GUIDELINES- GENERAL

The thing about coding is that it is NOT a lot of memorization, but it is a solid foundation and understanding of coding guidelines!

In this blog post, we will be going over the general guidelines. Be sure to print out your copy of the official ICD-10-CM guidelines and follow along.

ICD-10-CM

International Classification of Diseases 10th Revision Clinical Modification

This is a book for your diagnosis coding.

See in the name International, guess what that means this book is used all over the world.

The clinical modification is the part that is specific to us in the USA!

We are currently in the 10th revision of the book

Parts of ICD- 10-CM

The book is broken into 2 parts

• Alphabetic index
• Tabular list

The alphabetic index is broken into 4 parts

• Index to diseases and injury
• Index of external causes of injury
• Table of neoplasm
• Table of drugs and chemicals

FORMAT AND STRUCTURE

A code is 3-7 digits long

• Category is the 1st 3 digits of the code this tells what the code is about
• Subcategory is 4th and 5th digits thst further explain the code
• Subclassication- 6th and 7th digit
  • Sometimes you will need a dummy placeholder of “X” to make your code 7 digits

Dummy placeholder

The ICD-10 is very specified yet some codes have room for future expansion the X is required if there is not a character or digit option yet the code requires 7 digits.

ABBREVIATIONS

There are lots of abbreviations in the medical field. Coding is no different

• NEC- not elsewhere classifiable- used when a specific code is not available for a condition
• NOS- not otherwise specified- simply means unspecified

PUNCTUATION in alphabetical

• Brackets- manifesting codes
• Parenthesis- supplementary words this does not affect the code assignment
• Colon- incomplete term needing one or more modifiers following colon

PUNCTUATION in tabular

• Brackets- envlose synonyms, alternative wording or explanatory phrases
• Parenthesis – supplementary words this does not affect the code assignment

KEY WORDS

When you see these key words it is important to know what they mean and what you need to do

• Other- NEC- provider is more specific than the code set
• Unspecified- NOS- provider is not specific
• Includes- this list gives examples of what is included in the code
• Excludes- what can’t or shouldn’t be coded there are 2 different types
  • Excludes 1: one or the other hut not both also NOT CODED HERE- the excuses 1 list should never be coded with the code listed above the excludes list
    • Never ever coded together the 2 conditions contradict each other
  • Excludes 2: may need both codes in some instances- when appropriate code both the code and excluded code together abd it is acceptable(but not always)
    • Not included here- the condition excluded is not part of the condition represented by the code
• And- reads as or
• With- reads as in or due to
  • Presumes a causal relationship between the 2 conditions even if there is not documentation linking them
• See- go to the main term referenced with the see note to locate the correct code
• See also- look over there if you need isn’t here- you may have to go elsewhere to find the correct
• Code also- does not impact code order- two codes may be required but sequencing does not matter- depends on thr encounter

CAUSE AND EFFECT CODING

When a disease process causes something else to happen

Etiology- The cause

Manifestation – The effect

Code first instructional note- You will see this by the manifestation code- means you will need to code the etiology first

Use additional code instructional note – you will see this by the etiology code. Means you will need to include the manifestation code

STEPS TO CODE

• 1- locate the main term in alphabetical index
• 2- verify or confirm code in tabular
• 3- read and be guided by instructional notes in both alphabetical and tabular

When you see a (-) at the end of a code in the alphabetical this shows you more digits are required

Level of detail in coding- a code is considered invalid if it is missing characters

SIGNS AND SYMPTOMS

• Signs- manifestation of a disease process that a physician or qualified health professional can see
• Symptoms- manifestation of a disease process that the patient feels this cannot be seen

Only code signs and symptoms if you don’t have a definitive diagnosis or the signs and symptoms are unrelated to the definitive diagnoses

Acute and chronic

• Acute- an illness that develops suddenly and lasts a short time often a few days to a few weeks
• Chronic- illness that develops slowly and may Worden over an extended period of time- months to years
• Acute on chronic- Patients that have a chronic condition and then experience an exacerbation or flare up of symptoms

Coding using 1 code or multiple codes

Sometimes when coding you will need multiple codes like in cause and effect coding

Sometimes you will only need one code to describe everything this is called a combination code

Sequela

Late effect- a residual effect that happens after the acute phase of an illness or injury has ended

There is no time limit on when sequels codes can be used

Generally there are 2 codes for this situation

Impending or threatened condition

Sometimes like in the case of a CVA (Cerebrovascular Accident) the patient will present and it will look like they are having or getting ready to have a stroke(impending) when a woman is pregnant and maybe discovers she is spotting an abortion(muscarriage) is threatened

• If it did occur code it as a confirmed condition
• If it did not occur- reference alphabetical for impending or threatened
  • If there assign the code
  • If not code for the underlying condition and not the impending or threatened condition

Laterality

What side of the body are we talking about. Most things in our body have laterality(right or left).

• Right side unilateral
• Left side unilateral
• Both sides bilateral

Unspecified laterality should rarely if ever used

Laterality is important in both diagnosis snd procedure coding

Next up

Chapter 1 infectious diseases