Mary Jo Bowie MS, BS, AAS, RHIA, RHIT

ICD-10-CM Coding Conventions CHAPTER 3 ICD-10-CM Coding Conventions

Coding Conventions Coding conventions are instructional notes, punctuation marks, abbreviations, and symbols that are used throughout ICD-10-CM and ICD-10-PCS to provide direction when selecting codes.

Instructional Notes Instructional notes appear in the Alphabetic Index and Tabular List INCLUDES: - This notation is used to define and/or give examples of the content of a particular category or block of categories within ICD-10-CM.

Instructional Notes (cont.) EXCLUDES 1: This note means that the terms listed are not coded to the category or subcategory. It means NOT CODED HERE EXCLUDES 2: This note is used to signal that the terms listed after the note are not part of the conditions represented by the code or code block. It means NOT INCLUDED HERE

Instructional Notes (cont.) SEE: This is used in the Alphabetical Index and instructs the coder to cross-reference the term or diagnosis that follows the notation. SEE ALSO: This is also a cross-reference note that refers the coder to another location in the Index.

Instructional Notes (cont.) USE ADDITIONAL CODE: This notation appears in the Tabular List and instructs the coder to use an additional code to identify the manifestation that is present.

Instructional Notes (cont.) CODE FIRST: This notation appears in the Tabular List and instructs the coder to select a code to represent the etiology that caused the manifestation. This code is sequenced first.

Instructional Notes (cont.) IN DISEASES CLASSIFIED ELSEWHERE: Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code and is not permitted to be used as a first listed or principal diagnosis code.

Instructional Notes (cont.) CODE ALSO: This notation is used to indicate to the coder that two codes are needed to fully code the diagnostic phrase being coded. The note does not provide sequencing direction.

Punctuation Marks Punctuation marks are used in both the Index and Tabular List to provide guidance to coders when selecting codes.

Punctuation (cont.) Parentheses—Used in both the Index and Tabular List to enclose supplementary words that may be present or absent in the statement being coded. The code assignment is not affected. Nonessential modifiers—Terms found within the parentheses.

Punctuation (cont.) Brackets—Used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases. Brackets—Used in the Index to identify manifestation codes. Colons—Used in the Tabular List after an incomplete term that needs one or more of the modifiers listed to make it assignable to a given category.

Abbreviations There are two abbreviations used. NEC—Not Elsewhere Classified. This represents “other specified.” NOS—Not Otherwise Specified. This is interpreted as “unspecified.”

Symbols The point dash symbol is used to signal to the coder that the code contains a list of options at a level of specificity past the three-character category.

ICD-10-CM Official Coding Guidelines Section I: Conventions, general coding guidelines and chapter specific guidelines contains guidelines relevant to (See Appendix A in textbook): The Alphabetic Index and Tabular List Format and Structure Use of codes for reporting purposes Placeholder character 7th Characters

ICD-10-CM Official Coding Guidelines Section Guidelines continued Abbreviations- NEC and NOS Punctuation Use of “and” “Other” codes “Unspecified” codes Inclusion terms Excludes 1 Excludes 2

ICD-10-CM Official Coding Guidelines Section Guidelines continued: Etiology/manifestation convention “And” “With” “See” and “See also” “Code also note” Default codes Syndromes

Points to Remember When selecting codes, the coder must follow all instructional notes present. Instructional notes, abbreviations, and punctuation provide direction to coders. When cross-references are present in the Index the additional terms need to be referenced by the coder.