ICD-10-­CM AND ICD-10-­PCS

Coding Handbook
with Answers

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2022 Revised Edition

O
NELLY LEON-­CHISEN,
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RHIA

CENTRAL OFFICE ON ICD-10-­CM AND ICD-10-­PCS

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OF THE
AMERICAN HOSPITAL ASSOCIATION
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HEALTH FORUM, INC.

An American Hospital Association Com­pany
Chicago —-1
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 This publication is designed to provide accurate and authoritative information in regard to the subject
­matter covered. It is sold with the understanding that neither the authors nor the publisher are engaged
in rendering l­egal, accounting, or other professional ser­vice. If l­egal advice or other expert assistance
is required, the ser­vices of a competent professional should be sought.

The views expressed in this publication are strictly t­hose of the authors and do not necessarily
represent official positions of the American Hospital Association.

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is a ser­vice mark of the American Hospital Association used u­ nder license by Health
Forum, Inc.

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Copyright © 2011–2021 by Health Forum, Inc., an American Hospital Association com­pany. All rights
reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,

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in any form or by any means, electronic, mechanical, photocopying, recording, or other­wise, without
the prior written permission of the publisher.

Printed in the United States of Amer­i­ca—07/2021

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COVER DESIGN: Mellissa Dempsey
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INTERIOR DESIGN AND TYPOGRAPHY: Fine Print, Ltd.

COMPOSITION: Westchester Publishing Ser­vices
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NEW ILLUSTRATIONS FOR THE 2012 AND SUBSEQUENT EDITIONS: Christoph Blumrich

Figure 32.1 on page 553, “Five Types of Endoleaks,” is from Li, J., Tian, X., Wang, Z. et al. Influ-
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ence of endoleak positions on the pressure shielding ability of stent-graft after endovascular aneurysm
repair (EVAR) of abdominal aortic aneurysm (AAA). BioMed Eng OnLine 15, 135 (2016). https://
doi.org/10.1186/s12938-016-0249-z. Used under Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/) / Unmodified.
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PAPERBACK ISBN: 978-1-55648-460-5, Item Number 148077

DIGITAL ISBN: 978-1-55648-461-2, Item Number P148077

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 Contents

List of T
­ ables and Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
About the Author and Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Acknowl­edgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
How to Use This Handbook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

FORMAT AND CONVENTIONS AND CURRENT CODING PRACTICES

FOR ICD-10-­CM AND ICD-10-­PCS

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1 Introduction to the ICD-10-­CM Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2 ICD-10-­CM Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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3 Uniform Hospital Discharge Data Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4 The Medical Rec­ord as a Source Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

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5 Basic ICD-10-­CM Coding Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6 Basic ICD-10-­CM Coding Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
7 Introduction to the ICD-10-­PCS Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
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8 Basic ICD-10-­PCS Coding Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9 ICD-10-­PCS Root Operations in the Medical and Surgical Section . . . . . . . . . . . . . 85
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10 ICD-10-­PCS Medical-­ and Surgical-­Related, Ancillary,
and New Technology Procedure Sections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
11 Z Codes and External Cause of Morbidity Codes. . . . . . . . . . . . . . . . . . . . . . . . . . 121
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CODING OF SIGNS AND SYMPTOMS

12 Symptoms, Signs, and Ill-­Defined Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

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CODING OF INFECTIOUS AND PARASITIC DISEASES, ENDOCRINE DISEASES

AND METABOLIC DISORDERS, AND M
­ ENTAL DISORDERS
13 Infectious and Parasitic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
14 Endocrine, Nutritional, and Metabolic Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . 161
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15 ­Mental Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

CODING OF DISEASES OF THE BLOOD AND BLOOD-­FORMING ORGANS,

CERTAIN DISORDERS INVOLVING THE IMMUNE MECHANISM,
AND DISEASES OF THE NERVOUS SYSTEM
16 Diseases of the Blood and Blood-­Forming Organs
and Certain Disorders Involving the Immune Mechanism . . . . . . . . . . . . . . . . . . . 195
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17 Diseases of the Ner­vous System and Sense Organs. . . . . . . . . . . . . . . . . . . . . . . 207 vii —0
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 viii
CODING OF DISEASES OF THE RESPIRATORY, DIGESTIVE,
AND GENITOURINARY SYSTEMS
18 Diseases of the Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
19 Diseases of the Digestive System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
20 Diseases of the Genitourinary System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267

CODING OF DISEASES OF THE SKIN AND DISEASES OF THE

MUSCULOSKELETAL SYSTEM
21 Diseases of the Skin and Subcutaneous Tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . 293
22 Diseases of the Musculoskeletal System and Connective Tissue . . . . . . . . . . . . . 303

CODING OF PREGNANCY AND CHILDBIRTH COMPLICATIONS, ABORTION,

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CONGENITAL ANOMALIES, AND PERINATAL CONDITIONS
23 Complications of Pregnancy, Childbirth, and the Puerperium . . . . . . . . . . . . . . . . 325

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24 Abortion and Ec­topic Pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
25 Congenital Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371

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26 Perinatal Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379

CODING OF CIRCULATORY SYSTEM DISEASES AND NEOPLASTIC DISEASES

27 Diseases of the Circulatory System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
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28 Neoplasms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461

CODING OF INJURIES, BURNS, POISONING, AND COMPLICATIONS OF CARE

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29 Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
30 Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
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31 Poisoning, Toxic Effects, Adverse Effects, and Underdosing of Drugs . . . . . . . . . 531

32 Complications of Surgery and Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541

Final Review Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565

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Appendix A Coding and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583

Appendix B Reporting of the Pre­sent on Admission Indicator . . . . . . . . . . . . . . . . . . 591

Appendix C Case Summary Exercises

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(An expanded t­able of contents can be found on page 599.) . . . . . . . . 599

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727

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 List of ­Tables and Figures

FIGURE 1.1 ­Table of Contents from ICD-10-­CM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

FIGURE 7.1 Sample Excerpt of ICD-10-­PCS T

­ able. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
FIGURE 7.2 Structure of Codes in the Medical and Surgical Section . . . . . . . . . . . . . . . . . . . . . 64
FIGURE 7.3 Examples of Body Part Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
­TABLE 7.1 ICD-10-­PCS Sections and Their Corresponding Character Values . . . . . . . . . . . . . 66
­TABLE 7.2 Medical and Surgical Section Body Systems and Values. . . . . . . . . . . . . . . . . . . . . 67
­TABLE 7.3 ICD-10-­PCS Root Operations and Their Corresponding Values. . . . . . . . . . . . . . . . 68

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FIGURE 7.4 Excerpt from ­Table Showing Bilateral Body Part. . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
­TABLE 7.4 Medical and Surgical Section Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

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FIGURE 7.5 Illustrations of Medical and Surgical Section Approaches. . . . . . . . . . . . . . . . . 74–75
FIGURE 7.6 Excerpt from the Device Aggregation T
­ able. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

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FIGURE 8.1 Excerpt of 0FT T
­ able from ICD-10-­PCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
FIGURE 8.2 Excerpt of 0Y6 T
­ able from ICD-10-­PCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
FIGURE 9.1 ­Table Excerpt Demonstrating Location of Root Operation Definition. . . . . . . . . . . . 86

­TABLE 9.1 Root Operations to Take Out Some or All of a Body Part. . . . . . . . . . . . . . . . . . . . . 89
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­TABLE 9.2 Root Operations to Take Out Solids/Fluids/Gases from a Body Part . . . . . . . . . . . . 91
­TABLE 9.3 Root Operations Involving Cutting or Separation Only. . . . . . . . . . . . . . . . . . . . . . . 92
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­TABLE 9.4 Root Operations to Put In/Put Back or Move Some/All of a Body Part. . . . . . . . . . . 93
­TABLE 9.5 Root Operations to Alter the Dia­meter or Route of a Tubular Body Part. . . . . . . . . . 94
­TABLE 9.6 Root Operations That Always Involve a Device. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
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­TABLE 9.7 Root Operations That Involve Examination Only. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

­TABLE 9.8 Root Operations That Include Other Repairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
­TABLE 9.9 Root Operations That Include Other Objectives. . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
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­TABLE 10.1 Medical-­and Surgical-­Related Sections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

FIGURE 10.1 Structure of Codes in the Placement Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
­TABLE 10.2 Placement Section Root Operation Values and Definitions. . . . . . . . . . . . . . . . . . . 103
FIGURE 10.2 Structure of Codes in the Administration Section. . . . . . . . . . . . . . . . . . . . . . . . . . 105
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FIGURE 10.3 Structure of Codes in the Mea­sure­ment and Monitoring Section. . . . . . . . . . . . . . 106
FIGURE 10.4 Structure of Codes in the Extracorporeal or Systemic Assistance
and Per­for­mance Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
FIGURE 10.5 Structure of Codes in the Extracorporeal or Systemic Therapies Section . . . . . . . 108
FIGURE 10.6 Structure of Codes in the Osteopathic Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
FIGURE 10.7 Structure of Codes in the Other Procedures Section . . . . . . . . . . . . . . . . . . . . . . . 111
FIGURE 10.8 Structure of Codes in the Imaging Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
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FIGURE 10.9 Structure of Codes in the Nuclear Medicine Section . . . . . . . . . . . . . . . . . . . . . . . 114
FIGURE 10.10 Structure of Codes in the Radiation Therapy Section. . . . . . . . . . . . . . . . . . . . . . . 115

FIGURE 10.11 Structure of Codes in the Physical Rehabilitation and

Diagnostic Audiology Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
­TABLE 10.3 Physical Rehabilitation and Diagnostic Audiology
Root Types. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
FIGURE 10.12 Structure of Codes in the New Technology Section . . . . . . . . . . . . . . . . . . . . . . . . 119

­TABLE 13.1 Gram-­Negative and Gram-­Positive Bacteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

FIGURE 14.1 Major Organs of the Endocrine System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
FIGURE 15.1 Side View of the Brain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
­TABLE 15.1 Root Type Values in the M
­ ental Health Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
­TABLE 15.2 Root Type Values in the Substance Abuse Treatment Section. . . . . . . . . . . . . . . . 190

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FIGURE 16.1 Four Major Types of Blood Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
The Ner­vous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

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FIGURE 17.1

FIGURE 17.2 The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

­TABLE 17.1 Coding of Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

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FIGURE 17.3 The Ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
FIGURE 18.1 The Respiratory System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
FIGURE 19.1 The Digestive System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
FIGURE 19.2 Excerpt from ICD-10-­PCS T
­ able for Hepatobiliary System Extirpation. . . . . . . . . . 258
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FIGURE 19.3 Illustrations of Bariatric Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
FIGURE 20.1 The Urinary System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
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­TABLE 20.1 Hypertensive Chronic Kidney Disease and Hypertensive

Heart and Chronic Kidney Disease and the Applicable CKD Stages . . . . . . . . . . 273
FIGURE 20.2 The Male Reproductive System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
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FIGURE 20.3 Common Sites of Endometriosis Implantation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

FIGURE 20.4 The Female Reproductive System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
FIGURE 20.5 Breast Reconstruction Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
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FIGURE 21.1 The Skin and Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

FIGURE 22.1 The ­Human Skeleton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
FIGURE 22.2 The Spinal Column. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
­TABLE 22.1 Components of Each Column of the Spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
FIGURE 22.3 Structure of the Spine Involved in Spinal Fusion. . . . . . . . . . . . . . . . . . . . . . . . . . . 315
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FIGURE 22.4 Columns of the Spine, Lateral View. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316

FIGURE 22.5 Types of Spinal Fusion Surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
­TABLE 22.2 Common Fusion and Refusion ICD-10-­PCS Qualifiers. . . . . . . . . . . . . . . . . . . . . . 318
FIGURE 23.1 Primary Organs of the Female Reproductive System. . . . . . . . . . . . . . . . . . . . . . . 327
FIGURE 23.2 Examples of Fetal Pre­sen­ta­tions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
FIGURE 23.3 Structure of Codes in the Obstetrics Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
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FIGURE 24.1 Excerpt from ICD-10-­PCS T
­ able for Abortion Procedures. . . . . . . . . . . . . . . . . . . . 365
FIGURE 27.1 Major Vessels of the Arterial System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
FIGURE 27.2 Major Vessels of the Venous System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
FIGURE 27.3 The Interior of the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
FIGURE 27.4 Decision Tree for Coding Acute Type 1 Myo­car­dial Infarction . . . . . . . . . . . . . . . . 405
FIGURE 27.5 Types of Ce­re­bral Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
FIGURE 27.6 Pacemaker Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
FIGURE 27.7 Angioplasty with Stent Insertion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
FIGURE 27.8 Coronary Artery Bypass Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
FIGURE 27.9 Central Venous Catheter (CVC). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
FIGURE 27.10 Peripherally Inserted Central Catheter (PICC). . . . . . . . . . . . . . . . . . . . . . . . . . . . 450

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FIGURE 27.11 Aorta and Lower Side Branches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453

FIGURE 27.12 Open Aneurysmectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454

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FIGURE 27.13 Open Surgical Aneurysm Repair via Tube Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . 455

FIGURE 27.14 Endovascular Aneurysm Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456

­TABLE 28.1 Section of the Neoplasm T

­ able in the Alphabetic Index

FIGURE 28.1

FIGURE 29.1
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of Diseases and Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
The Lymphatic System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Examples of Open and Closed Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
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FIGURE 29.2 Sample Tabular List Seventh-­Character Values. . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
FIGURE 29.3 Gustilo Classification of Open Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
­TABLE 29.1 Definitions of Terms Used for Qualifiers for “Detachment” Procedures . . . . . . . . . 516
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FIGURE 30.1 Skin Layers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524

FIGURE 31.1 Decision Tree for Coding Adverse Effects of Drugs or Poisoning
Due to Drugs or Medicinal or Biological Substances. . . . . . . . . . . . . . . . . . . . . . . 535
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FIGURE 31.2 Excerpt from ICD-10-­CM T

­ able of Drugs and Chemicals. . . . . . . . . . . . . . . . . . . . 535
­TABLE 32.1 Types of Endoleaks and the ICD-10-­CM Code Assignment. . . . . . . . . . . . . . . . . . 552
FIGURE 32.1 Types of Endoleaks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
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 About the Author and Contributors

Nelly Leon-­Chisen, RHIA, is the executive director of coding and classification at the American
Hospital Association (AHA), where she heads the Central Office on ICD-10-­CM and ICD-10-­PCS
and the Central Office on HCPCS. She represents the AHA as one of the Cooperating Parties
responsible for the development of AHA Coding Clinic® for ICD-10-­CM and ICD-10-­PCS, the
ICD-10-­CM Official Guidelines for Coding and Reporting, and the ICD-10-­PCS Official Coding
Guidelines. She is the executive editor for the AHA Coding Clinic® publications.
Ms. Leon-­Chisen’s other ICD-10 activities include past membership in the ICD-10-­PCS
Technical Advisory Panel, past co-­chair of the Workgroup for Electronic Data Interchange (WEDI)
ICD-10 Implementation Workgroup, and numerous testimonies on ICD-10-­CM and ICD-10-­PCS

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before the ICD-9-­CM Coordination and Maintenance Committee and the National Committee on
Vital and Health Statistics. She was also the AHA lead proj­ect man­ag­er on the joint American Hos-

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pital Association–­American Health Information Management Association (AHIMA) ICD-10-­CM
Field Study. She was a first-­generation AHIMA-­approved ICD-10 Trainer.
Ms. Leon-­Chisen has lectured on ICD-9-­CM, ICD-10, and POA coding, data quality, and
DRGs throughout the United States, Eu­rope, Asia, and Latin Amer­i­ca. She has often served as

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a speaker for the popu­lar AHA Coding Clinic® webinar series. She has broad health information
management (HIM) experience in hospital inpatient and outpatient management, consulting, and
teaching. She has been an instructor in the HIM and Health Information Technology programs for
the University of Illinois and Truman Community College, both in Chicago. She is a past president
of the Chicago Area Health Information Management Association and the recipient of its Dis-
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tinguished Member Award. She is the recipient of the Professional Achievement Award from the
Illinois Health Information Management Association. She was a member of the Advisory Board of
the Health Information Technology Program of DeVry University in Chicago.
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The Central Office on ICD-9-­C M was first created through a written Memorandum of
Understanding between the AHA and the National Center for Health Statistics in 1963 to do the
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following:

• Serve as the U.S. clearing­house for issues related to the use of ICD-9-­CM
• Work with the National Center for Health Statistics and the Centers for Medicare &
Medicaid Ser­vices to maintain the integrity of the classification system
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• Recommend revisions and modifications to the current and ­future revisions of the ICD
• Develop educational material and programs on ICD-9-­CM

The Central Office on ICD-10-­CM and ICD-10-­PCS provides expert advice by serving as
the clearing­house for the dissemination of information on ICD-10-­CM and ICD-10-­PCS.
In 2014, the Central Office s­topped providing ICD-9-­CM advice and fully transitioned to
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ICD-10-­CM/PCS advice while launching the stand-­alone publication AHA Coding Clinic® for ICD-
10-­CM and ICD-10-­PCS.

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 Acknowl­edgments

Nelly Leon-­Chisen gratefully acknowledges the invaluable contributions of Anita Rapier, Gretchen
Young-­Charles, and Denene M. Harper, members of the American Hospital Association’s Central
Office on ICD-10-­CM and ICD-10-­PCS, who assisted in the revision and review of the manuscript
for the handbook and the case summary exercises, as well as the preparation of instructors’ ancil-
lary materials.

Anita Rapier, RHIT, CCS, is a se­nior coding con­sul­tant at the AHA Central Office
on ICD-10-­CM and ICD-10-­PCS. She is also the managing editor of AHA Coding
Clinic® for ICD-10-­CM and ICD-10-­PCS, for which she is responsible for developing

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educational material. She has more than 25 years of experience in health informa-
tion management and has held several positions in HIM, including education, quality,
compliance, hospital-­based outpatient and acute care, and long-­term care. Ms. Rapier

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has presented numerous educational seminars and has authored articles on coding and
compliance. She is also a speaker for the popu­lar AHA Coding Clinic® webinar series.

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Gretchen Young-­Charles, RHIA, is a se­nior coding con­sul­tant at the AHA Central
Office on ICD-10-­CM and ICD-10-­PCS. In this role, she develops educational articles
on official coding advice for publication in AHA Coding Clinic® for ICD-10-­CM
and ICD-10-­PCS. Ms. Young-­Charles has more than 25 years of experience in the
HIM field. She has worked in numerous HIM roles, including education, quality, and
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hospital-­based outpatient and acute care. She also spent a number of years with the Peer
Review Organ­ization for the state of Illinois. She is also a speaker for the popu­lar AHA
Coding Clinic® webinar series.
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Denene M. Harper, RHIA, is a se­nior coding con­sul­tant at the AHA Central Office on
ICD-10-­CM and ICD-10-­PCS. She is responsible for writing articles on official coding
advice for publication in AHA Coding Clinic® for ICD-10-­CM and ICD-10-­PCS. Ms.
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Harper has more than 25 years of experience in the HIM field, including hospital-­based
outpatient and acute care, utilization review, and quality improvement. She is also the
moderator for the popu­lar AHA Coding Clinic® webinar series.
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In addition, Nelly Leon-­Chisen gratefully acknowledges the significant contributions of

Janatha R. Ashton, MS, RHIA, who authored the original case summary exercises in appendix C, and
Therese M. (Teri) Jorwic, who revised ­those exercises and converted them from ICD-9 to ICD-10.

Therese M. (Teri) Jorwic, MPH, RHIA, CCS, CCS-­P, FAHIMA, is a former assis-
tant professor in Health Information Management at the University of Illinois at Chi-
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cago. She has presented numerous workshops and developed educational material for
in-­class and online courses on ICD-10-­CM/PCS, ICD-9-­CM, and HCPCS/CPT coding
as well as on reimbursement systems for hospitals, physicians, and other health care
providers. She also has presented workshops for associations and served as external
faculty for the AHIMA ICD-10 Acad­emy programs.

Thanks are due to Richard Hill, a se­nior editor at the American Hospital Association, who
read the author’s drafts and helped me to say in plain En­glish what I wanted to say, even without
being a coding professional himself. Additional thanks are due to Jennifer Gillespie, who has served —-1
as the production man­ag­er since the 2019 edition. xiii —0
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 xiv
A sincere thanks to the representatives of the Cooperating Parties: Donna Pickett, RHIA,
MPH; Mady Hue, RHIA; and Sue Bowman, RHIA, CCS—­whose collaboration and friendship
continue to make Coding Clinic advice and the Official Coding Guidelines a real­ity.
Thanks are also in order for the coding professionals and instructors who ­were early adopters
of this handbook, and who provided many helpful suggestions (and, the author is a tad ashamed
to say, corrections) to the early versions of the handbook. Their efforts made this work a better
resource for students. Special thanks in this regard are due to Minnette Terlep, Linda Holtzman,
Ann Zeisset, Lisa DeLiberto, Margaret Foley, Alicia Reinbolt, Noemi Staniszewski, Pat Poli, and
Anne Pavlik.
Fi­nally, Ms. Leon-­Chisen wishes to acknowledge the tradition of excellence in coding edu-
cation established by Faye Brown through the ICD-9-­CM Coding Handbook. Ms. Brown’s work
served as the foundation on which the pre­sent handbook was built. The author humbly hopes this
handbook can continue educating generations of coding professionals as the field implements
ICD-10-­CM and ICD-10-­PCS.

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 How to Use This Handbook

This edition of the handbook is designed as a versatile resource:

• Textbook for academic programs in health information technology and administration

• Text for in-­service training programs
• Self-­instructional guide for individuals who would like to learn coding or refresh their
skills outside a formal program
• Reference tool for general use in the workplace

The general and basic areas of information covered in chapters 1 through 10 are designed to

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meet the requirements of vari­ous basic courses on the use of ICD-10-­CM and ICD-10-­PCS. They
may also be used as a foundation for moving on to the study of individual chapters of ICD-10-­CM

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and ICD-10-­PCS. Chapters 11 through 32 of the handbook include advanced material for both
continuing education students and professionals in the field.
This handbook is designed to be used in conjunction with the ICD-10-­CM and ICD-10-­PCS
coding manuals (­either in book or PDF format) or comparable software. The ICD-10-­CM and ICD-

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10-­PCS classifications must be consulted throughout the learning pro­cess, and the material in this
text cannot be mastered without using them. The official versions are available in PDF format from
the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (ICD-
10-­CM) and the Centers for Medicare & Medicaid Ser­vices (ICD-10-­PCS). Several publishers offer
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unofficial printed versions. ­There may be minor variations between the way material is displayed in
this handbook and the way it is displayed in printed or digital versions.
The chapters in this handbook are not arranged in the same sequence as the chapters in ICD-
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10-­CM or ICD-10-­PCS. The first section of the handbook (chapters 1–11) provides discussions
on the format and conventions followed in ICD-10-­CM and ICD-10-­PCS, as well as basic coding
guidelines and introductory material on Z codes and External cause of morbidity codes. The next
eight sections (chapters 12–32) pro­gress from the less-­complicated ICD-10-­CM/PCS chapters to
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the more difficult. Faculty in academic and in-­service programs can rearrange this sequence to suit
their par­tic­u­lar course outlines.
Appendix A, Coding and Reimbursement, contains basic information on the role of coding
with reimbursement models for hospitals, physician practices, and other health care settings.
Appendix B, Reporting of the Pre­sent on Admission Indicator, contains information on the
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reporting of the Medicare requirement associated with the hospital inpatient reporting of all
ICD-10-­CM diagnosis codes.
Appendix C, Case Summary Exercises, is designed for students who have learned the basic
coding princi­ples and need additional practice applying the princi­ples to ­actual cases. The exercises
are geared for students with beginning to intermediate levels of knowledge. The case summaries
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are based on a­ ctual health rec­ords of both inpatients and outpatients. The patients described often
have multiple conditions that may or may not relate to the current episode of care. Some exercises
include several episodes of care for a patient in vari­ous settings.
Additional resources for educators are available for download on the AHA Central Office
website: www​.­CodingClinicAdvisor​.­com. AHA offers materials designed to supplement classroom
work and exercises in this handbook. Available materials include slide decks covering the key points
of each chapter and exercise test banks. Please visit www​.C ­ odingClinicAdvisor​.­com and register
as an educator to download ­these training materials.
Students using the handbook edition without answers ­will need to ask their instructors for —-1
the answers. ­After students have completed the exercises, they can check their answers against the xv —0
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 xvi
instructor’s edition, which lists the appropriate codes for each exercise, with the codes for the prin-
cipal diagnosis and principal procedure sequenced first. Explanatory comments discuss why certain
codes are appropriate and ­others are not and why some conditions listed in the case summaries are
not coded at all. The comments also indicate how the principal diagnosis and procedure codes ­were
designated, and which symptoms are inherent to certain conditions and so are not coded separately.
The ICD-10-­CM Official Guidelines for Coding and Reporting and the ICD-10-­PCS Official
Coding Guidelines, referenced throughout this handbook, may be downloaded from the AHA Cen-
tral Office website: www​.­CodingClinicAdvisor​.­com.
To use this handbook effectively, readers should work through the coding examples provided
throughout the text ­until they fully understand the coding princi­ples ­under discussion. Readers
should be able to arrive at correct code assignments by following the instructions provided and
reviewing the pertinent handbook material ­until it is fully understood. Exercises in the body of
each chapter should be completed as they come up in the discussion, rather than at the end of the
chapter or section. Most chapters provide a review exercise with additional material that covers the
entire chapter. ­There is also a final review exercise, located before appendix A in this handbook,

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that offers additional coding practice. Answers to all of ­these exercises are provided in the edition
with answers.

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The handbook follows three conventions:

• In some examples, a hyphen is used at the end of a code to indicate that additional
characters are required but cannot be assigned in the example ­because certain

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information needed for assignment of ­these characters is not given. This is done to
emphasize concepts and specific guidelines without ­going too deeply into specific coding
situations.
• The underlining of codes in text examples indicates correct sequencing; that is, the
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underlined code must be sequenced first in that par­tic­u­lar combination of codes. When no
code is underlined, ­there is no implicit reason why any of the codes in the series should
be sequenced first. In ­actual coding, of course, other information in the health rec­ord may
dictate a dif­fer­ent sequence. This underlining convention is used in the handbook solely
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as a teaching device. It is not an ele­ment of the ICD-10-­CM/PCS coding system.

• In the edition with answers, the underlining of words in exercise questions indicates
the appropriate terms to be referenced in using the alphabetic indexes. The under-
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lining of codes in the answer column of the exercises indicates correct code sequenc-
ing, as it does in the examples in the main text.

Changes in Code Usage

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Official coding guidelines approved by the four Cooperating Parties responsible for adminis-
tering the ICD-10-­CM and ICD-10-­PCS systems in the United States (American Hospital Associa-
tion, American Health Information Management Association, Centers for Medicare & Medicaid
Ser­vices, and National Center for Health Statistics) are published on a yearly basis. The fiscal year
2022 (FY 2022) updates to the ICD-10-­CM and ICD-10-­PCS code sets have been incorporated into
this edition of the handbook.
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AHA Coding Clinic® for ICD-10-­CM and ICD-10-­PCS advice published through Second
Quarter 2021 has been included in this edition of the handbook.

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 Format AND Conventions
AND Current Coding Practices

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FOR ICD-10-­CM AND ICD-10-­PCS

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 CHAPTER 1 Introduction to the
ICD-10-­CM Classification

CHAPTER OVERVIEW LEARNING OUTCOMES

• ICD-10-­CM is a medical diagnosis classification system. ­ fter studying this chapter, you should
A
• The Tabular List of Diseases and Injuries displays codes in be able to:
alphanumeric order. ­There are three-­, four-­, five-­, six-­, and seven-­ Explain the basic princi­ples of the
character codes. medical classification system
• The Alphabetic Index of Diseases and Injuries uses a specific ICD-10- ­CM.

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pattern to the indentions. Demonstrate understanding of the
—­Main terms are flush to the left-­hand margin. three-­, four-­, five-­, six-­, and
seven-­character subdivisions.

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—­Subterms are indented. The more specific the subterm, the
farther the indent. Explain the alphabetization rules and
indention patterns.
—­Carryover lines are two indents from the indent level of the

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preceding line.
—­­There are also strict alphabetization rules.
TERM TO KNOW
ICD-10-­CM
International Classification of
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Diseases, Tenth Revision, Clinical
Modification; a medical classification
system used for the collection of
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information regarding disease and
injury
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 4
INTRODUCTION
CHAPTER 1 The International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-­CM)
Introduction to is a clinical modification of the World Health Organ­ization’s (WHO) ICD-10. It expands ICD-10
the ICD-10-CM codes to facilitate more precise coding of clinical diagnoses. ICD-10-­CM is a closed classification
Classification system—it provides one and only one place to classify each condition. Despite the large number of
dif­fer­ent conditions to be classified, the system must limit its size to be usable. Certain conditions
that occur infrequently or are of low importance are often grouped together in residual codes labeled
“other” or “not elsewhere classified.” A final residual category is provided for diagnoses not stated
specifically enough to permit more precise classification. Occasionally, ­these two residual groups
are combined in one code.
Medical coding professionals must understand the basic princi­ples ­behind the classification
system to use ICD-10-­CM appropriately and effectively. This knowledge is also the basis for under-
standing and applying the official coding advice provided through the AHA Coding Clinic®, published
by the Central Office of the American Hospital Association. It is impor­tant for medical coding profes-

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sionals in all health care settings to keep current with the ICD-10-­CM Official Guidelines for Coding
and Reporting, as well as the Coding Clinic. This official advice is developed through the editorial

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board for the Coding Clinic and is approved by the four cooperating parties: the American Hospital
Association (AHA), the American Health Information Management Association (AHIMA), the Cen-
ters for Medicare & Medicaid Ser­vices (CMS), and the Centers for Disease Control and Prevention’s
(CDC) National Center for Health Statistics (NCHS). In addition, representatives from several physi-

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cian specialty groups provide the Coding Clinic editorial advisory board with clinical input.

DEVELOPMENT OF ICD-10-­CM
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ICD-10 was released by WHO in 1993 and contains only diagnosis codes. ICD-10-­CM is the
clinical modification developed ­under the leadership of the NCHS for use in the United States.
ICD-10-­CM was officially implemented in the United States in October 2015. All modifications to
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ICD-10 need to conform to the WHO conventions for ICD. ICD-10-­CM is in the public domain.
However, neither the codes nor the code titles may be changed except through the Coordination
and Maintenance Pro­cess overseen jointly by the CDC and CMS. ICD-10-­CM consists of more
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than 72,000 codes.

FORMAT
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ICD-10-­CM is divided into the Tabular List and the Alphabetic Index. The Tabular List is an alpha-
numeric list of codes divided into chapters based on body system or condition. The Index is an
alphabetical list of terms and their corresponding codes.

TABULAR LIST OF DISEASES AND INJURIES

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The main classification of diseases and injuries in the Tabular List of Diseases and Injuries consists
of 22 chapters. (See the ­table of contents reproduced in figure 1.1.) Approximately half of the first
21 chapters are devoted to conditions that affect a specific body system; the rest classify conditions
according to etiology. Chapter 2, for example, classifies neoplasms of all body systems, whereas
chapter 10 addresses diseases of the respiratory system only. Chapter 22 contains codes for special
purposes.
In addition, Z codes represent ­factors influencing health status and contact with health ser­
-1— vices that may be recorded as diagnoses. V, W, X, and Y codes are used to indicate the external
0— circumstances responsible for injuries and certain other conditions. V, W, X, Y, and Z codes are
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 5

FIGURE 1.1   Table of Contents from ICD-10-­CM

CHAPTER 1
Introduction to
the ICD-10-CM
Preface
Classification
Introduction

ICD-10-­CM Conventions

ICD-10-­CM Official Guidelines for Coding and Reporting

ICD-10-­CM Index to Diseases and Injuries

ICD-10-­CM Neoplasm ­Table

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­Table of Drugs and Chemicals

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ICD-10-­CM Index to External ­Causes

ICD-10-­CM Tabular List of Diseases and Injuries

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CHAPTER 1—­Certain infectious and parasitic diseases
CHAPTER 2—­Neoplasms
CHAPTER 3—­Diseases of the blood and blood-­forming organs and certain
disorders involving the immune mechanism
CHAPTER 4—­Endocrine, nutritional and metabolic diseases
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CHAPTER 5—­Mental, behavioral and neurodevelopmental disorders
CHAPTER 6—­Diseases of the ner­vous system
CHAPTER 7—­Diseases of the eye and adnexa
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CHAPTER 8—­Diseases of the ear and mastoid pro­cess
CHAPTER 9—­Diseases of the circulatory system
CHAPTER 10—­Diseases of the respiratory system
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CHAPTER 11—­Diseases of the digestive system

CHAPTER 12—­Diseases of the skin and subcutaneous tissue
CHAPTER 13—­Diseases of the musculoskeletal system and connective tissue
CHAPTER 14—­Diseases of the genitourinary system
CHAPTER 15—­P regnancy, childbirth and the puerperium
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CHAPTER 16—­Certain conditions originating in the perinatal period

CHAPTER 17—­Congenital malformations, deformations and chromosomal
abnormalities
CHAPTER 18—­Symptoms, signs and abnormal clinical and laboratory findings
not elsewhere classified
CHAPTER 19—­Injury, poisoning and certain other consequences of external c­ auses
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CHAPTER 20—­External ­causes of morbidity

CHAPTER 21—­Factors influencing health status and contact with health ser­vices
CHAPTER 22—­Codes for special purposes

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 6
reviewed briefly in chapter 12 of this handbook and in more detail in the chapters discussing the
conditions to which they apply.
CHAPTER 1 The variation in chapter titles in ICD-10-­CM’s ­table of contents represents the compromises
Introduction to made during the development of a statistical classification system based partially on etiology, par-
the ICD-10-CM tially on anatomical site, and partially on the circumstances of onset. The result is a classification
Classification system based on multiple axes. In contrast, a single-­axis classification would be based entirely on
the etiology of the disease, the anatomical site of the disease, or the nature of the disease pro­cess.
Codes in the Tabular List appear in alphanumeric order. References from the Alphabetic
Index to the Tabular List are by code number, not by page number. Code numbers and titles appear
in bold type in the Tabular List. Instructional notes that apply to the section, category, or subcat-
egory are also included in the Tabular List.

Code Structure
All ICD-10-­CM codes have an alphanumeric structure, with all codes starting with an alpha-

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betical character. The basic code structure consists of three characters. A decimal point is used to
separate the basic three-­character category code from its subcategory and subclassifications (for

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example, L98.491). Most ICD-10-­CM codes contain a maximum of six characters, with a few cat-
egories having a seventh-­character code value.
Each chapter in the main classification is structured to provide the following subdivisions:

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• Sections (groups of three-­character categories), e.g., Infections of the skin and subcutane-
ous tissue (L00–­L08)
• Categories (three-­character code numbers), e.g., L02, Cutaneous abscess, furuncle and
carbuncle
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• Subcategories (four-­character code numbers), e.g., L02.2, Cutaneous abscess, furuncle
and carbuncle of trunk
• Fifth-­, sixth-­, or seventh-­character subclassifications (five-­, six-­, or seven-­character code
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numbers), e.g., L02.211, Cutaneous abscess of abdominal wall
The ICD-10-­CM Tabular List contains categories, subcategories, and codes. The basic code
used to classify a par­tic­u­lar disease or injury consists of three characters and is called a category
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(e.g., K29, Gastritis and duodenitis). Characters for categories, subcategories, and codes may be
­either a letter or a number. All categories are three characters. A three-­character category that has
no further subdivision is equivalent to a code. Subcategories are e­ ither four or five characters. Codes
may be three, four, five, six, or seven characters. That is, each level of subdivision ­after a category
is a subcategory. The final level of subdivision is a code.
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Codes that have applicable seventh characters are still referred to as codes, not subcategories.
A code that has an applicable seventh character is considered invalid without the seventh character.
For example:

• K29 Gastritis and duodenitis (category)

K29.0 Acute gastritis (subcategory)
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K29.00 Acute gastritis without bleeding (code)

• R10 Abdominal and pelvic pain (category)

R10.8 Other abdominal pain (subcategory)
R10.81 Abdominal tenderness (subcategory)
R10.811 Right upper quadrant (code)
abdominal tenderness

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 7
Placeholder Character
ICD-10-­CM uses the letter “x” as a placeholder character in certain codes to allow for f­ uture CHAPTER 1
expansion. An example of this may be seen at the poisoning, adverse effect, underdosing (T36–­T50), Introduction to
and toxic effects (T51–­T65) codes. For t­hese categories, the sixth character represents the intent: the ICD-10-CM
accidental, intentional self-­harm, assault, undetermined, adverse effect, or underdosing. Where a
Classification
placeholder exists, the “x” must be used for the code to be considered valid.
For example, “x” is used as the fifth character in the following codes where the sixth character
of “1” represents accidental, and “2” represents intentional self-­harm:

T37.5x1 Poisoning by antiviral drugs, accidental (unintentional)

T37.5x2 Poisoning by antiviral drugs, intentional self-­harm
T52.0x1 Toxic effect of petroleum products, accidental (unintentional)
T52.0x2 Toxic effect of petroleum products, intentional self-­harm

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Certain categories have an additional seventh-­ character value. The applicable seventh-­
character value is required for all codes within the category, or as the notes in the Tabular List
instruct. The seventh-­character value must always be the seventh character in the code. If a code

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is not a full six characters, a placeholder character “x” must be used to fill in the empty characters
when a seventh-­character value is required. Seventh-­character values can be seen in chapter 15 of
ICD-10-­CM, Pregnancy, Childbirth and the Puerperium (O00–­O9A), as well as in chapter 19 of

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ICD-10-­CM, Injury, Poisoning and Certain Other Consequences of External ­Causes (S00–­T88),
and in chapter 20 of ICD-10-­CM, External ­Causes of Morbidity (V00–­V99).
An example of the use of the placeholder character “x” and the seventh-­character value is
shown ­here with an excerpt from the Tabular List:
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T16 Foreign body in ear
Includes: foreign body in auditory canal
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The appropriate 7th character values are to be added to each code from
category T16:
A initial encounter
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D subsequent encounter
S sequela
T16.1 Foreign body in right ear
T16.2 Foreign body in left ear
T16.9 Foreign body in ear, unspecified ear
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A child pre­sents to the emergency department with a bean in the right ear. The m ­ other has brought
the child ­because she was not able to remove the bean at home. This encounter would be assigned
code T16.1xxA. The Tabular List shows subcategory T16.1 as the descriptor best fitting this sce-
nario. Category T16 requires a seventh-­character value. B­ ecause the code subcategory has only four
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characters (T16.1), the placeholder “x” is inserted twice to preserve the code structure before the
seventh character “A” is added to report this as the initial encounter.

ALPHABETIC INDEX
The Alphabetic Index consists of the Index of Diseases and Injuries, the Index to External C
­ auses,
the Neoplasm ­Table, and the ­Table of Drugs and Chemicals.
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 8
The Alphabetic Index includes entries for main terms, subterms, and more specific subterms.
An indented format is used for ease of reference.
CHAPTER 1 Main terms identify disease conditions or injuries. Subterms indicate site, type, or etiology
Introduction to for conditions or injuries. For example, acute appendicitis is listed u­ nder Appendicitis, acute, and
the ICD-10-CM stress fracture is listed u­ nder Fracture, traumatic, stress. Occasionally, it is necessary to think of a
Classification synonym or another alternative term in order to locate the correct entry. ­There are, however, excep-
tions to this general rule, including the following:
• Congenital conditions are often indexed ­under the main term Anomaly rather than ­under
the name of the condition.
• Conditions that complicate pregnancy, childbirth, or the puerperium are usually found
­under such terms as Delivery, Pregnancy, and Puerperal. They may also appear ­under
the main term for the condition causing the complication by referencing the subterm
“complicating childbirth (­labor),” “complicating pregnancy,” or “complicating puerpe-
rium.” (Examples of t­hese types of entries appear ­under the main term Hypertension

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in the Alphabetic Index.)
• Many of the complications of medical or surgical care are indexed ­under the term

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Complications rather than ­under the name of the condition.
• Late effects of an ­earlier condition can be found ­under Sequelae, or u­ nder the condition
(as in the case of traumatic injuries).

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A clear understanding of the format of the Alphabetic Index is a prerequisite for accurate
coding. Understanding the indention pattern of the entries is a very impor­tant part of learning how
to use the Index. A variety of vendors provide printed versions and o­ thers have computer programs
for coding, but the format may not be consistent across versions. The PDF version of the Index from
the NCHS represents each indention level by a hyphen. In general, however, the following pattern
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is used by several code­book publishers:
• Main terms are set flush with the left-­hand margin. They are printed in bold type and
begin with a capital letter.
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• Subterms are indented one standard indention (equivalent to about two word-­processing
spaces) to the right ­under the main term. They are printed in regular type and begin with
a lowercase letter.
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• More specific subterms are indented farther and farther to the right as needed, always indented
by one standard indention from the preceding subterm and listed in alphabetical order.
• A dash (-) at the end of an index entry indicates that additional characters are required.
Carryover lines are indented two standard indentions from the level of the preceding line.
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Carryover lines are used only when the complete entry cannot fit on a single line. They are indented
farther to avoid confusion with subterm entries.
In printed versions, entries are presented in two, three, or four columns per page, dictionary style.
The subterms listed ­under the main term Metrorrhagia in the following entry provide an
example:
Fo

Metrorrhagia N92.1 [main term]

climacteric N92.4 [subterm]
menopausal N92.4 [subterm]
postpartum NEC (atonic) (following delivery [subterm]
   of placenta) O72.1 [carryover line]
delayed or secondary O72.2 [more specific subterm]
-1— preclimacteric or premenopausal N92.4 [subterm]
0— psychogenic F45.8 [subterm]
+1—

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 9
Each of the subterms (climacteric, menopausal, postpartum, preclimacteric, and psychogenic)
is indented one standard indention from the level of the main term and is listed in alphabetical order.
The fifth line is a carryover line set two standard indentions from the preceding line. The sixth line CHAPTER 1
is a more specific entry (“delayed or secondary” ­under the subterm “postpartum”). Introduction to
the ICD-10-CM
Classification
EXERCISE 1.1

A reproduction of a page from the Alphabetic Index is shown below. Label the numbered
lines as ­either main terms, subterms, or carryover lines. Each hyphen is meant to represent
one level of indention.

1. Railroad neurosis F48.8 Main term

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2. Railway spine F48.8 Main term

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Raised—­see also Elevated
3. -­-­antibody titer R76.0 Carryover line

Rake teeth, tooth M26.39
Rales R09.89
4. Ramifying renal pelvis Q63.8 O Main term
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Ramsay-­Hunt disease or syndrome—(see also
5. -­-­Hunt’s disease) B02.21 Carryover line
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6. -­meaning dyssynergia cerebellaris myoclonica G11.1 Subterm

Ranula K11.6
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-­congenital Q38.4

7. Rape Main term

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8. -­adult Subterm
-­-­confirmed T74.21
-­-­suspected T76.21
-­alleged, observation or examination, ruled out
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9. -­-­adult Z04.41 Subterm

-­-­child Z04.42

10. -­child Subterm

-­-­confirmed T74.22
-­-­suspected T76.22
—-1
—0
—+1

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 10
Alphabetization Rules
CHAPTER 1 To locate main terms and subterms quickly and efficiently, it is impor­tant to understand the
Introduction to alphabetization rules followed in the Alphabetic Index. Letter-­by-­letter alphabetization is used. The
the ICD-10-CM system of alphabetization ignores the following:
Classification • Single spaces between words
• Single hyphens within words
• The final “s” in the possessive forms of words

The following list shows an example of letter-­by-­letter alphabetization with t­ hese modifications:

Beckwith-­Wiedemann syndrome Q87.3 [ignores hyphen]

Beer drinker’s heart (disease) I42.6 [ignores space between words]
Blood-­forming organs, disease D75.9

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[ignores hyphen]
Bloodgood’s disease—­see Mastopathy, cystic [ignores possessive form]

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Numerical Entries

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Subterm entries that contain numerical characters or words indicating numbers are the first
entries ­under the appropriate main term or subterm. Subterm entries are listed in alphabetical order
when they include numbers written in their spelled-­out form. For example, Paralysis, nerve, fourth,
comes before, rather than ­after, Paralysis, nerve, third.
­There are two dif­fer­ent patterns for displaying numerical entries, depending on the book pub-
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lisher or software used. One version arranges Roman numerals (such as “II”) and Arabic numerals
(such as “2”) in numerical order (for example, I, II, III, IV, V, VI, VII, VIII, IX, X, and so forth).
However, the official government version arranges Roman numerals as letters in alphabetical order,
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as shown in the following example (each hyphen below represents one level of indention):
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Deficiency . . .
­factor
-­-­Hageman D68.2
--­I (congenital) (hereditary) D68.2
--­II (congenital) (hereditary) D68.2
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--­IX (congenital) (functional) (hereditary) (with functional defect) D67

-­-­multiple (congenital) D68.8
-­-­-­acquired D68.4
--­V (congenital) (hereditary) D68.2
--­VII (congenital) (hereditary) D68.2
--­VIII (congenital) (functional) (hereditary) (with functional defect) D66
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-­-­-­with vascular defect D68.0

--­X (congenital) (hereditary) D68.2
--­XI (congenital) (hereditary) D68.1
--­XII (congenital) (hereditary) D68.2
--­XIII (congenital) (hereditary) D68.2

-1—
0—
+1—

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 11
Connecting Words
Words such as “with,” “in,” “due to,” and “associated with” are used to express the relationship CHAPTER 1
between the main term and a subterm (or between the subterm and a sub-­subterm); ­these words Introduction to
indicate an associated condition or etiology. Subterms preceded by “with” or “without” are not the ICD-10-CM
listed in alphabetical order in the version of the Index from NCHS. Such subterms appear imme-
Classification
diately below the main term or any appropriate subterm entries. Coding professionals who fail to
remember this feature of the alphabetization rules often make coding errors by overlooking the
appropriate subterm. Please note that some publishers and encoder software vendors have deviated
from this practice and listed the subterms “with” and “without” in alphabetical order. Review the
following subterm entries ­under the main term Bronchitis using the instructions at the end of this
example. Note that each hyphen represents one level of indention:

Bronchitis (diffuse) (fibrinous) (hypostatic) (infective) (membranous) J40

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1 -­with
-­-­influenza, flu or grippe—­see Influenza, with respiratory manifestations NEC

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2 -­-o­ bstruction (airway) (lung) J44.9
3 -­-­tracheitis (15 years of age and above) J40
-­-­-­acute or subacute J20.9

4
5
-­-­-­chronic J42
-­-­-u­ nder 15 years of age J20.9

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-­acute or subacute (with bronchospasm or obstruction) J20.9
-­-­with
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-­-­-­bronchiectasis J47.0
-­--­ chronic obstructive pulmonary disease J44.0
6 -­-­chemical (due to gases, fumes or vapors) J68.0
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7 -­-­due to
-­-­-fumes or vapors J68.0
-­-­-Haemophilus influenzae J20.1
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-­-­-Mycoplasma pneumoniae J20.0

-­-­-­radiation J70.0
-­--­ specified organism NEC J20.8
-­-­-Streptococcus J20.2
-­-­-­virus
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-­-­-­-coxsackie J20.3
-­-­-­-­echovirus J20.7
-­-­-­-parainfluenzae J20.4
-­-­-­-­respiratory syncytial J20.5
-­-­-­-­rhinovirus J20.6
-­-­viral NEC J20.8
Fo

8 -­allergic (acute) J45.909

9 -­-­with
-­-­-­­exacerbation (acute) J45.901
-­-­-­status asthmaticus J45.902
10 -­arachidic T17.528

—-1
—0
—+1

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 12
Refer to sections 1, 4, 8, and 10 as indicated in the example. Note that the subterms preceded
by the connecting word “with” immediately follow the main term Bronchitis and precede the sub-
CHAPTER 1 terms beginning with the letter “a” (sections 4, 8, and 10).
Introduction to Refer to sections 5, 6, and 7 as indicated in the example. Note that the more specific subterms
the ICD-10-CM preceded by the connecting word “with” immediately follow the subterm “acute or subacute.” In
Classification this case, the subterms beginning with the word “with” precede the subterms beginning with the
letters “c” and “d” (sections 6 and 7).
Also note that the subterms indented ­under the connecting word “with” are listed in alpha-
betical order. For example, sections 1, 2, and 3 indicated in the example are in alphabetical order.

Index ­Tables
The main body of the Alphabetic Index uses a t­able for the systematic arrangement of sub-
terms ­under the main entry Neoplasm. This t­ able simplifies access to complex combinations of sub-
terms. The location of the Neoplasm ­Table ­will vary in printed editions of the code­book, depending

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on the publisher. It may be found following the Index entry Neoplasm or following the Alphabetic
Index and before the ­Table for Drugs and Chemicals. The use of this t­ able is discussed in chapter 29

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of this handbook. The ­Table of Drugs and Chemicals is discussed in chapter 32 of this handbook.
The format and alphabetization rules used within the ­tables are the same as ­those followed in
the rest of the Alphabetic Index. Although the uses of t­hese two ­tables are discussed in detail l­ater

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in this handbook, it is useful for the reader to become familiar with the location and format of the
­tables at this point in the discussion.
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ev
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Fo

-1—
0—
+1—

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