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

diagnosis code for hyperthyroidismdizziness and giddiness definitionicd 9 codes for dyslipidemiaintertrochanteric fracture icd 9icd 9 code cerebral vascular accidentprolonged second stage of labor complicationslumbar spondylosis icd 9femoral bursitisrash intertrigothyroid enlargement icd 9neonatal hepatitis syndromeicd 9 code 788.30296.99parapneumonic effusion icd 9 codeintrinsic asthma symptomsicd 9 for substance abuseicd 9 code ischemic strokeeyelid skin tagscocaine induced psychosisicd9 code for ibsdiagnosis code 789.03x ray nasal bone fractureicd 9 code for disc bulgeicd 9 code for elevated testosterone levelscongenital hyperammonemiaprocaine allergysvc syndrome icd 9icd 9 mononucleosis434.91 icd 9status epilepticus icd 10icd 9 b12 deficiencyhypoplasia optic nervesynovial sacdiagnosis code for gi bleedprinzmetal angina icd-9 codeicd 9 sarcoidosishepatic flexturecpt code for spinal stenosisgave watermelon stomach problemscongestive heart failure icd 9 codera icd 9 codebrachioradial pruritisicd 9 short bowel syndromechronic obstructive bronchitis icd 9 codeptsd 309.81acute pyelonephritisdiagnosis code for varicose veinsicd 9 code for hypertensive cardiovascular diseaseicd 10 code for substance abusebilateral serous otitis medianonspecific abnormal electrocardiogram ecg ekgstroke icd 9 codesuprapubic catheter icd 9icd allergic rhinitis296.32 dsmwhat is hip effusionicd 9 code for angiomyolipoma717.7 chondromalacia patellasymbolic dysfunction definitionicd 10 code for tubal ligationcerebral palsy noshydrocele nosdiagnosis code 436diagnosis code for ventricular tachycardiachoroidal hemorrhageicd 9 code hammertoedx code for pneumoniacin carcinoma in situvaricose penispyelitis kidney infection846.0 icd 9left eyelid droopingwound icd 10icd code for hyperkalemiageneralised periodontitisicd9 code for ankle painicd 9 codes for cellulitisicd9 knee osteoarthritiseosinophilia icd 9nasal bone fracture icd 9cerebellar tonsillar ectopia icd 9