Medical Coding Conventions ICD 10-CM 2024 Guide lines With Blue Print

Medical Coding Conventions ICD 10-CM 2024 Guide lines With Blue Print

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. ICD stands for International classification of Diseases

It is an international standard diagnostic tool in which all the diseases are categorised,  nothing but Diseases and Symptoms classified into alpha numeric number.

. Projected transition to ICD -10 CM-October 1st of every year .Reason for transition

.ICD -9 CM has outdated terms .ICD – 9 CM has limited room for expansion .ICD-9 CM codes provide limited detail

Transition will affect everyone covered by HIPAA

CPT coding is not affected (Medical coding conventions )

• ICD has a major in medical coding to get the right E&M and specific diagnosis in short time with accuracy
• Present we are using ICD 10 CM, it means it is the 10THrevision of Whole set of ICD’S that resemble with “ 10” and CM Means Clinical modifications,
• every year on Oct 1stICD has undergoes some changes this resembles with clinical modifications “ CM”     

 Origination of ICD :

Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics(NCHS) two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS)provide the following guidelines for coding and reporting using the International Classification of Diseases

These guidelines have been approved by the four organizations those are American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS HIPAA plays major role in ICD

Conventions for ICD-10-CM:

The conventions for the ICD-10-CM are the general rules to code ICD’S. The ICD 10 CM is divided into Alphabetic index and tabular list .

a)Alphabetic index: It is an alphabetical list of terms and their respectable code. It consist of 4 parts,

➢The index of diseases and injuries

➢The index of external causes of injuries

➢The table of neoplasms

➢The table of drugs and chemicals.

b) Tabular list: The list of codes divided into chapters based on body system or condition.

Locating and Level of Detail in Coding :

Step 1 : Read and understand the diagnosis carefully ,

2 : Search the code in alphabetic index first

3 : Refer the code in tabular list ( because A.I doesn’t provide full code always )

4 : Check if any 4,5,6,7 digits are required

5 : Read the notations that are present in Excludes ,code first, use additional code etc

6: Check whether ICD needs to place holder “ X”

7 : Confirm any need of 4,5,6,7 characters if the code is 7 characters then we should report it By this way we can locate a code with detail coding.

Leading Mechanism of ICD 10 :

If any diagnosis has been confirmed by the provider we should code that condition Lets say if provider documented that the patient is having ASTHMA, we have to find the ICD 10 CM Code for the condition asthma, The ICD 10 CM Leading process includes 2 steps

Step 1 : We have to search the condition in ICD 10 Alphabetic index just like the term we are looking at dictionary( In our case Asthma is our condition we have to search that In alphabetic index) Note : The code we find in the Alphabetic index is not complete, in order to get the complete code we have to confirm our code in Tabular list

Step 2: Based on the code results that we found in the Alphabetic index we have to search this code in tabular list in order to find the full and complete code.

Here there is Number 6th behind the code J45.90 it means that code is not completed code and it require another digit.

Under J45.90 section we have J45.901, J45.902 and J45.909 are there since our code is only Asthma hence we should report J45.909

Format and structure:

ICD-10-CM tabular list contains categories, sub categories and codes.

Eg: S52.011A Torus fracture of upper end of right ulna, initial encounter for closed fracture

S52 : Fracture of forearm

01 : Torus fracture of upper end of Ulna

1A : Right side initial encounter

Characters for categories, subcategories and codes may be either a letter or a number.

By the above way we know how many characters should we give to complete this code This symbol denotes next character needed finish the code The complete code is S52.011A

Add a three character category that has no further subdivision is taken as a complete code.

Some times the ICD code doesn’t further divided to sub category or code at that time 3 character code can be Considered as complete code

Ex : Hypertension, The code of HTN is I10

Place holder character:

Excludes :

It has 2 types Excludes

Excludes ,1

Excludes,2

1 : “ Not coded here “

Notations are very important in ICD 10CM, While searching a code in ICD 10 CM if you find

Excludes 1 notation bellow to that code, that it means we never code these 2 conditions at the same time Lets say we are not allowed to code a congenital form versus an acquired form of the same condition together

Eg: A patient is having Bipolar disorder and depression

From the above image we can understand that Bipolar and depression should not code together since these are coming under Excludes 1

An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other

b) Excludes2 : “Not included here ”

While searching a code in ICD 10 CM if you find Excludes 2 notation bellow to the code, that it means we can code both the conditions together

Eg: Patient is having Hypertension and HTN involving vessels of brain From the above image we can understand that HTN involving in the vessels of brain is present as excludes 2 under I10

hence we can code both I10 AND I60-I69 Codes together

Etiology/manifestation convention:

(“code first”, “use additional code” and “in diseases classified elsewhere” notes)

Etiology: it means Root cause, It is the main condition that develops other

complications

Manifestation : it means Because of underlying Etiology some other conditions occurs these are called as manifestation.

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology

In such scenarios etiology should be sequenced first

followed by manifestation

Wherever such a combination exists, there is a “use additional code” note at the etiology

code, and a “code first” note at the manifestation code

“In diseases classified elsewhere” :

In most cases the manifestation codes will have in the code title, “in diseases classified elsewhere.”, Codes with this title are a component of the etiology/ manifestation convention.“In diseases classified elsewhere” codes are never permitted to be used as first-listed or principal diagnosis codes

They must be used in conjunction with an underlying condition and the underlying condition should be coded as primary diagnosis

Eg: Patient is having Dementia in disease classified elsewhere and Parkinson’s disease We have already discussed that in disease classified elsewhere codes as never permitted as primary diagnosis

AND :

The word “and” should be used to mean either “and” otherwise “or

Eg: A patient is having “tuberculosis of bones”, “tuberculosis of joints”“ tuberculosis of bones and joints” are classified to subcategory

A18.0 – Tuberculosis of bones and joints

A18.02 Tuberculous arthritis of other joints

WITH:

The word “with” or “in” should be used to mean “associated with” or “due to”

The classification presumes a causal relationship between the two conditions linked by

these terms in the Alphabetic Index or Tabular List. Lets say if you are searching a condition and that is linked with another condition by the term “ WITH”, Then we should take a casual linkage between these two terms

These conditions should be coded as related even in the absence of provider documentation

When the documentation clearly stating that these two conditions are unrelated to each other then only we don’t take the linkage

Eg: Diabetes and Hypertension have some WITH terms in that we find casual linkages that Should we take in the absence of provider linkage

Eg: 45 years male patient is diagnosed with Diabetes and Chronic Kidney disease

Here Diabetes and CKD having a casual linkage by the term “ WITH” hence should take linkage and code them together

Sequence would be like this →E11.22, N18.9

“ See and See also Convention :See :

The “see” instruction following a main term in the Alphabetic Index indicates that another term should be referenced

Lets say if you are searching a code and if you find See

notation then it means you have to search with term that Is present as See

See also : A “see also” instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful.

It is not necessary to follow the “see also” note when the original main term provides the necessary code.

Lets say if you are searching a code and if you find See also notation then it means there is another main term is present, if you didn’t find the code then we should follow See also notation.

Code also :

A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.

Eg: Hypertensive Crisis and Hypertension

Default codes :

A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code.

The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition

Lets say if you are searching a condition A code present next that searching condition is known Default code

Eg: Appendicitis is documented without mention of as acute or chronic the default code should assigned

Signs and symptoms :

When a related definitive diagnosis has not been established (confirmed) by the provider then we have to report the symptoms only If when provider suspecting another condition but he is not confirming then also we should report symptoms only

Examples for suspecting terms :

Ruled out (R/O), Versus(V.S),Consistent with, probably, may be , suspecting, might be, could be, likely etc ..Some symptom examples : Patient has chest pain R/O Congestive heart failure

Here CHF is not confirmed hence chest pain R07.9 should be coded.

Conditions that are an integral part of a disease process :

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Lets say if the provider has confirmed a diagnosis then we should not allowed to code the symptoms

Eg: Patient visited the hospital for chest pain and provider confirms that his chest pain due to Heart failure

We can not code chest pain ICD because chest pain is the symptom of CHF (integral part of a disease process) Sequence would be like this –> I50.9

Conditions that are not an integral part of a disease process :

Additional signs and symptoms that may not be associated routinely with a disease process should be coded Lets say some symptoms may not be related to the main disease or they may be related to other disease which is not yet confirmed in that case we can code these symptoms.

Eg: Patient comes with chest pain, Abdominal pain and provider confirms chest pain due Congestive heart failure Here abdominal pain is not a symptom( not an integral part of a disease process) of CHF (Congestive heart failure ) so we should code both CHF and abdominal pain Separately

Sequence would be like this →I50.9 ,R10.9

Multiple coding for a single condition :

By checking Etiology and Manifestation notations and capturing codes by “Code first” notation At Manifestation and “ Use additional code “ notation at Etiology by this way we are doing Multiple coding for a single condition

At Etiology notation At Manifestation notation

Acute & Chronic:

The same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same level, code both the forms and sequence the acute (subacute) form first.

Eg: Provider diagnosis a patient with Acute and Chronic appendicitis We have codes for both acute and chronic appendicitis by that we can take both acute and chronic codes for Appendicitis but we have to sequence first acute condition then chronic condition as second

Sequence would be like this →K35.80,K36

Combination Code :

A combination code is a single code used to classify Two diagnoses or A diagnosis with an associated secondary process (manifestation)

Lets say A diagnosis with an associated complication

Combination codes are identified by referring to sub term entries in the Alphabetic Index ; code combo codes if Alphabetic Index and tabular list so directs

Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.

Sequela (Late Effects) :

A sequela is the residual effect, this occurred after the acute phase of an illness or injury has resolved There is no time limit on when a sequela code can be used The residual effect may be occurred early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury

Eg: Scar formation resulting from a burn, Deviated septum due to a nasal fracture Here scar is the late effect of the burn Coding of sequela generally

requires two codes sequenced in the following order:

The condition or nature of the sequela is sequenced first.

The sequela code is sequenced second.

Eg: Female patient seen for significant scarring on her left elbow from a third-degree burn from child hood.

Here scar is the late effect of burn, as per our guideline we can understand that to code sequela we need two codes

L90.5 Scar conditions and fibrosis of skin →Nature of the sequela T22.322S Burn of third degree of left elbow, sequela →Sequela code

Sequence will be like this →L90.5,T22.322S

An exception to the above guidelines where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s).Means that whole code contain Sequela effect followed by manifestation in one set and expanded to 4,5,6,7 characters

Eg: A patient comes with hemiplegia due to the late effects of CVA

Here hemiplegia is the late effect of CVA, Normally we required two codes to code sequala but in this scenario there will only code we have to give

I69.959 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side

Impending or Threatened Condition :

If condition occurs code confirmed

diagnosis If the condition didn’t confirmed and saying only impending or threatened then search in alphabetic index and find the condition has a subentry term for “impending” or “threatened” also reference main term entries for “Impending” and for “Threatened.

If the sub terms are listed, assign the given code.

If the sub terms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened

Eg: Patient is having impending Myocardia infarction

       Impending

coronary syndrome i20.0 ,

delirium tremens F10.239,

myocardial infarction i20.0

If any impending condition not getting results under impending term means we have to code signs and symptoms only

Reporting Same Diagnosis Code More than Once :

Each unique ICD-10-CM diagnosis code may be reported only once for an encounter For bilateral conditions when there are no distinct codes for identifying laterality different conditions classified to the same ICD-10-CM diagnosis code Lets say if a code contain bilateral category then we have to report the bilateral code, if Bilateral code is not available then we have to give code for the both literalities.

Laterality :

Some ICD-10-CM code indicate laterality ; specifying whether the condition occurs on the left ,right or is bilateral .

If the condition is bilateral but there is no bilateral code then we have to report left and right code separately

If the laterality specification is not mentioned in the chart then we have to unspecified code

When a patient has a bilateral condition and each side is treated during separate encounters , assign the “bilateral” code.

In bilaterality condition one side of the condition is resolved then assign only unilateral code.

If the treated on the first side did not completely resolve the condition then bilateral code would still be appropriate.

ICD 10 Conventions -2022Documentation by Clinicians Other than the Patient’s Provider :

The diagnosis of the conditions are based on the document of the patient’s provider (physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis)There are a few exceptions, such as codes for the

Body Mass Index (BMI),

depth of non-pressure chronic ulcers,

pressure ulcer stage, coma scale,

and NIH stroke scale (NIHSS) codes,

these code assignment may be based on medical record documentation from clinicians who are not the patient’s provider

Syndromes :

Follow the alphabetic index guidance when coding syndromes. In the absence of index guidance, assign codes for the documented manifestations of the syndrome.

Eg: Viral syndrome

Documentation of Complications of Care :

Code the condition based on the relationship of the condition and care or procedure It is important to note that all conditions occur during or following medical care or surgery are Classified as complications.

Borderline Diagnosis :

A diagnosis that is documented as “borderline” at the time of discharge is coded as a confirmed diagnosis, unless there is a specific index entry in ICD-10-CM for a borderline condition Eg., Borderline diabetes

If the specific index not mentioned in borderline term then we should code the diagnosis as normal

Eg: Borderline Hypercholesterolemia

Hence the Borderline hypercholesterolemia code should be coded as E78.00

If the specific index not mentioned in borderline term then we should code the diagnosis as normal

Eg: Borderline Hypercholesterolemia Hence the Borderline hypercholesterolemia code should be coded as E78.00

Coding for Healthcare Encounters in Hurricane Aftermath :

Use of External Cause of Morbidity Codes These codes assigned to identify the cause of the injuries caused as a result of the external causes ( eg: accidents, hittings etc. )

These codes are never to be recorded as a principal diagnosis

The appropriate injury code should be sequenced before any external cause codes.

These codes captured by this ways

• how injury or health condition happened –cause
• the intent (unintentional or accidental; or intentional, such as suicide or assault)
• the place where the event occurred
• the activity of the patient at the time of the event
• the person’s status(e.g., civilian, military )

Sequencing of External Causes of Morbidity Codes :

Codes for major cause of injury takes the priority over the other external causes code

except child and adult abuse and terrorism and should be sequenced before other external cause of injury codes.

Assign as many external cause of morbidity codes as necessary to fully explain each cause

For example, if an injury occurs as a result of a building collapse during the hurricane

In this scenario external causes will be hurricane and collapse of building ,hurricane takes priority over the other then the collapse of building should be coded as secondary

For example if a person strucked by collapse of building due to the flood caused by Hurricane on behalf his military duty on beach as result of this he has a lower back pain

And the sequence will be like this :

M54.2, X37.0XXA, X38.XXXA, X36.0XXA, Y92.832, Y99.1

M54.2 →Lower back pain

X37.0XXA →Hurricane, initial encounter

X38.XXXA →Flood, initial encounter

X36.0XXA →Collapse of dam or man-made structure causing earth movement, initial encounter

Y92.832 →Beach as the place of occurrence of the external cause

Y99.1 →Military activity

For example if a person strucked by collapse of building due to the flood caused by Hurricane on behalf his military duty on beach as result of this he has a lower back pain

And the sequence will be like this :

M54.2, X37.0XXA, X38.XXXA, X36.0XXA, Y92.832, Y99.1

M54.2 →Lower back pain

X37.0XXA →Hurricane, initial encounter

X38.XXXA →Flood, initial encounter

X36.0XXA →Collapse of dam or man-made structure causing earth movement, initial encounter

Y92.832 →Beach as the place of occurrence of the external cause

Y99.1 →Military activity

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