General Coding Guidelines Flashcards
Discuss Section 1 of the ICD-10-CM guidelines
What is the format of a code?
A code may be 3 to 7 characters long.
Character #1 is always a letter.
Character #2 and #3 may be a number or letter.
After #3 is a period followed by up to 4 more numbers. A 3 digit code with no period is almost never a valid code. Each number brings a degree of specificity. e.g.:
C50.111 = malignant neoplasm of the right female breast
You must be as specific as possible!
Explain the 7th character.
Some categories require the 7th character, as do some portions of the Tabular List. If so, you must fill in any unused characters with Xs. Episode of Care is an example main category.
Example code: S52.362C - Displaced segmental fracture of shaft of radius, left arm, initial encounter for open fracture type IIIA, IIIB or IIIC.
What does the abbreviation NEC mean in the Alphabetic Index?
Not elsewhere classifiable. It means “otherwise specified” - the alphabetic index marking with this abbreviation directs the coder to the “other specified” code in the Tabular List.
What does the abbreviation NOS mean in the Alphabetic Index?
Not otherwise specified. This means “unspecified”.
What does the abbreviation NEC mean in the Tabular List?
Not elsewhere classifiable. The Tabular List includes an NEC entry under a code to identify the code as the other specified code.
What does the abbreviation NOS mean in the Tabular List?
Not otherwise specified. This means “unspecified”.
What are brackets [] for?
Tabular list: synonyms, alternative wording, explanatory phrases
Alphabetic index: manifestation codes
What are parentheses ( ) for?
In both the Alphabetic Index and Tabular List, these enclose supplementary words that could be present with the statement of a disease/procedure, WITHOUT affecting the code. They are nonessential modifiers.
What is the colon : for?
In the Tabular List indicates an incomplete term which needs one or more modifiers to make it assignable.
Explain “other” codes.
When the information in the medical record contains detail for which a code doesn’t exist. This is usually .8.
Explain “unspecified” codes.
Use when the information in the medical record is insufficient to assign a more specific one. When an unspecified code is not available, the other code may be used in place. Other codes usually are .9.
What are “Includes Notes”?
These are notes next to a 3 character code to further explain and define the content of the category.
What are “inclusion terms”?
These terms are the conditions for the code to be used, included under some codes. Sometimes listed under “other” codes to identify cases when it should be used. The terms are not exhaustive.
Explain how to use the Excludes notes.
There are two: Excludes1 and Excludes2.
Excludes 1: “not coded here, and cannot exist at the same time UNLESS they are unrelated to each other”
Excludes2: “not included here, but a patient can have both at once”
What is the sequencing rule for codes?
Code the etiology first, followed by the manifestation(s).
What does “code first” mean?
The code it appears at has an etiology, and is the manifestation code you must code AFTER that etiology. The code first code is listed after “code first”.
What does “in diseases classified elsewhere” mean?
This is a manifestation code and must be coded with an underlying cause.
What does “use additional code” mean?
Etiology codes will have this note if the manifestation code doesn’t have “in diseases classified elsewhere” in its title. The manifestation code will instead say “code first”.
When might “code first” + “use additional” code appear rather than “in diseases classified elsewhere”?
To indicate sequencing rules for certain codes that aren’t an etiology/manifestation combination.
What does “and” mean in a code title?
“and” or “or”. The two terms may exist at the same time or individually.
Tuberculosis of the hands and joints ALSO MEANS
Tuberculosis of the hands
Tuberculosis of the joints
What does “with” and “in” mean?
This means “associated with” or “due to” in a code title, index, or an instructional note. There is a causal relationship between the two conditions.
They should be coded as related, even in the absence of provider documentation explicitly linking them, UNLESS the documentation says they are unrelated or another guideline exists.
What is the difference between “see” and “see also”?
“See” means you MUST go to the main term referenced with the note.
“See also” means there is another term that may provide useful Alphabetic Index entries, but it is not necessary to follow if the main entry provides the necessary code.
What does “code also” mean?
Two codes may be required to fully describe a condition but does not provide sequencing direction.
What is a default code?
The code listed next to a main term Alphabetic Index. This represents the condition most commonly associated with the term OR an unspecified term. If a condition isn’t documented with additional information, then use this code.
What information is sufficient to list a code?
The provider’s statement that the patient has it. You do not need clinical backup information.
What does a dash - mean at the end of an alphabetic index entry?
Additional characters are required, at the tabular list entry.
When it is appropriate to use a symptoms or signs code instead of diagnoses?
When a related definitive diagnosis has not been established by the provider. These are located at Chapter 18, R00.0-R99.
Do you code signs and symptoms routinely associated with a disease process?
No, unless otherwise instructed by the classification.
What does “code, if applicable, any causal condition first” mean?
This code can be assigned as the primary diagnosis if the causal condition is not known.
Acute and Chronic Conditions are..?
If the same condition is described as both acute and chronic, AND as separate entries in the Alphabetic Index at the same indentation level, code BOTH, and list acute FIRST.
