M131/HIM1125 Rasmussen College SEC4 Coding Skills Assessment Assignment

To complete the Coding Skills Assessment, complete the following steps.

• Click here to download the Coding Skills Assessment Worksheet.
• Use the ICD-10-CM Codebook to assign codes to each of the given scenarios.
• Sequence codes according to the UHDDS definition of principal diagnosis.
• Add additional diagnoses as appropriate.
• Step 1 – Find a Diagnosis in theAlphabetic Index
• See if you can locate the term Acne. Tofind this term, you need to turn to the Alphabetic Index to Diseases – which isafter the guidelines near the beginning of your book. In the index, the mainterm acne links to the code L70.9But what if the doctor states the diagnosis asAcne rosacea? Now review the indented list below the main term acne (calledsubterms) and find the subterm rosacea. Acne rosacea is coded as L71.9.
  Step 2 – Verify the Code in the TabularList of Diseases

  Once you find a code in the Alphabetic Index, thevery important next step is to verify the code in the tabular. Coders have tobe very careful in assigning a code because what seems like a simple thing todo (linking a name of a disease to a number) isn’t always so simple. There aremany rules involved in coding and by checking the Tabular, coders verify thatthey are assigning the correct code.Find the code L71.9. It’s not too difficult,because this section is in alpha-numerical order. L71.9 Rosacea is the mainterm in the Tabular List. Notice what else is mentioned below it. Other namesfor the same disease are listed, and also a definition of the term acne isgiven. In this case, there are no coding rules involved, and you can assign thecode L71.9.

  Giving it Another Try

  Step 1 – Find the Diagnosis in the AlphabeticIndex Let’s try coding another disease, postmenopausalosteoporosis. We know that step one is to find the disease in theAlphabetic Index – easy enough. But wait a minute – what is the main term ofthe disease? Do we look up the word postmenopausal or osteoporosis?This is where courses like Medical Terminologyand Pathophysiology are going to help you. Osteoporosis is the actual disease, whilepostmenopausal is a subterm that applies to this disorder.

  Asyou practice identifying the main term, if you can’t find it under one word,try another. Remember, the main term will be a disease, injury or conditionthat the patient has. Do not try to find codes by anatomic site.

  Look up Osteoporosis and scan down thesubterms to find postmenopausal. The code for postmenopausal osteoporosis isM81.0Step 2 – Verify the Code in the Tabular Listof DiseasesNotice that M81.0 links to the main term SenileOsteoporosis in the Alphabetic Index. Reading just below the code,Postmenopausal Osteoporosis is listed as another term for the same disorder.Hooray! You found the correct code. Or did you?Take a look at the M81.0 section justabove the code you found, and read the coding rules in red. These rules apply toany codes beginning with M81.0. There is a rule telling you to use anadditional code if other conditions are going on at the same time. In thiscase, you won’t need to use an additional code, but in the real world, this isa reminder to the coder to add other codes if the patient has other relateddisorders.Also, check the M81 category just aboveOsteoporosis. These rules apply to any codes beginning with M81. Notice thereis an Excludes note, where if any of the listed diseases occur at the same timeas osteoporosis, they can’t be coded.Congratulations! You found the correct codeM81.0. As a rule of thumb, remember to always double check your code andcarefully read information the Tabular List tells you.

  Terms	Definitions
  1. Principal diagnosis	The condition established after study to bechiefly responsible for occasioning the admission of the patient to thehospital for care.
  2. Principal procedure	Procedure performed for definitivetreatment, rather than for diagnostic or exploratory purposes, or one thatwas necessary to take care of a complication.
  3. Instructional notes	Provide additional information regardingproper code assignment; examples are: Includes; Excludes; Code First; UseAdditional Code; and Code, If Applicable, Any Causal Condition First.
  4. Main term	Term that identifies disease conditions orinjuries; it is identified in bold print and set flush with the left marginof each column in the Alphabetic Index.
  5. Subterms	Give more specific information about a mainterm; listed below and indented to the right of the main term.
  6. Category	In the Tabular List, a single three-digitcode that describes a disease or similarly related group of conditions.
  7. Subcategory	In the Tabular List, a fourth-digit codethat provides additional information or specificity.
  8. Subclassification	In the Tabular List, a fifth, sixth orseventh characters that provides even greater specificity.
  9. Section	Consists of a group of three-digitcategories that represent diseases or conditions that are similar.
  10. Specificity	Coding to the greatest detail possible for acode.