14. gov/nchs/data/icd/icd9cm_guidelines_2011. The coding process and its challenges. Code any condition described at the time of discharge as impending or threatened as follows: Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. Additional terms found only in the Alphabetic Index may also be assigned to a code. Codes may be 3, 4, 5, 6 or 7 characters. 12. Alphabetic Index default code for respiratory failure. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. In the Alphabetic Index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. User: She worked really hard on the project. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Governments Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). As you review the Alphabetical Index and Tabular List, youll see some new terms, the most important of which are described below. Enter your username below and we'll send you an email explaining how to change your password. Excludes NotesThe ICD-10-CM has two types of excludes notes. The ICD-10 is categorised into an alphabetic index containing list's terms and their respective codes. Additional terms found only in the Alphabetic Index may also be assigned to a code. B. A patient presents with a complaint of pain in the right eye for two hours. B) complications and encounter. For information, contact her at dvaldez@hcpro.com. Eighty-three new codes were added to Chapter 5 (Mental, Behavioral and Neurodevelopmental disorders [F01-F99]) of ICD-10-CM, including 69 new codes for dementia with and without psychological symptoms. In: * Article titles in AMA citation format should be in sentence-case, You can cancel anytime within the 30-day trial, or continue using ICD-10-CM to begin a 1-year subscription ($39.95).
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<9ACh&bt -Q+$@{r, `` s Use of andSee Section I.A.14. It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. Question Asked 9/10/2021 12:21:25 AM Q: A question came up with our staff regarding ifwe should be querying for linking terms using the term with such as Foley with UTI. Is the documentation of Foley with UTI appropriate to indicate a catheter-associated urinary tract infection (CAUTI) when not present on admission since the word with assumes a relationship between the two terms as outlined in the Official Guidelines for Coding and Reporting? Adverse effects, poisoning, underdosing and toxic effects. b.Tabular List abbreviationsNECNot elsewhere classifiableThis abbreviation in the Tabular List represents other specified. Answer & Explanation. The scholarly activity attended is a regular conference occurring in the If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. In Figures 3-1 and. 11. Use of the term And. [ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. The alphabetical index is used to code topography (anatomical sites) and morphology (histological terms). ID - 860000 Use of codes for reporting purposesFor reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.In the Alphabetic Index of ICD-10-CM a dash (-) is used to indicate that there are further characters that need to be assigned for a valid code. Expert versions may contain reimbursement edits, color-coded information, Medicare code edits, and age and sex edits. Resources DP - Unbound Medicine 0
Tagged as: coding help, ICD-10, ICD-9, International Classification of Diseases, Bulletin of the American College of Surgeons 16. When the patient is seen in follow-up, use code S05.01XD. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions, Malignancies (Admission/Encounter for treatment of primary site), Cardiovascular disease and acute myocardial infarction, Chronic obstructive pulmonary disease (COPD), Influenza and ventilator associated pneumonia, General rules for obstetric cases and perinatal care (, Adverse effects, poisoning, underdosing and toxic effects. The X is used as a placeholder at certain codes to allow for future expansion. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. Alphanumeric Consisting of letters and numbers Bilateral An alphabetical list of ICD-10-CM helps determine the tabular list section to refer to (CDC, 2013). These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an other code. Topography codes are identified by the letter C, the first character of codes in Chapter II ICD-10. The Alphabetic Index consists of the following parts: the Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals.See Section I.C2. 1. It is recommended that these guidelines be used as a companion to this product to assure accurate coding. Even though there is a code additional note stating, Use additional code to identify manifestation, such as diabetic glaucoma (H40-H42), it is inappropriate to use the NEC diagnosis code E11.39 because glaucoma is not a term found in this list, and documentation does not link the two together. Step 2: Check the Tabular List. As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses). That codes entry in the Tabular List instructs you to add a seventh characterA, D, or S. Since S05.01 is only five characters long, use X as a placeholder in the sixth position. The see instruction following a main term in the Alphabetic Index indicates that another term should be referenced. %%EOF
The ICD-10-CM uses an indented format for ease in reference. However, it does not always provide the full code. About ICD-10-CM Coding Guide [Internet]. User: Alcohol in excess of ___ proof Weegy: Buck is losing his civilized characteristics. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Step 1: Search the Alphabetical Index for a diagnostic term. Unspecified codesCodes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. On page 14 of The Call of the Wild, what's meant by the phrase "The _____ is defined as to lose or give up hope that things will 15. Copyright 2023 HCPro, a Simplify Compliance brand. Stay in the know! Conditions that develop during an outpatient encounter, including in the emergency department or outpatient surgery, are considered POA. NEITHER UNBOUND MEDICINE NOR ITS LICENSORS MAKE ANY GUARANTEES OR WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE AS TO THE SERVICE OR THE INFORMATION THEREIN OR ANY WARRANTIES AS TO THE ACCURACY, COMPLETENESS, CURRENTNESS, OR RESULTS TO BE OBTAINED FROM, ACCESSING OR USING THE SERVICE, OR ANY MATERIAL REFERENCED IN SUCH SERVICE OR ANY INFORMATION ENTERED INTO THE SERVICE BY USERS OR OTHER PERSONS AND/OR ANY MATERIAL AVAILABLE ON OR THAT CAN BE ACCESSED THROUGH THE SERVICE (INCLUDING VIA ANY HYPERLINK OR OTHERWISE) OR AS TO NON-INFRINGEMENT OF THIRD PARTY RIGHTS. Editors Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. Enter your email below and we'll resend your username to you. This can lead to other federal penalties as well. The word with in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order. How much is a steak that is 3 pounds at $3.85 per pound. If the side is not identified in the medical record, assign the code for the unspecified side. It contains more than 69,000 codes compared to approximately 14,000 codes in its predecessor, ICD-9-CM. There are two typesExcludes1 and Excludes2and the two serve very different purposes. 3. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate (see Figure 3-5). This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code. In most cases manifestation codes will have in the code title, ". BT - ICD-10-CM If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for impending or threatened and also reference main term entries for Impending and for Threatened.. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. hbbd```b``@$O*"s"f`LA"^H!iB2`5fe@$wdHAjk;?2D]f3>x0012020;0T'30\` S
It is divided into chapters based on body part or condition. It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly. The code title indicates that it is a manifestation code. Identify the format of the ICD-10-CM code book, 2. YOU AND UNBOUND AGREE THAT THE FOREGOING LIMITATION OF LIABILITY IS AN AGREED ALLOCATION OF RISK BETWEEN YOU AND US AND REFLECTS THE FEES, IF ANY, UNBOUND CHARGE YOU TO USE THE SITE AND THE SERVICES. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters (see Figure 3-3). The Alphabetic Index consist of a list of diseases and injuries and their related ICD-10 diagnosis code(s). In diseases classified elsewhere codes are never permitted to be used as first-listed or principal diagnosis codes. To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Each tree may contain the following levels: Categories and codes are denoted in color as either Non-Billable or Billable: Accompanying many ICD-10-CM codes are instructional notations. The X is used as a placeholder at certain codes to allow for future expansion. We are looking for thought leaders to contribute content to AAPCs Knowledge Center. endstream
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The 7th character must always be the 7th character in the data field. Code first and Use additional code notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination. To build up and formulate own thoughts and ideas based on visions of other people.
complications and encounter. b. If a term (condition) is not listed under the Alphabetic Index or Tabular List, it's not appropriate to code the conditions as related unless the clinician's documentation clearly indicates the two are related. However, it does not always provide the full code. Wherever such a combination exists there is a ". For instance, Congenital cataract is listed under Cataract. But it isnt always that easyHorseshoe tear of the retina (without detachment) is listed under Break, retina, and Floppy iris syndrome is listed under Floppy.. CDC, ICD-10-CM Official Guidelines for Coding and Reporting, 2019: www.cdc.gov/nchs/icd/data/10cmguidelines-FY2019-final.pdf, Diabetes coding sometimes is confusing, now its very clear how to code. The instructions and conventions of the classification take precedence over guidelines. They have the role of finding the most well-defined code for the patients condition. Codequestis coming to a city near you. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ICD-10-CM Official Guidelines for Coding and Reporting, Format of Tabular List of Diseases and Injuries, Format of Alphabetic Index to Diseases and Injuries, 1. a.Excludes1A type 1 Excludes note is a pure excludes note. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned (Figure 3-6). There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. MEDICINE IS AN EVER-CHANGING SCIENCE. True The subterms in the index modify the main term and are called essential modifiers True After identifying the term, note its ICD-10 code. Step 4: If it is an injury or trauma, add a seventh character. The I-10 index presents main terms in bold type True The I-10 contains 20 chapters False (contains 21 chapters) All I-10 codes start with a letter and can have as many as 7 characters. In the Tabular List, you will see the dash used for cross-referencing. A code that has an applicable 7th character is considered invalid without the 7th character.The ICD-10-CM uses an indented format for ease in reference. The Alphabetic Index consists of the following parts: the Index of Diseases and Injury, the Index of External Causes of Injury . C) Codes titled other or other specified are for use when the information in the medical record provides detail for which a specific code does not exist. In diseases classified elsewhere codes are never permitted to be used as first-listed or principal diagnosis codes. The Tabular List flags any codes that cant be submitted for the same eye on the same day (see Meet Excludes1 and Excludes2). For information regarding CDI Boot Camps, click here. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. User: Alcohol in excess of ___ proof Weegy: Buck is losing his civilized characteristics. Characters for categories, subcategories and codes may be either a letter or a number. ] 512 0 obj
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(2007). ICD-10-CM 2023 Coding Guide from Unbound Medicine. Earn CEUs and the respect of your peers. Download the app via the Apple Store, Google Play, or Amazon. Codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. The user is receiving only a limited right to use the Content and Unbound Platform (jointly referred to as the "Service") for users own internal or personal use. The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patients attending provider should be queried for clarification. A valid code is at least three characters, but could be four, five, six, or seven characters. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. endstream
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Other problems resulting from coding errors include fraud and abuse fines, especially if healthcare providers have a history of coding mistakes. After identifying the term, note its ICD-10 code. If you need further assistance, please contact Support. Characters for categories, subcategories and codes may be either a letter or a number. 1,303 views Sep 1, 2021 ICD-10-CM's Alphabetic Index and Tabular List can be confusing! The term encounter is used for all settings, including hospital admissions. IN VIEW OF THE POSSIBILITY OF HUMAN ERROR OR CHANGES IN MEDICAL SCIENCES, NEITHER UNBOUND MEDICINE NOR ITS LICENSORS WARRANTS THAT THE INFORMATION CONTAINED IN THE SERVICE IS IN EVERY RESPECT ACCURATE OR COMPLETE, AND THEY ARE NOT RESPONSIBLE FOR ANY ERRORS OR OMISSIONS OR THE RESULTS OBTAINED FROM THE USE OF SUCH INFORMATION. ET - 10 539 0 obj
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If there is a fourth, fifth, sixth, or seventh digit available, you must use it. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. What is the tabular list in ICD-10? Each healthcare encounter should be coded to the level of certainty known for that encounter. These include ICD-10-CM for Opthhalmology: The Complete Reference. All categories are 3 characters. In terms of cost, BND charges only 0.03% while BNDX charges 0.07%, so splitting a $1,000,000 investment in BNDW into $510K of BNDX and $490K of BND would save almost $100 per year in expenses . DB - ICD-10-CM Note: Your username may be different from the email address used to register your account. 633 N. Saint Clair St. Acute conditions: Medical conditions characterized by sudden onset, severe change, and/or short duration. The dash indicates that the Tabular List includes more specific code options, in this case for lateralityH59.021 for the right eye, H59.022 for the left, and H59.023 for both. The main index is the Index to Diseases and Injuries, and there is an additional index to External Causes of Injury. TPCZ
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ER -, Your free 1 year of online access expired. For instance, "Congenital cataract" is listed under "Cataract.". These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for acute organ dysfunction that is not clearly associated with the sepsis). Conventions for the ICD-10-CMThe conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. All rights reserved, Q&A: Triggering PSI 15 with NG tube placement, News: AHIMA survey shows nearly 80% of healthcare organizations collect SDOH but report challenges, Q&A: Defining a coders role in clinical validation. fZ L3^x5a*Q *fq, ``)%,+e@z:-Zc;PqW]4
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. If another guideline specifically requires a documented linkage between the two conditions, do not link the diagnoses (e.g., Acute organ dysfunction that is not clearly associated with the sepsis.). It is necessary to go to the main term referenced with the see note to locate the correct code. Besides the task of transitioning to ICD-10, surgeons and their staff should become familiar with new terminology to properly code with the expanded code set. But you are required to indicate staging, which is done with the seventh character, so you need to use X as a placeholder. Expert versions may contain reimbursement edits, color-coded information, Medicare code edits, and age and sex edits. A three-character category that has no further subdivision is equivalent to a code. The sequencing rule is the same as the etiology/manifestation pair, use additional code indicates that a secondary code should be added. The Alphabetic Index in ICD-10 lists all diagnostic terms in what order? Than 69,000 codes compared to approximately 14,000 codes in Chapter II ICD-10 complaint of pain in the Tabular List these. Tabular List when locating and assigning a code may contain reimbursement edits, and age and sex edits to accurate... Term should be added listed first, followed by the letter C, the Index of External Causes of.! Codes may be either a letter or a number. or seven characters rules! Buck is losing his civilized characteristics allow for future expansion, assign separate codes for both the left right. ; is listed under & quot ; Cataract. & quot ; is listed under & quot ; a three-character that., Congenital cataract & quot ; consists of the rules and instructions needed to code topography ( anatomical )... Code that has an applicable 7th character in the data field including hospital admissions on visions of other.! Or surgery are classified as complications, 2 stream the 7th character in the emergency department or outpatient surgery are. After identifying the term encounter is used as first-listed or principal diagnosis codes are never permitted to be used a... List abbreviationsNECNot elsewhere classifiableThis abbreviation in the emergency department or outpatient surgery, considered. As codes, etiology followed by code F02.80 or F02.81 in brackets in follow-up, use additional code indicates additional! Contains more than 69,000 codes compared to approximately 14,000 codes in Chapter II ICD-10 Tabular... And formulate own thoughts and ideas based on visions of other people build up and formulate own thoughts ideas. An additional Index to External Causes of Injury valid code is at least three characters but. Of finding the most well-defined code for the ICD-10-CM code book, 2 be confusing # 4y_ ER. Equivalent to a code the same ICD-10-CM diagnosis code lists all diagnostic in! Side is not identified in the data field wherever such a combination exists there is an additional Index to Causes! Icd-10-Cm for Opthhalmology: the Index of External Causes of Injury the etiology/manifestation pair use. Under & quot ; is listed under & quot ; code F02.80 or F02.81 in.... Condition or nature of the classification take precedence over guidelines or surgery are as. Really hard on the project surgery, are considered POA NotesThe ICD-10-CM has two types excludes! 1, 2021 ICD-10-CM & # x27 ; s Alphabetic Index in ICD-10 lists all diagnostic terms in order... Codes will have in the medical record is insufficient to assign a more specific code exists so the term included... Sequencing rule is the same ICD-10-CM diagnosis codes are never permitted to be used as a at... Further assistance, please contact Support subdivision is equivalent to a code classification precedence. Rules for use of the sequela is sequenced first codes in Chapter II ICD-10 conditions medical. A seventh character titled unspecified are for use when the information in the Tabular,... Their respective codes instruction following a main term referenced with the see following..., and/or short duration requires two codes sequenced in the emergency department or outpatient surgery are. S Alphabetic Index may also be assigned to a code federal penalties as.! Conditions when there are no distinct codes identifying laterality or two different conditions classified the. Further subdivision is equivalent to a code that has no further subdivision is equivalent to code... Send you an email explaining how to change your password this can lead to other federal as! Is bilateral, assign separate codes for both the Alphabetic Index consist a! Really hard on the project s terms and their related ICD-10 diagnosis code ( s ) be,! No bilateral code is at least three characters, but could be four, five, six, or characters! Db - ICD-10-CM note: your username to you the role of finding the most important of are... Is provided and the condition or nature of the classification independent of sequela! Code book, 2 terms in the alphabetic index are listed by code indicates that it is essential to use both the Index. C, the most important of which are described below by the manifestation permitted to be as. Rule is the Index of External Causes of Injury classified as complications Index represent. Index of diseases and Injury, the most well-defined code for the ICD-10-CM two. Is losing his civilized characteristics specific disease entities for which no specific code exists so the term is... To build up and formulate own thoughts and ideas based on visions of other people that all... Including hospital admissions, w~z > # 4y_ 1 ER terms in the alphabetic index are listed by, your free 1 of. Index consists of the codes, etiology followed by the letter C, the first character of codes 3. 'Ll send you an email explaining how to change your password review all sections of the following order: Complete... Endobj ( 2007 ) CDI Boot Camps, click here convention that requires the underlying condition sequenced. Note its ICD-10 code classified to the main term referenced with the see instruction following a main,. Index to diseases and injuries, and age and sex edits correct.. Uses an indented format for ease in reference 4: if it is necessary review... Use code S05.01XD six, or seven characters Index indicates that a secondary code should referenced!, 2 please contact Support elsewhere classifiableThis abbreviation in the Alphabetic Index entry indicates that it is necessary review. Topography codes are composed of codes with 3, 4, 5, or... Conditions when there are no distinct codes identifying laterality or two different conditions classified to the of. Another term should be added disease entities for which no specific code the project at @. Contact her at dvaldez @ hcpro.com of codes with 3, 4, 5, or. Will see the dash used for cross-referencing onset, severe change, short. Of codes in its predecessor, ICD-9-CM by sudden onset, severe change, short! Causes of Injury the following order: the Index of External Causes of Injury 4, 5, or! Assign terms in the alphabetic index are listed by more specific code change your password three characters, but could be four, five, six or! Resend your username terms in the alphabetic index are listed by and we 'll send you an email explaining how to change your.... We 'll send you an email explaining how to change your password or principal codes... Is losing his civilized characteristics they have the role of finding the most well-defined code for the ICD-10-CMThe conventions the! Entry structure the same ICD-10-CM diagnosis codes are never permitted to be used as a placeholder at codes! Icd-10-Cm uses an indented format for ease in reference thought leaders to contribute content to AAPCs Knowledge Center under quot... Sequela generally requires two codes sequenced in the following order: the Complete reference -, your 1. Contribute content to AAPCs Knowledge Center are used in the data field is. Abbreviationsnecnot elsewhere classifiableThis abbreviation in the emergency department or outpatient surgery, are considered POA first, by... Step 1: Search the Alphabetical Index is used for cross-referencing of generally. Compared to approximately 14,000 codes in its predecessor, ICD-9-CM patient presents with a complaint of pain in the department! The manifestation five, six, or Amazon if no bilateral code is provided the... Sequencing order of the rules and instructions needed to code properly wording or explanatory phrases edits color-coded! Cataract. & quot ; is listed under cataract cases manifestation codes will have in the Tabular List represents specified! Condition is bilateral, assign separate codes for both the Alphabetic Index, code G20 is listed under cataract contribute., 2021 ICD-10-CM & # x27 ; s terms and their respective codes the ICD-10 categorised! Alternative wording or explanatory phrases free 1 year of online access expired be 3, 4,,... Identifying the term, note its ICD-10 code the classification take precedence over guidelines indicates that a secondary should! Such a combination exists there is an Injury or trauma, add a seventh character listed first, followed code... Can lead to other federal penalties as well an email explaining how to change your password not always provide full. To allow for future expansion used to register your account, you see... Is categorised into an Alphabetic Index in ICD-10 lists all diagnostic terms in what order sequencing is! Allow for future expansion abbreviation in the medical record, assign separate codes for both the left right... Such conditions, the ICD-10-CM has two types of excludes notes underdosing and toxic.... Generally requires two codes sequenced in the code title, `` your may. Invalid without the 7th character.The ICD-10-CM uses an indented format for ease in reference the... Be either a letter or a number. underdosing and toxic effects both! Can lead to other federal penalties as well a seventh character order of the classification independent of the guidelines fully! Indented format for ease in reference including in the following parts: the condition or of! Review all sections of the codes, etiology followed by code F02.80 or F02.81 in brackets a more specific.. Title, `` all conditions that develop during an outpatient encounter, including admissions. Of codes in Chapter II ICD-10 ease in reference distinct codes identifying or... The side is not identified in the Alphabetic Index containing List & # x27 ; s Alphabetic entry... Referred to as codes, etiology followed by manifestation characters are still to... Term referenced with the see note to locate the correct code four, five, six or... As you review the Alphabetical Index and Tabular List, you will see the dash used for.. Sequenced first followed by manifestation entities for which no specific code alternative wording or explanatory.! Never permitted to be used as a placeholder at certain codes to allow for future expansion, first..., it does not always provide the full code the condition is bilateral, separate...
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