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ICD-10-CM Coding Guidelines: Questions and Answers, Exams of Nursing

Howard Community CollegeNursing

A question and answer format overview of the icd-10-cm coding guidelines and conventions. It covers key definitions, coding conventions, and updates related to the international classification of diseases, tenth revision, clinical modification. It includes topics such as medical necessity, codebook layout, neoplasms, metastasis, main terms, subterms, qualifiers, placeholder characters, alphabetic index, tabular list, excludes notes, and etiology/manifestation convention. This resource is designed to help coders and healthcare professionals understand and apply the icd-10-cm guidelines effectively in clinical settings, ensuring accurate diagnosis reporting and compliance with coding standards. It serves as a quick reference guide for understanding the structure and usage of icd-10-cm codes.

Typology: Exams

2024/2025

Available from 12/03/2025

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ICD-10-CM: General Coding, Guidelines and Conventions
Questions and Answers
Define: medical necessity - ANSWER --
Care that is reasonable, necessary, and/or
appropriate
- Evidence-based clinical standards of care
What does ICD-10-CM stand for? -
ANSWER -- International Classification of
Diseases - Tenth Revision - Clinical Modification
What is the ICD-10-CM? - ANSWER --
diagnosis code set used to report diagnoses in
all clinical settings
What does ICD-10-PCS stand for? -
ANSWER -- International Classification of
Diseases - Tenth Revision - Procedure
Classification System
What is the ICD-10-PCS? - ANSWER --
Procedure code set used to report hospital
inpatient procedures only
What is the purpose of the ICD-10? -
ANSWER -- Developed by the World
Health Organization (WHO)
- A standard diagnostic tool for epidemiology,
health management, and clinical purposes
- Designed to compile and present statistical data
on morbidity (the rate or frequency of disease)
and mortality (the rate or frequency of deaths)
- Classification system use to identify and record
health conditions
-Key storyteller to insurance companies (see
medical necessity)
How often is the ICD-10 updated? Dates? -
ANSWER -- ICD-10-CM/PCS is updated
every year
- October 1st -> major updates
- April 1st -> updates
ICD-10 Codebook Layout - ANSWER -- A.
Official ICD-10-CM guidelines for Coding and
Reporting
-- I.Coding Conventions
-- II. General Coding Guidelines
-- III. Chapter Specific Coding Guidelines
- B. Alphabetic Index
-- I. Index to Diseases and Injuries
--- a. Table of Neoplasms
--- b. Table of Drugs and Chemicals
-- II. Index to External Causes of Injuries
- Tabular List of Diseases and Injuries
What is a Neoplasm? - ANSWER -- a tumor
or an abnormal clump of tissue that may be
benign or malignant. It serves no useful function
but grows at the expense of the healthy
organism.
What is a Benign Neoplasm? - ANSWER --
growth not spreading by metastases or infiltration
of tissue
What is a Histoid Neoplasm? - ANSWER --
a neoplasm in which structure resembles the
tissues and elements that surround it.
What is a Malignant Neoplasm? -
ANSWER -- growth that infiltrates tissue,
metastasizes, and often recurs after attempts at
surgical removal.
- SYN: cancer
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Questions and Answers

Define: medical necessity - ANSWER -- Care that is reasonable, necessary, and/or appropriate

  • Evidence-based clinical standards of care What does ICD- 10 - CM stand for? - ANSWER -- International Classification of Diseases - Tenth Revision - Clinical Modification What is the ICD- 10 - CM? - ANSWER -- diagnosis code set used to report diagnoses in all clinical settings What does ICD- 10 - PCS stand for? - ANSWER -- International Classification of Diseases - Tenth Revision - Procedure Classification System What is the ICD- 10 - PCS? - ANSWER -- Procedure code set used to report hospital inpatient procedures only What is the purpose of the ICD-10? - ANSWER -- Developed by the World Health Organization (WHO)
  • A standard diagnostic tool for epidemiology, health management, and clinical purposes
  • Designed to compile and present statistical data on morbidity (the rate or frequency of disease) and mortality (the rate or frequency of deaths)
  • Classification system use to identify and record health conditions
  • Key storyteller to insurance companies (see medical necessity) How often is the ICD-10 updated? Dates? - ANSWER -- ICD- 10 - CM/PCS is updated every year
    • October 1st - > major updates
    • April 1st - > updates ICD-10 Codebook Layout - ANSWER -- A. Official ICD- 10 - CM guidelines for Coding and Reporting -- I.Coding Conventions -- II. General Coding Guidelines -- III. Chapter Specific Coding Guidelines
    • B. Alphabetic Index -- I. Index to Diseases and Injuries --- a. Table of Neoplasms --- b. Table of Drugs and Chemicals -- II. Index to External Causes of Injuries
    • Tabular List of Diseases and Injuries What is a Neoplasm? - ANSWER -- a tumor or an abnormal clump of tissue that may be benign or malignant. It serves no useful function but grows at the expense of the healthy organism. What is a Benign Neoplasm? - ANSWER -- growth not spreading by metastases or infiltration of tissue What is a Histoid Neoplasm? - ANSWER -- a neoplasm in which structure resembles the tissues and elements that surround it. What is a Malignant Neoplasm? - ANSWER -- growth that infiltrates tissue, metastasizes, and often recurs after attempts at surgical removal.
    • SYN: cancer

Questions and Answers

What are the four types of Coding Conventions?

  • ANSWER - 1. Instructional Notes
  1. Punctuation Marks
  2. Abbreviations
  3. Symbols Define: Metastasis - ANSWER -- movement of bacteria or body cells (esp., cancer cells) from one part of the body to another
  • change in location of a disease or of its manifestations or transfer from one organ or part to another not directly connected
  • Metastasize: to invade distant structures of the body. To disseminate widely. Coding Conventions: What are Main Terms? - ANSWER -- bold text, capitalized and left alignment
  • describes the diseases, conditions, eponyms, injuries, drugs, and external causes followed by their corresponding code What is an Eponym? - ANSWER -- a name for anything (disease, organ, function, place) adapted from the name of a particular person or sometimes a geographical location What do Parenthetical Terms which follow the main term represent? - ANSWER -- nonessential modifiers (does not change the meaning of the main term) -- supplemental terms -- provides additional information What other main terms should one refer to when the condition in the diagnostic statement is not easily found in the index? - ANSWER -- abnormal
  • anomaly
    • complication
    • delivery
    • disease
    • disorder
    • findings
    • foreign body
    • infection
    • injury
    • late effects
    • lesion
    • neoplasm
    • obstruction
    • pregnancy
    • puerperal
    • syndrome
    • wound Coding Conventions: What are Subterms? - ANSWER -- further describe a main term
    • indented below a main term
    • must be included in the diagnostic statement
    • known as an essential modifier
    • affects the code selection
    • followed by corresponding code
    • may have additional indented subterms Coding Conventions: What are Qualifiers? - ANSWER -- 2nd qualifier: term that further modifies the subterm
    • 3rd qualifier: term that further modifies the 2nd qualifier
    • 4th qualifier: term that further modifies the 3rd qualifier Use of codes for reporting purposes - ANSWER -- For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required. Placeholder character - ANSWER -- The

Questions and Answers

designate "other" codes in the Tabular List. - These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code. "Unspecified" codes - ANSWER -- Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code.

  • For those categories for which an unspecified code is not provided, the "other specified" code may represent both other and unspecified. Includes Notes - ANSWER -- This note appears immediately under a three character code title to further define, or give examples of, the content of the category. Inclusion terms - ANSWER -- List of terms is included under some codes.
  • These terms are the conditions for which that code is to be used.
  • The terms may be synonyms of the code title
  • in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code
  • The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code. Excludes Notes - ANSWER -- The ICD- 10 - CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other. Excludes1 - ANSWER -- a pure excludes note
    • means "NOT CODED HERE!"
    • indicates that the code excluded should never be used at the same time as the code above the Excludes1 note
    • used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Excludes2 - ANSWER -- represents "Not included here"
    • indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.
    • When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate Etiology/manifestation convention ("code first", "use additional code" and "in diseases classified elsewhere" notes) - ANSWER -- the underlying condition is sequenced first followed by the manifestation
    • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.
    • etiology/manifestation convention requires two codes to fully describe a single condition that affects multiple body systems
    • Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
    • In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component

Questions and Answers

of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention.

  • There are manifestation codes that do not have "in diseases classified elsewhere" in the title. For such codes, there is a "use additional code" note at the etiology code and a "code first" note at the manifestation code and the rules for sequencing apply.
  • In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.
  • An example of the etiology/manifestation convention is dementia in Parkinson's di "And" - ANSWER -- "and" or "or" when it appears in a title "With" - ANSWER -- "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.
  • The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order. "See" - ANSWER -- The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced.
    • It is necessary to go to the main term referenced with the "see" note to locate the correct code. "See Also" - ANSWER -- A "see also" instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful.
    • It is not necessary to follow the "see also" note when the original main term provides the necessary code. "Code also note" - ANSWER -- A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. Default codes - ANSWER -- A code listed next to a main term in the ICD- 10 - CM Alphabetic Index
    • represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition
    • If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned Locating a code in the ICD- 10 - CM - ANSWER -- To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.
    • It is essential to use both the Alphabetic Index

Questions and Answers

organism code to be added as a secondary code. "Code first" 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 causal 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 causal 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 sequela, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction. Acute and Chronic Conditions - ANSWER -
  • If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first Combination Codes - ANSWER -- a single code used to classify: a. Two diagnoses b. A diagnosis with an associated secondary process (manifestation) c. A diagnosis with an associated complication
  • identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.
  • Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs.
    • Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.
    • When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. Sequela (Late Effects) - ANSWER -- the residual effect (condition produced) after the acute phase of an illness or injury has terminated.
    • There is no time limit on when a sequela code can be used.
    • Examples of sequela: 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.
    • An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. See Section I.C.9. Sequelae of cerebrovascular disease See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium

Questions and Answers

See Section I.C.19. Application of 7th characters for Chapter 19 Impending or Threatened Condition - ANSWER - Code any condition described at the time of discharge as "impending" or "threatened" as follows: I. If it did occur, code as confirmed diagnosis. II. 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. Reporting Same Diagnosis Code More than Once - ANSWER -- Each unique ICD- 10 - CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10CM diagnosis code. Laterality - ANSWER - Some 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 Documentation for BMI, Non-pressure ulcers and Pressure Ulcer Stages - ANSWER -- code assignment may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages)
    • the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient's provider.
    • If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.
    • The BMI codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses). Syndromes - ANSWER -- Follow the Alphabetic Index guidance when coding syndromes.
    • In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome.
    • Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code. Documentation of Complications of Care - ANSWER -- Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure.
    • The guideline extends to any complications of care, regardless of the chapter the code is located in.
    • *note: not all conditions that occur during or following medical care or surgery are classified