THE CODING CIRCUIT: BACK TO THE BASICS FOR THOSE OF US WHO ARE NOT TRUE CODERS

May 24th, 2011

By Theresa L. Jones, MSEd, RHIA

The following information is provided by the Centers for Disease Control (CDC). The information consists of guidelines provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). Content is constructed in the interest of helping those of us who are not coders to heighten our awareness and to help facilitate understanding in the world of ICD-10 coding.

Please note that the following list is not exhaustive and therefore should not be used exclusively in the interest of proper code assignment or for complete understanding of ICD-10. Again, content is created in the interest of facilitating awareness for the non-coder.

10 Rules for ICD-10

1. Just like in ICD-9, you must reference the alphabetic index before the tabular list.
2. The ICD-10 tabular list contains categories, subcategories and codes. Categories are three characters in length.
3. ICD-10 codes can range between three to seven alphanumeric characters.
4. The letter “X” is used as a place holder for certain codes to allow for expandability.  If a code requires a seventh character but does not have a sixth character, the placement holder “X” must be used.
5. NEC “Not else wise classified” in the alphabetic index routes the coder to “other specified” code in the tabular list.
6. The word “and” in a narrative or title means “and” or “or”
7. Inclusions notes located under a category are for the purpose of defining or providing content of a category
8. There are two types of exclusion notes
   • one means “not coded here”
   • the second one means  “not included here”
9. When in the alphabetic index you see the term “see”, it is necessary to follow the instructions as provided.  In opposition to this is a case when you see the term “see also”.  Here you do not have to follow the instruction “see also” when the original term provides the code.
10. Default codes are located in the alphabetic index next to main terms.  They serve to identify conditions that are commonly related to the main term.

For a complete list of the guidelines, please feel free to reference the link below.

Reference: CDC (2011) ICD-10-CM Official Guidelines for Coding and Reporting 2011

http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf