Basic Steps of Coding

Review of the Health Record

As described in Chapter 2 of this textbook, the first step in coding the principal diagnosis (condition established after study to be chiefly responsible for occasioning admission of the patient to the hospital for care), other reportable diagnoses, and procedures is review of the health record.

The discharge summary (DS), if available, may be the first document to be reviewed for code selection. The coder reads the summary to understand the highlights of this encounter. The discharge summary is a synopsis of the events included in a patient’s hospital stay. Most pertinent information is contained in the discharge summary. A physician should list the diagnoses and the procedures that were performed during this encounter. The coder should not solely rely on the discharge summary to capture all diagnoses and procedures that occurred during this encounter.

For many reasons, the discharge summary is not the only document from which codes are captured.

Most coders start the coding process as they begin their document review. A coder is continually trying to determine the principal diagnosis during the record review. Clues to determination of the principal diagnosis can be found in the ER record or in the admitting orders. Physicians, in their admitting orders, give a reason for admitting the patient. When evaluating an ER record, a coder first looks for the chief complaint (CC), which is the reason in the patient’s own words for presenting to the hospital.

As the coder continues the review of the ER document, the ER physician provides a diagnosis for admission to the hospital. The admitting diagnosis is the condition that requires the patient to be hospitalized. This condition may be a sign or a symptom that requires testing and evaluation to determine a diagnosis. This may be a known diagnosis or a probable diagnosis, or it may include a differential diagnosis. In the previous example, the ER physician might document, “Admit patient to the hospital for possible pneumonia, and dehydration.” In this case, the pneumonia has not yet been confirmed, but the dehydration is known.

A differential diagnosis occurs when a patient presents with a symptom that could represent a variety of diagnoses. During the patient’s stay, a variety of studies may be conducted to rule out or confirm the differential diagnoses.

A coder continues on through the health record, reviewing all progress notes, operative reports, anesthesiology notes, and consults to arrive at all diagnoses and procedures that need to be captured or reported.

The second most important concept that a coder must remember (after the definition of principal diagnosis and principal procedure) is that once a term has been located in the Alphabetic Index, the code must then be verified in the Tabular Index. This is not the case in ICD-10-PCS, in which you do not need to refer to the Index before referring to the tables.

Alphabetic Index

The Alphabetic Index consists of an Alphabetic Index to Diseases and an Alphabetic Index to Procedures. In ICD-10-PCS, the purpose of the Alphabetic Index is to locate the appropriate table.

Locate the Main Term in the Index to Diseases

Once the coder begins to establish diagnoses and procedures, the first task in selecting a code is to locate the main term, which is always identified by bold type, in the Alphabetic Index.

Example

Using pneumonia as the principal diagnosis, locate this term in the Alphabetic Index. The code for pneumonia is 486 (JI8.9) (Figure 4-1).

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Related posts:

1. Diseases of the Digestive System: (ICD-9-CM Chapter 9, Codes 520-579, and ICD-10-CM Chapter 11, Codes K00-K95)
2. Diseases of the Blood and Blood-Forming Organs: (ICD-9-CM Chapter 4, Codes 280-289, and ICD-10-CM Chapter 3, Codes D50-D89)
3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
4. Introduction to ICD-10-PCS

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