Here’s a simplified look at ICD-10-CM’s format. To review: the first digit of an ICD-10-CM code is always an alpha, the second digit is always numeric, and digits three through seven may be alpha or numeric. That is, if this is the first time a healthcare provider has seen the patient for this condition/injury/disease, it’s listed as the “initial encounter.” Every encounter after the first is listed as a “subsequent encounter.” Patient visits related to the effects of a previous injury or disease are listed with the term “sequela.” The extension describes the type of encounter this is. ![]() This is followed by up to two subclassifications, which further explain the cause, manifestation, location, severity, and type of injury or disease. The category is followed by a decimal point and the subcategory. The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease. Each code begins with a letter, and that letter is followed by two numbers. The word "with" in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order.ICD-10-CM is a seven-character, alphanumeric code. For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related. 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"). The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. The word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The code in brackets is always to be sequenced second. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. For such codes, there is a "use additional code" note at the etiology code and a "code first" note at the manifestation code, and the rules for sequencing apply. There are manifestation codes that do not have "in diseases classified elsewhere" in the title. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. "In diseases classified elsewhere" codes are never permitted to be used as first listed or principal diagnosis codes. The code title indicates that it is a manifestation code. In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/ manifestation convention. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ![]() Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.
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