Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. The guidelines are organized into sections. Only this set of guidelines, approved by the Cooperating Parties, is official. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. The term encounter is used for all settings, including hospital admissions. ![]() The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. Without such documentation accurate coding cannot be achieved. The importance of consistent, complete documentation in the medical record cannot be overemphasized. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. The instructions and conventions of the classification take precedence over guidelines. ![]() These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO). The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Italics are used to indicate revisions to heading changes Items underlined have been moved within the guidelines since the 2012 version ![]() ICD-10-CM Official Guidelines for Coding and Reporting MS-DRG Medicare Severity diagnosis-related groups ICD-O International Classification of Diseases for Oncology ![]() ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification Explain and apply the conventions and guidelinesĭSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Identify the format of the ICD-10-CM code bookĢ.
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