August 9th, 2011
By Deborah A. Balentine M.Ed., RHIA, CCS-P and Daniel Jamieson, CCA
The transition to ICD-10-CM will be challenging for even the most seasoned codingcoder. Whereas the level of detail in ICD-10-CM is a welcome change for all coders, there are some new conventions and instructional notes that may seem to go “against the grain” from the ICD-9-CM version. In this article we will take a more in-depth look at the ICD-10-CM conventions and instructional note formats.
The structure of ICD-10-CM conventions and instructional notes is basically the same as in ICD-9-CM. In the Alphabetical Index to Diseases there are the usual cross-reference terms such as “See” and “See Also” and in the Tabular Listing of Diseases there are still “Code First” and “Use Additional Code” instructional notes. Many new instructional notes have been added to ICD-10-CM to assist the coder in the use of the new ICD-10-CM codes and guidelines.
“Includes” and “Excludes” Instructional Notes
One major change in ICD-10-CM conventions is the structure of the “Includes” and “Excludes” notes in the ICD-10-CM Tabular List. Includes notes serve the same function in ICD-10-CM as in ICD-9-CM. An Includes note is used to define or further clarify an example of a category or section. Includes notes may also be used to provide general information about the content of a chapter or range of codes. For example:
I66 Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction
Includes:
embolism of cerebral artery
narrowing of cerebral artery
obstruction (complete) (partial) of cerebral artery
thrombosis of cerebral artery
Chronic rheumatic heart diseases (I05-I09)
Rheumatic mitral valve diseases
Includes: conditions classifiable to both I05.0 and I05.2-I05.9, whether specified as rheumatic or not
In the first example, the includes note identifies other terms that are synonymous with occlusion and stenosis. In the second example, the includes note gives additional information about the types of conditions that would be classified to rheumatic mitral valve diseases.
Excludes notes indicate the exact opposite of includes notes. This type of note indicates that the conditions listed are classified to a different category in ICD-10-CM. Excludes notes also provides the coder with an alternative code range for locating codes.
In ICD-10-CM there are two types of excludes notes (“Excludes 1” and “Excludes 2”). An “Excludes 1” note identifies codes for conditions that generally would never occur together. An “Excludes 2” note identifies codes for conditions that can occur together without a direct relationship and if present should be reported together to completely represent the situation. For example:
R10 - Abdominal and pelvic pain
Excludes1:
renal colic (N23)
Excludes2:
dorsalgia (M54.-)
flatulence and related conditions (R14.-)
O22 - Venous complications in pregnancy
venous complications of:
abortion NOS (O03.9)
ectopic or molar pregnancy (O08.7)
failed attempted abortion (O07.35)
induced abortion (O04.85)
spontaneous abortion (O03.89)
obstetric pulmonary embolism (O88.-)
venous complications of childbirth and the puerperium (O87.-)
In the first example, the Excludes 1 note excludes renal colic because it is specific to the kidney and should be coded to Category N23. In the Excludes 2 note the conditions of dorsalgia and flatulence can be present and not directly attributed to the abdominal and/or pelvic pain.
In the second example, the Excludes 1 note excludes venous conditions that are related to abortions and ectopic pregnancies. This may seem confusing at first because the codes for these complications are contained in the Pregnancy, Childbirth and Puerperium section. The Excludes 2 note is more straightforward because the codes are for conditions related to pregnancy, childbirth and the puerperium.
When in doubt, coders should always remember to query the clinician for additional guidance when attempting to determine if a condition should be included or excluded from diagnostic reporting.
As we prepare to make the transition from ICD-9-CM to ICD-10-CM, a thorough review of the basic structure of the ICD-10-CM classification system is essential to optimize your knowledge base.
References
National Center for Health Statistics. "ICD-10-CM Official Guidelines for Coding and Reporting." 2011. Available online at www.cdc.gov/nchs/icd/icd10cm.htm.
National Center for Health Statistics. "ICD-10-CM Index and Tabular." 2011. Available online at www.cdc.gov/nchs/icd/icd10cm.htm.
D. BalentineDeborah A. Balentine M.Ed., RHIA, CCS-P, has been a Health Information Management professional for over 15 years. She currently works as a Coding Specialist for the Northwestern Medical Faculty Foundation in Chicago, IL. She also is an online faculty instructor for Colorado Technical University and the University of Cincinnati.
The author wishes to acknowledge the valuable assistance of Mr. DanielD. Jamieson Jamieson, CCA, in the preparation of this article. Mr. Jamieson is a newly credentialed Health Information Management professional and a graduate of Colorado Technical University.