AAPC CPC Prep Course - Chap 3 Notes
CPC Prep CourseChapter 3 NotesIntroduction to ICD-10-CMIntroduction● ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into use in WHO Member States in 1994 (including US)○ The classification is the latest in a series, which has its ...
Introduction
● ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into
use in WHO Member States in 1994 (including US)
○ The classification is the latest in a series, which has its origins in the 1850s
○ The first edition, known as the International List of Causes of Death, was adopted
by the International Statistical Institute in 1893
○ WHO took over the responsibility for the ICD at its creation in 1948 when the
sixth revision, which included causes of morbidity for the first time, was published
○ The World Health Assembly adopted in 1967 the WHO Nomenclature
Regulations that stipulate use of ICD in its most current revision for mortality and
morbidity statistics by all Member States
● The ICD is the international standard diagnostic classification for all general
epidemiological, many health management purposes, and clinical use
○ These include the analysis of the general health situation of population groups
and monitoring if the incidence and prevalence of diseases and other health
problems in relation to other variables such as the characteristics and
circumstances of the individuals affected, reimbursement, resources allocation,
quality, and guidelines
● It is used to classify diseases and other health problems recorded on many types of
health and vital records including death certificates and health records
○ In addition to enabling the storage and retrieval of diagnostic information for
clinical, epidemiological, and quality purposes, these records also provide the
basis for the compilation of national mortality and morbidity statistics by WHO
Member states
● The National Center for Health Statistics (NCHS) developed ICD-10-CM (International
Classification of Diseases, Tenth Revision, Clinical Modification) in consultation with
technical advisory panel, physician groups, and clinical coders to assure clinical
accuracy and utility
○ There are no codes for procedures in ICD-10-CM and procedures are coding
using the procedure classification appropriate for the encounter setting (EX: CPT
or ICD-10-PCS
● During this Chapter, we will discuss:
○ Overview of the ICD-10-CM layout
○ ICD-10-CM conventions
○ How to look up an ICD-10-CM code
○ Official ICD-10-CM coding guidelines
Overview of ICD-10-CM Layout
● ICD-10-CM is published in two sections:
○ Alphabetic Index or Index to Diseases and Injuries:
■ Diagnostic terms organized in alphabetical order for the disease
descriptions in the Tabular List
■ In this curriculum, the terms Alphabetic Index and Index to Diseases and
Injuries are used interchangeably
○ Tabular List: Diagnosis codes organized in sequential order and divided into
chapters based on body system or condition
● This guide will focus on the proper use of ICD-10-CM only
○ Coders use ICD-10-CM to assign diagnosis codes for services rendered, and to
establish medical necessity to support those services
Medical Necessity
● One of the most important requirements to receive payment for services is to establish
medical necessity
○ You must justify care provided by presenting the appropriate facts
○ Payers require the following information to determine the need for care:
■ Knowledge of the emergent nature or severity of the patient’s complaint or
condition
■ All signs, symptoms, complaints, or background facts describing the
reason for care
■ The facts must be substantiated by the patient’s medical record, and that
record must be available to payers on request
● For example, a patient complains of pain in her right knee and the provider performs a
knee X-ray
○ When the claim is submitted, the payer needs to know why the service was
performed
○ The diagnosis code on the claim will indicate the reason or the medical necessity
○ In this example, we select a code to report the X-ray with a diagnosis code for
knee pain to support the reason the service was performed
○ We will discuss the proper section of diagnosis codes later in this chapter
Index to Diseases and Injuries
● The Index to Diseases and Injuries (Alphabetic Index) is divided into sections and is
organized by main terms
○ The Sections include:
■ Index to Diseases and Injuries (Alphabetic Index)
■ Table of Neoplasms
■ Table of Drugs and Chemicals
■ External Cause of Injuries Index
● Main terms in the Alphabetic Index usually reference the disease, condition, or symptom
○ Subterms modify the main term to describe differences in site, etiology, or clinical
type
○ Main terms are in BOLD in the Alphabetic Index
○ Subterms add specificity to the main term
○ The code listed next to the main term is considered the default code
○ The default code represents the condition most commonly associated with the
main term
○ As with all code assignment, always verify the default code in the Tabular List to
assure proper reporting
○ EXAMPLE: Look up term MASS
■ The indented subterms further define the location of the mass
Tabular List
● The tabular list contains 22 chapter and contains categories, subcategories and code
○ Each character for all categories, subcategories, and codes may be either a letter
or a number
○ Codes can be 3, 4, 5, 6, or 7 characters
○ The 1st character of a category is a letter
○ The 2nd and 3rd characters may be either letters or numbers
○ Subcategories are either four or five characters and may be either letters or
numbers
○ Codes are 3, 4, 5, or 6 characters and the final character in a code may either be
a letter or a number
○ Certain categories have a 7th character extension
○ There are symbols throughout the Tabular List to identify when a code requires
an additional character
■ EXAMPLE: E28, G47.5, H16.33, S36.260, S36.92
● At the beginning of each chapter, there may be excludes and includes notes that apply
to the entire chapter
○ EXAMPLE: Chapter 3- Diseases of the Blood and Blood-forming Organs and
Certain Disorders involving the Immune Mechanism (D50-D89)
● The 4th character in an ICD-10-CM code further defines the site, etiology, and
manifestation or state of the disease or condition
○ The four character subcategory includes the three character category plus a
decimal with an additional character to further identify the condition to the highest
level of specificity
■ EXAMPLE: D56 - Thalassemia
● The 5th or 6th character subclassifications represent the most accurate level of
specificity regarding the patient’s condition or diagnosis
○ EXAMPLE: D57.4 - Sickle-cell thalassemia
● Certain ICD-10-CM categories have applicable 7th characters
○ The applicable 7th character is required for all codes within the category must
always be in the 7th character must always be in the 7th position
○ If a code is three, four, or five characters, but requires a 7th character extension,
a placeholder X must be used to fill the empty characters
■ EXAMPLE: M48.4 Fatigue Fracture of Vertebra
● The appropriate 7th character is to be added to each code from
Subcategory M48.4
○ A - initial encounter for fracture
○ D - subsequent encounter for fracture with routine healing
○ G - subsequent encounter for fracture with delayed healing
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