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:
  1. Locate the main term in the Alphabetic Index.
  2. Verify the code in the Tabular List.
  3. 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].