ICD-10-CM Overview and

Coding Guidelines

Presented by: Katherine Abel/Rhonda Buckholtz

1
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 Introduction
• The Health Insurance Portability and
Accountability Act (HIPAA) of 1996
includes provisions for the standardization
of health care information.

Electronic
Claim Provider
Privacy Code Sets
Submissio Identifiers
ns

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 ICD-10-CM
• ICD-10-CM contains significant
improvements
– Expanded injury codes
– Creation of combination diagnosis symptom
codes
– Addition of up to seven-character
alphanumeric subclassifications
– Addition of laterality in code assignment

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 Final Rule

• 5010 to be used for

January electronic submissions
1, 2012

• ICD-10-CM to be used for

October Outpatient Services
• ICD-10-PCS to be used
1, 2014 for Inpatient Services

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 History of ICD
• ICD-10 was endorsed by the 43rd World
Health Assembly in May 1990

– Came into use in 1994

– ICD has origins into the 1850’s

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 Characteristics of ICD-10-CM
• Expanded to include health-related
conditions and to provide greater
specificity at the 6th character level and
with a 7th character extension

• Guidance is found in Official Coding and

Reporting guidelines section of ICD-10-
CM

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 Format and Structure
• Differences from ICD-9-CM include:
– Some chapters have been rearranged.
– Some titles have changed.
– Conditions have been regrouped.
– ICD-10 has almost twice as many
categories as ICD-9.
– Minor changes have been made in the
coding rules for mortality.

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 Format and Structure
• ICD-10-CM consists of:
– Tabular lists containing cause-of-death titles
and codes, Inclusion and exclusion terms
for cause-of-death titles, Alphabetical index
to diseases and nature of injury
– External causes of injury
– Table of drugs and chemicals description,
guidelines, and coding rules

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 Key Terms
• Combination Codes
• Granularity
• Laterality
• Morbidity
• Mortality
• Principal or First-listed diagnosis code
• Rubric

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 Code Structure
• All categories are three characters
– The first character of a category is a letter. The second
and third characters may be either numbers or alpha
characters.
• Subcategories are either four or five characters.
– Subcategory characters may be either letters or
numbers.
• Codes are three, four, five, or six characters and the final
character in a code may be either a letter or number.
• Certain categories have 7th character extensions which
may be either a letter or a number.

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 Three Character Categories
• Each chapter begins with three character
categories

Chapter 1 Certain Chapter 2 Neoplasms Chapter 4 Endocrine,

Infectious and Parasitic (C00–D49) Nutritional and
Diseases (A00–B99) • C00–C14 Lip, oral Metabolic Diseases
• A00–A09 Intestinal cavity and pharynx (E00–E90)
infectious diseases • C51–C58 Female • E08–E14 Diabetes
• B15–B19 Viral genital organs mellitus
hepatitis • E65–E68 Obesity
and other
hyperalimentation

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 Four Character Categories
• The four character categories further define the
site, etiology, and manifestation or state of the
disease or condition.
Example:
– C15 Malignant neoplasm of the esophagus
– C15.3 Malignant neoplasm of upper third of esophagus
– C15.4 Malignant neoplasm of middle third of esophagus
– C15.5 Malignant neoplasm of lower third of esophagus
– C15.8 Malignant neoplasm of overlapping sites of
esophagus
– C15.9 Malignant neoplasm of esophagus, unspecified

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 Five-Six Character Classification
• In ICD-10-CM, a 5th or 6th six character sub-
classifications represents the most accurate level
of specificity
Example:
– J10.8 Influenza due to other influenza virus with other
manifestations
– J10.81 Influenzal gastroenteritis
– J10.89 Influenza with other manifestations
Influenzal encephalopathy
Influenzal myocarditis

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 Seventh Character Extension
• Certain ICD-10-CM categories have
applicable seven characters
– The applicable 7th character is required for
all codes within the category, or as the
notes in the Tabular List instruct.
– The seventh character must always be the
7th character in the data field.

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 Seventh Character Extension

Example:
– T50.B96A Underdosing of
other viral vaccines, initial
encounter
– T50.B96D Underdosing of
other viral vaccines,
subsequent encounter
– T50.B96S Underdosing of
other viral vaccines, sequela

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 Dummy Placeholders
• ICD-10-CM utilizes a placeholder
character “X”
– The “X” is used as a 5th character
placeholder at certain six character codes to
allow for future expansion.

Example:
– T15.12XS Foreign body in conjunctival sac,
left eye, sequela

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 Locating a Code

Locate
Code in
Index

Verify
Code in
Tabular
List
Assign codes
based on
coding
conventions

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 ICD-10-CM Conventions
Code First/Use Additional Code Notes
– Etiology/manifestation paired codes have a
specific index entry structure .
– In the index both conditions are listed
together with the etiology code first followed
by the manifestation codes in brackets.
– The code in brackets is always to be
sequenced second.

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 ICD-10-CM Conventions
NEC
An alphabetic index entry that states NEC
directs the coder to an “other specified”
code in the Tabular List.
NOS
“Not otherwise specified.” This
abbreviation is the equivalent of
unspecified.

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 ICD-10-CM Conventions
[ ] Brackets are used in the Tabular List to enclose synonyms, alternative
wording, or explanatory wording. Brackets are used in the alphabetic
Index to identify manifestation codes.
( ) Parentheses are used in both the Alphabetic Index and Tabular List to
enclose supplemental words that do not affect the code number.
: Colon is used after an incomplete term that needs one or more of the
modifiers that follow to make it assignable to a given category.
} The brace encloses a series of terms each of which is modified by the
statement appearing at the right of the brace.
, Words following a comma are essential modifiers. The term in the
inclusion note must be present in the diagnostic statement to qualify
the code.

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 ICD-10-CM Conventions
Code Also
– A “code also” note instructs that two codes may be
required to fully describe a condition, but the
sequencing of the two codes depends on the severity
of the conditions and the reason for the encounter.
“See” and “See Also”
– The “see” instruction following a main term in the
Index indicates that another term should be referenced.

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 ICD-10-CM Conventions
Example:

Amentia—see also Disability, intellectual

—Meynert’s
(nonalcoholic) F04
Annular—see also
condition

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 Default Codes
Code listed next to a
main term in the
ICD-10-CM Index is
referred to as a
default code.

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 ICD-10-CM Conventions
Code First/Use Additional Code Notes
• Codes that have both an underlying
etiology and multiple body system
manifestations due to the underlying
etiology require sequencing the underlying
condition first followed by the
manifestation.

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 ICD-10-CM Conventions
Example:
H42 Glaucoma in diseases classified
elsewhere
Code first underlying condition, such
as:
– amyloidosis (E85.)
– aniridia (Q13.1)
– Lowe’s syndrome (E72.03)
– Reiger’s anomaly (Q13.81)
– specified metabolic disorder (E70-E90)
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 ICD-10-CM Conventions
Excludes notes
• Two types of excludes notes
– Independent of each other.
• Excludes1
– Indicates that the code excluded should never be used
at the same time as the code above the Excludes1
note.
• Excludes2
– Indicates that the condition excluded is not part of the
condition represented by the code, but from a patient
who may have both conditions at the same time.

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 ICD-10-Conventions
Example:
I10 Essential (primary) Hypertension
Includes:
High blood pressure hypertension (arterial)
(benign) (essential) (malignant) (primary)
(systemic)
Excludes1: hypertensive disease
complicating pregnancy, childbirth and the
puerperium (O10-O11, O13-O16)

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 ICD-10-Conventions
EXAMPLE:

• J03 Acute tonsillitis

Excludes2: chronic tonsillitis (J35.0)

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 ICD-10-Conventions
Inclusion Terms
– Lists of terms are included under some
codes. These terms are some of the
conditions for which that code number is to
be used.
Other specified and NEC
– An index entry that states NEC directs the
coder to an “other specified” code in the
Tabular List

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 ICD-10-CM Conventions
Unspecified and NOS
• The abbreviation NOS, “Not otherwise
specified,” in the Tabular List is the
equivalent of “unspecified.”

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 ICD-10-CM Conventions

Example:

A04.9 Bacterial intestinal

infection, unspecified

Bacterial enteritis NOS

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 ICD-10-CM Conventions
Use of “and”
– When the term “and” is used in a narrative
statement, it represents and/or.

With/Without
– When “with” and “without” are the two
options for the final character of a set of
codes, the default is always “without.”

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 With/Without Special Special
Example:

G40.501

G40.509
epileptic epileptic
syndromes, syndromes,
not intractable,
intractable without
with status status
epilepticus epilepticus

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 ICD-10-CM Conventions
Laterality
• For bilateral sites, the final character of the codes
in the ICD-10-CM indicates laterality
– The right side is usually character 1.
– The left side character 2.
– In those cases where a bilateral code is provided the
bilateral character is usually 3.
– The unspecified side is either a character 0 or 9
depending on whether it is a fifth or sixth character. An
unspecified side code is also provided should the side
not be identified in the medical record.

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 ICD-10-CM Conventions
Example:
A patient is treated for an abscess of a bursa on the
left wrist.
M71.03- Abscess of bursa, wrist

M71.031 Abscess of bursa, right wrist

M71.032 Abscess of bursa, left wrist

M71.039 Abscess of bursa,

unspecified wrist

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 General Coding Guidelines
Locating a code
– Read and be guided by instructional
notations that appear in both the Index and
the Tabular List.

Level of detail in coding

– A code is invalid if it has not been coded to
the full number of characters required for
that code, including the seventh character, if
applicable.
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 General Coding Guidelines
Signs and Symptoms
• As with ICD-9-CM coding signs and
symptoms should not be reported with a
confirmed diagnosis if the symptom is
integral to the diagnosis.
• A symptom code is used with a confirmed
diagnosis only when the symptom is not
associated with the confirmed diagnosis.

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 General Coding Guidelines

Abnormal Liver Function

Test
• R94.5

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 General Coding Guidelines
A patient is diagnosed with epigastric pain. The
physician referred the patient to a
gastroenterologist to rule out ulcer.
ICD-9- •• 789.06 Abdominal pain,
CM epigastric

ICD-10- • R10.13
• Epigastic pain
CM
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 General Coding Guidelines
Conditions that are an integral part of a disease
process
– Signs and symptoms that are associated routinely with
a disease process should not be assigned as
additional codes, unless otherwise instructed by the
classification.
Conditions that are not an integral part of a
disease process
– Additional signs and symptoms that may not be
associated routinely with a disease process should be
coded when present.

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 General Coding Guidelines
Multiple Coding for a Single Condition
– In addition to the etiology/manifestation
convention that requires two codes to fully
describe a single condition that affects multiple
body systems, there are other single conditions
that also require more than one code.
– “Code, if applicable, any causal condition first,”
notes indicate that this code may be assigned
as a principal diagnosis when the causal
condition is unknown or not applicable.

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 General Coding Guidelines
Example: A patient is treated by his primary care
physician for impetigo manifested by otitis externa
of the right ear
– The underlying condition is the impetigo and the
manifestation in this example is the otitis externa.
– The Impetigo is sequenced first followed by the otitis
externa:
• L01.00 Impetigo, unspecified
• H62.41 Otitis externa in other diseases
classified elsewhere, right ear

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 General Coding Guidelines
Acute and Chronic Conditions
– If the same condition is described as both
acute and chronic, and separate subentries
exist in the Alphabetic Index at the same
indentation level, code both and sequence
the acute code first.

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 General Coding Guidelines
Example: A patient was diagnosed with
acute maxillary sinusitis that is chronic.
In ICD-10-CM both codes for the acute and chronic condition are reported.

– J01 Acute sinusitis

– Includes: acute abscess of sinus acute empyema of sinus acute
infection of sinus acute inflammation of sinus acute suppuration of
sinus
Use additional code (B95-B97) to identify infectious agent.
• Excludes1: sinusitis NOS (J32.9)
• Excludes2: chronic sinusitis (J32.0-J32.8)

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 General Coding Guidelines
Combination Code

A combination code is a single code used to

classify:

– Two diagnoses, or
– A diagnosis with an associated secondary
process (manifestation)
– A diagnosis with an associated complication

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 General Coding Guidelines
Combination Code – CAUTION
Combination codes can lead to what appears to be
redundant coding when multiple clinical conditions
exist.
EXAMPLE:
A patient is suffering from Type 2 diabetes with mild
nonproliferative diabetic retinopathy and diabetic
dermatitis.
E11.321 Type 2 diabetes mellitus with mild
nonproliferative diabetic retinopathy
E11.620 Type 2 diabetes mellitus with diabetic
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dermatitis
 General Coding Guidelines
Late Effects (Sequela)
• A late effect is the residual effect
(condition produced) after the acute phase
of an illness or injury has terminated.
– An exception to the above guidelines are
those instances where the code for late
effect is followed by a manifestation code
identified in the Tabular List and title, or the
late effect code has been expanded.

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 General Coding Guidelines
Impending or Threatened Condition
– If it did occur, code as confirmed diagnosis.
– If it did not occur, reference the Alphabetic Index to
determine if the condition has a subentry term for
“impending” or “threatened” and also reference main
term entries for “Impending” and for “Threatened.”
– If the subterms are listed, assign the given code.
– If the subterms are not listed, code the existing
underlying condition(s) and not the condition described
as impending or threatened.

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 General Coding Guidelines
Complications of Surgery and Other
Medical Care

• The complication code is sequenced as

the first-listed code when treatment is
resulting from surgery or other medical
care.

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 General Coding Guidelines
Reporting Same Diagnosis Code More
than Once
• 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.

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 General Coding Guidelines
Principal or First-listed Diagnosis
• If no sequencing rules apply, what was the
condition that was the main focus of
treatment?
– Sequence that first

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 General Coding Guidelines
1. A sign or symptom code is not to be used
as a principal diagnosis when a definitive
diagnosis for the sign or symptom has
been established.

2. A sign or symptom code is to be used as

principal/first-listed if no definitive
diagnosis is established at the time of
coding.
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 General Coding Guidelines
3. If anticipated treatment is not carried out
due to unforeseen circumstances, the
principal diagnosis/first-listed code
remains the condition or diagnosis that the
provider planned to treat.
4. When the admission is for treatment of a
complication resulting from surgery or
other medical care, the complication code
is sequenced as the principal
diagnosis/first-listed code.
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 General Coding Guidelines
Selection of Secondary Diagnoses
• In most cases, more than one code is necessary
to fully explain a health care encounter. Although
a patient has an encounter for a principal/first-
listed diagnosis, the additional conditions or
reasons for the encounter also need to be coded.
These codes are referred to as secondary,
additional, or “other” diagnoses.

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 General Coding Guidelines
Symptom Codes with Confirmed
Diagnoses
• Two rules apply to use the symptom codes
with confirmed diagnoses:
– (1) a symptom code should not be used with a
confirmed diagnosis if the symptom is integral to the
diagnosis;
– (2) a symptom code should be used with a confirmed
diagnosis if the symptom is not always associated with
that diagnosis, such as the use of various signs and
symptoms associated with complex syndromes.
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 General Coding Guidelines
Previous Conditions
– For example if the patient is being treated
for hypertension and diabetes during the
patient encounter and the patient had
pneumonia which was resolved three
months ago, and has no bearing on the
services rendered at the visit…
• Would you code the pneumonia?

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 General Coding Guidelines
Abnormal Test Findings
– Abnormal test findings (laboratory, X-ray,
pathologic, and other diagnostic results) are
not coded and reported unless the
physician indicates their clinical
significance.

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