Foundations of Coding For ICD-10 CM

A simple and easy-to-understand guide to coding for ICD-10 CM

All Coding Conventions, Guidelines, and Section References are taken from
the ICD-10 CM Official Guidelines for Coding and Reporting FY 2020.
Integrity Coding DOES NOT TAKE ANY CREDIT FOR ANY OF THESE
GUIDELINES, CONVENTIONS, DESCRIPTIONS AND SECTIONS.

**The Centers for Medicare and Medicaid Services (CMS) and the National
Center for Health Statistics (NCHS), two departments within the U.S. Federal
Government’s Department of health and Human Services (DHHS) provide the
following guidelines for coding and reporting using the International
Classification of Disease, 10th Revision, Clinical Modification (ICD-10 CM).
Integrity Coding takes no credit whatsoever for any code descriptors. They
were not written by Integrity Coding.
This Guide Sheet is Copyright Protected by Law to Integrity Coding
2020

ICD-10 CM stands for International Classification of Disease Tenth Edition.

When I began my coding and billing career, we used ICD-9 and let me tell
you, the thoughts of using anything different was frightening. We always fear
what we do not know to be truth. When I sat down to learn ICD-10, it was
not anywhere near as bad as I thought it would be. Actually, a great many of
the code descriptors were combined, compared to what we used for ICD-9.
Those of you/us that used ICD-9 know this is true, especially when it came to
diabetes, for example. With ICD-9, we had to code every condition the
patient had that was involved or associated with their diabetes. For example,
if the documentation stated that the patient had diabetes and some type of
retinopathy, we coded each of these conditions separately. With ICD-10 CM,
we would use only one code because they combined it, E11.311. In many
ways, ICD-10 was and is much easier than ICD-9. So, here we go onto
learning how to code for ICD-10 CM!
This guide sheet is designed with the student in mind. I will be going over
only Coding Conventions, Coding Guidelines and Sequencing that I believe
are the most pertinent and what is not covered here will be covered in your
accompanying lecture, which is extensive.
Coding is really a story. It relays why the patient left the house. This in no
way includes everything in your training books but it does give you a great
foundation and what I believe students will be required to know, understand,
and apply for your nation coding certification.
As you go through this guide sheet, I want you to continually be asking
yourself that question, “why did this patient leave the house”? You see, as a
coder, you are actually a narrator
Books: As a Coding Instructor, I prefer my students to use the AAPC Coding
Books. The reason for this is because they have great diagrams to help
students understand coding sequencing and remember when you go into your
National CPC Exam, you can only take your CPT, ICD-10 CM and HCPCS
Level II Books.
This Guide Sheet is written in Danita Terms. Meaning: It is broken down in
verbiage that I would understand or as some call it “Danitaisms”
Section 1 Conventions, general coding guidelines and chapter specific
guidelines
In my opinion, I think of coding conventions as amazingly simple directives.
Each item mentioned in conventions is really directing and guiding your
understanding of the code description and its meaning (s). We first must
understand the sections of your ICD-10 CM Book and again, this guide sheet
is for students preparing to test so I keep it to just the most pertinent
information you/they need to understand ICD 10 CM.
Alphabetic Index: The alphabetic index is located at the beginning of
our ICD 10 book. They are in, you guessed it, ALPHABETIC
ORDER, hence the name “alphabetic index”. You look at the main
term or subject and then look it up in alphabetic order. i.e. “The
patient has appendicitis”. The main term or condition being treated is
appendicitis. You then go to the code reference and confirm that this is
exactly or close to exact what your documentation indicated. NEVER
use the code in the alphabetic index until you confirm it in the Tabular
Index

Tabular Index: This is what I call the confirmation. You always

confirm the code you are guided to from the Alphabetic Index

Format and Structure: ICD-10 CM Codes have patterns and logistics.

Let us look up a code together so you can begin to see how ICD-10 CM
is set up. Please look, IN YOUR TABULAR LIST, at code S62.25.
We first see the code’s description “Fracture of neck of first metacarpal
bone”. Notice the red circle next to this code, which has a 5 within a
red bullseye and the codes beneath it, which we call an indented code
has a number 7 within the bullseye. ICD 10 Codes are either 3, 4, 5, 6-
or 7-character spaces. As a coder, you must go by the directives
indicated by these red circles, or as I call them red bullseyes. We will
discuss this further.

Main Codes extend to the left-hand margin and then they also have
indented codes beneath them. Let’s continue to look at the code S62.25
and I want you to begin to notice the patterns within this book.
First, notice the body part that they are referring to, which is the
Metacarpal Bone. When you break this word down into medical terms
Meta: Beyond Carpal: Referring to our carpal bones. When you
put this together, it is the medical term metacarpal bone. Your thinking,
“that’s great, but what is it”? Please look at the picture below:

The picture above is your metacarpal bones and phalanges.

Code S62.25 shows that it requires at least six placeholder characters

(look at the red bullseye and the number 6). Your thinking, “where do I
get the sixth character space”? You find this by looking to your indented
codes beneath that gives you more specificity such as right, left, and
unspecified. However, the indented codes have a red bullseye denoting
7 required character placeholders. Where do you get the 7th character?
There are boxes that are located either on the current page you are on or
you have to look at the pages before or after. These are called your
seventh character extender boxes. There are many 7th character
extender boxes. In my book they are located directly under code S62.
Notice that your 7th characters end in a letter, NOT A NUMBER. This
7th character further tells the story of this patient’s visit. They are
defined as follows, but note the definitions are defined and dependent on
the chapter of ICD-10 CM chapter you are in. They read slightly
different, for example, in chapter 19 then they would in chapter

A-Initial encounter for closed fracture

B-Initial encounter for open fracture
D-Subsequent encounter for fracture with routine healing
G-Subsequent encounter for fracture with delayed healing
K-Subsequent encounter for fracture with nonunion
P-Subsequent encounter for fracture with malunion
S-Sequela

By adding this 7th character to the code, you meet the requirements for
your code to be valid. If you did not add this character, do you know
what would happen? Your claim would be denied, your practice would
not receive payment for that procedure line and it makes more work for
someone else to fix. Of course, we do have claim scrubbers now that
hopefully would catch this before it went to the clearing house but it all
begins with us, the coder’s, making sure it is coded correctly. Now are
you seeing why these conventions and rules are so important?

Placeholder Character: Placeholder characters are signified by using

the letter X. Remember the saying “X marks the spot”, well in this case
X saves the spot. When do we use this? When your code REQUIRES
a certain number of placeholders (p.s. the period (.) in a code is not a
place holder). You will see this a lot when you get into chapter 19 and
specifically your “T” codes. The X simply means it is holding a space
for right now.

NEC: Not elsewhere classified, when seen in either the alphabetic or

tabular portion of your ICD-10 CM Book means that the book does not
have a code for that exact condition and you MUST use the code that
states “other specified”. Next to NEC in my coding book, I have
students write the word Book is not specific enough.

NOS: Not otherwise specified, which means “unspecified”. Next to

NOS I have students write Provider was not specific enough. There are
times you must refer to your provider and have them be more specific.
**Excludes 1: Not coded here. I have a star next to this because I
cannot overstate enough how important it is to always look before and
after the code descriptor to see what it includes and what it does not
include. What should jump out at you is that Excludes 1 is written in
dark black. When you see excludes 1, it will give you a list of codes that
YOU CANNOT CODE IN CONJUNCTION WITH THE CODE
YOU ARE LOOKING AT. For example, please look at code E05-
Thyrotoxicosis (hyperthyroidism-p.s., when you see words in
parenthesis, this means that the code CAN ALSO means whatever you
see in parenthesis-yup ( ) is a coding convention)! Notice the Excludes
1 box- “chronic thyroiditis with transient thyrotoxicosis (E06.2). You
cannot code both E05 and E06.2 together. CANNOT! This is usually
because the conditions do not occur at the same time.

**Excludes 2: Not included here Please look at code F20

Schizophrenia. You have an excludes 1 note at this code, but look
further and you will see an Excludes 2 box. This time, the box is
written in grey. I tell my students to think of it as a “grey matter”; its
not good but its not bad, it’s in between. Excludes 2 means, if
necessary, you may use the codes under excludes 2. It is acceptable, if
deemed necessary.

***Etiology/Manifestation convention (“code first”, “use additional

code” and “in diseases classified elsewhere” notes). An extremely easy
way to remember this is E comes before M. Etiology comes before the
Manifestation. I’d like to say I thought of this, but I didn’t but it sure
helped me to remember the coding convention.

Without a doubt, you will be expected to know this coding convention

for your exam. Certain diseases or conditions trigger another reaction.
Again, think of coding as a story and you are the narrator. You are
responsible to tell the story and history of events solely based on the
documentation presented to you. You must know what is coded first
and what follows. How do you know this? Our books will direct us.
Here is an example. Please look at code A41 Other sepsis. Directly
underneath this it states Code first in Red. Stop and think for a
moment, many diseases do not show up on their own and although I am
not a physician, just by living life we have come to understand how this
body works. Sepsis, to the best of my understanding, is the result of
another condition going on in the body, which causes a poising in the
blood system. Example: A young woman presents with fever, chills,
low blood pressure and elevated white count. These are all symptoms of
septicemia. Upon pelvic exam, the patient is in extreme discomfort
exam and the provider feels she has a rupture cyst. Tests were run and
she did in fact have a rupture cyst on her right ovary. Why did the
patient leave the house? Because of the ruptured cyst. What did the
ruptured cyst produce? Septicemia. Follow the sequence of events? E
BEFORE M

The code will always give you directives on what to do. If states, “code
first”-you code the condition referenced first. If it states, “use additional
code”, then you use an additional code.

Signs and Symptoms: It is perfectly permittable to code signs and

symptoms when a definite and definitive diagnosis has not been
documented. However, and this is a big however, you cannot code
signs and symptoms when you DO HAVE A DEFNITIVE
DIAGNOSIS and those symptoms are an integral part of the condition.

Here is an example: Patient presents with fever, vomiting and

abdominal pain. The provider states in his/her documentation that the
patient has appendicitis. Would you also code the signs and symptoms?
No. Why? Because fever, abdominal pain and vomiting are assumed
correlations with appendicitis.

Here is another example: Patient presents with fever, vomiting, ankle

pain and abdominal pain. The provider documents that the patient has
appendicitis. Would you code the signs and symptoms? Only the ankle
pain. Why? Because ankle pain has no correlation to appendicitis
unless our appendix has now been in relocated in the ankle. Little joke
there. You get the point.
Sequela (Late Effects): Sequela means residual effects from a previous
condition. Sequela has no time frame of when it can occur. An
example of Sequela is arthritis from a broken leg. The documentation
may state that patient had a broken ankle but is now being seen for
“secondary” arthritis. The arthritis, in a sense, is the result of the
broken ankle (or caused by). The example we see frequently is a scar
formation from a previous injury. The scar did not appear on its own.
It was the result of a previous injury.

Laterality: When I was a coder in orthopaedic surgery, I cannot tell

you how many times the laterality was not specified. Now that we have
ICD-10, there absolutely no reason to ever have an ICD 10 code that
does not specific right and left. Here is a testing strategy I teach my
students:

When we are dealing with the right side, it will usually be a 1

When we are dealing with the left side, it will usually be a 2
Many bilateral codes (certainly not all) will end in a 3
Many (not all) unspecified codes usually end with a 9 or 0

Why is this important? Because it will help students on their national

coding exam. If you see that the documentation states left, you know
you will be looking for a code that has a 2 at the end (usually in the fifth
or sixth character space). Why? Because 2 signifies the left side.

ICD-10 CM Official Guidelines

I will be focusing on several Coding Guidelines but not all. The ones I
will focus on are ones that I believe will be asked of you on your exam.
We go into much more extensive teaching on your lecture and
PowerPoint.

Tabbing your Books: Being organized is essential as a coder, as a

student and in preparation for your exam. Each Chapter in your
Coding Conventions and especially your Coding Guidelines should be
tabbed so that you can easily access the area they are asking you on the
 exam. Also, each alphabetic and tabular chapter must be tabbed. What
this means is you get tabs from any drug store and use a laundry maker
(so it does not smudge) and go chapter by chapter and Tab the beginning
of your A, B, C and so on. Likewise, you also Tab your Coding
Guideline Chapters (i.e. Chapter 1-which I put as HIV)

Chapter 1: Certain Infectious and parasitic Diseases (A00-B99)

You will be asked a question on the exam about HIV and AIDS. The
questions to ask is:

1. Why did the patient leave the house?

2. Does the patient already have a confirmed case of HIV?
3. Is the condition related or unrelated to the HIV?
You MUST follow the coding sequence/order the coding guidelines require.
It is not a suggestion; it is a requirement. ***Look with me at Chapter 1,
bullet point 2 Selection and sequencing of HIV codes
(b) Patient with HIV disease admitted for unrelated condition
If a patient with HIV disease is admitted for an unrelated condition (such as
traumatic injury), the code for the unrelated condition (e.g. the nature of injury
code) should be THE PRINCIPAL DIAGNOSIS. Other diagnoses would be
B20 FOLLOWED BY ADDITIONAL DIAGNOSIS CODES FOR ALL
REPORTED HIV-RELATED CONDITIONS.
Example: The patient has a broken ankle but also has HIV. He goes to see
the orthopaedic provider. What would you code first? The broken ankle.
Why? Because the broken ankle is unrelated to the fact that he/she has HIV.
This does not mean you would not code the HIV, but that you would code it
as a secondary diagnosis.
**Code Descriptor taken from the AAPC Expert Edition 2020 Published by
AAPC-Integrity Coding takes no credit for this.
Sepsis: Too much information to go over in guide sheet alone. Please be
sure to listen to the attached lecture for all notes. **Very Important

Chapter 2: Neoplasms (C00-D49)**Refer to your audio lecture

First, you need to know and have your neoplasm table tabbed within your
ICD-10 CM Book. Your Neoplasm Table is immediately after (or it is in my
ICD-10 CM Book) your Alphabetic Index. Stop now please and tab this.
When you look at your Neoplasm Table I want you to stop and ask yourself,
“what is the pattern here”? Notice first that this table is set up like a spread
sheet. You have the headings of “Neoplasm, Malignant Primary, Malignant
Secondary, CA in situ, Benign, Uncertain Behavior, Unspecified Behavior”.
Let’s look first at the main heading Neoplasm, neoplastic. What do you
notice? They are categorized in alphabetic order (i.e. abdomen, abdominal).
Within each anatomic category you have subheadings (indented i.e. cavity,
organ viscera), which are also….you guessed it alphabetic. As simplistic as
this sounds, for me it made coding much easier to understand because I had
some logistics that helped me look up a code. You will choose the correct
code by choosing the correct type of malignancy and again this is a GUIDE,
YOU ALWAYS CONFIRM THE CODE YOU ARE GUIDED TO IN
YOUR TABULAR. So, let us practice. If you were looking up a code for
neoplasm of the urinary bladder, where would you look first? Alphabetically,
look up bladder and in parenthesis you will see it states urinary. From here,
based on your documentation, you would then ask if it is the primary site, the
secondary site, in situ, benign, uncertain behavior or unspecified behavior.
Never guess and you can also confirm this by any pathology documentation as
well.
How you code for neoplasms or any diagnosis is based on documentation and
asking yourself “why did the patient leave the house”. When the reason for
the visit is for the primary site of malignancy, then you code for the primary
site. If the reason for the visit is because the primary malignancy has now
spread to a secondary site, called metastasis, you code for the secondary site
FIRST. You will hear me go over this during the lecture so do not worry.
Testing Tip: When code for neoplasms, and it is confirmed as a neoplasm
these codes will usually begin with a C. Think of C as carcinoma and it will
help your process of elimination. AAPC’s ICD-10 CM Book has a great table
within chapter 2 that help you to code correctly as well.
Coding for Anemia and Dehydration-Do Not Skim Over these guidelines in
your coding book. Questions to ask yourself:
1. Is the reason for the anemia associated with the malignancy or THE
TREATMENT FOR THE MALIGNANCY? This is where
sequencing comes into play. A correct code sequenced in an incorrect
manner equals a wrong answer on your exam. ***Coding guidelines
tell us in bullet point 2 of chapter 2 states: When the
admission/encounter is for the management of an anemia associated
with an adverse effect of the administration of chemotherapy or
immunotherapy and the only treatment is for the anemia, the anemia
code is SEQUENCED FIRST followed by the appropriate code for the
neoplasm and the adverse effect (T45.1X5 Adverse effect of
antineoplastic and immunosuppressive drugs).
***Taken from the AAPC 2020 Expert Edition page 10-Integrity Coding
takes no credit for this.
2. Is the reason for the dehydration is due to the TREATMENT of the
malignancy? If so, coding guidelines tell us to code the dehydration
FIRST followed by the code for the malignancy.
Testing Tip: When the patient is being seen for chemotherapy or radiation,
your primary code must be a Z Code. Again, why did the patient leave the
house-Chemotherapy. Management of Chemotherapy begins with Z
codes, process of elimination.

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

The most important tips I can give you about coding in this section is to
remember what your guidelines state about they type of diabetes NOT
DOCUMENTED. If your documentation does not state if the patient has
Type 1 or Type 2, it always defaults to Type II.
Testing Tip: This is how I teach my students to map and connect ICD-10
Codes. When coding for diabetes, think of the endocrinologist treating
them. Endocrinologist begins with E and therefore diabetes codes begin
with E. Simplistic but it works.
Questions to ask yourself when coding for Chapter 4:
1. What type of Diabetes is documented?
 2. Does the medical record indicate that the patient uses insulin? If so, use
code E11 and Z79 to indicate long-term use of insulin
3. Is there a complication of underdosing or overdose due to insulin pump
failure? If so, watch to be sure you use the correct “T” code that goes
along with either the overdose or underdose-Do not confuse the two of
them.
Testing Tip: Think of the use of T codes as trouble. Meaning that the
patient is in trouble or has a complication. If the patient is being seen because
of these complications, you must have a T code. The sequencing of the T
code is based on what the guidelines state.
The remainder of your ICD-10 CM Coding Guidelines purchase will be
covered in the accompanying Lecture and PowerPoint. Please listen carefully
and take notes as we go over ICD-10 CM. The notes and testing techniques
given will absolutely help you to understand, and correctly apply the codes in
the correct order.
Thank you for your purchase and if you have any questions, please feel free
to contact [email protected].

Thank you.