173 Questions
What are the conventions for the ICD-10-CM?
The general rules for use of the classification
What are the two main components of the ICD-10-CM?
The Alphabetic Index and the Tabular List
What is the format and structure of the Tabular List in the ICD-10-CM?
It contains categories, subcategories, and codes, with specific character lengths
What is the purpose of the Alphabetic Index in the ICD-10-CM?
It is an alphabetical list of terms and their corresponding codes
What is the significance of a 7th character in an ICD-10-CM code?
It provides additional specificity to the code
What is the purpose of the codes in the ICD-10-CM?
To report diagnoses and procedures for billing and statistics
What does the term 'Excludes Notes' refer to in the ICD-10-CM?
Notes that indicate when two codes should never be used together
What is the purpose of an Excludes1 note?
To indicate that two conditions cannot occur together and should not be coded together
When is it appropriate to use both a code and a condition listed under its Excludes2 note?
When the patient has both conditions at the same time, if appropriate
How should the word 'and' be interpreted when it appears in a code title?
It should be interpreted to mean either 'and' or 'or'
What is the meaning of the word 'with' or 'in' when it appears in a code title or instructional note?
It should be interpreted to mean 'associated with' or 'due to'
When is provider documentation required to link two conditions in the ICD-10-CM?
When the conditions are not specifically linked by relational terms in the classification
What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
To list additional terms that can be assigned to a particular code
Where can additional terms be found that may be assigned to a particular code in the ICD-10-CM?
In the Alphabetic Index
How is the word 'with' sequenced in the Alphabetic Index of the ICD-10-CM?
Immediately following the main term or subterm
What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
To indicate when two codes should not be used together
What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
To allow for future expansion of the coding system
What is the purpose of the 7th character in the ICD-10-CM coding system?
To specify the episode of care
What does the abbreviation 'NEC' mean in the ICD-10-CM Alphabetic Index?
Not elsewhere classified
What does the abbreviation 'NOS' mean in the ICD-10-CM Alphabetic Index?
Not otherwise specified
What is the purpose of the brackets [] in the ICD-10-CM Tabular List?
To enclose synonyms or alternative wording
What is the purpose of the parentheses () in the ICD-10-CM Tabular List and Alphabetic Index?
To indicate that the terms within are nonessential modifiers
What is the purpose of the colon : in the ICD-10-CM Tabular List?
To indicate that the term before the colon is an incomplete term that needs one or more of the modifiers following the colon to make it assignable to a given category
What do "other" codes in the ICD-10-CM Tabular List represent?
Codes for conditions not elsewhere classified
What do "unspecified" codes in the ICD-10-CM Tabular List represent?
Codes for conditions where the information in the medical record is insufficient to assign a more specific code
What is the purpose of the Alphabetic Index in the ICD-10-CM?
To serve as an alphabetical list of terms and their corresponding codes
What is the structure of the ICD-10-CM Tabular List?
It contains categories, subcategories, and codes organized by body system or condition
How are codes represented in the ICD-10-CM?
Codes can be 3, 4, 5, 6, or 7 characters long
What is the significance of a 7th character in an ICD-10-CM code?
It provides additional information about the encounter, such as the episode of care
What is the purpose of the Inclusion Terms in the ICD-10-CM?
To provide additional terms that may be assigned to a particular code
What do the 'Excludes Notes' refer to in the ICD-10-CM?
Notes that indicate conditions that should not be coded together
What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
It is used as a placeholder at certain codes to allow for future expansion.
When is a 7th character required for an ICD-10-CM code?
When the notes in the Tabular List instruct the use of a 7th character.
What does the abbreviation 'NEC' mean in the ICD-10-CM Alphabetic Index?
Not elsewhere classified
What does the abbreviation 'NOS' mean in the ICD-10-CM Tabular List?
Not otherwise specified
What is the purpose of the brackets [] in the ICD-10-CM Tabular List?
To enclose synonyms, alternative wording, or explanatory phrases.
What do 'other' codes in the ICD-10-CM Tabular List represent?
Codes for conditions that are not specified elsewhere in the coding system.
What is the purpose of the colon (:) in the ICD-10-CM Tabular List?
To introduce a list of modifiers that are required to assign a specific code.
What do 'unspecified' codes in the ICD-10-CM Tabular List represent?
Codes for conditions where the information in the medical record is insufficient to assign a more specific code.
What is the purpose of the parentheses () in the ICD-10-CM Tabular List and Alphabetic Index?
To enclose supplementary words that may be present or absent without affecting the code assignment.
What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
To provide a list of terms that are included under some codes.
How should you code a condition described as 'impending' or 'threatened' at the time of discharge?
All of the above.
When a patient has a bilateral condition and each side is treated during separate encounters, how should the laterality be coded?
Assign the appropriate unilateral code for the side still affected for the second encounter.
When can code assignment be based on documentation by clinicians other than the patient's provider?
For codes related to BMI, depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, NIH stroke scale, social determinants of health, laterality, blood alcohol level, and underimmunization status.
What is the rule for reporting the same ICD-10-CM diagnosis code more than once for an encounter?
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.
If a patient has a bilateral condition and the treatment on the first side did not completely resolve the condition, how should the laterality be coded?
Assign the bilateral code, as the condition still exists on both sides.
What should be done if there is conflicting medical record documentation regarding the affected side of a condition?
Query the patient's provider for clarification.
When should 'unspecified' side codes be used in ICD-10-CM?
Unspecified side codes should be used when the documentation is insufficient to determine the affected side and it is not possible to obtain clarification.
What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
To indicate that the conditions excluded should never be coded together.
What is the purpose of the Alphabetic Index in the ICD-10-CM?
To provide a way to locate diagnostic terms and their corresponding codes.
What is the purpose of the 7th character in the ICD-10-CM coding system?
To indicate the episode of care for the condition.
What must be documented by the patient's provider for the associated diagnosis?
The patient's overweight, obesity, acute stroke, pressure ulcer, or alcohol-related disorder
What should the provider do if there is conflicting medical record documentation?
Query the patient's provider for clarification
How should syndromes be coded according to the text?
What is the purpose of a 'use additional code' note in the ICD-10-CM?
To specify that a secondary code should be added to fully describe a condition
When should an underlying condition be sequenced first according to the ICD-10-CM guidelines?
When it is unknown or not applicable
What does a 'code, if applicable, any causal condition first' note indicate in the ICD-10-CM?
The code must be assigned as a principal diagnosis
In the ICD-10-CM, what is required to fully describe a sequela?
Two codes sequenced in a specific order
What is the significance of a 'code first' note under certain codes in the ICD-10-CM?
It specifies that the code must be the primary diagnosis
What does a 'combination code' represent in the ICD-10-CM?
A single code for two diagnoses or an associated process/complication
When is it appropriate to assign only a combination code in the ICD-10-CM?
When all elements are clearly identified by the combination code
What is the purpose of 'code, if applicable, any causal condition first' notes in diagnostic coding?
'Causal condition' indicates priority in sequencing
How should you sequence an acute (subacute) and chronic condition in ICD-10-CM?
Code both and sequence acute (subacute) first
What is the purpose of an Excludes1 note in the ICD-10-CM?
It means 'NOT CODED HERE!' and the excluded code should never be used with the code above the Excludes1 note.
What does the word 'with' or 'in' imply when it appears in a code title or instructional note in the ICD-10-CM?
It implies an associated or causal relationship between the two conditions, unless documentation states otherwise.
When is it appropriate to use both a code and a condition listed under its Excludes2 note?
It is acceptable to use both codes together when appropriate, as an Excludes2 note indicates the excluded condition is not part of the code's condition.
How should the word 'and' be interpreted when it appears in a code title in the ICD-10-CM?
It should be interpreted to mean either 'and' or 'or', depending on the clinical scenario.
What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
They represent common synonyms or alternative terms for the code title.
When is provider documentation required to link two conditions in the ICD-10-CM?
When the two conditions are not specifically linked by relational terms in the classification or a guideline requires explicit documentation.
What is the purpose of an Excludes2 note in the ICD-10-CM?
It represents 'Not included here', meaning the excluded condition is not part of the code's condition but can be coded together when appropriate.
Where can additional terms be found that may be assigned to a particular code in the ICD-10-CM?
In both the Alphabetic Index and the Tabular List's 'Inclusion Terms'.
What is the meaning of the word 'see' in the Alphabetic Index of the ICD-10-CM?
It indicates that the term should be referenced under another main term to locate the correct code.
What does the 'see also' instruction in the Alphabetic Index of the ICD-10-CM indicate?
It instructs that there are other main terms that may provide additional Alphabetic Index entries that could be useful.
What should be done if there is conflicting medical record documentation?
Query the provider for clarification
When should additional codes be assigned for manifestations that are not an integral part of the disease process?
When there is no Alphabetic Index guidance available
What must be documented by the patient's provider for the associated diagnosis?
Relationship between the condition and care or procedure
When is a cause-and-effect relationship between care provided and a condition necessary to report a complication?
Always required
How should complications of care be coded?
Based on provider's documentation of relationship
What does it mean when it is stated that 'not all conditions following medical care or surgery are classified as complications'?
They must have a cause-and-effect relationship with care provided
What is the purpose of a 'code also' note in the ICD-10-CM?
It instructs that two codes may be required to fully describe a condition, but does not provide sequencing direction.
What is a 'default code' in the ICD-10-CM?
A code that represents the unspecified code for a condition.
How is the code assignment based on in the ICD-10-CM?
The code assignment is based on the provider's statement that the patient has a particular condition.
What is the purpose of using both the Alphabetic Index and Tabular List when locating and assigning an ICD-10-CM code?
The Alphabetic Index is used to locate the term, and the Tabular List is used to verify the code and ensure it is coded to the full number of characters required.
What is the level of detail required when coding in the ICD-10-CM?
Diagnosis codes must be used and reported at the highest number of characters available and at the highest level of specificity documented in the medical record.
How should signs and symptoms be coded in the ICD-10-CM?
Codes that describe symptoms and signs should only be assigned if a related definitive diagnosis has not been established.
How should conditions that are an integral part of a disease process be coded in the ICD-10-CM?
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
How should conditions that are not an integral part of a disease process be coded in the ICD-10-CM?
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
How should multiple codes be used to describe a single condition in the ICD-10-CM?
Multiple codes may be required to fully describe a single condition, depending on the circumstances of the encounter.
What are the conventions for the ICD-10-CM?
Rules for use of the classification independent of guidelines
What is the purpose of the Alphabetic Index in the ICD-10-CM?
Alphabetical list of terms and corresponding codes
How are categories, subcategories, and codes represented in the ICD-10-CM Tabular List?
Categories can be either a letter or number
What is the structure of the codes in the ICD-10-CM?
3-character categories have no further subdivisions
Why are codes with applicable 7th characters still referred to as codes in the ICD-10-CM?
Because they have an additional level of specificity
What is the purpose of using codes in the ICD-10-CM for reporting purposes?
For tracking diseases and conditions
Which code should be assigned when an injury is incurred as a result of flooding caused by a levee breaking related to the hurricane?
X37.0-, Hurricane
Which code should be assigned when an injury is from flooding resulting directly from the storm?
X38.-, Flood
When should code X36.0.-, Collapse of dam or manmade structure, be assigned?
X36.0- is not to be assigned when the cause of the collapse is due to the hurricane
When should code X37.0-, Hurricane, be assigned?
For injuries incurred as a direct result of the hurricane
How should injuries that are not a direct result of the hurricane be coded?
Assign the appropriate external cause of morbidity code(s) to describe the cause of the injury, but do not assign code X37.0-, Hurricane
When should code X37.0-, Hurricane, be assigned if it is not clear whether the injury was a direct result of the hurricane?
Assume the injury is due to the hurricane and assign code X37.0-, Hurricane, as well as any other applicable external cause of morbidity codes
What is the purpose of the Z codes mentioned in the text?
To further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter
When should confirmed cases of HIV infection/illness be coded?
Only confirmed cases should be coded
What is the purpose of the 'Excludes Notes' in the ICD-10-CM?
To indicate that the code excluded is not part of the condition represented by the code that has the Excludes note
What is the purpose of the Alphabetic Index in the ICD-10-CM?
To provide an index of terms to help locate the appropriate code
What is the placeholder character used in ICD-10-CM for future expansion?
X
What does the 7th character signify in ICD-10-CM codes?
Time frame
In the Alphabetic Index, what does the abbreviation 'NEC' stand for?
Not Elsewhere Classified
What does 'NOS' stand for in the Tabular List of ICD-10-CM?
Not Otherwise Specified
What is the function of brackets in the Tabular List and Alphabetic Index of ICD-10-CM?
Enclose synonyms or alternative wording
How are parentheses used in both the Alphabetic Index and Tabular List of ICD-10-CM?
To enclose nonessential modifiers
What does the colon punctuation after an incomplete term signify in the Tabular List of ICD-10-CM?
Indicates additional modifiers are required
'Other' codes in ICD-10-CM are used for what purpose?
Provide detail when a specific code is absent
'Unspecified' codes are utilized in ICD-10-CM for what reason?
For insufficiently detailed records
What is the purpose of 'Includes note' in ICD-10-CM?
Provide additional defining terms
What does an Excludes1 note indicate in the ICD-10-CM?
The code excluded should never be used at the same time as the code above the Excludes1 note.
When should a query be sent to the provider regarding an Excludes1 note?
When it is not clear if the two conditions are related or unrelated.
What does an Excludes2 note indicate in the ICD-10-CM?
The condition excluded is independent of the condition represented by the code.
How should an Excludes2 note be interpreted when it appears under a code?
Both the code and the excluded code can be used together when appropriate.
When is it acceptable to use both a code and an excluded code listed under an Excludes2 note?
When a patient may have both conditions at the same time.
What is the difference between an Excludes1 note and an Excludes2 note in the ICD-10-CM?
Excludes1 notes mean conditions cannot occur together, while Excludes2 notes mean they can occur together.
Under what circumstances should a provider query a patient regarding Excludes1 notes?
When it is uncertain if two conditions can occur together.
When is it appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis?
When a definitive diagnosis has not been established by the end of the encounter.
What is the appropriate way to code healthcare encounters for hurricane victims when no injury, adverse effect or poisoning is involved?
Do not assign any external cause of morbidity codes.
When should 'unspecified' codes be reported according to the guidelines?
When they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter.
What is the appropriate sequencing of external cause of morbidity codes in the aftermath of a hurricane?
Assign codes for cataclysmic events, such as a hurricane, before all other external cause codes.
How many external cause of morbidity codes should be assigned for each healthcare encounter related to the hurricane aftermath?
As many external cause of morbidity codes as necessary to fully explain each cause should be assigned.
What is the purpose of assigning external cause of morbidity codes in the aftermath of a hurricane?
All of the above.
When should external cause of morbidity codes be assigned for healthcare encounters related to the hurricane aftermath?
Only for encounters where the patient sustained an injury or poisoning.
What is the appropriate way to sequence the external cause of morbidity codes and the injury codes for healthcare encounters related to the hurricane aftermath?
Assign the appropriate injury code first, followed by the external cause of morbidity codes.
What is the appropriate way to code a definitive diagnosis that has not been established by the end of the healthcare encounter?
Assign a code for the patient's sign(s) and/or symptom(s) in lieu of a definitive diagnosis.
How should HIV cases be sequenced when a patient is admitted for an HIV-related condition?
The principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease, followed by additional codes for reported HIV-related conditions.
How should HIV cases be sequenced when a patient with HIV disease is admitted for an unrelated condition?
The code for the unrelated condition should be the principal diagnosis, followed by B20 and codes for any reported HIV-related conditions.
How should asymptomatic HIV infections be coded?
Use code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.
How many characters are codes in the ICD-10-CM typically?
4 characters
What is the final level of subdivision in the ICD-10-CM Tabular List?
Code
What is the purpose of the 'Alphabetic Index' in the ICD-10-CM?
To list terms alphabetically with corresponding codes
In the ICD-10-CM, what does a three-character category without further subdivision represent?
A code
What does the term 'invalid' refer to in the ICD-10-CM coding system?
A code without applicable 7th character
What are the types of characters used for categories, subcategories, and codes in the ICD-10-CM?
Letters and numbers intermixed
What is the purpose of the placeholder character 'X' in the ICD-10-CM coding system?
To allow for future expansion of codes
What does the abbreviation 'NEC' mean in the ICD-10-CM Tabular List?
Not elsewhere classifiable
What is the purpose of the 7th character in the ICD-10-CM coding system?
To represent the episode of care
What does the abbreviation 'NOS' mean in the ICD-10-CM Alphabetic Index?
Not otherwise specified
What is the purpose of the brackets '[]' in the ICD-10-CM Tabular List?
To enclose synonyms, alternative wording or explanatory phrases
What is the purpose of the parentheses '()' in the ICD-10-CM Tabular List and Alphabetic Index?
To enclose supplementary words that may be present or absent without affecting the code number
What is the meaning of the term 'other' codes in the ICD-10-CM?
Codes to be used when the information in the medical record provides detail for which a specific code does not exist
What is the meaning of the term 'unspecified' codes in the ICD-10-CM?
Codes to be used when the information in the medical record is insufficient to assign a more specific code
What is the purpose of the 'Inclusion Terms' in the ICD-10-CM?
To further define or give examples of the content of a category
What is the purpose of the colon ':' in the ICD-10-CM Tabular List?
To indicate an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category
When should a code from subcategory R65.2 be assigned for severe sepsis?
As a secondary diagnosis when severe sepsis develops after admission
How should sepsis/severe sepsis with a localized infection be coded if the reason for admission is the sepsis/severe sepsis?
Assign the code for sepsis/severe sepsis first, followed by the code for the localized infection
If a patient is admitted with a localized infection and sepsis/severe sepsis develops after admission, how should it be coded?
Assign the code for the localized infection first, followed by the sepsis/severe sepsis codes
If the documentation is unclear whether severe sepsis was present on admission, what should be done?
Query the provider on how to code sepsis or severe sepsis with a localized infection
When should a code from subcategory R65.2 be assigned for severe sepsis in addition to the codes for the underlying systemic infection?
If the patient has severe sepsis, regardless of when it developed
How should a localized infection be coded if sepsis/severe sepsis is also present?
Assign the sepsis/severe sepsis codes first, followed by the code for the localized infection
What is the purpose of Excludes1 notes in the ICD-10-CM?
To indicate that two codes should never be used together
How should the word 'and' be interpreted in a code title or the Alphabetic Index?
It can mean either 'and' or 'or'
When is an additional code from Chapter 1 required to identify the organism for certain infections classified in other chapters?
When the infection code does not identify the organism
What does an Excludes2 note indicate in the ICD-10-CM?
The excluded condition is not part of the coded condition
How should the word 'with' or 'in' be interpreted when it appears in a code title or the Alphabetic Index?
It means the conditions are associated or related
When is provider documentation required to link two conditions in the ICD-10-CM?
When the conditions are not explicitly linked by relational terms
What is the purpose of the Inclusion Terms in the ICD-10-CM?
To list the various conditions assigned to a code
How is the word 'with' sequenced in the Alphabetic Index of the ICD-10-CM?
Immediately following the main term or subterm
When should a query be sent to the provider regarding an Excludes1 note?
When it is unclear if the two conditions are related or not
What do the 'Excludes Notes' in the ICD-10-CM refer to?
Conditions that should not be coded together
How should antibiotic resistant infections be coded?
Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.
How should sepsis with unspecified organism be coded?
Assign code A41.9, Sepsis, unspecified organism, for the infection.
How should negative or inconclusive blood cultures be coded in the presence of clinical evidence of sepsis?
Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, but the provider should be queried.
How should the term 'urosepsis' be coded?
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis, and the provider should be queried for clarification.
How should sepsis with associated acute organ dysfunction or multiple organ dysfunction (MOD) be coded?
Assign a code for the underlying systemic infection, a code from subcategory R65.2, Severe sepsis, and additional code(s) for the associated acute organ dysfunction.
How should acute organ dysfunction not clearly associated with sepsis be coded?
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis.
What is the minimum number of codes required to code severe sepsis?
Two codes: one for the underlying systemic infection and one from subcategory R65.2, Severe sepsis.
How should septic shock be coded?
Assign the code for the systemic infection first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock, and any additional codes for other acute organ dysfunctions.
Study Notes
Conventions for ICD-10-CM
- Conventions are general rules for using the ICD-10-CM classification
- Incorporated into the Alphabetic Index and Tabular List as instructional notes
Alphabetic Index and Tabular List
- ICD-10-CM divided into:
- Alphabetic Index: an alphabetical list of terms with corresponding codes
- Tabular List: structured list of codes divided into chapters by body system or condition
- Alphabetic Index consists of:
- Index of Diseases and Injury
- Index of External Causes of Injury
- Table of Neoplasms
- Table of Drugs and Chemicals
Format and Structure of the Tabular List
- Contains categories, subcategories, and codes
- Characters for categories, subcategories, and codes can be letters or numbers
- Categories are 3 characters; subcategories are 4 or 5 characters; codes can be 3, 4, 5, 6, or 7 characters
- Final level of subdivision is a code; codes with applicable 7th characters are still referred to as codes
Use of Codes for Reporting Purposes
- Codes represent conditions for which that code is to be used
- Inclusion terms are not exhaustive; additional terms may be found only in the Alphabetic Index
- A code that requires a 7th character is invalid without it
Excludes Notes
- Two types of Excludes notes: Excludes1 and Excludes2
- Excludes1 note means "NOT CODED HERE!"
- Excludes2 note means "Not included here"
- Excludes notes indicate codes excluded from each other are independent of each other
Placeholder Character
- "X" is used as a placeholder in certain codes to allow for future expansion
7th Characters
- Certain ICD-10-CM categories have applicable 7th characters
- 7th character is required for codes within a category
- 7th character must always be the 7th character in the data field
Abbreviations in the Alphabetic Index and Tabular List
- NEC: "Not elsewhere classifiable", represents "other specified"
- NOS: "Not otherwise specified", equivalent to unspecified
Punctuation
- Brackets: used to enclose synonyms, alternative wording, or explanatory phrases in the Tabular List
- Brackets: used to identify manifestation codes in the Alphabetic Index
- Parentheses: used to enclose supplementary words in the Alphabetic Index and Tabular List
- Colons: used after incomplete terms in the Tabular List to indicate the need for modifiers
Other Codes
- "Other" codes: for use when no specific code exists
- "Unspecified" codes: for use when information is insufficient to assign a more specific code### Etiology/Manifestation Convention
- Requires two codes to fully describe a single condition that affects multiple body systems
- "Use additional code" notes indicate that a secondary code is useful to fully describe a condition
Use Additional Code Notes
- Found in the Tabular List at codes that are not part of an etiology/manifestation pair
- Indicate that a secondary code should be added, if known
- Example: bacterial infections require a secondary code from category B95 or B96 to identify the bacterial organism causing the infection
Code First Notes
- Found under certain codes that are not specifically manifestation codes but may be due to an underlying cause
- When an underlying condition is present, it should be sequenced first, if known
Sequencing Multiple Codes
- Multiple codes may be needed for sequela, complication codes, and obstetric codes to fully describe a condition
- See specific guidelines for each condition for further instruction on how to code
Combination Codes
- A single code used to classify two diagnoses, or a diagnosis with an associated secondary process (manifestation) or complication
- Identified by referring to subterm entries in the Alphabetic Index and reading the inclusion and exclusion notes in the Tabular List
- Assign only the combination code when it fully identifies the diagnostic conditions involved or when the Alphabetic Index directs to do so
Sequela
- Residual effect (condition produced) after the acute phase of an illness or injury has terminated
- No time limit on when a sequela code can be used
- Examples: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis
- Coding of sequela generally requires two codes sequenced in the following order:
- The condition or nature of the sequela is sequenced first
- The sequela code is sequenced second
Impending or Threatened Conditions
- Code any condition described at the time of discharge as "impending" or "threatened" as follows:
- If it did occur, code as a confirmed diagnosis
- If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened"
- If the subterms are listed, assign the given code
- If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened
Laterality
- Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or is bilateral
- If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side
- If the side is not identified in the medical record, assign the code for the unspecified side
Placeholder Character
- "X" is used as a placeholder at certain codes to allow for future expansion
- Example: poisoning, adverse effect, and underdosing codes, categories T36-T50
7th Characters
- Required for certain ICD-10-CM categories
- The applicable 7th character must always be the 7th character in the data field
- If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters### Conventions for ICD-10-CM
- The conventions for ICD-10-CM are general rules for using the classification, independent of the guidelines.
- These conventions are incorporated within the Alphabetic Index and Tabular List as instructional notes.
Structure of ICD-10-CM
- The ICD-10-CM is divided into two main components: the Alphabetic Index and the Tabular List.
- The Alphabetic Index is an alphabetical list of terms and their corresponding codes.
- The Alphabetic Index consists of:
- Index of Diseases and Injury
- Index of External Causes of Injury
- Table of Neoplasms
- Table of Drugs and Chemicals
- The Tabular List is a structured list of codes divided into chapters based on body system or condition.
Format and Structure of the Tabular
- The Tabular List contains categories, subcategories, and codes.
- Characters for categories, subcategories, and codes may be either a letter or a number.
- Categories are 3 characters and may have further subdivision into subcategories and codes.
- Codes can be 3, 4, 5, 6, or 7 characters in length.
Use of Codes for Reporting Purposes
- Codes for external causes of morbidity and mortality should be assigned in addition to the code for the injury or disease.
- External cause codes should be sequenced in a specific order (e.g., hurricane, then building collapse).
- Z codes may be assigned to further explain the reasons for presenting for healthcare services.
Coding for HIV Cases
- Code only confirmed cases of HIV infection/illness.
- Use code B20, Human immunodeficiency virus [HIV] disease, as the principal diagnosis.
- Assign additional diagnosis codes for all reported HIV-related conditions.
- Use code Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, for patients without symptoms or manifestations of HIV disease.
Other Coding Guidelines
- Use placeholder character "X" when necessary.
- 7th characters are required for certain categories and must be the 7th character in the data field.
- NEC (not elsewhere classifiable) and NOS (not otherwise specified) codes are used when no specific code exists.
- Brackets are used to enclose synonyms, alternative wording, or explanatory phrases.
- Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure.
- Colons are used to indicate that a modifier is required to make the term assignable to a given category.
Test your knowledge on the conventions of ICD-10-CM, which are the general rules for using the classification system. Learn about the Alphabetic Index and Tabular List within the ICD-10-CM.
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