ICD-10 Clinical Modification

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provided by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), for medical coding and reporting in the United States. The ICD-10-CM is a morbidity classification for classifying diagnoses and reason for visits in all American health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO) which replaces ICD-9. [1]

Conventions

General rules for use of the guidelines. They are incorporated within the ICD-10-CM as instructional notes.[2]

Level of detail in coding

ICD-10-CM Diagnosis codes are to be used and reported at their highest number of digits available. They are composed of codes with 3, 4, 5, 6 or 7 digits. Three digits are used as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits (preceded by a decimal, i.e. A00.1 Cholera due to Vibrio cholerae 01, biovar eltor), which provides greater detail. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

Seventh character and placeholders

Some codes require the use of a seventh character for codes in chapters M, O, R, S, T, V, W, X, Y. If there are fewer than six characters in the code (not counting the decimal point) the placeholder "x" is used to ensure that the seventh character is always in the seventh position. For example, "A" (for initial encounter) is in the seventh position in "S03.4xxA Sprain of jaw, initial encounter".

Excludes Notes

ICD-10-CM has two types of excludes notes.

CHAPTER I - Certain infectious and parasitic diseases (A00-B99)

This chapter contains the following blocks:

CHAPTER II - Neoplasms (C00-D49)

This chapter contains the following broad groups of neoplasms:

  • C00-C14 Malignant neoplasms of lip, oral cavity and pharynx
  • C15-C26 Malignant neoplasms of digestive organs
  • C30-C39 Malignant neoplasms of respiratory and intrathoracic organs
  • C40-C41 Malignant neoplasms of bone and articular cartilage
  • C43-C44 Malignant neoplasms of skin
  • C45-C49 Malignant neoplasms of mesothelial and soft tissue
  • C50 Malignant neoplasms of breast
  • C51-C58 Malignant neoplasms of female genital organs
  • C60-C63 Malignant neoplasms of male genital organs
  • C64-C68 Malignant neoplasms of urinary tract
  • C69-C72 Malignant neoplasms of eye, brain and other parts of central nervous system
  • C73-C75 Malignant neoplasms of thyroid and other endocrine glands

CHAPTER III - Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)

This chapter contains the following blocks:

CHAPTER IV - Endocrine, nutritional and metabolic diseases (E00-E90)

This chapter contains the following blocks:

CHAPTER V - Mental and behavioral disorders (F01-F99)

This chapter contains the following blocks:

[3]

CHAPTER VI - Diseases of the nervous system (G00-G99)

This chapter contains the following blocks:

CHAPTER VII - Diseases of the eye and adnexa (H00-H59)

This chapter contains the following blocks:

CHAPTER VIII - Diseases of the ear and mastoid process (H60-H95)

This chapter contains the following blocks:

CHAPTER IX - Diseases of the circulatory system (I00-I99)

This chapter contains the following blocks:

CHAPTER X - Diseases of the respiratory system (J00-J99)

This chapter contains the following blocks:

CHAPTER XI - Diseases of the digestive system (K00-K93)

This chapter contains the following blocks:

CHAPTER XII - Diseases of the skin and subcutaneous tissue (L00-L99)

This chapter contains the following blocks:

CHAPTER XIII - Diseases of the musculoskeletal system and connective tissue (M00-M99)

This chapter contains the following blocks:

CHAPTER XIV - Diseases of the genitourinary system (N00-N99)

This chapter contains the following blocks:

CHAPTER XV - Pregnancy, childbirth and the puerperium (O00-O99)

Note: CODES FROM THIS CHAPTER ARE FOR USE ONLY ON MATERNAL RECORDS, NEVER ON NEWBORN RECORDS This chapter contains the following blocks:

CHAPTER XVI - Certain conditions originating in the perinatal period (P00-P96)

NOTE: CODES FROM THIS CHAPTER ARE FOR USE ON NEWBORN RECORDS ONLY, NEVER ON MATERNAL RECORDS This chapter contains the following blocks:

CHAPTER XVII - Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)

Note: CODES FROM THIS CHAPTER ARE NOT FOR USE ON MATERNAL OR FETAL RECORDS

CHAPTER XVIII - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

This chapter contains the following blocks:

CHAPTER XIX - Injury, poisoning and certain other consequences of external causes (S00-T98)

This chapter contains the following blocks:

CHAPTER XX - External causes of morbidity (V01-Y99)

This chapter contains the following blocks:

CHAPTER XXI - Factors influencing health status and contact with health services (Z00-Z99)

This chapter contains the following blocks:

7th Character

The appropriate 7th character is to be added to each code from category.[4]

M1A

M48.4 - M48.5

M80, M84.3 - M84.6

O31 - O32, O33.4 - O33.7, O35 - O41, O60.1 - O60.2, O64, O69

7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies.

R40.21, R40.22, R40.23

S00 - S78

S79.0, S79.1

A fracture not designated as open or closed should be coded to closed

S79.8, S79.9, S80 - S81, S83 - S88, S89.8, S89.9, S90 - S99

S82

A fracture not designated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification

S89.0, S89.1, S89.2, S89.3

A fracture not designated as open or closed should be coded to closed

T15 - T28, T33 - T85, T88

V00 - V99, W00 - W99, X00 - X99, Y00 - Y04, Y08 - Y38

See also

Wikisource has original text related to this article:

References

  1. ↑ CMS (February 23, 2010). "2010 ICD-10-CM" (web). Centers for Medicare and Medicaid Services. Retrieved April 9, 2010.
  2. ↑ ICD-10-CM Official Guidelines for Coding and Reporting 2010
  3. ↑ F1
  4. ↑ ICD-10-CM TABULAR LIST of DISEASES and INJURIES

External links

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