Fall 2013

B.Sc/Diploma in Health Information Administration

(B.Sc.HIA/DHIA) Semester IV
BH0047 International Classification of Diseases and Coding

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1. Describe the SNDO Dual system of classification. (10)

Answer:
The Standard Nomenclature of Diseases and Operations (SNDO) represents a dual system of
classification. Each disease entity is described in two ways: first, according to the disease site (organ or
portion of the body concerned), or topography, and secondly, according to the cause of the disease or
etiology. Similarly, operative procedures are classified according to the site, or topography, and according
to the operative technique or procedure employed on that site. The following sample entries will serve to
demonstrate this point:
Every disease and, operative code number consists of two parts separated by a hyphen. In both the disease
and the operative codes, the portion to the left of the hyphen represents the site or topography. The
etiology is shown in the digits to the right of the hyphen in a disease code, while the procedure is shown
in the digits to the right of the hyphen in an operative code. Every disease code must contain a minimum
of six digits, three topographical and three etiological but might be amplified for more detail to as many
as twelve digits plus one or two behavior letters. Operative codes range from three topographical digits
and two procedural digits, to a maximum of ten digits. Completion of Codes -Every disease code must

contain a minimum of three topographical and three etiological digits. However some of the code
numbers listed in the nomenclature section of SNDO does not contain the minimum numbers of digits.
Pyramids (A) appear in the codes in place of some digits. In order to make a complete code number the
pyramid must be replaced by digits. Code numbers containing pyramids are of two types -open-end codes
and master codes.
Open-end Codes -Open-end codes, found only in the topographical section of the code number, have three
pyramids to the left of the hyphen. By referring to the topographical listing in the front of SNDO the
coder is able to fill in the appropriate topographical digits to complete the code. As an example, when
coding the diagnosis of gangrene of the leg due to trauma", the coder would be referred from the index
to the code number -400.1. By checking the topographical listing, one finds that 093- is the site
number for leg. The final code becomes 093-400.1.1f the gangrene occurred in the thumb, the final code
would be 0861-400.1.
It should be noted that open-end codes are not used indiscriminately. If there is an appropriate code listed
for a specific organ in the nomenclature, that specific code is used rather than employing an open-end
code.
Master Codes Master codes differ from open-end codes in two ways. First, master codes contain at least
one digit in the portion of the code with pyramids.
Secondly, the pyramids in master codes are found in either the topographical or etiological portion of the
code, or in both portions. Sample types of master codes are shown below:
18 103
631 4
55 9
Recall that in an open-end code, only the topographical portion of the code contains all pyramids.
Completing a master code number follows the same pattern as completing an open-end code. Reference,
is made to the classification listings in the front of SNDO, and the correct digit or digits found which are
required to complete the code. In all instances, each missing digit should be supplied. The master codes as
well as the open-end code numbers have been used to conserve space in the book. Figure 1.1 is a
composite - from a section of SNDO illustrating how the listings appear.

2. With a help of an example explain the steps in coding. (10)

Answer:
Understanding What the Codes Are used for & Different Coding Systems

According to the American Health Information Management Association, medical codes are used
for reimbursement claims, to calculate the practices and outcomes of health care-related services, as well
as for health care management activities, research and planning purposes. Different health care facilities,
including hospitals, clinics and doctors' offices, use numeric or alphanumeric procedure codes to record
the specific health services performed by health care providers. The standard coding systems are intended
to regulate the classification of these procedures and the fees or charges for them.
Depending on the type of procedure or healthcare establishment, different coding systems may be used.
For example, the medical procedure coding system used can be the: Current Procedural Terminology
(CPT), International Statistical Classification of Diseases and Related Health Problems (ICD), Healthcare
Common Procedure Coding System (HCPS), and Diagnosis Related Group (DRG). Chances are you'll be
using either CPT or ICD-9 (the nine stands for the revision).
Reviewing Medical Documents & Assigning a Code

Look over all of the medical documentations put forward by the health care provider. These
documents may consist of patient records, evaluations, and other like reports that provide detailed data
concerning a patient's illness, injuries, surgical procedures and more. After identifying the medical
procedure, you must then assign and categorize the correct procedural code(s) by using one of the
standard coding systems. The accuracy of the code is critical, as it must abide by all insurance
requirements and federal regulations.
Medical Procedures Codes & Categories & Identification

Consult the manual for the coding system that you are using in order to locate the corresponding
code. As noted by the Centers for Disease Control and Prevention, ICD-9 is centered on the World Health
Organization's Ninth Revision, International Classification of Diseases, and serves as the authorized
method of conveying codes to diagnoses and procedures.
The ICD-9-CM is made up of an arranged numerical directory of the code numbers for all of the diseases,
an alphabetized directory to where the disease code is located in within the manual, and a taxonomy
structure used for surgical, diagnostic, and therapeutic procedures.
Current Procedural Terminology is developed and maintained by the American Medical Association
(AMA). CPT is divided into Category I CPT Codes, Category II CPT Codes, and Category III CPT
Codes. According to the American Medical Association, CPT I Codes are used to signify definite services
or procedures, and the entries are made up of a five digit numeral code and definition. Category I, codes
are also divided by: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and

Laboratory, and Medicine. Category II codes have a set of supplemental tracking codes that may be
employed for performance measurement. Category II code entries are made up of a four digit numeric
code following the letter F. Category III is a temporary set of codes used for emerging technologies,
services, and procedures. These code entries are made up of a four digit numeric code that's followed by
the letter T. Similar to ICD, the CPT Manual is also includes: Section Headings, Subsections, Categories,
Subcategories, Guidelines, Symbols, Colons & Semi-colons Modifiers, Appendices, Indices and
Examples. The classes and grouping within the manuals are intended to make it easier for you to locate
and assign the correct code.
Additional Tips

When it comes to coding medical procedures, it's critical to familiarize yourself with the way
coding systems work and their classification schemes. You'll also want to have a fundamental knowledge
of medical terminology, anatomy and physiology to help you when it comes time to locate the area in
which a code is situated. For example, let's say that you're looking to find the CPT code for a specific
surgical procedure. In CPT, surgery codes are included in the numbers 10000-69999. Next, you'll have to
search in the category's subheading to discover the type of procedure that was performed, the body part or
system it was done on, and supplementary data, like the dimension of an incision that was made.

3. Explain CMIT in terms of purpose and structure of code numbers with examples. (10)
Answer:
CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical
practitioner may provide to a patient (although not a Medicare patient - see note below) including
medical, surgical and diagnostic services. They are then used by insurers to determine the amount of
reimbursement that a practitioner will receive by an insurer when he or she performs that service. Since
everyone uses the same codes to mean the same thing, they ensure uniformity.
CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As
the practice of health care changes, new codes are developed for new services, current codes may be
revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated
annually. Development and maintenance of these codes is overseen by editorial boards at the AMA, and

the publications of all the software, books and manuals needed by those who use them brings millions in
income (*see note below) to the AMA each year.
It should be noted, however, that uniformity in understanding what the service is, and the amount
different practitioners get reimbursed will not necessarily be the same. For example, Doctor A may
perform a physical check up (99396) and be reimbursed $100 by your insurance company. If you went to
Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only
be $90.
Examples of CPT Codes:

99214 may be used for an office visit

99397 may be used for a preventive exam if you are over 65

90658 indicates a flu shot

90716 may be used for chicken pox vaccine (varicella)

12002 may be used to stitch up a one-inch cut on a patient's arm

Some CPT codes are bundled; that is, they are used in combination with each other so they actually
describe a number of aspects of care. You can learn more about bundled medical codes here.
If you use Medicare, you'll see CPT codes, but used a bit differently. Medicare uses HCPCS
codes (Healthcare Common Procedure Coding System) which are an adjusted form of CPT code.

4. What are the guidelines to be followed while selecting preferred main condition when coding
neoplasms? Explain with examples. (10)
Answer:
The word "neoplasm" is often used interchangeably with the word "cancer" despite this inaccuracy.
Neoplasm, which literally means "new growth," is an abnormal mass of tissue, and can be benign (not
cancer) or malignant (cancer).

Understanding the differences in primary, secondary, in-situ, benign and undetermined behavior
neoplasms is the first step in choosing the correct neoplasm code. A primary neoplasmis cancer
(malignant), and designates the location (its origin) of where the cancer started. A secondary
neoplasm (metastases) is cancer (malignant) that designates where the cancer spread. In-situ is cancer
(malignant); however, it is confined to a specific area of origin, such as in the cervix or breast.
A benign neoplasm is not cancer and is a localized tumor that has well-differentiated cells that do not
metastasize or invade surrounding tissues. Some examples of benign neoplasms include lipoma, adeoma
and hemangioma. A neoplasm of undetermined behavior is a diagnosis that can only be utilized if the
pathologist notes in his pathology report that the behavior of the tumor is undetermined.
The general guidelines for neoplasms include first determining if a neoplasm is benign, in-situ, malignant
or of uncertain histological behavior. In addition, if the neoplasm is malignant, determination needs to be
made if there are any secondary (metastatic) sites involved.
The guidelines for neoplasm are divided into nine separate categories to help with assigning the
appropriate neoplasm code(s).
1. Treatment directed at the malignancy
If the treatment is directed at the malignancy, assign the malignancy code as the principal diagnosis. (An
exception to this rule is when the patient is admitted for chemotherapy, radiation therapy or
immunotherapy for the malignancy. In this situation, utilize the V58.x code as the principal diagnosis
followed by the code for the malignancy.) An example of this would be a patient with sigmoid colon
cancer admitted for a colectomy. The principal diagnosis would be the sigmoid colon cancer (primary
site), as opposed to the patient being admitted for chemotherapy for the sigmoid colon cancer. In this
situation, the chemotherapy code would be used as the principal diagnosis (V58.11), with an additional
code for the sigmoid colon cancer.
2. Treatment directed at the secondary site
If a patient is admitted with metastatic cancer, and the treatment is directed toward the secondary
(metastatic) site, utilize the metastatic cancer code as the principal diagnosis followed by the primary
cancer site (if still present) or a V code for a history of the primary neoplasm. An example of this would
be a patient with prostate cancer who is currently undergoing chemotherapy admitted for a severe
headache. After an MRI of the brain, it is determined that the patient has metastatic cancer of the brain
from his prostate cancer. The principal diagnosis would be the metastatic (secondary) brain cancer and an
additional code would be added for the prostate cancer.

3. Coding and sequencing of complications

Anemia is often a result of neoplasms, as well as, therapy directed toward the neoplasm. When a patient is
admitted for anemia due to a neoplasm and the treatment is directed toward the anemia, utilize the code
285.22, Anemia due to neoplasm as the principal diagnosis followed by the code for the neoplasm.
Anemia due to a neoplasm, 285.22, can also be utilized as a secondary diagnosis if the patient suffers
from anemia and is being treated for the malignancy.
When a patient is admitted for anemia due to chemotherapy, immunotherapy or radiation therapy, and the
treatment is directed at the anemia, the anemia code should be the principal diagnosis. An additional code
should be used to capture the neoplasm.
When anemia due to a neoplasm (285.22) and anemia due to chemotherapy (285.3) are both documented
on the same encounter, both 285.22 and 285.3 can be coded. If both are documented as the reason for
admission, based upon coding guidelines, either can be chosen as the principal diagnosis.
When a patient is admitted due to dehydration due to a malignancy or therapy directed at the malignancy,
and only the dehydration is being treated, the dehydration is sequenced as the principal diagnosis
followed by a code for the malignancy.
When a patient is admitted due to complications that resulted from a surgical procedure, code the
complication as the principal or first-diagnosis if the treatment is directed toward the complication.
4. Primary malignancy previously excised
When a primary neoplasm has been excised and no further treatment (i.e., chemotherapy, immunotherapy,
radiation therapy) is being directed toward that neoplasm, and there is no evidence of any existing
primary neoplasm, utilize a code from V10.x for a personal history of a malignant neoplasm. Should an
extension, metastases or invasion to another site be documented, code a secondary malignancy to that
site. The secondary malignancy can be utilized as the principal or first-listed diagnosis followed by a
V10.x code for the personal history of a malignancy.
5. Admission/encounter involving chemotherapy, immunotherapy and radiation therapy
When a patient is admitted for the administration of chemotherapy, immunotherapy or radiation therapy,
the appropriate V58.x code is used as the first-listed or principal diagnosis followed by the code for the
neoplasm(s) that is being treated.

When a patient is admitted for chemotherapy, immunotherapy or radiation therapy, and develops
complications, such as dehydration or uncontrolled nausea and vomiting, code the appropriate V58.x code
as the principal diagnosis followed by codes for the complications.
When a patient is admitted for the surgical removal of a neoplasm and receives chemotherapy,
immunotherapy or radiation therapy after the surgery, the appropriate neoplasm code should be listed as
the principal diagnosis.
6. Admission/encounter to determine extent of malignancy
When a patient is admitted to determine the extent of a primary or secondary malignancy, the malignancy
is coded as the principal diagnosis.
7. Symptoms, signs and ill-defined conditions listed in Chapter 16 associated with neoplasms
Should any signs, symptoms or ill-defined conditions listed in Chapter 16 be related with a primary or
secondary neoplasm, the neoplasm is listed as the principal diagnosis.
8. Admission/encounter for pain control/management
When a patient is admitted for pain control due to pain related to a neoplasm, utilize the code 338.3 as the
principal diagnosis followed by a code for the neoplasm. In addition, 338.3, pain related to neoplasm can
be utilized as the principal or a secondary diagnosis dependent on the reason for admission, and is used if
the pain is acute or chronic.
9. Malignant neoplasm associated with transplanted organ
When a patient is admitted for a malignant neoplasm in a transplanted organ, the principal diagnosis will
be a complication of a transplant (996.8x) followed by the code 199.2, malignant neoplasm associated
with transplanted organ. Also, utilize a code for the specific neoplasm.
To obtain the correct neoplasm code, the coder should carefully read over the documentation, determine
the type(s) of neoplasm(s), assess the reason for admission, and then review the coding guidelines.

CONTACT ME TO GET FULLY SOLVED SMU

ASSIGNMENTS/PROJECT/SYNOPSIS/EXAM GUIDE PAPER
Email Id: mrinal833@gmail.com

Contact no- 9706665251/9706665232/

www.smuassignmentandproject.com
COST= 100 RS PER SUBJECT