Introduction to Surgery Coding

Diagnosis Coding

We are about to begin surgery coding but before we do, I want to go into Diagnosis (ICD-9) coding for just a moment. It is not separated in this course because at this point in your career (the point where you decided you were ready for an "advanced" course) you should be well aware of the basics to diagnosis coding. It is used in every specialty and every setting and thus "advanced" coders, no matter what you code, use diagnosis codes daily.

But as you also know, there are a lot of rules and we forget these or even fall into habitual coding as time passes. I will briefly relay a few things about diagnosis coding coder tend to forget.

  • Do you remember what a main term is? This is the word or phase used to begin the search for a diagnosis code. The word or phrase within the physician's diagnosis that is the term for the condition. (Ex: irritation, otitis, Gunther's disease or syndrome, Hartmann's pouch, detachment, wound)

  • Don't forget there are modifiers in diagnosis coding too! When using your alphabetic index of the ICD-9 book, modifiers are the terms which "modify" your condition. They can be:

    • Essential Modifiers - Words that do effect the code that is selected. These words are found indented under the main term in the alphabetic index of the ICD-9 book.

    • Non-Essential Modifiers - Words that do not effect the code that is selected. These words are found beside the main term in parenthesis within the alphabetic index of the ICD-9 book.

  • V-codes are the codes that describe health care encounters for reasons other than diseases and injuries or they describe reasons that influence the health care or condition of a patient. Hopefully you understand by now that a V-code doesn't mean an automatic rejection. It depends on the benefit structure of the insurance involved and the type of V-code you are utilizing. For instance, the only way to justify removing internal fixation when the injury is healed and its "just time" for it to be removed is to assign a V-code describing "aftercare". Don't let the "old coders" tale fool you.

  • Without the famous unspecific categories, we could not assign a code to an "unlisted" diagnosis or a code to a diagnosis which lacks specifics in the documentation. You and I both know new diseases/conditions are found everyday thus the coding book is not going to have everything and that our providers documentation sometime not so much. But in either case if you know the basics of the disease/condition, you can assign a code. Lets say there is a new disease of the skin and there is not an existing code to describe it, this is when you look up the main term "disease" and then look for the modifying term "skin" (and also "specified type" when it applies). You get the code 709.9 or 709.8.

    • NEC is "Not elsewhere classified". This says you have documentation of a more specific diagnosis but there currently is not a code specific to it. NEC is another way of saying other specified.

    • NOS is "Not otherwise stated". This says the documentation lacks the information to give a specific code. NOS is another way of saying unspecified. Continue to read pages 30-37 of the ICD text book.

  • Last but not least, don't forget about the Official Coding and Reporting Guidelines. The following link will take you to the ICD-9-CM Official Guidelines For Coding and Reporting. It is important for you to know all of the guidelines or at least know where to look when you are in question. Click HERE to review the guidelines.

In addition to reviewing diagnosis coding, I want to remind you of the National Correct Coding Initiative (CCI). This applies to all CPT coding but is especially important for surgery coding. Click HERE to review the most current CCI including chapter specifics remembering that although many other insurance plans follow Centers for Medicare and Medicaid Services (CMS) guidelines, the CCI is specific to the CMS.

The Surgery chapter is broken down into 14 different sections. The whole chapter has guidelines and then each individual area may have additional guidelines. Be sure to read all of these before assigning a code to any surgery.

The textbook has lots of good information which is chapter specific but the general guidelines on the surgery section are found at the beginning of the section within the CPT coding manual. Read through carefully for better review.

As you should know, each surgery section is arranged by body system, then anatomical site starting from the top of the body and working down, then from the outside of the body to the inside, and then by the type of procedure. This organization can help in the code selection process. Locating a code in the surgery section can be very tricky. This is because the terms in reports versus the terms listed in the CPT book can be very different and you must be able to find the 'like' term or use the organization of the CPT book to look for the code.

Now, let's take this valuable information and begin the chapter specifics!

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