Coding 1. 7

Front 1

First Basic Principle

Back 1

•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.

Front 2

•Consistent reference to the Alphabetic Index and the Tabular List is imperative, -

Back 2

no matter how experienced the coder is.

Front 3

Assign Codes to the Highest Level of Detail •Second basic principle:

Back 3

Codes must be used to the highest number of characters available.

Front 4

•Steps:

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1. Assign a three-character disease code only if it is not further divided (when there are no four-character codes within that category).

2. Assign a four-character code only when there are no five-character codes within that subcategory.

3. Assign a five-character code only when there are no six-character codes for that subcategory.

4. Assign a six-character code when a sixth-character subclassification is provided.

5. Assign a seventh-character extension when provided.

Front 5

Use All Characters

Back 5

•All characters must be used. None can be omitted and none can be added.

Front 6

Use All Characters -

•EXCEPTION:

Back 6

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).

Front 7

Assign Residual Codes (NEC and NOS) as Appropriate

Back 7

•The main term entry in the Alphabetic Index is usually followed by the code number for the unspecified condition.

Front 8

•The unspecified code should never be assigned without -

Back 8

a careful review of subterms to determine whether a more specific code can be located.

Front 9

Assign Combination Codes When Available •Combination code:

Back 9

A single code used to classify either two diagnoses, or a diagnosis with an associated secondary condition, or a diagnosis with an associated complication.

Front 10

•Combination codes can be located in the Index with reference to subterms that follow -

Back 10

connecting words such as “with,” “due to,” “in,” and “associated with.”

Front 11

•Other combination codes can be found in -

Back 11

inclusion and exclusion notes in the Tabular List.

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•Only the combination code is assigned when -

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that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs.

Front 13

Assign Combination Codes When Available •When a combination code lacks the necessary specificity in describing the manifestation or complication,

Back 13

an additional code may be assigned.

Front 14

Assign Combination Codes When Available •Follow the directions in the Tabular List for the use of an additional code or codes

Back 14

that may provide more specificity.

Front 15

Assign Multiple Codes as Needed

Back 15

•Multiple coding is the use of more than one code to fully identify the component elements of a complex diagnostic or procedural statement.

Front 16

•A complex statement is one with connecting words or phrases such as -

Back 16

“with,” “due to,” “incidental to,” “secondary to,” or similar terminology.

Front 17

•Follow directions in the Tabular List for the use of -

Back 17

additional code(s) to provide more specificity.

Front 18

•If no combination code is provided, -

Back 18

assign multiple codes as needed to fully describe the condition regardless of whether there is advice to that effect.

Front 19

Mandatory Multiple Coding

Back 19

•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.

Front 20

•Mandatory multiple coding is identified in the Alphabetic Index by the use of -

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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.

Front 21

Dual Coding

•The need for dual coding is indicated in the Tabular List by a ___ __________ ____ note with the code for the underlying condition, and a ____ _____ __________ _________ note with the manifestation code.

Back 21

-“use additional code”

-“code first underlying condition”

Front 22

True / False

In printed versions of the manuals, the manifestation code is in italics.

Back 22

True

Front 23

•Manifestation codes -

Back 23

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.

Front 24

•A code in brackets in the Alphabetic Index can be used only -

Back 24

as a secondary code for the specific condition or procedure indexed in this way.

•Example:

G20 + F02.80 Dementia in Parkinson’s disease

Front 25

Discretionary Multiple Coding

•When there is a “code first” note and an underlying condition is present, -

Back 25

the underlying condition should be sequenced first.

•Example:

–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

Front 26

“Code, If Applicable, Any Causal Condition First”

•The “code, if applicable, any causal condition first” note indicates -

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that multiple codes should be assigned only if the causal condition is documented as being present.

•Example:

–“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..

Front 27

“Use Additional Code”

•The instruction to “use additional code” indicates that -

Back 27

multiple codes should be assigned only if the condition mentioned is documented as being present.

•Example:

–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).

Front 28

Avoid Indiscriminate Multiple Coding

•Indiscriminate coding of irrelevant information should be -

Back 28

avoided.

–For example, codes for symptoms or signs characteristic of the diagnosis and integral to it should not be assigned.

Front 29

a) Codes are never assigned solely on the basis of findings of diagnostic tests, such as laboratory, X-ray, or electrocardiographic tests, unless -

_______________________________________________

b) This differs from the coding practices in the outpatient setting when there are -

Back 29

the diagnosis is confirmed by the physician.

________________________________________________

coding encounters for diagnostic tests that have been interpreted by a physician.

Front 30

•Codes should not be assigned for conditions that -

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do not meet Uniform Hospital Discharge Data Set (UHDDS) criteria for reporting.

Front 31

•Assigning a code is inappropriate for reporting purposes unless -

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the physician provides documentation to support the condition’s significance for the episode of care.

Front 32

•Codes designated as unspecified are never assigned when -

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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.

Front 33

Laterality

•Some ICD-10-CM codes indicate laterality, specifying -

Back 33

whether the condition occurs on the left or right, or whether it is bilateral.

Front 34

Laterality

•If no bilateral code is provided, and the condition is bilateral, -

Back 34

assign separate codes for both the left and right sides.

Front 35

Laterality

•If the side is not identified in the medical record, -

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assign the code for the unspecified side.

Front 36

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 -

Back 36

be coded and reported as though the diagnosis were established.

Front 37

Code Unconfirmed Diagnoses as if Established

•Other terms that fit the definition of a probable or suspected condition are:

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“consistent with,” “compatible with,” “indicative of,” “suggestive of,” “appears to be,” and “comparable with.”

Front 38

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), -

Back 38

code only cases confirmed by physician documentation.

Front 39

Code Unconfirmed Diagnoses as if Established—Exceptions

•For outpatients, the first-listed diagnosis is the -

Back 39

highest degree of certainty, such as symptoms, signs, or abnormalities.

Front 40

Code Unconfirmed Diagnoses as if Established—Exceptions

•For physician services regardless of the setting, coders should be guided by the -

Back 40

Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office).

Front 41

Coding Unconfirmed Diagnoses

•Use caution in coding unconfirmed diagnoses of conditions such as -

Back 41

epilepsy, HIV disease, and multiple sclerosis as if they were established.

Front 42

Coding Unconfirmed Diagnoses

•Incorrect reporting of epilepsy, HIV disease, and multiple sclerosis can -

Back 42

have serious personal consequences for the patient.

Front 43

Coding Unconfirmed Diagnoses

•Consult the physician before assigning codes for -

Back 43

epilepsy, HIV disease, and multiple sclerosis unconfirmed conditions.

Front 44

•“Rule out”

Back 44

—the diagnosis is still considered to be possible at the time of inpatient discharge

Front 45

–Code as if established for inpatient episodes of care in the same way that diagnoses described as -

Back 45

possible or probable are coded.

Front 46

•“Ruled out”

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—a diagnosis originally considered as likely is - no longer a possibility at the time of inpatient discharge

Front 47

True / False

Never code a diagnosis documented as “ruled out.”

Back 47

True

Front 48

–If an alternative condition has been identified, that diagnosis should be coded; otherwise, -

Back 48

assign a code for the presenting symptom or other precursor condition.

Front 49

"Borderline” Diagnoses

•Care should be exercised with “borderline” diagnoses.

Back 49

–They are not the same as uncertain diagnoses.

Front 50

True / False

"Borderline” Diagnoses

•No distinction is made between the care setting (inpatient versus outpatient).

Back 50

True

Front 51

"Borderline" Diagnoses

•Code as confirmed, unless -

Back 51

the classification provides a specific entry

(e.g., borderline diabetes mellitus).

Front 52

"Borderline” Diagnoses

•If the borderline condition has a specific index entry, -

Back 52

code it as such.

Front 53

•Whenever the documentation is unclear regarding a borderline condition, coders are -

Back 53

encouraged to query for clarification.

Front 54

Use of Sign/Symptom/Unspecified Codes

•While coders should make every attempt to report specific diagnosis codes when supported by the available medical record, the use of sign/symptom and "unspecified" codes is acceptable, even necessary, as in the following situations:

Back 54

–If a definitive diagnosis has not been established by the end of the encounter

–When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code

Front 55

•Unspecified codes should be reported when -

Back 55

they are the codes that most accurately reflect what is known about the patient's condition at the time of the encounter.

Front 56

Acute and Chronic Conditions

•When the same condition is described as both acute (or subacute) and chronic,

Back 56

it should be coded according to the Alphabetic Index subentries for that condition.

Front 57

•If separate subterms for acute (or subacute) and chronic are listed at the same indention level in the Alphabetic Index, -

Back 57

both codes are assigned, with the code for the acute condition sequenced first.

Front 58

•A condition described as subacute is coded as acute if

Back 58

there is no separate subterm entry for subacute.

Front 59

Acute and Chronic Conditions

Back 59

•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.

Front 60

•Combination codes may be provided when -

Back 60

the condition is described as both acute and chronic.

Front 61

•When there are no subentries for acute (or subacute) or chronic, -

Back 61

these modifiers are disregarded in coding the condition.

Front 62

Impending or Threatened Condition

Back 62

•Code selection depends first on whether the condition actually occurred. If so, the threatened/impending condition is coded as a confirmed diagnosis.

Front 63

•If neither the threatened/impending condition nor a related condition occurred, the coder must refer to the Alphabetic Index.

Back 63

–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.

Front 64

Reporting Same Diagnosis Code More Than Once

Back 64

-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.

Front 65

Late Effects

Back 65

•Residual condition remaining after the termination of the acute phase of an illness or injury.

Front 66

Late Effects

Back 66

•May occur at any time after an acute injury or illness.

Front 67

Late Effects

Back 67

•There is no set period of time that must elapse before a condition is considered to be a late effect.

Front 68

Late Effects

Back 68

•Include conditions reported as such or as sequela of a previous illness or injury.

Front 69

Late Effects

Back 69

•May be inferred with the following terms:

–Late

–Old

–Due to previous injury or illness

–Following previous injury or illness

–Traumatic, unless there is evidence of current injury

Front 70

Locating Cause of Late Effect Codes

Back 70

•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).

Front 71

Locating Cause of Late Effect Codes

Back 71

•ICD-10-CM provides only a limited number of codes to indicate the cause of a late effect.

Front 72

Late Effects Require Two Codes

Back 72

•Complete coding of late effects requires two codes:

–The condition or nature of the late effect

–The late effect code

Front 73

Late Effects Require Two Codes

Back 73

•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.

Front 74

Late Effects Require Two Codes

Back 74

•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).

Front 75

Exceptions to Two Codes for Late Effect

Back 75

•When the residual effect is not stated, the cause of late effect code is used alone.

Front 76

Exceptions to Two Codes for Late Effect

Back 76

•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.

Front 77

Exceptions to Two Codes for Late Effect

Back 77

•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

Front 78

Late Effect versus Current Illness or Injury

Back 78

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.