CODING

STEPS/GUIDE

1) Look up that main term in the alpha index and scan the subterm entries as appropriate. Review continued lines and additional subterms that may appear in the next column or on the next page 2) Note all parenthetical terms (non essential modifiers) that help in code selection but do not affect code assignment. Shaded vertical guidelines in the index are provided to help determine the indentation level for each subterm in relation to the main terms. 3) Pay close attention to the following instructions in the index: - "see", "see also", and "see category" cross-references - "with", "without" notes - "omit code" notes - "Due to" subterms - Other instructions found in note boxes, such as "code by site" - Following references and Check Additional character symbol in the indexes. The following references (designed and used exclusively by Optum 360) help coders locate thpse alpha numeric codes that are out of sequence in the tabular section. 4) Do not code from the alpha index without verifying the accuracy of the code in the tabular list. Locate the code in the alphanumerically arranged tabular list 5) To determine the appropriateness of the code selection and proper coding, read all instructional material: - "Includes" and both types of "Excludes" notes - "Use additional code" and "code first underlying disease" instructions - "Code also" - 4th, 5th, 6th character requirements and 7th character extension requirements - Age and sex symbols 6) Consult the ICD 10 CM guidelines, which govern the use of specific codes. These guidelines provide both general and chapter specific coding guidance. 8) Confirm and assign the correct code

ORGANIZATION

A. Introduction- history of ICD 10CM and overview of the classification system B. ICD-10CM Conventions and Guidelines C. Alpha Index of Diseases D. Neoplasm Table - provides the proper code based upon histology of the neoplasm and site E. Table of Drugs and Chemicals - lists the drug and the specific codes that identify the drug and intent F. Index to External Causes G. Tabular List of Diseases H. Illustrations

FORMAT

Divided into 2 main parts INDEX - an alphabetical list of terms and their corresponding code - contains the index to diseases and injuries (main index) and the index to External causes of injury it also Includes the neoplasm table and table of drugs and chemical. TABULAR - contains categories, subcategories, and valid codes. The ICD 10CM is an alphanumeric classification system. The 1st character of a 3 character category is a letter. The 2nd and 3rd Characters may be numbers or alpha characters. A 3 character category without further sub classification is equivalent to a valid 3 character code. Subcategories are either 4 or 5 characters. Subcategory characters include either letters or numbers. Codes may be three, four, five, six, or seven characters in length, in which each level of subdivision after a category is a subcategory. The final level of subdivision is a valid code. The final character in a code may be either a letter or a number.

KEY WORD

Green Font is used throughout the Tabular List of Diseases to differentiate the key words that appear in similar code descriptions in a given category or subcategory. The portion of the code description that appears in green font in the tabular list assists the coder in quickly identifying the key terms and in identifying the correct code. This convention is especially useful when the codes describe laterality (left,right,bilateral). The key word convention is used only in those categories in which there are multiple codes with very similar descriptions with only a few words that differentiate them.

ITALICS

Italicized type is for all exclusion notes and to identify manifestation codes, those codes that should not be reported as principal dx.

COLOR CODING/SYMBOLS

NEW CODE - solid dot - identifies the codes that are new to the classification system for the current year. The icon is to the left of the code. REVISED CODE TITLE - solid triangle - Icon is to the left of a code - alerts the user to a change in that code's title. This change may be as simple as adding or removing punctuation, which may or may not change the intent of the code, to adding or removing specific terms from a code description that completely alter the circumstances in which the code would be used. REVISED TEXT - solid bow ties - alert the user to changes in parenthetical notes for the current year. Revised text may include the following: >>> A change in a current parenthetical description >>> A change in the codes associated with a current parenthetical notes >>> A change in how a current parenthetical note is classified >>> Addition of a new parenthetical note to a code

ADDITIONAL CHARACTERS REQUIRED.

Red box with a check mark and 4th,5th,6th,7th - This symbols indicate that the code requires a 4th,5th,6th,7th character Blue box with a check mark, X, 7th - the symbol indicates that the code requires a 7th character following the placeholder X. Codes with fewer than 6 characters that required a 7th character must contain placeholder X to fill in the empty characters.

ADDITIONAL ANNOTATIONS CODE LEVEL NOTATIONS TABULAR LIST

The tabular section of the ICD 10 has various colors, symbols and other tabular annotations that may help in code selection, provide clinical or coding information, or alert the coder to reimbursement issues affected by the diagnosis code assignment. Some codes may have more than one annotation. For quick reference to the meanings of the colors and symbols, look at the color/symbol legend at the bottom of each page in the tabular list.