Basic Coding
Guidelines
The Alphabetic
Indexes contain many terms not included in the Tabular Lists, and coding
requires that both the Index and the Tabular List are consulted before a code
is assigned.
The
following is a simple guide intended to assist the occasional user of ICD-10-AM
and ACHI.
1. Identify the type of statement to be coded
and refer to the appropriate section of the Alphabetic Index.
2. Locate the lead term. For disease and
injuries, this is usually a noun for the pathological condition. For
procedures, this is usually a noun identifying the type of procedure performed.
However, some conditions expressed as adjectives or eponyms are included in the
Index as lead terms.
3. Read and be guided by any note that appears
under the lead term.
4. Read any terms enclosed in parentheses
after the lead term (these nonessential modifiers do not affect the code
number), as well as any terms indented under the lead term (these essential
modifiers may affect the code number), until all the words in the clinical
expression have been accounted for.
5. Follow carefully any cross-references
('see' and 'see also') found in the Index.
6. Refer to the Tabular List to verify the
suitability of the code number selected. For disease classification, note that
a three character code in the Index with a dash in the fourth or fifth position
means that there is a fourth or fifth character to be found in the Tabular
List. Further subdivisions to be used in a supplementary character position are
not indexed and, if used, must be located in the Tabular List.
7. Be guided by any inclusion or exclusion
notes under the selected code or under the chapter, block or category heading.
8. Assign the code.
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