ICD-10-CM Components Latest Update Graded A+

ICD-10-CM Components Latest Update Graded A+ ICD-10-CM a coding system specifically used to identify diseases or injuries for which a patient is being treated. Coding involves an alphanumeric coding structure, which is a combination of letters and numbers. Where to Find Diagnostic Statements in Health Record Operative reports: Contain information or diagnostic statements made by the provider Discharge summary: Reviews a patient's diagnosis at the time the patient is discharged from an inpatient facility Ancillary services reports: Contain information from radiologists and pathologists that support the patient diagnosis through imaging and lab information History and physical exam report: Provide a past look at the patient's health, as well as information about the patient's current physical status used to come up with a diagnosis ICD-10-CM Coding Structure Codes can consist of three to seven characters Character 1 is alpha (letter) Character 2 is numeric Characters 3, 4, 5, 6, and 7 may be either alpha or numeric A decimal is placed after the third character Examples: A18.01 (code for tuberculosis of the spine) O9A.319 (code for physical abuse complicating pregnancy, unspecified semester) S90.922A (code for unspecified superficial injury of left foot, initial encounter) ICD-10-CM Characters 1, 2, 3 The first three characters represent the code category, such as the category in which the disease or injury belongs. An example of a category is Certain Infectious and Parasitic Diseases. ICD-10-CM Characters 4, 5, 6 Characters 4, 5, and 6 represent the etiology, anatomic site, and severity. ICD-10-CM Character 7 If a code has seven characters, the seventh character is also called the "extension code." It is used mainly to define specific details of injury, poisoning, consequences of external causes and pregnancy, childbirth, and puerperium (postpartum). Main Terms (ICD-10-CM) Represent the essence of the disease definition without any details Appear in bold Nonessential Modifiers (ICD-10-CM) Serve as supplementary words or explanatory information Are placed in parentheses Do not affect the code assignment Essential Modifiers (ICD-10-CM) Terms that change the description of the diagnosis (in bold) Indented one space to the right