This is the written document to accompany my YouTube video: https://www.youtube.com/watch?v=ctOG4-jrGCs&list=PLr1wI57Ez8GQuRAOyFpYclp1pE0WkJisq
While reading this document, it will be beneficial to download a copy of the current edition of the Official ICD-10-CM Coding Guidelines from www.CMS.gov
Purpose:
The purpose of the ICD-10-CM Coding Guidelines is to provide a standardized set of rules and instructions for assigning medical codes to diagnoses. This ensures consistency and accuracy in medical coding by guiding healthcare providers and coders on how to properly select the most appropriate diagnosis codes based on patient documentation. Ultimately, this facilitates accurate billing, data analysis, and communication across healthcare systems.
These guidelines have been developed to assist the healthcare provider and the coder in identifying the diagnoses to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.
Why do we assign codes for diagnoses and procedures? The number one reason is confidentiality! Unless you are a trained medical coder, when you view a patient’s medical record and the diagnosis is identified with a code, you won’t know what that code stands for. However, there are other reasons as well. For example, to identify patterns in disease and treatment, develop new treatments, and improve the quality of healthcare.
Let’s start our review of these ICD-10-CM Official Guidelines for Coding and Reporting.
A morbidity classification (ailment) is published to provide a common language for reporting, coding, and monitoring diseases. It allows the world to share and compare data in a consistent and standard way. Some code books include these guidelines within the ICD-10-CM Code Book.
These ICD-10- Official Guidelines for Coding and Reporting have been approved by four organizations:
- The American Hospital Association (AHA)
- The American Health Information Management Association (AHIMA)
- The Center for Medicare and Medicaid Services (CMS), and
- The National Center for Health Statistics (NCHS)
These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. Therefore, as you are coding, follow the actual codebook instructions, as these take precedence.
These guidelines are organized into four different sections:
- Conventions, general coding guidelines and chapter-specific guidelines
- Selection of Principal Diagnosis
- Reporting Additional Diagnosis
- Diagnostic Coding and Reporting Guidelines for Outpatient Services
Let’s start our review of Section I: Conventions, general coding guidelines, and chapter-specific guidelines.
A “convention” is a written agreement or promise usually under seal between two or more parties especially for the performance of some action. The conventions for the ICD-10-CM are the general rules for the use of the classification. Within ICD-10-CM, there is an Alphabetic Index, which is an alphabetical list of terms and their corresponding alphanumeric code, which you refer to in the Tabular List. The Tabular List is a structured list of codes divided into chapters based on body system or condition.
The Alphabetic Index consists of the following parts:
Index to Diseases and Injury
Index to External Causes of Injury
Table of Neoplasm
Table of Drugs and Chemicals
Format and Structure:
Alpha-numeric structure – all codes start with an alphabetical character.
Basic Code Structure: 3 Characters Ex. S02.- –
Section: Group of three-character codes (Ex. S00 – T88)
Categories: A three-character code (Ex. S02)
Subcategories: Four-character code (Ex. S02.1)
Subclassification: Five, six, or seven-character code (Ex. S02.110A)
(pay attention to how the code S02. expands from a “Category” code to a “Subclassification” code)
Attached is a copy of the ICD-10-CM Code Book at code S02._. Look at how the code book instructs you to add the additional digits, indicating that the code must expand to complete the code.
3. Use of codes for reporting purposes
For reporting purposes only, codes are permissible, not categories or subcategories, and any applicable 7th character is required. The category S02._ must expand to the 4th, 5th, 6th and 7th characters.
4. Placeholder character
The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder
at certain codes to allow for future expansion.
(Example: Code S02.0 above) There is a circle with a “7th” in a circle. This indicates that the 7th character must be added to this code. Because S02.0 is only four digits long, we must add the placeholder character “X” to the vacant spaces between digits four and seven (S02.0xx-). Then we must determine which 7th character applies to this encounter.
5. 7th Characters
The 7th character must always be the 7th character in the data field. If a code
that requires a 7th character is not 6 characters; a placeholder “X” must be used to fill in
the empty characters. Example again: Code S02.0 above)
6. Abbreviations
NEC: Not Elsewhere Classified Prior to April 1, 2020: There was no code for COVID-19, so we coded it as close as we could to what was identified in the code book. Ex. Infectious Disease, NEC (no code in classification for condition)
NOS: Not Otherwise Specified (Example: Two people go to dinner together. They order the same chicken dinner. Later that evening, they are both not feeling well. They are throwing up and have diarrhea. They decide to go to the Emergency Room. One doctor sees one of them and another doctor sees the other. When they are discharged, one record says, “Food Poisoning” and the other record says, “Salmonella Poisoning”. There is specificity in the “Salmonella Poisoning” that was not documented in the “Food Poisoning” diagnosis. Therefore, one chart will be coded as “Salmonella Poisoning” while the other chart will be coded as “Food Poisoning, unspecified”. This means the second chart was “Not Otherwise Specified” and therefore cannot be coded with the specificity as the other chart.
7. Punctuation
[ ] Brackets: In the Tabular List: enclose alternative wordings or abbreviations –
Ex. Code J00 [common cold] – Notice how at code J00 there are brackets at the code that state [common cold] – This confirms that you are in the right place.
( ) Parentheses: (nonessential modifiers)- Supplemental words that may or may not be present in the diagnosis, but give greater specificity. Ex. “Burn” – At the main term “Burn” you see in parentheses (electricity) (flame) (hot gas, liquid or hot object) (radiation) (steam) (thermal) – these describe the type of burn. These may or may not be present in your diagnosis. If your provider states an electrical burn, I have confirmation that I am at the right place. And, if the provider just states “burn”, I’m at the right place.
Colons: Incomplete terms that need one or more of the terms following the colon for the term to apply.
Ex. M25.3 Other instability of joint
Excludes1: instability of joint secondary to:
old ligament injury (M24.2-)
removal of joint prosthesis (M96.8-)
In the above example, the Excludes 1 note indicates that “instability of joint secondary to: old ligament injury should not be coded at M25.3 but instead at M24.2-“. And, “instability of joint secondary to: removal of join prosthesis should not be coded at M25.3 but instead at M96.8-.”
8. Use of “and” – Tells you to refer to #14 below.
9. Other and Unspecified codes – (refer to Guidelines)
(sometimes the Provider gives greater specificity than the classification has. In those cases, refer to “other specified”. There are other times when the Provider just does not give the specificity. However, the classification does have it, but because it was not given, you cannot code it.)
10. Includes Notes – (refer to Guidelines) Confirmation that you are at the right place.
11. Inclusion terms – Included here!
12. Excludes Notes – Two types:
Excludes1: NOT CODED HERE. (ex. Congenital condition vs. Acquired condition)
Excludes2: NOT INCLUDED HERE. (ex. These two conditions are so closely related that you have to question if the provider meant one or the other or both. And, both can be coded, if documented but at different places in the classification.)
13. Etiology/manifestation convention (“code first”, “use additional code” and “in diseases classified elsewhere” notes)– (Refer to Guideline first then picture)
Parkinsonism, dementia G20.C, [F02.80] – Alphabetic Index (1st picture go to Main Term “Parkinsonism” and subterm “dementia”. 2nd picture is the Tabular List for G20, which tells you to “Use Additional code”.
14. “And” – (Refer to guideline first) Then code A18.0 in the Tabular List. There is a symbol of an eye that states “See Official Guidelines “And” I.A.14” – meaning this code can stand for “Tuberculosis of bone”, “Tuberculosis of joints”, and “Tuberculosis of bone and joints”.
15. “With” – (Refer to Guideline first, then picture: “Diabetes, “with” or “in”
16. “See” and “See Also” – Refer to Guideline then picture
Hemarthrosis”nontraumatic vs. traumatic”. For the main term “Hemarthrosis” there is a nonessential modifier in parenthesis (nontraumatic), which means if the condition is nontraumatic, you are at the right place. Now, look further down the subterms to “traumatic”. It refers to “see Sprain, by site”. It is telling you that if the “Hemarthrosis” is traumatic, you should refer to the main term “Sprain”.
17. “Code also” note – Refer to Guideline.
18. Default codes -refer to Guideline first then picture “Appendicitis”
If no specificity is given, only code “Appendicitis”.
19. Code assignment and Clinical Criteria – Refer to Guideline.
These guidelines are so long, it will take more than one blog post to fully cover them. Please refer to the continuation as I add them.
Don’t forget to download a copy of the Official ICD-10-CM Guidelines here: www.CMS.gov
as well as follow along on my YouTube at: https://www.youtube.com/watch?v=ctOG4-jrGCs&list=PLr1wI57Ez8GQuRAOyFpYclp1pE0WkJisq
