Coding Tip of the Week: Understanding "Code Also" Notes in ICD-10-CM
This week's coding tip focuses on a crucial instruction within the ICD-10-CM coding guidelines: the "Code also" note. Understanding and correctly applying this instruction can significantly improve coding accuracy and ensure a complete picture of the patient's condition is captured.
Coding Tip:
When you encounter a "Code also" note under a particular ICD-10-CM code, it signifies that more than one code may be required to fully represent the condition. The "Code also" note indicates a second condition that is usually present with the primary condition. You must code both conditions if documented.
Why This Improves Accuracy:
This week's coding tip focuses on a crucial instruction within the ICD-10-CM coding guidelines: the "Code also" note. Understanding and correctly applying this instruction can significantly improve coding accuracy and ensure a complete picture of the patient's condition is captured.
Coding Tip:
When you encounter a "Code also" note under a particular ICD-10-CM code, it signifies that more than one code may be required to fully represent the condition. The "Code also" note indicates a second condition that is usually present with the primary condition. You must code both conditions if documented.
Why This Improves Accuracy:
- Completeness: Ignoring a "Code also" note can lead to an incomplete representation of the patient's diagnosis, potentially impacting reimbursement and quality reporting.
- Specificity: Coding both conditions provides a more specific and nuanced understanding of the patient's health status.
- Avoiding Under-Coding: Failing to code a co-existing condition indicated by a "Code also" note can result in under-coding the complexity of the patient's case.
- Always read the "Includes," "Excludes1," "Excludes2," and importantly, the "Code also" notes associated with the primary diagnosis code you are considering.
- Pay close attention to the wording. "Code also" is a mandatory instruction to code the additional condition if documented.
- Code the conditions in the order that best reflects the principal diagnosis and any sequencing rules. The "Code also" note itself doesn't dictate sequencing unless specifically stated elsewhere in the guidelines.
- Ensure the "Code also" condition is clearly documented in the medical record. You cannot code a condition solely based on the instructional note; it must be supported by the physician's documentation.