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

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

3. 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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

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

12. 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.

13. 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.

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

15. 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.

16. 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

17. 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

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

19. 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.