Section III. USE OF ICD-9-CM
a. In the ICD-9-CM, the tabular list is in Volume 1 and the alphabetical index is in
Volume 2. Having the alphabetical index in a separate volume eliminates turning pages
back and forth and makes it easier to verify codes in Volume 1. Volume 3, the
procedures manual, contains both the tabular list and alphabetical index. The
alphabetical index is located at the back of Volume 3.
b. As explained in lesson 1, each ITR must have two copies of an ITRCS: a
handwritten physician's work copy and a typewritten copy. The physician writes the
diagnoses and any procedures the patient undergoes on the work copy of the ITRCS.
When the work copy is received in the Patient Administration Division, you locate the
diagnostic or procedural codes in the ICD-9-CM. These codes are entered on the
typewritten copy (see figure 2 -2).
c. Since medical nomenclatures (names) may be obtained from laboratory
reports, radiological reports, consultations, and other sources where information is
recorded by approved and authorized clinicians, medical officers, and dental officers,
the patient administration specialist must check the clinical record thoroughly for any
nomenclature or qualifying terms that may have been overlooked. Although the
ICD-9-CM set of volumes is not provided to physicians for their use as guides in
expressing diagnoses, physicians are not precluded from using them to assist medical
records personnel in the proper coding of diseases and surgical procedures.
d. The nomenclature of a diagnosis or procedure must be as explicit and
complete as possible. In addition to the name of the disease or pathological condition,
body parts or anatomical sites must be given, when relevant, and terms such as "right,"
"left," "bilateral," "posterior," and "anterior" must be included, when applicable.
e. In coding diseases and injuries, you should locate the diagnoses in the
Alphabetical Index, Volume 2, then verify the diagnoses in the Tabular List, Volume 1.
Close attention to any notes or directions found in Volume 1 is necessary for accurate
coding. Since you must begin the coding process with the Alphabetical Index of Volume
2, it will be covered first.
2-14. ARRANGEMENT OF THE ALPHABETICAL INDEX
a. The Alphabetical Index is divided into three sections.
(1) Section I, "Alphabetical Index to Diseases and Injuries." This section
contains an alphabetical index of diseases, injuries, and other conditions, except
poisoning or other adverse effects of drugs and other chemical substances.