Skip to main content


Showing posts with the label ICD-10 Guidelines

Conventions and General Coding Guidelines - PART 3

Continuation of PART 2 Etiology/Manifestation Convention 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 to be sequenced first , if applicable, followed by the manifestation.  Wherever such a  combination exists,  there is a “use additional code” note at the etiology code,  and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes,  etiology followed by manifestation.  In  most cases, the manifestation codes will have in  the code  title,  “in  diseases classified elsewhere.”  Codes with this title are components of the etiology/ manifestation convention.  There are manifestation codes that do not have  “in diseases classified elsewhere” in the title. For such codes,  there is a  “use additional code” note at the etiology code and a “code fi

Conventions and General Coding Guidelines - PART 2

Continuation of PART 1  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 A 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 Notes  The  ICD-10-CM  has two types of excludes notes. Each type of note has a  different definition for use,  but they are all similar in that they indicate that codes excluded from each other are independent of each other.  Excludes1  A type1 Excludes note is pure excludes note. It means “NOT  CODED HERE!”  An  Excludes1 note indicates that the code excluded should never be used a

ICD-10 CM Conventions and General Coding Guidelines - PART 1

Format and Structure The Tabular List contains are Categories Subcategories codes.   All categories are 3 characters. A three-character category that has no further subdivision. The Subcategories are either 4 or 5 characters. The Codes maybe 3,  4, 5,  6, or  7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a  code.  Placeholder Character The ICD-10-CM utilizes a placeholder character  “X”.  The “X” is used as a placeholder at certain codes to allow for future expansion.  An example of this is at the poisoning, adverse effect, and underdosing codes, categories  T36-T50.  Where a placeholder exists, the X  must be used in order for the code to be considered a valid code NEC - Not  Elsewhere Classifiable NEC - This  abbreviation  in the  Alphabetic  Index & Tabular List represents “other  specified.” When a  specific code is not available for a  condition,  the  Alphabetic Index directs the coder to the “other spec

Usage of ICD 10 CM - Drive the Codes

Alphabetic Index and Tabular List The ICD-10-CM is divided into the Alphabetic Index and Tabular List Alphabetic Index - An alphabetical list of terms and their corresponding code and contains the following parts. Diseases Injury External Causes of Injury Neoplasms Table Drugs and Chemicals Tables Tabular List - A structured list of codes divided into chapters based on body system or condition. Drive the Codes To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record. First, locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read thoroughly and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. It is essential to use both the Alphabetic Index and Tabular List when driving and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applic

ICD-10 CM Clinical Examples for Documentation

CLINICAL DOCUMENTATION The providers need to be specifying the anatomical location and laterality in the documentation to select the appropriate most specific ICD codes.  There are a few examples of clinical documentation updated below and how the physicians and clinicians communicate and what they pay attention to it is a matter of ensuring the information is captured in your documentation. In ICD-10-CM, there are three main categories of changes, Definition Changes Terminology Differences Increased Specificity The expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s). Clinical Examples:1 - ACUTE MYOCARDIAL INFARCTION (AMI) When documenting an AMI, include the following, Timeframe An AMI is now considered “acute” for 4 weeks from the time of the incident. The episode of care ICD-10 does not capture an episode of care (e.g. initial,

New ICD codes for COVID-19

In March 2020 the Novel Coronavirus Disease, COVID-19, was declared a pandemic by the World Health Organization. The Centers for Disease Control (CDC), under the National Emergencies Act Section 201 and 301, is announcing further additions to the ICD-10-CM Classification related to COVID-19, which will become effective January 1, 2021. As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and\ Prevention’s National Center for Health Statistics (CDC/NCHS) is implementing additional codes into ICD-10-CM for reporting to include, Encounter for screening for COVID-19  - Z11.52 Contact with and (suspected) exposure to COVID-19 - Z20.822 Personal history of COVID-19 - Z86.16 Multisystem inflammatory syndrome (MIS) - M35.81 Other specified systemic involvement of connective tissue - M35.89 Pneumonia due to coronavirus disease 2019 - J12.82 COVID-19 Positive - U07.1 These new codes will be effective January 1, 2021, to identify conditions resulting from C

BURN Guidelines

Definition of Burn The burn is tissue damage with the  partial or complete destruction of the skin caused by heat, chemicals, electricity, sunlight, or nuclear radiation.  Scalds from hot liquids and steam, building fires, and flammable liquids and gases are the most common causes of burns. Inhalation injury, another type of burn, results from breathing smoke. Burn Types Thermal burns are caused by an external heat source such as fire or hot liquids in direct contact with the skin, causing tissue cell death or charring. Electrical burns happen when the body makes contact with an electric current. Electrical burns can be more extensive than what is seen externally, often affecting internal tissues and muscles. Radiation dermatitis is a type of dermatitis resulting from exposure of the skin, eyes, or internal organs to types of radiatio n. Causes include exposure from sources such as Cobalt therapy, fluoroscopy, welding arcs, sun exposure, and tanning bed lights. Corrosion's are