Basic ICD 10-CM/PCS and - PowerPoint Presentation

1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 EditionChapter 1: Characteristics of ICD-9-CM and ICD-10-CM

2. Learning Objectives Review the chapter’s learning objectivesA thorough understanding of the basic concepts of the ICD-9-CM and ICD-10-CM classification systems is critical in order to comprehend the more advanced theory to follow in the rest of the chapters.

3. Characteristics of ICD-9-CMSingle codebook, 3 volumesVolume 1 Diseases: Tabular ListVolume 2 Diseases: Alphabetic IndexVolume 3 Procedures: Tabular List and Alphabetic IndexOfficial version available only on CD-ROM from US Government Printing Office

4. ICD-9-CM Volume 1: Tabular ListTabular List of Diseases and InjuriesClassification of diseases and injuriesClassify conditions according to etiology (cause of disease) or by specific anatomical (body) systemSupplementary classificationsV CodesE CodesAppendices

5. ICD-9-CM Classification of Diseases and Injuries17 chaptersSpecific anatomical systemEtiology (cause of disease)Codes 001–999

6. ICD-9-CM Chapter FormatEach chapter is structured into the following subdivisionsSectionsCategoriesSubcategories5th-digit subclassifications

7. ICD-9-CM SectionsA group of 3-digit categories Represent a single disease entity or a group of similar or closely related conditionsExample:Disorders of Thyroid Gland (240–246)

8. ICD-9-CM CategoriesConsist of 3 digits Represent a single disease entity or a group of similar or closely related conditionsExample:520 Disorders of tooth development and eruption

9. ICD-9-CM SubcategoriesRepresented by 4th digit Provide more specificity or information regarding the condition’sEtiologySiteManifestation4th-digit subcategories are collapsible to the 3-digit levelExample: 476.0 Chronic laryngitis

10. ICD-9-CM Fifth-Digit SubclassificationsThe 5th digit adds greater specificity to certain 4th-digit codes5th-digit assignments and instructions appear at the beginning of a ChapterFor example, in Chapter 13, Diseases of Musculoskeletal System, certain categories must be assigned a fifth digit to describe the affected body site

11. Fifth-Digit Subclassifications (continued)5th-digit assignments and instructions appear at the beginning of a SectionFor example, at beginning of section 200–208, Malignant Neoplasm of Lymphatic and Hematopoietic Tissue, fifth digits must be assigned to categories 200–202 to describe the site of the lymph node involved.

12. Fifth-Digit Subclassifications (continued)5th-digit assignments and instructions appear at the beginning of a CategoryFor example, at the beginning of category 250, Diabetes mellitus, a fifth digit should be assigned to describe the type of diabetes mellitus

13. Fifth-Digit Subclassifications (continued)5th-digit assignments and instructions appear at the beginning of a SubcategoryFor example, the fourth-digit subcategory 786.5, Chest pain, is further subdivided to the fifth-digit level to describe specific types of chest pain

14. 3, 4, or 5 Digits?Must code to the highest level of specificity3-digit code only used when there is no subcategory or subclassification with it4-digit code only used when there is no subclassification with itWhen available, all 5 digits must be usedWatch for required 4th and 5th digits

15. ICD-9-CM Residual SubcategoriesCode titles that include:Other UnspecifiedAllows every disease or condition to have a code

16. Residual Subcategories (continued).8 = other Describes a specific condition that is not otherwise classified to preceding fourth digits in same category.9 = unspecified Describes a condition that has not been described as specific enough to assign it to another 4th digit in the same category.9 = sometimes is both “other and unspecified” in some categories

17. ICD-9-CM Supplementary ClassificationsV codes: Supplementary classification of factors influencing health status and contact with health servicesE codes: Supplementary classification of external causes of injury and poisoning

18. ICD-9-CM AppendicesAppendix A: Morphology of NeoplasmsAppendix C: Classification of Drugs by the American Hospital Formulary Service (AHFS) ListAppendix D: Classification of Industrial Accidents According to AgencyAppendix E: List of Three-Digit Categories

19. ICD-9-CM Volume 2: Alphabetic Index to DiseasesThree major sectionsIndex to Diseases and InjuriesTable of Drugs and ChemicalsAlphabetic Index to External Causes of Injury and Poisoning (E Codes)

20. Volume 2: Alphabetic Index to Diseases (continued)Three levels of indentationMain termsSubtermsCarryover lines

21. ICD-9-CM Alphabetic Index Main TermsWord that must be used in Alphabetic Index to locate possible code in Tabular ListBoldface typeLeft margin of each column

22. Alphabetic Index Main Terms (continued)Main terms represent:Diseases: Influenza, bronchitisConditions: Fatigue, fracture, injuryNouns: Disease, disturbance, syndromeAdjectives: Double, large, kinkUsually not an anatomical site; entry for anatomical site tells coder to “see condition”

23. Alphabetic Index Main Terms (continued)May be more than one way to find a termComplicationsName of complication or “Complications”Obstetrical conditions “Delivery,” “Labor,” “Pregnancy,” and “Puerperal”“Disease” or “Syndrome”

24. ICD-9-CM Alphabetic Index SubtermsIndented under main term to the right by one standard indentation Alphabetical orderException: “with” and “without” appear at the beginning of all the subtermsDescribe differences in conditionAnatomic siteCauseClinical type

25. Alphabetic Indec Subterms (continued)Subterms may have more specific terms indented beneathFarther to the right, one standard indentationAlphabetic orderReview all subterms following the main term to determine appropriate code

26. ICD-9-CM Carryover LinesCarryover lines are needed for main terms or subterms because the number of words that fit on a single line of print in the Alphabetic Index is limitedIndented two standard indentsDo not confuse with another subtermExample: review “Rubella” with subterm “complicating pregnancy, childbirth, or puerperium”

27. ICD-9-CM Nonessential ModifiersSeries of terms in parentheses that may follow main term or subtermPresence or absence of parenthetical term has no effect on code assignmentWord in parentheses can be in the diagnostic statement (or not appear in the diagnostic statement) and it does not affect the code assignmentExample: Review “Pneumonia” in Alphabetic Index

28. Eponyms—Proper NamesThe name of a disease, structure, operation, or procedure named after a person, usually the person who discovered or described it firstProper nameIndex entries Eponym (proper name)Disease, syndrome, or disorder

29. Terms Not Listed in Tabular List of ICD-9-CMMany more disease or condition entries in Alphabetic Index than under code in Tabular ListTabular List includes the most common related phrases but not all possibleExample: “Listlessness” Guidance of the Alphabetic Index should be trusted

30. Index Tables in ICD-9-CMMain terms and subterms are arranged in tables instead of standard columnsHypertensionNeoplasmSimplifies access to complex combinations of subterms

31. Conventions Used in ICD-9-CMCross-reference termsUsed in the Alphabetic IndexSee: points to an alternative termSee also: requires review of another main term for more informationSee category: instruction to consult a specific category in Volume 1, Tabular List

32. ICD-9-CM Instructional NotationsAppear in Tabular List to clarify information or provide additional directionAppear at the beginning of a chapter or section or directly below a category or subcategory codeIncludes notesExcludes notes

33. ICD-9-CM Includes NotesFurther define or provide an example of code(s)The notes usually list other common phrases used to describe the same condition but it may not be an exhaustive listBecause an inclusion note is not repeated, coder must look back to beginning of chapter, section, category, or subcategory

34. ICD-9-CM Excludes NotesAppear in italicized print with a box around itProvide a direction to code the particular condition listed elsewhere, usually with the code listed in the exclusion noteExcludes:

35. Excludes Notes (continued)Excludes notes have three different meanings1. Code under consideration cannot be assigned if the associated condition specified in the exclusion note is present. Example: subcategory code 424.3 Exclusion note indicates that code 397.1 should be assigned if the pulmonary valve disorder is specified as rheumatic

36. Excludes Notes (continued)Condition may have to be coded elsewhereThe etiology of the condition determines whether the code under review or the code suggested in the exclusion note should be assigned.One or the other code is used but not both.Example: See category 603. Code 603 is not used for congenital hydrocele

37. Excludes Notes (continued)Note indicates that an additional code may be required to fully explain the condition The condition in the exclusion note is not included in the code under reviewIf the condition specified in the exclusion note is present, the additional code should be assignedExample: Chapter 4 codes 280–289 states anemia complicating pregnancy or the puerperium requires a different code (648.2)

38. ICD-9-CM NotesAppear in Tabular List and Alphabetic IndexDescribe needed 5th digitsProvide additional coding instructionProvide definition of termsAlphabetic Index notes are boxed and in italic typeTabular List notes are located at various levels and are not boxed

39. Notes (continued)ExamplesTabular List: 831 Dislocation of ShoulderFifth digits are requiredAlphabetic Index: Main term “injury”Gives direction on how to code certain injuriesTabular List: 326 Late EffectDescribes when this category code is usedTabular List: 765.0 Extreme ImmaturityDefines what extreme immaturity implies

40. ICD-9-CM Multiple CodingIn ICD-9-CM, it is often necessary to use more than one code number to fully identify a given conditionA diagnostic statement that includes phrases such as “due to,” “secondary to,” or “with” may require multiple codesCoder must follow the directions in the Tabular List for the use of additional codesThe Alphabetic Index may refer the coder to a combination code through the use of connection termsWhen no combination codes are available, multiple codes are assigned to fully describe the condition

41. ICD-9-CM Multiple CodingMandatory multiple codingCertain conditions require multiple coding one code for the underlying condition (cause, etiology) andanother code for the manifestation(s)Alphabetic Index identifies both codes with the second code in bracketsExample: Diabetic amyotrophy 250.6 [358.1]

42. Multiple Coding (continued)Mandatory multiple coding (continued)1st code is the underlying condition2nd code in brackets is the manifestationBoth codes must be assignedCodes must be sequenced in the order listed in the Alphabetic IndexBrackets are not used by the coder but are used to highlight the second required code in the book

43. Multiple Coding (continued)Indiscriminate multiple codingMultiple codes should not be used to code irrelevant medical informationSigns and symptoms that are characteristic of an illness are not coded once the cause is identifiedConditions listed in diagnostic test reports should not be coded unless the diagnosis is confirmed by the physician

44. Multiple Coding (continued)Indiscriminate multiple coding (continued)Follow UHDDS guidelines for reporting additional diagnosesCoding both an unspecified and a specified type of condition is not done to describe the same general condition

45. Multiple Coding (continued)Use additional code, if desiredAppears in the Tabular ListThe use of an additional code may provide more complete description of the condition“If desired” should be ignoredAdditional code must be assigned if the health record provides supportive documentation

46. Multiple Coding (continued)Code first underlying conditionAppears in the Tabular ListFound under codes that should not be listed first or as a single codeThe underlying condition and code number(s) appear after the phrase, “Code first”Note appears after codes in italicized print, which indicates this code should not be listed first or appear as a single code

47. ICD-9-CM Connecting WordsAppear in Alphabetic IndexSubterms indicate a relationship between the main term and the associated condition or etiology

48. ICD-9-CM Connecting WordsAssociated withComplicated (by)Due toOfDuringFollowingInWithoutSecondary toWithWith mention of

49. Examples of Connecting WordsPoint to rememberThe connecting words “with” and “without” are sequenced before all other subterms in the Alphabetic Index immediately under the main termAll other connecting terms are listed in alphabetic order in the Alphabetic Index under the main term49

50. Abbreviations and Punctuation Marks in ICD-9-CMNECNot elsewhere classifiedNOSNot otherwise specifiedParenthesesSquare bracketsSlanted bracketsColon

51. NEC: Not Elsewhere ClassifiedUsed with ill-defined terms in the Tabular List to warn coder that specified forms of the condition are coded differentlyNEC can be used with terms for which a more specific code is unavailable, even though the diagnostic statement is very specific

52. NOS: Not Otherwise SpecifiedEquivalent of “unspecified”In the Tabular ListUsually included with .9 codesDiagnostic statement does not contain enough information to assign the condition to a more specific code

53. Parentheses ( )Enclose supplementary words or explanatory information that may or may not be present in the diagnosis or procedure statementWords in parentheses do not affect the code number assignedTerms within the parentheses are called “nonessential modifiers”

54. Square Brackets [ ]Only in the Tabular Lists for diagnoses and proceduresEnclose synonyms, alternative wording, abbreviations, and explanatory phrasesTerms in square brackets are not required to be part of the diagnosis or procedure statement in order to be assigned to the given code

55. Slanted brackets [ ]Appear only in the Alphabetic IndexEnclose a code number that must be used in conjunction with a code immediately preceding it (the code in the slanted brackets is always sequenced second)Second code enclosed in the slanted or italicized brackets is the disease’s manifestation

56. Colon : Use in the Tabular ListAppears after an incomplete term that needs one or more modifiers or adjectives in order to be assigned to a given category or codeSee as an example Category 204Lymphatic leukemia, lymphoblastic leukemia, lymphocytic leukemia, lymphogenous leukemia are all coded to category 204

57. Basic Steps in ICD-9-CM CodingIdentify all main terms in the diagnostic statementLocate each main term in the Alphabetic IndexRefer to any subterms indented under the main term and read all subterms beneath the main term to identify all possible codes

58. Basic Steps in ICD-9-CM Coding (continued)Follow all cross-reference instructionsVerify the code selected in the Tabular List— do not skip this step!Read and be guided by any instructional terms in the Tabular List— read all includes notes, excludes notes, and multiple coding references.

59. Basic Steps in ICD-9-CM Coding (continued)Assign codes to their highest level of specificity: A three-digit code can only be used when no four-digit codes appear within the categoryA fifth-digit code must be used when a fifth-digit subclassification is providedContinue coding the diagnostic statement until all the components are fully identified

60. Introduction to ICD-10-CMTwo essential documents are required reading each year by all coders using ICD-10-CMICD-10-CM Official Guidelines for Coding and ReportingOfficial Addendum to ICD-10-CM and ICD-10-PCS60

61. ICD-10-CM Official GuidelinesApproved by the Cooperating Parties for ICD-10-CMAHA, AHIMA, CMS, and NCHSGuidelines compliment the official conventions and instructions provided within the ICD-10-CM code setGuidelines provide additional instruction

62. ICD-10-CM Official GuidelinesHIPAA requires all coders to adhere to these guidelinesGuidelines identify the diagnoses and procedures to be reportedCoding is based on consistent, complete documentation in the health record62

63. ICD-10-CM Official GuidelinesThe convention, general guidelines and chapter specific ICD-10-CM guidelines are applicable to all healthcare settingsThe guidelines for the principal and additional diagnoses are only applicable to the inpatient setting63

64. Official Addendum to ICD-10-CM and ICD-10-PCSICD-10-CM and ICD-10-PCS undergo annual updates in the United StatesAn Official Addendum documents the changes which are effective April 1 and October 1 of each year. CMS and NCHS publish the addenda with the approval of WHO64

65. Official Addendum to ICD-10-CM and ICD-10-PCSNCHS is responsible for maintaining the diagnosis classification, ICD-10-CMCMS is responsible for maintaining the procedure classification, ICD-10-PCS65

66. Coordination and Maintenance CommitteeThe ICD-10-CM Coordination and Maintenance (C&M) Committee is chaired by a representative from NCHS and CMSTwo open meetings each year, public forumMeeting minutes found on the NCHS and CMS websites66

67. Characteristics of ICD-10-CMBeginning October 1, 2015Conventions similar to ICD-9-CMAlphabetic Index Alphabetic listing of terms and codesTabular ListNumerical list of codes divided by chapters

68. Conventions for ICD-10-CMCoding conventions address the structure and format of the coding systemHow to use the Alphabetic IndexHow to use the Tabular ListRules and instructions the coder must follow68

69. Conventions for ICD-10-CMAlphabetic IndexTwo partsThe Index to Diseases and Injury containsNeoplasm TableTable of Drugs and ChemicalsThe Index to External Causes of Injury69

70. Conventions for ICD-10-CMAlphabetic IndexFormatted with main terms in boldface listed in alphabetic order.Main terms are flush with the left margin of each columnMain terms represent diseases, conditions, nouns and adjectives70

71. Conventions for ICD-10-CMAlphabetic IndexIndented beneath the main term are applicable subterms or essential modifiers in their own alphabetic listIndented subterm is always read in combination with the main termA dash (-) at the end of the Index entry indicates that additional characters are required

72. Conventions for ICD-10-CMAlphabetic IndexNonessential modifiers are terms or series of terms that appear in parentheses following a main term or subtermThe presence or absence of these parenthetical terms in a diagnosis statement has no effect on the selection of the codes listed for that main term or subterm72

73. Conventions for ICD-10-CM“See” and “See Also” InstructionsAppear in the Alphabetic Index following a main term“See” is a cross-reference term to direct coder to look elsewhere in the Index before assigning a code“See” points to an alternative term and is a mandatory instruction73

74. Conventions for ICD-10-CM“See also” is a cross-reference term to direct coder to look elsewhere in the Index before assigning a code“See also” requires review of another term in the Index if all the needed information cannot be found under the first main termNot necessary to follow the “see also” note when the original term provides the necessary code74

75. Conventions for ICD-10-CM“Code Also” Note appears when two code may be required to fully describe a conditionManifestation of disease codes appear as the code code, shown in brackets, directly under the underlying etiology code which should always be reported first.Dementia, with, Parkinson’s disease G20 [F02.80]75

76. Conventions for ICD-10-CMDefault code is the code listed next to the main term in the Alphabetic IndexRepresents the condition that is most commonly associated with the main termIs the unspecified code for the conditionDefault code used when the condition is documented without additional information to describe it.76

77. ICD-10-CM Tabular ListNumerical listing of all codes, divided into 21 chaptersFor some chapters, the body or organ system is the axisOther chapters group together conditions by etiology or nature of the disease processICD-10-CM contains chapters for External Causes of Morbidity Previously known as E codes in ICD-9-CMFactors Influencing Health Status and Contact with Health ServicesPreviously known as V codes in ICD-9-CM

78. ICD-10-CM Code Format and StructureCategories, subcategories and codesCodes contain either letters or numbersAll categories contain 3 charactersSubcategories are either 4 or 5 characters longCodes are 3, 4, 5, 6, or 7 characters long

79. ICD-10-CM Code Format and StructureThe final subdivision of a category is a codeCertain categories have an additional 7th character, that must always be the final character of a codeWhen the code contains few than 7 characters, a placeholder X must be used to fill the empty character(s)

80. ICD-10-CM Code Structure: First characterFirst character of ICD-10-CM code is an alphabetic characterAll letters of the alphabet are used with the exception of the letter “U”ICD-10-CM code format: A23.4567 First 3 characters = categoryNext 3 characters = etiology, anatomic site, severity7th character adds specificity

81. ICD-10-CM Code Structure: Placeholder characterICD-10-CM uses a placeholder character, which is always the letter “X” and it has two usesThe “X” provides for future expansion without disturbing the overall code structureUsed when a code has less than 6 characters and 7th character is required. The “X” is assigned for all characters less than six in order to meet the requirements of coding to the highest level of specificity.

82. ICD-10-CM Code Structure: Seventh characterRequired with certain categories according to the notes in the Tabular ListMust appear as the seventh character in the data fieldIf a code requires a seventh character but does not contain six characters, a placeholder X must be used to fill in the empty characters

83. ICD-10-CM AbbreviationsNEC: Not Elsewhere ClassifiedAppears in Alphabetic Index Index directs coder to the “other specified” code in the Tabular List, usually includes the number 8 as the character

84. ICD-10-CM AbbreviationsNOS: Not Otherwise SpecifiedAppears in the Alphabetic Index and Tabular List and is the equivalent of “unspecified,” usually appears as the number 9 as the characterUsed when the documentation of the conditions identified by the provider does not contain enough information to assign a more specific code

85. ICD-10-CM Punctuation MarksSquare Brackets [ ]Used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases. Used in the Alphabetic Index to identify manifestation codesWords in the square brackets are not required to be part of the diagnostic statement to use the code

86. ICD-10-CM Punctuation MarksSlanted brackets [ ]Used in the Alphabetic Index to identify manifestation codes.Manifestation codes represent the secondary condition that is present in addition to the underlying or primary disease that caused the secondary condition

87. ICD-10-CM Punctuation MarksSlanted brackets [ ]Two codes are required when the patient has both the underlying disease and the secondary condition. The use of the slanted bracket provides sequencing direction.The code that appears in the slanted bracket is listed as the secondary code or follows the disease code listed directly after the diagnosis term in the Index

88. ICD-10-CM Punctuation MarksParentheses ( )Used on both Alphabetic Index and Tabular ListEnclose supplementary words that may be present or absent in the statement of the disease without affecting the code numbers to which it is assignedTerms contained within the parentheses are referred to as “nonessential modifiers”

89. ICD-10-CM Punctuation MarksColon :Used in the Tabular List after an incomplete term that needs one or more additional terms in order to be assigned to a particular codeIn the official ICD-10-CM electronic version, the colon is used with “includes” and “excludes” notes, in which words that precede the colon are not considered complete terms

90. ICD-10-CM Instructional NotesInstructional notesUsed in the ICD-10-CM Tabular List to clarify information and provide additional directions for the coderInclusion termsIncludes notesExcludes notes

91. ICD-10-CM Instructional NotesInclusion Terms are list of medical diagnoses under some codes in the Tabular list. These are conditions for which the code is to be usedTerms may be synonymous with the code titleInclusion terms are not an exhaustive list as additional terms found only in the Alphabetic Index may also be assigned to a code

92. ICD-10-CM Instructional NotesIncludes NotesAppear immediately under a three-character code title to further define, or give examples of, the content of the category

93. ICD-10-CM Instructional NotesExcludes NotesIndicates that codes excluded from each other are independent of each otherTwo types of excludes notes designated as eitherExcludes1Excludes2Either or both may appear under a category, subcategory or code

94. ICD-10-CM Instructional NotesExcludes1 NoteConditions listed after an Excludes1 Note cannot be used at the same time as the code above the Excludes1 note.Mutually exclusive conditions; a patient cannot have both conditions at the same timeExcludes1 Note means the coder must decide which condition the patient has to assign code

95. ICD-10-CM Instructional NotesExcludes2 Note Means two codes are applied when both conditions are present. The condition that appears as an Excludes2 note is not part of the code that is listed above it.A patient may have both conditions at the same time and one code does not include both conditions, so two codes are applied

96. Etiology and Manifestation ConventionSome diseases produce another disease or conditionICD-10-CM requires two codes for situations when one disease produces another condition.First disease is considered the “etiology” and coded firstThe second condition is called the “manifestation” and listed as additional codes96

97. Etiology and Manifestation Convention“Code First” note appears in the Tabular List under the manifestation codeTitle of manifestation code usually includes the phrase “in diseases classified elsewhere”These codes are never first-listed or principal diagnosis codes, always are additional codesAppear in italicized fonts

98. Etiology and Manifestation Convention“Use Additional Code”There are diseases that require two codes to completely describe the condition. All the facts of the disease are not expressed in one code.ICD-10-CM will remind the coder to “use additional code” to fully describe the conditionThe “use additional code” is listed as an additional code, never a code listed first

99. Etiology and Manifestation ConventionEtiology and manifestation conventions appear in both Alphabetic Index and Tabular ListAlphabetic IndexBoth conditions may be listed on one line with the etiology code listed first and the manifestation code appearing in slanted brackets after it.The code in the brackets is never listed first or as a single code

100. Etiology and Manifestation ConventionEtiology and manifestation conventions appear in both Alphabetic Index and Tabular ListTabular ListThere are noted the coder must read at the category or at the code level to “code first” a certain condition or “use additional code” as an additional code to the code that it appears with

101. Multiple Coding for a Single ConditionMultiple codes may be required to code a disease that includes multiple disease processes or factorsRequirements for multiple coding can be identified in ICD-10-CM with such notes asCode firstCode, if applicable, a causal condition firstCode also101

102. Multiple Coding for a Single Condition“Code first” notes appear under certain codes that are not specifically manifestation codes but certain conditions may be due to an underlying causeWhen there is a “code first” note and an underlying condition is present, the underlying condition is sequenced first. Example is code R18.0 Malignant Ascites102

103. Multiple Coding for a Single Condition“Code, if applicable, a causal condition first” note indicates that this code may be assigned as a first-listed or principal diagnosis when the causal condition is unknown or not applicable. If the causal condition is know, then the code for that condition is sequenced first. Example is code R33.8 Other Retention of Urine103

104. Multiple Coding for a Single Condition“Code Also” note indicates that two codes may be required to fully describe a conditionThis code does not provide sequencing direction, that is, either code may be listed first depending on the circumstances of the medical visit or admissionExample is category code Z49, encounter for care involving renal dialysis104

105. Cross-References and Other TermsCross-references are used as directions for the code to look elsewhere in the Alphabetic Index before assigning a codeOther terms are used to explain the relationship between the diagnoses and conditions included in both the Alphabetic Index and the Tabular list.105

106. Cross-Reference and Other TermsAndThe term “and” is interpreted to mean “and/or” when it appears in a code title within ICD-10-CM Tabular ListPatient may have one or the other of the statements included in the code title

107. Cross-Reference and Other TermsWithAppears in Alphabetic Index immediately following the main term where it first appearsWith terms do not appear with other subterms starting with the letter WAppears in Tabular List and means the term “with” appearing in the code title means two conditions must be present in the patient to use that particular code

108. Cross-Reference and Other Terms“See” direction is used to instruct the coder to reference another term in the Alphabetic Index that provides more complete information about the condition to be coded“See” note also appears with an anatomic site listed as a main term in the Alphabetic Index to instruct the coder to “see condition” or the disease/condition that exists at that anatomic site.

109. Cross-Reference and Other Terms“See also” in the Alphabetic Index follows a main term if the coder should reference another term in the Index for additional information.However, it is not necessary to follow the “see also” note when the original main term provides all the necessary information to assign a complete code

110. Cross-Reference and Other TermsConnecting words or connecting termsThese words/terms appear as subterms in the Alphabetic Index after the main termIndicate a relationship between the main term and an associated condition or etiologyExamples of connecting words areAssociated with, Complicated by, Due to, During, Following, In, Secondary to, With, With mention of, Without

111. General Coding GuidelinesThere are basic concepts and rules that a coder must understand in order to assign ICD-10-CM codes accurately and completelyThe following slides provide a review of these general coding guidelines111

112. General Coding Guidelines(1) Locating a code in the ICD-10-CMCoder must use both the Alphabetic Index and the Tabular ListLocate main term and its code in the IndexVerify the code in the Tabular ListAlphabetic Index does not always provide the complete codeTabular List provides additional direction112

113. General Coding Guidelines(2) Level of Detail in CodingCodes are reported with the highest number of characters available. For example, a three-character code is only used if it is not further subdividedA code is invalid if it is not coded to the full number of characters required for that code113

114. General Coding Guidelines(3) Signs and SymptomsSign and symptom codes are reported when that is what is known for certain about a patient and no definitive diagnosis has been madeMost sign and symptom codes appear in Chapter 18 but certain sign and symptom codes may appear in a body system chapter when it only can be related to one body system114

115. General Coding Guidelines(4) Conditions That Are an Integral Part of a Disease ProcessSigns and symptoms that are associated routinely with a disease process should not be assigned as additional codes with that disease, unless other instructions exist.Once the reason for the sign or symptom is known as routine, their codes are not assigned115

116. General Coding Guidelines(5) Conditions That Are Not an Integral Part of a Disease ProcessAdditional signs and symptoms that may not be associated routinely with a disease process should be coded when present.Coder’s knowledge of disease pathology is essential in knowing whether a sign or symptom is routinely associated with a disease116

117. General Coding Guidelines(6) Acute and Chronic ConditionsIf a patient has both the acute and chronic forms of a disease and the Alphabetic Index has separate entries at the same indentation level for both acute and chronic forms of the disease, both codes are assignedThe acute or subacute code is sequenced first followed by the chronic code for the disease117

118. General Coding Guidelines(7) Combination CodesA combination code is a single code to classify two diagnosesA combination code may represent a diagnosis with an associated secondary manifestationA combination code may be a diagnosis with an associated complication118

119. General Coding Guidelines(7) Combination Codes continuedIdentified by referring to subterm entries in the Index that identify conditions associated with or due to each otherIdentified by reading all the includes and excludes notes in the Tabular ListOnly assigned when one code fully describes the condition119

120. General Coding Guidelines(7) Combination Codes continuedMultiple coding should not occur when a combination code identifies all the elements of the diseaseAn additional code is only used as a secondary code when the combination code lacks specificity in describing the manifestation or complication120

121. General Coding Guidelines(8) Sequela or Late EffectsA sequela is a condition that is produced by another illness or injury and remains after the acute phase of the illness or injury is overThere is no time period to when a sequela must appear121

122. General Coding Guidelines(8) Sequela or Late Effects continuedThe sequela condition may be present at the same time as the original condition.Other sequela may develop after a period of time when the acute phase of the illness is over122

123. General Coding Guidelines(8) Sequela or Late Effects continuedTwo codes are required to code sequela conditionsFirst code is the condition that exists at present and is called the sequelaSecond code is the original condition identified as the cause of the present condition123

124. General Coding Guidelines(8) Sequela or Late Effects (continued)The code for the acute phase of an illness that led to the sequela is never used with a code for the sequelaTwo exceptions to this rule124

125. General Coding Guidelines(8) Sequela or Late Effects (continued)Two exceptions to this rule, coder should follow the codes as listed in the IndexThe code for the sequela is followed by a manifestation code identified in the Tabular List and titleThe sequela code has been expanded at the fourth, fifth, or sixth character levels to include the manifestation.125

126. General Coding Guidelines(8) Sequela or Late Effects (continued)The main term “sequela” must be used in the Index to identify if a combination code for the sequela and the underlying condition exists. Tabular List may have “code first condition resulting from (sequela of).”126

127. General Coding Guidelines(8) Sequela or Late Effects (continued)Step by step process to code scar on the face due to a previous burnFirst access the main term of “scar” in IndexThere is no combination code for scar due to burnNext access the main term of “sequela” in IndexSequela, burn—code to injury with seventh character SThese two codes are required127

128. General Coding Guidelines(9) Impending or Threatened ConditionGuideline I.B.12, if condition described at the time of discharge as “impending” or “threatened,” it should be coded as follows:If condition did occur, code as a confirmed diagnosis128

129. General Coding Guidelines(9) Impending or Threatened ConditionIf condition did not occur, follow Index to see if subterm entry of “impending” or “threatened” is listed. Also use main term of “impending” or threated” in IndexIf subterms are listed, assign the given codeIf subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened129

130. General Coding Guidelines(10) Reporting Same Diagnosis Code More Than OneEach unique ICD-10-CM diagnosis code may be reported only once for an encounterThis applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code130

131. General Coding Guidelines(11) LateralitySome ICD-10-CM diagnosis code include laterality or whether the condition exists on the right or left side of the bodyBilateral codes have the final character indicating bilateral131

132. General Coding Guidelines(11) Laterality (continued)An unspecified code is used if the side of the body is not identified in the medical recordIf no bilateral code is provided and the condition is bilateral, the coder must assign separate codes for both the left and right side.132

133. General Coding Guidelines(12) Documentation for BMI and Pressure Ulcer StagesFor BMI value and pressure ulcer stage codes, the code may be made based on medical record documentation from clinicians who are not the patient’s provider such as the physician/providerHowever, the diagnosis of obesity or pressure ulcer must be made by the physician/provider133

134. General Coding Guidelines(13) SyndromesCoder should follow the Alphabetic Index when coding named syndromesIf the Alphabetic Index does not contain the named syndrome, the coder should assign codes for each of the documented individual manifestations or conditions identified as the syndrome134

135. General Coding Guidelines(14) Documentation of Complications of CareCode assignment is based on the provider’s documentation of the relationship between the condition and the care or procedureNot all conditions that occur during or following medical or surgical care are classified as complications135

136. General Coding Guidelines(14) Documentation of Complications of CareThere must be a cause-and-effect relationship between the care and the condition and an indication in the documentation that it is a complicationThe physician should be queried or asked for clarification if the complication is not clearly documented136

137. Basic Steps in ICD-10-CM CodingTo code completely and accurately, coder should follow these eight steps:1. Identify all main terms included in the diagnostic statement2. Locate each main term in the Alphabetic Index3. Refer to any subterms indented under the main term. The subterms form individual line entries and describe essential differences by site, etiology, or clinical type

138. Basic Steps in ICD-10-CM CodingTo code completely and accurately, coder should follow these eight steps (continued)4. Follow cross-reference instructions if the needed code is not located under the first main entry consulted5. Verify the code selected in the Tabular List6. Read and be guided by an instructional terms in the Tabular List

139. Basic Steps in ICD-10-CM CodingTo code completely and accurately, coder shouldfollow these eight steps (continued)7. Assign codes to their highest level of specificity, up to a total of seven characters if applicable8. Continue coding the diagnostic statement until all the component elements are fully identified