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2024 ICD-10-CM General Coding Guidelines
Mar 11, 2025
Codemaster Coach: 2024 ICD-10-CM Official Coding Guidelines (Part B)
Introduction
Continuation of the review of the 2024 ICD-10-CM Official Coding Guidelines.
Focus on General Coding Guidelines (Part B).
General Coding Guidelines
1. Locating a Code in ICD-10-CM
Steps to coding:
Locate the main term in the Alphabetic Index.
Verify the code in the Tabular List.
Assign the verified code.
Main term describes the patient's condition, not the body part.
Alphabetic Index doesn't always provide the full code; the full code is verified in the Tabular List.
Example: Main term for "breast mass" is "mass."
2. Level of Detail in Coding Diagnoses
Codes should be reported to the highest level of specificity documented.
ICD-10-CM codes require up to seven characters.
Codes with three characters are headings and may require fourth, fifth, sixth, or seventh characters.
3. Code or Codes from Specific Categories
Use appropriate codes from categories A00.0-T88.9, Z00-Z99.8, U00-U85.
4. Signs and Symptoms
Signs and symptoms codes are used when a definitive diagnosis has not been established.
Symptoms are observed by the patient; signs by the physician.
5. Conditions Integral to a Disease Process
Do not assign additional codes for signs and symptoms that are integral to a disease process, unless otherwise instructed.
6. Conditions Not Integral to a Disease Process
Code signs and symptoms when they are not routinely associated with the disease process.
7. Multiple Coding for a Single Condition
Use additional code notes often found in the Tabular List for more detail.
Example: Urinary Tract Infection (UTI) requires the identification of the infectious agent.
8. Acute and Chronic Conditions
Code both acute and chronic conditions, sequence acute conditions first.
9. Combination Codes
Single codes that classify two diagnoses or a diagnosis with a secondary process or complication.
10. Sequela (Late Effects)
A residual effect of a condition or injury after the acute phase has resolved.
Requires two codes: sequela code and the condition or nature of sequela.
11. Impending or Threatened Conditions
Code as confirmed if they occurred; use main terms "impending" or "threatened" if they didn't.
12. Reporting the Same Diagnosis Code More Than Once
Unique ICD-10-CM diagnosis codes should only be reported once per encounter.
13. Laterality
Codes indicate laterality (right, left, bilateral) if available.
If bilateral code isn't available, assign separate codes for each side.
14. Documentation by Clinicians Other Than Provider
Coding may be based on documentation by other healthcare professionals in certain cases (e.g., BMI, ulcer depth).
15. Syndromes
Follow Alphabetic Index guidelines when coding syndromes.
In absence of guidance, assign codes for documented manifestations.
16. Documentation of Complications
A complication must show a cause-and-effect relationship between care and condition.
17. Borderline Diagnoses
Code as confirmed unless a specific entry exists (e.g., borderline diabetes).
18. Use of Signs and Symptoms and Unspecified Codes
Appropriate when a definitive diagnosis is not achievable.
19. Codes for Healthcare Encounters in Hurricane Aftermath
Use external cause codes to identify causes of injuries from hurricanes.
Sequence hurricane code before other external causes unless abuse/terrorism is involved.
Z Codes
Used to explain reasons for healthcare encounters not classified as diseases (e.g., homelessness, poverty).
Conclusion
Completion of Part B of the 2024 ICD-10-CM guidelines.
Next video will cover Part C, chapter-specific guidelines.
Questions can be directed to
[email protected]
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