM, focusing on the crucial 'locate and verify' method. The video begins by reinforcing the importance of identifying the principal diagnosis from medical records. It then delves into the specifics of locating main terms in the alphabetic index and verifying them in the tabular list for accurate coding. Through practical examples, including urinary tract infections and hernias, viewers learn to navigate the complexities of coding by identifying main terms, subterms, and utilizing non-essential modifiers. This tutorial is essential for understanding the intricacies of medical coding and the importance of specificity and accuracy in the coding process.

Takeaways
  • 📚 The process of coding in ICD-10-CM involves two main steps: locate and verify.
  • 📃 Locating involves finding the main term in the alphabetic index, which is in bold type and flush left with the margin.
  • 🔍 If the exact main term is not found, look for synonyms, eponyms, or alternative wording that conveys the same meaning.
  • 📈 For more specificity, sub terms are used, which are indented to the right of the main term and begin with a lowercase letter.
  • 📝 Non-essential modifiers, words in parentheses beside the main term, can also provide additional context.
  • 👁‍🗨 Verification requires checking the located code in the tabular list to ensure accuracy and completeness.
  • 📆 Codes can be up to seven digits long, requiring attention to laterality (left or right) and applicable seventh digit for full accuracy.
  • 🔧 A dash beside a code in the alphabetic index indicates that additional digits or characters are needed for a complete code.
  • 🔢 Placeholder 'X' is used for codes less than six digits to reach the necessary length for a seventh digit when required.
  • 💾 The transition from ICD-9 to ICD-10 was necessary due to the need for more specific diagnosing and the inclusion of causes and conditions.
Q & A

  • What are the two main steps in coding ICD-10-CM as described in the video?

    -The two main steps in coding ICD-10-CM are to locate and verify.

  • How do you begin the process of coding in ICD-10-CM according to the video?

    -The process begins with locating the main terms in the alphabetic index, which is considered volume 2 but located at the front of the coding book.

  • What are the characteristics of a main term in the alphabetic index as mentioned in the video?

    -A main term is flush left with the left-hand margin, in bold type, and begins with a capital letter.

  • What should you do if you cannot find the main term word-for-word as described in the video?

    -If you cannot find the main term word-for-word, you should look for synonyms, eponyms, and alternative wording that means the same thing as your main term.

  • What is the purpose of sub terms in the coding process according to the video?

    -Sub terms provide greater specificity to the diagnosis by being indented to the right from the main term, in regular type, and beginning with a lowercase letter.

  • What is the significance of non-essential modifiers in the coding process as explained in the video?

    -Non-essential modifiers are words in parentheses beside the main term that, while not critical, can often provide useful context for more accurate coding.

  • How is the main term 'infection' determined from the diagnosis 'Urinary tract infection due to E.coli'?

    -'Infection' is determined as the main term because it describes what is wrong, while 'urinary tract' specifies the location and 'E.coli' the organism causing the infection.

  • What does a dash beside a code in the alphabetic index indicate?

    -A dash beside a code in the alphabetic index indicates that additional digits or characters are required to completely code or assign that code.

  • What role does the tabular list play in the verification step of coding?

    -The tabular list is used to verify the code found in the alphabetic index, ensuring the selection of a full code, including laterality and any applicable seventh digit.

  • How are codes that are less than six digits but require a seventh digit handled according to the video?

    -For codes that are less than six digits but require a seventh digit, placeholder 'X's are used to fill in the gaps so that the seventh digit can be added as specified.

Outlines
00:00
📚 Basic Steps to Coding ICD-10-CM

This segment introduces viewers to the foundational steps of coding with ICD-10-CM, emphasizing the importance of locating and verifying codes. The process begins in the alphabetic index of the coding manual, where main terms related to the diagnosis are identified. These terms are bold, flush left, and begin with a capital letter. If the exact term isn't found, synonyms, eponyms, or alternative wording are suggested. The segment also discusses the role of subterms and non-essential modifiers in achieving specificity in diagnosis. Examples are given to illustrate how to determine the main term from a given diagnosis, such as identifying 'infection' as the main term for a urinary tract infection due to E. coli. The process of verifying the code in the tabular list is briefly introduced, highlighting the necessity of this step for accurate coding.

05:00
🔍 Locating and Verifying Codes in Detail

This part delves deeper into the specifics of selecting a full code, including considerations for laterality and the required seventh digit, which can only be completed by referencing the tabular list. It explains the significance of dashes and placeholder 'X's when looking up codes in the alphabetic index. The importance of detailed coding is underscored by the need for accuracy in medical diagnosis and billing. The narrative includes a practical guide on how to handle various scenarios, such as coding for diseases with known causative agents like E. coli. The speaker shares tips on navigating the coding manual, using examples of common medical conditions to demonstrate how to locate and verify the correct codes.

10:02
🎯 Coding Practice Examples

The final segment provides a practical walkthrough of coding several medical conditions, including a urinary tract infection due to E. coli, a recurrent ventral hernia, and hypertrophy of the tonsils. Each example illustrates the process of identifying the main term, locating the appropriate code in the alphabetic index, and then verifying it in the tabular list for completeness and accuracy. The speaker emphasizes the two-step coding process of 'locate and verify' and offers to provide additional exercises and a lesson plan through email. This segment reinforces the coding principles discussed earlier, aiming to solidify the viewer's understanding and application of ICD-10-CM coding.

Mindmap
Keywords
💡ICD-10-CM
ICD-10-CM stands for International Classification of Diseases, Tenth Revision, Clinical Modification. It is a coding system used to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care in the United States. The video focuses on teaching the basic steps of coding with ICD-10-CM, highlighting its importance in medical coding for accurate record-keeping and billing. The emphasis is on the procedural aspects of using the ICD-10-CM coding system, including locating and verifying codes.
💡Locate and Verify
The 'Locate and Verify' process is emphasized as the two main steps in coding with ICD-10-CM. This involves first locating the correct codes using the alphabetic index and then verifying them in the tabular list. The video demonstrates this process, illustrating how medical coders must navigate through the coding book to ensure accurate coding. Examples include locating main terms, verifying with subterms, and using additional codes for specificity.
💡Main Term
The main term is described as a key element in the alphabetic index of the ICD-10-CM coding system. It is flush left, in bold type, and begins with a capital letter. The video clarifies that the main term is the starting point for locating a code and is typically the condition or diagnosis itself. The process includes searching for the main term that represents what is wrong with the patient, such as 'Infection' in a urinary tract infection.
💡Sub Term
Sub terms are used for greater specificity when coding a diagnosis in the ICD-10-CM system. They are indented to the right from the main term, in regular type, and begin with a lowercase letter. The video discusses using sub terms to refine the search for the correct code, highlighting their role in navigating the coding book for more accurate and specific coding.
💡Non-essential Modifiers
Non-essential modifiers are words in parentheses beside the main term in the ICD-10-CM coding system. They provide additional information that can help in coding but are not crucial for identifying the correct code. The video mentions these modifiers as a tool for coders to use when more context is needed to accurately determine the appropriate code.
💡Alphabetic Index
The alphabetic index in the ICD-10-CM coding book is described as the starting point for finding codes. It is an alphabetical listing of diseases, conditions, and symptoms. The video explains how to use the alphabetic index by identifying main terms and related sub terms, illustrating the first step in the 'Locate and Verify' coding process.
💡Tabular List
The tabular list in the ICD-10-CM coding book contains detailed descriptions of diseases and conditions along with their assigned codes. It is used for verifying the codes found in the alphabetic index. The video emphasizes the importance of checking the tabular list to confirm the full code, including all necessary digits and details for accurate coding.
💡Synonyms, Eponyms, and Alternative Wording
These terms refer to different ways that a condition or diagnosis might be described in the medical record. The video advises coders to look for synonyms, eponyms, and alternative wording if the main term or sub term cannot be found as described. This approach ensures that coders can accurately code a wide range of medical conditions using different terminologies.
💡Placeholder X
The placeholder X is used in ICD-10-CM coding to fill empty character spaces when a code requires a specific length. The video explains that if a code is less than six digits but needs to include a seventh digit, Xs are used as placeholders to reach the required length. This is part of the system's flexibility to accommodate additional details in coding.
💡Seventh Digit Extension
The seventh digit extension is a feature of the ICD-10-CM coding system that allows for the addition of a character to provide further specificity about the condition being coded, such as laterality or episode of care. The video highlights how the seventh digit is crucial for capturing the full scope of the patient's condition, demonstrating its use in the verification step of the coding process.
Highlights

Introduction to the basic steps for coding ICD-10-CM.

The two main steps in coding: Locate and Verify.

Explanation of how to locate main terms in the alphabetic index.

The significance of main terms being flush left, in bold type, and starting with a capital letter.

Using synonyms, eponyms, and alternative wordings if the exact term isn't found.

The role of sub terms for greater specificity in diagnosis coding.

The importance of non-essential modifiers in coding.

Demonstration of locating a main term through the example of a urinary tract infection due to E.coli.

Verification process: Referring to the tabular list to verify the code.

Detailed example of coding a urinary tract infection due to E.coli.

Explanation of coding recurrent ventral hernia by looking up the main term 'hernia'.

Clarification on the use of placeholder 'X' for codes less than six digits but requiring a seventh digit.

The need for ICD-10 due to specificity in diagnosing over ICD-9.

Overview of the process to locate and verify codes with specific examples.

Offer of additional exercises and lesson plans through email.

Transcripts

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