Home Health ICD-9/ICD-10 Alert

When it comes to cross-references, know the difference between 'see' and 'see also.'

Know how the alphabetic index is organized. Understanding the construction of an entry in the alphabetic index can help keep you from being overwhelmed, says Carol Spencer, RHIA, with the American Health Information Management As-sociation (AHIMA) in Chicago.

For example: Suppose you were looking for the right code to indicate a personal history of colon cancer. Looking under the main term "History," you'll notice that the sub-terms go in alphabetic order starting with "abuse." If you simply scan through the list to locate the first mention of "malignant neoplasm of colon" (V16.0) you may mistakenly assign a "family history of" code rather than the personal history code (V10.05). Looking up through the indents to see whether you are under the sub-term "family" rather than the sub-term "personal" will help ensure you're making the right code choice.

Tip: Next to the main term, you'll often see terms in parentheses. These are non-essential modifiers for this particular diagnosis. You don't need to find these terms listed in your patient's medical record, but if you do, it's OK, Spencer says. For example, when looking under Hyperthyroidism, you'll see (latent) (preadult) (recurrent) (without goiter) all following the main term.

The alphabetic list isn't entirely alphabetic. For some terms, the alphabetic index starts its list of sub-terms with "with." For example, if you look under the main term "Failure" to find the right code for a patient with renal failure, the first entry you'll see is "with." Following this is a list of sub-terms: abortion, ectopic pregnancy, edema, hypertension, etc. Each of these sub-terms refers you to another set of codes, Spencer says. The codes for acute and chronic renal failure actually follow after the sub-term "with."

Understand the different types of cross-reference notes. As you work through the alphabetic index, you'll find four different types of cross-reference notes: "see," "see also," "see category," and "see condition." Each term requires slightly different action, Spencer says.

• See: You must go and look at these terms. The code for this condition isn't located in the term you are searching under. For example, if you're looking for the correct code for hepatic cirrhosis of the liver, and you look under main term "Hypertrophy, hypertrophic" next to sub-term "liver, cirrhotic" you'll be directed to "see Cirrhosis, liver." Only when you turn to the main term "Cirrhosis" will you find a suggested code.
• See also: Suggests another place you should look if your term isn't listed in this section. For example, under main term "Cellulitis" you'll be directed to "see also Abscess." If you find your target code in the cellulitis section, that's fine, says Spencer. If not, you can also look in the abscess category.
• See category: Just as with "see," you must go and look at these terms.
• See condition: If you look something up by an adjective rather than a condition, you'll find this note. For example, if you look under "Cerebral" to code a cerebrovascular accident (CVA), you'll find "see condition." Refocus your search under the condition -- in this case "accidents" -- and you'll find a section of possible codes as well as a suggestion to "see also" Disease, cerebrovascular.

To make sure your coding is specific and correct, follow these steps, advises Margaret W. Rush, RHIA, HCS-D, with Alacare Home Health & Hospice in Birmingham, AL: