When using ICD-9-CM codes, there are four main steps that should be followed to make sure that the code is an accurate description of the diagnosis. Using the Library and other outside references, list and describe the four steps necessary to establish the proper ICD-9-CM code.

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To establish the proper ICD-9-CM code, you can follow these four main steps:

1. Identify the Main Term: Begin by identifying the main term that describes the patient's diagnosis. The main term is often found in the diagnostic statement or medical record, and it represents the condition or disease that best characterizes the patient's primary reason for seeking medical attention.

2. Locate the Main Term in the Alphabetic Index: Once you have identified the main term, proceed to the Alphabetic Index of the ICD-9-CM manual. Look for the main term in the index, ensuring that you select the appropriate code based on the condition and its associated characteristics.

3. Verify the Code in the Tabular List: After locating the main term in the Alphabetic Index, verify the code by cross-referencing it in the Tabular List. The Tabular List contains categories, subcategories, and codes that provide more specific information about the condition, including any necessary modifiers or extensions.

4. Review any Applicable Inclusion and Exclusion Notes: As you locate the code in the Tabular List, make sure to review any inclusion and exclusion notes associated with the code. These notes provide additional guidance and clarification regarding the applicability of the code and help ensure its accuracy in accurately representing the patient's diagnosis.

By following these four steps and utilizing the Alphabetic Index, Tabular List, and relevant inclusion and exclusion notes, you can establish the proper ICD-9-CM code that accurately describes the patient's diagnosis.