ICD-10-CM Basic Coding Guidelines Flashcards
Locating a code in the ICD-10-CM
Locate in term in the Alphabetic Index, Verify code in the Tabular List, and then assign code.
Code or Codes from A00.0 through T88.9, Z00-Z99.8
must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit.
Signs and symptoms
Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, not elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms.
Conditions that are an integral part of a disease process
signs and symptoms routinely part of the condition, and are not assigned additional codes.
Conditions that are not an integral part of the disease process
Signs and symptoms not associated routinely with a condition, and should be coded if present.
Multiple Coding for a Single condition
In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code "Use additional codes" notes are found in the Tabular List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. the sequencing is the same as the etiology/manifestation pair, "use additional code" indicates that a secondary code should be added.
notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first.
"Code if applicable, any casual condition first",
notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a casual condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.
Multiple codes may be needed for these, complication codes, and obstetric codes to more fully describe the condition.
Acute and Chronic Condition
if described as both and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute first.
Single code used to clarify: Two diagnoses or A diagnosis with an associated secondary process (manifestation), A diagnosis with an associated complication. Assign only when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index directs.
Sequela (Late Effects)
Residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit. Generally requires two codes sequenced in the following order. the condition or nature is coded first. the sequela is coded second.
An exception are those instances the code for sequala is followed by the manifestation code identified in the Tabular list and title, or the sequela code has expanded to include the manifestation.
Impending or Threatned Condition
If it did occur, code as confirmed; if it did not occur, reference the Alphabetic Index to determine if the condition is under "impending or threatned"; if the subterm is listed, assign given code, if not listed assign existing underlying condition and not the condition described.
Reporting Same Diagnosis Code More Than Once
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no diameter codes identifying laterality of two different conditions classified to the same ICD-10-CM diagnosis code.
Some ICD-10-CM codes specify whether the condition occurs on 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 code.