Home Health & Hospice

Q: We have a new coder working with our agency, what steps should we highlight for accurate coding?

Homecare Insider, November 18, 2013

Q: We have a new coder working with our agency, and it would be great to give them a step-by-step overview for accurate coding. What steps should we highlight?

A: To code correctly, you need to follow certain steps, especially if you are new to coding. Here are the five steps coders need to follow to obtain the correct code:

Step 1: Locate the diagnosis in the Index to Diseases and Injuries. Locate the main term in the Alphabetic Index to Diseases and Injuries. Certain conditions may be listed under more than one main term. Look up the word alphabetically under the most general condition first. Indent with more specific information to find the complete code.

Step 2: Refer to notes under the main term. The main term is the word in boldface type. Follow the instructions in any notes that may appear in a box immediately after the main term, as well as any cross-reference instructions. You must follow the instructional terms “see” and “see also” to locate the correct code. Note the subterms indented beneath the main term.

Step 3: Verify the code in the Tabular List of Diseases. Confirm the code selection in the Tabular List of Diseases. Verify the selected code with the diagnostic wording. The book is organized in alphabetical order by code, beginning with A–Z. Look for the code numerically; watch for any additional characters needed (up to the seventh character).

Step 4: Read any notes under the main term. The main term is the three-digit rubric. Follow instructional terms in the Tabular List of Diseases. Watch for exclusion terms, notes, and seventh character instructions that apply to the code being verified. Instructional information may be located above the one or more pages after the page containing the code number. To accurately verify the code, return to the three-digit code category. Read any instructions.

Step 5: Assign the code. Finally, you should assign the code number you have determined to be correct. Repeat steps 1 through 4 until all codes have been assigned for each diagnosis listed on the Outcome and Assessment Information Set (OASIS-C). Select ICD-10-CM codes at the highest level of specificity. Assign three-digit codes only if there are no four-digit codes within the coding category. Assign four-digit codes only if there is no fifth-digit subcategory for that category. Assign the fifth-digit subcategory only if there is no sixth-digit subcategory. Assign sixth digit subcategory only if there is no seventh digit extension. Remember, if a seventh digit extension is required, the dummy placeholder “x” must be inserted.