How do you use the ICD-10-CM guidelines?

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The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) guidelines provide a standardized system for coding diagnoses and health conditions in clinical settings, primarily used in the U.S. for billing, reporting, and epidemiology.

How to use ICD-10-CM guidelines:

1. Identify the Main Condition:
   Start with the patient's medical record to determine the principal diagnosis or main reason for the encounter.

2. Locate the Code in the Alphabetic Index:
   Use the alphabetical index to find the diagnosis term or condition. This will direct you to a code or code range.

3. Verify in the Tabular List:
   Confirm the code in the numeric tabular list to ensure accuracy. Check for any notes, instructions, or exclusions that may affect code selection.

4. Apply Official Guidelines:
   Follow ICD-10-CM conventions such as:

   • Use of “Code First” or “Use Additional Code” notes for underlying conditions.

   • Laterality: Indicate if the condition affects left, right, or bilateral parts.

   • Code to the Highest Level of Specificity: Always choose the most detailed code available.

5. Use Combination Codes if Available:
   These codes capture multiple related conditions in a single code (e.g., diabetes with complications).

6. Sequencing:
   Assign codes in the correct order—primary diagnosis first, then any secondary or related conditions.

7. Check for Exclusions and Inclusion Notes:
   Certain conditions might be excluded or require additional codes.

Summary:

Using ICD-10-CM involves carefully reviewing medical documentation, consulting the alphabetic index and tabular list, following official coding rules and notes, and selecting the most specific and accurate codes for proper reporting and billing.

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