Medical Coding Training and Placements In Hyderabad

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Chapter 4Basic Steps of Coding
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Learning Objectives

• Assign a diagnosis or procedure from the
  Alphabetic Index using main terms, subterms, and
  essential modifiers
• Explain the necessity of referencing the
  Alphabetic Index and the Tabular List
• Describe basic steps of coding
• Explain how to use both Alphabetic Index and
  Tabular List
• Know more at Medical Coding Training Hyderabad

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Basic Steps of Coding

• Review the health record
• Identify the diagnoses and procedures to be coded
• Identify the principal diagnosis and principal
  procedure
• Identify main term(s) in the Alphabetic Index
• Review any subterms under the main term in the
  Index
• Follow any cross-reference instructions, such as
  see also

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Basic Steps of Coding

• Verify the code(s) selected from the Index in the
  Tabular List
• Refer to any instructional notation in the
  Tabular
• Assign codes to the highest level of specificity
• Code the diagnoses and procedures until all
  elements are completely identified and sequenced
  in accordance with any applicable guidelines

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Review the Health Record

• Goal of the review
• Identify all diagnoses and procedures to be coded
• Identify the principal diagnosis and principal
  procedure
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Review the Health Record

• Looking for a principal diagnosis/principal
  procedure
• Key pieces to review the record
• Discharge summary
• Look for diagnoses and procedures
• Not the only place to look
• May not be available
• Long stays can be a problem
• Not all diagnoses currently applicable
• History of versus current treatment issues

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Review the Health Record

• Other places to look for a principal diagnosis
• Emergency Room record
• Chief Complaint (CC)
• Diagnosis for admission
• Possible
• Known
• Differential

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Review the Health Record

• Keep on looking!
• More places to look for diagnosis and procedures
• Progress notes
• Operative reports
• Anesthesiology notes
• Consultations
• Identify all diagnoses and procedures

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Alphabetic Index

• Two alphabetic indexes
• diseases
• procedures
• Locate the Main Term in the Index of Diseases
• Example Locate pneumonia in the alphabetic index

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Alphabetic Index
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Alphabetic Index

• Main term key points
• Disease conditions
• Nouns
• Not body parts or sites
• Subterms
• Further specificity
• Example locate Klebsiella pneumonia

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Alphabetic Index
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Alphabetic Index

• Which is the main term?
• Gastric upset
• Chronic mastoiditis
• Herpes simplex
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Alphabetic Index

• Main terms more than one place to look
• Eponyms
• Disease or syndrome named for a person
• Adjectives and anatomic sites are generally not
  main terms
• See condition

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Alphabetic Index

• Mandatory directions
• See
• Other directions
• See also
• General rule exceptions
• V codes
• Pregnancy, labor, and the puerperium
• Late effects
• Never code from the index!

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Alphabetic Index

• Location of the Main Term in the Index of
  Procedures
• Main terms for procedures are identified by the
  type of procedure performed
• Not listed by anatomic site
• Places to look
• Excision, incision or removal

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Alphabetic Index
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Alphabetic Index
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Alphabetic Index

• Terminology in the procedure index
• Different terminology can be confusing
• Try alternative terms
• Example Swan Ganz is a type of catheter
• Never code from the index!
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Alphabetic Index

• Example The operative report (OR) describes the
  procedure as a laparoscopic appendectomy
• Look up appendectomy in the Alphabetic Index
• Look up intramedullary nailing of the leg

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Tabular List

• Verify your code in the tabular list
• Look for exclusion notes
• Look for other instructional notes
• Browse the tabular
• Use Coding Clinic for clarification
• Example code it - patient in psychiatric unit
  with anorexia

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Tabular List

• Look up arteriovenous malformation of the
  intestine

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Tabular and Alphabetic Rules

• Never code directly from the alphabetic index
  without reviewing the tabular list
• Never code from instructional notes within the
  tabular without first reviewing the actual
  tabular listing
• Never code directly from the tabular
• Always check both locations

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Chapter Highlights

• Basic Steps of Coding
• Review of the Health Record
• Alphabetic Index
• Location of the Main Term in the Index of
  Diseases
• Location of the Main Term in the Index of
  Procedures
• Verify in the Tabular List

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THANK YOU
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