list and describe the four steps necessary to establish the proper ICD-9-CM code.
To establish the proper ICD-9-CM code, you need to follow these four steps:
1. Identify the Main Term: Start by identifying the main term that describes the patient's condition or symptom. This can typically be found in the medical documentation provided by the healthcare provider.
2. Locate the Alphabetic Index: Once you have identified the main term, locate it in the Alphabetic Index section of the ICD-9-CM coding manual. The Alphabetic Index lists terms in alphabetical order and provides a list of possible codes associated with each main term.
3. Verify the Code in the Tabular List: After locating the main term in the Alphabetic Index, verify the code in the Tabular List section of the ICD-9-CM manual. The Tabular List provides detailed information on each code, including the applicable subterms, instructional notes, and any necessary code modifications.
4. Assign the Code: Once you have verified the code in the Tabular List, assign it to the patient's condition or symptom. Ensure that you apply any necessary modifiers or additional codes indicated in the Tabular List to accurately capture the patient's diagnosis.
It's important to note that these steps are specific to the ICD-9-CM coding system, which is no longer in use as of October 1, 2015. Since then, healthcare providers have transitioned to the ICD-10-CM coding system, which uses a similar process but with different code sets and manuals.