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This session will walk through a 10-step approach to correct ICD-10-CM coding. This approach is designed to help healthcare organizations improve the accuracy and efficiency of their coding process and reduce the risk of denied claims, and expert Julie will walk through some examples.
10-step approach to correct ICD-10-CM coding is a comprehensive approach that helps healthcare organizations improve the accuracy and efficiency of their coding process. By following these steps, healthcare organizations can reduce the risk of denied claims and improve the overall quality of their coding process.
- Identify the reason for the visit or encounter
- Using the alphabetic index
- Locating the main term
- Scanning sub-term entries
- Understanding the sub-term instructions
- Choosing the code and finding it in the tabular list
- Understanding the tabular instructions
- Understanding the conventions and guidelines
- Confirming the chosen code
- Sequencing the codes
Areas Covered in the Session:
- The proper process for finding the appropriate diagnosis code(s) based on the documentation.
- Identifying the reason(s) for the visit or encounter. Reading and understanding the medical record documentation is the key for this step. The medical record documentation should accurately reflect the patient’s condition, using terminology that includes specific diagnoses and symptoms or clearly states the reasons for the encounter.
- How to find the appropriate diagnose in the alphabetic index is an important step in the process. One of the most critical steps is to ALWAYS start your search in the alphabetic index. Never start your search in the tabular list.
- Locating the main term(s) in the alphabetic index. This requires an understanding of the terms which may be expressed as nouns or eponyms, with critical use of adjectives.
- Scanning and understanding the sub-term(s) and how to apply them. It is vital to review all sub-term entries to ensure you don’t miss the correct sub-term.
- Understanding the instructions included in the ICD-10-CM manual is a major key to finding the correct diagnosis codes.
- Choosing the potential code in the index and then finding that chosen diagnosis code(s) in the tabular list is the next step. To prevent coding errors, always use both the alphabetic index (to identify a code) and the tabular list (to verify a code), as the index does not include the important instructional notes found in the tabular list.
- Reading all of the instructions and information in the tabular list is another major component to finding the correct diagnosis code(s). As a coder, you must follow any Includes, Excludes 1, and Excludes 2 notes, and other instructional notes, such as “Code first” and “Use additional code,” listed in the tabular list for the chapter, category, subcategory, and sub-classification levels of code selection that direct the coder to use a different or additional code.
- Reviewing and understanding the conventions and guidelines will be a critical step in your journey to find the appropriate diagnosis code(s). These guidelines provide both general and chapter-specific coding guidance.
- Confirming the diagnosis code(s) is the 9th step in the process. After reviewing all of the relevant information about the possible code choices, assign the appropriate code for the condition(s) documented in the medical record.
- Finally, the sequencing of the diagnoses for the encounter is critical for proving the medical necessity of the services performed. Sequencing is the order in which the codes are listed on the claim.
- Claims Adjusters
- Surgery Schedulers
- Reimbursement Staff
Julie Davis, CPC, COC, CRC, CPMA, CPCO, CDEO, Approved Instructor has 20+ years of experience in coding, auditing, compliance, documentation improvement, consulting, and teaching. Her background includes coding and auditing for several large multispecialty medical groups, managing coders, auditors, and physician educators for several national consulting companies and multispecialty medical groups, and consulting for national clients. She has created a curriculum and taught a variety of coding courses, for clients, private classes, and AAPC. She is currently a member of the AAPC Documentation Advisory Committee. She has also held officer positions in several AAPC Local Chapters in both California and Colorado.
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