1. CHAPTER 9
USING ICD-10-CM

2. ICD-10-CM Official Guidelines
Official Guidelines for Coding and Reporting
Developed by Cooperating Parties
AHA
CMS
NCHS
(Cont’d ...)
• A complete listing of the ICD-10-CM Guidelines for Coding and Reporting are posted on the web at

3. ICD-10-CM Official Guidelines
(Cont’d …)
Arranged in sections
Section I, structure, conventions, general guidelines
Section II and III, inpatient PDX (principal diagnosis) and additional DX
Section IV, outpatient
Outpatient also reference Sections I, II, and III

4. Index and Tabular
Example of the Use of Both the Alphabetic Index and Tabular List
1. Diagnosis: Hodgkin’s Disease
Index: Hodgkin (main term) disease (subterm) - see Lymphoma, Hodgkin C81.90
Tabular: C81 Hodgkin’s disease [category code] C81.9 Unspecified Hodgkin’s disease [subcategory code] C81.90 Unspecified Hodgkin’s disease, unspecified site (subclassification code)
Code: C81.90 Unspecified Hodgkin’s disease, unspecified site
• Verify C81.90 in the Tabular.
• Read any notes indicated in the Tabular to ensure the code is complete and correct before assigning.

5. Level of Specificity Report highest character available
Cannot report 5th character if 6th character available
Highest level of specificity 7 characters
M48.49xA (A= initial encounter)
No 6th character for M48.49, but there is a 7th, x = placeholder
• What is the maximum number of character in an I-10 code? (7)

6. Integral Conditions
Diagnosis stated: Do not report signs and symptoms separately
Fever and shortness of breath due to pneumonia
Report only pneumonia
Fever and shortness of breath = symptoms of pneumonia
• If a patient came into the clinic with complaints of ear pain and fever due to otitis media, what would you report? (Otitis media only, since ear pain and fever are both symptoms of the otitis media)

7. Not Integral Condition
Sign or symptom NOT part of disease condition = report separately
Pneumonia and dehydration
J18.9, Pneumonia
E86.0, Dehydration
Not all patients with pneumonia have dehydration
Dehydration was not stated to be due to
• When the signs and symptoms are not due to a diagnosed condition, the signs and symptoms are reported.

8. Etiology and Manifestation
Diabetic retinopathy
Diabetes = etiology (cause)
Retinopathy = manifestation (symptom)
Combination code
E Type 1 diabetic retinopathy
Staphylococcal aureus cellulitis of face
Multiple Code
L (Cellulitis) and B95.6 (Staph)

9. Acute and Chronic
Same condition, both acute and chronic, with separate, same level of indention in Index, report acute first
• When acute and chronic conditions both exist and the index contains separate entries for both, use both codes.
• Always sequence the acute code first.
Figure: 9.1
I-10 Index entry Pancreatitis (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

10. Combination Codes Reports
Two diagnoses
Diagnosis with manifestation
Diagnosis with associated complication
K80.00 Acute cholecystitis with cholelithiasis
A combination code is:
A single code used to classify two diagnoses
A diagnosis with an associated secondary manifestation
A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading Inclusion and Exclusion notes in the Tabular List.
Multiple coding should not be used when the classification provides a combination code that clearly identifies all elements documented in the diagnosis.
If the combination code lacks necessary specificity in describing the manifestation or complication, then an additional code may be reported as a secondary code.

11. Residual and Cause Sequela or Residual
Malunion of fracture—Residual
Late effect of fracture—Cause
Report residual as first-listed diagnosis
Followed by late effects code
Some combination codes report 1 code, others require 2 codes

12. Laterality Left/Right = extensive in I-10 Figure: 9.4
• In the I-10, for bilateral sites, the final character indicates laterality:
right
left
unspecified
Figure: 9.4
Laterality of codes in I-10. (From Buck CJ: 2010 ICD-10-CM Standard Edition DRAFT (Softbound), St. Louis, 2010, Saunders. )

13. Conclusion CHAPTER 9
USING the ICD-10-CM