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Co1 icd 10 cm job aid final

Co1 icd 10 cm job aid final

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University Hospital

ICD-10-CM Coding

Job Aid Template

Part 1: The ICD-10-CM Code Book

Part 2:

Instructional Notes

The ICD-10-CM Code Book

Section 1

Title: Alphabetic Index

Descriptionan alphabetical list of terms

and their corresponding code:

Example: Aarskog’s syndrome Q87.19

Section 2

Title: Tabular List

Description: a chronological list of

codes divided into chapters based on

body system or condition.

Example: Q87.19 Other congenital

malformation syndromes

predominatley associatedwith short

stature

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Instructional Note Type

Description

Example

Code First/Use Additional Code

Certain conditions have both an

underlying etiology and multiple

body system manifestations due

to the underlying etiology.it

requires that the underlying

condition is sequenced first

followed by the manifestation.

Use additional code for any

associated drug resistance (Z16)

Punctuation

( ) Parentheses are used in both

the Alphabetic Index and the

Tabular List to enclose

supplementary words that may be

present or absent in the statement

of a disease or

procedure without affecting the

code number to which it is

assigned.

[ ] Brackets are used in the

Tabular List to enclose

synonyms, alternative wording,

or explanatory phrases. Brackets

are used in the Alphabetic Index

to identify manifestation codes

: Colons are used in the Tabular

List after an incomplete term

which needs one or more of the

modifiers following the colon to

make it assignable to a given

category

Escherichia coli [E.coli]

Pressure (pressure area) L89.9

443.0 Raynaud’s syndrome

Raynaud’s: Disease Phenomenon

(secondary)

Code Also

A “code also” note tells you that

two codes may be required to

fully describe a condition, but the

sequencing of the two codes is

discretionary depending on the

severity of the conditions and the

reason for the encounter

S83 Dislocation and sprain of

joints and ligaments of knee

Code also: any associated open

wound

Laterality

For bilateral sites, the final

character of the codes in the ICD-

10-CM indicates laterality.

The right side is usually character

The left side character 2. – In

those cases where a bilateral code

is provided the bilateral character

is usually 3.

The unspecified side is either a

character 0 or 9 depending on

whether it is a fifth or sixth

character. An unspecified side

code is also provided should the

side not be identified in the

medical record.

M71.03- Abscess of bursa, wrist

M71.031 Abscess of bursa, right

wrist

M71.032 Abscess of bursa, left

wrist

M71.039 Abscess of bursa

unspecified wrist

With/ Without

When “with” and “without” are

the two options for the final

character of a set of codes, the

default is always “without.”

G40.501

Special epileptic syndromes, not

intractable with status epilepticus

G40.509

Special epileptic syndromes,

intractable, without status

epilepticus

7th Character

It is required for all codes within

the chapter or as the notes in the

Tabular List instruct. The 7th

character must always be the 7th

character in the data field. W

M80.08xA

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University Hospital ICD-10-CM Coding Job Aid Template Part 1: The ICD-10-CM Code Book The ICD-10-CM Code Book Section 2 Section 1 Title: Alphabetic Index Descriptionan alphabetical list of terms and their corresponding code: Example: Aarskog’s syndrome Q87.19 Instructional Notes Title: Tabular List Description: a chronological list of codes divided into chapters based on body system or condition. Example: Q87.19 Other congenital malformation syndromes predominatley associatedwith short stature Part 2: Instructional Note Type Code First/Use Additional Code Punctuation Code Also Laterality With/ Without 7th Character Description Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.it requires that the underlying condition is sequenced first followed by the manifestation. ( ) Parentheses are used in both the Alphabetic Index and the Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. [ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording, or explanator ...
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