Chapter-specific guidelines, first-listed diagnosis rules, combination codes, excludes notes, laterality and symptom coding.
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- What does an Excludes1 note mean in ICD-10-CM?
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The two conditions cannot occur together and must never be coded at the same time (e.g., a congenital form vs. an acquired form of the same condition).- What does an Excludes2 note mean in ICD-10-CM?
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The excluded condition is not part of the condition represented by the code, so both codes may be assigned together if the patient has both.- What is a combination code?
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A single code used to classify two diagnoses, or a diagnosis with an associated secondary process or complication.- When a combination code fully identifies a diagnosis and its associated symptom, should the symptom also be coded separately?
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No, an additional code for the symptom should not be assigned.- How is the principal diagnosis defined for inpatient coding?
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The condition established after study to be chiefly responsible for occasioning the patient's admission to the hospital.- How is the first-listed diagnosis defined for outpatient coding?
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The condition, after study, that is chiefly responsible for the outpatient services provided during the encounter.- In the etiology/manifestation convention, what does a "code first" note instruct the coder to do?
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Sequence the underlying etiology (cause) code before the manifestation code.- What does a "use additional code" note instruct the coder to do?
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Add a secondary code to provide more detail about the etiology or cause of a condition.- Can a manifestation code (shown in italics, with an "in diseases classified elsewhere" title) ever be sequenced as the first-listed diagnosis?
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No, manifestation codes can never be sequenced first; the underlying condition must be coded first.- When coding sepsis, what is sequenced first?
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The code for the underlying systemic infection is sequenced first, followed by the code for the localized infection if present.- What additional code is assigned for severe sepsis with organ dysfunction?
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A code from subcategory R65.2- is assigned, along with code(s) for the associated acute organ dysfunction.- When should an "unspecified side" laterality code be assigned?
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Only when the medical record documentation does not specify which side (right, left, or bilateral) is affected.- If a condition affects both sides but no bilateral code exists, how should it be coded?
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Assign separate codes for the right side and the left side.- What does the 7th character "S" represent in injury coding?
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Sequela, a residual or late effect after the acute phase of the injury has resolved.- What does the 7th character "A" represent for an injury or fracture code?
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Initial encounter, while the patient is receiving active treatment for the condition.
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