Section 1: ICD-10-CM Coding Guidlines – Flashcards

The ICD - 10 - CM is divided into the Alphabetic Index , an alphabetical list of terms and their corresponding code, and the Tabular List, a structured list of codes divided into chapters based on body system or condition. The Alphabetic Index consists of the fol lowing parts: the Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals

The ICD-10- CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that hasno further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3,4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character.The ICD-10-CM uses an indented format for ease in reference.

For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.

The ICD-10-CM utilizes a placeholder character "X". The "X" is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and underdosing codes, categories T36-T50. ICD-10-CM Official Guidelines for Coding and Reporting 2013 Page 8 of 113 Where a placeholder exists, the X must be used in order for the code to be considered a valid code.

Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in thedata field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in theempty characters.

NEC-"Not elsewhere classifiable" This abbreviation in the Alphabetic Index represents "other specified" *When a specific code is not available for a condition,the Alphabetic Index directs the coder to the "other specified" code in the Tabular List . NOS-"Not otherwise specified" This abbreviation is the equivalent of unspecified.

NEC-"Not elsewhere classifiable" This abbreviation in the Tabular List represents "other specified". When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the "other specified" code. NOS-"Not otherwise specified" This abbreviation is the equivalent of unspecified.

Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.

Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that maybe present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.

Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line 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.

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.

This note appears immediately under a three character code title to further define, or give examples of, the content of the category

List of terms is included under so me codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, 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.

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.

A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

A type 2 Excludes note represents "Not included here". An excludes2 note 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.

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. 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 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 disease. In the Alphabetic Index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying ICD-10-CM Official Guidelines for Coding and Reporting 2013 Page 11 of 113 etiology, Parkinson's disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance. "Code first" and "Use additional code" notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination.

The word "and" should be interpreted to mean either "and" or "or" when it appears in a title. For example, cases of "tuberculosis of bones", "tuberculosis of joints" and "tuberculosis of bones and joints" are classified to subcategory A18.0, Tuberculosis of bones and joints.

The word "with" should be interpreted to mean "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.

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. 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

A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code 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, ICD-10-CM Official Guidelines for Coding and Reporting 2013 Page 12 of 113 appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.

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 and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash(-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

Diagnosis codes are to be used and reported at their highest number of characters available. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters 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 characters and/or sixth characters, which provide greater detail. A three- character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

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.

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not ICD-10-CM Official Guidelines for Coding and Reporting 2013 Page 13 of 113 Elsewhere Classified(codesR00.0-R99) contains many, but not all codes for symptoms.

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

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 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 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, Staphylococcus, and Enterococcus, as the cause of diseases 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 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.

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.

A 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 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.

A sequela is 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. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. 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

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 to determine if the condition has a sub entry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened." If the sub terms are listed, assign the given code. If the sub terms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.

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 liberality or two different conditions classified to the same ICD-10-CM diagnosis code

Some ICD-10-CM codes indicate liberality, 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

For the Body Mass Index (BMI), depth of non-pressure chronic ulcers and pressure ulcer stage codes, 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) However, 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, wither 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)

Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes from 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.

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. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, of the complication is not clearly documented.

If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting ( inpatient versus outpatient) Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.

Code only confirmed cases of HIV infection/illness. Thus is an exception to the hospital inpatient guideline Section II, H. In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the provider's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.

If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related condition

If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions

Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV, "HIV test positive," or similar terminology. Do not use this code if the term "AIDS" is used or if the patient is treated for any HIV=related illness or is described as having any condition(s) resulting from his/her HIV positive status; us B20 in these cases.

Patients with inconclusive HIV serology, but no definite diagnosis or manifestations of the illness may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV]

Patient with any known prior diagnosis of an HIV-related illness should be coded to B20. Onve a patient has developed an HIV-related illness, the patient should always be assigned code B20 on every subsequent admission/encounter. Patients previously diagnosed with any HIV illness (B20) should never be assigned R75 or Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.

During pregnancy, childbirth, or the puerperal, a patient admitted (or presenting for a health care encounter because of an HIV-related illness should receive a principal diagnosis code of o98.7-, Human immunodeficiency [HIV] disease complication pregnancy, childbirth, and the puerperal, followed by B20 and the code(s) for the HIV-related illness(es). Codes form Chapter 15 always take sequencing priority. Patents with asymptotic HIV infection status admitted (or presenting for a health care encounter during pregnancy, childbirth, or the puerperal should receive codes of O98.7- and Z21

If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk behavior. If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms. An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test. When a patient returns to be informed of his.her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] counseling. If the results are positive, see previous guidelines and assign codes as appropriate

Certain infections are classified in chapter other than Chapter 1 ans no organism is identfied as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code form category B95, Streptococcus, Staphylovovvus, and Enterococcus as the cause of disease classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is ti be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required.

Many bacterial infections are resistant to current antibiotics. It is necessary to identify 16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.

For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified assign code A41.9, Sepsis, unspecified organism. A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented

Negative or inconclusice blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, however, the provider should be queried

The Term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis

If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code form subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the sever sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.

The coding of severe sepsis requires a minimum of 2 codes: first code for the underlying systemic infection, followed by a code from subcategory R65.2, severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.

For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, sever sepsis with septic shock or code T81.12, Post procedural septic shock. Any additional codes for the other acute organ dysfunction should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis

If sever sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis. When sever sepsis develops during an encounter (it was not present on admission) the underlying systemic infection and appropriated as secondary diagnoses. Sever sepsis may be present on admission by the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether sever sepsis was present on admission, the provider should be queried.

If the reason for admission is both sepsis or sever sepsis and a localized infection, such as pneumonia or cellulitis, a code(d0 for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/sever sepsis codes.

As with all post-procedural complications, code assignment is based on the provider's documentation of the relationship between the infection and the procedure.

For such cases, the post-procedural infection code, such as, T80.2, Infections following infusion,transfusion and therapeutic injection, T81.4, Infection following a procedure, T88.0 Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed ny the code for the specific infection. If the patient has sever sepsis the appropriate code form subcategory R65.2 should aslo be assigned with the additional code(s) for any acute organ dysfunction

In cases where a post-procedural infection has occurred and has resulted in severe sepsis and post-procedural septic shock, the code for the precipitating complication such as cod T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound shoul be coded first followed by R65.21, severe sepsis with septic shock and a code for the systemic infection

In some cases a noninfectious process (condition), such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. If severe sepsis, is present a code form subcategory R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1 systemic inflammatory response syndrome (SIRS) of non-infectious origin, for theses cases. If the infection meets the definition of principal diagnosis it should be sequenced before the non-infectious condition. When both the associated non-infectious condition and the infection meet the definition of principal diagnosis either may be assigned as principal diagnosis. Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a non infectious condition leads to an infection resulting in severe sepsis, assign the appropriate code from subcategory R65.2, sever sepsis. Do Not additionally assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of non-infections origin

When a patient is diagnosed with an infection that is due to methicillin resistant staphylococcus aureus (MRSA), and that infection has a combination code that includes that causal organism (e.g., sepsis, pneumonia) assign the appropriate combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin resistant Staphylococcus aureus or code J15.212, Pneumonia due to Methicillin resistant staphylococcus aureus). Do not assign code B95.62, Methicillin resistant staphylococcus aureus infection as the cause fo diseases classified elsewhere, as an additional code because the combination code includes the type of infection and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to penicillin, as an additional diagnosis.

When there is documentation of a current infection (e.g., wound infection, stretch abscess, urinary tract infection) due to MRSA, and that infection does not have combination code that includes the causal organism assign the appropriate code to identify the condition along with code B95.62, Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere for the MRSA infection. Do no assign a code form subcategory Z16.11, Resistance to penicillin

The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MSRA is present on ot in the cody without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as "MRSA" screen positive or "MRSA nasal swab positive" Assign code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, for patients documented as having MRSA colonization. Assign code Z22.321, Carrier ir suspected carrier of Methicillin susceptible staphylococci aureus, for patient documented as having MSSAA colonization. Colonization is not necessarily indicative of disease process or as the cause of a specific condition thw patient may have unless documented as such by the provider.

If a patient is documented as having both MRSA colonization and infection during a hospital admission, cod Z22.322, Carrier or suspected carrier of Methicillin resistant staphylococcus aureus and a code for MRSA infection may both be assigned