Chapter 4, Introduction to ICD-10-CM
Diagnosis Coding
*Abstract* - -To abstract from the medical record means to read the medical
record and determine which elements of the encounter require codes.
-*Arrange* - -To arrange codes means to place codes in the order dictated
by the OGCR and instructional notes.
-*Assign* - -To assign codes means to determine codes that accurately
describe a patient's condition, reflect the highest level of specificity possible,
and contain the correct number of characters for that code.
After identifying the first-listed diagnosis or principal diagnosis in the medical
record, the next step is to assign the most specific code possible that
describes the condition. To assign a diagnosis code, first look up the
condition in the Index to Diseases and Injuries, then verify the code in the
Tabular List. Both of these steps MUST be completed each and every time.
[Electronic coding software typically saves much time in this process.]
-ICD-10-CM Manual *Block* or *Subchapter* - -A contiguous range of codes
within a chapter.
-ICD-10-CM Manual *Category* - -A category is three characters in length. A
three-character category that has no further subdivisions is called a *code*.
-ICD-10-CM Manual *Chapters* - -The ICD-10-CM Tabular List of Diseases
and Injuries is further subdivided into *21 chapters*. Each chapter contains
codes for a body system or related conditions. Coders must become
acquainted with the chapter topics within ICD-10-CM as well as the internal
structure within each chapter in order to locate information and follow
instructional notes.
Each chapter is subdivided into *blocks*, *categories*, *subcategories*, and
*codes*.
-*Circumstances of Admission* - -When two or more interrelated conditions
each potentially meet the definition for principal diagnosis, either condition
may be sequenced first if the circumstances of admission (the facts, signs,
and symptoms that require an admission), the Index, or the Tabular List
provide no further guidance.
-*Clinically Significant Condition* - -Those conditions defined by the Uniform
Hospital Data Discharge set as "all conditions that coexist at the time of
, admission that develop subsequently or that affect the treatment received
and/or the length of stay.
Diagnoses that relate to an earlier episode which have no bearing on the
current hospital stay are to be excluded.
-ICD-10-CM Manual *Code* - -A code is the final level of subdivision. Codes
may be three, four, five, six, or seven characters in length. (Examples: Three
Characters: I10; Four Characters: F52.8; Five Characters: K70.30; Six
Characters: L89.511; Seven Characters: L89.511A). *The first character is
always alphabetic and the second character is always numeric.*
All codes in the Tabular List of the official version of the ICD-10-CM appear in
*boldface* type. Entries that require a seventh character are referred to as
codes, NOT subcategories, even though they are not complete without the
seventh character.
-*Coding Paths* - -Conditions may have multiple coding paths, which means
they can be indexed under more than one Main Term.
-*Combination Code* - -A combination code refers to two or more conditions
described by a single code.
Sometimes coders do not necessarily know how many codes will be required
when they begin the process of assigning diagnosis codes. In some cases, a
combination code is available, which describes two or more conditions in a
single code.
-ICD-10-CM Manual *Conventions* - -Conventions are the use of symbols,
typeface, and layout features to succinctly convey interpretive information.
Conventions help you to avoid costly errors and point you in the right
direction. *Coders need to memorize the conventions. Most conventions also
appear in Section 1.A. of the OGCR.
Conventions include: parentheses *( )*, colon *:*, brackets *[ ]*, the word
*and*, *bold*face (heavy type), italics, and terms *code also*, *code first/use
additional code*, *includes notes*, *inclusion terms*, *NEC* (not elsewhere
classifiable), *NOS* (not otherwise specified), *See*, *See Also*, *With*,
*Excludes 1*, *Excludes 2*, *X*, short dash (*-*), and *with/without*.
Coders' skills to recognize and interpret the conventions which are crucial to
interpreting ICD-10-CM instructions and assigning the accurate codes.
In addition to the ICD-10-CM conventions, many individual publishers include
proprietary symbols and color-coding that alert the user to special rules,
warnings, and guidelines.
Diagnosis Coding
*Abstract* - -To abstract from the medical record means to read the medical
record and determine which elements of the encounter require codes.
-*Arrange* - -To arrange codes means to place codes in the order dictated
by the OGCR and instructional notes.
-*Assign* - -To assign codes means to determine codes that accurately
describe a patient's condition, reflect the highest level of specificity possible,
and contain the correct number of characters for that code.
After identifying the first-listed diagnosis or principal diagnosis in the medical
record, the next step is to assign the most specific code possible that
describes the condition. To assign a diagnosis code, first look up the
condition in the Index to Diseases and Injuries, then verify the code in the
Tabular List. Both of these steps MUST be completed each and every time.
[Electronic coding software typically saves much time in this process.]
-ICD-10-CM Manual *Block* or *Subchapter* - -A contiguous range of codes
within a chapter.
-ICD-10-CM Manual *Category* - -A category is three characters in length. A
three-character category that has no further subdivisions is called a *code*.
-ICD-10-CM Manual *Chapters* - -The ICD-10-CM Tabular List of Diseases
and Injuries is further subdivided into *21 chapters*. Each chapter contains
codes for a body system or related conditions. Coders must become
acquainted with the chapter topics within ICD-10-CM as well as the internal
structure within each chapter in order to locate information and follow
instructional notes.
Each chapter is subdivided into *blocks*, *categories*, *subcategories*, and
*codes*.
-*Circumstances of Admission* - -When two or more interrelated conditions
each potentially meet the definition for principal diagnosis, either condition
may be sequenced first if the circumstances of admission (the facts, signs,
and symptoms that require an admission), the Index, or the Tabular List
provide no further guidance.
-*Clinically Significant Condition* - -Those conditions defined by the Uniform
Hospital Data Discharge set as "all conditions that coexist at the time of
, admission that develop subsequently or that affect the treatment received
and/or the length of stay.
Diagnoses that relate to an earlier episode which have no bearing on the
current hospital stay are to be excluded.
-ICD-10-CM Manual *Code* - -A code is the final level of subdivision. Codes
may be three, four, five, six, or seven characters in length. (Examples: Three
Characters: I10; Four Characters: F52.8; Five Characters: K70.30; Six
Characters: L89.511; Seven Characters: L89.511A). *The first character is
always alphabetic and the second character is always numeric.*
All codes in the Tabular List of the official version of the ICD-10-CM appear in
*boldface* type. Entries that require a seventh character are referred to as
codes, NOT subcategories, even though they are not complete without the
seventh character.
-*Coding Paths* - -Conditions may have multiple coding paths, which means
they can be indexed under more than one Main Term.
-*Combination Code* - -A combination code refers to two or more conditions
described by a single code.
Sometimes coders do not necessarily know how many codes will be required
when they begin the process of assigning diagnosis codes. In some cases, a
combination code is available, which describes two or more conditions in a
single code.
-ICD-10-CM Manual *Conventions* - -Conventions are the use of symbols,
typeface, and layout features to succinctly convey interpretive information.
Conventions help you to avoid costly errors and point you in the right
direction. *Coders need to memorize the conventions. Most conventions also
appear in Section 1.A. of the OGCR.
Conventions include: parentheses *( )*, colon *:*, brackets *[ ]*, the word
*and*, *bold*face (heavy type), italics, and terms *code also*, *code first/use
additional code*, *includes notes*, *inclusion terms*, *NEC* (not elsewhere
classifiable), *NOS* (not otherwise specified), *See*, *See Also*, *With*,
*Excludes 1*, *Excludes 2*, *X*, short dash (*-*), and *with/without*.
Coders' skills to recognize and interpret the conventions which are crucial to
interpreting ICD-10-CM instructions and assigning the accurate codes.
In addition to the ICD-10-CM conventions, many individual publishers include
proprietary symbols and color-coding that alert the user to special rules,
warnings, and guidelines.
