By now the new ICD 10 medical codes should have been implemented in all facilities that provide medical care across the country. The new coding system was devised by the World Health Organization to be the only set of codes to be used to report medical services. Every healthcare provider who has a basic knowledge of the older ICD 9 system should by now have learned the new ICD 10 medical code basics in order to make sure that the transition runs smoothly. This will require all medical billers and certified coders to acquire an in-depth understanding of the new system and how to apply its principles to their documenting of patient care.
Assigning ICD Codes:
Each code in the new system has its own unique definition. When it comes to accurately coding diagnosis, the code needs to convey the exact aspect of the patient's condition. The healthcare provider should base this coding on four main parts: first, the patient's primary concern and reason for the visit; second, the observations of the healthcare provider; third, the provider's assessment and diagnosis; fourth, a specified plan of care.
When coding in an outpatient setting, the ICD Code is assigned only after a definitive diagnosis has been determined. In cases where the patient is treated in an emergency room or in an ambulance and diagnosis has not yet been determined providers may code based on their suspected condition to justify the services provided.
There is a reason why the new codes need to be more precise. In most cases, the ICD 10 medical code basics dictate that coding needs to be done first and foremost to justify payment of services. Usually insurance companies and other payers responsible for patient care require this information. However, the data collected by these new codes will also be used to compile statistical reports to government agencies, for drug trials, or for tracking activities and duties performed within a healthcare institution.
Primary And Secondary Codes:
Some of the new codes will have primary and secondary roles. In cases where the diagnosis of care is the result of pre-existing conditions, the older condition should be coded as the primary code. However, the new resulting condition discovered may be the underlying cause for the patient's issue. Once that is discovered it must be given a secondary code. This will require coders to know the many nuances of the system to ensure that the codes are issued accurately and the healthcare claims are filed properly.
The new ICD 10 codes are very different from the simpler ICD 9 and it will take new coders time to master them all. The first section of the code focuses on infectious diseases while the second section considers neoplasms. The rest of the system lists every possible definable disease known at the time the system was implemented. It also covers bodily injuries, and a section on complications that may develop from surgery. While coders and medical professionals are required to master the ICD 10 medical code basics, it will take dedication to study and understand the new system and how to implement it properly.