The official Guidelines for Coding and Reporting are updated every year by CMS and AMA.
If there are separate codes for both the acute and chronic forms of a condition, the code for the chronic condition is sequenced first as long as both codes are listed at the same indentation level of the Index.
Section IV of the Official Guidelines for Coding and Reporting contains information regarding outpatient coding.
A late effect is the residual effect after the acute phase of an illness or injury has passed.
It is unacceptable to report an impending condition as if it exists in an outpatient facility.
Assign codes as directed in the Index, only after verifying the code in the Tabular.
Each unique 1-10 diagnosis code may be reported more than once for an encounter.
It is important to follow any cross-reference instruction in the Index of the I-10, such as see also.
For bilateral sites, the final character of the codes in the I-10 indicated laterality.
Systemic lupus erythermatosus with associated endocardititis (M32.11) is an example of dual coding.
Multiple codes are often required for late effects, complication codes, and obstetric codes.
A combination code is a single code used to classify:
ALL OF THE ABOVE: two diagnoses, a diagnosis with an associated secondary process (manifestation), a diagnosis with an associated complication
The following statements is true regarding late effects:
ALL OF THE ABOVE: there is no time limit for the development of a residual, a patient may develop more than one residual, a residual may occur months after an injury
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