ICD-10-CM Guidelines 2023 I.B General Coding Guidelines Flashcards
Locating a code in ICD-10-CM
- Locate the term in the Alphabetic Index
- Verify the code in the Tabular List
- Read and be guided by instructional notations in both the Index and Tabular
- Always validated the code in the Tabular List to validate no 7th character is required
A dash (-) at the end of an Alphabetic Index entry indicates additional characters are required but may not always be reflected in the Index entry.
Level of Detail in Coding
- Dx codes may be 3, 4, 5, 6, or y characters
- A code is invalid if not coded to the full number of characters required for that code
Signs and Symptoms
Codes describing signs and symptoms are acceptable when a relative definitive diagnosis has not been established by the provider.
Ch. 18, Symptoms, Signs and Abnormal Clinical and Lab Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for symptoms.
Conditions that are integral to a disease process
Signs and symptoms routinely associated with a disease process should not be assigned as an additional diagnosis, unless otherwise instructed by the classification
Conditions NOT integral to a disease process
Additional signs/symptoms that may not be routinely associated with a disease process should be coded when present.
Multiple coding for a single condition
- Like etiology/manifestation covention
- May require more than one code
- “use additional code”, “code first”, and “code any causal condition first” notes
- “Code first notes” are also used with underlying conditions
Bacterial infections not included in chapter 1, require a second code to
Acute and Chronic conditions
If the same condition is described as both acute (subacute) and chronic and separate entries exist in the Index at the same indention level, code both and sequence the acute (subacute) code first.
Combination Code
- single code combining two diagnoses, a diagnosis with an associated secondary process (manifestation) or associated complication
- only assign a combination code when the code fully identifies the diagnostic conditions involved or with the Index directs to do so.
- multiple coding should not be used if there is a combination code that encompasses all of the elements in the diagnosis
- if a combination code lacks necessary specificity in describing the manifestations/complications, an additional code should be used as a secondary code
Sequela (Late Effects)
- residual effect (condition produced) after the acute phase of illness or injury has ended
- no time limit on when a squela code can be used
- generally requires to codes - 1st the condition/nature of the sequela; 2nd the sequela
- EXCEPTION - instances where the code for the sequela is followed by a manifestation code in the Tabular List and Title or the sequela code has been expanded to include the manifestation(s).
- codes for the acute phase of an illness/injury that led to the sequela are never used with a code for the late effect
Examples: scar formation from burn, deviated nasal septum due to previou
Impending or Threatened Condition
coding conditions described at the time of discharge as impending or thr
- if it did occur, code as confirmed diagnosis
- If it did NOT occur, reference th Index to see if there is a subentry for for the condition as impending or threatened; also refer to Index main terms ‘Impending’ and ‘Threatened’
** if subterms are listed, assign the given code
if subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threated.*
Laterality
- if no bilateral code is available, assign separate codes for both the left and right side
- if the side is not identified, assign the unspecified side
- when a bilateral condition is treated during separate encounters, assign the bilateral code (as the condition still exists on both sides)
- for the second encounter after one side has been previously treated and no longer exists, assign the unilateral code for the side where the condition still exists
- if the treatment on the first side did not completely resolve the condition, the bilateral code is still appropriate
- laterality may be based on other clinician documentation; if there is conflicting documentation - query the attending provider.
Documentation by Clinicians Other than the Patient’s Provider
Code assignment may be based on non-provider conditions for the followin
- Body Mass Index (BMI)
- Depth of non-pressure chronic ulcers
- Pressure ulcer stage
- Coma scale
- NIH stroke scale (NIHSS)
- Social determinates of health (SDOH)
- Laterality
- Blood alcohol level
- Underimmunization status
Syndromes
- Follow the Alphabetic Index guidance
- Assign codes for the documented manifestations of the syndrome
- Additional codes for manifestations that are not integral to the disease may also be assigned
Documentation of Complications of Care
- Based on provider documentation of the relationship b/w the conditon and the care/procedure unless otherwise instructed by the classification.
- Documentation must support the condition is clinically significant
- The provider doesn’t have to document ‘complication’
- If the condition alters the course of surgery as documented in the Op report, it would be appropriate to report a complication
- If documentation is not clear as to the relationship, query the provider
Borderline Diagnosis
(at the time of discharge)
- Code the condition as confirmed, unless there is a specific code for ‘borderline’
- Same between inpatient and outpatient care setting
Ex: borderline diabetes
