ICD 10 CM Guidelines Section 1. B

This paragraph introduces the ICD-10-CM general coding guidelines, emphasizing their importance for accurate and complete code assignment. It outlines the necessity of using both alphabetical and tabular lists to locate codes, the importance of specificity in coding, and the process of identifying codes for patient encounters. The summary highlights the 19 components of these guidelines and sets the stage for a detailed discussion on each component.

This section delves into the process of locating codes using the ICD-10-CM system, stressing the use of both the alphabetical index and tabular list for the most specific code assignment. It explains the importance of coding to the highest level of specificity, including the use of 4th, 5th, 6th, or 7th character reporting. The paragraph also discusses the classification of patient diagnoses or symptoms using codes from 0.0.0 to Z99.8 and the distinction between signs, symptoms, and diseases in the context of coding.

This paragraph focuses on coding for conditions that are integral and non-integral to a disease process. It explains the difference between conditions that are part of the disease process and those that are not, and how to assign additional codes accordingly. The section also covers multiple coding for a single condition, including etiology and manifestation conventions, and the distinction between combination codes and multiple codes for different diagnoses or complications.

This section discusses the coding of sequela, or late effects, of illnesses or injuries, emphasizing the residual nature of these conditions. It outlines the rules for coding impending or threatened conditions, including the use of the alphabetical index to determine appropriate codes. The paragraph also highlights the importance of verifying codes in the tabular list and the sequencing rules for acute and chronic conditions, as well as the exceptions to the guidelines.

This paragraph addresses the reporting of the same diagnosis code more than once and the rules for coding bilateral conditions. It clarifies that each unique ICD-10-CM code can be reported once per encounter and provides guidance on coding for bilateral conditions, unspecified side conditions, and separate encounters for treating each side of a bilateral condition.

This section discusses the role of documentation by clinicians other than the patient's provider, such as nurses or dietitians, in the coding process. It covers exceptions to the rule where BMI, ulcer stages, coma scales, and stroke scale codes can be documented by other professionals. The paragraph also introduces social determinants of health codes (Z55-Z65) and the circumstances under which these codes can be assigned based on non-medical documentation.

This paragraph covers the coding of syndromes, emphasizing the use of the alphabetical index and the assignment of codes for documented manifestations. It also discusses complications of care, highlighting the need for a cause-and-effect relationship between the condition and the care or procedure. Additionally, it addresses borderline diagnoses, which are coded as confirmed when a specific entry exists in the ICD-10-CM index.

This section provides guidance on the appropriate use of sign or symptom codes, especially when a definitive diagnosis has not been established. It also introduces a new guideline for coding encounters in the aftermath of hurricanes, detailing the use of external cause morbidity codes, the sequencing of these codes, and the assignment of other external cause codes to fully describe each cause of a condition. The paragraph concludes with the mention of Z codes for other reasons for healthcare encounters, which may be relevant in the context of hurricane aftermath.

This final paragraph summarizes the key points discussed in the ICD-10-CM general coding guidelines section 1B. It reiterates the importance of these guidelines in ensuring accurate and complete coding and sets the stage for the next segments, which will cover chapter-specific guidelines. The summary provides a concise overview of the comprehensive information provided in the previous paragraphs.