HIT 202 6,7 Icd-10-Cm coding
steps & Guidelines
In ICD-10-CM Alphabetic Index Diseases and Injuries and the Index to
External Causes include - -entries for main terms (diseases, conditions, or
injuries) and subterms (site, type, or etiology), the Neoplasm Table, and the
Table of Drugs and Chemicals
-Tabular list in ICD-10-CM include - -Categories, subcategories, and valid
codes.
-Basic Coding steps in ICD-10-CM - -Locate the main term in the Alphabetic
Index
- Review subterms and nonessential modifiers related to the main term.
- Follow any cross reference instructions.
- Refer to any notes in the Alphabetic Index.
- A dash (-) at the end of an Index entry indicates additional characters are
required.
Verify the code number in the Tabular List.
- Read the code titles.
- Read and follow any instructional notes. Refer to other codes as instructed.
- Determine whether an additional character must be added.
Assign the verified codes.
-How to locate entry in Alphabetic Index - -The first step in coding is to
locate the main term in the Alphabetic Index.
- Condition listed as the main term, usually a noun.
- General terms used to locate codes for Z code section: admission,
encounter , and examination.
Some conditions are indexed under more than one main term.
Consider synonym, eponym, or other alternative term.
Search for subterms, notes, or cross references.
Subterms provide more specific information of many types and must be
checked carefully, following all alphabetization rules.
Do not assign main term code entry until all subterm possibilities have been
exhausted.
Refer again to the medical record to determine whether any additional
information is available to permit assignment of a more specific code.
If a subterm can't be located , review the nonessential modifiers for the
subterm.
Consider alternative terms.
-How to verify code number in Tabular List - -Do not assign codes without
verifying them in the Tabular List.
, Review titles for the code entry, chapter, section, and category to ensure
accuracy.
The title for the code entry in the Tabular List does not always match the
Alphabetic Index entry exactly.
Significant discrepancies between the Index entry and the Tabular List alert
the coder to review Alphabetic Index for a more appropriate term.
Read and follow all instructional terms and notes.
Pay particular attention to exclusion notes.
ordinarily, the code listed with the main term entry in the index is for the
unspecified condition.
Review other codes in the related area to determine whether a more specific
code can be assigned.
-Hirsutism ICD-10-CM code - -Main term Hirsutism code L68.0
-Portal vein obstruction ICD-10-CM code - -Main term in the Alphabetic
Index: Obstruction
Subterm: Portal (circulation) (vein)
Code I81
-Abscess abdominal wall due to Staphylococcus - -Main term : Abscess
Subterm : Abdomen, Abdominal
The code for Abscess abdominal wall is L02.211
Use additional code note: assign a code to identify the responsible organism.
Look for the mainterm infection and subterm Staphylococcal as cause of
disease classified elsewhere.
code title as Unspecified staphylococcus as the cause fo disease classified
elsewhere.
The code is B95.8
-Aplasia of pulmonary artery - -Main term Aplasia
Check Subterms; there is no entry for pulmonary artery.
Cross reference note directs coder to see also Agenesis.
The code is Q25.79
-Acute bronchopneumonia due to aspiration of oil - -Main term
Bronchopneumonia
Cross reference instruction see Pneumonia, broncho
Follow the cross reference by turning to the main term Pneumonia........
The code is J69.1
-Main term in: Acute myocardial infarction - -Infarction
-Main term in: chronic hypertrophy of tonsils and adenoids - -Hypertrophy
-Main term in: Acute suppurative cholecystitis - -Cholecystitis
steps & Guidelines
In ICD-10-CM Alphabetic Index Diseases and Injuries and the Index to
External Causes include - -entries for main terms (diseases, conditions, or
injuries) and subterms (site, type, or etiology), the Neoplasm Table, and the
Table of Drugs and Chemicals
-Tabular list in ICD-10-CM include - -Categories, subcategories, and valid
codes.
-Basic Coding steps in ICD-10-CM - -Locate the main term in the Alphabetic
Index
- Review subterms and nonessential modifiers related to the main term.
- Follow any cross reference instructions.
- Refer to any notes in the Alphabetic Index.
- A dash (-) at the end of an Index entry indicates additional characters are
required.
Verify the code number in the Tabular List.
- Read the code titles.
- Read and follow any instructional notes. Refer to other codes as instructed.
- Determine whether an additional character must be added.
Assign the verified codes.
-How to locate entry in Alphabetic Index - -The first step in coding is to
locate the main term in the Alphabetic Index.
- Condition listed as the main term, usually a noun.
- General terms used to locate codes for Z code section: admission,
encounter , and examination.
Some conditions are indexed under more than one main term.
Consider synonym, eponym, or other alternative term.
Search for subterms, notes, or cross references.
Subterms provide more specific information of many types and must be
checked carefully, following all alphabetization rules.
Do not assign main term code entry until all subterm possibilities have been
exhausted.
Refer again to the medical record to determine whether any additional
information is available to permit assignment of a more specific code.
If a subterm can't be located , review the nonessential modifiers for the
subterm.
Consider alternative terms.
-How to verify code number in Tabular List - -Do not assign codes without
verifying them in the Tabular List.
, Review titles for the code entry, chapter, section, and category to ensure
accuracy.
The title for the code entry in the Tabular List does not always match the
Alphabetic Index entry exactly.
Significant discrepancies between the Index entry and the Tabular List alert
the coder to review Alphabetic Index for a more appropriate term.
Read and follow all instructional terms and notes.
Pay particular attention to exclusion notes.
ordinarily, the code listed with the main term entry in the index is for the
unspecified condition.
Review other codes in the related area to determine whether a more specific
code can be assigned.
-Hirsutism ICD-10-CM code - -Main term Hirsutism code L68.0
-Portal vein obstruction ICD-10-CM code - -Main term in the Alphabetic
Index: Obstruction
Subterm: Portal (circulation) (vein)
Code I81
-Abscess abdominal wall due to Staphylococcus - -Main term : Abscess
Subterm : Abdomen, Abdominal
The code for Abscess abdominal wall is L02.211
Use additional code note: assign a code to identify the responsible organism.
Look for the mainterm infection and subterm Staphylococcal as cause of
disease classified elsewhere.
code title as Unspecified staphylococcus as the cause fo disease classified
elsewhere.
The code is B95.8
-Aplasia of pulmonary artery - -Main term Aplasia
Check Subterms; there is no entry for pulmonary artery.
Cross reference note directs coder to see also Agenesis.
The code is Q25.79
-Acute bronchopneumonia due to aspiration of oil - -Main term
Bronchopneumonia
Cross reference instruction see Pneumonia, broncho
Follow the cross reference by turning to the main term Pneumonia........
The code is J69.1
-Main term in: Acute myocardial infarction - -Infarction
-Main term in: chronic hypertrophy of tonsils and adenoids - -Hypertrophy
-Main term in: Acute suppurative cholecystitis - -Cholecystitis
