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- 1. Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 3 ICD-10-CM Format and Conventions
- 2. 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
- 3. 3Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 4. 4Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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
- 5. 5Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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.
- 6. 6Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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
- 7. 7Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting
- 8. 8Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting Punctuation Brackets [ ] Parentheses ( ) Colons : “And” “Other” codes “Unspecified” codes
- 9. 9Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting Includes Notes Inclusion terms Excludes Notes Excludes 1 • NOT CODED HERE Excludes 2 • NOT INCLUDED HERE
- 10. 10Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting
- 11. 11Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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
- 12. 12Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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
- 13. 13Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting “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
- 14. 14Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting 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
- 15. 15Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. ICD-10-CM Official Guidelines for Coding and Reporting
- 16. 16Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 17. 17Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Format of Tabular List ICD-10-CM 21 chapters based on body systems and conditions • Blocks/Sections • Categories • Subcategories • Valid codes
- 18. 18Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Format of Tabular List 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
- 19. 19Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Format of Tabular List 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
- 20. 20Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 21. 21Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Format of Alphabetic Index
- 22. 22Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding Conventions Coding conventions include: Abbreviations Punctuation/symbols Instructional notes Linking terms Cross-references
- 23. 23Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 24. 24Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 25. 25Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding Conventions Instructional Notes Inclusion Notes • Further definitions or examples Inclusion Terms • Various conditions that apply
- 26. 26Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding Conventions Instructional Notes Exclusion Notes • Excludes I – Do not use two codes together • Excludes 2 – Look elsewhere
- 27. 27Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. Coding Conventions
- 28. 28Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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”
- 29. 29Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 30. 30Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 31. 31Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. 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
- 32. 32Copyright © 2014, 2013, 2012 by Saunders, an imprint of Elsevier Inc. All rights reserved. QUESTIONS
Notas do Editor
- Characters may be either a letter or a number
- Brackets - Used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases. Used in the Index to identify manifestation codes. Parentheses - Used to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. Nonessential modifiers. Colons - Used after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category And - Represents and/or Other - For use when the information in the medical record provides detail for which a specific code does not exist Unspecified - For use when the information in the medical record is insufficient to assign a more specific code
- Includes – Appears immediately under a 3-digit code title to further define, or give examples of, the content of the category Inclusion – Conditions for which that code is to be used. May be synonyms of the code title or are a list of the various conditions assigned to that code Excludes 1 – Indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time
- And – Should be interpreted to mean and/or With – Sequenced immediately following the main term, not in alphabetical order See – indicates that another term should be referenced See Also – instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful
- The Main Index to Diseases and Injuries has two tables Neoplasm table Table of Drugs and Chemicals There is an additional index for External Causes of Injury
- Block/sections – Three digit categories that represent diseases or conditions that are similar Categories – First character of a 3-digit category is a letter, and each letter is associated with a particular chapter except for D and H. The 2 nd and 3 rd characters are numbers. Subcategory – 4 or 5 characters or further subdivided into 5 or 6 characters. Either letters or numbers. Final character may be a letter or number. Valid Code – The letter x in ICD-10-CM is a dummy placeholder. 5 th and 6 th character positions. Used for future code expansion.
- Categories – Each letter is associated with a particular chapter except for D and H. D can be found in Chapters 2 and 3; H can befound in Chapters 7 and 8. Chapter 19 uses both letters S and T.
- Codes in ICD-10-CM can be 3 to 7 characters in length. When a placeholder exists, the x must be used for the code to be considered valid. Some categories have 7 th characters. If a code in these categories is not 6 characters in length, a dummy placeholder must be added before the 7 th character.
- Main and subterms are alphabetized. Numbers appear first under the main term or subterm. Connecting words: With and without Associated with Due to In With mention of With and without appear first Main terms – are bold print and flush with left margin Subterms – indented to the right of the main term. You can have subterms of a subterm. It is sometimes difficult to follow the indentation. Carryover lines are used when text won ’ t fit on one line
- The indented format saves space Beware of changes within the indents as you move from column to column and page to page
- These are the conventions that we are going to discuss
- Index abbreviations: NEC “ Not elsewhere classifiable ” represents “ other specified ” when a specific code is not available for a condition. Tabular abbreviations: NEC “ Not elsewhere classifiable ” represents “ other specified ” when a specific code is not available for a condition. NOS “ Not otherwise specified ” is the equivalent of unspecified when a more specific code is not available.
- [ ] Brackets: synonyms, alternative wording or explanatory phrases. Brackets are used in the index to identify manifestation codes. ( ) Parentheses are in both the index and tabular. They enclose supplementary words; conditions may be present or absent; they do not affect code assigned; terms within the parentheses are referred to as nonessential modifiers. : Colons are used in the Tabular List after an incomplete term that needs one or more of the modifiers following the colon.
- Includes and Excludes Notes and Inclusion terms: Usually appear immediately under a three-digit code title; further define, or give examples of, the category. Inclusion Terms: Define conditions for which that code may be used. May be synonyms. May be a list of various conditions that are assigned to that code (the list is not necessarily a complete list).
- Excludes : The terms excluded from the code are to be coded elsewhere
- In most cases the manifestation codes will have “in disease classified elsewhere” in the title. When this terminology is used these codes are never to be used first. If the manifestation codes do not have this terminology but do have a “use additional code” note the same sequencing rules apply as for “in diseases classified elsewhere.” In the Index, manifestation codes will be listed together with the etiology code first, followed by the manifestation code in brackets. The code in brackets is always sequenced second. When there is not an etiology/manifestation combo but the terms “code first” and “use additional code” are used, the same sequencing rules apply.
- “ And ” means either “ and ” or “ or ” QUESTION: Must you have both conditions to code from this category? (No) “ With ” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.
- “ See ” – another term should be referenced. It is necessary to follow the “ see ” note to locate the correct code. “ See also ” – another main term MAY also be referenced. MAY provide additional index entries that may be useful. NOT necessary to follow the “ see also ” if the original main term provides the necessary code.
- CHAPTER HIGHLIGHTS : Go around the room and ask students to give examples of the topics covered: If no interest – ask the following: QUESTION: True or false? Physician services use CPT and HCPCS codes for procedures and do not use ICD-10-PCS . (True) QUESTION: True or false? All ICD-10 books have the same notations and edits. (At this point only one publisher has published ICD-10 but Elsevier will be coming out with an edition soon – so this would be False at that time) QUESTION: True or false? “ See ” and “ See Also ” do not mean the same thing . (True – for “ see ” you must look elsewhere, for “ see also ” you may not have to look elsewhere) QUESTION: Yes or No? You have found a term in the Alphabetic Index. You take the code you find and go to the Tabular List, and it is not listed there, although the conditions seem to be similar. There are no excludes that list your term. Do you use the code you found in the Index? (Yes. Additional terms found only in the Index may also be assigned to a code.)