CHAPTER

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4Diagnostic Coding:

ICD-10-CM

Learning Outcomes

When you finish this chapter, you will be able to:4.1 Discuss the purpose of ICD-10-CM.

4.2 Describe the organization of ICD-10-CM.

4.3 Summarize the structure, content, and key conventions of the Alphabetic Index.

4.4 Summarize the structure, content, and key conventions of the Tabular List.

4-2

Learning Outcomes (continued)

When you finish this chapter, you will be able to:4.5 Apply the rules for outpatient coding that are

provided in the ICD-10-CM Official Guidelines for Coding and Reporting.

4.6 Briefly describe the content of Chapters 1 through 21 of the Tabular List.

4.7 Assign correct ICD-10-CM diagnosis codes.

4.8 Differentiate between ICD-9-CM and ICD-10-CM.

4-3

Key Terms

• acute• Alphabetic Index• category• chief complaint (cc)• chronic• code• coexisting condition• combination code• convention• default code• diagnostic statement

4-4

• eponym

• etiology

• excludes 1

• excludes 2

• exclusion notes

• external cause code

• first-listed code

• GEMs

• ICD-9-CM

• ICD-10-CM

Key Terms (continued)

• ICD-10-CM Official Guidelines for Coding and Reporting

• inclusion notes

• Index to External Causes

• laterality

• main term

• manifestation

• NEC (not elsewhere classified)

• Neoplasm Table

• nonessential modifier

4-5

• NOS (not otherwise specified)

• placeholder character (x)• primary diagnosis• principal diagnosis• sequelae• seventh-character

extension• subcategory• subterm• Table of Drugs and

Chemicals• Tabular List• Z code

4.1 ICD-10-CM 4-6

• Used to code and classify morbidity data• Clinical modification (CM) codes describe

conditions and illnesses more precisely than ICD-10

• Mandated for diagnoses under HIPAA Electronic Health Care Transactions and Code Sets standard beginning October 1, 2014

4.1 ICD-10-CM (continued) 4-7

• Code Makeup – 3-7 character alphanumeric• Category has three characters• Subcategories have four or five character codes

• Updates called addenda available on government website

4.2 Organization of ICD-10-CM 4-8

• Alphabetic Index – lists diseases and injuries alphabetically with appropriate diagnosis codes

• Tabular List – lists diagnosis codes in chapters alphanumerically

• Neoplasm Table – table of code numbers for neoplasms by anatomical site, divided by description

• Table of Drugs and Chemicals – index of drugs and chemicals from Tabular List

• Index to External Causes – index of external causes from Tabular List

4.2 Organization of ICD-10-CM (continued) 4-9

• Diagnostic statement – physician’s description of the main reason for the patient encounter; begins the process of assigning ICD-10-CM code

• Conventions – technique providing visual guidance for understanding coding information

4.3 The Alphabetic Index 4-10

• Main Terms, Subterms and Nonessential Modifiers– Main term – identifies disease or condition– Default code – listed next to main term– Subterm – word or phrase describing a main term– Etiology – cause or origin of disease or condition– Nonessential modifier – supplementary word or

phrase helping to define a code

4.3 The Alphabetic Index (continued) 4-11

• Common terms – similar names for conditions

• Eponyms – name or phrase formed from or based on a person’s name

• Indention: Turnover lines – indented farther to the right than subterms

• Cross-references see and see also indicate further information is available

• Not elsewhere classifiable (NEC) – if disease or condition cannot be placed in any category

• Not otherwise specified (NOS) – if disease or condition is not completely described in medical record

4.3 The Alphabetic Index (continued) 4-12

• Multiple Codes, Connecting Words, and Combination Codes– manifestation – disease’s typical signs, symptoms or

secondary process – needs second code indicated by brackets after the term

– first-listed code – diagnosis that is the main condition– combination code – single code describing etiology

and manifestation(s) of a particular condition

4.4 The Tabular List 4-13

• placeholder character (x) - character “x” inserted in a code to fill a blank space

• seventh-character extension – necessary assignment of a seventh character to a code; often for the sequence of an encounter

• category – three-character code for classifying disease or condition

• subcategories - four- or five- character code number

4.4 The Tabular List (continued) 4-14

• inclusion notes – entries addressing applicability of certain codes to specified conditions

• exclusion notes – entries limiting applicability of particular codes to specified conditions– excludes 1 – used when two conditions could not

exist together, such as an acquired and a congenital condition; means “not coded here”

– excludes 2 – means a particular condition is not included here, but a patient could have both conditions at the same time

4.4 The Tabular List (continued) 4-15• Punctuation

– colon (:) – indicates an incomplete term

– parentheses ( ) – used around descriptions that do not affect the code

– brackets [ ] – used around synonyms, alternative wordings, or explanations

– NEC and NOS used with same meanings as in Alphabetic Index

• etiology/manifestation coding – may include instructions on required use of additional code or to code first the underlying disease

• Laterality – documents side of the body being classified with the fourth, fifth or sixth characters of a code

4.5 ICD-10-CM Official Guidelines for Coding and Reporting

4-16

• ICD-10-CM Official Guidelines for Coding and Reporting – General rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS, AHA, AHIMA, NCHS)

• primary diagnosis – listed and coded first• coexisting condition – additional illness that

either has an effect on the patient’s primary illness or is also treated during the encounter

4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued)

4-17

• acute – illness or condition with severe symptoms and a short duration

• chronic – illness or condition with a long duration

• sequelae – conditions that remain after an acute illness or injury has been treated and resolved

4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued)

4-18

• Code to the highest level of certainty– principal diagnosis – in inpatient coding, the

condition established after study to be chiefly responsible for the admission of the patient

– If different, postoperative diagnosis would have a higher level of certainty than primary diagnosis

• Code to the highest level of specificity – coder must be able to distinguish between not mentioned in the documentation or not specified in the code listing

4.6 Overview of ICD-10-CM Chapters 4-19

• A00-B99 – Certain Infectious and Parasitic Diseases

• C00-D49 – Neoplasms• M codes – used by pathologists• D50-D89 – Diseases of the Blood and Blood-

forming Organs and Certain Disorders involving the Immune Mechanism

• E00-E89 – Endocrine, Nutritional, and Metabolic Diseases

4.6 Overview of ICD-10-CM Chapters (continued)

4-20

• F01-F99 – Mental and Behavioral Disorders• G00-G99 – Diseases of the Nervous System• H00-H59 – Diseases of the Eye and Adnexa• I00-I99 – Diseases of the Circulatory System• J00-J99 – Diseases of the Respiratory System• K00-K94 – Diseases of the Digestive System• L00-L99 – Diseases of the Skin and

Subcutaneous Tissue• M00-M99 – Diseases of the Musculoskeletal

System and Connective Tissues

4.6 Overview of ICD-10-CM Chapters (continued)

4-21

• N00-N99 – Diseases of the Genitourinary System

• (O00-O9A) – Pregnancy, Childbirth, and the Puerperium

• P00-P96 – Certain Conditions Originating in the Perinatal Period

• Q00-Q99 – Congenital Malformations, Deformations, and Chromosomal Abnormalities

• R00-R99 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified

4.6 Overview of ICD-10-CM Chapters (continued)

4-22

• S00-T88 – Injury, Poisoning, and Certain Other Consequences of External Causes

• V00-Y99 – External Causes of Morbidity– external cause code reports cause of injuries from

events such as transportation accidents, falls, and fires and are not used alone or as first-listed codes

• Z00-Z99 – Factors Influencing Health Status and Contact with Health Services– Z code is abbreviation for codes identifying

encounters not due to illness or injury

4.7 Coding Steps 4-23

• Step 1: Review complete medical documentation– chief complaint – patient’s reason for seeking care

• Step 2: Abstract the medical conditions from the visit documentation

• Step 3: Identify the main term for each condition• Step 4: Locate the main term in the Alphabetic

Index• Step 5: Verify the code in the Tabular List• Step 6: Check compliance with any applicable

Official Guidelines and list codes in appropriate order

4.8 ICD-10-CM and ICD-9-CM 4-24

• ICD-9-CM – previous HIPAA-mandated diagnosis code set

• ICD-10-CM provides many more categories for disease and other health-related conditions with higher level of specificity possible

• Codes in ICD-10-CM combine etiology and manifestations, poisoning and external cause, or diagnosis and symptoms

4.8 ICD-10-CM and ICD-9-CM (continued) 4-25

• ICD-9-CM had 17 chapters and two supplemental classifications, V codes, and E codes

• ICD-10-CM has 21 chapters and the order of chapters has changed

• ICD-9-CM codes were 3-5 characters and ICD-10-CM codes are 5-7 characters to reach a higher level of specificity

• GEMs – general equivalence mappings to assist in the transition from ICD-9-CM to ICD-10-CM

Summary

Summary

Summary