Title: Introduction to Coding and Classification
Course: Introduction to Coding and Classification Systems > Section: Module 1: Introduction to Coding and Classification

Introduction

In Module 1, you will study the first 6 chapters in the AHA ICD-9-CM Coding Handbook/textbook. This will provide the necessary foundation for learning how to code accurately using the ICD-9-CM diagnosis coding classification system and some historical information on the International Classification of Disease, ninth revision, Clinical Modification (ICD-9-CM). We will cover the ICD-9-CM code book format and coding conventions, Uniform Hospital Discharge Data Set (UHDDS), medical record documentation, basic coding steps and the basic coding guidelines in the first week.

It is imperative that you master the first 6 Chapters before progressing on to the actual coding sections in the book and the course!

Course Outcomes

- Recognizes the basic coding steps for coding medical diagnosis in both ICD-9-CM and ICD-10-CM. (1)
- Comprehends the basic coding guidelines established by the American Hospital Association for both ICD-9-CM and ICD-10CM (2)
- Converts medical documentation into both ICD-9-CM and ICD-10-CM codes. (3)
- Interprets medical documentation to assign accurate codes for reimbursement of health care services. (4)
- Applies the official coding guidelines to the coding of medical diagnosis for all body systems (circulatory, respiratory, musculoskeletal, urinary, blood-forming organs, reproductive, gastrointestinal, etc.) (5)
- Demonstrates thorough understanding of selection of the principal diagnosis and any secondary diagnosis associated with the episode of care or hospital admission. (6)
- Demonstrates thorough understanding of the proper sequencing of diagnosis codes for maximum reimbursement of the health care services provided. (7)
- Performs accurate diagnosis code assignment for all body systems based upon the documentation provided in the health record. (8)

Objectives

Upon completion of this module, the student will be able to:

- Explain the basic principles of the medical classification system ICD-9-CM.
- Describe the differences among the three volumes of the ICD-9-CM.
- Demonstrate understanding of the three-, four-, and five-digit subdivisions.
- Explain the alphabetization rules and indentation patterns.
- Differentiate between the codes in volumes 1 and 2 and the procedure codes in volume 3.
- List the different types of instructional notes.
- Explain the importance of additional notes to the coding process.
- Describe the difference between the abbreviations NEC and NOS.
- Use your knowledge of cross-reference notes to navigate the ICD-9-CM.
- Define the specialized meanings of punctuation marks and relational terms in ICD-9-CM.
- Correctly identify a principal diagnosis.
- Understand the guidelines for assigning a principal diagnosis.
- Understand when other diagnoses have significance and should be reported.
- Explain the difference between a principal diagnosis and an admitting diagnosis.
- Explain the importance of accurate and ethical coding.
- Explain what is present in a medical record.
- Understand when it is appropriate to query a physician about his or her documentation.
- Locate code entries in the Alphabetic Index.
- Determine the course of action when there are discrepancies between the Alphabetic Index and the Tabular List.
- Perform basic coding techniques.
- Determine what level of detail to assign to a code.
- Understand how to use combination codes.
- Explain how to assign multiple codes to fully describe a condition.
- Determine what qualifications determine whether an unconfirmed diagnosis is coded as though it were an established diagnosis.
- Explain the difference between "rule out" and "ruled out."
- Code acute and chronic conditions.
- Code a condition labeled "impending," "threatened," or "late effect."

Readings & Resources

Before reading Chapters 1-6, please view the four part video: ICD-9-CM Coding Overview. Also, be certain to bookmark the websites used as resources for both courses.

- Chapters 1-6 and completion of all exercises in the AHA ICD-9-CM Coding Handbook in preparation for test 1.
- General Coding Guidelines
- AHA Coding Central
- Convert from ICD -9 to ICD -10
- ICD-10 Medicare and Medicaid Service Centers
- CMS ICD-10 Website
- Web access for QuadraMed Quantim Coding Reimbursement System http://quantim.ahima.org:8080/topaz/logout.do
- Web access for 3M Coding and Reimbursement System http://3M.ahima.org

To access these online resources you must be a subscriber to the AHIMA Virtual Lab applications through your college or university. Your school's HIT program manager/director will register you for the V-Lab if your school is a subscriber and give you the Username and Password to sign on.

Perfect Practice from the Start
The above link will take you to the assignment page. Follow the directions on how to submit your exercises from the textbook.
Difficult exercises
The above link will take you to the assignment page. Follow the directions on how to submit your work.

Discussion

The above link will take you to the discussion page.  Please read the  directions and post your response.

Quiz

The above link will take you to the quiz for module 1. You may use your coding manuals, textbook, or the coding software to look up your codes and coding guidelines for all the modules' tests. Tests are timed to allow you one hour to complete. You may re-take each test once to improve your score, if you so desire. Typically, tests have True/False, Multiple Choice, Fill in the Blank, and Matching types of questions. The questions are presented one at a time, backtracking is not allowed, and the order of the questions being presented is random.

In this test there are 25 questions worth 2 points each.