Some of you have asked for a step by step instruction on how to establish
an ICD-10 code. Here are 3 typical examples on how to find a code.
Example 1:
1. Identify the main term or condition in the diagnostic statement. The
main term is the key word that will be used to locate the correct diagnostic
code. The main term should be the term that describes the condition or disease
process that is occurring. Underline the main term in the diagnostic statement.
a. Facial Pain
2. Look up the main term in the alphabetic index
a. Pain
3. If necessary check for any indented terms under the main term
a. Face: R51
i. Atypical: G50.1 (since the statement does not state Atypical we cannot
use this code)
4. Go to the numeric index and see if the code matches the statement
a. R51 – Headache and indented under it you see Facial pain (NOS) so this
is a good code.
Example 2:
Now what happens if there is more than one diagnosis? You would code the reason
for the visit or the most serious first or follow the guidelines in the ICD-10
book.
Patient presents with pneumonia and rheumatic fever.
1. Since the patient came in with pneumonia you would look that up first in
the alphabetic index. There is a long list of terms indented under pneumonia
and one of them is rheumatic fever – I00 [J17]
2. Go to I00 and you see it is Rheumatic fever without heart involvement.
Since our statement does not state heart involvement this is better than I01.
3. Go to the next code in brackets J17 – in the numeric index the code is
italicized which means it is a manifestation and does not come first. Indented
under it J17 it says "Code first underlying disease…" In our statement the
underlying disease was rheumatic fever.
4. The sequence would then be I00 followed by J17 just the way it was listed
in the alphabetic index.
Example 3:
Let's now look at placeholders and extensions. A placeholder allows for future
expansion and is given the symbol x. An extension is used to provide additional
information about the encounter. Depending on the publisher you would need
a 7th digit if there were a ? (circled 7) or a check 7 to the left of the
code or a "-" to the right of the code. The guideline states that you must
code to maximum specificity (most digits possible) or the code is invalid.
To find the 7th character generally read above the code under the category
code.
Patient presents with radial nerve injury of the right shoulder. This visit
was a sequela. (Sequela will be discussed in the ICD-10 class).
1. Underline the main term. Look up injury and indented under it we find
radial and indented under it the best choice is upper arm: S44.2-
2. There is a dash to the right of the 2 so we know we need more digits. Indented
under S44.2 we see the right arm is S44.21.
3. There is a ?7 to the left of the S44.21 which means we need 7 digits. S44.21
is only 5 digits so we use an x for the 6th
4. Next go up under S44 and you see:
"The appropriate 7th character is to be added to each code from category S44
A initial encounter
D subsequent encounter
S sequela"
5. Since our statement says it was a sequela we would use S as the 7th digit.
6. Our code is S44.21x S
I hope this helps.
By: Liz Jones, Academic Director
Source: Medical Association of Billers - Founded in 1995, the Medical Association of Billers is the premier training and credentialing association for medical billing and coding. The MAB curriculum has been approved and licensed by the Commission for Post Secondary Education and MAB is an approved vendor for Federal agencies. http://www.physicianswebsites.com/
