Chapter

4
Introduction to ICD-10-CM

International Classification of Diseases, tenth revision, Clinical For example, a patient complains of left wrist pain and a
Modification (ICD-10-CM) classifies patient morbidity and provider takes a wrist X-ray, which is negative for fracture.
mortality information for statistical purposes. It also provides When the claim is submitted, the payer needs to know why
a basis for indexing health records by diseases and procedures the service was performed; that is the diagnosis (ICD-10-CM)
for data storage and retrieval. The ICD-10-CM code(s) listed code. In the example here, a code for wrist pain is reported
with a patient encounter explain why a patient had services (for with the wrist X-ray to support medical necessity for the
example, a nebulizer treatment for asthma, a biopsy for a skin service. Proper ICD-10-CM code selection will be discussed
lesion, an X-ray for a radial fracture, etc). ICD-10-CM codes are later in this chapter.
up to seven alpha and numeric characters in length. In 1988,
the Medicare Catastrophic Coverage Act required appropriate
Billing Tip
diagnosis codes to be submitted with Medicare Part B claims.
Although later repealed for the most part, diagnosis codes are When submitting the primary diagnosis code, it is important to
still required for Medicare claims. ICD-10-CM is based on the review other ICD-10-CM codes listed on the claim form and, if
official version of the World Health Organization’s (WHO) necessary, pertinent medical records. Other ICD-10-CM codes
tenth revision of the International Classification of Diseases. assigned to the encounter may provide additional information
Prior to October 1, 2015, codes from the ninth revision, ICD- supporting treatment. For example, the primary reason for a
9-CM, were used. WHO no longer maintains ICD-9-CM. visit may be headaches, but the patient also has urinary urgency
Updates to ICD-10-CM are published in October of each year. which supports the medical necessity of a urinalysis. Headache
is the primary diagnosis for the office visit and urinary urgency is
Correct coding facilitates the payment of services, tracks
the diagnosis attached to the urinalysis. Some insurance carriers
healthcare usage, predicts trends, aids patient care and
will only review the first diagnosis attached to each procedure
advances research. The diagnosis codes should be reported to
code.
the highest level of specificity and reflect the information in
the patient record. The entire record must be reviewed to deter-
mine the specific reasons for the encounter and conditions
treated. ICD-10-CM codes and the medical record collectively This chapter is a high-level overview of the core elements of
provide the logic to support the medical necessity of proce- ICD-10-CM coding. It is expected that the medical biller have
dures performed and services provided. Many payers have a basic understanding of diagnosis coding and how to use
claim edits in their adjudication systems regarding “diagnosis the ICD-10-CM codebook. If more in-depth information is
to procedure codes” relationships. It is important for billers to needed, refer to further in-depth curriculum available from
have access to and be familiar with the specific policies of each AAPC.
payer.

One of the main denials that occur is due to medical neces- Codebook Structure
sity. Any services that are sent to a payer must be justified by The ICD-10-CM codebook has two sections:
presenting the appropriate facts. Payers require that reimburs-
able services be reasonable and medically necessary. They also 1. Alphabetic Index or Index to Diseases and Injuries:
require that the following information be available to deter- Diagnostic terms organized in alphabetic order for the
mine the need for care, if requested: disease descriptions in the Tabular List.

ll Knowledge of the emergent nature or severity of the 2. Tabular List: Diagnosis codes organized in numerical
patient’s complaint or condition order and divided into chapters based on body system
or condition.
ll All signs, symptoms, complaints, or background facts
describing the reason for care
Diagnosis codes are applicable to all healthcare settings unless
ll The facts must be substantiated by the patient’s medical otherwise noted.
record, and that record must be available to payers on
request ICD-10-PCS includes procedure codes, and typically is used
by facilities only. Hospitals use ICD-10-PCS in the outpatient

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Introduction to ICD-10-CM Chapter 4

facility for tracking purposes only; they do not submit claims

using those codes. This guide will focus on the proper use of
Chapter Descriptive Title Code Range
ICD-10-CM only. Coders use the two sections of ICD-10-CM 19. Injury, Poisoning and Certain Other S00-T88
to assign diagnosis codes for services rendered, and to establish Consequences of External Causes
medical necessity to support those services. 20. External Causes of Morbidity V00-Y99
21. Factors Influencing Health Status Z00-Z99
Tabular List of Diseases and Contact With Health Services
The Tabular List of Diseases is a numerical listing that
contains: 21 chapters to classify diseases and injuries by The Tabular List is broken down into three-character code
etiology (cause) or anatomical (body) site, and appendices. The categories (rubrics), with some code categories being complete
topic areas for each are as follows: codes. The code category is followed by a decimal point
followed by up to four additional digits. The fourth, fifth, sixth
Chapter Descriptive Title Code Range and seventh digits may be required.
1. Certain Infectious and Parasitic A00-B99
Diseases Each character for all categories, subcategories, and codes
may be either a letter or a number. Codes can be three, four,
2. Neoplasms C00-D49 five, six, or seven characters. The first character of a category
3. Disease of the Blood and Blood- D50-D89 is a letter. The second and third characters may be either
Forming Organs and Certain numbers or alpha characters. Subcategories are either four or
Disorders Involving the Immune five characters and may be either letters or numbers. Codes
Mechanism are three, four, five, or six characters and the final character
4. Endocrine, Nutritional and Meta- E00-E89 in a code may be either a letter or number. Certain categories
bolic Diseases have a seventh character extension (discussed later in this
chapter). The fourth character in an ICD-10-CM code further
5. Mental, Behavioral and Neurodevel- F01-F99 defines the site, etiology, and manifestation or state of the
opmental Disorders disease or condition. The four character subcategory includes
6. Diseases of the Nervous System G00-G99 the three character category plus a decimal with an additional
character to further identify the condition to the highest level
7. Diseases of the Eye and Adnexa H00-H59
of specificity.
8. Diseases of the Ear and Mastoid H60-H95
Process The fifth or sixth character subclassifications represent the
9. Diseases of the Circulatory System I00-I99 most accurate level of specificity regarding the patient’s
condition or diagnosis. Certain ICD-10-CM categories have
10. Diseases of the Respiratory System J00-J99 applicable seven characters. The applicable seventh character is
11. Diseases of the Digestive system K00-K95 required for all codes within the category, or as the notes in the
Tabular List instruct. The seventh character must always be in
12. Diseases of the Skin and L00-L99
the seventh position. If a code is three, four, or five characters,
Subcutaneous Tissue
but requires a seventh character extension, a placeholder X
13. Diseases of the Musculoskeletal M00-M99 must be used to fill the empty characters.
System and Connective Tissue
14. Diseases of the Genitourinary system N00-N99 Example
15. Pregnancy, Childbirth, and the O00-O9A
Puerperium Code J42 Unspecified chronic bronchitis does not break down
any further. J44 Other chronic obstructive pulmonary disease
16. Certain Conditions Originating in P00-P96 is a code category and must have a fourth character to be a
the Perinatal Period complete code, including:
17. Congenital Malformations, Q00-Q99 J44.0 Chronic obstructive pulmonary disease with acute lower
Deformations, and Chromosomal respiratory infection
Abnormalities
J44.1 Chronic obstructive pulmonary disease with (acute)
18. Symptoms, Signs and Abnormal R00-R99
exacerbation
Clinical and Laboratory Findings,
not elsewhere classified J44.9 Chronic obstructive pulmonary disease, unspecified.

58 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

There are symbols throughout the Tabular List to identify when a In the process of finding a code in the Index to Diseases, it
code requires an additional character. is important to figure out the main term. It is almost never a
body part or an adjective. For example, if a patient has leg pain,
the main term is pain, not leg. If the term leg is referenced first
in the Index to Diseases, it indicates:
Example
Leg—see condition
F01 Vascular Dementia
When the term Pain is referenced in the Index to Diseases,
H21.4 Pupillary membranes though, there are three columns of subterms, including:
I87.00 Postthrombotic syndrome without complications
Pain(s) (see also Painful) R52
O32.0 Maternal care for unstable lie
abdominal R10.9
colic R10.83
generalized R10.84
Index to Diseases and Injuries (Alphabetic Index) with acute abdomen R10.0
The Index to Diseases and Injuries is an alphabetic listing of lower R10.30
diseases, conditions, and injuries along with their accompa-
nying codes. It is used as a guide in finding the correct codes. In order to find a code, both the Index and the Tabular List
must be used. First, locate the main term in the Index to
The Index has four distinct divisions: Diseases, then drop down to the subterm, and see what code(s)
: Alphabetic Index to Diseases and Injuries (Table ofNeoplasms it lists. Then, the Tabular List is referenced with the code
listed in the Index to Diseases. Any instructional notes in the
Table of Drugs and Chemicals (includes extensive list of drugs, category should be reviewed and followed, and a final code
industrial solvents, corrosive gases, noxious plants, pesticides, should be selected. A code should never be chosen by the Index
and other toxic agents to identify poisonings and external to Diseases alone, It is imperative that the Tabular List is refer-
causes of adverse effects) enced for guidance on the use of additional digits, alternative
codes, additional codes, or sequencing instructions.
External Cause of Injuries Index (includes codes and terms
that describe environmental circumstances such as accidents
or acts of violence and other conditions which may be the Example
cause of injury or other adverse effects)
A patient is diagnosed with arteriosclerosis with chronic
Main terms in the Index to Diseases usually reference the total occlusion of the coronary artery. When the main term
disease, condition, or symptom. Subterms modify the main Arteriosclerosis is referenced in the Index to Diseases, and then
term to describe differences in site, etiology, or clinical type. the subterms coronary (artery) which sends the user to I25.10.
Subterms add specificity to the main term. In the Tabular List, codes in category I25 are instructed to Use
additional code to identifychronic total occlusion of the coronary
artery with code I25.82. If the Tabular List was not referenced, the
Example additional code would probably be coded.
Lesion(s) (nontraumatic)
abducens nerve (see Strabismus, paralytic, sixth nerve)
alveolar process K08.9 Tables
The Index contains three tables with which the biller should be
angiocentric immunoproliferative D47.Z9 familiar: the, Neoplasm Table, the Table of Drugs and Chemi-
anorectal K62.9 cals, and the Index to External Causes.
In this example, the subterms abducens nerve, alveolar process, The Neoplasm Table identifies neoplasms by behavior (benign,
angiocentric immunoproliferative, and anorectal further define malignant, secondary, carcinoma in situ, uncertain, or unspec-
the type of lesion. ified) and by anatomical location.

The correct code selection is driven by the behavior of the

neoplasm documented in the medical record. If malignant, it is
important to determine whether there is a secondary (meta-

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Introduction to ICD-10-CM Chapter 4

static) site. In sequencing neoplasm codes, first determine Billing Tip

whether the neoplasm treated on the day of the encounter is
primary or secondary and the location of the tumor treated. ICD-10-CM contains Z codes to indicate when the reason for
If the treatment is directed at a metastasis, it is appropriate admission is radiotherapy, chemotherapy, or immunotherapy.
to report the secondary site as the principal diagnosis. Billers When the patient is seen solely for the administration of chemo-
should refer to the Index to Diseases for additional guidelines. therapy, immunotherapy or radiation therapy, the appropriate Z
code should be reported as the primary diagnosis, followed by
Malignant is a severe form of neoplasm having the property the ICD-10-CM code for the malignancy.
for destructive growth and metastasis.
Malignant Primary describes the site of the original cancer.
Malignant Secondary describes a cancer that has Example
metastasized.
Carcinoma in situ (Ca in situ) describes a neoplasm that is Z51.0 Encounter for antineoplastic radiation therapy
contained within the original site or location. C01 Malignant neoplasm, base of tongue
Benign describes a neoplasm that does not undergo
metastasis.
Uncertain behavior indicates microscopy was unable to The Table of Drugs and Chemicals is a table that contains
determine the pathology of the neoplasm. a classification of drugs and other chemical substances to
identify poisoning states and external causes of adverse effects.
Unspecified behavior indicates documentation has insuffi- Poisonings can be any of the following:
cient data to be able to categorize the neoplasm.
Accidental overdose of a drug
Radiation therapy or chemotherapy treatment encounters for Wrong substance taken or given
neoplasms are reported using Z codes.
Drug taken inadvertently
Accident in usage of drug
Suicide attempt
Assault
An adverse effect is when a correct substance is properly
administered in therapeutic or prophylactic dosage and the
patient has a reaction.

Below is a portion of the Neoplasm Table:

Malignant Malignant Ca in situ Benign Uncertain Unspecified

Primary Secondary Behavior Behavior
lung C34.9- C78.0- D02.2- D14.3- D38.1 D49.1
azygos lobe C34.1- C78.0- D02.2- D14.3- D38.1 D49.1
carina C34.0- C78.0- D02.2- D14.3- D38.1 D49.1
hilus C34.0- C78.0- D02.2- D14.3- D38.1 D49.1
lingula C34.1- C78.0- D02.2- D14.3- D38.1 D49.1
lobe NEC C34.9- C78.0- D02.2- D14.3- D38.1 D49.1

When documentation indicates a personal history of malignancy, but does not indicate current treatment, it is appropriate to code
the encounter with a history code, such as, Z85.9, Personal history of malignant neoplasm, unspecified.

60 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

Below is a portion of the Table of Drugs and Chemicals.

External Cause
Poisoning, Poisoning, Poisoning, Poisonig, Adverse Under-
Accidental Intentional Assault Undetermined Effect dosing
(unintentional) self-harm
Amitriptyline T43.011 T43.012 T43.013 T43.014 T43.015 T43.016
Amitriptylinoxide T43.011 T43.012 T43.013 T43.014 T43.015 T43.016
Amlexanox T48.6X1 T48.6X2 T48.6X3 T48.6X4 T48.6X5 T48.6X6
Ammonia (fumes)(gas)(vapor) T59.891 T59.892 T59.893 T59.894 ------ ------
aromatic spirit T48.991 T448.992 T48.993 T48.994 T48.995 T48.996
liquid (household) T54.3X1 T54.3X2 T54.3X3 T54.3X4 ------ ------
Ammoniated mercury T49.0X1 T49.0X2 T49.0X3 T49.0X4 T49.0X5 T49.0X6
Ammonium
acid tartrate T49.5X1 T49.5X2 T49.5X3 T49.5X4 T49.5X5 T49.5X6
bromide T42.6X1 T42.6X2 T42.6X3 T42.6X4 T42.6X5 T42.6X6
carbonate T54.3X1 T54.3X2 T54.3X3 T54.3X4 ------ ------

ICD-10-CM Conventions NOS = “Not otherwise specified”

This abbreviation is the equivalent of ‘unspecified’ and is used
The ICD-10-CM codebook has established conventions for ease
only when the coder lacks the information necessary to code to
of reading, explanation, and use. “Official” and “Additional”
a more specific code.
Conventions are located in the introduction section of the
book, most of which are used in the ICD-10-PCS book as well.
Section I of the Official ICD-10-CM Guidelines for Coding and Example
Reporting includes instructions for the conventions, general
coding guidelines, and chapter specific guidelines. Most of the The provider documents the patient has hypotension. When the
conventions will be found in the Tabular List, but some apply main term Hypotension is referenced in the Index to Diseases, it
to the Index to Diseases. A biller needs to understand how to leads the user to code I95.9, Hypotension, unspecified.
apply the conventions in order to ensure that the proper codes
were reported on the claim in the proper order.

NEC = “Not elsewhere classifiable” Billing Tip

This abbreviation is used when the ICD-10-CM system does With the advent of ICD-10-CM, some payers may refuse to pay
not provide a code specific for the patient’s condition. Selecting unspecified codes. It may be necessary to review the documen-
a code with the NEC classification means that the provider tation and/or query the provider when the code is unspecified if
documented more specific information regarding the patient’s such a denial is received.
condition, but there is not a code in ICD-10-CM to report the
condition accurately.

Example Punctuation:
Brackets [ ] are used in the Tabular List to enclose synonyms,
The provider documents a patient has a congenital cyst. When explanatory phrases, or alternate wording
the main term Cyst is referenced in the Index to Diseases with
the subterm congenital NEC, it leads the user to code Q89.8 Other
specified congenital malformations. Example
B20 Human immunodeficiency virus [HIV] disease

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Introduction to ICD-10-CM Chapter 4

[ ] Brackets are used in the Alphabetic Index to identify mani- Example

festation codes.
N40 Enlarged prostate
Example adenofibromatous hypertrophy of prostate
benign hypertrophy of the prostate
Hepatitissyphilitic (late) A52.74congenital (early) A50.08 [K77]
benign prostatic hyperplasia
late A50.59 [K77]
benign prostatic hypertrophy
In this example, two codes are required to accurately report BPH
congenital syphilitic hepatitis: A50.08 Early visceral congenital
nodular prostate
syphilis and K77 Liver disorders in diseases classified elsewhere.
( ) Parentheses are used in both the Alphabetic Index and Tabular polyp of prostate
list to enclose supplementary words that may be present or INCLUDES Benign neoplasms of prostate (adenoma, benign)
absent in the statement of a disease or procedure, without (fibroadenoma) (fibroma) (myoma) (D29.1)
affecting the code number to which it is assigned. The terms in
the parentheses are referred to as nonessential modifiers. EXCLUDES Malignant neoplasm of prostate (C61)
In this example, a diagnosis of BPH is included in category N40
because it is listed by the Includes icon. A diagnosis of a benign
neoplasm of the prostate is coded to D29.1 according to the
Example Excludes1 note, and is not coded with codes from category N40.
If the patient had both an enlarged prostate and a malignant
Cyst (colloid) (mucus) (simple) (retention)In the Conventions
neoplasm of the prostate, both are coded, but if the patient only
section at the front of the book there are important instructional
had a malignant neoplasm of the prostate, only C61 is reported
notes listed that will help a biller ensure that the appropriate
according to the Excludes2 note.
codes have been chosen.
Includes Notes: This note apears immediately under a three char-
acter code title and provides further definition or gives examples. Sequencing instructions are also given in this section In the
Excludes Notes: there are two types of excludes notes. Each type Etiology/Manifestation Convention (“code first”, “use addi-
of note has a different definition for use. They are similar in tht tional code” and “in diseases classified elsewhere” notes).
they indicate that codes excluded from each other are Indepen- Certain conditions have both an underlying etiology and
dent of each other. multiple body system manifestations due to the underlying
etiology. In these cases, ICD-10-CM has a coding convention
INCLUDES A type 1 excludes note represents that the condi- that requires the underlying condition be sequenced first,
tion is not coded here. This note indicates that followed by the manifestation. Instructional notes are some-
the code excluded should never be used at the times used for these situations.
same time as the code above the Excludes1 note.
An Excludes1 note indicates when two conditions Code first
cannot occur together, such as a congenital form This notation is used in categories not intended to be the
versus an acquired form of the same condition. principal diagnosis. These codes are written in italics with a
Conditions listed with Excludes1 are mutually note. The note requires that the underlying disease (etiology)
exclusive. It means “NOT CODED HERE!” be recorded first, and the particular manifestation be recorded
EXCLUDES A type 2 excludes note represents that the condi- second. The “Code first” note will only appear in the Tabular
tion is not included here. A type 2 excludes note List. This is why it is important to always verify codes in the
indicates that the condition excluded is not part Tabular List to assure proper code sequencing.
of the condition represented by the code, but a
patient may have both conditions at the same
time. When a type 2 excludes note appears under
a code, it is acceptable to use both the code and
the excluded code together. It means “Not included
here”.

62 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

Example Look up the main term in the Index to Diseases. The main
term is the disease, illness, or condition of the patient.
D63.0 Anemia in neoplastic disease
Code first neoplasm (C00-D49) Examples
The Code first note indicates the codes listed should be
sequenced first. If a female patient with right breast cancer has Diagnosis: Acute maxillary sinusitis Main term: sinusitis
anemia due to the cancer, the proper codes and sequencing are Diagnosis: Left knee pain Main term: pain
C50.911, D63.0. Diagnosis: Intrinsic asthma with acute Main term: asthma
exacerbation

Use additional code

This notation is used to indicate that an additional code is There may be additional descriptive terms that affect code
needed to provide a more complete picture of the diagnosis, selection such as chronic or acute. All subterms should be
such as a manifestation. This notation indicates that the code(s) reviewed to determine the most specific code. All “see” and
listed should be coded as additional (secondary) codes. “see also” notes should be reviewed.

Example The code referenced in the Index to Diseases should be

looked up in the Tabular List. All the “includes,” “excludes1,”
D70 Neutropenia “excludes2” and “use additional code” notations should be
reviewed to verify accuracy of the code. The notations and
INCLUDES agranulocytosis
conventions in the ICD-10-CM codebook provide hints to the
decreased absolute neurophile count (ANC)
biller when a more appropriate code should be reported. Infor-
Use additional code for any associated: mation also is provided when more than one code is required
fever (R50.81) to report a diagnosis accurately.
mucositis (J34.81, K12.3-, K92.81, N76.81)

Examples of Additional Conventions

used the the Tabular List are:

ll Sex edits using symbols for male and female

ll Age edits using letters A=Adult (18–124); M=Maternity
(12–55 years); N=Newborn 0 years and P=Pediatric (0–17
years)
ll Principle Diagnosis Flags used are, blue highlighting
for Manifestation code/not principal diagnosis and grey
highlighting for Other Specified Code

Examinees taking the CPB® exam are expected to be familiar

with these and other conventions noted in the codebook to
accurately identify correct use of the ICD-10-CM codes.

Steps to Look up a Diagnosis Code

Determine the main term of the diagnosis documented in
the medical record. This information usually is found in the
assessment and plan for the patient’s care, or operative reports,
progress notes, encounter form, billing form, or procedure
notes. A coder must have a solid foundation in medical
terminology and anatomy to effectively review the medical
record and determine the documented diseases/conditions that
should be reported.

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Introduction to ICD-10-CM Chapter 4

Section Review 4.1

1. Which of the following is not a table in ICD-10-CM?

A. Table of Drugs and Chemicals

B. Index of External Causes of Injury
C. Neoplasm Table
D. Hypertension Table

2. If a patient has acute diastolic heart failure, what is the main term that is used in the Index to Diseases?

A. Heart
B. Acute
C. Failure
D. Diastolic

3. Which sections of ICD-10 does a biller use to code for a physician’s office?

A. Index to Diseases and Injuries, Tabular List

B. Index to Diseases and Injuries only
C. Tabular List only
D. ICD-10-CM and ICD-10-PCS

4. In looking at the following listing in the Index to Diseases, what can you tell about the codes for curvature of the spine due
to Charcot-Marie-Tooth disease?

Curvature
spine (acquired) (angular) (idiopathic) (incorrect) (postural) see Dorsopathy, deforming
due to or associated with
Charcot-Marie-Tooth disease (see also subcategory M49.8) G60.0

A. Only one code is required G60.0

B. Two codes are required with a code from subcategory M49.8coded first
C. Two codes are required and it does not matter which one is coded first
D. Two codes may be required, double check the Tabular List to be sure on both codes

64 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

5. In looking at the notes with this code, which statement is TRUE?

K67 Disorders of peritoneum in infectious diseases classified elsewhere
Code first underlying disease, such as:
Congenital syphilis(A50.0)
helminthiasis (B65.0-B83.9)
Excludes1: peritonitis in chlamydia (A74.81)
peritonitis in diphtheria (A36.89)
peritonitis in gonococcal (A54.85)
peritonitis in syphilis (late) (A52.74)
peritonitis in tuberculosis (A18.31)
A. Code K67 may be a first-listed code
B. Code K67 may be coded with code A74.81
C. Code K67 may never be coded with codes A74.81, A36.89, A54.85, A52.74 and A18.31
D. Code K67 is a secondary code with codes A74.81, A36.89 or A52.74 being coded first

ICD-10-CM Official I.C.2.b is referencing the following guideline on treatments of

secondary sites:
Guidelines for Coding and Reporting
CMS and NCHS provide the ICD-10-CM Official Guidelines When a patient is admitted because of a primary neoplasm
for Coding and Reporting. These guidelines are found in the with metastasis and treatment is directed toward the
front of the ICD-10-CM codebook. The guidelines provide secondary site only, the secondary neoplasm is designated as
instructions for proper code selection, and code sequencing the principal diagnosis even though the primary malignancy is
rules. Section I of the official guidelines includes conventions, still present.
general coding guidelines, and chapter specific guidelines.
Subsection A includes the conventions and punctuation
discussed in the beginning of this chapter. Subsection B
Section I. B. General Coding Guidelines
includes general coding guidelines. Section C includes chapter
specific coding guidelines. A biller should be familiar with the
Use Both Index to Diseases and Tabular List
location of these and how to apply them. Always use both the Tabular List and theIndex to Diseases and
Injuries (Alphabetic Index). Verify the code number in the
Tabular List. Never code directly from the Index to Diseases
Referencing the Guidelines and Injuries because important instructions often appear in
Documenting the guidelines is done by referencing the section, the Tabular List.
chapter, and section of the guidelines being referred to. To
understand the reference to the guidelines, start by looking
through the Table of Contents for the guidelines provided at
Locate Each Term in the
the beginning of the ICD-10-CM codebook. For example, a Index to Diseases and Injuries
documented reference appears as Section I.C.2.b. 1. Locate the main term in the Index to Diseases and
Injuries.
This indicates the guideline is found in:
Section I. C
 onventions, general coding guidelines and 2. Refer to any notes under the main term.
chapter specific guidelines
3. Read any terms enclosed in parentheses following the
Section I.C. Chapter-Specific Coding Guidelines main term.
Section I.C.2. Chapter 2: Neoplasms (C00-D49)
4. Refer to any modifiers of the main term.
Section I.C.2.b. Treatment of secondary site
5. Do not skip subterms indented under the main term.

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Introduction to ICD-10-CM Chapter 4

6. Follow any cross-reference instructions, such as “see test results, or other reason(s) for the encounter. Do not code
also.” from this section when the symptom is considered an integral
part of the disease process.
7. Use of a medical dictionary can help you to identify
main terms and understand the disease process to assist
with accurate coding. Example
A physician documents “Cough, fever—Rule out pneumonia” on
Example a patient. In this instance, cough and fever are reported as the
diagnoses because the physician has not confirmed the patient
ESRD: This acronym is not found in the ICD-10-CM Index to has pneumonia.
Diseases. A medical abbreviations dictionary can tell you that R05 Cough
ESRD is end stage renal disease (a condition of the kidneys). With
this information, the coder/biller will be able to identify properly R50.9 Fever, unspecified
the main term in the Index to Diseases. In the index, ESRD can
be found under the main term Disease, then the sub-term renal,
and the sub-term end-stage. The correct code isN18.6, End-stage In the inpatient setting for facility diagnosis coding, it is
renal disease. appropriate to report suspected or rule out diagnoses as if the
Disease condition does exist. This is only true for facility reporting for
inpatient services, for all diagnoses except HIV. HIV is the only
renal condition that must be confirmed if it is to be reported in the
end-stage N18.6 inpatient setting.

In searching the Index to Diseases, if you start with the wrong

main term, you may be directed to the correct term. For example, Conditions That Are Not an
if you looked under the main term “Renal,” there is a note Integral Part of the Disease Process
informing you to “see condition.” This notation instructs you to Codes for signs and symptoms that are not routinely associated
look under the condition, not the anatomic site. with other definite diagnoses should be reported.
When trying to determine the main term, it is sometimes helpful
to read the diagnosis right to left. For example, End-stage renal Example
disease can be found by looking under Disease/renal/end-stage.
A patient presents with nasal congestion and facial pain. The
provider diagnoses the patient with acute frontal sinusitis. The
patient also complains of constipation. In this example, a code
Level of Detail in Coding is selected for the acute sinusitis and the constipation. The nasal
Code to the highest degree of specificity. There are valid three- congestion and facial pain are symptoms of the acute sinusitis
character codes, but these codes may be used only when the (J01.10) and are not reported. Constipation (K59.00) is not typically
category is not subdivided further. When a three-character related to the sinusitis, and is reported separately.
code has subdivisions, the appropriate subdivision must be J01.10 Frontal acute sinusitis
coded. There are symbols to alert the coder/biller when an
additional character is required. K59.00 Constipation, unspecified
To locate the codes, look in the Index to Diseases for the main
Signs and Symptoms term Sinusitis, the subterm acute, then the subterm frontal.
You are directed to J01.10. Verify the code in the Tabular List.
Signs, symptoms, and ill-defined conditions may be coded in
Then, look in the Index to Diseases for Constipation and you are
the medical record in the absence of a definitive diagnosis.
directed to K59.00. Verify the code in the Tabular List.
Codes from chapter 18 are considered ‘general’ signs and
symptoms. The use of codes from this section (R00-R99) may
be appropriate to use when a more specific diagnosis cannot be
made even after additional review of the patient’s condition has
been conducted. Probable, suspected, questionable or rule out
Multiple Coding for a Single Condition
diagnoses should never be coded or reported in the outpatient Multiple coding of diagnoses is required for certain conditions
setting. The condition should be coded that most accurately not subject to the rules for combination codes. Some instances
describes the encounter such as signs, symptoms, abnormal of multiple codes were discussed earlier with “use additional
code” and “code first” notations. Multiple coding is indicated

66 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

in the Index to Diseases and Injuries by listing two codes with Sequela (Late Effects)
the second code in brackets, [ ]. Both codes are assigned in the
A sequela (late effect) is the residual effect or condition
sequence they are listed in the Index. In the Tabular List, the
produced after the acute portion of an injury or illness has
instructional notes above are followed. When a “code first”
terminated. Key phrases such as “due to an old injury” or
note is seen, it indicates that another code is the first-listed
“due to previous illness” are indicators that the problem or
code. When a “use additional code” note is seen, it indicates
condition may be a sequela. If these indicators are not present
that a secondary code is necessary.
in the diagnostic statement, the injury or condition may be
considered a sequela if sufficient time has elapsed between
Combination Code the original condition and sequela. There is no time limit on
A combination code is used to fully identify an instance when a late effect code can be used. The residual effect may
in which two diagnoses, or a diagnosis with an associated be apparent early after an acute phase of an illness, as in a
secondary process (manifestation) or complication, are cerebrovascular accident, or it may occur much later (one year
included in the description of a single code number. Assign a or more), as with a previous injury or illness (eg, following an
combination code only when that code fully identifies the diag- auto accident).
nostic conditions involved, or when instructed in the Index to
When a patient is being treated for a condition that is a “late
Diseases and Injuries.
effect” of an earlier injury or disease, reference the main
term “sequelae” from the Alphabetic Index.Sequelae should
Example be coded according to the nature of the residual condition of
the late effect. Two codes usually are required when coding
A patient has acute on chronic systolic heart failure. Instead of sequela. The residual condition is coded first, and the code(s)
reporting code I50.21 for acute systolic heart failure and I50.22 for for the cause of the sequelae are coded as secondary. It may
chronic systolic heart failure, the correct code to report is I50.23 be necessary for the biller to go to the Index for External
Acute on chronic systolic (congestive) heart failure. Causes to identify and reference the appropriate late effect of
Look in the Index to Diseases for Failure, failed/heart/systolic/ an external cause. The documentation in the medical record
acute/(and) on chronic (congestive) I50.23. Verify the code in the should support the manifestation or residual effect, as well as
Tabular List. the cause.

The code for the cause of the sequelae may be used as a prin-
cipal diagnosis when no residual diagnosis is identified. The
Acute vs. Chronic code for the acute phase of an illness or injury that leads to the
Codes often differentiate between “acute” and “chronic” late effect is never used with a sequelae code.
manifestations of diseases. “Acute” usually refers to conditions The following examples are sequela and their cause:
that have sudden onset, relatively short duration and expected
ll Limp due to old fracture of the right femur
recovery or improvement. “Chronic” refers to conditions that
are of longer duration and usually do not resolve completely ll Traumatic arthritis following fracture of the right hand

over time. Chronic diseases are often punctuated by acute ll Facial droop following a stroke
exacerbations or episodes of sudden worsening of the chronic ll Scar contracture of the left elbow due to third degree
condition that resolve with intervention leaving the patient at burns
their baseline level.

When a code exists for acute exacerbation of a chronic condi- Example

tion, it is the code reported. For example, J45.901 is used for
asthma with (acute) exacerbation. There are instances when A patient is diagnosed with reflex sympathetic dystrophy in his
a patient will have both the acute form and the chronic form right hand due to an old traumatic fracture of the hand. In this
of a condition and there is not a combination code to report example, the reflex sympathetic dystrophy is the first-listed code,
both the acute and the chronic condition. In this case, the with the fracture of the upper extremity being the secondary
acute code is sequenced first followed by the code for the diagnosis. The codes reported and the sequencing they are
chronic condition. For example, when a patient has both acute reported in are:
and chronic tonsillitis, it is reported as J03.90 Acute tonsillitis
followed by J35.01 Chronic tonsillitis. G90.511 Complex regional pain syndrome I of right upper limb
S62.91XS Unspecified fracture of right wrist and hand, sequela.

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Introduction to ICD-10-CM Chapter 4

Impending or Threatened Condition The BMI and pressure ulcer stage codes should only be
reported as secondary diagnoses. As with all other secondary
When a patient is discharged with a condition described as
diagnosis codes, the BMI and pressure ulcer stage codes should
“impending” or “threatened,” review the Index to Diseases and
only be assigned when they meet the definition of a reportable
Injuries for the sub-term “impending” or “threatened” under
additional diagnosis.
the main term of the condition. If a sub-term does not exist,
reference “impending” or “threatened” as the main term, with
the condition as a sub-term. If a suitable code does not exist, Example
report the signs and symptoms that led the provider to suspect
an impending or threatened condition. A patient with a BMI of 39.8 has a stage 3 pressure ulcer on her
right buttock. The correct codes are L89.313 Pressure ulcer, right
buttock, stage 3 and Z68.39 Body Mass Index 39.0-39.9 adult.
Example
A pregnant patient is seen complaining of bloody discharge. She
is admitted with a diagnosis of threatened abortion. When the
main term “Threatened” with the sub-term “Abortion” is refer-
Syndromes
enced in the Alphabetic Index it sends the user to code O20.0. When coding syndromes, if the syndrome is not located in
Since a code is listed, the sign/symptom of bloody discharge is the Alphabetic Index, code the patient’s signs and symptoms.
not coded. For example, a patient is diagnosed with Alstrom syndrome
(a rare genetic disease). From the Alphabetic Index, look for
Syndrome/Alstrom, which does not have a listing. There also is
no listing for Alstrom in the index. Review the documentation
Reporting Same Diagnosis Code More than Once to report the patient’s signs and symptoms.
Do not report the same diagnosis code more than once. There
will be instances when a provider will document a bilateral General Coding Practices
condition, or two different conditions reported with the same The ICD-10-CM codebook contains numerous general and
diagnosis code. When either situation occurs, report the specific practices for successful coding. Medical billers
unique ICD-10-CM code just once. preparing and reviewing claims must be familiar with appro-
priate practices to bill accurately on behalf of a physician’s
ICD-10-CM allows for the reporting of laterality (right, left,
office or other medical entity. The following are a few examples
bilateral). For bilateral sites, the final character of the code
of coding practices that should be utilized and reflected on
indicates laterality. An unspecified side code is also provided
claims submitted to payers.
should the side not be identified in the medical record. If no
bilateral code is provided and the condition is bilateral, assign
separate codes for both the left and right side. Documentation of Complications of Care
Not all conditions that occur during or following surgery or
For example, if a patient complains of pain in his right and left
other medical care are classified as complications of care. To
leg. There are codes to distinguish between the right and left
code a complication of care, there must be a cause-and-effect
leg. Code M79.604 Pain in right leg and M79.605 Pain in left leg
relationship between the care provided and the condition
are both reported.
that the patient has contracted due to the surgery or medical
care. The provider must also specifically document that the
Documentation of BMI and Pressure Ulcer Stages condition is a complication.
Codes for body mass index (BMI) and pressure ulcer stage
External Causes of Morbidity (V00-Y99)External cause codes
codes can be reported based on documentation from any
are supplemental to the diagnosis codes in chapters 1–19
clinician involved in the patient’s case. For example, a
of ICD-10-CM. The external causes of morbidity provide
nurse caring for the patient’s pressure ulcer will provide
information on how the injury happened (cause), the intent
documentation needed to determine the proper stage of a
(unintentional or accidental; or intentional, such as suicide
pressure ulcer. However, the patient’s provider must document
or assault), the person’s status (eg, civilian, military), the
the underlying condition, such as diabetes or obesity. If there
associated activity, and the place where the event occurred.
is conflicting medical record documentation, either from the
same provider or different providers of service, the patient’s External cause codes are supplemental. They are never
attending provider should be queried for clarification. sequenced first. Report all external cause codes needed to
explain the external causes. Place of occurrence codes are
reported to identify where an injury occurred such as in the

68 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.
Chapter 4 Introduction to ICD-10-CM

patient’s home or at a baseball field. External cause codes are routine physical, screening mammogram) to report a specific
used for the length of treatment only if required by the payer. type of care (eg, physical therapy, chemotherapy) or to identify
The activity code, place of occurrence code, and activity status the status of the patient that may affect the management of
code are only reported on the initial treatment, not subsequent care (eg, family history of colon cancer). A Z code is always the
treatment. first listed code to report a newborn birth status.

Z codes can be used in any healthcare setting. They can

Factors Influencing Health Status and be sequenced as primary or secondary codes. There is a
list of all the Z codes that can only be reported as the first
Contact with Health Services (Z00-Z99) listed diagnosis. The complete list can be found in Section
Not all patient encounters are for a problem or condition. I.C.21.c.16., Z Codes That May Only be Principal/First-Listed
Chapter 21 of ICD-10-CM includes codes reported to identify Diagnosis, in the Official Coding Guidelines. Z codes are
the reason why the patient is receiving services when a disease divided into sixteen categories. Using the titles of the following
or disorder is not the reason the services are rendered. Codes Z categories is helpful when locating terms in the Index to
in this chapter are referred to as Z codes. Z codes are reported Diseases and Injuries.
when the patient is not sick and presents for specific care (eg,

Section Review 4.2

1. What are the correct code for a patient with type 1 diabetic neuropathy?

A. E11.40
B. E90.40
C. E10.9, G62.9
D. E10.40

2. How many chapters does ICD-10-CM contain?

A. 17
B. 19
C. 21
D. 20

3. What general guideline is addressed in I.C.1.a.2.c?

A. Documentation unclear as to whether sepsis or severe sepsis is present on admission

B. Other codes for MRSA
C. Whether the patient is newly diagnosed
D. Code only confirmed cases

4. What are the correct codes for benign hypertensive heart disease and stage 3 chronic kidney disease?

A. I10, I11.9, I12.9, N18.3

B. I13.10, N18.3
C. N18.3, I13.10
D. I13.0, N18.3

CPT ® copyright 2015 American Medical Association. All rights reserved. www.aapc.com 69
Introduction to ICD-10-CM Chapter 4

5. What is/are the correct code(s) for a patient with acute on chronic maxillary sinusitis?

A. J01.00, J32.0
B. J01.00
C. J32.0, J01.00
D. J01.01

Glossary
Acute—A condition with a rapid and short course. Nonessential Modifiers—Subterms that follow the main term
and are enclosed in parentheses; they can clarify the diagnosis
Anatomical—Body site. but are not required.
And—Can mean either “and” or “or” when it is in the code NOS—Not otherwise specified.
description.
Parentheses ( )—Symbol to enclose supplementary words
Brackets [ ]—Symbol to enclose synonyms, alternate wording, that may be present or absent in the statement of a disease or
or explanatory phrases. procedure, without affecting the code number to which it is
assigned.
Chronic—A condition that develops slowly and lasts a long
time. See Also—Note in the Index to Diseases that indicates
additional information is available that may provide an
Combination Code—Single code used to classify two
additional diagnostic code.
diagnoses.
See—Note in the Index to Diseases that directs you to a more
External Codes—Codes reported to identify how an injury
specific term under which the correct code can be found.
occurred and the location of where it occurred.
Sequela—An inactive, residual effect or condition produced
Etiology—Cause of the disease.
after the acute portion of an injury or illness has passed.
Eponym—Disease or syndrome named after a person.
Tabular List—Diagnosis codes organized in numerical order.
Essential Modifiers—Subterms that are listed below the main
Unspecified—Codes are used when the information in the
term in the alphabetical order, and are indented.
medical record is not available for coding more specifically.
Excludes1—Note in the tabular list to indicate the terms listed
Use Additional Code—Note in the tabular list instructing you
are to be reported with a code from another category.
report a second code, if the information is available, to provide
Excludes2—A type 2 Excludes note indicates that the condi- a more complete picture of the diagnosis.
tion excluded is not part of the condition represented by the
With—Means “associated with” or “due to” in a code title in
code, but a patient may have both conditions at the same time.
the Index to Diseases or an instructional note in the Tabular
When a type 2 Excludes note appears under a code, it is accept-
List.
able to use both the code and the excluded code together.
Z Codes—Codes used to describe circumstances or conditions
Includes—Note in the tabular list under a three digit category
that could influence patient care.
title to define further, or to give an example of the contents of
the category.

Index to Diseases and Injuries—Diagnosis codes organized in

an Alphabetic Index.

NEC—Not elsewhere classified.

70 2016 Medical Billing Training: Certified Professional Biller (CPB™) CPT ® copyright 2015 American Medical Association. All rights reserved.