The ICD-10-CM Official Guidelines for Coding and Reporting

  • Review IDC-10-CM Official Guidelines for Coding and Reporting on the CMS website.

  • Guidelines have been approved by the Cooperating Parties, for ICD-10-CM: The American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Disease Control (CDC), and National Center for Health Statistics (NCHS).

  • The instructions, conventions, and notations with the Index and Tabular List take precedence over the Official Guidelines. You must read the Tabular List carefully and then refer to the Official Guidelines before determining what code or codes to report.

  • Code sequencing when there is more than one diagnosis code:

    • Determine the Principal Diagnosis (inpatient).

      • Principal Diagnosis: "Condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care" (Federal Register, 1985).

    • Determine the First Listed Diagnosis (outpatient)

      • First Listed Diagnosis: This term is used in the outpatient setting instead of principal diagnosis. Follow the coding conventions in ICD-10-CM and disease-specific chapter guidelines

    • Follow any chapter-specific coding guidelines

    • List relevant secondary diagnosis codes

  • Acute and Chronic Conditions: When a patient's health concern is documented as acute (severe), and chronic (ongoing), follow coding guidelines carefully. Sometimes there may be a combination code to report both conditions. If there is one code, then the combination code is required. if there is not combination code, then report the acute code first followed by the chronic condition.

  • Combination Codes: When a combination code is available report the combination code. It is inappropriate to report two codes if there is a combination code.

  • Comparative or Contrasting Diagnosis: A comparative or contrasting diagnosis is indicated by the word "versus" or the word "or" between two diagnostic statements. You must code both as if they were confirmed; either code may be listed first.

  • Co-morbidity, complication, and manifestations:

    • Co-morbidity: A condition unrelated to the principal diagnosis that requires care and attention during the same encounter. For example, a patient with heart disease and diabetes.

    • Complication: A condition that is caused by a procedure or treatment. Complications will be documented by the provider, in the patient record. For example, a patient is given a flu immunization and 10 minutes later the patient has a rash.

    • Manifestation: A condition that is caused by another, existing condition. There is a known cause-and-effect relationship. For example, neuropathy is a manifestation of diabetes.

  • Signs and symptoms:

    • Inpatient: When a confirmed diagnosis has not been documented by the end of the encounter in an inpatient setting , report the suspected, probable, or likely diagnosis as if it had been confirmed.

    • Outpatient: When a confirmed diagnosis has not been documented by the end of the encounter in an outpatient setting, report the codes for the signs and symptoms that have been documented.

  • Integral conditions: Do not assign conditions that are part of another condition or disease process. For example, if a patient has strep throat, do not assign pharyngitis since pharyngitis is integral to strep throat.