ICD-10 Guidelines for Coding and Reporting

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. 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. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. 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.
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for ICD-10-CM Official Guidelines for Coding and Reporting outpatient coding and reporting. It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.


Related pages


icd 10 code for hemophiliadyspnea icd9edema icd 10tetanus descriptiondiagnosis code for itpcongenital reduction deformities of brainicd 9 code for aspiration pneumonitisfascia dehiscencereflux icd 10rp hematomaicd 9 abnormal uterine bleedingmass on scalp331.83 mild cognitive impairmentabnormal gait icd 9780.79 fatigueicd 9 for pes planusicd 9 code for long qt syndromeicd 9 code for aphasia724.3 icd 9 codepyuria icd 9 codemyofascial pain syndrome icd 9dx code for esrdseventh cervical vertebraicd 9 code for afibtmj pain icd 9allergic reaction to codeine in tylenolalzheimer icd 10icd 9 code for pressure ulcerpregnancy icd 9 codesicd 9 neck painhiv icd 9icd 9 code for chronic pelvic painsarcoidosis icd 10 codewbc esterase urinemild erythematous gastritisms exacerbation icd 9 codepiriformis syndrome icd 9icd 9 code 799.9icd 9 codes knee painhow to diagnose sarcoidosis786.50diagnosis code 250.01diagnosis code for low vitamin dpancreatic mass icd 9icd9 code for leukocytosissymptoms of borderline intellectual functioningtumor marker listpre b cell lymphoblastic lymphomaicd 9 tbperivascular dermatitis treatmentbuttock abscess icd 9hairline fracture pelvisicd 9 code for early pregnancythromboangiitis obliterans buerger's diseaseintramammary lymph node stagingacq acanthosis nigricansicd 9 code 729.1icd 9 code for gonorrheaicd 9 code parotitisradial head fracture icd 9cheek lacerationlattice degeneration icd 9icd 9 299.80icd 9 dizzinessampulla of vater carcinomahyperkeratosis icd 9icd 9 code for irregular heart rhythmdx code hypoxiaicd 10 code for respiratory distressicd9 code for hyperlipidemia