Hi, everyone is Dr. Campbell and today, I'm going to provide you with an orientation to the icd-10-cm manual. Now you notice that the version that I have mentions that it's for hospitals. But this version does contain icd-10-cm cults.
This particular version in a certain part of the manual has some information that's important for Hospital coders. But the coach themselves are the same all right. So let's begin, and I'm going to jump over to an area that I believe is near and dear to my heart and. Those are the icd-10-cm official guidelines for coding and reporting, the guidelines are really one of the heart beats if you will of the icd-10-cm coding process, if you don't know, your guidelines guys, it could be pretty difficult to assign the icd-10-cm codes. The guidelines themselves are divided into four sections.
And they actually begin on page one of the manual and let's scroll down. So you can see that coding guidelines page one so guys in a separate video I've, actually broken down these. Guidelines, and actually when I say a separate video, let me rephrase that oh, there's about 20-25 videos that I have that are focusing on the guidelines themselves. And so today, we're not gonna look at guidelines today. We're gonna talk about proper usage of the code manual. And of note, you're going to hear me refer to guidelines through this process. So I'm going to go past the guidelines, and I'm going to go over to the process or the place I should say where the coding process begins and the coding.
Process begins in the alphabetical index. Now let me give a disclaimer. The alphabetical index actually has four parts let's say that again, the coding process for icd-10-cm, once you've figured out what diagnosis you're going to Co. The process begins in the index in icd-10-cm. The index is divided into four parts.
First is your index to diseases and injuries. This portion is divided into alphabetical order starting with a and goes all the way over to Z the second part of the alphabetical index. And if. You notice I am turning the different pages.
The next part is known as the neoplasm table. And just like the alphabetical index. The neoplasm table is in alphabetical index as well. All right guys.
The third portion of your icd-10-cm alphabetical index is your table of drugs and chemicals and guys your table of drugs and chemicals is also in alphabetical order. And then the last part of the alphabetical index to diseases is the portion that is known as the index to external causes. And likewise, guys. This index portion is an alphabetical order as well. So let's review, icd-10-cm coding, manual very beginning.
We have our guidelines immediately after that. You have the alphabetical index to diseases. Immediately after that, the alphabetical index is divided into four parts.
Part. One is your index to diseases and injury. Part. Two is your neoplasm table.
Part three is your table of drugs and chemicals. And then part four is the external causes index that's, the alphabetical index. Now once the alphabetical. Index gives us our a code per guidelines. We are to verify the code in what is known as the tabular list in icd-10-cm. There are 21 chapters in the tabular list and let's turn our manual sideways.
And if you turn your sideways, you'll, see exactly what I'm talking about. So there are 21 chapters. The very first one is infectious and parasitic diseases. And as you start to turn I want you to notice how the colors change, then we have neoplasms. And after neoplasms, a very, very tiny section diseases of the.
Blood and blood forming organs, followed by chapter four, endocrine nutritional metabolic disorder, euro developmental disorders mental behavioral that's, Chapter, five Chapters, six diseases of the nervous system chapter seven I. And at Nexus chapter eight diseases of the ear and mastoid process chapter nine, the circulatory system chapter ten, our respiratory system, Chapter, eleven, the digestive system chapter, twelve skin and subcutaneous tissue noticed. The colors are changing as I'm going from chapter. To chapter the musculoskeletal and connective tissue after that we have chapter 14, which is our genital urinary system after that we have pregnancy childbirth in to prepare I am after that. 16 is our perinatal period codes chapter, 17, congenital, malformation, deformation and chromosomal abnormalities chapter, 18 signs symptoms and abnormal clinical and laboratory findings, not elsewhere classified bone chapter, 19, injuring poisoning and certain other consequences of external causes and chapter 20. Our. External causes of morbidity.
And then lastly, chapter 21, which are the factors influencing health status and contact with health services. So now that you know unless this quick review so three parts of the manual that I've shown you. So first I have pointed out the guidelines.
Next I have pointed out. The alphabetical index I mentioned to you that the alphabetical index was divided into four parts. Those four parts are the index of diseases and injuries followed by the neoplasm table, followed by the. Table of drugs and chemicals, followed by the external causes index, that's, your four parts of your alphabetical index. And then the second portion, which is your tabular list, you know, has 21 chapters. So guys I want to start just giving you some pointers for using the manual.
So it doesn't matter what coding system you are using. There is a process that you must execute 100% of the time. So for purposes of our example, I want to use a main term of diabetes. The first thing I want you to notice is that.
The main term of diabetes is in bold, print directly behind diabetes. You see a term in parentheses that is known as a non-essential modifier that does not impact your code assignment. And then immediately behind it. You have what's known as a default code. Let me just give a disclaimer in my guidelines videos.
I actually talked about what's, a default code. So the next thing I want you to notice with the alphabetical index are two gray lines. Now let's see if we can kind of zoom in okay, and I want to. Touch the screen, but I want you to see directly under the first term under diabetes with that's, where the first gray line is and then going through the word that starts with an A amyotrophic as the second grade line.
These great lines are important the first gray line, which is directly kind of like a little to the right of the main term that is what separates the main term for from the sub term. So diabetes is the main term. And my sub term is width. Okay.
Now under the term with you see all. Of these options, but notice they're indented over just a little more, and they're in alphabetical order. Now, as we go through, and I'm going to follow with all the way down. So all of those are diabetes with all right now, if we keep going, and when the second column of the same page, notice with is still there. And then after with notice, how on the first gray line we have brittle under brittle.
We have bronze complicating, pregnancy, dietary due to these options here and then due to drug, so I. Wanted to give this example because with diabetes, for example, there are five types of code and so indexing. Your term is going to be critical in ensuring that you're picking up the correct code, and I'm going to show you why. So remember I mentioned amyotrophic diabetes with amyotrophic.
Notice that says, II, eleven point, four, but guys look over here due to drug or chemical with amyotrophic. Notice how that Co is actually different from this code. So one key rule to remember is that as you capture. Your main term, and then you start to look through your sub terms, it's, very, very important that you are following this gray line, all the way through now something I will tell you that I think it's important, especially if this is your first time or first couple of times using the manual, take a look at all the primary subteams options that are available under a main term just to get familiar. So like we saw that with was our first option and with us like a w. So you're like wait a minute with, but.
Then after that, we got to Britt and bronzed and dietary and due to. And if I turn my page due to continues again, and then look what happens when I get down a little further I have gestational. So here, we're, following alphabetical order, oh guys. And let me show you something else member I've been talking about cameo trophy.
So I want to show you Me trophy a third time so diabetes due to underlying condition with amyotrophic. Now you see a third option. E, zero, eight point, four, four, so I know, You're like okay, well, how will I know what to index, and it's going to be based upon your documentation, and I'm going to show you another? One let's, just let's, just keep this going, so I'm, looking at and let's turn the page all the way over. So you can see it so specified type with amyotrophic point for I'm still under diabetes type, one with amyotrophic, eat endpoint for four and guys last diabetes type, two with amyotrophic so guys. What are you thinking you're thinking paying attention to the details is. Going to be very very very important.
So after the index gives you a potential code, or let me just give you a rule. You never ever code from the index because the index doesn't give you the complete code. So let's say, we had a patient that was a type one diabetic and let's say, they had a foot ulcer. So I'm under diabetes and let's make sure everybody can see this I'm under diabetes type 1 with a foot ulcer. Ii. Ten point, six one. The very next step is to verify the code in the tabular list.
So that. Means I'm going to go over remember, these colored pages, I'm going to go over to the endocrine section, and I'm going to fine code. E, ten point, six, two, one alrighty. So first things first I want you to take notes of the different notations that you're seeing in the manual? So number one I want you to notice we came to look at e, 10 point, six, two one, but I want you to notice that there are some words in green. These words are very important is because they give each of the codes their own unique.
Characteristics so, for example, e, 10 620 is day type, one diabetes, mellitus with diabetic dermatitis. Then you have the code. We were looking at a ten point six to one, which is type 1 diabetes with foot ulcer. E, 10 point 6 to 2 type 1 diabetes with other skin ulcer. And then notice eat n. 628, that's type 1 diabetes with other skin complications. So we have come to verify. E, 10 point 6 to 1.
And it does indeed say type 1 diabetes with foot officer. But I want you to notice that there is a note under e. 10. Point six to one that says use additional code to identify the site of the officer. And it gives you two options. L9, seven point, four with a hyphen behind it. That lets you know that that code is not complete or L 97.5 with a hyphen behind it, which again, lets, you know that that code isn't complete so let's, pause for a second.
If we had not verified this code, we would have missed the fact that an additional code was needed and guys that's. The reason why coding guidelines tells us that we must. Must must must verify our code in the tabular list. So we're not done yet, because we now have to pick up one of these two codes.
So I am going to turn over to L, 97, 0.4 and ill. 97.5. Now, guys there are a lot of things going on here, and I'm gonna I'm going to show you l. Ninety-seven point, four first. So notice L. Ninety seven point four is non-pressure, chronic ulcer of heal and mid-foot. But then I want you to notice that L. Ninety seven point four says, check fifth, digit this guy's, let you let, you know that L.Ninety-seven point four is actually not a complete code. It requires a fifth digit. So then, if you notice, if you go down to L, ninety, seven, forty that says, check six digits.
So that lets you know that that code isn't complete. And the reason that you're being given this guidance is because this category is further broken down and guys, remember the words in green it's further broken down to classify. Not only is this the hill in mid-foot. Not only is this an unspecified hill in mid-foot, but we can get a. Specific as to what's actually going on with this non-pressure, chronic ulcer. So you may be asking, well, how am I supposed to know? You know?
Regarding these words in green, which one applies to my patient, well, guys it's going to be based upon what is actually documented in your medical record. Now, I, I know, some of you may be thinking what's this other stuff right here. Well in each manual at the very bottom. There is always a little grid that tells you what the symbols mean, and it's across each page. So.
I encourage you to take a look at that. So we were looking at L. Ninety seven point, four and L 97.5 let's, turn over and guys. Guess what? AO. Ninety-seven point four was not done. Now we have L. Ninety, seven, four, zero, six, four, zero, eight and four zero, nine and guys.
Notice the words and green again, giving unique characteristics about a non pressure, chronic ulcer. And notice the words guys, unspecified heal and mid-foot. Now, guys I want you to see something that's important. This is where documentation plays. A huge role, notice the index or the diabetes code, just told us, L. Ninety, seven point, four that's it.
We didn't realize that there's an L ninety, seven forty with a bunch of cows and guys look L. 9741 is non-pressure, chronic ulcer, but it's the right heel and mid-foot and then guys same thing. All of these different call options that are divided based upon the words and green, again, your documentation would support what you would actually pick up guys. Then we have a ninety-seven point, four to code. Family, and this is for the left heel. Notice, checked six digits it's, letting you know that code is not a complete code and so guys here again, same thing all the different options that we can have available. But this is focusing on the left.
Now remember the index told us, L. Ninety, seven point, four and L 97.5. Well, guys here is ninety-seven point, five non-pressure, chronic ulcer of other part of the foot. Remember, this was heel and mid-foot. And now we're talking about other part of the unspecified foot. And guys I want to show you a little trick it's the same setup. First, we have unspecified part of the unspecified foot, and then all the different options that we had before remember our words in green and guys then I want you to notice we have an option for other part of the right foot other part of the left foot. And again, the codes are differentiated based upon your documentation in your medical record.
So guys, this has been your very brief introduction to actually using the icd-10 code system. And specifically with a focus on diagnosis coding, as you can see coding is a process that requires you to follow same steps each and every time. And if you're going to be taking a national coding exam, you must not only know your guidelines, but you must also know your way around your code manual all right guys. Thank you so much for listening. Please be sure to subscribe to my channel and I hope you all have a wonderful day.