Format & Structure
The ICD-10-CM Tabular List contains categories, subcategories and codes.
Use of codes for reporting purposes
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" s used as a placeholder at certain codes to allow for future expansion.
Certain ICD-10-CM categories have applicable 7th characters.
"Not elsewhere classifiable" This abbreviation represents "other specified". When a specific code is not available for a condition.
"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 may be present or asent in the statement of a disease or procedure without affecting the code number to which it 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.
When the term "and" is used in a narrative statement it represents and/or.
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.
Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code.
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 some codes. These terms are the conditions for which that code is to be used.
A type 1 Exclude note is a pure exclude note. It means "NOT CODED HERE!" An Exclude 1 note indicates that the code excluded should never be used at the same time as the code above the Exclude 1 note.
A type 2 excludes note represents "Not included here". An excludes 2 note indicates that the condition excluded is not part of the condition represented y the code but a patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together, when appropriate.
The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or and instructional not in the Tabular List.
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.
"Code also note"
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. Example, appendicitis, w/o any additional information, such as acute or chronic, the default code should be assigned.
Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndromes.
Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
Conditions that are an integral part of the disease process
Signs and symptoms that are associated routinely with a disease process should not be assigned a additional codes unless otherwise instructed by the classifications
Conditions that are NOT an integral part of the disease process
Additional signs an symptoms that may not be associated routinely with a disease process should be coded when present.
Multiple coding for a single condition
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.
Acute or Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphbetic 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
Late Effects (Sequela)
A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated.
Impending or Threatened Condition
Code any condition described at the time of discharge a s "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 subentry term for "impending" or "threatened" and also reference main term for "Impending and for "Threatened".
Reporting Same DX code more than Once
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 laterally or two different conditions classified to the same ICD-10-CM diagnosis code.
For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterally.