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

gout icd 10urticarial vasculitis icd 9diagnosis code 920ligaments neckrotaviral enteritisicd 9 code for vaginal dischargeicd 9 for testosterone deficiencywhere is the peroneal veinicd 415.19diagnosis of anemia of chronic diseaseicd 9 codes 781.2hemophilia icd 9 codeicd 10 code for cadheadache icd 10icd 9 foot painicd 9 code for back abscessurethral wartsicd 9 carotid bruiticd 9 code for glucose intoleranceicd 9 codes abscessrsv codeicd 10 code for pyelonephritisicd 9 for scoliosispurulent rhinitis icd 9left eustachian tube dysfunctionicd code traumatic brain injuryicd9 code for elbow painwhat is the diagnosis code for copdicd 10 code for hemorrhoidsaortic stenosis icd 9icd 9 code for congestionicd 9 code for myalgiathrombocytopenia icdicd 9 code malaisecatheter icd 9acute promyelocytic leukemia diagnosisarnold chiari treatmentv22 2 pregnancy state incidental185 diagnosis codeicd code atrial fibrillationmasticator spacesambulatory dysfunction icd 9 code2nd cervical vertebraoccipital osteomaicd 9 721.3mitral valve repair icd 9hypoglycemia and comaicd9 250.02icd 9 arthritisosteoarthritis icdicd 9 code for retained ureteral stentptsd icd-9-cm 309.81near syncope icd 9icd 9 atherosclerosisradicular pain icd 9 codeicd 9 416.0icd 9 code for hepatitis exposureicd 9 hypernatremiaicd 9 code for fetal demiseicd 9 173.31icd 9 constipationagoraphobia synonymsgerd icd codeicd 9 code syncopehysterectomy icd 10 codeicd 10 code for hematomanon ischemic cardiomyopathy icd 9 codenosebleed termicd 9 lumbar radiculopathy 729.2gastroc soleus equinus icd 9 codeicd 10 code for screening colonoscopyaxillary artery thrombosisadnexal pain icd 9list of interstitial lung diseasesicd 9 code for mild mitral regurgitationicd code cardiomyopathyz78meconium amniotic fluidhypercholesterolemia pureicd 303.90