ICD-10-CM is a seven-character, alphanumeric code. Each code begins with a letter, and that letter is followed by two numbers. The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease. The category is followed by a decimal point and the subcategory. This is followed by up to two subclassifications, which further explain the cause, manifestation, location, severity, and type of injury or disease. The last character is the extension.
The conditions listed in an Excludes1 note are mutually exclusive with the main condition the coder is looking up. An Excludes1 note informs the coder that if the code they are looking up is in the Excludes1 note, the coder cannot, under any circumstances, use the code that houses the note.
Code O80 is always a principal diagnosis.
If a patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for hypertension, heart disease and chronic kidney disease, or codes from I11 or I12. For patients with both acute renal failure and chronic kidney disease, an additional code for acute renal failure is required.
It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the provider's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient. Patient admitted for HIV-related condition. Patient admitted for HIV-related condition.
Severe Sepsis. The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection.
If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The primary site is to be sequenced first, followed by any metastatic sites. Encounter for treatment of secondary malignancy.
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used.