By now, everyone dealing with medical coding should have made the switch from ICD 9 to the new and improved ICD 10 system. This latest edition from the International Classification of Diseases brings with it a large number of changes that everyone must adjust to. There will definitely be an extended learning curve as the new system holds at least five times more data than the old one. When it comes to ICD 10 diagnosis code descriptions here are a few things you need to know to help you get started.
Active Treatment:
When a code includes the letter A it represents an active treatment of an injury. When coding injuries, always include a 7th character extender that will define the area of care and the healing status. Throughout the course of treatment, the diagnosis code will remain unchanged but the 7th character extender will not.
These initial changes can be very confusing because each coded letter has a specific designation. The letter A ,for example, focuses on initial care given to a patient whereas the letter D is for any subsequent encounter, and S is for sequelae. Many may wonder when would initial care begin and a subsequent encounter start. According to the guidelines that accompany the new ICD 10 diagnosis code descriptions, it states that coders should not just use that 7th character designation only for the first encounter with a patient but should continue to use it on follow-up visits if the patient is still receiving active treatments. Coders should switch to the D designation changes only when the patient is receiving routine care or in a recovery phase of treatment.
Bilateral Diagnosis Codes:
Another question that arises with the new coding system is a need for the clarification of the word 'bilateral'. This is likely to come up when coding treatments involve two lateral parts of the body. For example, was the right knee or the left knee treated or was the injury to the right eye or the left eye. If a patient is experiencing pain in both knees the coder should report two different codes indicating both right and left knee pain. The bilateral diagnosis codes should not change how you report the procedure but coders should continue to use modifiers and report the condition twice if dealing with both lateral parts of the body are being treated.
Causes Of Injury:
When reporting causes of injury with the new coding system, follow the index of external causes that best describe how the injury occurred. Even though in many cases, these codes are optional some payers (insurance companies for example) may require them in order to process the proper payments. These codes are detailed and may be difficult to find but if they are required, coders will have to take the extra time to seek them out and learn how to use them.
The new ICD diagnosis code descriptions are very detailed and there is a lot to be learned in order to use them well. However, once they are learned they will provide a much more accurate coding system that will make understanding all types of patient treatments clear for everyone concerned.