ICD-10-CM Official Coding Guidelines
Exam|40 Q’s and A’s
1. Locating a code in the ICD-10-CM - -To select a code in the classification
that corresponds to a diagnosis or reason for visit documented in a medical
record, first located the term in the Index, and then verify the code in the
Tabular List. Read and be guided by instructional notations that appear in
both the Index and the Tabular List.
It is essential to use both the Index and Tabular List when locating and
assigning a code. The Index does not always provide the full code, including
laterality and applicable 7th can only be done in the Tabular list. A dash (-) at
the end of an Index entry indicate that additional characters are required.
Even if a dash is not included at the Index entry, it is necessary to refer to
the Tabular list to verify that no 7th character is required.
-2. Levels of Detail in Coding - -Diagnosis codes are to be used and reported
at their highest number of digits available.
ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6, or 7 digits.
Codes with three digits are included in ICD-10-CM as the heading of a
category of codes that may be further subdivided by the use of fourth and/or
fifth digits, which provide greater detail.
A three-digit code is to be used only if it is not further subdivided. A code is
invalid if it has not be coded to the full number of characters required for
that code, including the 7th character, if applicable.
-3. Code or codes from A00.0 through T88.9, Z00-Z99. - -The appropriate
code or codes from A00.0 through T88.9, Z00-Z99.8 must be used to identify
diagnoses, symptoms, conditions, problems, complaints or other reason(s)
for the encounter/visit.
-4. Signs and Symptoms - -Codes that describe symptoms and signs as
opposed to diagnoses, are acceptable for reporting purposes when a related
definitive diagnosis has not ben established (confirmed) by the provider.
Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings, Not Elsewhere Classified (codes R00.0-R99) contains
many, but not all codes for symptoms.
-5. Conditions that are an integral part of a disease process - -Signs and
symptoms that are associated routinely with a disease process should not be
assigned as additional codes, unless otherwise instructed by the
classification.
, -6. Conditions that are not an integral part of a disease process - -Additional
signs and symptoms that may not be associated routinely with a disease
process should be coded when present.
-7. Multiple coding for a single condition - -In addition to the
etiology/manifestation convention that requires two codes to fully describe a
single condition that affects multiple body systems, there are other single
conditions that also require more than one code. "Use additional code" notes
are found in the Tabular at codes that are not part of an
etiology/manifestation pair, where a secondary code is useful to fully
describe a condition. The sequencing rule is the same as the
etiology/manifestation pair, "use additional code" indicates that a secondary
code should be added.
For example, for bacterial infections that are not included in chapter 1, a
secondary code from category B95, Streptococcus, and Enterococcus, as the
cause of disease classified elsewhere, or B96, Other bacterial agents as the
cause of diseases classified elsewhere, may be required to identify the
bacterial organism causing the infection. A "use additional code" note will
normally be found at the infectious disease code, indicating a need for the
organism code to be added as a secondary code.
"Code first" notes are also under certain codes that are not specifically
manifestation codes but may be due to an underlying cause. When there is a
"code first" note and an underlying condition present, the underlying
condition should be sequenced first.
"Code, if applicable, any casual condition first", notes indicate that this code
may be assigned as a principal diagnosis when the casual condition is
unknown or not applicable. If a casual condition is known, then the code for
that condition should be sequenced as the principal or first-listed diagnosis.
Multiple codes may be needed for late effects, complication codes and
obstetric codes to more fully describe a condition. See the specific guidelines
for those conditions for further instruction.
-8. Acute and Chronic Conditions - -If the same condition is described as
both acute (subacute) and chronic, and separate subentries exist in the
Alphabetic Index at the same indentation level, code both and sequence the
acute (subacute) code first.
-9. Combination Code - -Combination code is a single code used to classify:
Two diagnoses, or
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
Exam|40 Q’s and A’s
1. Locating a code in the ICD-10-CM - -To select a code in the classification
that corresponds to a diagnosis or reason for visit documented in a medical
record, first located the term in the Index, and then verify the code in the
Tabular List. Read and be guided by instructional notations that appear in
both the Index and the Tabular List.
It is essential to use both the Index and Tabular List when locating and
assigning a code. The Index does not always provide the full code, including
laterality and applicable 7th can only be done in the Tabular list. A dash (-) at
the end of an Index entry indicate that additional characters are required.
Even if a dash is not included at the Index entry, it is necessary to refer to
the Tabular list to verify that no 7th character is required.
-2. Levels of Detail in Coding - -Diagnosis codes are to be used and reported
at their highest number of digits available.
ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6, or 7 digits.
Codes with three digits are included in ICD-10-CM as the heading of a
category of codes that may be further subdivided by the use of fourth and/or
fifth digits, which provide greater detail.
A three-digit code is to be used only if it is not further subdivided. A code is
invalid if it has not be coded to the full number of characters required for
that code, including the 7th character, if applicable.
-3. Code or codes from A00.0 through T88.9, Z00-Z99. - -The appropriate
code or codes from A00.0 through T88.9, Z00-Z99.8 must be used to identify
diagnoses, symptoms, conditions, problems, complaints or other reason(s)
for the encounter/visit.
-4. Signs and Symptoms - -Codes that describe symptoms and signs as
opposed to diagnoses, are acceptable for reporting purposes when a related
definitive diagnosis has not ben established (confirmed) by the provider.
Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings, Not Elsewhere Classified (codes R00.0-R99) contains
many, but not all codes for symptoms.
-5. Conditions that are an integral part of a disease process - -Signs and
symptoms that are associated routinely with a disease process should not be
assigned as additional codes, unless otherwise instructed by the
classification.
, -6. Conditions that are not an integral part of a disease process - -Additional
signs and symptoms that may not be associated routinely with a disease
process should be coded when present.
-7. Multiple coding for a single condition - -In addition to the
etiology/manifestation convention that requires two codes to fully describe a
single condition that affects multiple body systems, there are other single
conditions that also require more than one code. "Use additional code" notes
are found in the Tabular at codes that are not part of an
etiology/manifestation pair, where a secondary code is useful to fully
describe a condition. The sequencing rule is the same as the
etiology/manifestation pair, "use additional code" indicates that a secondary
code should be added.
For example, for bacterial infections that are not included in chapter 1, a
secondary code from category B95, Streptococcus, and Enterococcus, as the
cause of disease classified elsewhere, or B96, Other bacterial agents as the
cause of diseases classified elsewhere, may be required to identify the
bacterial organism causing the infection. A "use additional code" note will
normally be found at the infectious disease code, indicating a need for the
organism code to be added as a secondary code.
"Code first" notes are also under certain codes that are not specifically
manifestation codes but may be due to an underlying cause. When there is a
"code first" note and an underlying condition present, the underlying
condition should be sequenced first.
"Code, if applicable, any casual condition first", notes indicate that this code
may be assigned as a principal diagnosis when the casual condition is
unknown or not applicable. If a casual condition is known, then the code for
that condition should be sequenced as the principal or first-listed diagnosis.
Multiple codes may be needed for late effects, complication codes and
obstetric codes to more fully describe a condition. See the specific guidelines
for those conditions for further instruction.
-8. Acute and Chronic Conditions - -If the same condition is described as
both acute (subacute) and chronic, and separate subentries exist in the
Alphabetic Index at the same indentation level, code both and sequence the
acute (subacute) code first.
-9. Combination Code - -Combination code is a single code used to classify:
Two diagnoses, or
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
