CH. 3- General Guidelines and Notations

Reminder:

From chapter 1, that in outpatient facilities you are not permitted to code diagnoses identified as probable, suspected, rule out, or possible. You may code only what you know for a fact: a confirmed diagnosis or signs and/or symptoms that from the basis for the encounter, additional testing, and/or procedures. That rule will also apply should tests be done and result in a normal, or negative, finding. Ex.= pt. Had pain in her abdomen. Dr. did tests to rule out appendicitis. The tests were negative, and Dr. diagnosed pt. with abdominal pain RLQ. Report this with code R10.31, Abdominal pain, right lower quadrant.

Not otherwise specified (NOS)

Not otherwise specified means that the physician did not document any additional details that are identified in any of the other available code descriptions. Ex.=O03.9 Miscarriage NOS K08.20 Unspecified atrophy of edentulous alveolar ridge (atrophy of the mandible NOS).

Excludes2

Note in the Tabular List to indicate the terms listed are to be reported from another category and may be reported with the current selected code if both conditions exist.

Excludes1

Note in the Tabular List to indicate the terms listed are to be reported with a code from another category and are not to be reported with the current selected code

Category notes

Occasionally, you may see informational notes under the description of a three-character code or at the top of a subsection in the Tabular List. Ex.= I69 Sequelae of cerebrovascular disease. Note: Category I69 is to be used to indicate conditions in I60-I67 as the cause of sequelae. The "sequelae" include conditions specified as such or as residuals which may occur at any time after the onset of the casual condition.

Not elsewhere classified (NEC)

Not elsewhere classified (NEC), or not elsewhere classified, indicates that the physician provided additional details of the condition but the ICD-10-CM book did not include those extra details in any of the other codes in the book. Ex.= M12.8 Other specific arthropathies, not elsewhere classified infection, coronavirus NEC B34.2

Code also

A cold also notation is similar to the code first and use additional code notations without the predetermination of sequencing. ICD-10-CM is alerting you that the physician's notes may contain some additional condition or issue that should be reported with a separate code, in addition to the code above this notation. This notation leaves it up to you to decide whether or not the additional code is needed to tell the whole story. If it is needed, you will need to use the Official Guidelines, Section 2 and 3, to determine in what order to report them. Ex.= C7A Malignant neuroendocrine tumors, code also any associated multiple endocrine neoplasia (MEN) syndromes (E31.2-).

Other current conditions

Another important issue that needs to be coded is a current condition that might be subtly addressed by the physician. It might be the writing of a prescription refill or a short discussion on the state of the patient's well-being as the result of ongoing therapy for a matter other than that which brought the patient to see the physician today. Ex.= pt. comes for a follow-up on a previous diagnosis of paraoxysmal atrial fibrillation. Dr. examined pt. and did a blood test to monitor the effectiveness of the prescription medication Coumadin, a blood thinner. Dr. told pt. he was pleased with his progress and that he was doing well. Before he left, pt. asked Dr. for a refill of trinalin, his allergy medication because his allergies caused inflammation and irritation to his nose (rhinitis). Dr. wrote the refill prescription. I48.0 Paroxysmal atrial fibrillation J30.1 Allergic rhinitis, due to pollen (hayfever) Z79.01 Long-term (current) use of anticoagulants the code for the atrial fibrillation supports the office visit and exam, the code for the long-term use of the Coumadin (an anticoagulant) justifies the blood test, and the code for the allergic rhinitis supports the medical necessity for the trinalin prescription.

[ ]

Brackets will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description. In our example, the provider may have diagnosed the patient with foodborne intoxication due to either Clostridium perfringens or C. welchii. In other cases, A05.2 would be the correct code. The same for our second example: If the documentation reads either "third nerve palsy" or "palsy of the oculomotor nerve," code H49.02 is valid. Ex.= A05.2 Foodborne Clostridium perfringens [C. welchii] intoxication H49.02 Third [oculomotor] nerve palsy, left eye

"Code first" ex.:

C80.2 Malignant neoplasm associated with transplanted organ. Code first complication of transplanted organ (T86.-) This notation tells you that: 1. You need to report both code C80.2 and a code from category T86 (as per the physician's notes). 2. You need to report the code from T86.- first, followed by C80.2

Combination codes

If one code exists with a description that includes two or more diagnoses identified in one patient at the same time, you must choose the code that includes as many conditions as available. You may not code each separately. When the physician's notes indicate that the patient suffered with both acute respiratory failure and chronic respiratory failure, you must code J96.2-, you are not allowed to use J96.0- and J96.1- even though, technically, you are reporting the patient's condition accurately. It is required that you use the combination code, as discussed in the Official Guidelines.

Acute and chronic conditions

If one pt. has one health concern diagnosed by the physician as being both acute (severe) and chronic (ongoing) and the condition offers you separate codes for the two descriptors, you should report the code for the acute condition first, as directed by the guidelines. Remember that acute is more serious than chronic.

See Also

In other places in the Alphabetic Index, you may see that the instruction see also is next to the term you are investigating. Here, the ICD-10-CM index is explaining that additional details may be found under another term, as well as what you see here. In the example below, you can see that several suggested codes follow the main term. The index is providing you with an alternate term that may show terms more accurate to the physician's documentation. Ex.= Angiofibroma-see also Neoplasm, benign, by the site. Disease, diseased- see also Syndrome.

Four-character, five-character, and six-character codes (subcategories)

In some cases, additional characters are required to report a more specific description. If so, ICD-10-CM Tabular List will tell you with an indented listing of all the available choices for these extended descriptions, shown below the code category.

See

In the Alphabetic Index of ICD-10-CM, you may look up a term and notice that next to it, the book instructs you to see another term. This is an instruction in the index that the information you are looking for is listed under another term. In the example below, you can see that the alphabetic index is sending you to a different spelling of the diagnostic term. Ex.= Ankylostoma-see Ancylostoma

Differential diagnoses

In the cases where a provider indicates differential diagnosis by using the word versus or or between two diagnostic statements, you need to code both as if they were confirmed, and either may be listed first.

How to identify screening diagnosis codes when a screening test is performed with no signs, symptoms, or diagnosis of a condition.

Many times, you can identify such instances because they are usually determined not by the patient's feelings or health but by the calendar. ex.= annual mammogram, yearly physical, well-baby visit.

Preoperative/postoperative diagnosis

Procedure and operative reporting usually include both a preoperative diagnosis and a postoperative diagnosis. For cases where the two statements differ, the guidelines state that you should code the postoperative diagnosis because it is expected that it is more accurate of the two.

Ex.= of code sequencing

Pt. was diagnosed with myocarditis due to E. coli. You will find notations directing you on how to sequence these two codes. I41 Myocarditis in diseases classified elsewhere code first underlying disease, such as: typhus (A75.0-A75.9) I40.0 Infective myocarditis use additional code (B95-B97) to identify infectious agent

Use additional code

Similar to the "code first" notation, the "use additional code" notation is the ICD-10-CM's way of informing you that you may need to report another code as well as the code above to tell the whole story and that this extra code would be reported after the code above this notation. Ex.= L58 Radiodermatitis use additional code to identify the source of the radiation (W88, W90). This notation tells you that: 1. You need to report both the code from category L58 and either W88 or W90 (as per the physician's notes). 2. You need to report the code from L58 first, followed by W88 or W90.

Seventh character

Some ICD-10-CM codes require a seventh character. Different subsections use this position-the seventh character-to add different types of information. Most often, these choices will be listed at the top of the code category and are used for all codes within that category. You must always check the top of the code category for this information. Ex.= A initial encounter for fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion S sequela

Code first

The "code first" notation is a reminder that you are going to need another code to identify the underlying disease that caused this condition. This notation is also telling you in what order to report the two codes: the underlying condition first, followed by the code for the manifestation. Often, the notation will offer you a reference to the most common underlying diseases along with their codes.

See condition

The alphabetic index may also point you in a less detailed way when you look up a term and the notation tells you to see condition. This can be confusing. The index is not telling you to look up the term condition. What it is instructing you to do is to find the term that describes the health-related situation involved with this word and look up that term. You will see this most often next to the listing for an anatomical site. Ex.=Heart-see condition.

Principal diagnosis

The condition that is the primary, or main, reason for the encounter.

When multiple confirmed diagnosed are identified

The guidelines instruct you to list the codes in order of severity from the most severe to the least severe. Ex.= pt. came to see doctor after falling off of his bicycle. Doctor diagnosed pt. with a closed fracture of the fifth, left metacarpal shaft and an anterior dislocation of his left shoulder. For this pt.'s encounter, a fracture is more severe than a dislocation. Therefore, you would show the codes in the following order: S62.357A Nondisplaced fracture of shaft of fifth metacarpal bone, left hand M25.812 Other specified joint disorders, left shoulder

Reminder:

The guidelines state that a confirmed diagnosis should precede a sign or symptom.

Other specified

The phrase other specified means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn't have in any of the other codes in the category. Ex.= H80.81 Other otosclerosis, right ear K03.8 Other specified diseases of hard tissues of teeth.

Placeholder character

There are times when a fourth, fifth, sixth, or seventh character is required, yet there are no previous characters. In these cases, ICD-10-CM uses a placeholder character, the letter '"x," so the following characters will fall into their correct locations. Ex.= T15.01xA Foreign body in cornea, right eye, initial encounter T47.5x2D Poisoning by digestants, intentional self-harm, subsequent encounter T88.6xxS Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, sequela Y26.xxxA Exposure to smoke, fire, and flames, undetermined intent, initial encounter.

Includes Notes

This notation provides you with additional terms and diagnoses that are also reported with the above code or included in this code's description to match what the physician wrote in the documentation. Ex.= F31 Bipolar disorder INCLUDES: manic-depressive illness, manic-depressive psychosis, manic-depressive reaction. This example shows that diagnoses of bipolar disorder, manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction are all reported from code category F31.

Unspecified

Unspecified has the same meaning as NOS: the physician was not specific in his or her notes. Ex.= H81.92 Unspecified disorder of vestibular function, left ear Tumor, yolk sac, unspecified site, male C62.90

Reminder:

When codes with additional characters (and details) are available, you must use them. This is not optional- it is mandatory. And when a six-character code is available, the three, four, and five-character codes become invalid.

Code sequencing

When more than one diagnosis code is required to tell the whole story of the encounter accurately, you then must determine in which order the codes should be listed. The code reporting the most important reason for the encounter is the PRINCIPAL DIAGNOSIS. Sometimes the ICD-10-CM book will tell you which code should come first and, which should come second with the CODE FIRST and use ADDITIONAL CODE notations. Remember, an external cause code can never be the principal, or first-listed, diagnosis.

Preoperative evaluations

Whenever a pt. is scheduled for a surgical procedure (on a non-emergency basis), there are typical tests that must be done to ensure that the pt. is healthy enough to have the operation. Cardiovascular, respiratory, and other examinations are often done within a couple of days prior to the date of surgery. Often these tests do not necessarily relate directly to the diagnostic reason the surgery will be performed. Therefore, they will need a different diagnosis code to report medical necessity. Coding those encounters carries a specific guideline. In such cases, the principal, or first-listed, diagnosis code will be from the following category: Z01.8 Encounter for other specified special examinations. Follow that code with the code or codes that identify the condition(s) documented as the reason for the upcoming surgical procedure. Ex.= pt. was diagnosed with carpal tunnel syndrome in her right wrist. Dr. recommended a surgical solution. Because of her history of atrial fibrillation, pt. was required to get approval from her cardiologist before she could have the procedure. G56.01, Carpal tunnel syndrome, right upper limb, is the code that will be used to report the medical necessity for the surgery on pt. wrist. However, it will not support the examination performed by her cardiologist. Z01.810, Encounter for preprocedural cardiovascular examination, will support the cardiologist's time and expertise to clear pt. for the procedure on her wrist.

Test Results

You are not permitted to affirm a diagnosis from a test result without a physician's documentation. This refers to laboratory tests, x-rays, and other imaging, pathology, and any other diagnostic testing done for the pt. In such cases, especially when the healthcare professional has ordered additional tests based on an abnormal finding, you should query, or ask, the physician whether or not you should document the results. Be certain to get your answer in writing in the pt.'s record because if it's not in writing, you can't code it. In outpatient settings, if a physician, or other health care professional, interpreted the tests results and the final report has been placed in the pt.'s file with a diagnostic statement, you should include the code. Ex.= laboratory report in patient's file shows: Glucose 155 Norm Range: 65-105 mg/dL you can see that the pt.'s glucose is abnormally high. However, you cannot code it without a physician's written interpretation and diagnostic statement. Ex.2= report from radiology states: "X-ray shows an open fracture of the anatomical neck of the humerus, right arm. Signed: Frederick L. McCoy, MD, Chief of Radiology." The report, signed by a physician, included a specific diagnostic statement that should be coded. However, you should always check with the attending physician and permit him or her the opportunity to update the pt.'s chart with the confirmed diagnosis.

manifestation

a condition caused or developed from the existence of another condition.

Three character code categories

each type of illness or injury is divided into a separate category identified by a 3 character code. Sometimes the 3 character code is all that is needed to report the whole story about the pt.'s condition. Ex.= J14 Pneumonia due to Hemophilus influenzae. The three character code is complete and requires no further info or detail.

chronic

long duration; continuing over a long period of time

Underlying condition

one disease that affects or encourages another condition.

( ) parentheses

parentheses show you additional descriptions, terms, or phrases, that are also included in the description of the particular code. The additional terms are called nonessential modifiers. The modifiers can be used to provide additional definition but do not change the description of the condition. The additional terms are not required in the documentation, so if the provider did not use the additional term, the code description is still valid. Ex.= whether the physician wrote Malaria or Malarial fever. code B54 would still apply. Ex2.= this code would be valid for a diagnosis written by the physician as "sarcoma of dendritic cells" or "sarcoma of accessory cells."--> Malaria, malarial (fever) B54 C96.4 Sarcoma of dendritic cells (accessory cells).

acute

severe, serious

And

the guidelines for the accurate use of ICD-10-CM instruct you to interpret the use of the word and in a code description as "and/or." Therefore, if the physician notes include only one part but not the other, the code still may be correct. Ex.= C41.0 Malignant neoplasm of bones and skull and face. You would be correct to report code C410.0 on the basis of physician's notes that may confirm a diagnosis of a malignant neoplasm of the bones of the skull, a malignant neoplasm of the bones of the face, or a malignant neoplasm of the skull and face.

ICD-10-CM diagnosis codes are from __ to __ characters?

three to seven

A colon :

will emphasize that one or more of the following descriptors are required to make the code valid for the diagnosis.

Italicized, or slanted brackets [ ]

will surround an additional code or codes (secondary codes) that must be included with the initial code. It is the alphabetic index's version of the code first and use additional code notations. The italic brackets tell you that if the pt. has been diagnosed with a muscle disorder due to leprosy, you have to use two codes: first, A30.9 for the underlying cause of the muscle disorder (the leprosy) and, second, M63.80 for the muscle disorder itself. Ex.= Leprosy A30- with muscle disorder A30.9 [M63.80.]