Description of an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.

alphabetic index (AI)

A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes.

A three-digit code used for classifying a disease or condition.

A patient’s description of the symptoms or other reasons for seeking medical care from a provider.

Description of an illness or condition with a long duration.

In ICD-10-CM, three-, four-, five-, six-, or seven-digit characters used to represent a disease, injury, or symptom.

Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter.

A single code that classifies both the etiology and the manifestation(s) of an illness or injury.

Agreement to use typographic techniques or standard practices that provide visual guidelines for understanding printed material.

ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition.

A physician’s description of the main reason for a patient’s encounter; may also describe related conditions or symptoms.

A name or phrase that is formed from or based on a person’s name.

The cause or origin of a disease.

A type of exclusion note that is used when two conditions could not exist together.

A type of exclusion note that is used when a condition is “not included here,” but a patient could have both conditions at the same time.

Tabular List entries limiting applicability of particular codes to specified conditions.

Diagnosis code that reports the cause of injuries from various environmental events.

Code for diagnosis that is the patient’s main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code.

Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, the HIPAA-mandated diagnosis code set as of October 1, 2015.

ICD-10-CM Official Guidelines for Coding and Reporting

The general rules, inpatient (hospital), and outpatient coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS).

Notes that are located in the Tabular List of the ICD-10-CM

Index to External Causes

An index of all the external causes of diseases and injuries that are listed in the related chapter of the Tabular List.

Use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s).

A word that identifies a disease or condition in the Alphabetic Index.

A disease’s typical signs, symptoms, or secondary processes.

NEC (not elsewhere classifiable)

An abbreviation indicating the code to use when a disease or condition cannot be placed in any other category.

A summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm.

nonessential modifier

Supplementary terms that are not essential to the selection of the correct code, and which are shown in parentheses on the same line as a main term or subterm.

NOS (not otherwise specified)

An abbreviation indicating the code to use when no information is available for assigning the disease or condition to a more specific code; unspecified.

placeholder character (X)

Designated as “x” in some codes when a fifth-, sixth-, or seventh-digit character is required but the digit space to the left of that character is empty.

principle diagnosis (INPATIENT)

In inpatient coding, the condition that after study is established as chiefly responsible for a patient’s admission to a hospital.

Conditions that remain after a patient’s acute illness or injury has ended.

seventh-character extension

A requirement contained in the note at the start of the code it covers; a seventh character must always be in position 7 of the alphanumeric code.

Social Determinants of Health (SDOH)

Social determinants of health comprise a category of Z codes assigned to capture a patient’s social determinants of health as documented in the medical record.

A four- or five-character code number.

Word or phrase that describes a main term in the Alphabetic Index.

Table of Drug and Chemicals

An index in table format of drugs and chemicals that are listed in the Tabular List.

The part of ICD 10-CM that lists diagnosis codes in chapters alphanumerically.

Abbreviation for code from the twenty-first chapter of the ICD-10-CM that identify factors that influence health status and encounters that are not due to illness or injury.

under HIPAA, the diagnosis codes that must be used in the US started on this date:

lists diseases and codes according to a system copyrighted by the WHO of the United Nations

International Classification of Diseases

National Center for Health Statistics

are either 3, 4, 5, 6, or 7 characters in length, depending on the number of subcategories provided

is more specific than one with only fourth or fifth characters

Seventh character extension

can provide additional specific information about the health-related condition.

ICD-10-CM updates released from the NCHS and CMS

U.S. Government Printing Office (GPO)

publishes the official ICD-10-CM on the Internet and in CD-ROM format every year

Two major parts of the ICD-10-CM

ICD-10-CM Index to Diseases and Injuries & Tabular List of Diseases and Injuries

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Introduction to ICD-10-CM

Term	Definition
acute	Description of an illness or condition having severe symptoms and a short duration; can also refer to a sudden exacerbation of a chronic condition.
alphabetic index (AI)	A part of ICD-10-CM and of ICD-9-CM that lists disease and injuries alphabetically with corresponding diagnosis codes.
category	A three-digit code used for classifying a disease or condition.
chief complaint (CC)	A patient’s description of the symptoms or other reasons for seeking medical care from a provider.
chronic	Description of an illness or condition with a long duration.
code	In ICD-10-CM, three-, four-, five-, six-, or seven-digit characters used to represent a disease, injury, or symptom.
coexisting condition	Additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter.
combination code	A single code that classifies both the etiology and the manifestation(s) of an illness or injury.
convention	Agreement to use typographic techniques or standard practices that provide visual guidelines for understanding printed material.
default code	ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition.
diagnostic statement	A physician’s description of the main reason for a patient’s encounter; may also describe related conditions or symptoms.
eponym	A name or phrase that is formed from or based on a person’s name.
etiology	The cause or origin of a disease.
excludes 1	A type of exclusion note that is used when two conditions could not exist together.
excludes 2	A type of exclusion note that is used when a condition is “not included here,” but a patient could have both conditions at the same time.
exclusion notes	Tabular List entries limiting applicability of particular codes to specified conditions.
external cause code	Diagnosis code that reports the cause of injuries from various environmental events.
first-listed code	Code for diagnosis that is the patient’s main condition; in cases involving an underlying condition and a manifestation, the underlying condition is the first-listed code.
ICD-10-CM	Abbreviated title of International Classification of Diseases, Tenth Revision, Clinical Modification, the HIPAA-mandated diagnosis code set as of October 1, 2015.
ICD-10-CM Official Guidelines for Coding and Reporting	The general rules, inpatient (hospital), and outpatient coding guidance from the four cooperating parties (CMS advisers and participants from the AHA, AHIMA, and NCHS).
inclusion notes	Notes that are located in the Tabular List of the ICD-10-CM
Index to External Causes	An index of all the external causes of diseases and injuries that are listed in the related chapter of the Tabular List.
laterality	Use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s).
main term	A word that identifies a disease or condition in the Alphabetic Index.
manifestation	A disease’s typical signs, symptoms, or secondary processes.
NEC (not elsewhere classifiable)	An abbreviation indicating the code to use when a disease or condition cannot be placed in any other category.
neoplasm table	A summary table of code numbers for neoplasms by anatomical site and divided by the description of the neoplasm.
nonessential modifier	Supplementary terms that are not essential to the selection of the correct code, and which are shown in parentheses on the same line as a main term or subterm.
NOS (not otherwise specified)	An abbreviation indicating the code to use when no information is available for assigning the disease or condition to a more specific code; unspecified.
placeholder character (X)	Designated as “x” in some codes when a fifth-, sixth-, or seventh-digit character is required but the digit space to the left of that character is empty.
primary diagnosis	The first-listed diagnosis.
principle diagnosis (INPATIENT)	In inpatient coding, the condition that after study is established as chiefly responsible for a patient’s admission to a hospital.
sequelae	Conditions that remain after a patient’s acute illness or injury has ended.
seventh-character extension	A requirement contained in the note at the start of the code it covers; a seventh character must always be in position 7 of the alphanumeric code.
Social Determinants of Health (SDOH)	Social determinants of health comprise a category of Z codes assigned to capture a patient’s social determinants of health as documented in the medical record.
subcategory	A four- or five-character code number.
subterm	Word or phrase that describes a main term in the Alphabetic Index.
Table of Drug and Chemicals	An index in table format of drugs and chemicals that are listed in the Tabular List.
Tabular List (TL)	The part of ICD 10-CM that lists diagnosis codes in chapters alphanumerically.
Z code	Abbreviation for code from the twenty-first chapter of the ICD-10-CM that identify factors that influence health status and encounters that are not due to illness or injury.
October 1, 2015	under HIPAA, the diagnosis codes that must be used in the US started on this date:
ICD-10	lists diseases and codes according to a system copyrighted by the WHO of the United Nations
ICD	International Classification of Diseases
NCHS	National Center for Health Statistics
Category	has three characters
Valid Codes	are either 3, 4, 5, 6, or 7 characters in length, depending on the number of subcategories provided
Sixth character code	is more specific than one with only fourth or fifth characters
Seventh character extension	can provide additional specific information about the health-related condition.
Addenda	ICD-10-CM updates released from the NCHS and CMS
U.S. Government Printing Office (GPO)	publishes the official ICD-10-CM on the Internet and in CD-ROM format every year
Two major parts of the ICD-10-CM	ICD-10-CM Index to Diseases and Injuries & Tabular List of Diseases and Injuries
Alphabetic Index	provides an index of the disease descriptions in the second major part, the Tabular List
Tabular List	is made up of 21 chapters of disease descriptions and their codes
ICD-10-CM three additional sections	Neoplasm Table \| Table of Drugs and Chemicals \| Index to External Causes
Neoplasm table	provides code numbers for neoplasms by anatomical site and divided by the description of the neoplasm
Table of Drugs and Chemicals	provides in table format an index o drugs and chemicals that are listed in the Tabular list
Index to External Causes	provides an index of all external causes of diseases and injuries that are listed in the related chapter of the Tabular list
diagnostic statement	contains the medical term describing the condition for which a patient is receiving care.
diagnostic statement	this medical documentation includes the main reason for the patient encounter
conventions	typographic techniques that provide visual guidance for understanding information, help coders understand the rules and select the right code
Primary rule	both the Alphabetic Index and Tabular list are used sequentially to pick a code
Code followed by a hyphen	this means the coder will need to drill down to select the right code
Alphabetic Index	contains all the medical terms in the Tabular list classifications. It also lists common terms that are not found in the Tabular list
The Condition	the Alphabetic Index is organized by this, not by the body part in which it occurs
Main term	appears in boldface type and is followed by its default code
Default code	the one most frequently associated with a main term
Subterms	located below the main term, these are essential in the selection of correct codes.
Nonessential modifiers	are shown in parentheses on the same line of the main term or subterm
Nonessential modifiers	are supplementary terms that are not essential to the selection of the correct code
Nonessential modifiers	they help point to the correct term, but do not have to appear in the physician's diagnostic statement for the coder to correctly select the code
diagnostic statement	provides descriptions of additional conditions or symptoms that have been treated or that are related to the patient's current illness
Eponyms	usually describes a condition or procedure associated with that person
Eponyms	is usually listed both under that name and under the main term disease or syndrome
Alphabetic Index	the guide for coding other syndromes, or HIV infection
Indention/Turnover Lines	if the main term or subterm is too long to fit on one line, this is used
Indention/Turnover Lines	are always indented farther to the right than subterms
Indention/Turnover Lines	without close attention, it is possible to confuse this with a subterm
Cross-References	appears after a main term
See reference	means that the main term where the coder first looked is not correct; another category must be used
See also category	indicates that the coder should review the additional categories that are mentioned
NEC	not elsewhere classifiable
NEC (not elsewhere classifiable)	appears with a term when there is no code that is specific for the condition
NEC (not elsewhere classifiable)	this abbreviation means that no code matches the exact situation
NOS (not otherwise specified)	means unspecified
NOS (not otherwise specified)	indicates that the code to be located in the Tabular List should be used when a condition is not completely described in the medical record
NOS	not otherwise specified
Two codes some conditions may require	one for the etiology and second for the manifestation: this requirement is indicated when 2 codes, the 2nd in brackets, appear after a term
Manifestation	the disease's typical signs, symptoms, or secondary processes
Brackets around a code in the alphabetic index	this means that it cannot be the first-listed code in coding this diagnostic statement. these codes are listed after the codes for the etiology
Types of connecting words	due to, during, following, and with
The use of connecting words	may also indicate the need for two codes or for a single code that covers both conditions
Tabular list entry	when the AI indicates the possible need for two codes, this is used to determine whether in fact they are needed
Combination codes	this is available to describe both the etiology and the manifestation instead of two separate codes
Combination codes	this classifies two diagnoses or a diagnosis with an associated complication that may also exist
Nonessential Modifiers	types of terms show in parentheses
Tabular List	received its name from the language of statistics
Tabulate	means to count, record, or list systematically
Tabular List	diseases and injuries are organized into chapters according to etiology, body system, or purpose
Placeholder character	A.K.A: the "dummy placeholder"
Placeholder character	designated a "X" in some codes when a 5th, 6th, or 7th digit character is required but the digit space to the left of that character is empty
Seventh-character extension	ICD-10-CM assigns this in some categories usually to specify the sequence of the visit
Sequela	the problem results from a previous disease or injury
Sequela	complications or conditions that occur after an illness, injury, or trauma
Sequelae	the plural version of Sequela
Seventh-character extension	a requirement contained in a note at the start of the codes it covers
Seventh-character extension	must always be in position SEVEN of the alphanumeric code
Section Mark	this: (§) or other symbol (a number enclosed in a circle) appears next to a chapter, category, subcategory, or a code that requires a 5th, 6th, or 7th digit to be assigned
Section Mark	these are important reminders to assign the appropriate characters
category	a 3-character alphanumeric code that covers a single disease or related condition.
subcategory	a 4 or 5-character alphanumeric subdivision of a category.
subcategory	this provides a further breakdown of the disease to show its etiology, site, or manifestation.
ICD Codes	the smallest division, has either 3, 4, 5, 6, or 7 alphanumeric characters
ICD Codes	the first character is ALWAYS a letter
The letter "U"	the only letter of the alphabet that is not used in ICD-10-CM
Valid ICD Code	has to have at least THREE characters, if it has more than that, a period is placed following the 3rd character
ICD codes	the 2nd & 3rd characters may be either numbers or letters, although currently the 2nd character is usually (not always) a number
Inclusion notes	are headed by the word includes and refine the content of the category appearing above them
Exclusion notes	are headed by the word excludes and indicate conditions that are not classifiable to the preceding code
Excludes 1	is used when two conditions could not exist together, such as an acquired and a congenital condition
Excludes 1	it means "not coded here"
Excludes 2	means "not included here" but a patient could have both conditions at the same time
Colon ( : )	indicates an incomplete term
Colon ( : )	when this is used, the diagnostic statement must include one of the terms after this to be assigned a code from the particular category
Parentheses	are used around descriptions that do not affect the code. examples are nonessential and supplementary terms
Brackets	are used around synonyms, alternative wordings, or explanations
NEC and NOS	are used in the Tabular list with the same meanings as in the Alphabetic Index
Etiology code	may be followed by the instruction "use an additional code" or a note saying the same thing
Etiology code	comes first followed by the manifestation code in the Alphabetic Index
"Use additional code"	this note appears when ICD-10-CM requires assignment of codes for health factors such as tobacco use and alcohol use
laterality	a preference for one side of the body, such as left-handedness
laterality	this is the idea that the classification system should capture the side of the body that is documented for a particular condition
4th, 5th, or 6th characters	these specify the affected side, such as: right arm, left wrist, both eyes
Unspecified code	this is assigned when the affected side of the condition is not known
ICD-10-CM Official Guidelines for Coding and Reporting	known as the "Official Guidelines"
ICD-10-CM Official Guidelines for Coding and Reporting	these rules are developed by a group known as the four cooperating parties made up of CMS advisers, AHA, AHIMA, and NCHS
AHA	American Hospital Association
AHIMA	American Health Information Management Association
NCHS	National Center for Health Statistics
General medical examination (with abnormal finding)	refers to a condition/diagnosis that is newly identified or a change in severity of a chronic condition during a routine physical examination
Acute conditions	are coded with the specific code that is designated acute, if listed
Sequelae	often called residual effects or late effects
Sequelae	is followed by subterms that list the causes
Sign	an OBJECTIVE indication that can be evaluated by the physician, such as weight loss
Symptom	a SUBJECTIVE statement by the patient that cannot be confirmed during an examination, such as pain
Not Confirmed Diagnoses	these diagnoses preceded by "rule out", "suspected" , "probable" or "likely" are not coded in the OUTPATIENT setting
After Study	means at the patient's discharge from the facility
Coding to the highest level of specificity	using the MOST specific code possible that is documented in the medical record is referred to:
Three types of malignant tumors	Malignant Primary \| Malignant Secondary \| Carcinoma in situ (preinvasive cancer)
Malignant Primary	the neoplasm that is the encounter's main diagnosis is found at the site of origin
Malignant Secondary	the neoplasm that is the encounter's main diagnosis metastasized to an additional body site from the original location
Carcinoma in Situ	the neoplasm is restricted to one site ( a noninvasive type); this may also be referred to as preinvasive cancer
Benign	slow growing, not life-threatening, made of normal or near-normal cells
Uncertain behavior	not classifiable when the cells were examined
Unspecified behavior	no documentation of the nature of the neoplasm
M codes (morphology codes)	these codes contain the letter M followed by four digits, a slash, and a final digit
Pathologists	these medical professionals use M codes to report on and study the prevalence of various types of neoplasms
M codes (morphology codes)	these codes are not used in physician (outpatient) practices
Adverse effects	unintentional, harmful reactions to a proper dosage of a drug properly taken
Poisoning	refers to the medical result of the incorrect use of a substance
Underdosing	taking less of a medication than is prescribed by a provider or the manufacturer
External cause codes	these codes are located by first using the third section of the Alphabetic Index, Index to External Causes
External cause codes	these codes are often used in collecting public health information
External cause codes	these codes capture cause, intent, place, and activity
Z codes	can be used as either a primary code for an encounter or as an additional code
Z code TERMS	contact/exposure; counseling; status; supervision (of); vaccination/inoculation; Social Determinants of Health
Social Determinants of Health (SDOH) Codes	these codes are important in identifying the need for health-improving interventions that affect the patient's environment
Z codes	are used to show MEDICAL NECESSITY, such as family history or a patient's previous condition to demonstrate why a service was medically necessary
External cause codes	these codes ARE NOT used ALONE or as FIRST-LISTED codes. they always supplement a code that identifies the injury or condition
GEM	General Equivalence Mappings
General Equivalence Mappings (GEMs)	a tool prepared by the federal government that helps convert data between ICD-9-CM and ICD-10-CM and PCS codes.
General Equivalence Mappings (GEMs)	a reference dictionary that helps users navigate between the two code sets
Acute & Chronic	ALWAYS sequence the ACUTE code first
AHA	American Hospital Association
CMS	Centers for Medicare & Medicaid Services
Integral Conditions-Diagnosis Stated	Example: Fever and shortness of breath due to pneumonia {only report Pneumonia}
Non-Integral Conditions	Example: Pneumonia and Dehydration {not all patients with Pneumonia have Dehydration}
Residual & Cause [Sequela or Residual]	Example: malunion of fracture {Residual} - late effect of fracture {Cause}
NCHS	National Center for Health Statistics
Residual & Cause [Sequela or Residual]	Some combination codes report 1 code, others require 2 codes
Combination Codes	a diagnosis with an associated complication
Combination Codes	a diagnosis with an associated secondary manifestation
Combination Codes	a single code used to classify two diagnoses
Combination Codes	are identified by referring to subterm entries in the Alphabetic Index and by reading Inclusion and Exclusion notes in the Tabular List
Level of Specificity	cannot report 5th character if 6th character is available
Etiology & Manifestation	cause (example: Diabetes) symptom (example: Retinopathy)
Official Guidelines for Coding and Reporting	developed by AHA / CMS / NCHS
Integral Conditions - Diagnosis Stated	do not report signs and symptoms separately
Non-Integral Conditions	if sign or symptom is NOT part of the disease condition, report separately
Combination Codes	if this type of code lacks necessary specificity in describing the manifestation or complication, then an additional code may be reported as a secondary code
Official Guidelines - Section II & III	inpatient PDx (principal diagnosis) and additional Dx
Official Guidelines for Coding and Reporting	is arranged in FOUR sections
Official Guidelines - Section IV	outpatient [outpatient is also referenced in Sections I, II, & II]
Residual & Cause [Sequela or Residual]	report residual as first-listed diagnosis, followed by late effects code
Level of Specificity	report the highest character available
Multiple Coding	should not be used when the classification provides a combination code that clearly identifies all elements documented in the diagnosis
Residual & Cause [Sequela or Residual]	some combination codes report 1 code, others require 2 codes
Official Guidelines - Section I	structure, conventions, general guidelines
Level of Specificity	the HIGHEST level of specificity is 7 characters
Bilateral Sites	the final character indicates laterality {Right/Left/Unspecified}
Acute & Chronic	when acute and chronic conditions both exist and the index contains separate entries for both, use both codes
Certain Infectious and Parasitic Diseases, Chapter 1	A00-B99, U07.1, U09.9
Certain Infectious and Parasitic Diseases, Chapter 1	classified according to etiology (cause) of disease
Resistant Infections and Sepsis	FIRST-listed Dx {Infection} - FOLLOWED by code from category Z16 { Infection with drug resistant microorganism}
Resistant Infections and Sepsis	multiple coding is acceptable when it takes more than one code to fully describe the condition
Sepsis {Septicemia}	If unknown organism, report A41.9, Sepsis, unspecified
SIRS	inflammatory condition associated with sepsis
Severe Sepsis	single or multiple organ dysfunction, MUST BE DOCUMENTED {report infection, followed by an R65.2 code}
Septic Shock	circulatory failure associated with severe sepsis
Sepsis {Septicemia}	infection in the blood
Septic Shock	is when the infection is so bad the circulatory system starts to shut down
Septic Shock	Report infection first, followed by R65.21
Severe Sepsis	Report infection, followed by an R65.2 code
Vaping-related disorder	U07.0 {OGCR Section I.C.10.e.}
COVID-19	U07.1 {OGCR Section I.C.1.g.1.}
Post COVID-19	U09.9 {condition, unspecified}
Post COVID-19	Not reported with active COVID-19
Post COVID-19	Code first the specific condition related to COVID-19
Human Immunodeficiency Virus	B20 reports HIV infection and includes AIDS
Human Immunodeficiency Virus	Positive serology or culture, but no symptoms, report {Z21, Asymptomatic HIV status}
Human Immunodeficiency Virus	HIV exposure, but no positive serology, report {Z20.6, contact/exposure to HIV}
Human Immunodeficiency Virus	Inconclusive serology, R75 {Used for newborns of AIDS mothers}
Human Immunodeficiency Virus	Only confirmed cases of HIV infection/illness should be coded because the diagnosis stays in the patient’s record forever.
Human Immunodeficiency Virus	If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions.
Human Immunodeficiency Virus	Z21, Asymptomatic HIV infection, is to be applied when the patient without any documentation of symptoms is listed as HIV positive, known HIV, HIV test positive or similar terminology.
Human Immunodeficiency Virus	HIV testing, report Z11.4, Encounter for screening for HIV
Human Immunodeficiency Virus	Assign additional codes for documented high-risk behavior {Z72.51
Human Immunodeficiency Virus	If the visit is for a patient’s HIV status, code B20 first followed by any additional diagnoses that may exist
Human Immunodeficiency Virus	If the patient goes to the physician due to a sore throat and happens to be HIV positive, code the sore throat first and the HIV second
Neoplasms, Chapter 2	C00-D49 \| C00-C96, Malignant neoplasms {Primary and secondary}
Neoplasms, Chapter 2	D00-D09 \| Ca in situ (CIS) {Not invasive}
Neoplasms, Chapter 2	D10-D3A, Benign
Neoplasms, Chapter 2	D37-D48, Uncertain {Not clearly benign or malignant}
Neoplasms, Chapter 2	D49, Unspecified behavior {Not stated as to behavior}
Neoplasms, Chapter 2	Neoplastic conditions can affect all parts of the body
Neoplasms, Chapter 2	First, locate the type of the neoplasm in the Index.
Neoplasms, Chapter 2	to properly code a neoplasm, it is necessary to determine from the medical documentation whether the neoplasm is benign, in situ, malignant, or of uncertain histologic behavior.
Neoplasms, Chapter 2	if malignant, any secondary sites should also be determined
Staged neoplasms	means that they are evaluated for placement on a grading scale based on the level of invasion. there are FOUR stages
Stages of Neoplasms	Pathology report and staging information will be documented in medical record
Sequencing and Complications	if there are complications present, sequence complication first
Sequencing and Complications	treatment directed at: PRIMARY site, sequence PRIMARY first \| SECONDARY site, sequence SECONDARY first
History of Neoplasm Codes	History of neoplasm codes are only reported when neoplasm eradicated and is no longer present with no active treatment
History of Neoplasm Codes	If active treatment, such as chemo, no history code can be reported
History of Neoplasm Codes	If a neoplasm is being treated following surgical removal of the cancer, report the neoplasm as if it still exists.
History of Neoplasm Codes	Do not report a “history of” Z codes
History of Neoplasm Codes	the patient must be no longer under any treatment for his or her cancer. This includes chemotherapy and/or radiation therapy.
Diseases of the Blood and BloodForming Organs and Certain Disorders Involving the Immune Mechanism, Chapter 3	D50-D89
Diseases of the Blood and BloodForming Organs and Certain Disorders Involving the Immune Mechanism, Chapter 3	This is the chapter where codes for blood disorders will be found.
Diseases of the Blood and BloodForming Organs and Certain Disorders Involving the Immune Mechanism, Chapter 3	These are not only disorders of the blood but also of the bloodforming organs
Anemia	is the most common blood disease
Anemia	Under the main term of this blood disease are many subterms that relate to the type or cause of the disease
Anemia	D50-D64
Coagulation Defects	D65-D69
Other Disorders of Blood and BloodForming Organs	D70-D77
The Endocrine System	consists of glands that are located throughout the body and are responsible for secreting hormones into the bloodstream
Endocrine, Nutritional, and Metabolic Diseases, Chapter 4	E00-E89
Diabetes Mellitus (Diabetes codes)	E08-E13 are the most frequently used codes in Chapter 4 of the I-10
Endocrine, Nutritional, and Metabolic Diseases, Chapter 4	Due to conditions classified elsewhere, E08 \| Drug or chemical induced DM, E09 \| Type 1 DM, E10 \| Type 2 DM, E11 \| Other specified DM, E13
Diabetes Mellitus	Combination codes that include: Type of diabetes \| Body system involved \| Complications affecting that body system
Diabetes Mellitus	DM codes are combination codes that include type of DM, body system affected, and complications
Diabetes Mellitus	Example: E10.21 Type 1 diabetes mellitus with diabetic nephropathy
Diabetes Mellitus	If type of DM not stated, query physician
Mental, Behavioral, & Neurodevelopmental Disorders, Chapter 5	F01-F99
Alcohol dependence and use	F10
Opioid, cannabis, sedatives, cocaine, stimulants, hallucinogens, nicotine	F11-F19
Psychological disorders	F20-F29
Mood disorders (such as Bipolar Disorder)	F30-F39
Mental, Behavioral, &
Anxiety, stress-related, etc.	F40-F48
Behavior syndromes (eating and sleep disorders)	F50-F59
Adult personality and behavior	F60-F69
Intellectual disabilities	F70-F79
Developmental disorders	F80-F89
Child or adolescent behavioral and emotional disorders	F90-F98
Unspecified mental disorder	F99
Pain disorders related to psychological factors	G89 for pain and F45.41 for pain related to psychological factors
Vascular Dementia	F01
Dementia in diseases classified elsewhere	F02
Unspecified Dementia	F03
Diseases of the Nervous System, Chapter 6	G00-G99
Diseases of the Nervous System, Chapter 6	This chapter uses some combination codes in which one code identifies both the manifestation and the etiology
Diseases of the Nervous System, Chapter 6	This chapter includes some conditions that are manifestations of other diseases
Diseases of the Nervous System, Chapter 6	These categories appear in italics in the Tabular List and instruct the coder to code the underlying disease process first
Intracranial abscess and granuloma	G06.0
Manifestation codes	Example: G21.11 Neuroleptic induced parkinsonism
Manifestation codes	Use additional code for adverse effect, if applicable to identify drug (T43.3X5, T43.4X5, T43.505, T43.595)
Non-Psychological Pain	Localized pain is reported with codes throughout the I-10 \| Example: ear pain (H92.0-) or limb pain (M79.6-)
Category G89 is NEC pain	Example, G89.11 NEC acute pain due to trauma or G89.21 NEC chronic pain due to trauma
R52	reports unspecified pain that is: Acute, chronic, generalized, or NOS
Dominant and Nondominant Sides	For ambidextrous patients, the default should also be dominant
Dominant and Nondominant Sides	if dominant side is unknown, report dominant if right-sided
Paralysis (plegia)	is reported based on dominant or nondominant side
Diseases of the Eye and Adnexa, Chapter 7	H00-H59
Diseases of the Eye and Adnexa, Chapter 7	Does not contain all the eye and adnexa codes
Diseases of the Eye and Adnexa, Chapter 7	The terminology within Chapter 7 is complex
Diseases of the Eye and Adnexa, Chapter 7	Chapter Excludes 2 directs to other categories, such as: injury /trauma of eye and orbit (S05.-) \| injury, poisoning & certain other consequences of external causes (S00-T88) \| neoplasms (C00-D49)
Hordeolum	an inflammatory staphylococcal infection of the sebaceous glands at the base of the eyelashes
Chalazion	a staphylococcal infection of the eyelid that forms a mass
Hordeolum	External, report H00.01- \| Internal, report H00.02-
Chalazion	H00.1
Entropion	turning inward of eyelid, H02.0-
Ectropion	turning outward of eyelid, H02.1-
Disorders of the lacrimal system	Dacryoadenitis \| Dacryops \| Epiphora \| Dacryolith
Lacrimal System	Category H04
Diseases of the Ear and Mastoid Process, Chapter 8	H60-H95
Diseases of the Ear and Mastoid Process, Chapter 8	Excludes2 indicates other categories for reporting other ear conditions
Diseases of the Ear and Mastoid Process, Chapter 8	Excludes2 other ear conditions: endocrine, nutritional & metabolic diseases (E00-E89) \| injury, poisoning & certain other consequences of external causes (S00-T88) \| neoplasms (C00D49)
H60-H95 codes	these codes report diseases of external, middle, and inner ear, as well as mastoid, other, and surgical complications NEC
Diseases of the Ear and Mastoid Process, Chapter 8	Divided based on the structure of the ear (external, middle and mastoid, and inner)
Diseases of the Circulatory System, Chapter 9	I00-I99
I00-I99	reports conditions such as rheumatic fever, hypertension, ischemic heart disease, cerebrovascular diseases
Diseases of the Circulatory System, Chapter 9	Excludes2 note indicates other categories for other circulatory conditions: neoplasms (C00-D49) \| symptoms, signs & abnormal clinical & laboratory findings, not elsewhere classified (R00R94) \| systemic connective tissue disorders (M30-M36)
Diseases of the Circulatory System, Chapter 9	this chapter contains codes for diseases of the heart and blood vessels.
Diseases of the Circulatory System, Chapter 9	Hypertension is one of the most common conditions coded in this chapter.
Hypertension	I10
Hypertension - I10	includes arterial, benign, essential, malignant, primary, & systemic
Arterial Hypertension	Increased arterial blood pressure, hypertension
Systemic Hypertension	Arterial blood pressure exceeds norm for several months
Primary Hypertension	Essential, cause unknown
Secondary Hypertension	Due to underlying condition
Transient Hypertension	R03.0
Transient Hypertension	Temporary, elevated blood pressure without Dx of hypertension
Transient Hypertension	During or due to pregnancy, O13.- or O14.-
Hypertension with Heart Disease	I11, Hypertensive heart disease
Hypertension with Heart Disease (I50.or I51.4-I51.9)	includes conditions reported with (myocarditis, cardiomegaly, ill-defined or unspecified heart disease) when condition due to hypertension
Hypertension with Heart Disease	refers to secondary effects on the heart of prolonged, sustained, or systemic hypertension.
Heart Conditions	are assigned to a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive)
Hypertension with Heart Disease	use an additional code from category I50.- to identify type of heart failure in those patients with heart failure.
Hypertensive heart disease without heart failure	I11.9
Hypertensive heart disease NOS	I11.9
Hypertensive heart disease with heart failure	I11.0
Hypertensive heart failure	I11.0
I50.-	use this additional code to identify type of heart failure
Report the Heart Disease and Hypertension separately	if the same heart condition is not stated to be "due to hypertension” or “hypertensive"
Chronic Kidney Disease and Hypertension	assume a relationship between the chronic kidney disease and the hypertension
I13	combination code for category hypertensive heart and chronic kidney disease
I50	if heart disease is present, assign a category
Chronic Kidney Disease and Hypertension	no causal link assumed in acute kidney disease
Chronic Kidney Disease (N18)	this code is reported as a secondary code to I12.9 to identify the stage of chronic kidney disease
Query the Physician	if the physician does not state the stage of renal dysfunction, be sure to do this!
Acute Renal Disease and Hypertension	there is no assumed causal relationship between this disease and heart condition
CRF/CKD/CRI + hypertension	I12.9 + N18.9
CKD stage 1 + hypertension	I12.9 + N18.1
CKD stage 2 + hypertension	I12.9 + N18.2
CKD stage 3 + hypertension	I12.9 + N18.30-N18.32
CKD stage 4 + hypertension	I12.9 + N18.4
CKD stage 5 + hypertension	I12.0 + N18.5
CKD stage 5 + hypertension + chronic dialysis	I12.0 + N18.6 + Z99.2
ESRD + hypertension + chronic dialysis	I12.0 + N18.6 + Z99.2
CKD NOS + hypertension + chronic dialysis	I12.9 + N18.6 + Z99.2
Myocardial infarction (MI)	an acute heart attack that occurs when a coronary artery is blocked
Category I21, (MI)	requires specific documentation in the medical record to indicate the infarction site
ST-segment elevation myocardial infarction (STEMI)	I21.01 {ST elevation MI, most severe, total occlusion}
Non-ST-Segment Elevation Myocardial Infarction (NSTEMI)	I21.4 {non-ST elevation MI, less severe, partial occlusion}
STEMI	ST-segment elevation myocardial infarction
NSTEMI	Non-ST-Segment Elevation Myocardial Infarction
The ST segment	is a part of an electrocardiogram (ECG) that connects the QRS complex & the T wave
The ST segment	it's a key indicator of myocardial ischemia and necrosis
Non-ST-Segment Elevation Myocardial Infarction (NSTEMI)	a type of heart attack where there is a partial blockage of a coronary artery, which reduces blood flow to the heart muscle
ST-segment elevation myocardial infarction (STEMI)	a type of heart attack that occurs when a coronary artery becomes completely blocked, preventing blood flow to the heart muscle
When the infarction site is not indicated	Query the physician
When the infarction site is not indicated	Assign the default code I21.9
Diseases of the Respiratory System, Chapter 10	J00-J99, U07.0
Diseases of the Respiratory System, Chapter 10	includes diseases and disorders of the respiratory tract
Diseases of the Respiratory System, Chapter 10	some codes are combination codes that identify condition and causative organism
Diseases of the Respiratory System, Chapter 10	other codes require separate reporting of organism
Other codes require separate reporting of organism	Example: J01.01 Acute recurrent maxillary sinusitis (Use additional code (B95-B97) to identify infectious agent)
Some codes are combination codes that identify condition and causative organism	Example: J03.01 Acute recurrent streptococcal tonsillitis
Seventh-character: "A"	Initial encounter for active treatment
Seventh-character: "D"	Subsequent encounter for routine healing
Seventh-character: "G"	Subsequent encounter for delayed healing
Seventh-character: "K"	Subsequent encounter for nonunion
Seventh-character: "P"	Subsequent encounter for malunion
Seventh-character: "S"	Sequela (a complication that arose as a direct result of the injury or condition)
Seventh-character: "B"	Initial encounter for open fracture, type I or II
Seventh-character: "C"	Initial encounter for open fracture, type IIIA, IIIB, or IIIC
Seventh-character: "E"	Subsequent encounter for open fracture, type I or II, with routine healing
Seventh-character: "F"	Subsequent encounter for open fracture, type IIIA, IIIB, or IIIC, with routine healing

Created by: VA_MedCod3r

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