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


adjustment disorder icd 9circadian rhythm jet lagphlegmasia alba dolensdiabetes type 2 icd 10 codewhat is the icd 9 code for colitiscardiomyopathy icd 9icd 9 code for arm swellingcva icd 9 codemuscle strain icd 10severe pain icd 9adenocarcinoma icd 10icd 9 muscle painicd 9 code 592.0icd 9 code for g6pd deficiencyicd 9 code hepatic steatosissuppurative hydradenitisicd 599.0lupus icd 9dysphagia noscervical lesion icd 9icd 9 code for vision impairmenticd 9 code for atrial arrhythmiamidline facial cleftpickers nodule scalpicd 9 psaicd 9 toe painicd 9 ptsddiagnosis code for eczemadiagnosis code 847.2icd 9 codes lumbagochronic neck pain icd 9 codehiv b20carpal tunnel icd 9lumbar compression fracture icd 9vertigo icd 10icd 9 code for lower back painherpes in eyeliddissociative identity disorder icd 10icd code lumbar radiculopathygreenish sputumicd 9 closed head injuryicd 9 code 564.1icd9 knee sprainabrasion elbow icd 10 codeicd 9 blindnesstyphus diagnosisicd 9 gi bleedinggeneralized weakness icd 9abscess icd 10 codeicd j32 9tibialis anterior dysfunctionmedical code 729.1corneal abrasion icd 9cholelithicd 9 code for poor appetitemild cognitive impairment icd 10diagnosis code 414.01chromosome 4q deletion syndromeicd 9 code 728.2cva icd 10icd 10 code for gallstonesicd 10 code for eustachian tube dysfunctionicd 9 code for osteoarthritis of kneediagnosis code for vasectomyfixed delusional systemmenopause icd 9loc prim osteoart l legpneumonitis icd 10icd 9 obsessive compulsive disordericd code for elevated troponinnephrolithiasis icd 9 codeicd 9 code lower extremity swellingv23.0right hip replacement icd 9 code