Step 1: Identify the reason for the visit( sign, symptom, diagnosis, condition to be coded.
If symptoms are present but a definitive diagnosis has not yet been determined, code the symptoms. Do not code conditions that are referred to as "rule out", "suspected" or "questionable"
Step 2: Always consult the Alphabetic Index, before turning to tabular list.
To prevent coding errors, use both the AI and TL when locating and assigning a code.
Step 3: Locate the main entry term.
Main terms are identified using boldface type. sub term and sub term's sub term.
Step 4: Read and interpret any notes listed with the main term.
Notes are identified using italicized type.
Step 5: Review entries for modifiers.
nonessential modifiers are in parenthesis. do not affect code assignment.
Step 6: interpret abbreviations, cross reference, symbols and brackets.
cross references used are "see", "see also", "see category". NEC , NOS, [ ], additional code.
Step 7: choose a tentative code and locate it in the TL
be guided by any inclusion or exclusion terms, notes or other instructions, such as "code first" and " use additional code"
Step 8: Determine whether the code is at the highest level of specificity.
assign 3 digit code, if there is no 4th digit code. assign 4 digit code if there is no 5th digit code.
Step 9: consult the color coding and reimbursement prompts, including the age and sex edits.
consult official guidlines