Understanding ICD-10-CM Coding Guidelines for 2024

ICD-10-CM Guidelines FY2024 (cms.gov) Diagnosis Coding Diagnosis codes are alphanumeric codes that describe medical terminology for diseases, disorders, or other medical conditions affecting the patient. Proper diagnosis coding involves using the ICD-10-CM classification to choose the right codes for diseases, disorders, or other medical conditions affecting the patient based on documentation in his or her medical record and assigning those codes correctly on claims. When providers report diagnosis codes on claims, the MAC uses the codes to decide coverage, not the amount CMS will pay for covered services. Next, let's review using diagnosis codes on claims. To submit valid claims, you must code them correctly. Use current, valid diagnosis codes and code them to the highest level of specificity available. You must send claims electronically, except in limited situations. Visit the Administrative Simplification Compliance Act (ASCA) Self Assessment webpage for more information on when you may submit paper claims. Health care providers and suppliers use Form CMS-1500 or its electronic equivalent to bill MACs. Institutional providers use Form CMS-1450 or its electronic equivalent to bill MACs. Visit the CMS Forms List webpage to download the paper forms. The Medicare Learning Network® (MLN) offers these MLN WBT resources that supply information on claims requirements for coding diagnoses and the claim fields for reporting diagnosis codes: § Medicare Billing: 837P & Form CMS-1500 WBT § Medicare Billing: 837I & Form CMS-1450 WBT

Background Next, let’s go over a few ICD-10-CM/PCS basics. ICD-10 is a classification system that consists of 2 parts: § ICD-10-CM § ICD-10-PCS Physicians, non-physician practitioners, outpatient facilities, and outpatient hospital departments use and report Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes and modifiers for physician services on Medicare Fee-for-Service claims for outpatient services. ICD-10-CM ICD-10-CM includes clinical detail, specificity, and terminology consistent with current practice. In addition, ICD-10-CM codes have the potential to reveal more about quality of care, so that data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms, and better track the outcomes of care. The classification system offers enhanced data for: § Measuring the quality, safety, and efficacy of care § Reducing the need for attachments when processing claims to explain the patient's condition § Designing payment systems and processing claims for payment § Conducting research, epidemiological studies, and clinical trials § Setting health policy The classification system also offers enhanced data for: § Operational and strategic planning § Designing health care delivery systems § Managing resource use

§ Improving clinical, financial, and administrative performance § Preventing and detecting health care fraud and abuse § Tracking public health and risks Unspecified codes are available for use when there isn’t enough information in the medical record to assign a more specific code. ICD-10-CM Structure ICD-10-CM diagnosis codes: □ Codes may be 3-7 characters long □ First character is always alphabetic □ Second character is always numeric □ Characters 3-7 are alphabetic or numeric □ All letters of the alphabet are used. The first character U is reserved for special purposes □ A decimal point is placed after the third character □ The first 3 characters make up the code category □ Code extension for the 7th character offers further specificity and used primarily in the Obstetrics, Injuries, and Poisoning chapters □ Dummy placeholder (X) is used to fill in any empty characters to make a complete code. assignment and also reserve space for future code expansion The ICD-10-CM includes the following sections: § Official Guidelines for Coding and Reporting § Alphabetic Index to Diseases and Injuries (Alphabetic Index)

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§ Table of Neoplasms § Table of Drugs and Chemicals § External Cause of Injuries Index § Tabular List of Diseases and Injuries (Tabular List) Where to Find ICD-10-CM Codes & Guidelines ICD-10-CM codes are available in both electronic and hard copy format. You can access the official ICD-10-CM codes electronically on the National Center for Health Statistics (NCHS), CDC website or on the CMS ICD-10 webpage. You can buy hard copy code books from code book publishers. CMS and NCHS offer the ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines are a set of rules they developed to go with the official conventions and instructions within ICD-10-CM. Download and print the ICD-10-CM Official Guidelines for Coding and Reporting from the CMS 2024 ICD-10-CM webpage. The Using the ICD-10-CM job aid includes information on ICD-10-CM coding conventions. To access the job aid, select the Job Aid button or select the Reference button at the top right of any course page. Job Aid

Coding Conventions Next, let's review 7th character, abbreviations, punctuation, and more coding conventions used in ICD-10-CM. 7th Character Certain ICD-10-CM categories have applicable 7th characters. You must use the applicable 7th character for all ICD-10-CM codes within the category or as notes in the Tabular List instruct. The meanings of the 7th character can differ across chapters and categories. Like in the External Cause of Injuries chapters, it identifies an initial encounter, subsequent encounter, or sequela late effect.

The 7th character must always be the 7th character in the data field. When it applies, codes missing this character are invalid. We’ll discuss more about placeholder character X in Lesson 2. > Abbreviations Alphabetic Index □ NEC (Not Elsewhere Classifiable): Represents “other specified”. When a specific code isn't available for a condition, the Alphabetic Index directs you to the other specified code in the Tabular List. When a specific code isn't available for a condition, the Tabular List includes an NEC entry under a code to identify it as the other specified code. □ NOS (Not Otherwise Specified): Is the equivalent of unspecified. Tabular List □ NEC (Not Elsewhere Classifiable): Represents “other specified”. When a specific code isn't available for a condition, the Tabular List includes an NEC entry under a code to identify the code as the other specified code. □ NOS (Not Otherwise Specified): Is the equivalent of unspecified. Punctuation The official guidelines include these 3 punctuation symbols: • ( ) Parentheses: Used in both the Alphabetic Index and the Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it’s assigned. The terms within parentheses are referred to as nonessential modifiers. • [ ] Brackets: Used in the Alphabetic Index to show manifestation codes. Used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases. • : Colons: Used in the Tabular List after an incomplete term that needs 1 or more modifiers following the colon to make it assignable to a given category. More coding conventions include:

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• And: Interpret to mean “and” or “or” when it appears in a code title. • Includes Notes: Appears immediately under a 3- character code title to further define, clarify, or give examples of the content of a code category. • Inclusion Terms: List of terms included under certain codes to show conditions for which that code may be used. The inclusion terms aren't necessarily exhaustive. • Excludes Notes: The ICD-10-CM has 2 kinds of excludes notes. Each kind of note has a different definition for use, but they each show that codes excluded from each other are independent of each other. • Etiology/manifestation convention (code first, use additional code and in diseases classified elsewhere notes): Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For conditions, the ICD-10-CM has a coding convention where the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever this combination exists, there's a use additional code note at the etiology code, and a code first note at the manifestation code. These instructional notes show the proper sequencing order of the codes, etiology followed by manifestation. § With: The words "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, either under a main term or subterm, or an instructional note in the Tabular List. § "See" and "See Also": ○ The "see" instruction following a main term in the Alphabetic Index shows that another term should be referenced. It’s necessary to go to the main term referenced with the see note to locate the correct code. ○ A "see also" instruction following a main term in the Alphabetic Index instructs that there’s another main term that may also be referenced that may show additional Alphabetic Index entries that may be useful. It’s not necessary to follow the "see also" note when the original main term gives the necessary code. § "Code also" note: A "code also" note instructs that 2 codes may be needed to fully describe a condition, but this note doesn’t give sequencing direction. The sequencing depends on the circumstances of the encounter. Key Concepts Key concepts in this lesson:

• ICD-10-CM includes clinical detail, specificity, and terminology consistent with current clinical practice • ICD-10-CM includes the following sections: ○ Official Guidelines for Coding and Reporting ○ Alphabetic Index to Diseases and Injuries ○ Table of Neoplasms ○ Table of Drugs and Chemicals ○ External Cause of Injuries Index ○ Tabular List of Diseases and Injuries • The ICD-10-CM Official Guidelines for Coding and Reporting ○ These guidelines are a set of rules developed to go with the official conventions and instructions within ICD-10-CM • Conventions are the general rules for the classification independent of the guidelines and are incorporated within the Alphabetic Index and Tabular List of ICD-10-CM as instructional notes Course Glossary 6 categories Malignant Categories: ○ Malignant, PRIMARY: Identifies the site of the original neoplasm ○ Malignant, SECONDARY: Identifies a secondary cancerous neoplasm site. Use for all secondary cancers, even if the primary malignancy has been eradicated or treated. ○ Malignant, CA IN SITU: Identifies cancerous neoplasms that are confined or noninvasive Other Categories: ○ Benign: Identifies a neoplasm that’s non-cancerous ○ Uncertain Behavior: The tumor has characteristics of a neoplasm, but there isn’t enough evidence to determine behavior and further investigation is needed ○ Unspecified Behavior: Indeterminate or unknown pathology, or the nature is pending lab results Alphabetic Index to Diseases and Injuries

This is an alphabetical list of ICD-10-CM terms and their corresponding code or category that helps you decide which section to refer to in the Tabular List. It doesn't always supply the full code. Alphanumeric Consisting of letters and numbers Bilateral A condition that affects both the left and right sides of the body or an organ or gland Character X Used as a placeholder in ICD-10-CM in certain codes to allow for future expansion and to fill in empty characters when a code that's less than 6 characters in length needs a 7th character Clearinghouses Public or private entities, including: ○ Billing services ○ Repricing companies ○ Community health management information or community health information systems ○ Value-added networks and switches Conventions These are the general rules for the classification independent of the guidelines. ICD-10-CM incorporates these conventions within the Alphabetic Index and Tabular List as instructional notes. Diagnosis Codes Alphanumeric codes that represent medical terminology for diseases, disorders, or other medical conditions affecting the patient Excludes Notes Notes indicating that codes excluded from each other are independent of each other External Cause of Injuries Index External cause-of-injury codes are the ICD-10-CM codes used to classify injury incidents by mechanism, like motor vehicle, fall, struck by or against, firearm, or poisoning and intent, like unintentional, homicide or assault, suicide or self-harm, or undetermined

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ICD-10-CM/PCS ICD-10, Clinical Modification/Procedure Coding System ICD-10-CM ICD-10 Clinical Modification ICD-10-CM The diagnosis classification system developed by the Centers for Disease Control and Prevention (CDC) for use in all U.S. health care treatment settings. ICD-10-PCS The procedure classification system developed by CMS for use only in the U.S. for inpatient hospital settings Inclusion and Exclusion Notes Notes included under certain ICD-10-CM codes showing conditions for which you may or may not use the code Intraoperative Occurring, carried out, or encountered in the course of surgery L23.6 Allergic contact dermatitis due to food in contact with the skin L24.6 Irritant contact dermatitis due to food in contact with skin L25.4 Unspecified contact dermatitis due to food in contact with skin Laterality Specifies whether a condition occurs on the left or right side of the body or an organ or gland or specifies that it's bilateral MAC Medicare Administrative Contractor (MAC) MLN Medicare Learning Network® NCHS National Center for Health Statistics

NEC Not Elsewhere Classifiable NOS Not Otherwise Specified Official Guidelines for Coding and Reporting These guidelines are a set of rules that have been developed to go with the official conventions and instructions given within the ICD-10-CM. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM but give more instruction. Payer Commercial organizations, Medicaid, Medicare, Pharmacy Benefit Management, Indian Health Services, Veterans Administration, military, other government providers, and voluntarily compliant entities like Coordination of Benefits Contractors Postoperative Occurring after a surgical operation Postprocedural Occurring after a procedure Sequela This is the residual effect or condition produced after the acute phase of an illness or injury has ended. There's no time limit on when you can report a sequela code. Subterm Appear indented under the main terms listed in the ICD-10-CM Alphabetic Index Tabular List of Diseases and Injuries A structured list of codes divided into chapters based on body system or condition Table of Drugs and Chemicals This table has a classification of drugs and other chemical substances to identify poisoning states and external causes of adverse effects. Use these codes when there's documentation of poisoning, overdose, wrong substance given or taken, or intoxication. Table of Neoplasms

This is a table with code numbers for neoplasms by anatomical site. Each site has 6 categories based on whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified behavior. Underdosing This is taking less of a medication than a health care provider prescribed or a manufacturer's instruction recommends. Discontinuing a medication on the patient's own initiative, not directed by the patient's provider, is also classified as an underdosing. Vendor Organizations include billing services; clearinghouses; electronic health record, electronic medical record, and practice management systems; network services; and value-added networks ICD-10-CM allows for the incorporation of specificity and clinical details, including: • Laterality • Combination codes for certain conditions and common associated symptoms and manifestations • Combination codes for poisonings and their associated external cause • Obstetric codes that show the trimester • Character X, used as a placeholder in certain codes • Two kinds of Excludes Notes • Specification of time frames in certain codes • Expanded codes for certain conditions like diabetes and postoperative complications Laterality Several ICD-10-CM codes show laterality, specifying whether the condition occurs on the left, right, or is bilateral. If no bilateral code is available, and the condition is bilateral, assign separate codes for both the left and right side. If the side isn't identified in the medical record, assign the code for the unspecified side or query the physician. This chart shows examples of laterality.

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Table 2. Examples of ICD-10-CM codes indicating laterality Malignant neoplasm of lower- outer quadrant of right female breast Combination Codes for Certain Conditions and Common Associated Symptoms and Manifestations ICD-10-CM includes combination codes for certain conditions and common associated symptoms and manifestations. A combination code is a single code used to classify: } Two diagnoses } A diagnosis with an associated secondary process or manifestation } A diagnosis with an associated complication You can identify combination codes by: } Referring to subterm entries in the ICD-10-CM Alphabetic Index } Reading the Inclusion and Exclusion Notes in the Tabular List Assign a combination code only when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index directs. Don’t use multiple coding when the classification gives a combination code that clearly identifies all elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, use an additional code as a secondary code. This chart shows examples of combination codes for certain conditions. Table 3. Examples of ICD-10-CM combination codes

Combination Codes for Poisonings & Their Associated External Cause ICD-10-CM features combination codes for poisonings and their associated external cause. These codes name both the substance taken and the intent. No additional external cause code is needed for poisonings, toxic effects, adverse effects, and underdosing codes. This chart gives an example of a combination code for poisonings. Table 4. Example of ICD-10-CM combination code for poisoning Obstetric Codes That Show Trimester Report the current trimester of pregnancy although the condition can occur in more than 1 trimester. The trimester is described in the final character of the code. If trimester isn’t part of a code, it’s because the condition always occurs in a specific trimester or the concept of trimester of pregnancy isn’t applicable. Certain ICD-10-CM codes have characters for only certain trimesters because the condition doesn’t occur in all trimesters, but it may occur in more than just 1. Each category that includes codes for trimester has a code for unspecified trimester. You rarely use the unspecified trimester code. Use it only when the documentation in the record is insufficient to determine the trimester and you can’t get clarification. This chart gives an example of an obstetric code that identifies trimester. Table 5. Example of an ICD-10-CM obstetric code

Character X Used as a Placeholder in Certain Codes ICD-10-CM uses a character X as a placeholder in certain codes to: w Allow for future expansion w Fill in other empty characters when a code less than 6 characters in length needs a 7th character If a placeholder exists, you must use X for the code to be considered valid. This chart shows 2 examples of using character X as a placeholder. Table 6. Examples of ICD-10-CM codes using the character X Excludes Notes ICD-10-CM has 2 kinds of Excludes Notes: Excludes1 and Excludes2. Each note has a different definition for use; but, they’re similar because they both show that codes excluded from each other are independent of each other. Note: Excludes Notes may not appear within each area of the course where coding examples are used when they’re not related to the principle being shown. Excludes1 Note A type 1 Excludes note is a pure excludes note. It means, NOT CODED HERE! An Excludes1 note shows that you should never use the excluded code at the same time as the code above the Excludes1 Note. An Excludes1 note is used when the 2 conditions can’t occur together, like a congenital form versus an acquired form of the same condition.

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The Excludes1 note in this example means that you can't report the codes under this category describing a congenital form of a disease with the code for the acquired form of the same condition. In this example, code Q21.0, describing congenital ventral septal defect can't be reported with I51.0, the code for acquired cardiac septal defect. Table 7. Example of Excludes1 Note Excludes2 Note A type 2 Excludes note represents “Not included here.” An Excludes2 note shows that the condition excluded isn’t part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it's acceptable to use both the code and the excluded code together. The Excludes2 note in this example shows that the code for dermatitis due to ingested food can also be reported with the code for dermatitis due to food in contact with skin. Table 8. Example of Excludes2 Note Excludes Notes More Excludes Notes Examples Let's review 2 additional Excludes Notes examples. Click each tab to view Excludes1 Note and Excludes2 Note examples.

Clinical Concepts ICD-10-CM includes clinical concepts, like: w Underdosing w Blood type w Blood alcohol level This chart shows examples of clinical concepts captured in ICD-10-CM codes. Table 12. Example of ICD-10-CM code showing clinical concepts Specificity & Clinical Detail Certain codes offer a high level of specificity for expanded clinical detail, including codes for: • Injuries • Diabetes • Substance abuse • Postoperative complications This chart shows examples of codes with expanded clinical detail. Table 13. Examples of expanded ICD-10-CM codes ICD-10-CM makes a distinction between intraoperative and postprocedural complications.

This chart shows examples of codes for intraoperative and postoperative complications. Table 14. Examples of ICD-10-CM codes for intraoperative and postprocedural complications Use of External Causes of Morbidity Codes in ICD-10-CM The external cause of morbidity codes capture: • How the injury or health condition happened or the cause • The intent: unintentional or accidental; or intentional, like suicide or assault • The place where the event occurred • The activity of the patient at the time of the event • The person's status, like civilian or military ICD- 10-CM external cause code reporting isn't mandatory unless a provider has a state- based external cause code reporting mandate or these codes are needed for a particular payer. Reporting ICD-10-CM codes in Chapter 20 of the ICD-10-CM, External Causes of Morbidity isn't needed. In the absence of a mandatory reporting requirement, we encourage providers to voluntarily report external cause codes, as they give valuable data for injury research and evaluation of injury prevention strategies.

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Use of Sign or Symptom, and Unspecified Codes in ICD-10-CM Sign or symptom, and unspecified codes have acceptable, even necessary, uses In ICD-10-CM. Report specific diagnosis codes when they’re supported by available medical record documentation and clinical knowledge of the patient's health condition. In certain instances, codes for signs, symptoms, or unspecified codes are the best choice to describe the health care encounter. Code each health care encounter to the level of certainty known for that encounter. If a definitive diagnosis hasn't been established by the end of the encounter, report codes for either signs or symptoms or both instead of a definitive diagnosis. When enough clinical information isn't known or available about a particular health condition to assign a more specific code, it's acceptable to report the appropriate unspecified code, for example, a diagnosis of pneumonia applies but the specific type hasn't been documented. Report unspecified codes when these codes most accurately describe what's known about the patient's condition at the time of that particular encounter. Key Concepts Key concepts in this lesson: • Several ICD-10-CM codes show the condition's laterality, and several codes show if the condition is bilateral • ICD-10-CM includes combination codes for certain conditions and common associated symptoms and manifestations • If a condition can occur in more than 1 trimester, you may report the current trimester of pregnancy in the final character of the ICD-10-CM code based on the provider's documentation • ICD-10-CM has 2 kinds of Excludes Notes, which are similar because they both show that codes excluded from each other are independent of each other • ICD-10-CM includes clinical concepts, like underdosing, blood type, and blood alcohol level • ICD-10-CM uses character X as a placeholder in certain codes to allow for future expansion and fill in other empty characters when a code less than 6 characters in length needs a 7th character • Voluntarily report external cause codes, because they supply valuable data for injury research and evaluation of injury prevention strategies

• If a definitive diagnosis hasn't been established, report codes for either signs or symptoms or both when these codes most accurately describe what's known about the patient's condition at the time of that particular encounter • Report unspecified codes when these codes most accurately describe what's known about the patient's condition at the time of that particular encounter

ICD NOTES

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