To code with ICD-10-CM, look up the main term for the documented condition in the Alphabetic Index, then verify the code in the Tabular List, follow every instructional note, and assign the code to its highest level of specificity. ICD-10-CM is the diagnosis code set used in every U.S. healthcare setting, and these steps are the same ones tested on the CPC exam.
What Is ICD-10-CM?
ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is the U.S. code set for diagnoses, symptoms, injuries, and reasons for encounters. It is maintained by the CDC’s National Center for Health Statistics and CMS and is updated every year, with new codes taking effect October 1.
ICD-10-CM Code Structure
- Codes are 3 to 7 characters long. The first character is always a letter.
- The first three characters are the category. A decimal point follows the third character.
- Characters 4 through 6 add detail such as etiology, anatomic site, severity, and laterality.
- Some codes require a 7th character, such as A (initial encounter), D (subsequent encounter), or S (sequela) for injuries. When a code has fewer than six characters but needs a 7th, the placeholder X fills the empty positions.
Example: type 2 diabetes mellitus with hyperglycemia is E11.65.
Guidelines for Coding with ICD-10-CM: Step-by-Step Approach
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes are vital for accurately documenting diagnoses and conditions in healthcare. This guide outlines the steps to effectively code using ICD-10-CM.
Step 1: Understand the Structure of ICD-10-CM Codes
ICD-10-CM codes are alphanumeric and consist of up to seven characters. Here’s how they are structured:
- Character 1: An alphabetical letter that indicates the category of the condition.
- Characters 2-3: Numeric digits that further define the condition.
- Character 4: A decimal point followed by additional characters that provide more specific details about the diagnosis.
- Characters 5-7: Used for additional information such as severity, laterality, and other specifics.
Step 2: Gather Necessary Information
Before coding, collect comprehensive information from the patient encounter, including:
- Patient history and clinical documentation
- Details of the diagnosis or condition
- Any relevant laboratory results or imaging reports
Step 3: Identify the Diagnosis
Determine the specific diagnosis or condition that needs to be coded. This involves:
- Reviewing the provider’s documentation for clarity on the diagnosis.
- Identifying whether the diagnosis is a primary or secondary condition.
Step 4: Use the Alphabetic Index
- Locate the Condition:
- Start with the Alphabetic Index of the ICD-10-CM manual.
- Look up the main term for the condition (e.g., “diabetes,” “hypertension”) to find corresponding codes.
- Follow the Instructions:
- The index will guide you to specific codes or range of codes. Pay attention to any “see” or “see also” notes, which may direct you to additional relevant terms.
Step 5: Review the Tabular List
After locating a potential code in the index, confirm it by checking the Tabular List:
- Code Descriptions: Review the code’s full description in the Tabular List to ensure it matches the patient’s diagnosis.
- Excludes Notes: Look for any exclusions or inclusion notes that may impact your code selection.
- Use of Additional Characters: If applicable, add the required characters to fully specify the diagnosis, especially for laterality or severity.
Step 6: Verify Coding Guidelines
Before finalizing your selection, consider the following:
- ICD-10-CM Guidelines: Review the general guidelines included in the ICD-10-CM manual for specifics on coding conventions, including code sequencing and combination codes.
- Payer-Specific Requirements: Check for any additional guidelines set by insurance payers, as they may have specific coding requirements or restrictions.
Step 7: Document Thoroughly
Accurate documentation is essential for supporting the codes selected:
- Ensure that the medical record contains all relevant details about the diagnosis.
- Confirm that the documentation clearly supports the ICD-10-CM codes used, particularly for any specific or complex conditions.
Step 8: Review and Submit Claims
- Double-Check Codes: Review all selected ICD-10-CM codes for accuracy and compliance before submission.
- Electronic Claims Submission: Use electronic systems to submit claims, which can help reduce errors and expedite processing.
Conclusion
By following these guidelines for coding with ICD-10-CM, healthcare professionals can enhance coding accuracy and ensure appropriate documentation of diagnoses. Staying informed about updates and changes in coding guidelines will further support effective coding practices.
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ICD-10-CM Coding FAQs
How many characters are in an ICD-10-CM code?
Between 3 and 7. Always report the code to the highest number of characters available for that category.
Can I code from the Alphabetic Index alone?
No. The index points you to a code, but you must verify it in the Tabular List, where the instructional notes and additional characters are found.
When are ICD-10-CM codes updated?
Every year on October 1, at the start of the federal fiscal year.
What is the difference between ICD-10-CM and ICD-10-PCS?
ICD-10-CM codes diagnoses in every setting. ICD-10-PCS codes procedures for hospital inpatient stays only.
Next, review the ICD-10-CM coding conventions, the ICD-10-CM Official Guidelines, and our CPT coding guide.