The source document for coding and reporting diagnoses and procedures is the patient's medical record. Coding specialists translate medical terminology from text into codes. They use a set of nationally recognized rules and guidelines to select the correct codes for the services provided and procedures performed. The codes are then used to report data on that patient for the purposes of data collection, quality assurance, reimbursement for the facility, and research, to name just a few. Before beginning this lesson, you should have access to the most recent version of ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification). If you do not have the most recent copy of an ICD-10-CM code book, then click the Resources tab to find and download the necessary documents. Be sure and download both the index and tabular listing of ICD-10-CM as well as the External Cause of Injuries Index, the Table of Drugs and Chemicals, and the Table of Neoplasms. The codes and information in this lesson are updated as needed and receive a comprehensive review annually.
“This program has been approved for 0.50 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
ICD-10-CM Coordination and Maintenance Committee
Coding Methods: Code Book
Coding Methods: Encoder
Coding Methods: Computer-Assisted Coding
The Coding Specialist Structure: Index to Diseases and Injuries Code Structure
Structure: Index to External Causes
Structure: Tabular List of Diseases and Injuries
Expert Reviewer: Sandra L. Macica, MS, RHIA
Marion Gentul, RHIA, CCS is a self-employed Consultant and Health Information Management (HIM) professional.© With 30 years of experience in HIM, Marion specializes in assisting clients with coding, coding education, and transitioning to ICD-10-CM/PCS.© She has been an AHIMA-Approved ICD-10-CM/PCS trainer since 2009.Disclosure: Marion K. Gentul, RHIA, CCS has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Most notably, Marion has authored or co-authored four texts on Health Information topics including Health Information Technology, 3rd Edition by Nadinia Davis and Melissa LaCour and Effective Management of Coding Services, 4th Edition by Lou Ann Schraffenberger, Ed. She has also contributed to the Basic ICD-10-CM/PCS Coding Workbook by Lou Ann Schraffenberger, Ed.
Marion was a recipient of the Mentor Award from AHIMA, the Distinguished Alumna award from the State University of New York at Downstate Medical Center, and the Distinguished Member Award from the New Jersey Health Information Management Association. She is a Past President of the New Jersey Health Information Management Association and has served in several volunteer roles for AHIMA. Marion was also a member of the Coding and Testing Workgroup for the HIMSS/WEDI ICD-10 National Pilot Project.
Formerly an adjunct faculty member at Kean University and Berkeley College in New Jersey, Marion currently serves on the Advisory Board of DeVry University in New Jersey.
Marion earned a Bachelor of Arts in Psychology from the University of Rhode Island and earned her certificate in HIM (formerly Medical Record Administration) from the State University of New York, SUNY Downstate.
Sandra Macica, MS, RHIA serves as the Coding Content Manager for the Revenue Cycle and Compliance segment of Elsevier. In her role, Sandy works with the Subject Matter Experts (authors) to ensure that the coding lessons are relevant, accurate and up-to-date with the latest coding guidelines.Disclosure: Sandra L. Macica, MS, RHIA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Prior to joining Elsevier, Sandy served as a Manager for a consulting firm in upstate New York. She was engaged in projects which assisted inpatient and outpatient health care facilities with regard to ICD-9-CM and HCPCS/CPT coding, billing and documentation reviews, health information services departmental management, Medicare and Medicaid reimbursement issues, compliance strategies and Charge Description Master (CDM) maintenance and consolidation.
Ms. Macica has many years of experience in the Health Information Management profession, previously serving as a Compliance/Reimbursement Specialist, Health Information Systems Supervisor, and Data Quality Specialist at a community hospital. Sandy has served as a clinical practicum instructor and as adjunct faculty in a Health Information Technology program instructing students in ICD-9-CM, CPT, and Pathophysiology. In recent years she has done extensive education for ICD-10-CM/PCS in her role with Elsevier as well as for many HIM associations and other organizations.
Sandy is a member of AHIMA, NYHIMA, and served on the board of Directors as President of the Adirondack Health Information Management Association (AdHIMA) and recently as President of the New York Health Information Management Association (NYHIMA).
Sandy earned a Master of Science degree in Health Service Administration from Russell Sage College in Albany, NY and a Bachelor of Science degree in Medical Record Administration from the SUNY College of Technology in Utica, NY. She is a Registered Health Information Administrator (RHIA), and an AHIMA approved ICD-10-CM and ICD-10-PCS trainer.
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