5 Quick ICD-9-CM Coding Tips

5 Quick ICD-9-CM Coding Tips

Always document and code to the highest specificity of the diagnosis for the services rendered. The ICD-9-CM Manual describes guidelines for outpatient/office visit diagnosis coding, as follows:

  1. Diagnosis and procedure codes are to be used at their highest number of digits available (highest degree of certainty) for the encounter/visit;
  2. List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided;
  3. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis,” or other similar terms indicating uncertainty;
  4. Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management;
  5. Do not code conditions that were previously treated and no longer exist.

The Diagnostic Coding and Reporting Guidelines for Outpatient Services are found in the ICD-9-CM Manual, Coding Guidelines (Section IV). The diagnoses should be sequenced in order, starting with the problem/condition chiefly responsible, then any secondary problems/conditions relevant for the services rendered. In best practice, the provider uses a system to identify the order in which diagnoses should appear on the claim form.

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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