ICD-10-CM Conventions & General Coding Guidelines March 26, 2014

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ICD-10-CM Conventions &

General Coding Guidelines

March 26, 2014

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Disclaimer: It is impossible to review every ICD-10-CM Convention and General Guideline in 60 minutes. Every effort has been made to capture the most significant Conventions and General Guidelines. This presentation is meant to enhance, but does not replace, your personal review of the Conventions and General Guidelines.

Agenda

• ICD-10-CM:

– Conventions

• Trends

– General Coding Guidelines

• Trends

• Questions

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Conventions

• Coders must understand conventions

• Found in 2014 Draft of ICD-10-CM book and

training manuals

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• Alphabetic Index and Tabular List

– ICD-10-CM has:

• Alphabetic Index- alphabetical list of terms and their corresponding code

• Tabular List- structured chronological list of codes divided into chapters based on body system or condition

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Conventions

• Alphabetic Index consists of the following:

• Index of Diseases and Injury

• Index of External Causes of Injury

• Table of Neoplasms

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• Format and Structure

– ICD-10-CM Tabular List contains categories,

subcategories, codes

– Characters for categories, subcategories and codes may be a letter or number

– Categories are 3 characters

– A 3 character category that has no further subdivision is equivalent to a code

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Conventions

• Format and Structure

– Subcategories are 4 or 5 characters

– Codes may be 3, 4, 5, 6 or 7 characters in length – A code that has an applicable 7th_{character is}

considered invalid without the 7th_character

Tip: watch for the box with a check mark and “4th_{”, “5}th_”, “6th_{”, “7}th_{” and “x7th” in it indicating the number of} characters needed for a complete code

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• Placeholder Character- letter “X” has 2 uses

• 5th_{character for some 6 character codes}

T56.0X2S Toxic effect of lead and its compounds, intentional self-harm, sequela

• Code has less than 6 characters and 7th_character

required, “X” is assigned for all characters less than 6 S17.0XXA Crushing injury of larynx and trachea, initial encounter

Tip: decimal does not count as a character

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Conventions

• Placeholder Character- letter “X”

Tip: Make sure your coders correctly use

this placeholder character

– Coders incorrectly apply 7

th

_{character in the 5}

th

_or

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• Seventh Characters

– Provides further specificity about condition

O64.3XX1 Obstructed labor due to brow presentation, fetus 1 S02.110B Type I occipital condyle fracture, initial encounter for open fracture

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Conventions

• Abbreviations

– Not Elsewhere Classified (NEC)

• ICD-10-CM contains codes to classify any and all

conditions

• Alphabetic Index uses NEC for a code description that directs the coder to the Tabular List showing an Other Specified code description

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• Abbreviations

– Not Otherwise Specified (NOS)

• Use when the documentation is insufficient to assign a more specific code

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Conventions

• Punctuation

– Parentheses ( )

• Used in both Alphabetic Index and Tabular List

• Enclose supplementary words that may be present or absent in the statement of a disease without affecting the code number to which it is assigned

• Terms within the parentheses are nonessential modifiers

Hemophilia (classical) (familial) (hereditary)

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• Punctuation

– Brackets [ ]

• Used in Tabular List to enclose synonyms, alternative

wordings, or explanatory phrases

B06, Rubella [German measles]

• Used in Alphabetic Index to identify manifestation codes

Disease, Alzheimer’s G30.9 [F02.80]

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Conventions

• Punctuation

– Colon :

• Used in Tabular List after an incomplete term which needs 1 or more modifiers following the colon to make it assignable to a given category

• Used with “includes” and “excludes” notes G73.7 Myopathy in diseases classified elsewhere

Excludes1: myopathy in:

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• Other format differences from ICD-9-CM

– Symbols not included in ICD-10-CM:

• Lozenge

• Section Mark § • Braces }

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Conventions

• Other format differences from ICD-9-CM

– Dashes

• Used in ICD-10-CM Alphabetic Indexes and the Tabular List

• Indexes utilize dash at end of code number to indicate

code is incomplete

• To determine additional character(s), locate code in Tabular List, review the options, assign appropriate code

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• Other format differences from ICD-9-CM

– Dashes

Fracture, pathologic ankle M84.47-carpus M84.44-21

Conventions

• Other format differences from ICD-9-CM

– Dashes

• Tabular List, dash preceded by a decimal point (.-) indicates incomplete code

• To determine additional characters, locate referenced category or subcategory in Tabular List, review

options, assign the appropriate code J43 Emphysema

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• Instructional Notes

– Variety of notes appear in both the Alphabetic

Index and Tabular List of ICD-10-CM

– The various notes are:

• “includes” • “excludes” • “code first”

• “use additional code” • cross reference

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Conventions

• Inclusion Notes

– Used in Tabular List to clarify conditions included

within a particular chapter, section, category,

subcategory, code

– List of inclusions terms not exhaustive, may

include diagnoses not listed in inclusion note

– Introduced by word “includes” when appearing at

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• Inclusion Notes

K25

Gastric Ulcer

Includes: erosion (acute) of stomach

pylorus ulcer (peptic) stomach ulcer (peptic)

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Conventions

• Inclusion Notes

– At code level, the word “includes” does not precede

the list of terms included in the code

K31.5 Obstruction of duodenum Constriction of duodenum Duodenal ileus (chronic) Stenosis of duodenum Stricture of duodenum Volvulus of duodenum

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• Exclusion Notes

– ICD-9-CM contains a single type of excludes note

– ICD-9-CM has 2 different meanings leaving it to

coder to determine correct meaning

– In ICD-10-CM, 2 types of excludes notes:

• Excludes1 • Excludes2

– Either or both may appear under a category, subcategory, or code

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Conventions

• Excludes1

– Is a pure “excludes” note

– Means not coded here

– Indicates the code excluded should never be

used at the same time as code above the

Excludes1 note

– Used when 2 conditions cannot occur together

• congenital form versus acquired form of the same

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• Excludes1

Q79.5 Other congenital malformations of

abdominal wall

Excludes1: umbilical hernia (K42.-)

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Conventions

• Excludes2

– Means not included here

– Indicates condition excluded is not part of

condition represented by the code, but a patient

may have both conditions at same time

– When an Excludes2 note appears under a code,

it is acceptable to use both the code and the

excluded code together if patient has both

conditions

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• Excludes2

J37.1 Chronic laryngotracheitis

Excludes2: acute laryngotracheitis (J04.2)

acute tracheitis (J04.1)

Tip: Make sure your coders understand

Excludes1 and Excludes2 notes

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Conventions

• Code First and Use Additional Code Notes

– Some conditions require an underlying etiology

code and manifestation code

– For these conditions, 10-CM (similar to

ICD-9-CM) requires underlying condition be

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• Code First and Use Additional Code Notes

– “Use additional code” note appears at etiology

code

– “Code first” note appears at manifestation code

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Conventions

• Use Additional Code Note

G30 Alzheimer’s disease

Use additional code to identify:

dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance

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• Code First Note

F02 Dementia in other diseases classified elsewhere

Code first the underlying physiological condition, such as Alzheimer’s (G30.-)

F02.80 Dementia in other diseases classified

elsewhere, without behavioral disturbance F02.81 Dementia in other diseases classified

elsewhere, with behavioral disturbance

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Conventions

• Cross Reference Notes

– In ICD-10-CM Alphabetic Index to advise coder

to look elsewhere before assigning a code

– “See”, “See Also” and “See Condition” are same

as those in ICD-9-CM

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• Cross Reference Notes

Pyocele

-mastoid – see Mastoiditis, acute -sinus (accessory) – see sinusitis -turbinate (bone) J32.9

-urethra (see also Urethritis) N34.0

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Conventions

• Relational Terms

– “And” means “and/or” when appears in code title within the ICD-10-CM Tabular List

– “With” means “associated with” or “due to” when appears in code title, Alphabetic Index, or

instructional note in Tabular List

• “With” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order

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• Relational Terms

Salpingitis (catarrhal) (fallopian tube) (nodular)

(pseudofollicular) (purulent) (septic) N70.91 with oophoritis N70.93 acute N70.01 with oophoritis N70.03 39

Conventions

• Additional Conventions

– Age edit symbols • Newborn = 0 years • Pediatric = 0 – 17 years • Maternity age = 12 – 55 years • Adult age = 15 – 124 years – Sex edit symbols

• Male • Female

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General Coding Guidelines

1. Locating a Code in ICD-10-CM

– First locate term in Alphabetic Index

– Verify code in Tabular List

Tip: Read instructional notes in Alphabetic

Index and Tabular List, and let them be your

guide to the appropriate code

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2. Level of Detail in Coding

– Diagnosis codes reported at their highest number

of characters available

– Codes may be 3, 4, 5, 6 or 7 characters in

length

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General Coding Guidelines

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

Z00 – Z99.8

– Identify diagnoses, symptoms, conditions,

problems, complaints, other reason(s) for the

encounter/visit

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4. Signs and Symptoms

– Acceptable for reporting when related definitive

diagnosis has not been established or

confirmed by provider

– Chapter 18 (Symptoms, Signs, and Abnormal

Clinical and Laboratory Findings, Not Elsewhere

Classified (codes R00.0 – R99) contains many,

but not all codes for symptoms

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General Coding Guidelines

5. Conditions that are an Integral Part of a Disease

Process

– Signs and symptoms associated routinely with a disease process should not be assigned as additional codes

UNLESS otherwise instructed by the classification Tip: make sure your coders understand what is

routinely associated with each disease process to avoid over-coding

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6. Conditions that are not an Integral Part of a

Disease Process

– Signs and symptoms that are NOT ROUTINELY

associated with a disease process should be

coded when present

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General Coding Guidelines

7. Multiple Coding for a Single Condition

– Etiology/manifestation convention – “Use additional code”

– “Code first”

– “Code, if applicable, any causal condition first”

– Multiple codes may be needed for sequela, complication codes and obstetric codes to fully describe condition

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8. Acute and Chronic Conditions

– If same condition described as both acute (subacute) and chronic, and separate subentries exist in

Alphabetic Index at same indentation level, code

both and sequence the acute (subacute) code first

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General Coding Guidelines

9. Combination Code

– Used to classify: • Two diagnoses, or

– A diagnosis with an associated secondary process (manifestation)

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10. Sequela (Late Effects)

– Residual effect after acute phase of an illness or injury

has terminated

– No time limit on when sequela code can be used – Residual effect may appear early, may occur months

or years later

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General Coding Guidelines

10. Sequela (Late Effects)

– Normally 2 codes required- condition or nature of sequela sequenced 1st_{and sequela code is sequenced 2}nd

• Exception- code for sequela is followed by a manifestation code identified in Tabular List and title, or sequela code has been expanded to include the manifestation(s)

Tip: 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

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Honest & Healthy Bottom Lines 11. Impending or Threatened Condition

– Did occur  code as confirmed diagnosis

– Did not occur  look in Alphabetic Index for “impending” or

“threatened”

– Reference main term entries for “Impending” and “Threatened”

– Subterms are listed  assign the given code

– Subterms are not listed  code the existing underlying

conditions and not the condition described as impending or threatened

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General Coding Guidelines

12. Reporting Same Diagnosis Code More than Once

– Each unique ICD-10-CM diagnosis code may be reported only

once for an encounter

– Applies to bilateral conditions when there are no distinct codes identifying laterality or 2 different conditions classified to the same diagnosis code

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13. Laterality

– If there is a code specifying left, right or bilateral assign the appropriate code based on documentation

– If no bilateral code exists and the condition is bilateral assign separate codes for both left and right

– If the side is not identified in the documentation  assign the code for the unspecified side

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General Coding Guidelines

14. Documentation for BMI and Pressure Ulcer

Stages

– 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 document the pressure ulcer stages).

– The associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient’s provider

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• Documentation for BMI and Pressure Ulcer Stages

– If there is conflicting medical record documentation, either 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 and they must meet the definition of a reportable additional diagnosis to be reported

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General Coding Guidelines

15. Syndromes

– Follow Alphabetic Index guidance

– In absence of Alphabetic Index guidance, assign codes for manifestations of syndrome

– Additional manifestation codes that are not integral to the disease process may be assigned when condition does not have a unique code

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16. Documentation of Complication of Care

– Not all conditions that occur during or following medical care or surgery are classified as complications

– Must be a cause-and-effect relationship between care provided and the condition

– Must be an indication in documentation that is it a complication – Query provider if complication is not clearly documented

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General Coding Guidelines

17. Borderline Diagnosis

– Diagnosis is coded as confirmed unless the classification provides a specific entry, (borderline diabetes)

– Not considered uncertain diagnoses

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18. Use of Sign/Symptom/Unspecified Codes

– Instances exist when signs/symptoms or

unspecified codes most accurately reflect

healthcare encounter

– Appropriate to use signs and/or symptoms codes

when definitive diagnosis has not been

established

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General Coding Guidelines

• Use of Sign/Symptom/Unspecified Codes

– Appropriate to report “unspecified” code when

clinical information isn’t known or available to

assign more specific code

– Code each encounter to level of certainty

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• ICD-10-CM The Complete Official Draft Code

Set, 2014 –

Optum Book

• DeVault, K., Barta, A., & Endicott, M. (2014). ICD-10-CM Coder Training Manual. Chicago, IL: AHIMA

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