ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a coding system used in the United States to classify and code diagnoses in healthcare. The ICD-10-CM guidelines provide instructions and rules for coding diagnoses in a consistent and accurate manner. In this self-study guide, we will provide you with an overview of the ICD-10-CM guidelines and some tips for coding diagnoses.
- Understand the Structure of ICD-10-CM : ICD-10-CM is organized into chapters based on body systems, with each chapter containing codes for specific diagnoses. Each code consists of a letter followed by three to seven alphanumeric characters, with the first character indicating the category of the diagnosis. For example, codes starting with the letter “C” are for neoplasms (tumors).
- Use the Index and Tabular List To find the appropriate code for a diagnosis, you should start by using the index. The index is a list of terms and phrases used to describe diagnoses, with corresponding codes listed next to each term. Once you find the appropriate term, you should verify the code in the tabular list, which provides additional information about the diagnosis and any applicable instructional notes.
- Follow the Official Guidelines for Coding and Reporting The ICD-10-CM guidelines provide instructions for coding diagnoses in a consistent and accurate manner. These guidelines cover topics such as coding conventions, general coding guidelines, and chapter-specific guidelines. It is important to follow these guidelines when coding diagnoses to ensure accuracy and compliance.
- Use Specificity When Coding Diagnoses ICD-10-CM places a high emphasis on specificity when coding diagnoses. This means that you should choose the most specific code possible to accurately describe the patient’s condition. For example, instead of coding “hypertension,” you should code “essential hypertension with kidney involvement.”
- Understand the Differences Between Primary and Secondary Diagnoses Primary diagnoses are the main reason for the patient’s encounter, while secondary diagnoses are additional conditions that are present during the encounter. It is important to code all relevant diagnoses, both primary and secondary, to ensure accurate billing and reimbursement.
- Code for Uncertain Diagnoses If the physician is unsure of the patient’s diagnosis, you should code for the signs and symptoms that led to the encounter. For example, if a patient presents with abdominal pain but the physician is unsure of the cause, you should code for the abdominal pain.
- Pay Attention to the Coding Conventions ICD-10-CM uses coding conventions to provide additional information about codes and their use. These conventions include instructional notes, abbreviations, and punctuation rules. It is important to pay attention to these conventions when coding diagnoses to ensure accuracy and compliance.
- Use Combination Codes When Applicable ICD-10-CM has many combination codes that allow you to code for two or more conditions that are commonly seen together. For example, instead of coding “hypertension” and “chronic kidney disease,” you can use a combination code to code for “hypertensive chronic kidney disease.”
- Understand the Differences Between Acute and Chronic Conditions Acute conditions are conditions that have a rapid onset and short duration, while chronic conditions are conditions that last for a long time or are permanent. It is important to distinguish between acute and chronic conditions when coding diagnoses, as the codes and documentation requirements may differ.
- Code for Sequela When Applicable Sequela refers to a condition that is a result of a previous injury or illness. When coding for sequela, you should use a separate code to indicate the sequela and any related conditions. For example, if a patient has a history of a stroke and presents with residual weakness