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CE Course Description

The importance of consistent and complete medical documentation in the medical record cannot be overemphasized.  Without such documentation, accurate coding cannot be achieved.  This CE course provides medical coding guidelines which have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: AHA, AHIMA, CMS, and NCHS.  Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).

Author:  Centers for Medicare & Medicaid Services and the National Center for Health Statistics.  ICD-10-CM Official Guidelines for Coding and Reporting.  10th Revision, Clinical Modification.  (2019).

Retrieved from:  https://www.cms.gov/medicare/coding/icd10/2019-icd-10-cm.html

CE Course Objectives

1. Compare and contrast the Tabular List and the Alphabetic Index.
2. Define colonization.
3. Determine when Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied.
4. Evaluate what should be done when both the associated non-infectious condition and the infection meet the definition of principal diagnosis.
5. Provide an exception to the Excludes1 definition.
6. Rate the priority of external cause codes.

CE Outline with Main Points

1.  Conventions, general coding guidelines and chapter specific guidelines

a.  Conventions for the ICD-10-CM

b.  General Coding Guidelines

c.  Chapter-Specific Coding Guidelines

2.  Selection of Principal Diagnosis

a.  Codes for symptoms, signs, and ill-defined conditions

b.  Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis

c.  Two or more diagnoses that equally meet the definition for principal diagnosis

d.  Two or more comparative or contrasting conditions

e.  A symptom(s) followed by contrasting/comparative diagnoses

f.  Original treatment plan not carried out

g.  Complications of surgery and other medical care

h.  Uncertain Diagnosis

i.  Admission from Observation Unit

j.  Admission from Outpatient Surgery

k.  Admissions/Encounters for Rehabilitation

3.  Reporting Additional Diagnoses

a.  Previous conditions

b.  Abnormal findings

c.  Uncertain Diagnosis

4.  Diagnostic Coding and Reporting Guidelines for Outpatient Services

a.  Selection of first-listed conditions

b.  Codes from A00.0 through T88.9, Z00-Z99

c.  Accurate reporting of ICD-10-CM diagnosis codes

d.  Codes that describe symptoms and signs

e.  Encounters for circumstances other than a disease or injury

f.  Level of Detail in Coding

g.  ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit

h.  Uncertain diagnosis

i.  Chronic diseases

j.  Code all documented conditions that coexist

k.  Patients receiving diagnostic services only

l.  Patients receiving therapeutic services only

m.  Patients receiving preoperative evaluations only

n.  Ambulatory surgery

o.  Routine outpatient prenatal visits

p.  Encounters for general medical examinations with abnormal findings

q.  Encounters for routine health screenings

ACE credit is not offered for this course. A list of courses offering ACE credit can be found here.

Course Development: Each course is identified and reviewed by the appropriate Quantum Units Education consultant with professional and licensed expertise in the various disciplines we serve. Our professional consultants oversee course development to satisfy the needs of various professionals based on their board requirements, rate course degrees of difficulty and ensure the course content and exam questions are appropriate, relevant and comprehensive. See our professional staff and their bios here.

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Added On: 01/01/2020