Four Types of Diagnostic Codes and How to Transcribe Them
What It Is
This discussion is regarding ICD-10 codes taken from the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, a medical classification list by the World Health Organization. International Classification of Diseases (ICD) codes are found on patient paperwork, including hospital records, medical charts, visit summaries, correspondence, and bills. These codes ensure that patients receive proper treatment and are charged appropriately for any medical services received.
Types of Coding
The Certified Professional Coder certification (CPC®), is the established standard for medical coding in physician office settings and hospitals. Certified professionals help maintain compliance and profitability within healthcare practices through accurate medical coding and documentation. CPCs have demonstrated mastery of all medical code sets, evaluation and management principles, surgical coding, pathology coding, dentistry coding with adherence to documentation and coding guidelines through rigorous examination and experience.
Before the CPCs can do their jobs, however, the diagnostic codes must be dictated and transcribed by a Medical Transcriptionist/Healthcare Documentation Specialist (MT/HDS). When transcribing, the codes are typed adjacent to the diagnosis for which they are intended (see codes below). Tab the codes over so they are easy to recognize and the report looks neat. Do not bury the codes within a diagnosis paragraph. Make sure they are positioned so that they are easy to spot for the coder. Medical coding is transcribed in arabic numerals with letters, decimal points, colons, brackets, and parentheses sometimes used. The more specific the dictated diagnoses, the better the coding can be.
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. The subcategory describes the digit that comes after the decimal point. This digit further describes the nature of the illness or injury and gives additional information as to the location or manifestation of the illness or condition.
Examples of Diagnostic Codes
Below are five samples, transcribed in different styles, that show exactly how coding is typed along with the exact meanings of each individual diagnostic code (see bolded exemplary remarks).
IMPRESSION
- Undisplaced fracture involving the left clavicle with abrasions and contusions. S42.001A
S42.001A Fracture of unspecified part of right clavicle, initial encounter for closed fracture
- Fracture involving the mandible. S02.600A
S02.600A Fracture of unspecified part of body of mandible, unspecified side, initial encounter for closed fracture
FINAL DIAGNOSES
- Chronic cholecystitis K81.1
K81.1 Chronic cholecystitis
- No evidence of malignancy is seen in these sections.
(No code exists for this comment.)
DIAGNOSTIC IMPRESSION: Mild to moderate osteoarthritis of the right knee, stable for viscosupplementation with Synvisc injection #2. M17.11
Because the above diagnosis is not specified as to whether the patient’s osteoarthritis is primary or post-traumatic, either of the following codes might be correct. If the code is dictated, then transcribe as dictated.
M17.11 Unilateral primary osteoarthritis, right knee
or
M17.31 Unilateral post-traumatic osteoarthritis, right knee
ASSESSMENT
- Otitis externa, infective. H60.393
H60.393 Other infective otitis externa, unspecified ear
- Bronchitis J40
J40 Bronchitis, not specified as acute or chronic
ASSESSMENT: Rule out appendicitis. K35.80
If this is an outpatient, this assessment has no diagnostic code; however, if it is an inpatient, all “rule-outs” are coded as the dictated condition, so the diagnostic code would be: K35.80 Unspecified acute appendicitis
Thanks to Jennifer Della’Zanna, CPC, CGSC, CEHRS, CHDS, AAPC Fellow, for her help with the above diagnostic codes and their specific meanings in ICD-10.
Abbreviations
As for medical coding acronyms and abbreviations, here are the top 25 you are sure to come up against:
ATD – Applied to Deductible
The funds owed to the provider, as determined and fixed by the agreed insurance policy.
AOB – Assignment of Benefits
Funds paid directly to the medical provider.
BCBS – Blue Cross Blue Shield
COB – Coordination of Benefits
Essentially which insurance agency is the primary provider, and which is the secondary when a patient has more than one policy.
DOS – Date of Service
DCI – Duplicate Coverage Inquiry
When an insurance provider contacts another to see if they’re currently providing specific coverage.
EDI – Electronic Data Interchange
The electronic network that collects information before delving it out to particular individual insurance providers.
Page 4
EFT – Electronic Funds Transfer
Transferring money electronically. A credit or debit charge or transfer must take place.
EMR – Electronic Medical Records
Digitally formatted health records: the complete record of a patient that is sent to a healthcare provider and/or insurance agency.
EOB – Explanation of Benefits
An explanation of what the insurance company provides, usually consisting of covered charges, payment methods, deductibles, patient responsibility and potential write-offs.
FDCPA – Fair Debt Collection Practices Act
Law explaining the guidelines for creditors and collections agencies trying to collect from delinquent accounts.
FI – Fiscal Intermediary
The Medicare official that handles Medicare claims and cases.
HIPAA – Health Insurance Portability & Accountability Act
HMO – Health Maintenance Organization
A healthcare policy that requires a gatekeeper or primary care physician. If a situation calls for further action, this gatekeeper will refer the patient to a different specialist.
INN – In-Network
A medical care provider that is contracted with the specific insurance provider used by a patient.
IPA – Independent Practice Association
The group of medical care providers contracted with an HMO plan.
Page 5
N/C – Non-Covered Charge
A healthcare service that is not covered by the insurance policy.
NEC – Not Elsewhere Classifiable
The abbreviation used on ICD forms when the information given does not permit a more refined assignment.
NOS — Not otherwise specified
OON – Out of Network
A medical service provider that does not currently work with the specific insurance agency.
PPO – Preferred Provider Organization
A network of medical care providers that patients are allowed to visit, as determined by the insurance agency.
PHI – Protected Health Information
Basic patient information that remains classified, usually consists of name, date of birth, social security number, insurance ID, medical records and telephone numbers.
TIN – Tax Identification Number
The specific number assigned to an individual for tax filing and tracking purposes.
TOP – Triple Option Plan
The cafeteria-style insurance plan that offers a choice of HMP, PPO or traditional insurance policies.
UCR – Usual Customary & Reasonable
The coverage limitations set in place by an insurance patient. Limits the maximum amount of funding a company will pay for a service.
WC – Workers’ Compensation
Work-related injury insurance claim
Written by Patricia A. Ireland, CMT, AHDI-F Medical Transcription Instructor, Consultant
