How do you find the correct diagnosis code using an ICD-10 book?

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To find the correct ICD-10 diagnosis code using an ICD-10-CM book, follow these structured steps:

1. Identify the Main Term

Start by identifying the main condition or diagnosis from the medical documentation (e.g., "diabetes," "fracture," "pneumonia").

2. Use the Alphabetic Index (Volume 2)

Look up the main term in the Alphabetic Index (usually at the front of the book).

• Find the most relevant subterms (e.g., "Diabetes → Type 2 → with neuropathy").

• This gives you a preliminary code (e.g., E11.40).

3. Verify in the Tabular List (Volume 1)

Turn to the Tabular List to verify and refine the code.

• Check for inclusion/exclusion notes, code specificity, and instructional notes like “Use additional code” or “Code first.”

• Confirm if more digits are needed (up to 7 characters total).

4. Check for Laterality and Encounter Type

Many ICD-10 codes require details like:

• Laterality (left/right)

• Encounter type (initial, subsequent, sequela)

5. Review Guidelines and Chapter Notes

Always consult ICD-10 coding guidelines, chapter-specific notes, and coding conventions to ensure proper usage.

Example:

Diagnosis: Type 2 diabetes with diabetic neuropathy

1. Alphabetic Index: Diabetes → type 2 → with → neuropathy → E11.40

2. Tabular List: Confirm E11.40 = Type 2 diabetes with diabetic neuropathy

3. No additional characters needed in this case

Using the ICD-10 book correctly ensures accurate, compliant coding for billing and documentation.

Read More

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How is the ICD-10-CM code structured?

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