ICD-10-CM Official Coding Guidelines | Exams Nursing

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ICD-10-CM Official Coding Guidelines

1. Locating a code in the ICD-10-CM - -To

select a code in the classification that

corresponds to a diagnosis or reason for visit

documented in a medical record, first located the

term in the Index, and then verify the code in the

Tabular List. Read and be guided by instructional

notations that appear in both the Index and the

Tabular List.

It is essential to use both the Index and Tabular

List when locating and assigning a code. The

Index does not always provide the full code,

including laterality and applicable 7th can only be

done in the Tabular list. A dash (-) at the end of

an Index entry indicate that additional characters

are required. Even if a dash is not included at the

Index entry, it is necessary to refer to the Tabular

list to verify that no 7th character is required.

2. Levels of Detail in Coding - -Diagnosis

codes are to be used and reported at their

highest number of digits available.

ICD-10-CM diagnosis codes are composed of

codes with 3, 4, 5, 6, or 7 digits. Codes with three

digits are included in ICD-10-CM as the heading

of a category of codes that may be further

subdivided by the use of fourth and/or fifth digits,

which provide greater detail.

A three-digit code is to be used only if it is not

further subdivided. A code is invalid if it has not

be coded to the full number of characters

required for that code, including the 7th

character, if applicable.

3. Code or codes from A00.0 through T88.9,

Z00-Z99. - -The appropriate 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.

4. Signs and Symptoms - -Codes that

describe symptoms and signs as opposed to

diagnoses, are acceptable for reporting purposes

when a related definitive diagnosis has not ben

established (confirmed) by the provider. 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.

5. Conditions that are an integral part of a

disease process - -Signs and symptoms

that are associated routinely with a disease

process should not be assigned as additional

codes, unless otherwise instructed by the

classification.

6. Conditions that are not an integral part of a

disease process - -Additional signs and

symptoms that may not be associated routinely

with a disease process should be coded when

present.

7. 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 code" notes are found in the Tabular at

codes that are not part of an

etiology/manifestation pair, where a secondary

code is useful to fully describe a condition. The

sequencing rule is the same as the

etiology/manifestation pair, "use additional code"

indicates that a secondary code should be

added.

For example, for bacterial infections that are not

included in chapter 1, a secondary code from

category B95, Streptococcus, and Enterococcus,

as the cause of disease classified elsewhere, or

B96, Other bacterial agents as the cause of

diseases classified elsewhere, may be required

to identify the bacterial organism causing the

infection. A "use additional code" note will

normally be found at the infectious disease code,

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Locating a code in the ICD- 10 - CM - - To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first located the term in the Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Index and the Tabular List. It is essential to use both the Index and Tabular List when locating and assigning a code. The Index does not always provide the full code, including laterality and applicable 7th can only be done in the Tabular list. A dash (-) at the end of an Index entry indicate that additional characters are required. Even if a dash is not included at the Index entry, it is necessary to refer to the Tabular list to verify that no 7th character is required.
Levels of Detail in Coding - - Diagnosis codes are to be used and reported at their highest number of digits available. ICD- 10 - CM diagnosis codes are composed of codes with 3, 4, 5, 6, or 7 digits. Codes with three digits are included in ICD- 10 - CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. A code is invalid if it has not be coded to the full number of characters required for that code, including the 7th character, if applicable.
Code or codes from A00.0 through T88.9, Z00-Z99. - - The appropriate 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 - - Codes that describe symptoms and signs as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not ben established (confirmed) by the provider. 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.
1. Conditions that are an integral part of a disease process - - Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
2. Conditions that are not an integral part of a disease process - - Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
3. 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 code" notes are found in the Tabular at codes that are not part of an etiology/manifestation pair, where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, "use additional code" indicates that a secondary code should be added. For example, for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, and Enterococcus, as the cause of disease classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A "use additional code" note will normally be found at the infectious disease code,

indicating a need for the 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 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 casual 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 late effects, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for those conditions for further instruction.

Acute and Chronic Conditions - - 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 Code - - Combination code is a single code used to classify: Two diagnoses, or A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion note 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 10. Late Effects (Sequela) - - A late effect is the residual effect (condition produced) after the acute phase of an illness or injury had terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as a cerebral infection, or it may occur months or years later, such as that due to a previous injury. Coding is late effects generally requires two codes sequences in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to the above guidelines are those instances where the code for late effect is followed y a manifestation code identified in the Tabular List and title, or the late effect 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 lead to the late effect 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 See Section I.C.19. Code extensions 11. Impending or Threatened Condition - - Code any condition described at the time of discharge as "impending" or "threatened" as follows: If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index

Note: This guideline is applicable only to impact admissions to short-term, acute, long-term care and psychiatric hospitals. G. Admission from Observation Unit or Outpatient Surgery - - 1. Admission Following Medical Observation When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for the same medical condition, the principal diagnosis would be the medical condition which lead to the hospital admission.

Admission Following Post-Operative Observation When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to ne chiefly responsible for occasioning to the admission of the patient to the hospital for care."
Admission from Outpatient Surgery When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:

If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated as the principal diagnosis. A. Previous conditions - - If the provider had included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolve conditions or diagnoses and status-post procedures from previous admissions that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical conditions or family history has an impact on current care or influences treatment B. Abnormal findings - - Abnormal findings (laboratory, x-ray, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider. C. Uncertain Diagnosis - - If the diagnosis documented at the time of the discharge is qualified as "probable", "suspected", "likely", questionable", "possible", or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for those guidelines are the diagnostic workup, arrangements for further workup or observation, an initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long- term care and psychiatric hospitals. A. Selection of first-listed condition - - In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding convention of ICD- 10 - CM, as well as the general and disease specific guidelines takes precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.

Outpatient Surgery When a patient presents for the outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
Observation Stay When a patient is admitted for observation for a medical condition, assign a code for a medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnosis. B. Codes from A00.0 through T88.9, Z00-Z99 -
- The appropriate code(s) from A00. through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. D. Codes that describe symptoms and sign -
  - Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD- 10 - CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00-R99) contain many, but not all codes for symptoms. C. Accurate reporting of ICD- 10 - Cm diagnosis code. - - For accurate reporting of ICD- 10 - CM diagnoses codes, the documentation should describe the patient's condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD- 10 - CM codes to describe all of those. G. ICD- 10 - CM code for the diagnosis, condition, problem, or other reason for encounter/visit -
  - List first the ICD- 10 - Cm code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the service provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. J. Code all documented conditions that coexist -
  - Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used a secondary codes if the historical condition or family history has an impact on current care or influences treatment.

abnormal findings on test results. L. Patients receiving therapeutic services only -

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g. chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the services is listed first, and the diagnosis or problem for which the service is being performed listed second. O. Routine outpatient prenatal visit - - See section I.C.15. Routine outpatient prenatal visits. P. Encounters for general medical examinations with abnormal findings - - The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination results in abnormal finding, the code for general medical examination with abnormal finding should be assigned as the first listed diagnosis. A Secondary code for abnormal finding should be coded. Q. Encounters for routine health screenings -
See Section I.C.21. Factors influencing heath status and contact with health services, Screening.

ICD-10-CM Official Coding Guidelines, Exams of Nursing

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