Enclose supplementary words or terms used for the condition
ONlY code CONFIRMED conditions or diseases.
DO NOT code a suspected or possible condition.
Code to the HIGHEST LEVEL of SPECIFICTY.
DO NOT select a general code if a more FOCUSED or PRECISE code is otherwise available.
Must accurately reflect available facts.
No speculation is allowed.
Each unique code should be only reported once per encounter.
In the order of what is most responsible for the patient encounter.
Signs and Symptoms: non-diagnosis codes used for identifying individual, unrelated conditions, such as sneezing or fever.
May or May not be associated with other conditions listed in the procedural notes.
Are present and a defintive diagnosis has not been confirmed.
Are not routinely associated with the confirmed diagnosis.
DO NOT Code Individually:
Are an integral part of or are routinely associated with confirmed diagnosis.
Leftover or residual condition that occur after an illness or injury has been handled, typicall caused by the intial problem.
May occur immediately following the condition, or they may occur months or even years later; there is no time limit for a sequela to occur.
chronic arthritis after fracturing wrist; severe scarring after a burn; aphasia after a brain hemorrhage.
1. Code Sequeal Condition First
2. Followed by th illness or injury responsible for the current condition.
A patient develops an intellectual disability due to poliomyelitis
1. F79 (unspecified intellectual disability)
2. B91 (sequela of poliomyelitis)
The code identifies the condition as following another condition, such as 169.120 (aphasia following nontraumatic intracerebral hemorrhage)
Only code confirmed cases of HIV:
*HIV (B20) should be included in all future cases
Condition related to HIV:
code HIV (B20), followed by the related conditions.
Patient admitted for an unrelated condition to HIV:
code unrelated condition and then code HIV (B20)
Inconlusive or asymptomatic HIV status:
code HIV (B20) if condition is HIV related
code the condition first followed by code Z21 if the condition isn't HIV related
1. Malignant primary: where a cancer has spread from
2. Malignant secondary: where cancer has spread to
3. Carcinoma in situ: for a malignant mass isolated to a single place
4. Benign: for noncancerous neoplasms
5. Uncertain behavior: for neoplasms whose behvior has not yet been identified
6. Unspecified behavior: for neoplasms whose behavior is not outlined in the procedural note
1. Primary Malignancy:
Code the primary site first and then any secondary metastasized sites.
2. Secondary Malignancy:
Code the metastatic sites first and then the primary site
3. Complication related to a neoplasm:
Code the complication first and then the neoplasm
4. Anemia related to a neoplasm:
Code the neoplasm first and then code D63.0 (anemia in neoplastic disease)
5. Pathological fracture due to a neoplasm:
Code the focus of the treatment first
6. Further treatment for excised primary malignancy:
Code primary malignancy until treatment is completed.
Afterward, if there is no evidence of malignancy at that site, use the appropriate code from category Z85.
1.If NOT SPECIFIED DIABETES in procedure notes or medical record:
Code the condition as type 2 diabetes mellitus (E11)
2. If NOT SPECIFIED DIABETES AND the procedure notes include the use of insulin:
Code type 2 diabetes mellitus AND include an additional code from category Z79 to identify long-tem use of insulin or hypoglycemic drugs
3.If GESTATIONAL DIABETES caused by pregnancy:
Assign code from subcategory 024.4 instead of the standard diabetes code
Commonly comorbid (they occur simultaneously) in patient.
1. Code from combiination category I13 for hypertension with heart and kidney involvement
2. If heart failure is present, use the appropriate code from category I50
3. Code from category N18 to identify the stage of chronic kidney disease
4. If the patient is suffering from acute renal failure as well, coe the level of renal failue last in the sequence.