HIM1103

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Rasmussen College, Florida *

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1103

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Mechanical Engineering

Date

Dec 6, 2023

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pdf

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17

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Module 02 ICD-10-CM Coding An In-Depth Look at How to Code for Diagnosis Documentation The 3M Encoder will be introduced for ICD-10-CM Coding
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 2 This week it will be important to do your reading assignment from the code book (ICD-10-CM pg. 1-54) and the Blackboard reading material. Also listen to the Live Classroom session before doing any of the assignments. The reading in the code book is critical in helping you to understand how the code book is structured and the coding guidelines are organized as well as how to apply them to the diagnostic statements. It is not intended for you to memorize all of the information. It is important, however, to become familiar with the guidelines and instructions to be able to find the information when needed to code correctly and code according to guidelines. Module 02 Reading Assignment
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 3 Data set for inpatient admissions and all other non-outpatient settings Coded data has many uses e.g. clinical reports, statistical analysis, billing and research to name a few. For data to be useful, there must be consistency in the collection process. UHDDS was created to establish a minimum data set to improve uniformity and comparability of hospital discharge data (Schraffenbergerer & Palkie, 2020). UHDDS definitions include Diagnoses, Principal Diagnosis, Other Diagnoses, Complications, Comorbidity, Significant Procedure, and Principal Procedure and more. The UHDDS definitions along with the Official Coding Guidelines are to be followed when coding all non-outpatient cases (long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.) Coders are responsible for ensuring all coded data is reliable. Uniform Hospital Discharge Data Set (UHDDS)
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 4 There are basic concepts and rules that a coder must understand and apply when assigning ICD-10- CM codes in order to be ethical, compliant, and accurate for reporting purposes (Schraffenbergerer & Pelkie, 2020). For ICD-10- CM there are “General Coding Guidelines” and “Chapter Specific Guidelines”. Review the guidelines in the ICD-10-CM code book. Official Coding Guidelines
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential General Coding Guidelines : How to …locate the guidelines in the front of the code book-Section I B. How to... locate a code and level of specificity (pg. 12) How to… code borderline diagnoses (pg. 17) How to …choose the Principal Diagnosis for inpatient coding-Section II (pg. 105) How to… report additional diagnosis- Section III (pg. 107) How to …code and report Outpatient Services-Section IV (pg. 109) Chapter Specific Coding Guidelines: Located in Section I C of the code book. Contains specific guidelines for specific chapters in the Tabular List. Guidelines are also located in the Tabular List of Diseases and Injuries at the beginning of the respective chapters. 5 Coding Guidelines
12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 6 Read and follow the steps given in Lesson Content under “ICD - 10- CM Coding Steps” and in the code book for a more in depth understanding of ICD-10- CM coding. Read also the “Key Terms” in your course. Remember, learning to code is a skill that requires practice. Learning to code is like learning a foreign language. ICD-10 Coding Steps In Depth
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