mo230 chapter 003

Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 3ICD-10-CM Format and Conventions

2Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Lesson 1.1: ICD-10-CM Format and Conventions

Identify the format of the ICD-10-CM code book

Explain and apply the conventions and guidelines


ICD-10-CM Official Guidelines for Coding and Reporting

Conventions for the ICD-10-CM The Alphabetic Index and Tabular List

Index—alphabetical list of terms and their corresponding codes• Index to Diseases and Injury

Neoplasm table Table of Drugs and Chemicals

• Index to External Causes of Injury

Tabular List—chronological list of codes divided into chapters based on body system or condition



Format and structure Categories

• 3 characters

Subcategories• 4 or 5 characters

• Each level of subdivision after a category

Codes• 4, 5, 6, or 7 characters

• Final level of subdivision



Use of codes for reporting purposes For reporting purposes only codes are

permissible, not categories or subcategories, and any applicable 7th character is required

Placeholder character The “X” is used as a 5th character placeholder at

certain 6-character codes to allow for future expansion.



7th characters The applicable 7th character is required for all

codes within the category, or as the notes in the Tabular List instruct.

Abbreviations Index

• NEC – Not elsewhere classifiable

Tabular• NEC – Not elsewhere classifiable

• NOS – Not otherwise specified



Punctuation Brackets [ ] Parentheses ( ) Colons :

“And” “Other” codes “Unspecified” codes



Includes Notes Inclusion terms Excludes Notes

Excludes 1• NOT CODED HERE

Excludes 2• NOT INCLUDED HERE



Etiology/manifestation convention Requires the underlying condition be sequenced

first, followed by the manifestation “Use additional code” note at the etiology code

and a “code first” note at the manifestation code “In diseases classified elsewhere” title for

manifestation codes. Never permitted to be used as first-listed or principal diagnosis code.

Must be used in conjunction with an underlying condition, and they must be listed following the underlying condition



Etiology/manifestation convention There are manifestation codes that do not have “in

diseases classified elsewhere” in the title. A “use additional code” note will still be present and the rules for sequencing apply

In the Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets

“Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an E/M combination



“And” “With” “See” and “See Also” “Code also note”

Instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction



Default codes A code listed next to a main term in the Index is

referred to as a default code Represents that condition that is most commonly

associated with the main term, or is the unspecified code for the condition


Format of ICD-10-CM Code Book Alphabetic Index

Terms and corresponding codes in alphabetic order

Tabular List Alphanumeric listing of codes divided into chapters

based on body system or conditions ICD-10-PCS

Additional book for procedures


Format of Tabular List

ICD-10-CM 21 chapters based on body systems and

conditions• Blocks/Sections

• Categories

• Subcategories

• Valid codes



Blocks/Sections 3-digit categories that represent diseases or

conditions that are similar Subchapter

Categories 1st 3 characters

• 1st character is a letter

• 2nd and 3rd characters are numbers



Subcategories 4 or 5 characters Can be either letters or numbers The final character may be a number or a letter

Placeholder character “x” is a dummy placeholder

• 5th digit position and in certain 6-character code positions

• Used for future code expansion

• 7th characters


Format of Alphabetic Index

Three levels of indentation used in the Alphabetic Index: Main terms Subterms

• Connecting subterms indicate a relationship between the main term and the subterm. Examples:

• Associated with

• Due to

• In

• With

• With mention of

Carryover lines


Format of Alphabetic Index


Coding Conventions

Coding conventions include: Abbreviations Punctuation/symbols Instructional notes Linking terms Cross-references


Coding Conventions

ICD-10-CM—Abbreviations: Index

• NEC “Not elsewhere classifiable” “Other specified”

Tabular• NEC “Not elsewhere classifiable”

“Other specified” “Not elsewhere classifiable”

• NOS “Not otherwise specified” More specific code not available


Coding Conventions

Punctuation [ ] Brackets

• Used in Tabular to enclose synonyms, alternative wording, or explanations

• Used in Index to identify manifestation codes

( ) Parentheses• Supplementary words

• Nonessential modifiers

: Colons• Used after a term that requires one or more modifiers

that follow the colon to make it assignable to a particular category


Coding Conventions

Instructional Notes Inclusion Notes

• Further definitions or examples

Inclusion Terms• Various conditions that apply


Coding Conventions

Instructional Notes Exclusion Notes

• Excludes I – Do not use two codes together

• Excludes 2 – Look elsewhere


Coding Conventions


Coding Conventions

Etiology/manifestation conventions The underlying condition is sequenced first,

followed by the manifestation “Use an additional code” “Code first the etiology code” “In diseases classified elsewhere”


Coding Conventions

Linking Terms “And”

• Means “and” or “or”

“With”• Both elements must be present and documented

• In Index, the word “with” is sequenced right after the main term


Coding Conventions

Cross-references “See”

• Mandatory term instructing coder to look elsewhere

“See Also”• Instruction to coder that a better term may exist

• Not mandatory if your main term works

“Code Also”• 2 codes may be required to fully describe a condition

• Do not give sequencing instruction


Coding Conventions

Default codes In the Index if a code is listed next to the main

term it is a default code May represent a condition that is most commonly

associated with the main term or is the unspecified term for that condition


QUESTIONS

mo230 chapter 003

Technology

imprint of elsevier

official guidelines

reporting use of codes

codes unspecified codes

reporting default codes

format of icd

character codes

manifestation codes