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AMCI ICD-10-CM Coding for Beginners- Part 1

AMCI Medical Coding・2 minutes read

The main takeaway from Mrs. J's presentation on ICD-10-CM includes the importance of understanding category codes, sub-category codes, and the correct coding process, emphasizing the significance of following specific steps to arrive at accurate medical codes. Remember to identify the main term, sub term, look up in the alphabetic index, verify in the tabular list, and use coding instructions to assign the appropriate codes for different medical conditions.

Insights

ICD-10-CM is a complex coding system utilized in healthcare, maintained by different organizations like NCHS and CMS, with specific steps and guidelines for accurate code selection.
The process of identifying main terms and sub-terms within diagnoses is crucial in medical coding, requiring a structured approach to navigate the alphabetic index and tabular list for correct code selection, focusing on diagnostic, active, and eponymous terms.

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Recent questions

What is ICD-10-CM?
A coding system for medical diagnoses.
Who maintains ICD-10-CM?
National Center for Health Statistics.
How many codes are in ICD-10-CM?
Approximately 72,000 codes.
What are the roles of CMS and AHIMA in ICD-10-CM?
CMS manages PCS, AHIMA played a role in development.
What are the steps to look up an ICD-10-CM code?
Check main term, verify in tabular list, review guidelines.

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Summary

00:00

ICD-10-CM: History, Structure, and Lookup

Mrs. J, the curriculum director at AMCI, is an ICD-10-CM instructor.
The presentation's goals include discussing the history and structure of ICD-10-CM, demonstrating code lookup, providing scenarios and quizzes, and showcasing trademarked AMCI techniques.
Trademarks like MCG, TTT, and AMCI Master 7 are associated with AMCI, while CPC and CCS are registered trademarks of AAPC and AHIMA, respectively.
ICD-10-CM is maintained by the National Center for Health Statistics, while PCS is managed by the Center for Medicare and Medicaid Services (CMS).
The process of looking up an ICD-10-CM code involves three steps: checking the main term in the alphabetic index, verifying the code in the tabular list, and reviewing all guidelines.
ICD-10-CM codes can be up to seven characters long, with the first three characters representing the category code.
ICD-10 was developed by the World Health Organization in 1993, with the US creating a clinically modified version, ICD-10-CM, in 2015.
Various organizations like CMS, AHIMA, AHA, and NCHS played roles in developing ICD-10-CM, mandated for use by all covered entities under HIPAA.
ICD-10-CM comprises around 72,000 codes, divided into four sections of guidelines and one appendix, with primary focus on sections 1 and 4.
The alphabetic index is crucial for looking up diagnoses, while the tabular list is where codes are verified, with specific guidelines and notes provided at different code levels.

22:15

Medical Coding: Specific Subcategories and Guidelines

Subcategories are more specific than categories in medical coding.
The fifth character space in a code represents a subcategory.
The fifth character code is even more specific than the four-character code.
The sixth and seventh characters in a code are called codes.
Laterality in codes indicates the side of the body affected.
Codes in medical coding are typically six to seven characters long.
Guidelines are crucial in determining the specificity of a code.
The main steps in looking up a code involve the alphabetic index and tabular list.
The ICD-10-CM code for hyperlipidemia is E78.5.
The ICD-10-CM code for rhinitis is J31.0.
The ICD-10-CM code for psoriasis is L40.9.
The ICD-10-CM code for hypertension is I10.
Eponyms, diagnoses, and active terms help identify the main term in medical coding.
Following a structured approach in identifying main terms can streamline the coding process.

44:34

Identifying Main Terms in Medical Diagnoses

The method advised eliminates unnecessary information, promoting its consistent use for optimal results.
The process of selecting main terms is explained, starting with heart failure as an example.
Heart failure is analyzed to determine the main term, which is identified as "failure" due to its active role.
Abdominal aortic aneurysm is discussed, with "aneurysm" recognized as the main term as it stands alone as a diagnosis.
Bacterial pneumonia is highlighted, with "pneumonia" identified as the main term due to its diagnostic nature.
Eye infection is examined, with "infection" determined as the main term for its diagnostic status.
Bone disorder is explored, with "disorder" established as the main term for its active role.
Parkinson's disease is recognized as an eponym, making "Parkinson's" the main term.
Stricture of the bladder neck is discussed, with "stricture" identified as the main term due to its diagnostic and active nature.
Drug overdose due to barbiturates is analyzed, with "overdose" determined as the main term for its diagnostic status.
Ectopic pregnancy is examined, with "pregnancy" established as the main term due to its diagnostic nature.

01:08:25

Coding Instructions for Medical Conditions

Key takeaways: understanding category code, boss, sub-category code, and code
Red boxes indicate codes that should not be used
If a code has a red box, go one more level for the correct code
For a 7-character code, use a 7-character extender if needed
Instructions for coding: identify main term, then sub term, look up main term in alpha index, then sub term, verify code in tabular list
Example with bunion: main term is bunion, sub term is foot, code is M21.611 for bunion of the right foot
Example with hypertrophy of tonsils and adenoids: main term is hypertrophy, sub terms are tonsils and adenoids, code is J35.3 for hypertrophy of tonsils with adenoids
Example with fibrocystic disease of breast: main term is disease, sub term is fibrocystic, code is N60.19 for fibrocystic disease of breast
Example with bronchiectasis with acute bronchitis: main term is bronchitis, sub term is bronchiectasis, code is J47.0 for bronchiectasis with acute bronchitis
Example with influenza with gastroenteritis: main term is influenza, sub term is gastroenteritis, code is J11.2 for influenza with gastroenteritis

01:35:42

Medical Coding Guidelines and Examples

The diagnosis is influenza gastroenteritis not otherwise specified.
The main term is acute bleeding peptic ulcer.
Coding tip: Assign code with hemorrhage when peptic and GI bleeding are documented.
The code for acute peptic ulcer with hemorrhage is K27.0.
Dementia with aggressive behavior is coded as F03.91.
Acute cystitis due to E. coli infection is coded as N30.00 and B96.20 in that order.

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