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ICD-10-CM Official Coding Guidelines

Terms in this set (40)

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. "Use additional code" notes are found in the Tabular at codes that are not part of an etiology/manifestation pair, where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, "use additional code" indicates that a secondary code should be added.
For example, for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, and Enterococcus, as the cause of disease classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A "use additional code" note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code.
"Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a "code first" note and an underlying condition present, the underlying condition should be sequenced first.
"Code, if applicable, any casual condition first", notes indicate that this code may be assigned as a principal diagnosis when the casual condition is unknown or not applicable. If a casual condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.
Multiple codes may be needed for late effects, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for those conditions for further instruction.
1. Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for the same medical condition, the principal diagnosis would be the medical condition which lead to the hospital admission.

2. Admission Following Post-Operative Observation
When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to ne chiefly responsible for occasioning to the admission of the patient to the hospital for care."

3. Admission from Outpatient Surgery
When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:
- If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
- If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
- If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated as the principal diagnosis.