When the combination code lacks the necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Combination codes are identified by referring to sub-term entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Combination CodeĪ combination code is a single code used to classify: two diagnoses, a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication. The sequencing rule is the same as the etiology/manifestation pair, ‘use additional code’ indicates that a secondary code should be added, if known. ‘Use additional code’ notes are found in the Tabular List for codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a 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. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7 th character, if applicable. A three-character code is to be used only if it is not further subdivided. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6, or 7 characters. Level of Detail in Codingĭiagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record. Even if a dash is not included in the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Selection of the full code, including laterality and any applicable 7 th character, can only be done in the Tabular List. The Alphabetic Index does not always provide the full code. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. To select a code in the classification that corresponds to a diagnosis or reason for a visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. General Coding Guidelines for ICD-10-CM Locating a code in the ICD-10-CM It is divided into chapters based on body parts or conditions. The Tabular List of ICD-10 codes is organized alphanumerically from A00.0 to Z99.89. Under each of those main terms, there is often a sub-list of more-detailed terms, for instance, ‘Cataract’ has a sub-list of 84 terms. The Alphabetical Index of diagnostic terms lists thousands of ‘main terms’ alphabetically. Before we proceed with coding guidelines, you’ll need access to two sets of lists in ICD-10 CM i.e., the Alphabetical Index of diagnostic terms and the Tabular List of ICD-10 codes. In this article, we shared general coding guidelines for ICD-10-CM which will help you in selecting accurate diagnosis codes. Selecting accurate diagnosis codes using ICD-10-CM is challenging due to the availability of more than 68,000 codes.
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