International Classification of Disease 10 CM 

• ICD update every 1st oct
• Who developed the ICD: WHO (World Health Organization)
• There are four organization in the USA who maintained the ICD 10 CM guidelines

CMS: Center for Medicare and Medicaid Services

NCHS: National Center for Health Statistics

AHIMA: American Health Information Management Association

AHA: American Hospital Association

Book Structure:

• ICD 10 CM book divided into 2 parts

Volume 2 and Volume 1

Volume 2:

• Index to Disease and Injuries
• Table of Neoplasms
• Table of Drugs and Chemicals
• Index to External Cause of Injury

Volume 1:

In tabular list we confirm the codes and take the complete codes.

In tabular list we search the code alphabetically for e.g.

A00.

B02

C00

D00

E00

Code Format & Structures

• In ICD 10 CM we have minimum 3 characters codes and maximum 7 characters.
• First character is always be alpha (A-Z)
• Second character is always be numeric (0-9)
• Third, Fourth, Fifth, and Sixth: It may be alpha. It may be numeric
• Seventy Character is always be alpha. That would be :
• A: Initial Encounter (Patient comes first time in provider clinic)
• D: Subsequent Encounter (Follow up visit)
• S: Sequela (Late effect)

What is Sequela

A sequela is the residual effect after the acute phase of an illness or injury has terminated. There is no time limit in the late effect.

What is laterality

In ICD 10 CM codes indicates the laterality whether the condition occurs on the left side, on the right side or bilateral (both side).

• Left shoulder pain
• Right shoulder pain
• Bilateral shoulder pain

Left, Right and Bilateral are laterality

What is placeholder

In ICD 10 CM placeholder character should be “X”. It is used as a hold the place to allow further expansion of the codes.

For E.g.  W19: Fall (Unspecified fall)

In W19 codes we required 7th character. The 7th character should be appropriate A, D, S.

For e.g. W19. __ __ __ A

Complete Code is: W19.XXXA

Abbreviation

We have 2 abbreviation in alphabetic index

NEC: Not elsewhere classifiable

NOS: Not otherwise specified . It is equivalent to unspecified

NEC: When the specific condition is not available in your book, so we code otherwise specified. Means coder is not able to find the code in the ICD-10 CM book.

NOS: Not otherwise specified. Means provider not specified the disease. For e.g. Headache, diabetes, so in that condition we take the code unspecified.

Include , Exclude 1 and Exclude 2

Include: This note appears to be immediately under the three character

J01: Acute sinusitis

Includes:

acute abscess of sinus

acute empyema of sinus

acute infection of sinus

acute inflammation of sinus

acute suppuration of sinus

Exclude 1

Exclude 1 note means “Do not code here”. Exclude1 codes never be used with Include, because in Include we find more specification of the code and in Exclude 1 we do not have specification.

For e.g.

Exclude 1

Sinusitis (NOS) : J32.9.

• It means we never code J01 with J32.9
• In J01 we have specification of Sinusitis i.e. Acute sinusitis. But in J32.9 we do not have specification, so we always use specified code, at the same time.

Exclude 2

An Exclude 2 “Not included here”

We code together Exclude 2 and Include.

J32.0 (Chronic sinusitis) Exclude 2

J01: (Acute Sinusitis) Include

In that condition we code together, but always code acute condition first and then chronic condition.

Acute means : Rapid onset

Chronic means : Long term

Important Guidelines:

Rule out, questionable, probable, suspected, working diagnosis, possible. Never be code these conditions.

For e.g. Rule out pneumonia, questionable anxiety. Suspected fever. Never code these disease

Sign and symptoms are integral part of the disease:

Sign and symptoms are integral part of the disease for e.g. patient is suffering for Kidney stones. He has sign and symptoms of urine incontinence, fever, body ache, and headache. These all are sign and symptoms of Kidney stones, so we code only Kidney stones because other disease are integral part of the Kidney stones.

Sign and symptoms are not integral part of the disease.

For e.g. Patient is suffering for kidney stone and also complaining of wrist pain, so the wrist pain is not a sign and symptoms of kidney stone. In that condition we code separately. wrist pain and Kidney stone

And & With

The word “and” should be interpreted to mean either and or “or”.

• Means if “and” is mentioned, so that disease not associated with each other.For e.g. Hypertension and fever. We code separately hypertension. We code separately fever.

With : Means disease associated with each other.

Nausea with vomiting (we use combo code.)

Hypertensive heart and chronic kidney disease. (We use combo code) I13

Guidelines

• V, W, X, Y series codes never goes primary and never goes alone. For e.g. W19.XXXA, S42.XXXA, I10 (This is wrong sequence)
• S42.XXXA, I10, W19.XXXA (This is the right sequence)

V, W, X, Y series codes use for external cause of injury.