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Coding ManualV7
For Hospitals and Other Healthcare Institutions
1st June, 2012
2011 Code Sets
Table of Contents
Page Number 1. Coding Guidelines
1.1
Statement of Coding Ethics
6 1.2 Coding Terms Definitions 8 1.3 Health data Elements for Standardization 13 1.4 Coding Conventions 14
1.4.1.
General
14 1.4.2. Admitting Diagnosis 17 1.4.3. Principal Diagnosis 18 1.4.4. Secondary Diagnosis 20 1.4.5. Outpatient and Ambulatory Patient Coding
21 2. Coding Diagnostic Guidelines
2.1
Body Systems
25
2.1.1.
Infectious and Parasitic Disease
25 2.1.2. Neoplasms 31 2.1.3. Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders 34 2.1.4. Disease of the Blood and Blood Forming Organs 37 2.1.5. Mental Disorders 38 2.1.6. Disease of the Nervous System and Sense Organs 38 2.1.7. Diseases of the Circulatory System 41 2.1.8. Diseases of the Respiratory System 45 2.1.9. Diseases of the Digestive System 47 2.1.10 Diseases of the Genitourinary System 47 2.1.11. Complications of Pregnancy, childbirth and the Puerperiuim 48 2.1.12. Diseases of the Skin and Subcutaneous Tissue 53 2.1.13. Diseases of the Musculoskeletal System and Connective Tissue 55 2.1.14. Congenital Anomalies 55 2.1.15. Certain Conditions Originating in the Perinatal Period 56 2.1.16. Symptoms, Signs and Ill Defined Conditions 58 2.1.17. Injury and Poisoning 59 2.1.18. Supplementary Classification of Factors Influencing Health Status and Contact with Health services 67 2.1.19. Supplementary Classification of External Causes of Injury and Poisoning 112 3. Coding Procedure Guidelines
3.1
Introduction CPT 4th Edition – 2011
118 3.2 Procedure Terms and Guidelines 120 3.3 Place of Service Codes 125 3.4 Modifiers 127 3.5 Unlisted Procedures or Services 129 3.6 Add-on Codes 129
Page Number
3.7
Time
130 3.8 Evaluation and Management 133 3.9 Anesthesia 142 3.10 Surgery 143
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