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Resource ICD-10 Guideline Figures

Figure I.A.9: Other & specified codes
Figure I.B.1: Locating a Code in ICD-10-CM
Figure I.B.11: Impending or Threatened Conditions
Figure I.C.a.2.d: Asymptomatic Human Deficiency Virus
Figure I.C.1.d: Sepsis, Severe Sepsis, and Septic Shock
Figure I.C.4.a: Diabetes Mellitus (DM)
Figure I.C.4.a.2: Type of diabetes Mellitus Not Documented
Figure I.C.5.b.2: Psychoactive Substance Use, Abuse, and Dependence
Figure I.C.9.a: Hypertension (HTN)
Figure I.C.10.b: Acute Respiratory Failure
Figure I.C.12.a: Pressure Ulcer Stage Codes
Figure I.C.13.c: Coding of Pathologic Fractures
Figure I.C.15.a.1: Codes From Chapter 15 and Sequencing Priority (Coding for Pregnancy)
Figure I.C.15.g: Conditions Affecting Pregnancy
Figure I.C.19.c: Coding of Traumatic Fractures
Figure I.C.21.c.5: Screening vs Therapeutic
Figure Section III: Reporting Additional Diagnoses
Figure IV.H: Uncertain Diagnosis
Figure IV.M: Patients Receiving Preopertive Evaluations Only
Figure Appendix I: Present on Admission Reporting Guidelines
 
Other & specified codes

9. Other and Unspecified codes

a. “Other” codes
Codes titled “other” or “other specified” are for use when the information in the
medical record provides detail for which a specific code does not exist.
Alphabetic Index entries with NEC in the line designate “other” codes in the
Tabular List. These Alphabetic Index entries represent specific disease entities
for which no specific code exists, so the term is included within an “other” code.

b. “Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical
record is insufficient to assign a more specific code. For those categories for
which an unspecified code is not provided, the “other specified” code may
represent both other and unspecified.

See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

18. Use of Sign/Symptom/Unspecified Codes

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While
specific diagnosis codes should be reported when they are supported by the available
medical record documentation and clinical knowledge of the patient’s health condition,
there are instances when signs/symptoms or unspecified codes are the best choices for
accurately reflecting the healthcare encounter. Each healthcare encounter should be
coded to the level of certainty known for that encounter.
As stated in the introductory section of these official coding guidelines, a joint
effort between the healthcare provider and the coder is essential to achieve
complete and accurate documentation, code assignment, and reporting of
diagnoses and procedures. The importance of consistent, complete documentation
in the medical record cannot be overemphasized. Without such documentation
accurate coding cannot be achieved. The entire record should be reviewed to
determine the specific reason for the encounter and the conditions treated.
If a definitive diagnosis has not been established by the end of the encounter, it is
appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive
diagnosis. When sufficient clinical information isn’t known or available about a
particular health condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined,
but not the specific type). Unspecified codes should be reported when they are the codes
that most accurately reflect what is known about the patient’s condition at the time of
that particular encounter. It would be inappropriate to select a specific code that is not
supported by the medical record documentation or conduct medically unnecessary
diagnostic testing in order to determine a more specific code.



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Locating a Code in ICD-10-CM

8 Steps to Code:
  1. Identify the main term(s) and sub-term(s) for procedures, tests, services, equipment, and supplies from the medical record.
  1. Locate the main term(s) in the Alphabetic Index by service or procedure, anatomic site, condition or disease, synonym, eponym, or abbreviation.
  1. Review any sub-term (s) under the main term in the index.
  1. Follow any cross-reference instructions such as SEE
  1. Verify the chosen code in the Tabular list for further coding specifics such as code first or code additional. (Never code directly from the Index alone as you may miss important things that may lead you to choose a more specific code choice).
  1. Refer to any Tabular list instructional notations such as conventions, notes, and related guidelines.
  1. Assign codes to the most specific code choice (CPT may require a modifier and both CPT and ICD-10-CM may require an unlisted or unspecified code choice).
  1. Code all diagnoses, procedures, supplies, tests, services, and equipment until all elements are completely identified.

ICD10 locate code.jpg
 
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