To improve health care cost and ensure fair reimbursement policies, The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provides guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

I learned that as per ICD-10-CM guidelines, all conditions needs to be coded regardless whether they affect MS-DRG assignment. All Inpatient cases that meets the guidelines of UHDDS needs to be coded which regardless of MS-DRG assignment. For Ambulatory/OP cases only those encounters which are established as medical necessity during the encounter needs to be coded. Supplemental information is also important to capture in coding, these needs to sequenced based upon the circumstances of admission and documentation.

I learned how to lookup the terms under index & then confirming that code in the tabular for accuracy.

I was able to follow each and every guideline to assign primary diagnosis in all my case studies. These understanding helped me to put diagnosis code to highest level of specificity.

ICD-10-PCS is applicable only for inpatient coding. These procedure codes needs to be coded as per documented procedure considered significant as defined by UHDDS. I learned about different root operations and followed procedures guidelines to assign proper codes.

ICD-10-PCS is composed on 16 different sections with specifics like - These codes are 7 digit long and alphanumeric (except letter O and I) and each character place stands for something very specific and contains no decimals.

I also learned that it's important to sequence procedures performed as related to principal diagnosis whenever it is applicable as a treatment of both principal and secondary diagnosis.

Artifacts

Coding abstract - including IP, AMB, Physician case studies.