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Chapter 7: Basic ICD-10-CM
Terms in this set (35)
Basic Coding Guidelines
The basic coding guidelines discussed in this chapter apply throughout the ICD-10-CM classification system.
Guidelines that apply to specific chapters of ICD-10-CM will be discussed in the relevant chapters of this handbook.
Adherence to these guidelines when assigning ICD-10-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA).
The instructions and conventions of the classification take precedence over guidelines.
1st Basic Principles
Both the Alphabetic Index and the Tabular List must be used to locate and assign appropriate codes.
First, locate in the Index the diagnosis, condition, or reason for visit; the code provided must be verified in the Tabular List.
The Index does not provide the full code; selection of the full code, including laterality and any applicable seventh character, can only be done using the Tabular List.
Follow instructional notes to determine that more specific subterms or important instructional notes are not overlooked.
Consistent reference to the Alphabetic Index and the Tabular List is imperative, no matter how experienced the coder is.
Second basic principle
Codes must be used to the highest number of characters available.
Assign a three-character disease code only if it is not further divided (when there are no four-character codes within that category).
Assign a four-character code only when there are no five-character codes within that subcategory.
Assign a five-character code only when there are no six-character codes for that subcategory.
Assign a six-character code when a sixth-character subclassification is provided.
Assign a seventh-character extension when provided.
All characters must be used
None can be omitted and none can be added.
EXCEPTION: placeholder character "x"
For codes less than six characters that require a seventh character, a placeholder "x" should be assigned for all characters less than six.
The seventh character must always be the seventh character of a code.
An example of this exception is found at categories T36-T50 (poisoning, adverse effects, and underdosing codes).
Examples of Basic Coding Principles
Refer to the Tabular List
Category J40, Bronchitis, not specified as acute or chronic
Code J40 has no fourth-character subdivisions; therefore, the three-character code is assigned.
Refer to Tabular List
Category K35, Acute appendicitis
This category includes fourth characters that indicate the presence of generalized or localized peritonitis. Because fourth-character subdivisions are provided, code K35 cannot be assigned.
Examples of Basic Coding Principles ( Cont...)
Refer to Tabular List
Category J45, Asthma, has five fourth-character subdivisions (J45.2, J45.3, J45.4, J45.5, and J45.9).
It also uses a final character (fifth- or sixth-character) subclassification to specify whether there is any mention of status asthmaticus or acute exacerbation.
Any code assignment from category J45 must have five characters (for subcategories J45.2-J45.5) or six characters (for subcategory J45.9) to ensure coding accuracy.
Examples of Basic Coding Principles (cont.)
Refer to Tabular List
Category T27, Burn and corrosion of respiratory tract, has eight four-character subdivisions to specify burn or corrosion and detail on the part of the respiratory tract affected.
General note indicates seventh character is to be added.
Category T27 subcategories are only four characters long; the placeholder character "x" is used as a fifth- and sixth-character placeholder before the seventh character can be added.
Example: T27.0xxA for initial encounter for burn of the larynx and trachea
Assign Residual Codes (NEC and NOS) as Appropriate
The main term entry in the Alphabetic Index is usually followed by the code number for the unspecified condition.
The unspecified code should never be assigned without a careful review of subterms to determine whether a more specific code can be located.
Assign Combination Codes When Available
Combination code: A single code used to classify either two diagnoses, or a diagnosis with an associated secondary condition, or a diagnosis with an associated complication.
Combination codes can be located in the Index with reference to subterms that follow connecting words such as "with," "due to," "in," and "associated with."
Other combination codes can be found in inclusion and exclusion notes in the Tabular List.
Only the combination code is assigned when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs.
Assign Combination Codes When Available (Cont..)
When a combination code lacks the necessary specificity in describing the manifestation or complication, an additional code may be assigned.
Follow the directions in the Tabular List for the use of an additional code or codes that may provide more specificity
Assign Multiple code as needed
Multiple coding is the use of more than one code to fully identify the component elements of a complex diagnostic or procedural statement.
A complex statement is one with connecting words or phrases such as "with," "due to," "incidental to," "secondary to," or similar terminology.
Follow directions in the Tabular List for the use of additional code(s) to provide more specificity.
If no combination code is provided, assign multiple codes as needed to fully describe the condition regardless of whether there is advice to that effect.
Mandatory Multiple Coding
The term "dual classification" is used to describe the required assignment of two codes to provide information about both a manifestation and the associated underlying disease or etiology.
Mandatory multiple coding is identified in the Alphabetic Index by the use of a second code in brackets.
The first code identifies the underlying condition, and the second identifies the manifestation. Both codes must be assigned and sequenced in the order listed.
The need for dual coding is indicated in the Tabular List by a "use additional code" note with the code for the underlying condition, and a "code first underlying condition" note with the manifestation code.
In printed versions of the manuals, the manifestation code is in italics.
Manifestation codes cannot be the principal diagnosis; and a code for the underlying condition must always be listed first, except for an occasional situation where other directions are provided.
A code in brackets in the Alphabetic Index can be used only as a secondary code for the specific condition or procedure indexed in this way.
Example: G20 + F02.80 Dementia in Parkinson's disease
Discretionary Multiple Coding
When there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first.
Malignant ascites (R18.0) has a note to "code first" the malignancy, such as: malignant neoplasm of ovary (C56.-).
Assign first C56.-, followed by code R18.0
Code, If Applicable, Any Causal Condition First"
The "code, if applicable, any causal condition first" note indicates that multiple codes should be assigned only if the causal condition is documented as being present.
"Other retention of urine" (R33.8) requires that the code to identify enlarged prostate (N40.1) be assigned as the first-listed code or principal diagnosis, but only if it is documented as being the cause of the urinary retention.
Use additional code
The instruction to "use additional code" indicates that multiple codes should be assigned only if the condition mentioned is documented as being present.
Urinary tract infection (N39.0) requires an additional code to identify the organism if it is documented, such as positive culture of E. coli (B96.20).
Avoid Indiscriminate Multiple Coding
Indiscriminate coding of irrelevant information should be avoided.
For example, codes for symptoms or signs characteristic of the diagnosis and integral to it should not be assigned.
Codes are never assigned solely on the basis of findings of diagnostic tests, such as laboratory, X-ray, or electrocardiographic tests, unless the diagnosis is confirmed by the physician.
This differs from the coding practices in the outpatient setting when there are coding encounters for diagnostic tests that have been interpreted by a physician.
Avoid Indiscriminate Multiple Coding ( Cont...)
Codes should not be assigned for conditions that do not meet Uniform Hospital Discharge Data Set (UHDDS) criteria for reporting.
Assigning a code is inappropriate for reporting purposes unless the physician provides documentation to support the condition's significance for the episode of care.
Avoid Indiscriminate Multiple Coding ( Cont..)
Codes designated as unspecified are never assigned when a more specific code for the same general condition is assigned.
Example: Diabetes mellitus with unspecified complication (E11.8) would never be assigned when a code for diabetes with renal complication (E11.29) is assigned for the same episode of care.
Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left or right, or whether it is bilateral.
If no bilateral code is provided, and the condition is bilateral, assign separate codes for both the left and right sides.
If the side is not identified in the medical record, assign the code for the unspecified side.
Code Unconfirmed Diagnoses as if Established
When a diagnosis for an inpatient at the time of discharge is qualified as "possible," "probable," "suspected," "likely," "questionable," "?," or "rule out," the condition should be coded and reported as though the diagnosis were established.
Other terms that fit the definition of a probable or suspected condition are: "consistent with," "compatible with," "indicative of," "suggestive of," "appears to be," and "comparable with."
Code Unconfirmed Diagnoses as if Established—Exceptions
For HIV infection/illness and influenza due to certain identified influenza viruses (e.g., avian influenza or other novel influenza A virus), code only cases confirmed by physician documentation.
For outpatients, the first-listed diagnosis is the highest degree of certainty, such as symptoms, signs, or abnormalities.
Coding unconfirmed diagnoses
Use caution in coding unconfirmed diagnoses of conditions such as epilepsy, HIV disease, and multiple sclerosis as if they were established.
Incorrect reporting of such conditions can have serious personal consequences for the patient.
Consult the physician before assigning codes for such unconfirmed conditions.
Rule Out versus Ruled out
"Rule out"—the diagnosis is still considered to be possible at the time of inpatient discharge
Code as if established for inpatient episodes of care in the same way that diagnoses described as possible or probable are coded.
"Ruled out"—a diagnosis originally considered as likely is no longer a possibility at the time of inpatient discharge
Never code a diagnosis documented as "ruled out."
If an alternative condition has been identified, that diagnosis should be coded; otherwise, assign a code for the presenting symptom or other precursor condition.
Care should be exercised with "borderline" diagnoses.
They are not the same as uncertain diagnoses.
No distinction is made between the care setting (inpatient versus outpatient).
Code as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes mellitus).
If the borderline condition has a specific index entry, code it as such.
Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.
Acute and Chronic Conditions
When the same condition is described as both acute (or subacute) and chronic, it should be coded according to the Alphabetic Index subentries for that condition.
If separate subterms for acute (or subacute) and chronic are listed at the same indention level in the Alphabetic Index, both codes are assigned, with the code for the acute condition sequenced first.
A condition described as subacute is coded as acute if there is no separate subterm entry for subacute.
Acute and Chronic Conditions (Cont...)
When only one term is listed as a subterm, with the other in parentheses as a nonessential modifier, only the code listed for the subterm is assigned.
Combination codes may be provided when the condition is described as both acute and chronic.
When there are no subentries for acute (or subacute) or chronic, these modifiers are disregarded in coding the condition.
Impending or Threatened Condition
Code selection depends first on whether the condition actually occurred. If so, the threatened/impending condition is coded as a confirmed diagnosis.
If neither the threatened/impending condition nor a related condition occurred, the coder must refer to the Alphabetic Index.
Is the condition indexed under the main term a threatened or impending condition?
Is there a subterm for impending or threatened under the main term for the condition?
When neither term is indexed, the precursor condition that actually existed is coded; a code is not assigned for the condition described as impending or threatened.
Reporting Same Diagnosis Code More Than Once
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-10-CM diagnosis code.
Residual condition remaining after the termination of the acute phase of an illness or injury.
May occur at any time after an acute injury or illness.
There is no set period of time that must elapse before a condition is considered to be a late effect.
Late effect (cont)
Include conditions reported as such or as sequela of a previous illness or injury.
May be inferred with the following terms:
Due to previous injury or illness
Following previous injury or illness
Traumatic, unless there is evidence of current injury
Locating cause of late effect codes
Refer to the main term "Sequelae" in the Alphabetic Index of Diseases and Injuries (with the exception of late effects due to injury, poisoning, and certain other consequences of external causes).
ICD-10-CM provides only a limited number of codes to indicate the cause of a late effect
Late effect requires two codes
Complete coding of late effects requires two codes:
The condition or nature of the late effect
The late effect code
The condition or nature of the late effect is sequenced first, followed by the code for the cause of the late effect, except in a few instances where the Alphabetic Index or the Tabular List directs otherwise.
If the late effect is due to injury, poisoning, and certain other consequences of external causes (S00-T88), a seventh-character value for "sequelae" should be assigned to the injury code as well as the external causes code (V01-Y95).
Exceptions to two Codes for late effects
When the residual effect is not stated, the cause of late effect code is used alone.
When no late effect code is provided, but the condition is described as being a late effect, code only the residual condition.
Note that conditions described as due to previous surgery are not coded as late effects but are classified as history of or complications of previous surgery, depending on the specific situation.
When the late effect code has been expanded at the fourth-, fifth-, or sixth-character level(s) to include the manifestation condition, only the cause of the late effect code is assigned.
Example, I69.01, Cognitive deficits following nontraumatic subarachnoid hemorrhage
Late Effect versus Current Illness or Injury
Do not use a late effect code with a code for a current injury or illness of the same type, with one exception:
Codes from category I69, Sequelae of cerebrovascular disease, may be assigned as an additional code with codes from I60-I67, if the patient has a current cerebrovascular disease and residual deficits from an old cerebrovascular disease.
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