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ICD-10 Conventions & Guidelines

Terms in this set (40)

"X"
placeholder character
Number of characters in an icd 10 code
3, 4, 5, 6 or 7 characters
NEC, "Not elsewhere classifiable"
the medical record provides detail for which a specific code does not exist.
NOS, "Not otherwise specified"
information in the medical record is insufficient to assign a more specific code.
[ ] Brackets
enclose synonyms, alternative wording or explanatory phrases. identify manifestation codes that are sequenced second.
( ) Parentheses
enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. nonessential modifiers.
: Colons
incomplete term which needs one or more of the modifiers following the ----- to make it assignable to a given category.
Includes Notes
This note appears immediately under a three character code title to further define, or give examples of, the content of the category.
Inclusion terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
Excludes 1
"NOT CODED HERE!" indicates that the code excluded
should never be used at the same time as the code above. Used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
Excludes 2
"Not included here". Condition excluded is not part of the condition represented by 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.
"use additional code" / "code first"
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
"in diseases classified elsewhere."
Codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition.
"Code also"
additional code(s) may be required to fully describe a condition, but this note does not provide sequencing direction.
dash (-)
additional characters are required.
A three-character code
is to be used only if it can not be further subdivided.
Signs and symptoms
are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
Acute and Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.
Combination Code
Two diagnoses, or
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
Sequela
residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit . The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. generally requires two codes sequenced in the following order: code is sequenced second.
Impending or Threatened Condition
If it did occur, code as confirmed diagnosis.
If it did not occur, determine if the condition has term for "impending" or "threatened"
If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.
Laterality
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.
Syndromes
Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.
Complications of Care
Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented
Borderline Diagnosis
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.
Use of Sign/Symptom/Unspecified Codes
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflects what is known about the patient's condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
NEC
Not Elsewhere Classified
NOS
Not Otherwise Specified
and
means and/or
Includes
synonyms or similar conditions
Excludes 1
"NOT CODED HERE!"
Excludes 1
instructs that the code referenced by the excludes note should never be used at the same time as the code above the excludes note
Excludes 2
"NOT INCLUDED HERE!"
Excludes 2
you can code both the coded referenced by the excludes note and the code above. May have both conditions at once
Code First
is a sequencing guideline
Code First
tells the coder this is a manifestation code and that another underlying condition should be coded first
Use additional code
tells the coder to identify the manifestation usually associated with the condition being coded
Code also
two codes may be required to fully describe a condition
See
coder must refer to another term
see also
refers to another place to look up terms
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