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Learning Scope #319
1 contact hour
Expires Nov. 9, 2011
1. Describe ICD-9-CM.
2. Describe the basics of ICD-9-CM code assignment.
3. Summarize the basic tenets of the official coding guidelines.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, take the test online; grade and certificate are available immediately after taking the test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
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The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the U.S. This system has been in use in the U.S. since 1979.
The ICD-9-CM consists of:
• a tabular list containing a numerical list of the disease code numbers in tabular form;
• an alphabetical index to the disease entries; and
• a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list).
The National Center for Health Statistics and the Centers for Medicare and Medicaid Services are the governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM. (Q#2)
In January 1999, the U.S. began using ICD-10 to code and classify mortality data from death certificates. Recently, the U.S. Department of Health and Human Services determined ICD-10-CM will be implemented in the U.S. on Oct. 1, 2013, for morbidity and medical necessity reporting.
All coding is based on the documentation presented in the medical record. Documentation is a reflection of the care your facility is giving. Your documentation reflects the severity of illness and the quality of care you are providing. Failure to document appropriately results in misrepresenting how ill your patients really are. Accurate documentation is essential to reflect true severity of illness, quality and proper utilization of resources.
Documentation must reflect:
• clinical evaluations;
• therapeutic treatments;
• diagnostic procedures;
• extended length of hospital stay; and
• increased nursing care and/or monitoring.
The following are coding basics published in the ICD-9-CM Official Coding Guidelines for Coding and Reporting. These guidelines are periodically updated and are available at the CDC Web site. The most recent guidelines were published on Aug. 31, 2009 and were effective as of Oct. 1, 2009.