Introduction to ICD 10C,

ICD-10-CM Overview

• The World Health Organization (WHO) is responsible for the International Statistical Classification of Diseases and Related Health Problems.

ICD-10 Implementation

• The ICD-10 came into use in 2015.

ICD-10-CM Goals and Structure

• The goal of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is to provide a standardized system of classification for diseases and health problems.
• The ICD-10-CM code set includes 21 chapters.

Alphabetic Index

• The Index to Diseases and Injuries section of the ICD-10-CM provides diagnostic terms arranged in alphabetical order.
• The External Causes Index provides information about external causes of injury.

ICD-10-CM Coding

• The 4th character in an ICD-10-CM code provides information about the extremity or body part.
• When selecting a code for a diagnosis or reason for a visit, coders should pay attention to the diagnosis description, severity, and manifestation.
• Codes that describe symptoms and signs are acceptable for reporting when a related definitive diagnosis has not been established.
• Additional codes should be used to fully identify a condition when necessary.
• Combination codes are used to classify a single diagnosis that consists of multiple components.
• A sequela code should be used when a residual effect of a previous injury or disease is present.
• Impending or threatened conditions should be coded using the appropriate diagnosis code.
• Each ICD-10-CM diagnosis code can be reported only once per encounter.

Special Coding Situations

• Separate codes should be assigned for each side of a bilateral condition.
• Code assignment can rely on medical record documentation from clinicians who are not the patient's provider in certain situations.
• When coding syndromes, coders should use their best judgment if there is no guidance in the Alphabetic Index.
• A complication code should be reported when a condition arises as a result of a treatment or procedure.

Test your knowledge of coding! Learn about the required number of characters, the range of applicable codes, and how to identify diagnoses, symptoms, conditions, and other reasons for an encounter/visit. Challenge yourself to classify signs and symptoms with the correct codes!