ICD-10-CM Official Guidelines For Coding and Reporting: Italics Are Used To Indicate Revisions To Heading Changes

ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-CM Official Guidelines for Coding and Reporting 2018

Narrative changes appear in bold text 13. Etiology/manifestation convention (“code first”, “use additional
Items underlined have been moved within the guidelines since the FY 2017 code” and “in diseases classified elsewhere” notes)........................... 4
version 14. “And” .............................................................................................................. 4
15. “With” ............................................................................................................ 4
Italics are used to indicate revisions to heading changes 16. “See” and “See Also” .................................................................................. 4
The Centers for Medicare and Medicaid Services (CMS) and the National 17. “Code also” note ......................................................................................... 4
Center for Health Statistics (NCHS), two departments within the U.S. Federal 18. Default codes ............................................................................................... 4
Government’s Department of Health and Human Services (DHHS) provide the 19. Code assignment and Clinical Criteria ................................................... 4
following guidelines for coding and reporting using the International B. General Coding Guidelines ............................................................................... 4
Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). 1. Locating a code in the ICD-10-CM .......................................................... 4
These guidelines should be used as a companion document to the official 2. Level of Detail in Coding ........................................................................... 4
version of the ICD-10-CM as published on the NCHS website. The ICD-10-CM is 3. Code or codes from A00.0 through T88.9, Z00-Z99.8 ....................... 4
a morbidity classification published by the United States for classifying 4. Signs and symptoms .................................................................................. 4
diagnoses and reason for visits in all health care settings. The ICD-10-CM is 5. Conditions that are an integral part of a disease process ................ 4
based on the ICD-10, the statistical classification of disease published by the 6. Conditions that are not an integral part of a disease process ......... 5
World Health Organization (WHO). 7. Multiple coding for a single condition .................................................. 5
These guidelines have been approved by the four organizations that make up 8. Acute and Chronic Conditions ................................................................ 5
the Cooperating Parties for the ICD-10-CM: the American Hospital Association 9. Combination Code ..................................................................................... 5
(AHA), the American Health Information Management Association (AHIMA), 10. Sequela (Late Effects) ................................................................................ 5
CMS, and NCHS. 11. Impending or Threatened Condition .................................................... 5
These guidelines are a set of rules that have been developed to accompany 12. Reporting Same Diagnosis Code More than Once ............................. 5
and complement the official conventions and instructions provided within the 13. Laterality ....................................................................................................... 5
ICD-10-CM itself. The instructions and conventions of the classification take 14. Documentation for BMI, Depth of Non-pressure ulcers, Pressure
precedence over guidelines. These guidelines are based on the coding and Ulcer Stages, Coma Scale, and NIH Stroke Scale ................................. 5
sequencing instructions in the Tabular List and Alphabetic Index of 15. Syndromes ................................................................................................... 5
ICD-10-CM, but provide additional instruction. Adherence to these guidelines 16. Documentation of Complications of Care ............................................ 5
when assigning ICD-10-CM diagnosis codes is required under the Health 17. Borderline Diagnosis .................................................................................. 6
Insurance Portability and Accountability Act (HIPAA). The diagnosis codes 18. Use of Sign/Symptom/Unspecified Codes ........................................... 6
(Tabular List and Alphabetic Index) have been adopted under HIPAA for all C. Chapter-Specific Coding Guidelines .............................................................. 6
healthcare settings. A joint effort between the healthcare provider and the 1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) ..... 6
coder is essential to achieve complete and accurate documentation, code a. Human Immunodeficiency Virus (HIV) Infections ........................ 6
assignment, and reporting of diagnoses and procedures. These guidelines b. Infectious agents as the cause of diseases classified to
have been developed to assist both the healthcare provider and the coder in other chapters........................................................................................ 6
identifying those diagnoses that are to be reported. The importance of c. Infections resistant to antibiotics ..................................................... 6
consistent, complete documentation in the medical record cannot be d. Sepsis, Severe Sepsis, and Septic Shock ......................................... 6
overemphasized. Without such documentation accurate coding cannot be e. Methicillin Resistant Staphylococcus aureus (MRSA)
achieved. The entire record should be reviewed to determine the specific Conditions............................................................................................... 8
reason for the encounter and the conditions treated. f. Zika virus infections ............................................................................. 8
The term encounter is used for all settings, including hospital admissions. In 2. Chapter 2: Neoplasms (C00-D49) ........................................................... 8
the context of these guidelines, the term provider is used throughout the a. Treatment directed at the malignancy ........................................... 8
guidelines to mean physician or any qualified health care practitioner who is b. Treatment of secondary site .............................................................. 8
legally accountable for establishing the patient’s diagnosis. Only this set of c. Coding and sequencing of complications ..................................... 8
guidelines, approved by the Cooperating Parties, is official. d. Primary malignancy previously excised ......................................... 9
The guidelines are organized into sections. Section I includes the structure and e. Admissions/Encounters involving chemotherapy,
conventions of the classification and general guidelines that apply to the immunotherapy and radiation therapy .......................................... 9
entire classification, and chapter-specific guidelines that correspond to the f. Admission/encounter to determine extent of malignancy ....... 9
chapters as they are arranged in the classification. Section II includes g. Symptoms, signs, and abnormal findings listed in
guidelines for selection of principal diagnosis for non-outpatient settings. Chapter 18 associated with neoplasms........................................... 9
Section III includes guidelines for reporting additional diagnoses in h. Admission/encounter for pain control/management ................ 9
non-outpatient settings. Section IV is for outpatient coding and reporting. It is i. Malignancy in two or more noncontiguous sites ......................... 9
necessary to review all sections of the guidelines to fully understand all of the j. Disseminated malignant neoplasm, unspecified ......................... 9
rules and instructions needed to code properly. k. Malignant neoplasm without specification of site ...................... 9
l. Sequencing of neoplasm codes ........................................................ 9
Section I. Conventions, general coding guidelines and chapter m. Current malignancy versus personal history of malignancy ....10
specific guidelines ............................................................................ 3 n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell
A. Conventions for the ICD-10-CM ....................................................................... 3 Neoplasms in remission versus personal history .......................10
1. The Alphabetic Index and Tabular List .................................................. 3 o. Aftercare following surgery for neoplasm ...................................10
2. Format and Structure: ............................................................................... 3 p. Follow-up care for completed treatment of a malignancy ......10
3. Use of codes for reporting purposes ..................................................... 3 q. Prophylactic organ removal for prevention of malignancy .....10
4. Placeholder character ............................................................................... 3 r. Malignant neoplasm associated with transplanted organ ......10
5. 7th Characters ............................................................................................. 3 3. Chapter 3: Disease of the blood and blood-forming organs and
6. Abbreviations .............................................................................................. 3 certain disorders involving the immune mechanism
a. Alphabetic Index abbreviations ....................................................... 3 (D50-D89) ...................................................................................................10
b. Tabular List abbreviations .................................................................. 3 4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases
7. Punctuation ................................................................................................. 3 (E00-E89)......................................................................................................10
8. Use of “and”. ................................................................................................ 3 a. Diabetes mellitus ................................................................................10
9. Other and Unspecified codes .................................................................. 3 5. Chapter 5: Mental, Behavioral and Neurodevelopmental
a. “Other” codes ........................................................................................ 3 disorders (F01-F99) ..................................................................................11
b. “Unspecified” codes ............................................................................. 3 a. Pain disorders related to psychological factors ..........................11
10. Includes Notes ............................................................................................. 3 b. Mental and behavioral disorders due to psychoactive
11. Inclusion terms ............................................................................................ 3 substance use ......................................................................................11
12. Excludes Notes ............................................................................................ 3 6. Chapter 6: Diseases of the Nervous System (G00-G99) ...................11
a. Excludes1 ............................................................................................... 3 a. Dominant/nondominant side .........................................................11
b. Excludes2 ............................................................................................... 4 b. Pain - Category G89 ...........................................................................11
ICD-10-CM 2018 Coding Guidelines – 1

ICD-10-CM Official Guidelines for Coding and Reporting 2018 ICD-10-CM Official Guidelines for Coding and Reporting 2018 ICD-10-CM 2018
7. Chapter 7: Diseases of the Eye and Adnexa (H00-H59) ...................12 f. Functional quadriplegia ................................................................... 19
a. Glaucoma ..............................................................................................12 g. SIRS due to Non-Infectious Process ............................................... 19
b. Blindness ...............................................................................................12 h. Death NOS ........................................................................................... 20
8. Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) ....12 i. NIHSS Stroke Scale ............................................................................. 20
9. Chapter 9: Diseases of the Circulatory System (I00-I99) .................12 19. Chapter 19: Injury, poisoning, and certain other consequences
a. Hypertension .......................................................................................12 of external causes (S00-T88) ................................................................. 20
b. Atherosclerotic Coronary Artery Disease and Angina ...............13 a. Application of 7th Characters in Chapter 19 ............................... 20
c. Intraoperative and Postprocedural Cerebrovascular b. Coding of Injuries ............................................................................... 20
Accident ................................................................................................13 c. Coding of Traumatic Fractures ....................................................... 20
d. Sequelae of Cerebrovascular Disease ............................................13 d. Coding of Burns and Corrosions .................................................... 20
e. Acute myocardial infarction (AMI) .................................................13 e. Adverse Effects, Poisoning, Underdosing and Toxic Effects ... 21
10. Chapter 10: Diseases of the Respiratory System (J00-J99) .............14 f. Adult and child abuse, neglect and other maltreatment ........ 22
a. Chronic Obstructive Pulmonary Disease [COPD] g. Complications of care ....................................................................... 22
and Asthma ..........................................................................................14 20. Chapter 20: External Causes of Morbidity (V00-Y99) ...................... 22
b. Acute Respiratory Failure .................................................................14 a. General External Cause Coding Guidelines ................................. 22
c. Influenza due to certain identified influenza viruses ................14 b. Place of Occurrence Guideline ....................................................... 23
d. Ventilator associated Pneumonia ..................................................14 c. Activity Code ....................................................................................... 23
11. Chapter 11: Diseases of the Digestive System (K00-K95) ...............14 d. Place of Occurrence, Activity, and Status Codes Used
12. Chapter 12: Diseases of the Skin and Subcutaneous with other External Cause Code ..................................................... 23
Tissue (L00-L99) .........................................................................................14 e. If the Reporting Format Limits the Number of External
a. Pressure ulcer stage codes ...............................................................14 Cause Codes ........................................................................................ 23
b. Non-Pressure Chronic Ulcers ...........................................................15 f. Multiple External Cause Coding Guidelines ................................ 23
13. Chapter 13: Diseases of the Musculoskeletal System and g. Child and Adult Abuse Guideline ................................................... 23
Connective Tissue (M00-M99) ...............................................................15 h. Unknown or Undetermined Intent Guideline ............................ 23
a. Site and laterality ................................................................................15 i. Sequelae (Late Effects) of External Cause Guidelines ............... 23
b. Acute traumatic versus chronic or recurrent j. Terrorism Guidelines ......................................................................... 23
musculoskeletal conditions .............................................................15 k. External cause status ........................................................................ 24
c. Coding of Pathologic Fractures .......................................................15 21. Chapter 21: Factors influencing health status and contact
d. Osteoporosis ........................................................................................15 with health services (Z00-Z99) ............................................................. 24
14. Chapter 14: Diseases of Genitourinary System (N00-N99) .............15 a. Use of Z codes in any healthcare setting ..................................... 24
a. Chronic kidney disease ......................................................................15 b. Z Codes indicate a reason for an encounter ............................... 24
15. Chapter 15: Pregnancy, Childbirth, and the Puerperium c. Categories of Z Codes ....................................................................... 24
(O00-O9A)....................................................................................................16
a. General Rules for Obstetric Cases ...................................................16 Section II. Selection of Principal Diagnosis ...................................28
b. Selection of OB Principal or First-listed Diagnosis ......................16 A. Codes for symptoms, signs, and ill-defined conditions ................. 29
c. Pre-existing conditions versus conditions due to B. Two or more interrelated conditions, each potentially
the pregnancy ......................................................................................16 meeting the definition for principal diagnosis.................................. 29
d. Pre-existing hypertension in pregnancy ......................................17 C. Two or more diagnoses that equally meet the definition for
e. Fetal Conditions Affecting the Management of the Mother ....17 principal diagnosis ................................................................................... 29
f. HIV Infection in Pregnancy, Childbirth and the Puerperium ....17 D. Two or more comparative or contrasting conditions ..................... 29
g. Diabetes mellitus in pregnancy ......................................................17 E. A symptom(s) followed by contrasting/comparative
h. Long term use of insulin and oral hypoglycemics .....................17 diagnoses ................................................................................................... 29
i. Gestational (pregnancy induced) diabetes ..................................17 F. Original treatment plan not carried out ............................................. 29
j. Sepsis and septic shock complicating abortion, G. Complications of surgery and other medical care............................ 29
pregnancy, childbirth and the puerperium .................................17 H. Uncertain Diagnosis ................................................................................ 29
k. Puerperal sepsis ..................................................................................17 I. Admission from Observation Unit ....................................................... 29
l. Alcohol and tobacco use during pregnancy, childbirth 1. Admission Following Medical Observation ................................. 29
and the puerperium............................................................................17 2. Admission Following Post-Operative Observation ................... 29
m. Poisoning, toxic effects, adverse effects and underdosing J. Admission from Outpatient Surgery ................................................... 29
in a pregnant patient..........................................................................17 K. Admissions/Encounters for Rehabilitation ........................................ 29
n. Normal Delivery, Code O80 ..............................................................17 Section III. Reporting Additional Diagnoses .................................29
o. The Peripartum and Postpartum Periods .....................................17 A. Previous conditions ................................................................................. 29
p. Code O94, Sequelae of complication of pregnancy, B. Abnormal findings ................................................................................... 30
childbirth, and the puerperium .......................................................18 C. Uncertain Diagnosis ................................................................................ 30
q. Termination of Pregnancy and Spontaneous abortions ...........18
r. Abuse in a pregnant patient ............................................................18 Section IV.Diagnostic Coding and Reporting Guidelines for
16. Chapter 16: Certain Conditions Originating in the Perinatal Outpatient Services ........................................................................30
Period (P00-P96) ........................................................................................18 A. Selection of first-listed condition ......................................................... 30
a. General Perinatal Rules .....................................................................18 1. Outpatient Surgery ............................................................................ 30
b. Observation and Evaluation of Newborns for Suspected 2. Observation Stay ................................................................................ 30
Conditions not Found ........................................................................18 B. Codes from A00.0 through T88.9, Z00-Z99 ....................................... 30
c. Coding Additional Perinatal Diagnoses ........................................19 C. Accurate reporting of ICD-10-CM diagnosis codes ......................... 30
d. Prematurity and Fetal Growth Retardation .................................19 D. Codes that describe symptoms and signs ......................................... 30
e. Low birth weight and immaturity status ......................................19 E. Encounters for circumstances other than a disease or injury ....... 30
f. Bacterial Sepsis of Newborn ............................................................19 F. Level of Detail in Coding ........................................................................ 30
g. Stillbirth ................................................................................................19 1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters ......................... 30
17. Chapter 17: Congenital malformations, deformations, and 2. Use of full number of characters required for a code ............... 30
chromosomal abnormalities (Q00-Q99) .............................................19 G. ICD-10-CM code for the diagnosis, condition, problem, or
18. Chapter 18: Symptoms, signs, and abnormal clinical and other reason for encounter/visit .......................................................... 30
laboratory findings, not elsewhere classified (R00-R99)..................19 H. Uncertain diagnosis ................................................................................. 30
a. Use of symptom codes ......................................................................19 I. Chronic diseases ....................................................................................... 30
b. Use of a symptom code with a definitive diagnosis code ........19 J. Code all documented conditions that coexist .................................. 30
c. Combination codes that include symptoms ...............................19 K. Patients receiving diagnostic services only ....................................... 31
d. Repeated falls ......................................................................................19 L. Patients receiving therapeutic services only ..................................... 31
e. Coma scale ...........................................................................................19 M. Patients receiving preoperative evaluations only ........................... 31
N. Ambulatory surgery ................................................................................ 31
2 – Coding Guidelines ICD-10-CM 2018

ICD-10-CM 2018 ICD-10-CM Official Guidelines for Coding and Reporting 2018

O. Routine outpatient prenatal visits ....................................................... 31 includes an NEC entry under a code to identify the code as the
P. Encounters for general medical examinations with abnormal “other specified” code.
findings ....................................................................................................... 31 NOS “Not otherwise specified”
Q. Encounters for routine health screenings .......................................... 31
This abbreviation is the equivalent of unspecified.
Appendix I. Present on Admission Reporting Guidelines .............31 7. Punctuation
[ ] Brackets are used in the Tabular List to enclose synonyms,
alternative wording or explanatory phrases. Brackets are used in the
Section I. Conventions, general coding Alphabetic Index to identify manifestation codes.
guidelines and chapter specific guidelines ( ) Parentheses are used in both the Alphabetic Index and Tabular List
to enclose supplementary words that may be present or absent in
The conventions, general guidelines and chapter-specific guidelines are the statement of a disease or procedure without affecting the code
applicable to all health care settings unless otherwise indicated. The number to which it is assigned. The terms within the parentheses
conventions and instructions of the classification take precedence over are referred to as nonessential modifiers. The nonessential modifiers
guidelines. in the Alphabetic Index to Diseases apply to subterms following a
main term except when a nonessential modifier and a subentry are
A. Conventions for the ICD-10-CM mutually exclusive, the subentry takes precedence. For example, in
The conventions for the ICD-10-CM are the general rules for use of the the ICD-10-CM Alphabetic Index under the main term Enteritis,
classification independent of the guidelines. These conventions are “acute” is a nonessential modifier and “chronic” is a subentry. In this
incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as case, the nonessential modifier “acute” does not apply to the
instructional notes. subentry “chronic”.
1. The Alphabetic Index and Tabular List : Colons are used in the Tabular List after an incomplete term which
The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list needs one or more of the modifiers following the colon to make it
of terms and their corresponding code, and the Tabular List, a structured assignable to a given category.
list of codes divided into chapters based on body system or condition. 8. Use of “and”.
The Alphabetic Index consists of the following parts: the Index of See Section I.A.14. Use of the term “And”
Diseases and Injury, the Index of External Causes of Injury, the Table of 9. Other and Unspecified codes
Neoplasms and the Table of Drugs and Chemicals. a. “Other” codes
See Section I.C2. General guidelines Codes titled “other” or “other specified” are for use when the
See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects information in the medical record provides detail for which a
specific code does not exist. Alphabetic Index entries with NEC in
2. Format and Structure: the line designate “other” codes in the Tabular List. These
The ICD-10-CM Tabular List contains categories, subcategories and Alphabetic Index entries represent specific disease entities for which
codes. Characters for categories, subcategories and codes may be either no specific code exists so the term is included within an “other”
a letter or a number. All categories are 3 characters. A three-character code.
category that has no further subdivision is equivalent to a code.
Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 b. “Unspecified” codes
characters. That is, each level of subdivision after a category is a Codes titled “unspecified” are for use when the information in the
subcategory. The final level of subdivision is a code. Codes that have medical record is insufficient to assign a more specific code. For
applicable 7th characters are still referred to as codes, not subcategories. those categories for which an unspecified code is not provided, the
A code that has an applicable 7th character is considered invalid without “other specified” code may represent both other and unspecified.
the 7th character. See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
The ICD-10-CM uses an indented format for ease in reference. 10. Includes Notes
3. Use of codes for reporting purposes This note appears immediately under a three character code title to
For reporting purposes only codes are permissible, not categories or further define, or give examples of, the content of the category.
subcategories, and any applicable 7th character is required. 11. Inclusion terms
4. Placeholder character List of terms is included under some codes. These terms are the
The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a conditions for which that code is to be used. The terms may be
placeholder at certain codes to allow for future expansion. An example synonyms of the code title, or, in the case of “other specified” codes, the
of this is at the poisoning, adverse effect and underdosing codes, terms are a list of the various conditions assigned to that code. The
categories T36-T50. inclusion terms are not necessarily exhaustive. Additional terms found
only in the Alphabetic Index may also be assigned to a code.
Where a placeholder exists, the X must be used in order for the code to
be considered a valid code. 12. Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a
5. 7th Characters different definition for use but they are all similar in that they indicate
Certain ICD-10-CM categories have applicable 7th characters. The that codes excluded from each other are independent of each other.
applicable 7th character is required for all codes within the category, or
as the notes in the Tabular List instruct. The 7th character must always be a. Excludes1
the 7th character in the data field. If a code that requires a 7th character A type 1 Excludes note is a pure excludes note. It means “NOT
is not 6 characters, a placeholder X must be used to fill in the empty CODED HERE!” An Excludes1 note indicates that the code excluded
characters. should never be used at the same time as the code above the
Excludes1 note. An Excludes1 is used when two conditions cannot
6. Abbreviations occur together, such as a congenital form versus an acquired form of
a. Alphabetic Index abbreviations the same condition.
NEC “Not elsewhere classifiable”
An exception to the Excludes1 definition is the circumstance when
This abbreviation in the Alphabetic Index represents “other the two conditions are unrelated to each other. If it is not clear
specified.” When a specific code is not available for a condition, the whether the two conditions involving an Excludes1 note are related
Alphabetic Index directs the coder to the “other specified” code in or not, query the provider. For example, code F45.8, Other
the Tabular List. somatoform disorders, has an Excludes1 note for “sleep related
NOS “Not otherwise specified” teeth grinding (G47.63),” because “teeth grinding” is an inclusion
This abbreviation is the equivalent of unspecified. term under F45.8. Only one of these two codes should be assigned
for teeth grinding. However psychogenic dysmenorrhea is also an
b. Tabular List abbreviations inclusion term under F45.8, and a patient could have both this
NEC “Not elsewhere classifiable” condition and sleep related teeth grinding. In this case, the two
This abbreviation in the Tabular List represents “other specified”. conditions are clearly unrelated to each other, and so it would be
When a specific code is not available for a condition, the Tabular List appropriate to report F45.8 and G47.63 together.

b. Excludes2 16. “See” and “See Also”
A type 2 Excludes note represents “Not included here.” An excludes2 The “see” instruction following a main term in the Alphabetic Index
note indicates that the condition excluded is not part of the indicates that another term should be referenced. It is necessary to go to
condition represented by the code, but a patient may have both the main term referenced with the “see” note to locate the correct code.
conditions at the same time. When an Excludes2 note appears A “see also” instruction following a main term in the Alphabetic Index
under a code, it is acceptable to use both the code and the excluded instructs that there is another main term that may also be referenced
code together, when appropriate. that may provide additional Alphabetic Index entries that may be useful.
13. Etiology/manifestation convention (“code first”, “use additional It is not necessary to follow the “see also” note when the original main
code” and “in diseases classified elsewhere” notes) term provides the necessary code.
Certain conditions have both an underlying etiology and multiple body 17. “Code also” note
system manifestations due to the underlying etiology. For such A “code also” note instructs that two codes may be required to fully
conditions, the ICD-10-CM has a coding convention that requires the describe a condition, but this note does not provide sequencing
underlying condition be sequenced first, if applicable, followed by the direction. The sequencing depends on the circumstances of the
manifestation. Wherever such a combination exists, there is a “use encounter.
additional code” note at the etiology code, and a “code first” note at the
manifestation code. These instructional notes indicate the proper 18. Default codes
sequencing order of the codes, etiology followed by manifestation. A code listed next to a main term in the ICD-10-CM Alphabetic Index is
referred to as a default code. The default code represents that condition
In most cases the manifestation codes will have in the code title, “in that is most commonly associated with the main term, or is the
diseases classified elsewhere.” Codes with this title are a component of unspecified code for the condition. If a condition is documented in a
the etiology/ manifestation convention. The code title indicates that it is medical record (for example, appendicitis) without any additional
a manifestation code. “In diseases classified elsewhere” codes are never information, such as acute or chronic, the default code should be
permitted to be used as first-listed or principal diagnosis codes. They assigned.
must be used in conjunction with an underlying condition code and
they must be listed following the underlying condition. See category 19. Code assignment and Clinical Criteria
F02, Dementia in other diseases classified elsewhere, for an example of The assignment of a diagnosis code is based on the provider’s diagnostic
this convention. statement that the condition exists. The provider’s statement that the
patient has a particular condition is sufficient. Code assignment is not
There are manifestation codes that do not have “in diseases classified based on clinical criteria used by the provider to establish the diagnosis.
elsewhere” in the title. For such codes, there is a “use additional code”
note at the etiology code and a “code first” note at the manifestation
code, and the rules for sequencing apply. B. General Coding Guidelines
In addition to the notes in the Tabular List, these conditions also have a 1. Locating a code in the ICD-10-CM
specific Alphabetic Index entry structure. In the Alphabetic Index both To select a code in the classification that corresponds to a diagnosis or
conditions are listed together with the etiology code first followed by reason for visit documented in a medical record, first locate the term in
the manifestation codes in brackets. The code in brackets is always to be the Alphabetic Index, and then verify the code in the Tabular List. Read
sequenced second. and be guided by instructional notations that appear in both the
An example of the etiology/manifestation convention is dementia in Alphabetic Index and the Tabular List.
Parkinson’s disease. In the Alphabetic Index, code G20 is listed first, It is essential to use both the Alphabetic Index and Tabular List when
followed by code F02.80 or F02.81 in brackets. Code G20 represents the locating and assigning a code. The Alphabetic Index does not always
underlying etiology, Parkinson’s disease, and must be sequenced first, provide the full code. Selection of the full code, including laterality and
whereas code F02.80 and F02.81 represent the manifestation of any applicable 7th character can only be done in the Tabular List. A dash
dementia in diseases classified elsewhere, with or without behavioral (-) at the end of an Alphabetic Index entry indicates that additional
disturbance. characters are required. Even if a dash is not included at the Alphabetic
“Code first” and “Use additional code” notes are also used as sequencing Index entry, it is necessary to refer to the Tabular List to verify that no 7th
rules in the classification for certain codes that are not part of an character is required.
etiology/ manifestation combination. 2. Level of Detail in Coding
See Section I.B.7. Multiple coding for a single condition. Diagnosis codes are to be used and reported at their highest number of
characters available.
14. “And”
The word “and” should be interpreted to mean either “and” or “or” when ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7
it appears in a title. characters. Codes with three characters are included in ICD-10-CM as the
heading of a category of codes that may be further subdivided by the
For example, cases of “tuberculosis of bones”, “tuberculosis of joints” and use of fourth and/or fifth characters and/or sixth characters, which
“tuberculosis of bones and joints” are classified to subcategory A18.0, provide greater detail.
Tuberculosis of bones and joints.
A three-character code is to be used only if it is not further subdivided. A
15. “With” code is invalid if it has not been coded to the full number of characters
The word “with” or “in” should be interpreted to mean “associated with” required for that code, including the 7th character, if applicable.
or “due to” when it appears in a code title, the Alphabetic Index, or an
instructional note in the Tabular List. The classification presumes a causal 3. Code or codes from A00.0 through T88.9, Z00-Z99.8
relationship between the two conditions linked by these terms in the The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8
Alphabetic Index or Tabular List. These conditions should be coded as must be used to identify diagnoses, symptoms, conditions, problems,
related even in the absence of provider documentation explicitly linking complaints or other reason(s) for the encounter/visit.
them, unless the documentation clearly states the conditions are 4. Signs and symptoms
unrelated or when another guideline exists that specifically Codes that describe symptoms and signs, as opposed to diagnoses, are
requires a documented linkage between two conditions (e.g., acceptable for reporting purposes when a related definitive diagnosis
sepsis guideline for “acute organ dysfunction that is not clearly has not been established (confirmed) by the provider. Chapter 18 of
associated with the sepsis”). ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory
For conditions not specifically linked by these relational terms in the Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many,
classification or when a guideline requires that a linkage between but not all, codes for symptoms.
two conditions be explicitly documented, provider documentation See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
must link the conditions in order to code them as related. 5. Conditions that are an integral part of a disease process
The word “with” in the Alphabetic Index is sequenced immediately Signs and symptoms that are associated routinely with a disease process
following the main term, not in alphabetical order. should not be assigned as additional codes, unless otherwise instructed
by the classification.


6. Conditions that are not an integral part of a disease process See Section I.C.19. Application of 7th characters for Chapter 19
Additional signs and symptoms that may not be associated routinely 11. Impending or Threatened Condition
with a disease process should be coded when present. Code any condition described at the time of discharge as “impending” or
7. Multiple coding for a single condition “threatened” as follows:
In addition to the etiology/manifestation convention that requires two If it did occur, code as confirmed diagnosis.
codes to fully describe a single condition that affects multiple body
systems, there are other single conditions that also require more than If it did not occur, reference the Alphabetic Index to determine if the
one code. “Use additional code” notes are found in the Tabular List at condition has a subentry term for “impending” or “threatened” and
codes that are not part of an etiology/manifestation pair where a also reference main term entries for “Impending” and for
secondary code is useful to fully describe a condition. The sequencing “Threatened.”
rule is the same as the etiology/manifestation pair, “use additional code” If the subterms are listed, assign the given code.
indicates that a secondary code should be added, if known. If the subterms are not listed, code the existing underlying
For example, for bacterial infections that are not included in chapter 1, a condition(s) and not the condition described as impending or
secondary code from category B95, Streptococcus, Staphylococcus, and threatened.
Enterococcus, as the cause of diseases classified elsewhere, or B96, Other 12. Reporting Same Diagnosis Code More than Once
bacterial agents as the cause of diseases classified elsewhere, may be Each unique ICD-10-CM diagnosis code may be reported only once for
required to identify the bacterial organism causing the infection. A “use an encounter. This applies to bilateral conditions when there are no
additional code” note will normally be found at the infectious disease distinct codes identifying laterality or two different conditions classified
code, indicating a need for the organism code to be added as a to the same ICD-10-CM diagnosis code.
secondary code.
13. Laterality
“Code first” notes are also under certain codes that are not specifically Some ICD-10-CM codes indicate laterality, specifying whether the
manifestation codes but may be due to an underlying cause. When there condition occurs on the left, right or is bilateral. If no bilateral code is
is a “code first” note and an underlying condition is present, the provided and the condition is bilateral, assign separate codes for both
underlying condition should be sequenced first, if known. the left and right side. If the side is not identified in the medical record,
“Code, if applicable, any causal condition first” notes indicate that this assign the code for the unspecified side.
code may be assigned as a principal diagnosis when the causal condition When a patient has a bilateral condition and each side is treated during
is unknown or not applicable. If a causal condition is known, then the separate encounters, assign the “bilateral” code (as the condition still
code for that condition should be sequenced as the principal or exists on both sides), including for the encounter to treat the first side.
first-listed diagnosis. For the second encounter for treatment after one side has previously
Multiple codes may be needed for sequela, complication codes and been treated and the condition no longer exists on that side, assign the
obstetric codes to more fully describe a condition. See the specific appropriate unilateral code for the side where the condition still exists
guidelines for these conditions for further instruction. (e.g., cataract surgery performed on each eye in separate encounters).
8. Acute and Chronic Conditions The bilateral code would not be assigned for the subsequent encounter,
If the same condition is described as both acute (subacute) and chronic, as the patient no longer has the condition in the previously-treated site.
and separate subentries exist in the Alphabetic Index at the same If the treatment on the first side did not completely resolve the
indentation level, code both and sequence the acute (subacute) code condition, then the bilateral code would still be appropriate.
first. 14. Documentation for BMI, Depth of Non-pressure ulcers, Pressure
9. Combination Code Ulcer Stages, Coma Scale, and NIH Stroke Scale
A combination code is a single code used to classify: For the Body Mass Index (BMI), depth of non-pressure chronic ulcers,
pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes,
Two diagnoses, or code assignment may be based on medical record documentation from
A diagnosis with an associated secondary process (manifestation) clinicians who are not the patient’s provider (i.e., physician or other
A diagnosis with an associated complication qualified healthcare practitioner legally accountable for establishing the
patient’s diagnosis), since this information is typically documented by
Combination codes are identified by referring to subterm entries in the other clinicians involved in the care of the patient (e.g., a dietitian often
Alphabetic Index and by reading the inclusion and exclusion notes in the documents the BMI, a nurse often documents the pressure ulcer stages,
Tabular List. and an emergency medical technician often documents the coma scale).
Assign only the combination code when that code fully identifies the However, the associated diagnosis (such as overweight, obesity, acute
diagnostic conditions involved or when the Alphabetic Index so directs. stroke, or pressure ulcer) must be documented by the patient’s provider.
Multiple coding should not be used when the classification provides a If there is conflicting medical record documentation, either from the
combination code that clearly identifies all of the elements documented same clinician or different clinicians, the patient’s attending provider
in the diagnosis. When the combination code lacks necessary specificity should be queried for clarification.
in describing the manifestation or complication, an additional code The BMI, coma scale, and NIHSS codes should only be reported as
should be used as a secondary code. secondary diagnoses.
10. Sequela (Late Effects) 15. Syndromes
A sequela is the residual effect (condition produced) after the acute Follow the Alphabetic Index guidance when coding syndromes. In the
phase of an illness or injury has terminated. There is no time limit on absence of Alphabetic Index guidance, assign codes for the documented
when a sequela code can be used. The residual may be apparent early, manifestations of the syndrome. Additional codes for manifestations
such as in cerebral infarction, or it may occur months or years later, such that are not an integral part of the disease process may also be assigned
as that due to a previous injury. Examples of sequela include: scar when the condition does not have a unique code.
formation resulting from a burn, deviated septum due to a nasal
fracture, and infertility due to tubal occlusion from old tuberculosis. 16. Documentation of Complications of Care
Coding of sequela generally requires two codes sequenced in the Code assignment is based on the provider’s documentation of the
following order: the condition or nature of the sequela is sequenced first. relationship between the condition and the care or procedure, unless
The sequela code is sequenced second. otherwise instructed by the classification. The guideline extends to any
complications of care, regardless of the chapter the code is located in. It
An exception to the above guidelines are those instances where the is important to note that not all conditions that occur during or
code for the sequela is followed by a manifestation code identified in the following medical care or surgery are classified as complications. There
Tabular List and title, or the sequela code has been expanded (at the must be a cause-and-effect relationship between the care provided and
fourth, fifth or sixth character levels) to include the manifestation(s). The the condition, and an indication in the documentation that it is a
code for the acute phase of an illness or injury that led to the sequela is complication. Query the provider for clarification, if the complication is
never used with a code for the late effect. not clearly documented.
See Section I.C.9. Sequelae of cerebrovascular disease
See Section I.C.15. Sequelae of complication of pregnancy, childbirth and
the puerperium

17. Borderline Diagnosis or if the patient is treated for any HIV-related illness or is
If the provider documents a “borderline” diagnosis at the time of described as having any condition(s) resulting from his/her
discharge, the diagnosis is coded as confirmed, unless the classification HIV positive status; use B20 in these cases.
provides a specific entry (e.g., borderline diabetes). If a borderline (e) Patients with inconclusive HIV serology
condition has a specific index entry in ICD-10-CM, it should be coded as Patients with inconclusive HIV serology, but no definitive
such. Since borderline conditions are not uncertain diagnoses, no diagnosis or manifestations of the illness, may be assigned
distinction is made between the care setting (inpatient versus code R75, Inconclusive laboratory evidence of human
outpatient). Whenever the documentation is unclear regarding a immunodeficiency virus [HIV].
borderline condition, coders are encouraged to query for clarification.
(f) Previously diagnosed HIV-related illness
18. Use of Sign/Symptom/Unspecified Codes Patients with any known prior diagnosis of an HIV-related
Sign/symptom and “unspecified” codes have acceptable, even illness should be coded to B20. Once a patient has
necessary, uses. While specific diagnosis codes should be reported when developed an HIV-related illness, the patient should always
they are supported by the available medical record documentation and be assigned code B20 on every subsequent
clinical knowledge of the patient’s health condition, there are instances admission/encounter. Patients previously diagnosed with
when signs/symptoms or unspecified codes are the best choices for any HIV illness (B20) should never be assigned to R75 or
accurately reflecting the healthcare encounter. Each healthcare Z21, Asymptomatic human immunodeficiency virus [HIV]
encounter should be coded to the level of certainty known for that infection status.
encounter.
(g) HIV Infection in Pregnancy, Childbirth and the
If a definitive diagnosis has not been established by the end of the Puerperium
encounter, it is appropriate to report codes for sign(s) and/or During pregnancy, childbirth or the puerperium, a patient
symptom(s) in lieu of a definitive diagnosis. When sufficient clinical admitted (or presenting for a health care encounter)
information isn’t known or available about a particular health condition because of an HIV-related illness should receive a principal
to assign a more specific code, it is acceptable to report the appropriate diagnosis code of O98.7-, Human immunodeficiency [HIV]
“unspecified” code (e.g., a diagnosis of pneumonia has been disease complicating pregnancy, childbirth and the
determined, but not the specific type). Unspecified codes should be puerperium, followed by B20 and the code(s) for the
reported when they are the codes that most accurately reflect what is HIV-related illness(es). Codes from Chapter 15 always take
known about the patient’s condition at the time of that particular sequencing priority.
encounter. It would be inappropriate to select a specific code that is not
supported by the medical record documentation or conduct medically Patients with asymptomatic HIV infection status admitted
unnecessary diagnostic testing in order to determine a more specific (or presenting for a health care encounter) during
code. pregnancy, childbirth, or the puerperium should receive
codes of O98.7- and Z21.
C. Chapter-Specific Coding Guidelines (h) Encounters for testing for HIV
If a patient is being seen to determine his/her HIV status,
In addition to general coding guidelines, there are guidelines for specific
use code Z11.4, Encounter for screening for human
diagnoses and/or conditions in the classification. Unless otherwise indicated,
immunodeficiency virus [HIV]. Use additional codes for any
these guidelines apply to all health care settings. Please refer to Section II for
associated high risk behavior.
guidelines on the selection of principal diagnosis.
If a patient with signs or symptoms is being seen for HIV
1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
testing, code the signs and symptoms. An additional
a. Human Immunodeficiency Virus (HIV) Infections
counseling code Z71.7, Human immunodeficiency virus
1) Code only confirmed cases [HIV] counseling, may be used if counseling is provided
Code only confirmed cases of HIV infection/illness. This is an during the encounter for the test.
exception to the hospital inpatient guideline Section II, H.
When a patient returns to be informed of his/her HIV test
In this context, “confirmation” does not require documentation results and the test result is negative, use code Z71.7,
of positive serology or culture for HIV; the provider’s diagnostic Human immunodeficiency virus [HIV] counseling.
statement that the patient is HIV positive, or has an HIV-related
illness is sufficient. If the results are positive, see previous guidelines and
assign codes as appropriate.
2) Selection and sequencing of HIV codes
b. Infectious agents as the cause of diseases classified to other
(a) Patient admitted for HIV-related condition
chapters
If a patient is admitted for an HIV-related condition, the
principal diagnosis should be B20, Human Certain infections are classified in chapters other than Chapter 1 and
immunodeficiency virus [HIV] disease followed by no organism is identified as part of the infection code. In these
additional diagnosis codes for all reported HIV-related instances, it is necessary to use an additional code from Chapter 1 to
conditions. identify the organism. A code from category B95, Streptococcus,
Staphylococcus, and Enterococcus as the cause of diseases classified
(b) Patient with HIV disease admitted for unrelated to other chapters, B96, Other bacterial agents as the cause of
condition diseases classified to other chapters, or B97, Viral agents as the
If a patient with HIV disease is admitted for an unrelated cause of diseases classified to other chapters, is to be used as an
condition (such as a traumatic injury), the code for the additional code to identify the organism. An instructional note will
unrelated condition (e.g., the nature of injury code) should be found at the infection code advising that an additional organism
be the principal diagnosis. Other diagnoses would be B20 code is required.
followed by additional diagnosis codes for all reported
c. Infections resistant to antibiotics
HIV-related conditions.
Many bacterial infections are resistant to current antibiotics. It is
(c) Whether the patient is newly diagnosed necessary to identify all infections documented as antibiotic
Whether the patient is newly diagnosed or has had resistant. Assign a code from category Z16, Resistance to
previous admissions/encounters for HIV conditions is antimicrobial drugs, following the infection code only if the
irrelevant to the sequencing decision. infection code does not identify drug resistance.
(d) Asymptomatic human immunodeficiency virus d. Sepsis, Severe Sepsis, and Septic Shock
Z21, Asymptomatic human immunodeficiency virus [HIV] 1) Coding of Sepsis and Severe Sepsis
infection status, is to be applied when the patient without (a) Sepsis
any documentation of symptoms is listed as being “HIV For a diagnosis of sepsis, assign the appropriate code for
positive,” “known HIV,” “HIV test positive,” or similar the underlying systemic infection. If the type of infection or
terminology. Do not use this code if the term “AIDS” is used causal organism is not further specified, assign code A41.9,
Sepsis, unspecified organism.


A code from subcategory R65.2, Severe sepsis, should not secondary diagnosis. If the patient has severe sepsis, a code
be assigned unless severe sepsis or an associated acute from subcategory R65.2 should also be assigned as a secondary
organ dysfunction is documented. diagnosis. If the patient is admitted with a localized infection,
(i) Negative or inconclusive blood cultures and sepsis such as pneumonia, and sepsis/severe sepsis doesn’t develop
until after admission, the localized infection should be assigned
Negative or inconclusive blood cultures do not
first, followed by the appropriate sepsis/severe sepsis codes.
preclude a diagnosis of sepsis in patients with clinical
evidence of the condition; however, the provider 5) Sepsis due to a postprocedural infection
should be queried. (a) Documentation of causal relationship
(ii) Urosepsis As with all postprocedural complications, code assignment
The term urosepsis is a nonspecific term. It is not to be is based on the provider’s documentation of the
considered synonymous with sepsis. It has no default relationship between the infection and the procedure.
code in the Alphabetic Index. Should a provider use (b) Sepsis due to a postprocedural infection
this term, he/she must be queried for clarification. For such cases, the postprocedural infection code, such as
(iii) Sepsis with organ dysfunction T80.2, Infections following infusion, transfusion, and
If a patient has sepsis and associated acute organ therapeutic injection, T81.4, Infection following a
dysfunction or multiple organ dysfunction (MOD), procedure, T88.0, Infection following immunization, or
follow the instructions for coding severe sepsis. O86.0, Infection of obstetric surgical wound, should be
(iv) Acute organ dysfunction that is not clearly coded first, followed by the code for the specific infection.
associated with the sepsis If the patient has severe sepsis, the appropriate code from
If a patient has sepsis and an acute organ dysfunction, subcategory R65.2 should also be assigned with the
but the medical record documentation indicates that additional code(s) for any acute organ dysfunction.
the acute organ dysfunction is related to a medical (c) Postprocedural infection and postprocedural septic
condition other than the sepsis, do not assign a code shock
from subcategory R65.2, Severe sepsis. An acute organ In cases where a postprocedural infection has occurred and
dysfunction must be associated with the sepsis in has resulted in severe sepsis the code for the precipitating
order to assign the severe sepsis code. If the complication such as code T81.4, Infection following a
documentation is not clear as to whether an acute procedure, or O86.0, Infection of obstetrical surgical wound
organ dysfunction is related to the sepsis or another should be coded first followed by code R65.20, Severe
medical condition, query the provider. sepsis without septic shock. A code for the systemic
(b) Severe sepsis infection should also be assigned.
The coding of severe sepsis requires a minimum of 2 codes: If a postprocedural infection has resulted in postprocedural
first a code for the underlying systemic infection, followed septic shock, the code for the precipitating complication
by a code from subcategory R65.2, Severe sepsis. If the such as code T81.4, Infection following a procedure, or
causal organism is not documented, assign code A41.9, O86.0, Infection of obstetrical surgical wound should be
Sepsis, unspecified organism, for the infection. Additional coded first followed by code T81.12-, Postprocedural septic
code(s) for the associated acute organ dysfunction are also shock. A code for the systemic infection should also be
required. assigned.
Due to the complex nature of severe sepsis, some cases 6) Sepsis and severe sepsis associated with a noninfectious
may require querying the provider prior to assignment of process (condition)
the codes. In some cases a noninfectious process (condition), such as
2) Septic shock trauma, may lead to an infection which can result in sepsis or
(a) Septic shock generally refers to circulatory failure severe sepsis. If sepsis or severe sepsis is documented as
associated with severe sepsis, and therefore, it associated with a noninfectious condition, such as a burn or
represents a type of acute organ dysfunction. serious injury, and this condition meets the definition for
For cases of septic shock, the code for the systemic principal diagnosis, the code for the noninfectious condition
infection should be sequenced first, followed by code should be sequenced first, followed by the code for the
R65.21, Severe sepsis with septic shock or code T81.12, resulting infection. If severe sepsis is present, a code from
Postprocedural septic shock. Any additional codes for the subcategory R65.2 should also be assigned with any associated
other acute organ dysfunctions should also be assigned. As organ dysfunction(s) codes. It is not necessary to assign a code
noted in the sequencing instructions in the Tabular List, the from subcategory R65.1, Systemic inflammatory response
code for septic shock cannot be assigned as a principal syndrome (SIRS) of non-infectious origin, for these cases.
diagnosis. If the infection meets the definition of principal diagnosis, it
3) Sequencing of severe sepsis should be sequenced before the non-infectious condition.
If severe sepsis is present on admission, and meets the When both the associated non-infectious condition and the
definition of principal diagnosis, the underlying systemic infection meet the definition of principal diagnosis, either may
infection should be assigned as principal diagnosis followed by be assigned as principal diagnosis.
the appropriate code from subcategory R65.2 as required by Only one code from category R65, Symptoms and signs
the sequencing rules in the Tabular List. A code from specifically associated with systemic inflammation and
subcategory R65.2 can never be assigned as a principal infection, should be assigned. Therefore, when a non-infectious
diagnosis. condition leads to an infection resulting in severe sepsis, assign
When severe sepsis develops during an encounter (it was not the appropriate code from subcategory R65.2, Severe sepsis. Do
present on admission), the underlying systemic infection and not additionally assign a code from subcategory R65.1,
the appropriate code from subcategory R65.2 should be Systemic inflammatory response syndrome (SIRS) of
assigned as secondary diagnoses. non-infectious origin.
Severe sepsis may be present on admission, but the diagnosis See Section I.C.18. SIRS due to non-infectious process
may not be confirmed until sometime after admission. If the 7) Sepsis and septic shock complicating abortion, pregnancy,
documentation is not clear whether severe sepsis was present childbirth, and the puerperium
on admission, the provider should be queried. See Section I.C.15. Sepsis and septic shock complicating abortion,
4) Sepsis and severe sepsis with a localized infection pregnancy, childbirth and the puerperium
If the reason for admission is both sepsis or severe sepsis and a 8) Newborn sepsis
localized infection, such as pneumonia or cellulitis, a code(s) for See Section I.C.16. f. Bacterial sepsis of Newborn
the underlying systemic infection should be assigned first and
the code for the localized infection should be assigned as a

e. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions the neoplasm is benign, in-situ, malignant, or of uncertain histologic
1) Selection and sequencing of MRSA codes behavior. If malignant, any secondary (metastatic) sites should also be
(a) Combination codes for MRSA infection determined.
When a patient is diagnosed with an infection that is due to Primary malignant neoplasms overlapping site boundaries
methicillin resistant Staphylococcus aureus (MRSA), and A primary malignant neoplasm that overlaps two or more
that infection has a combination code that includes the contiguous (next to each other) sites should be classified to the
causal organism (e.g., sepsis, pneumonia) assign the subcategory/code .8 ('overlapping lesion'), unless the combination
appropriate combination code for the condition (e.g., code is specifically indexed elsewhere. For multiple neoplasms of the
A41.02, Sepsis due to Methicillin resistant Staphylococcus same site that are not contiguous such as tumors in different
aureus or code J15.212, Pneumonia due to Methicillin quadrants of the same breast, codes for each site should be
resistant Staphylococcus aureus). Do not assign code assigned.
B95.62, Methicillin resistant Staphylococcus aureus Malignant neoplasm of ectopic tissue
infection as the cause of diseases classified elsewhere, as
an additional code, because the combination code includes Malignant neoplasms of ectopic tissue are to be coded to the site of
the type of infection and the MRSA organism. Do not origin mentioned, e.g., ectopic pancreatic malignant neoplasms
assign a code from subcategory Z16.11, Resistance to involving the stomach are coded to malignant neoplasm of
penicillins, as an additional diagnosis. pancreas, unspecified (C25.9).
See Section C.1. for instructions on coding and sequencing of The neoplasm table in the Alphabetic Index should be referenced first.
sepsis and severe sepsis. However, if the histological term is documented, that term should be
referenced first, rather than going immediately to the Neoplasm Table, in
(b) Other codes for MRSA infection order to determine which column in the Neoplasm Table is appropriate.
When there is documentation of a current infection (e.g., For example, if the documentation indicates “adenoma,” refer to the
wound infection, stitch abscess, urinary tract infection) due term in the Alphabetic Index to review the entries under this term and
to MRSA, and that infection does not have a combination the instructional note to “see also neoplasm, by site, benign.” The table
code that includes the causal organism, assign the provides the proper code based on the type of neoplasm and the site. It
appropriate code to identify the condition along with code is important to select the proper column in the table that corresponds to
B95.62, Methicillin resistant Staphylococcus aureus the type of neoplasm. The Tabular List should then be referenced to
infection as the cause of diseases classified elsewhere for verify that the correct code has been selected from the table and that a
the MRSA infection. Do not assign a code from subcategory more specific site code does not exist.
Z16.11, Resistance to penicillins.
See Section I.C.21. Factors influencing health status and contact with health
(c) Methicillin susceptible Staphylococcus aureus (MSSA) services, Status, for information regarding Z15.0, codes for genetic
and MRSA colonization susceptibility to cancer.
The condition or state of being colonized or carrying MSSA
a. Treatment directed at the malignancy
or MRSA is called colonization or carriage, while an
If the treatment is directed at the malignancy, designate the
individual person is described as being colonized or being
malignancy as the principal diagnosis.
a carrier. Colonization means that MSSA or MSRA is present
on or in the body without necessarily causing illness. A The only exception to this guideline is if a patient
positive MRSA colonization test might be documented by admission/encounter is solely for the administration of
the provider as “MRSA screen positive” or “MRSA nasal chemotherapy, immunotherapy or external beam radiation
swab positive”. therapy, assign the appropriate Z51.-- code as the first-listed or
principal diagnosis, and the diagnosis or problem for which the
Assign code Z22.322, Carrier or suspected carrier of
service is being performed as a secondary diagnosis.
Methicillin resistant Staphylococcus aureus, for patients
documented as having MRSA colonization. Assign code b. Treatment of secondary site
Z22.321, Carrier or suspected carrier of Methicillin When a patient is admitted because of a primary neoplasm with
susceptible Staphylococcus aureus, for patient metastasis and treatment is directed toward the secondary site only,
documented as having MSSA colonization. Colonization is the secondary neoplasm is designated as the principal diagnosis
not necessarily indicative of a disease process or as the even though the primary malignancy is still present.
cause of a specific condition the patient may have unless c. Coding and sequencing of complications
documented as such by the provider. Coding and sequencing of complications associated with the
(d) MRSA colonization and infection malignancies or with the therapy thereof are subject to the
If a patient is documented as having both MRSA following guidelines:
colonization and infection during a hospital admission, 1) Anemia associated with malignancy
code Z22.322, Carrier or suspected carrier of Methicillin When admission/encounter is for management of an anemia
resistant Staphylococcus aureus, and a code for the MRSA associated with the malignancy, and the treatment is only for
infection may both be assigned. anemia, the appropriate code for the malignancy is sequenced
f. Zika virus infections as the principal or first-listed diagnosis followed by the
1) Code only confirmed cases appropriate code for the anemia (such as code D63.0, Anemia in
Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus neoplastic disease).
disease) as documented by the provider. This is an exception to 2) Anemia associated with chemotherapy, immunotherapy
the hospital inpatient guideline Section II, H. In this context, and radiation therapy
“confirmation” does not require documentation of the type of When the admission/encounter is for management of an
test performed; the physician’s diagnostic statement that the anemia associated with an adverse effect of the administration
condition is confirmed is sufficient. This code should be of chemotherapy or immunotherapy and the only treatment is
assigned regardless of the stated mode of transmission. for the anemia, the anemia code is sequenced first followed by
If the provider documents “suspected”, “possible” or “probable” the appropriate codes for the neoplasm and the adverse effect
Zika, do not assign code A92.5. Assign a code(s) explaining the (T45.1X5-, Adverse effect of antineoplastic and
reason for encounter (such as fever, rash, or joint pain) or immunosuppressive drugs).
Z20.828, Contact with and (suspected) exposure to other viral When the admission/encounter is for management of an
communicable diseases. anemia associated with an adverse effect of radiotherapy, the
2. Chapter 2: Neoplasms (C00-D49) anemia code should be sequenced first, followed by the
General guidelines appropriate neoplasm code and code Y84.2, Radiological
Chapter 2 of the ICD-10-CM contains the codes for most benign and all procedure and radiotherapy as the cause of abnormal reaction
malignant neoplasms. Certain benign neoplasms, such as prostatic of the patient, or of later complication, without mention of
adenomas, may be found in the specific body system chapters. To misadventure at the time of the procedure.
properly code a neoplasm it is necessary to determine from the record if


3) Management of dehydration due to the malignancy secondary site malignancy cannot be used to replace the
When the admission/encounter is for management of malignancy as principal or first-listed diagnosis, regardless of the
dehydration due to the malignancy and only the dehydration is number of admissions or encounters for treatment and care of the
being treated (intravenous rehydration), the dehydration is neoplasm.
sequenced first, followed by the code(s) for the malignancy. See section I.C.21. Factors influencing health status and contact with
4) Treatment of a complication resulting from a surgical health services, Encounter for prophylactic organ removal.
procedure h. Admission/encounter for pain control/management
When the admission/encounter is for treatment of a See Section I.C.6. for information on coding admission/encounter for
complication resulting from a surgical procedure, designate the pain control/management.
complication as the principal or first-listed diagnosis if
treatment is directed at resolving the complication. i. Malignancy in two or more noncontiguous sites
A patient may have more than one malignant tumor in the same
d. Primary malignancy previously excised organ. These tumors may represent different primaries or metastatic
When a primary malignancy has been previously excised or disease, depending on the site. Should the documentation be
eradicated from its site and there is no further treatment directed to unclear, the provider should be queried as to the status of each
that site and there is no evidence of any existing primary tumor so that the correct codes can be assigned.
malignancy, a code from category Z85, Personal history of
malignant neoplasm, should be used to indicate the former site of j. Disseminated malignant neoplasm, unspecified
the malignancy. Any mention of extension, invasion, or metastasis Code C80.0, Disseminated malignant neoplasm, unspecified, is for
to another site is coded as a secondary malignant neoplasm to that use only in those cases where the patient has advanced metastatic
site. The secondary site may be the principal or first-listed with the disease and no known primary or secondary sites are specified. It
Z85 code used as a secondary code. should not be used in place of assigning codes for the primary site
and all known secondary sites.
e. Admissions/Encounters involving chemotherapy,
immunotherapy and radiation therapy k. Malignant neoplasm without specification of site
Code C80.1, Malignant (primary) neoplasm, unspecified, equates to
1) Episode of care involves surgical removal of neoplasm
Cancer, unspecified. This code should only be used when no
When an episode of care involves the surgical removal of a determination can be made as to the primary site of a malignancy.
neoplasm, primary or secondary site, followed by adjunct This code should rarely be used in the inpatient setting.
chemotherapy or radiation treatment during the same episode
of care, the code for the neoplasm should be assigned as l. Sequencing of neoplasm codes
principal or first-listed diagnosis. 1) Encounter for treatment of primary malignancy
2) Patient admission/encounter solely for administration of If the reason for the encounter is for treatment of a primary
chemotherapy, immunotherapy and radiation therapy malignancy, assign the malignancy as the principal/first-listed
If a patient admission/encounter is solely for the administration diagnosis. The primary site is to be sequenced first, followed by
of chemotherapy, immunotherapy or external beam radiation any metastatic sites.
therapy assign code Z51.0, Encounter for antineoplastic 2) Encounter for treatment of secondary malignancy
radiation therapy, or Z51.11, Encounter for antineoplastic When an encounter is for a primary malignancy with metastasis
chemotherapy, or Z51.12, Encounter for antineoplastic and treatment is directed toward the metastatic (secondary)
immunotherapy as the first-listed or principal diagnosis. If a site(s) only, the metastatic site(s) is designated as the
patient receives more than one of these therapies during the principal/first-listed diagnosis. The primary malignancy is
same admission more than one of these codes may be coded as an additional code.
assigned, in any sequence. 3) Malignant neoplasm in a pregnant patient
The malignancy for which the therapy is being administered When a pregnant woman has a malignant neoplasm, a code
should be assigned as a secondary diagnosis. from subcategory O9A.1-, Malignant neoplasm complicating
If a patient admission/encounter is for the insertion or pregnancy, childbirth, and the puerperium, should be
implantation of radioactive elements (e.g., brachytherapy) sequenced first, followed by the appropriate code from Chapter
the appropriate code for the malignancy is sequenced as 2 to indicate the type of neoplasm.
the principal or first-listed diagnosis. Code Z51.0 should 4) Encounter for complication associated with a neoplasm
not be assigned. When an encounter is for management of a complication
3) Patient admitted for radiation therapy, chemotherapy or associated with a neoplasm, such as dehydration, and the
immunotherapy and develops complications treatment is only for the complication, the complication is
When a patient is admitted for the purpose of external beam coded first, followed by the appropriate code(s) for the
radiotherapy, immunotherapy or chemotherapy and develops neoplasm.
complications such as uncontrolled nausea and vomiting or The exception to this guideline is anemia. When the
dehydration, the principal or first-listed diagnosis is Z51.0, admission/encounter is for management of an anemia
Encounter for antineoplastic radiation therapy, or Z51.11, associated with the malignancy, and the treatment is only for
Encounter for antineoplastic chemotherapy, or Z51.12, anemia, the appropriate code for the malignancy is sequenced
Encounter for antineoplastic immunotherapy followed by any as the principal or first-listed diagnosis followed by code D63.0,
codes for the complications. Anemia in neoplastic disease.
When a patient is admitted for the purpose of insertion or 5) Complication from surgical procedure for treatment of a
implantation of radioactive elements (e.g., brachytherapy) neoplasm
and develops complications such as uncontrolled nausea When an encounter is for treatment of a complication resulting
and vomiting or dehydration, the principal or first-listed from a surgical procedure performed for the treatment of the
diagnosis is the appropriate code for the malignancy neoplasm, designate the complication as the
followed by any codes for the complications. principal/first-listed diagnosis. See guideline regarding the
f. Admission/encounter to determine extent of malignancy coding of a current malignancy versus personal history to
When the reason for admission/encounter is to determine the determine if the code for the neoplasm should also be assigned.
extent of the malignancy, or for a procedure such as paracentesis or 6) Pathologic fracture due to a neoplasm
thoracentesis, the primary malignancy or appropriate metastatic When an encounter is for a pathological fracture due to a
site is designated as the principal or first-listed diagnosis, even neoplasm, and the focus of treatment is the fracture, a code
though chemotherapy or radiotherapy is administered. from subcategory M84.5, Pathological fracture in neoplastic
g. Symptoms, signs, and abnormal findings listed in Chapter 18 disease, should be sequenced first, followed by the code for the
associated with neoplasms neoplasm.
Symptoms, signs, and ill-defined conditions listed in Chapter 18 If the focus of treatment is the neoplasm with an associated
characteristic of, or associated with, an existing primary or pathological fracture, the neoplasm code should be sequenced

first, followed by a code from M84.5 for the pathological identify the long-term (current) use of insulin or oral
fracture. hypoglycemic drugs. If the patient is treated with both oral
m. Current malignancy versus personal history of malignancy medications and insulin, only the code for long-term
When a primary malignancy has been excised but further (current) use of insulin should be assigned. Code Z79.4
treatment, such as an additional surgery for the malignancy, should not be assigned if insulin is given temporarily to
radiation therapy or chemotherapy is directed to that site, the bring a type 2 patient’s blood sugar under control during
primary malignancy code should be used until treatment is an encounter.
completed. 4) Diabetes mellitus in pregnancy and gestational diabetes
When a primary malignancy has been previously excised or See Section I.C.15. Diabetes mellitus in pregnancy.
eradicated from its site, there is no further treatment (of the See Section I.C.15. Gestational (pregnancy induced) diabetes
malignancy) directed to that site, and there is no evidence of any 5) Complications due to insulin pump malfunction
existing primary malignancy, a code from category Z85, Personal (a) Underdose of insulin due to insulin pump failure
history of malignant neoplasm, should be used to indicate the
An underdose of insulin due to an insulin pump failure
former site of the malignancy.
should be assigned to a code from subcategory T85.6,
See Section I.C.21. Factors influencing health status and contact with Mechanical complication of other specified internal and
health services, History (of) external prosthetic devices, implants and grafts, that
n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell specifies the type of pump malfunction, as the principal or
Neoplasms in remission versus personal history first-listed code, followed by code T38.3X6-, Underdosing
The categories for leukemia, and category C90, Multiple myeloma of insulin and oral hypoglycemic [antidiabetic] drugs.
and malignant plasma cell neoplasms, have codes indicating Additional codes for the type of diabetes mellitus and any
whether or not the leukemia has achieved remission. There are also associated complications due to the underdosing should
codes Z85.6, Personal history of leukemia, and Z85.79, Personal also be assigned.
history of other malignant neoplasms of lymphoid, hematopoietic (b) Overdose of insulin due to insulin pump failure
and related tissues. If the documentation is unclear as to whether The principal or first-listed code for an encounter due to an
the leukemia has achieved remission, the provider should be insulin pump malfunction resulting in an overdose of
queried. insulin, should also be T85.6-, Mechanical complication of
See Section I.C.21. Factors influencing health status and contact with other specified internal and external prosthetic devices,
health services, History (of) implants and grafts, followed by code T38.3X1-, Poisoning
by insulin and oral hypoglycemic [antidiabetic] drugs,
o. Aftercare following surgery for neoplasm accidental (unintentional).
See Section I.C.21. Factors influencing health status and contact with
health services, Aftercare 6) Secondary diabetes mellitus
Codes under categories E08, Diabetes mellitus due to
p. Follow-up care for completed treatment of a malignancy underlying condition, E09, Drug or chemical induced diabetes
See Section I.C.21. Factors influencing health status and contact with mellitus, and E13, Other specified diabetes mellitus, identify
health services, Follow-up complications/manifestations associated with secondary
q. Prophylactic organ removal for prevention of malignancy diabetes mellitus. Secondary diabetes is always caused by
See Section I.C. 21, Factors influencing health status and contact with another condition or event (e.g., cystic fibrosis, malignant
health services, Prophylactic organ removal neoplasm of pancreas, pancreatectomy, adverse effect of drug,
r. Malignant neoplasm associated with transplanted organ or poisoning).
A malignant neoplasm of a transplanted organ should be coded as a (a) Secondary diabetes mellitus and the use of insulin or
transplant complication. Assign first the appropriate code from oral hypoglycemic drugs
category T86.-, Complications of transplanted organs and tissue, For patients with secondary diabetes mellitus who
followed by code C80.2, Malignant neoplasm associated with routinely use insulin or oral hypoglycemic drugs, an
transplanted organ. Use an additional code for the specific additional code from category Z79 should be assigned
malignancy. to identify the long-term (current) use of insulin or oral
3. Chapter 3: Disease of the blood and blood-forming organs and hypoglycemic drugs. If the patient is treated with both
certain disorders involving the immune mechanism (D50-D89) oral medications and insulin, only the code for
Reserved for future guideline expansion long-term (current) use of insulin should be assigned.
Code Z79.4 should not be assigned if insulin is given
4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases temporarily to bring a type 2 patient’s blood sugar
(E00-E89) under control during an encounter.
a. Diabetes mellitus
The diabetes mellitus codes are combination codes that include the (b) Assigning and sequencing secondary diabetes codes
type of diabetes mellitus, the body system affected, and the and its causes
complications affecting that body system. As many codes within a The sequencing of the secondary diabetes codes in
particular category as are necessary to describe all of the relationship to codes for the cause of the diabetes is based
complications of the disease may be used. They should be on the Tabular List instructions for categories E08, E09 and
sequenced based on the reason for a particular encounter. Assign as E13.
many codes from categories E08 – E13 as needed to identify all of (i) Secondary diabetes mellitus due to
the associated conditions that the patient has. pancreatectomy
1) Type of diabetes For postpancreatectomy diabetes mellitus (lack of
The age of a patient is not the sole determining factor, though insulin due to the surgical removal of all or part of the
most type 1 diabetics develop the condition before reaching pancreas), assign code E89.1, Postprocedural
puberty. For this reason type 1 diabetes mellitus is also referred hypoinsulinemia. Assign a code from category E13 and
to as juvenile diabetes. a code from subcategory Z90.41, Acquired absence of
pancreas, as additional codes.
2) Type of diabetes mellitus not documented
If the type of diabetes mellitus is not documented in the (ii) Secondary diabetes due to drugs
medical record the default is E11.-, Type 2 diabetes mellitus. Secondary diabetes may be caused by an adverse
effect of correctly administered medications,
3) Diabetes mellitus and the use of insulin and oral poisoning or sequela of poisoning.
hypoglycemics See section I.C.19.e for coding of adverse effects and
If the documentation in a medical record does not indicate the poisoning, and section I.C.20 for external cause code
type of diabetes but does indicate that the patient uses insulin, reporting.
code E11-, Type 2 diabetes mellitus, should be assigned. An
additional code should be assigned from category Z79 to


5. Chapter 5: Mental, Behavioral and Neurodevelopmental disorders A code from category G89 should not be assigned if the
(F01 – F99) underlying (definitive) diagnosis is known, unless the reason for
a. Pain disorders related to psychological factors the encounter is pain control/ management and not
Assign code F45.41, for pain that is exclusively related to management of the underlying condition.
psychological disorders. As indicated by the Excludes 1 note under When an admission or encounter is for a procedure aimed at
category G89, a code from category G89 should not be assigned treating the underlying condition (e.g., spinal fusion,
with code F45.41. kyphoplasty), a code for the underlying condition (e.g.,
Code F45.42, Pain disorders with related psychological factors, vertebral fracture, spinal stenosis) should be assigned as the
should be used with a code from category G89, Pain, not elsewhere principal diagnosis. No code from category G89 should be
classified, if there is documentation of a psychological component assigned.
for a patient with acute or chronic pain. (a) Category G89 Codes as Principal or First-Listed
See Section I.C.6. Pain Diagnosis
b. Mental and behavioral disorders due to psychoactive Category G89 codes are acceptable as principal diagnosis
substance use or the first-listed code:
1) In Remission • When pain control or pain management is the reason
Selection of codes for “in remission” for categories F10-F19, for the admission/encounter (e.g., a patient with
Mental and behavioral disorders due to psychoactive substance displaced intervertebral disc, nerve impingement and
use (categories F10-F19 with -11, -.21) requires the provider’s severe back pain presents for injection of steroid into
clinical judgment. The appropriate codes for “in remission” are the spinal canal). The underlying cause of the pain
assigned only on the basis of provider documentation (as should be reported as an additional diagnosis, if known.
defined in the Official Guidelines for Coding and Reporting), • When a patient is admitted for the insertion of a
unless otherwise instructed by the classification. neurostimulator for pain control, assign the appropriate
Mild substance use disorders in early or sustained pain code as the principal or first-listed diagnosis. When
remission are classified to the appropriate codes for an admission or encounter is for a procedure aimed at
substance abuse in remission, and moderate or severe treating the underlying condition and a
substance use disorders in early or sustained remission are neurostimulator is inserted for pain control during the
classified to the appropriate codes for substance same admission/encounter, a code for the underlying
dependence in remission. condition should be assigned as the principal diagnosis
2) Psychoactive Substance Use, Abuse and Dependence and the appropriate pain code should be assigned as a
When the provider documentation refers to use, abuse and secondary diagnosis.
dependence of the same substance (e.g. alcohol, opioid, (b) Use of Category G89 Codes in Conjunction with Site
cannabis, etc.), only one code should be assigned to identify the Specific Pain Codes
pattern of use based on the following hierarchy: (i) Assigning Category G89 and Site-Specific Pain
• If both use and abuse are documented, assign only the code Codes
for abuse Codes from category G89 may be used in conjunction
• If both abuse and dependence are documented, assign only with codes that identify the site of pain (including
the code for dependence codes from chapter 18) if the category G89 code
provides additional information. For example, if the
• If use, abuse and dependence are all documented, assign
code describes the site of the pain, but does not fully
only the code for dependence
describe whether the pain is acute or chronic, then
• If both use and dependence are documented, assign only both codes should be assigned.
the code for dependence. (ii) Sequencing of Category G89 Codes with
3) Psychoactive Substance Use Disorders Site-Specific Pain Codes
As with all other diagnoses, the codes for psychoactive The sequencing of category G89 codes with
substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, site-specific pain codes (including chapter 18 codes), is
F15.9-, F16.9-) should only be assigned based on provider dependent on the circumstances of the
documentation and when they meet the definition of a encounter/admission as follows:
reportable diagnosis (see Section III, Reporting Additional • If the encounter is for pain control or pain
Diagnoses). The codes are to be used only when the management, assign the code from category G89
psychoactive substance use is associated with a physical, followed by the code identifying the specific site of
mental or behavioral disorder, and such a relationship is pain (e.g., encounter for pain management for
documented by the provider. acute neck pain from trauma is assigned code
6. Chapter 6: Diseases of the Nervous System (G00-G99) G89.11, Acute pain due to trauma, followed by
a. Dominant/nondominant side code M54.2, Cervicalgia, to identify the site of pain).
Codes from category G81, Hemiplegia and hemiparesis, and • If the encounter is for any other reason except pain
subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia control or pain management, and a related
of upper limb, and G83.3, Monoplegia, unspecified, identify whether definitive diagnosis has not been established
the dominant or nondominant side is affected. Should the affected (confirmed) by the provider, assign the code for the
side be documented, but not specified as dominant or specific site of pain first, followed by the
nondominant, and the classification system does not indicate a appropriate code from category G89.
default, code selection is as follows:
2) Pain due to devices, implants and grafts
• For ambidextrous patients, the default should be dominant.
See Section I.C.19. Pain due to medical devices
• If the left side is affected, the default is non-dominant.
3) Postoperative Pain
• If the right side is affected, the default is dominant. The provider’s documentation should be used to guide the
b. Pain - Category G89 coding of postoperative pain, as well as Section III. Reporting
1) General coding information Additional Diagnoses and Section IV. Diagnostic Coding and
Codes in category G89, Pain, not elsewhere classified, may be Reporting in the Outpatient Setting.
used in conjunction with codes from other categories and The default for post-thoracotomy and other postoperative pain
chapters to provide more detail about acute or chronic pain and not specified as acute or chronic is the code for the acute form.
neoplasm-related pain, unless otherwise indicated below. Routine or expected postoperative pain immediately after
If the pain is not specified as acute or chronic, surgery should not be coded.
post-thoracotomy, postprocedural, or neoplasm-related, do not
assign codes from category G89.

(a) Postoperative pain not associated with specific the type of glaucoma for each eye with the seventh character
postoperative complication for the specific glaucoma stage documented for each eye.
Postoperative pain not associated with a specific 4) Patient admitted with glaucoma and stage evolves during
postoperative complication is assigned to the appropriate the admission
postoperative pain code in category G89. If a patient is admitted with glaucoma and the stage progresses
(b) Postoperative pain associated with specific during the admission, assign the code for highest stage
postoperative complication documented.
Postoperative pain associated with a specific postoperative 5) Indeterminate stage glaucoma
complication (such as painful wire sutures) is assigned to Assignment of the seventh character “4” for “indeterminate
the appropriate code(s) found in Chapter 19, Injury, stage” should be based on the clinical documentation. The
poisoning, and certain other consequences of external seventh character “4” is used for glaucomas whose stage
causes. If appropriate, use additional code(s) from category cannot be clinically determined. This seventh character should
G89 to identify acute or chronic pain (G89.18 or G89.28). not be confused with the seventh character “0”, unspecified,
4) Chronic pain which should be assigned when there is no documentation
Chronic pain is classified to subcategory G89.2. There is no time regarding the stage of the glaucoma.
frame defining when pain becomes chronic pain. The provider’s b. Blindness
documentation should be used to guide use of these codes. If “blindness” or “low vision” of both eyes is documented but
5) Neoplasm Related Pain the visual impairment category is not documented, assign
Code G89.3 is assigned to pain documented as being related, code H54.3, Unqualified visual loss, both eyes. If “blindness” or
associated or due to cancer, primary or secondary malignancy, “low vision” in one eye is documented but the visual
or tumor. This code is assigned regardless of whether the pain is impairment category is not documented, assign a code from
acute or chronic. H54.6-, Unqualified visual loss, one eye. If “blindness” or
This code may be assigned as the principal or first-listed code “visual loss” is documented without any information about
when the stated reason for the admission/encounter is whether one or both eyes are affected, assign code H54.7,
documented as pain control/pain management. The underlying Unspecified visual loss.
neoplasm should be reported as an additional diagnosis. 8. Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
When the reason for the admission/encounter is management Reserved for future guideline expansion
of the neoplasm and the pain associated with the neoplasm is 9. Chapter 9: Diseases of the Circulatory System (I00-I99)
also documented, code G89.3 may be assigned as an additional a. Hypertension
diagnosis. It is not necessary to assign an additional code for The classification presumes a causal relationship between
the site of the pain. hypertension and heart involvement and between hypertension
See Section I.C.2 for instructions on the sequencing of neoplasms and kidney involvement, as the two conditions are linked by the
for all other stated reasons for the admission/encounter (except for term “with” in the Alphabetic Index. These conditions should be
pain control/pain management). coded as related even in the absence of provider documentation
explicitly linking them, unless the documentation clearly states the
6) Chronic pain syndrome conditions are unrelated.
Central pain syndrome (G89.0) and chronic pain syndrome
(G89.4) are different than the term “chronic pain,” and therefore For hypertension and conditions not specifically linked by relational
codes should only be used when the provider has specifically terms such as “with,” “associated with” or “due to” in the
documented this condition. classification, provider documentation must link the conditions in
order to code them as related.
See Section I.C.5. Pain disorders related to psychological factors
1) Hypertension with Heart Disease
7. Chapter 7: Diseases of the Eye and Adnexa (H00-H59) Hypertension with heart conditions classified to I50.- or
a. Glaucoma I51.4-I51.9, are assigned to a code from category I11,
1) Assigning Glaucoma Codes Hypertensive heart disease. Use additional code(s) from
Assign as many codes from category H40, Glaucoma, as needed category I50, Heart failure, to identify the type(s) of heart failure
to identify the type of glaucoma, the affected eye, and the in those patients with heart failure.
glaucoma stage.
The same heart conditions (I50.-, I51.4-I51.9) with hypertension
2) Bilateral glaucoma with same type and stage are coded separately if the provider has specifically
When a patient has bilateral glaucoma and both eyes are documented a different cause. Sequence according to the
documented as being the same type and stage, and there is a circumstances of the admission/encounter.
code for bilateral glaucoma, report only the code for the type of 2) Hypertensive Chronic Kidney Disease
glaucoma, bilateral, with the seventh character for the stage.
Assign codes from category I12, Hypertensive chronic kidney
When a patient has bilateral glaucoma and both eyes are disease, when both hypertension and a condition classifiable to
documented as being the same type and stage, and the category N18, Chronic kidney disease (CKD), are present. CKD
classification does not provide a code for bilateral glaucoma (i.e. should not be coded as hypertensive if the physician has
subcategories H40.10, H40.11 and H40.20) report only one code specifically documented a different cause.
for the type of glaucoma with the appropriate seventh
The appropriate code from category N18 should be used as a
character for the stage.
secondary code with a code from category I12 to identify the
3) Bilateral glaucoma stage with different types or stages stage of chronic kidney disease.
When a patient has bilateral glaucoma and each eye is
See Section I.C.14. Chronic kidney disease.
documented as having a different type or stage, and the
classification distinguishes laterality, assign the appropriate If a patient has hypertensive chronic kidney disease and acute
code for each eye rather than the code for bilateral glaucoma. renal failure, an additional code for the acute renal failure is
required.
documented as having a different type, and the classification 3) Hypertensive Heart and Chronic Kidney Disease
does not distinguish laterality (i.e. subcategories H40.10, Assign codes from combination category I13, Hypertensive
H40.11 and H40.20), assign one code for each type of glaucoma heart and chronic kidney disease, when there is hypertension
with the appropriate seventh character for the stage. with both heart and kidney involvement. If heart failure is
present, assign an additional code from category I50 to identify
the type of heart failure.
documented as having the same type, but different stage, and
the classification does not distinguish laterality (i.e. The appropriate code from category N18, Chronic kidney
subcategories H40.10, H40.11 and H40.20), assign a code for disease, should be used as a secondary code with a code from
category I13 to identify the stage of chronic kidney disease.


See Section I.C.14. Chronic kidney disease. c. Intraoperative and Postprocedural Cerebrovascular Accident
The codes in category I13, Hypertensive heart and chronic Medical record documentation should clearly specify the cause-
kidney disease, are combination codes that include and-effect relationship between the medical intervention and the
hypertension, heart disease and chronic kidney disease. The cerebrovascular accident in order to assign a code for intraoperative
Includes note at I13 specifies that the conditions included at I11 or postprocedural cerebrovascular accident.
and I12 are included together in I13. If a patient has Proper code assignment depends on whether it was an infarction or
hypertension, heart disease and chronic kidney disease, then a hemorrhage and whether it occurred intraoperatively or
code from I13 should be used, not individual codes for postoperatively. If it was a cerebral hemorrhage, code assignment
hypertension, heart disease and chronic kidney disease, or depends on the type of procedure performed.
codes from I11 or I12. d. Sequelae of Cerebrovascular Disease
For patients with both acute renal failure and chronic kidney 1) Category I69, Sequelae of Cerebrovascular disease
disease, an additional code for acute renal failure is required. Category I69 is used to indicate conditions classifiable to
4) Hypertensive Cerebrovascular Disease categories I60-I67 as the causes of sequela (neurologic deficits),
For hypertensive cerebrovascular disease, first assign the themselves classified elsewhere. These “late effects” include
appropriate code from categories I60-I69, followed by the neurologic deficits that persist after initial onset of conditions
appropriate hypertension code. classifiable to categories I60-I67. The neurologic deficits caused
by cerebrovascular disease may be present from the onset or
5) Hypertensive Retinopathy
may arise at any time after the onset of the condition
Subcategory H35.0, Background retinopathy and retinal classifiable to categories I60-I67.
vascular changes, should be used with a code from category
I10- I15, Hypertensive disease to include the systemic Codes from category I69, Sequelae of cerebrovascular disease,
hypertension. The sequencing is based on the reason for the that specify hemiplegia, hemiparesis and monoplegia identify
encounter. whether the dominant or nondominant side is affected. Should
the affected side be documented, but not specified as
6) Hypertension, Secondary dominant or nondominant, and the classification system does
Secondary hypertension is due to an underlying condition. Two not indicate a default, code selection is as follows:
codes are required: one to identify the underlying etiology and
one from category I15 to identify the hypertension. Sequencing • For ambidextrous patients, the default should be dominant.
of codes is determined by the reason for admission/encounter. • If the left side is affected, the default is non-dominant.
7) Hypertension, Transient • If the right side is affected, the default is dominant.
Assign code R03.0, Elevated blood pressure reading without 2) Codes from category I69 with codes from I60-I67
diagnosis of hypertension, unless patient has an established Codes from category I69 may be assigned on a health care
diagnosis of hypertension. Assign code O13.-, Gestational record with codes from I60-I67, if the patient has a current
[pregnancy-induced] hypertension without significant cerebrovascular disease and deficits from an old
proteinuria, or O14.-, Pre-eclampsia, for transient hypertension cerebrovascular disease.
of pregnancy. 3) Codes from category I69 and Personal history of transient
8) Hypertension, Controlled ischemic attack (TIA) and cerebral infarction (Z86.73)
This diagnostic statement usually refers to an existing state of Codes from category I69 should not be assigned if the patient
hypertension under control by therapy. Assign the appropriate does not have neurologic deficits.
code from categories I10-I15, Hypertensive diseases.
See Section I.C.21. 4. History (of) for use of personal history codes
9) Hypertension, Uncontrolled
e. Acute myocardial infarction (AMI)
Uncontrolled hypertension may refer to untreated
hypertension or hypertension not responding to current 1) Type 1 ST elevation myocardial infarction (STEMI) and
therapeutic regimen. In either case, assign the appropriate code non-ST elevation myocardial infarction (NSTEMI)
from categories I10-I15, Hypertensive diseases. The ICD-10-CM codes for type 1 acute myocardial infarction
(AMI) identify the site, such as anterolateral wall or true
10) Hypertensive Crisis posterior wall. Subcategories I21.0-I21.2 and code I21.3 are
Assign a code from category I16, Hypertensive crisis, for used for type 1 ST elevation myocardial infarction (STEMI).
documented hypertensive urgency, hypertensive emergency or Code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, is
unspecified hypertensive crisis. Code also any identified used for type 1 non ST elevation myocardial infarction
hypertensive disease (I10-I15). The sequencing is based on the (NSTEMI) and nontransmural MIs.
reason for the encounter.
If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a
10) Pulmonary Hypertension type 1 STEMI converts to NSTEMI due to thrombolytic therapy,
Pulmonary hypertension is classified to category I27, it is still coded as STEMI.
Other pulmonary heart diseases. For secondary pulmonary
hypertension (I27.1, I27.2-), code also any associated For encounters occurring while the myocardial infarction is
conditions or adverse effects of drugs or toxins. The equal to, or less than, four weeks old, including transfers to
sequencing is based on the reason for the encounter. another acute setting or a postacute setting, and the
myocardial infarction meets the definition for “other diagnoses”
b. Atherosclerotic Coronary Artery Disease and Angina (see Section III, Reporting Additional Diagnoses), codes from
ICD-10-CM has combination codes for atherosclerotic heart disease category I21 may continue to be reported. For encounters after
with angina pectoris. The subcategories for these codes are I25.11, the 4 week time frame and the patient is still receiving care
Atherosclerotic heart disease of native coronary artery with angina related to the myocardial infarction, the appropriate aftercare
pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) code should be assigned, rather than a code from category I21.
and coronary artery of transplanted heart with angina pectoris. For old or healed myocardial infarctions not requiring further
When using one of these combination codes it is not necessary to care, code I25.2, Old myocardial infarction, may be assigned.
use an additional code for angina pectoris. A causal relationship can 2) Acute myocardial infarction, unspecified
be assumed in a patient with both atherosclerosis and angina Code I21.9, Acute myocardial infarction, unspecified, is the
pectoris, unless the documentation indicates the angina is due to default for unspecified acute myocardial infarction or
something other than the atherosclerosis. unspecified type. If only type 1 STEMI or transmural MI
If a patient with coronary artery disease is admitted due to an acute without the site is documented, assign code I21.3, ST elevation
myocardial infarction (AMI), the AMI should be sequenced before (STEMI) myocardial infarction of unspecified site.
the coronary artery disease. 3) AMI documented as nontransmural or subendocardial but
See Section I.C.9. Acute myocardial infarction (AMI) site provided
If an AMI is documented as nontransmural or subendocardial,
but the site is provided, it is still coded as a subendocardial AMI.

See Section I.C.21.3 for information on coding status post If the documentation is not clear as to whether acute
administration of tPA in a different facility within the last 24 hours. respiratory failure and another condition are equally
4) Subsequent acute myocardial infarction responsible for occasioning the admission, query the provider
A code from category I22, Subsequent ST elevation (STEMI) and for clarification.
non-ST elevation (NSTEMI) myocardial infarction, is to be used c. Influenza due to certain identified influenza viruses
when a patient who has suffered a type 1 or unspecified AMI Code only confirmed cases of influenza due to certain identified
has a new AMI within the 4 week time frame of the initial AMI. A influenza viruses (category J09), and due to other identified
code from category I22 must be used in conjunction with a influenza virus (category J10). This is an exception to the hospital
code from category I21. The sequencing of the I22 and I21 inpatient guideline Section II, H. (Uncertain Diagnosis).
codes depends on the circumstances of the encounter. In this context, “confirmation” does not require documentation of
Do not assign code I22 for subsequent myocardial positive laboratory testing specific for avian or other novel influenza
infarctions other than type 1 or unspecified. For A or other identified influenza virus. However, coding should be
subsequent type 2 AMI assign only code I21.A1. For based on the provider’s diagnostic statement that the patient has
subsequent type 4 or type 5 AMI, assign only code I21.A9. avian influenza, or other novel influenza A, for category J09, or has
5) Other Types of Myocardial Infarction another particular identified strain of influenza, such as H1N1 or
The ICD-10-CM provides codes for different types of H3N2, but not identified as novel or variant, for category J10.
myocardial infarction. Type 1 myocardial infarctions are If the provider records “suspected” or “possible” or “probable” avian
assigned to codes I21.0-I21.4. influenza, or novel influenza, or other identified influenza, then the
Type 2 myocardial infarction, and myocardial infarction appropriate influenza code from category J11, Influenza due to
due to demand ischemia or secondary to ischemic balance, unidentified influenza virus, should be assigned. A code from
is assigned to code I21.A1, Myocardial infarction type 2 category J09, Influenza due to certain identified influenza viruses,
with a code for the underlying cause. Do not assign code should not be assigned nor should a code from category J10,
I24.8, Other forms of acute ischemic heart disease for the Influenza due to other identified influenza virus.
demand ischemia. Sequencing of type 2 AMI or the d. Ventilator associated Pneumonia
underlying cause is dependent on the circumstances of 1) Documentation of Ventilator associated Pneumonia
admission. When a type 2 AMI code is described as NSTEMI As with all procedural or postprocedural complications, code
or STEMI, only assign code I21.A1. Codes I21.01-I21.4 assignment is based on the provider’s documentation of the
should only be assigned for type 1 AMIs. relationship between the condition and the procedure.
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are Code J95.851, Ventilator associated pneumonia, should be
assigned to code I21.A9, Other myocardial infarction type. assigned only when the provider has documented ventilator
The “Code also” and “Code first” notes should be followed associated pneumonia (VAP). An additional code to identify the
related to complications, and for coding of postprocedural organism (e.g., Pseudomonas aeruginosa, code B96.5) should
myocardial infarctions during or following cardiac surgery. also be assigned. Do not assign an additional code from
categories J12-J18 to identify the type of pneumonia.
10. Chapter 10: Diseases of the Respiratory System (J00-J99)
a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma Code J95.851 should not be assigned for cases where the
1) Acute exacerbation of chronic obstructive bronchitis and patient has pneumonia and is on a mechanical ventilator and
asthma the provider has not specifically stated that the pneumonia is
The codes in categories J44 and J45 distinguish between ventilator-associated pneumonia. If the documentation is
uncomplicated cases and those in acute exacerbation. An acute unclear as to whether the patient has a pneumonia that is a
exacerbation is a worsening or a decompensation of a chronic complication attributable to the mechanical ventilator, query
condition. An acute exacerbation is not equivalent to an the provider.
infection superimposed on a chronic condition, though an 2) Ventilator associated Pneumonia Develops after
exacerbation may be triggered by an infection. Admission
b. Acute Respiratory Failure A patient may be admitted with one type of pneumonia (e.g.,
code J13, Pneumonia due to Streptococcus pneumonia) and
1) Acute respiratory failure as principal diagnosis
subsequently develop VAP. In this instance, the principal
A code from subcategory J96.0, Acute respiratory failure, or diagnosis would be the appropriate code from categories
subcategory J96.2, Acute and chronic respiratory failure, may J12-J18 for the pneumonia diagnosed at the time of admission.
be assigned as a principal diagnosis when it is the condition Code J95.851, Ventilator associated pneumonia, would be
established after study to be chiefly responsible for occasioning
assigned as an additional diagnosis when the provider has also
the admission to the hospital, and the selection is supported by
documented the presence of ventilator associated pneumonia.
the Alphabetic Index and Tabular List. However,
chapter-specific coding guidelines (such as obstetrics, 11. Chapter 11: Diseases of the Digestive System (K00-K95)
poisoning, HIV, newborn) that provide sequencing direction Reserved for future guideline expansion
take precedence. 12. Chapter 12: Diseases of the Skin and Subcutaneous Tissue
2) Acute respiratory failure as secondary diagnosis (L00-L99)
Respiratory failure may be listed as a secondary diagnosis if it a. Pressure ulcer stage codes
occurs after admission, or if it is present on admission, but does 1) Pressure ulcer stages
not meet the definition of principal diagnosis. Codes from category L89, Pressure ulcer, identify the site of the
3) Sequencing of acute respiratory failure and another acute pressure ulcer as well as the stage of the ulcer.
condition The ICD-10-CM classifies pressure ulcer stages based on
When a patient is admitted with respiratory failure and another severity, which is designated by stages 1-4, unspecified stage
acute condition, (e.g., myocardial infarction, cerebrovascular and unstageable.
accident, aspiration pneumonia), the principal diagnosis will Assign as many codes from category L89 as needed to identify
not be the same in every situation. This applies whether the all the pressure ulcers the patient has, if applicable.
other acute condition is a respiratory or nonrespiratory
condition. Selection of the principal diagnosis will be 2) Unstageable pressure ulcers
dependent on the circumstances of admission. If both the Assignment of the code for unstageable pressure ulcer (L89.--0)
respiratory failure and the other acute condition are equally should be based on the clinical documentation. These codes are
responsible for occasioning the admission to the hospital, and used for pressure ulcers whose stage cannot be clinically
there are no chapter-specific sequencing rules, the guideline determined (e.g., the ulcer is covered by eschar or has been
regarding two or more diagnoses that equally meet the treated with a skin or muscle graft) and pressure ulcers that are
definition for principal diagnosis (Section II, C.) may be applied documented as deep tissue injury but not documented as due
in these situations. to trauma. This code should not be confused with the codes for
unspecified stage (L89.--9). When there is no documentation


regarding the stage of the pressure ulcer, assign the multiple codes should be used to indicate the different sites
appropriate code for unspecified stage (L89.--9). involved.
3) Documented pressure ulcer stage 1) Bone versus joint
Assignment of the pressure ulcer stage code should be guided For certain conditions, the bone may be affected at the upper or
by clinical documentation of the stage or documentation of the lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis,
terms found in the Alphabetic Index. For clinical terms M80, M81). Though the portion of the bone affected may be at
describing the stage that are not found in the Alphabetic Index, the joint, the site designation will be the bone, not the joint.
and there is no documentation of the stage, the provider b. Acute traumatic versus chronic or recurrent musculoskeletal
should be queried. conditions
4) Patients admitted with pressure ulcers documented as Many musculoskeletal conditions are a result of previous injury or
healed trauma to a site, or are recurrent conditions. Bone, joint or muscle
No code is assigned if the documentation states that the conditions that are the result of a healed injury are usually found in
pressure ulcer is completely healed. chapter 13. Recurrent bone, joint or muscle conditions are also
5) Patients admitted with pressure ulcers documented as usually found in chapter 13. Any current, acute injury should be
healing coded to the appropriate injury code from chapter 19. Chronic or
Pressure ulcers described as healing should be assigned the recurrent conditions should generally be coded with a code from
appropriate pressure ulcer stage code based on the chapter 13. If it is difficult to determine from the documentation in
documentation in the medical record. If the documentation the record which code is best to describe a condition, query the
does not provide information about the stage of the healing provider.
pressure ulcer, assign the appropriate code for unspecified c. Coding of Pathologic Fractures
stage. 7th character A is for use as long as the patient is receiving active
If the documentation is unclear as to whether the patient has a treatment for the fracture. While the patient may be seen by a new
current (new) pressure ulcer or if the patient is being treated for or different provider over the course of treatment for a pathological
a healing pressure ulcer, query the provider. fracture, assignment of the 7th character is based on whether the
patient is undergoing active treatment and not whether the
For ulcers that were present on admission but healed at the provider is seeing the patient for the first time.
time of discharge, assign the code for the site and stage of the
pressure ulcer at the time of admission. 7th character D is to be used for encounters after the patient has
completed active treatment for the fracture and is receiving
6) Patient admitted with pressure ulcer evolving into another routine care for the fracture during the healing or recovery
stage during the admission phase. The other 7th characters, listed under each subcategory in
If a patient is admitted to an inpatient hospital with a the Tabular List, are to be used for subsequent encounters for
pressure ulcer at one stage and it progresses to a higher stage, treatment of problems associated with the healing, such as
two separate codes should be assigned: one code for the site malunions, nonunions, and sequelae.
and stage of the ulcer on admission and a second code for the
same ulcer site and the highest stage reported during the stay. Care for complications of surgical treatment for fracture repairs
during the healing or recovery phase should be coded with the
b. Non-Pressure Chronic Ulcers appropriate complication codes.
1) Patients admitted with non-pressure ulcers documented See Section I.C.19. Coding of traumatic fractures.
as healed
No code is assigned if the documentation states that the d. Osteoporosis
non-pressure ulcer is completely healed. Osteoporosis is a systemic condition, meaning that all bones of the
musculoskeletal system are affected. Therefore, site is not a
2) Patients admitted with non-pressure ulcers documented component of the codes under category M81, Osteoporosis without
as healing current pathological fracture. The site codes under category M80,
Non-pressure ulcers described as healing should be Osteoporosis with current pathological fracture, identify the site of
assigned the appropriate non-pressure ulcer code based the fracture, not the osteoporosis.
on the documentation in the medical record. If the
documentation does not provide information about the 1) Osteoporosis without pathological fracture
severity of the healing non-pressure ulcer, assign the Category M81, Osteoporosis without current pathological
appropriate code for unspecified severity. fracture, is for use for patients with osteoporosis who do not
currently have a pathologic fracture due to the osteoporosis,
If the documentation is unclear as to whether the patient even if they have had a fracture in the past. For patients with a
has a current (new) non-pressure ulcer or if the patient is history of osteoporosis fractures, status code Z87.310, Personal
being treated for a healing non-pressure ulcer, query the history of (healed) osteoporosis fracture, should follow the code
provider. from M81.
For ulcers that were present on admission but healed at 2) Osteoporosis with current pathological fracture
the time of discharge, assign the code for the site and Category M80, Osteoporosis with current pathological fracture,
severity of the non-pressure ulcer at the time of admission. is for patients who have a current pathologic fracture at the
3) Patient admitted with non-pressure ulcer that progresses time of an encounter. The codes under M80 identify the site of
to another severity level during the admission the fracture. A code from category M80, not a traumatic fracture
If a patient is admitted to an inpatient hospital with a code, should be used for any patient with known osteoporosis
non-pressure ulcer at one severity level and it progresses who suffers a fracture, even if the patient had a minor fall or
to a higher severity level, two separate codes should be trauma, if that fall or trauma would not usually break a normal,
assigned: one code for the site and severity level of the healthy bone.
ulcer on admission and a second code for the same ulcer 14. Chapter 14: Diseases of Genitourinary System (N00-N99)
site and the highest severity level reported during the a. Chronic kidney disease
stay.
1) Stages of chronic kidney disease (CKD)
13. Chapter 13: Diseases of the Musculoskeletal System and The ICD-10-CM classifies CKD based on severity. The severity of
Connective Tissue (M00-M99) CKD is designated by stages 1-5. Stage 2, code N18.2, equates
a. Site and laterality to mild CKD; stage 3, code N18.3, equates to moderate CKD; and
Most of the codes within Chapter 13 have site and laterality stage 4, code N18.4, equates to severe CKD. Code N18.6, End
designations. The site represents the bone, joint or the muscle stage renal disease (ESRD), is assigned when the provider has
involved. For some conditions where more than one bone, joint or documented end-stage-renal disease (ESRD).
muscle is usually involved, such as osteoarthritis, there is a “multiple If both a stage of CKD and ESRD are documented, assign code
sites” code available. For categories where no multiple site code is N18.6 only.
provided and more than one bone, joint or muscle is involved,

2) Chronic kidney disease and kidney transplant status insufficient to determine the trimester and it is not possible to
Patients who have undergone kidney transplant may still have obtain clarification.
some form of chronic kidney disease (CKD) because the kidney 6) 7th character for Fetus Identification
transplant may not fully restore kidney function. Therefore, the Where applicable, a 7th character is to be assigned for certain
presence of CKD alone does not constitute a transplant categories (O31, O32, O33.3 - O33.6, O35, O36, O40, O41, O60.1,
complication. Assign the appropriate N18 code for the patient’s O60.2, O64, and O69) to identify the fetus for which the
stage of CKD and code Z94.0, Kidney transplant status. If a complication code applies.
transplant complication such as failure or rejection or other
transplant complication is documented, see section I.C.19.g for Assign 7th character “0”:
information on coding complications of a kidney transplant. If • For single gestations
the documentation is unclear as to whether the patient has a • When the documentation in the record is insufficient to
complication of the transplant, query the provider. determine the fetus affected and it is not possible to obtain
3) Chronic kidney disease with other conditions clarification.
Patients with CKD may also suffer from other serious conditions, • When it is not possible to clinically determine which fetus is
most commonly diabetes mellitus and hypertension. The affected.
sequencing of the CKD code in relationship to codes for other b. Selection of OB Principal or First-listed Diagnosis
contributing conditions is based on the conventions in the 1) Routine outpatient prenatal visits
Tabular List. For routine outpatient prenatal visits when no complications
See I.C.9. Hypertensive chronic kidney disease. are present, a code from category Z34, Encounter for
See I.C.19. Chronic kidney disease and kidney transplant supervision of normal pregnancy, should be used as the
complications. first-listed diagnosis. These codes should not be used in
conjunction with chapter 15 codes.
15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A)
a. General Rules for Obstetric Cases 2) Supervision of High-Risk Pregnancy
1) Codes from chapter 15 and sequencing priority Codes from category O09, Supervision of high-risk pregnancy,
Obstetric cases require codes from chapter 15, codes in the are intended for use only during the prenatal period. For
range O00-O9A, Pregnancy, Childbirth, and the Puerperium. complications during the labor or delivery episode as a result of
Chapter 15 codes have sequencing priority over codes from a high-risk pregnancy, assign the applicable complication codes
other chapters. Additional codes from other chapters may be from Chapter 15. If there are no complications during the labor
used in conjunction with chapter 15 codes to further specify or delivery episode, assign code O80, Encounter for full-term
conditions. Should the provider document that the pregnancy uncomplicated delivery.
is incidental to the encounter, then code Z33.1, Pregnant state, For routine prenatal outpatient visits for patients with high-risk
incidental, should be used in place of any chapter 15 codes. It is pregnancies, a code from category O09, Supervision of high-risk
the provider’s responsibility to state that the condition being pregnancy, should be used as the first-listed diagnosis.
treated is not affecting the pregnancy. Secondary chapter 15 codes may be used in conjunction with
2) Chapter 15 codes used only on the maternal record these codes if appropriate.
Chapter 15 codes are to be used only on the maternal record, 3) Episodes when no delivery occurs
never on the record of the newborn. In episodes when no delivery occurs, the principal diagnosis
3) Final character for trimester should correspond to the principal complication of the
The majority of codes in Chapter 15 have a final character pregnancy which necessitated the encounter. Should more
indicating the trimester of pregnancy. The timeframes for the than one complication exist, all of which are treated or
trimesters are indicated at the beginning of the chapter. If monitored, any of the complications codes may be sequenced
trimester is not a component of a code, it is because the first.
condition always occurs in a specific trimester, or the concept of 4) When a delivery occurs
trimester of pregnancy is not applicable. Certain codes have When an obstetric patient is admitted and delivers during that
characters for only certain trimesters because the condition admission, the condition that prompted the admission should
does not occur in all trimesters, but it may occur in more than be sequenced as the principal diagnosis. If multiple conditions
just one. prompted the admission, sequence the one most related to the
Assignment of the final character for trimester should be based delivery as the principal diagnosis. A code for any complication
on the provider’s documentation of the trimester (or number of of the delivery should be assigned as an additional diagnosis. In
weeks) for the current admission/encounter. This applies to the cases of cesarean delivery, if the patient was admitted with a
assignment of trimester for pre-existing conditions as well as condition that resulted in the performance of a cesarean
those that develop during or are due to the pregnancy. The procedure, that condition should be selected as the principal
provider’s documentation of the number of weeks may be used diagnosis. If the reason for the admission was unrelated to the
to assign the appropriate code identifying the trimester. condition resulting in the cesarean delivery, the condition
related to the reason for the admission should be selected as
Whenever delivery occurs during the current admission, and the principal diagnosis.
there is an “in childbirth” option for the obstetric complication
being coded, the “in childbirth” code should be assigned. 5) Outcome of delivery
A code from category Z37, Outcome of delivery, should be
4) Selection of trimester for inpatient admissions that included on every maternal record when a delivery has
encompass more than one trimester occurred. These codes are not to be used on subsequent
In instances when a patient is admitted to a hospital for records or on the newborn record.
complications of pregnancy during one trimester and remains
in the hospital into a subsequent trimester, the trimester c. Pre-existing conditions versus conditions due to the
character for the antepartum complication code should be pregnancy
assigned on the basis of the trimester when the complication Certain categories in Chapter 15 distinguish between conditions of
developed, not the trimester of the discharge. If the condition the mother that existed prior to pregnancy (pre-existing) and those
developed prior to the current admission/encounter or that are a direct result of pregnancy. When assigning codes from
represents a pre-existing condition, the trimester character for Chapter 15, it is important to assess if a condition was pre-existing
the trimester at the time of the admission/encounter should be prior to pregnancy or developed during or due to the pregnancy in
assigned. order to assign the correct code.
5) Unspecified trimester Categories that do not distinguish between pre-existing and
Each category that includes codes for trimester has a code for pregnancy-related conditions may be used for either. It is
“unspecified trimester.” The “unspecified trimester” code should acceptable to use codes specifically for the puerperium with codes
rarely be used, such as when the documentation in the record is complicating pregnancy and childbirth if a condition arises
postpartum during the delivery encounter.


d. Pre-existing hypertension in pregnancy j. Sepsis and septic shock complicating abortion, pregnancy,
Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium
childbirth and the puerperium, includes codes for hypertensive When assigning a chapter 15 code for sepsis complicating abortion,
heart and hypertensive chronic kidney disease. When assigning one pregnancy, childbirth, and the puerperium, a code for the specific
of the O10 codes that includes hypertensive heart disease or type of infection should be assigned as an additional diagnosis. If
hypertensive chronic kidney disease, it is necessary to add a severe sepsis is present, a code from subcategory R65.2, Severe
secondary code from the appropriate hypertension category to sepsis, and code(s) for associated organ dysfunction(s) should also
specify the type of heart failure or chronic kidney disease. be assigned as additional diagnoses.
See Section I.C.9. Hypertension. k. Puerperal sepsis
e. Fetal Conditions Affecting the Management of the Mother Code O85, Puerperal sepsis, should be assigned with a secondary
1) Codes from categories O35 and O36 code to identify the causal organism (e.g., for a bacterial infection,
Codes from categories O35, Maternal care for known or assign a code from category B95-B96, Bacterial infections in
suspected fetal abnormality and damage, and O36, Maternal conditions classified elsewhere). A code from category A40,
care for other fetal problems, are assigned only when the fetal Streptococcal sepsis, or A41, Other sepsis, should not be used for
condition is actually responsible for modifying the puerperal sepsis. If applicable, use additional codes to identify
management of the mother, i.e., by requiring diagnostic severe sepsis (R65.2-) and any associated acute organ dysfunction.
studies, additional observation, special care, or termination of l. Alcohol and tobacco use during pregnancy, childbirth and the
pregnancy. The fact that the fetal condition exists does not puerperium
justify assigning a code from this series to the mother’s record. 1) Alcohol use during pregnancy, childbirth and the
2) In utero surgery puerperium
In cases when surgery is performed on the fetus, a diagnosis Codes under subcategory O99.31, Alcohol use complicating
code from category O35, Maternal care for known or suspected pregnancy, childbirth, and the puerperium, should be assigned
fetal abnormality and damage, should be assigned identifying for any pregnancy case when a mother uses alcohol during the
the fetal condition. Assign the appropriate procedure code for pregnancy or postpartum. A secondary code from category
the procedure performed. F10, Alcohol related disorders, should also be assigned to
identify manifestations of the alcohol use.
No code from Chapter 16, the perinatal codes, should be used
on the mother’s record to identify fetal conditions. Surgery 2) Tobacco use during pregnancy, childbirth and the
performed in utero on a fetus is still to be coded as an obstetric puerperium
encounter. Codes under subcategory O99.33, Smoking (tobacco)
complicating pregnancy, childbirth, and the puerperium,
f. HIV Infection in Pregnancy, Childbirth and the Puerperium
should be assigned for any pregnancy case when a mother uses
During pregnancy, childbirth or the puerperium, a patient admitted any type of tobacco product during the pregnancy or
because of an HIV-related illness should receive a principal diagnosis postpartum. A secondary code from category F17, Nicotine
from subcategory O98.7-, Human immunodeficiency [HIV] disease dependence, should also be assigned to identify the type of
complicating pregnancy, childbirth and the puerperium, followed nicotine dependence.
by the code(s) for the HIV-related illness(es).
m. Poisoning, toxic effects, adverse effects and underdosing in a
Patients with asymptomatic HIV infection status admitted during
pregnant patient
pregnancy, childbirth, or the puerperium should receive codes of
A code from subcategory O9A.2, Injury, poisoning and certain other
O98.7- and Z21, Asymptomatic human immunodeficiency virus
consequences of external causes complicating pregnancy,
[HIV] infection status.
childbirth, and the puerperium, should be sequenced first, followed
g. Diabetes mellitus in pregnancy by the appropriate injury, poisoning, toxic effect, adverse effect or
Diabetes mellitus is a significant complicating factor in pregnancy. underdosing code, and then the additional code(s) that specifies the
Pregnant women who are diabetic should be assigned a code from condition caused by the poisoning, toxic effect, adverse effect or
category O24, Diabetes mellitus in pregnancy, childbirth, and the underdosing.
puerperium, first, followed by the appropriate diabetes code(s) See Section I.C.19. Adverse effects, poisoning, underdosing and toxic
(E08-E13) from Chapter 4. effects.
h. Long term use of insulin and oral hypoglycemics n. Normal Delivery, Code O80
See section I.C.4.a.3 for information on the long term use of
insulin and oral hypoglycemic. 1) Encounter for full term uncomplicated delivery
Code O80 should be assigned when a woman is admitted for a
i. Gestational (pregnancy induced) diabetes full-term normal delivery and delivers a single, healthy infant
Gestational (pregnancy induced) diabetes can occur during the without any complications antepartum, during the delivery, or
second and third trimester of pregnancy in women who were not postpartum during the delivery episode. Code O80 is always a
diabetic prior to pregnancy. Gestational diabetes can cause principal diagnosis. It is not to be used if any other code from
complications in the pregnancy similar to those of pre-existing chapter 15 is needed to describe a current complication of the
diabetes mellitus. It also puts the woman at greater risk of antenatal, delivery, or perinatal period. Additional codes from
developing diabetes after the pregnancy. Codes for gestational other chapters may be used with code O80 if they are not
diabetes are in subcategory O24.4, Gestational diabetes mellitus. No related to or are in any way complicating the pregnancy.
other code from category O24, Diabetes mellitus in pregnancy,
childbirth, and the puerperium, should be used with a code from 2) Uncomplicated delivery with resolved antepartum
O24.4. complication
Code O80 may be used if the patient had a complication at
The codes under subcategory O24.4 include diet controlled, insulin some point during the pregnancy, but the complication is not
controlled, and controlled by oral hypoglycemic drugs. If a patient present at the time of the admission for delivery.
with gestational diabetes is treated with both diet and insulin, only
the code for insulin-controlled is required. If a patient with 3) Outcome of delivery for O80
gestational diabetes is treated with both diet and oral hypoglycemic Z37.0, Single live birth, is the only outcome of delivery code
medications, only the code for "controlled by oral hypoglycemic appropriate for use with O80.
drugs" is required. Code Z79.4, Long-term (current) use of insulin or o. The Peripartum and Postpartum Periods
code Z79.84, Long-term (current) use of oral hypoglycemic drugs, 1) Peripartum and Postpartum periods
should not be assigned with codes from subcategory O24.4. The postpartum period begins immediately after delivery and
An abnormal glucose tolerance in pregnancy is assigned a code continues for six weeks following delivery. The peripartum
from subcategory O99.81, Abnormal glucose complicating period is defined as the last month of pregnancy to five months
pregnancy, childbirth, and the puerperium. postpartum.

2) Peripartum and postpartum complication 16. Chapter 16: Certain Conditions Originating in the Perinatal Period
A postpartum complication is any complication occurring (P00-P96)
within the six-week period. For coding and reporting purposes the perinatal period is defined as
3) Pregnancy-related complications after 6 week period before birth through the 28th day following birth. The following
Chapter 15 codes may also be used to describe guidelines are provided for reporting purposes.
pregnancy-related complications after the peripartum or a. General Perinatal Rules
postpartum period if the provider documents that a condition 1) Use of Chapter 16 Codes
is pregnancy related. Codes in this chapter are never for use on the maternal record.
4) Admission for routine postpartum care following delivery Codes from Chapter 15, the obstetric chapter, are never
outside hospital permitted on the newborn record. Chapter 16 codes may be
When the mother delivers outside the hospital prior to used throughout the life of the patient if the condition is still
admission and is admitted for routine postpartum care and no present.
complications are noted, code Z39.0, Encounter for care and 2) Principal Diagnosis for Birth Record
examination of mother immediately after delivery, should be When coding the birth episode in a newborn record, assign a
assigned as the principal diagnosis. code from category Z38, Liveborn infants according to place of
5) Pregnancy associated cardiomyopathy birth and type of delivery, as the principal diagnosis. A code
Pregnancy associated cardiomyopathy, code O90.3, is unique in from category Z38 is assigned only once, to a newborn at the
that it may be diagnosed in the third trimester of pregnancy but time of birth. If a newborn is transferred to another institution,
may continue to progress months after delivery. For this reason, a code from category Z38 should not be used at the receiving
it is referred to as peripartum cardiomyopathy. Code O90.3 is hospital.
only for use when the cardiomyopathy develops as a result of A code from category Z38 is used only on the newborn record,
pregnancy in a woman who did not have pre-existing heart not on the mother’s record.
disease. 3) Use of Codes from other Chapters with Codes from Chapter
p. Code O94, Sequelae of complication of pregnancy, childbirth, 16
and the puerperium Codes from other chapters may be used with codes from
1) Code O94 chapter 16 if the codes from the other chapters provide more
Code O94, Sequelae of complication of pregnancy, childbirth, specific detail. Codes for signs and symptoms may be assigned
and the puerperium, is for use in those cases when an initial when a definitive diagnosis has not been established. If the
complication of a pregnancy develops a sequelae requiring care reason for the encounter is a perinatal condition, the code from
or treatment at a future date. chapter 16 should be sequenced first.
2) After the initial postpartum period 4) Use of Chapter 16 Codes after the Perinatal Period
This code may be used at any time after the initial postpartum Should a condition originate in the perinatal period, and
period. continue throughout the life of the patient, the perinatal code
3) Sequencing of Code O94 should continue to be used regardless of the patient’s age.
This code, like all sequela codes, is to be sequenced following 5) Birth process or community acquired conditions
the code describing the sequelae of the complication. If a newborn has a condition that may be either due to the birth
q. Termination of Pregnancy and Spontaneous abortions process or community acquired and the documentation does
not indicate which it is, the default is due to the birth process
1) Abortion with Liveborn Fetus
and the code from Chapter 16 should be used. If the condition is
When an attempted termination of pregnancy results in a
community-acquired, a code from Chapter 16 should not be
liveborn fetus, assign code Z33.2, Encounter for elective
assigned.
termination of pregnancy and a code from category Z37,
Outcome of Delivery. 6) Code all clinically significant conditions
All clinically significant conditions noted on routine newborn
2) Retained Products of Conception following an abortion
examination should be coded. A condition is clinically
Subsequent encounters for retained products of conception
significant if it requires:
following a spontaneous abortion or elective termination of
pregnancy, without complications are assigned O03.4, • clinical evaluation; or
Incomplete spontaneous, abortion without complication, or • therapeutic treatment; or
codes O07.4, Failed attempted termination of pregnancy • diagnostic procedures; or
without complication. This advice is appropriate even when the
• extended length of hospital stay; or
patient was discharged previously with a discharge diagnosis of
complete abortion. If the patient has a specific complication • increased nursing care and/or monitoring; or
associated with the spontaneous abortion or elective • has implications for future health care needs
termination of pregnancy in addition to retained products Note: The perinatal guidelines listed above are the same as the
of conception, assign the appropriate complication in general coding guidelines for “additional diagnoses”, except for
category O03 or O07 instead of code O03.4 or O07.4 the final point regarding implications for future health care
3) Complications leading to abortion needs. Codes should be assigned for conditions that have been
Codes from Chapter 15 may be used as additional codes to specified by the provider as having implications for future
identify any documented complications of the pregnancy in health care needs.
conjunction with codes in categories in O04, O07 and O08. b. Observation and Evaluation of Newborns for Suspected
r. Abuse in a pregnant patient Conditions not Found
For suspected or confirmed cases of abuse of a pregnant patient, a 1) Use of Z05 codes
code(s) from subcategories O9A.3, Physical abuse complicating Assign a code from category Z05, Observation and evaluation
pregnancy, childbirth, and the puerperium, O9A.4, Sexual abuse of newborns and infants for suspected conditions ruled out, to
complicating pregnancy, childbirth, and the puerperium, and identify those instances when a healthy newborn is evaluated
O9A.5, Psychological abuse complicating pregnancy, childbirth, and for a suspected condition that is determined after study not to
the puerperium, should be sequenced first, followed by the be present. Do not use a code from category Z05 when the
appropriate codes (if applicable) to identify any associated current patient has identified signs or symptoms of a suspected
injury due to physical abuse, sexual abuse, and the perpetrator of problem; in such cases code the sign or symptom.
abuse. 2) Z05 on Other than the Birth Record
See Section I.C.19. Adult and child abuse, neglect and other A code from category Z05 may also be assigned as a principal or
maltreatment. first-listed code for readmissions or encounters when the code
from category Z38 code no longer applies. Codes from category


Z05 are for use only for healthy newborns and infants for which Whenever the condition is diagnosed by the physician, it is appropriate
no condition after study is found to be present. to assign a code from codes Q00-Q99.For the birth admission, the
3) Z05 on a birth record appropriate code from category Z38, Liveborn infants, according to
A code from category Z05 is to be used as a secondary code place of birth and type of delivery, should be sequenced as the principal
after the code from category Z38, Liveborn infants according to diagnosis, followed by any congenital anomaly codes, Q00- Q99.
place of birth and type of delivery. 18. Chapter 18: Symptoms, signs, and abnormal clinical and laboratory
c. Coding Additional Perinatal Diagnoses findings, not elsewhere classified (R00-R99)
1) Assigning codes for conditions that require treatment Chapter 18 includes symptoms, signs, abnormal results of clinical or
other investigative procedures, and ill-defined conditions regarding
Assign codes for conditions that require treatment or further
which no diagnosis classifiable elsewhere is recorded. Signs and
investigation, prolong the length of stay, or require resource
symptoms that point to a specific diagnosis have been assigned to a
utilization.
category in other chapters of the classification.
2) Codes for conditions specified as having implications for
a. Use of symptom codes
future health care needs
Codes that describe symptoms and signs are acceptable for
Assign codes for conditions that have been specified by the
reporting purposes when a related definitive diagnosis has not been
provider as having implications for future health care needs.
established (confirmed) by the provider.
Note: This guideline should not be used for adult patients.
b. Use of a symptom code with a definitive diagnosis code
d. Prematurity and Fetal Growth Retardation Codes for signs and symptoms may be reported in addition to a
Providers utilize different criteria in determining prematurity. A code related definitive diagnosis when the sign or symptom is not
for prematurity should not be assigned unless it is documented. routinely associated with that diagnosis, such as the various signs
Assignment of codes in categories P05, Disorders of newborn and symptoms associated with complex syndromes. The definitive
related to slow fetal growth and fetal malnutrition, and P07, diagnosis code should be sequenced before the symptom code.
Disorders of newborn related to short gestation and low birth
Signs or symptoms that are associated routinely with a disease
weight, not elsewhere classified, should be based on the recorded
process should not be assigned as additional codes, unless
birth weight and estimated gestational age.
otherwise instructed by the classification.
When both birth weight and gestational age are available, two
c. Combination codes that include symptoms
codes from category P07 should be assigned, with the code for birth
ICD-10-CM contains a number of combination codes that identify
weight sequenced before the code for gestational age.
both the definitive diagnosis and common symptoms of that
e. Low birth weight and immaturity status diagnosis.
Codes from category P07, Disorders of newborn related to short
When using one of these combination codes, an additional code
gestation and low birth weight, not elsewhere classified, are for use
should not be assigned for the symptom.
for a child or adult who was premature or had a low birth weight as
a newborn and this is affecting the patient’s current health status. d. Repeated falls
Code R29.6, Repeated falls, is for use for encounters when a patient
See Section I.C.21. Factors influencing health status and contact with
has recently fallen and the reason for the fall is being investigated.
health services, Status.
Code Z91.81, History of falling, is for use when a patient has fallen in
f. Bacterial Sepsis of Newborn
the past and is at risk for future falls. When appropriate, both codes
Category P36, Bacterial sepsis of newborn, includes congenital
R29.6 and Z91.81 may be assigned together.
sepsis. If a perinate is documented as having sepsis without
documentation of congenital or community acquired, the default is e. Coma scale
congenital and a code from category P36 should be assigned. If the The coma scale codes (R40.2-) can be used in conjunction with
P36 code includes the causal organism, an additional code from traumatic brain injury codes, acute cerebrovascular disease or
category B95, Streptococcus, Staphylococcus, and Enterococcus as sequelae of cerebrovascular disease codes. These codes are
the cause of diseases classified elsewhere, or B96, Other bacterial primarily for use by trauma registries, but they may be used in any
agents as the cause of diseases classified elsewhere, should not be setting where this information is collected. The coma scale may also
assigned. If the P36 code does not include the causal organism, be used to assess the status of the central nervous system for other
assign an additional code from category B96. If applicable, use non-trauma conditions, such as monitoring patients in the intensive
additional codes to identify severe sepsis (R65.2-) and any care unit regardless of medical condition. The coma scale codes
associated acute organ dysfunction. should be sequenced after the diagnosis code(s).
g. Stillbirth These codes, one from each subcategory, are needed to complete
Code P95, Stillbirth, is only for use in institutions that maintain the scale. The 7th character indicates when the scale was recorded.
separate records for stillbirths. No other code should be used with The 7th character should match for all three codes.
P95. Code P95 should not be used on the mother’s record. At a minimum, report the initial score documented on presentation
17. Chapter 17: Congenital malformations, deformations, and at your facility. This may be a score from the emergency medicine
chromosomal abnormalities (Q00-Q99) technician (EMT) or in the emergency department. If desired, a
Assign an appropriate code(s) from categories Q00-Q99, Congenital facility may choose to capture multiple coma scale scores.
malformations, deformations, and chromosomal abnormalities when a Assign code R40.24, Glasgow coma scale, total score, when only the
malformation/deformation or chromosomal abnormality is total score is documented in the medical record and not the
documented. A malformation/deformation/or chromosomal individual score(s).
abnormality may be the principal/first-listed diagnosis on a record or a f. Functional quadriplegia
secondary diagnosis. GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2017
When a malformation/deformation or chromosomal abnormality does g. SIRS due to Non-Infectious Process
not have a unique code assignment, assign additional code(s) for any
The systemic inflammatory response syndrome (SIRS) can develop
manifestations that may be present.
as a result of certain non-infectious disease processes, such as
When the code assignment specifically identifies the trauma, malignant neoplasm, or pancreatitis. When SIRS is
malformation/deformation or chromosomal abnormality, documented with a noninfectious condition, and no subsequent
manifestations that are an inherent component of the anomaly should infection is documented, the code for the underlying condition,
not be coded separately. Additional codes should be assigned for such as an injury, should be assigned, followed by code R65.10,
manifestations that are not an inherent component. Systemic inflammatory response syndrome (SIRS) of non-infectious
Codes from Chapter 17 may be used throughout the life of the patient. If origin without acute organ dysfunction, or code R65.11, Systemic
a congenital malformation or deformity has been corrected, a personal inflammatory response syndrome (SIRS) of non-infectious origin
history code should be used to identify the history of the malformation with acute organ dysfunction. If an associated acute organ
or deformity. Although present at birth, malformation/deformation/or dysfunction is documented, the appropriate code(s) for the specific
chromosomal abnormality may not be identified until later in life. type of organ dysfunction(s) should be assigned in addition to code

R65.11. If acute organ dysfunction is documented, but it cannot be 1) Superficial injuries
determined if the acute organ dysfunction is associated with SIRS or Superficial injuries such as abrasions or contusions are not
due to another condition (e.g., directly due to the trauma), the coded when associated with more severe injuries of the same
provider should be queried. site.
h. Death NOS 2) Primary injury with damage to nerves/blood vessels
Code R99, Ill-defined and unknown cause of mortality, is only for When a primary injury results in minor damage to peripheral
use in the very limited circumstance when a patient who has already nerves or blood vessels, the primary injury is sequenced first
died is brought into an emergency department or other healthcare with additional code(s) for injuries to nerves and spinal cord
facility and is pronounced dead upon arrival. It does not represent (such as category S04), and/or injury to blood vessels (such as
the discharge disposition of death. category S15). When the primary injury is to the blood vessels
i. NIHSS Stroke Scale or nerves, that injury should be sequenced first.
The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in c. Coding of Traumatic Fractures
conjunction with acute stroke codes (I63) to identify the patient's The principles of multiple coding of injuries should be followed in
neurological status and the severity of the stroke. The stroke scale coding fractures. Fractures of specified sites are coded individually
codes should be sequenced after the acute stroke diagnosis code(s). by site in accordance with both the provisions within categories S02,
At a minimum, report the initial score documented. If desired, a S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and
facility may choose to capture multiple stroke scale scores. the level of detail furnished by medical record content.
See Section I.B.14. for information concerning the medical record A fracture not indicated as open or closed should be coded to
documentation that may be used for assignment of the NIHSS codes. closed. A fracture not indicated whether displaced or not displaced
should be coded to displaced.
19. Chapter 19: Injury, poisoning, and certain other consequences of
external causes (S00-T88) More specific guidelines are as follows:
a. Application of 7th Characters in Chapter 19 1) Initial vs. Subsequent Encounter for Fractures
Most categories in chapter 19 have a 7th character requirement for Traumatic fractures are coded using the appropriate 7th
each applicable code. Most categories in this chapter have three 7th character for initial encounter (A, B, C) for each encounter
character values (with the exception of fractures): A, initial where the patient is receiving active treatment for the fracture.
encounter, D, subsequent encounter and S, sequela. Categories for The appropriate 7th character for initial encounter should also
traumatic fractures have additional 7th character values. While the be assigned for a patient who delayed seeking treatment for
patient may be seen by a new or different provider over the course the fracture or nonunion.
of treatment for an injury, assignment of the 7th character is based Fractures are coded using the appropriate 7th character for
on whether the patient is undergoing active treatment and not subsequent care for encounters after the patient has completed
whether the provider is seeing the patient for the first time. active treatment of the fracture and is receiving routine care for
For complication codes, active treatment refers to treatment for the the fracture during the healing or recovery phase.
condition described by the code, even though it may be related to Care for complications of surgical treatment for fracture repairs
an earlier precipitating problem. For example, code T84.50XA, during the healing or recovery phase should be coded with the
Infection and inflammatory reaction due to unspecified internal appropriate complication codes.
joint prosthesis, initial encounter, is used when active treatment is
provided for the infection, even though the condition relates to the Care of complications of fractures, such as malunion and
prosthetic device, implant or graft that was placed at a previous nonunion, should be reported with the appropriate 7th
encounter. character for subsequent care with nonunion (K, M, N,) or
subsequent care with malunion (P, Q, R).
7th character “A”, initial encounter is used for each encounter where
the patient is receiving active treatment for the condition. Malunion/nonunion: The appropriate 7th character for initial
encounter should also be assigned for a patient who delayed
7th character “D” subsequent encounter is used for encounters after seeking treatment for the fracture or nonunion.
the patient has completed active treatment of the condition and is
receiving routine care for the condition during the healing or The open fracture designations in the assignment of the 7th
recovery phase. character for fractures of the forearm, femur and lower leg,
including ankle are based on the Gustilo open fracture
The aftercare Z codes should not be used for aftercare for conditions classification. When the Gustilo classification type is not
such as injuries or poisonings, where 7th characters are provided to specified for an open fracture, the 7th character for open
identify subsequent care. For example, for aftercare of an injury, fracture type I or II should be assigned (B, E, H, M, Q).
assign the acute injury code with the 7th character “D” (subsequent
encounter). A code from category M80, not a traumatic fracture code,
should be used for any patient with known osteoporosis who
7th character “S”, sequela, is for use for complications or conditions suffers a fracture, even if the patient had a minor fall or trauma,
that arise as a direct result of a condition, such as scar formation if that fall or trauma would not usually break a normal, healthy
after a burn. The scars are sequelae of the burn. When using 7th bone.
character “S”, it is necessary to use both the injury code that
precipitated the sequela and the code for the sequela itself. The “S” See Section I.C.13. Osteoporosis.
is added only to the injury code, not the sequela code. The 7th The aftercare Z codes should not be used for aftercare for
character “S” identifies the injury responsible for the sequela. The traumatic fractures. For aftercare of a traumatic fracture, assign
specific type of sequela (e.g. scar) is sequenced first, followed by the the acute fracture code with the appropriate 7th character.
injury code. 2) Multiple fractures sequencing
See Section I.B.10 Sequelae, (Late Effects) Multiple fractures are sequenced in accordance with the
b. Coding of Injuries severity of the fracture.
When coding injuries, assign separate codes for each injury unless a d. Coding of Burns and Corrosions
combination code is provided, in which case the combination code The ICD-10-CM makes a distinction between burns and corrosions.
is assigned. Codes from category T07, Unspecified multiple injuries The burn codes are for thermal burns, except sunburns, that come
should not be assigned in the inpatient setting unless information from a heat source, such as a fire or hot appliance. The burn codes
for a more specific code is not available. Traumatic injury codes are also for burns resulting from electricity and radiation. Corrosions
(S00-T14.9) are not to be used for normal, healing surgical wounds are burns due to chemicals. The guidelines are the same for burns
or to identify complications of surgical wounds. and corrosions.
The code for the most serious injury, as determined by the provider Current burns (T20-T25) are classified by depth, extent and by agent
and the focus of treatment, is sequenced first. (X code). Burns are classified by depth as first degree (erythema),
second degree (blistering), and third degree (full-thickness
involvement). Burns of the eye and internal organs (T26-T28) are
classified by site, but not by degree.


1) Sequencing of burn and related condition codes 1) Do not code directly from the Table of Drugs
Sequence first the code that reflects the highest degree of burn Do not code directly from the Table of Drugs and Chemicals.
when more than one burn is present. Always refer back to the Tabular List.
a. When the reason for the admission or encounter is for 2) Use as many codes as necessary to describe
treatment of external multiple burns, sequence first the Use as many codes as necessary to describe completely all
code that reflects the burn of the highest degree. drugs, medicinal or biological substances.
b. When a patient has both internal and external burns, the 3) If the same code would describe the causative agent
circumstances of admission govern the selection of the If the same code would describe the causative agent for more
principal diagnosis or first-listed diagnosis. than one adverse reaction, poisoning, toxic effect or
c. When a patient is admitted for burn injuries and other underdosing, assign the code only once.
related conditions such as smoke inhalation and/or 4) If two or more drugs, medicinal or biological substances
respiratory failure, the circumstances of admission If two or more drugs, medicinal or biological substances are
govern the selection of the principal or first-listed reported, code each individually unless a combination code is
diagnosis. listed in the Table of Drugs and Chemicals.
2) Burns of the same local site 5) The occurrence of drug toxicity is classified in ICD-10-CM as
Classify burns of the same local site (three-character category follows:
level, T20-T28) but of different degrees to the subcategory (a) Adverse Effect
identifying the highest degree recorded in the diagnosis. When coding an adverse effect of a drug that has been
3) Non-healing burns correctly prescribed and properly administered, assign the
Non-healing burns are coded as acute burns. appropriate code for the nature of the adverse effect
Necrosis of burned skin should be coded as a non-healed burn. followed by the appropriate code for the adverse effect of
the drug (T36-T50). The code for the drug should have a
4) Infected Burn 5th or 6th character “5” (for example T36.0X5-) Examples of
For any documented infected burn site, use an additional code the nature of an adverse effect are tachycardia, delirium,
for the infection. gastrointestinal hemorrhaging, vomiting, hypokalemia,
5) Assign separate codes for each burn site hepatitis, renal failure, or respiratory failure.
When coding burns, assign separate codes for each burn site. (b) Poisoning
Category T30, Burn and corrosion, body region unspecified is When coding a poisoning or reaction to the improper use
extremely vague and should rarely be used. of a medication (e.g., overdose, wrong substance given or
6) Burns and Corrosions Classified According to Extent of taken in error, wrong route of administration), first assign
Body Surface Involved the appropriate code from categories T36-T50. The
Assign codes from category T31, Burns classified according to poisoning codes have an associated intent as their 5th or
extent of body surface involved, or T32, Corrosions classified 6th character (accidental, intentional self-harm, assault and
according to extent of body surface involved, when the site of undetermined. If the intent of the poisoning is unknown or
the burn is not specified or when there is a need for additional unspecified, code the intent as accidental intent. The
data. It is advisable to use category T31 as additional coding undetermined intent is only for use if the documentation in
when needed to provide data for evaluating burn mortality, the record specifies that the intent cannot be determined.
such as that needed by burn units. It is also advisable to use Use additional code(s) for all manifestations of poisonings.
category T31 as an additional code for reporting purposes If there is also a diagnosis of abuse or dependence of the
when there is mention of a third-degree burn involving 20 substance, the abuse or dependence is assigned as an
percent or more of the body surface. additional code.
Categories T31 and T32 are based on the classic “rule of nines” Examples of poisoning include:
in estimating body surface involved: head and neck are
(i) Error was made in drug prescription
assigned nine percent, each arm nine percent, each leg 18
Errors made in drug prescription or in the
percent, the anterior trunk 18 percent, posterior trunk 18
percent, and genitalia one percent. Providers may change these administration of the drug by provider, nurse, patient,
percentage assignments where necessary to accommodate or other person.
infants and children who have proportionately larger heads (ii) Overdose of a drug intentionally taken
than adults, and patients who have large buttocks, thighs, or If an overdose of a drug was intentionally taken or
abdomen that involve burns. administered and resulted in drug toxicity, it would be
7) Encounters for treatment of sequela of burns coded as a poisoning.
Encounters for the treatment of the late effects of burns or (iii) Nonprescribed drug taken with correctly prescribed
corrosions (i.e., scars or joint contractures) should be coded and properly administered drug
with a burn or corrosion code with the 7th character “S” for If a nonprescribed drug or medicinal agent was taken
sequela. in combination with a correctly prescribed and
8) Sequelae with a late effect code and current burn properly administered drug, any drug toxicity or other
When appropriate, both a code for a current burn or corrosion reaction resulting from the interaction of the two
with 7th character “A” or “D” and a burn or corrosion code with drugs would be classified as a poisoning.
7th character “S” may be assigned on the same record (when
(iv) Interaction of drug(s) and alcohol
both a current burn and sequelae of an old burn exist). Burns
and corrosions do not heal at the same rate and a current When a reaction results from the interaction of a
healing wound may still exist with sequela of a healed burn or drug(s) and alcohol, this would be classified as
corrosion. poisoning.
See Section I.B.10 Sequela (Late Effects) See Section I.C.4. if poisoning is the result of insulin pump
malfunctions.
9) Use of an external cause code with burns and corrosions
An external cause code should be used with burns and (c) Underdosing
corrosions to identify the source and intent of the burn, as well Underdosing refers to taking less of a medication than is
as the place where it occurred. prescribed by a provider or a manufacturer’s instruction. For
underdosing, assign the code from categories T36-T50 (fifth or
e. Adverse Effects, Poisoning, Underdosing and Toxic Effects sixth character “6”).
Codes in categories T36-T65 are combination codes that include the
substance that was taken as well as the intent. No additional Codes for underdosing should never be assigned as principal or
external cause code is required for poisonings, toxic effects, adverse first-listed codes. If a patient has a relapse or exacerbation of
effects and underdosing codes. the medical condition for which the drug is prescribed because

of the reduction in dose, then the medical condition itself Code T86.1- should be assigned for documented
should be coded. complications of a kidney transplant, such as transplant
Noncompliance (Z91.12-, Z91.13-) or complication of care failure or rejection or other transplant complication. Code
(Y63.6-Y63.9) codes are to be used with an underdosing code to T86.1- should not be assigned for post kidney transplant
indicate intent, if known. patients who have chronic kidney (CKD) unless a transplant
complication such as transplant failure or rejection is
(d) Toxic Effects documented. If the documentation is unclear as to whether
When a harmful substance is ingested or comes in contact with the patient has a complication of the transplant, query the
a person, this is classified as a toxic effect. The toxic effect codes provider.
are in categories T51-T65.
Conditions that affect the function of the transplanted
Toxic effect codes have an associated intent: accidental, kidney, other than CKD, should be assigned a code from
intentional self-harm, assault and undetermined. subcategory T86.1, Complications of transplanted organ,
f. Adult and child abuse, neglect and other maltreatment Kidney, and a secondary code that identifies the
Sequence first the appropriate code from categories T74, Adult and complication.
child abuse, neglect and other maltreatment, confirmed) or T76, For patients with CKD following a kidney transplant, but
Adult and child abuse, neglect and other maltreatment, suspected) who do not have a complication such as failure or rejection,
for abuse, neglect and other maltreatment, followed by any see section I.C.14. Chronic kidney disease and kidney
accompanying mental health or injury code(s). transplant status.
If the documentation in the medical record states abuse or neglect it 4) Complication codes that include the external cause
is coded as confirmed (T74.-). It is coded as suspected if it is As with certain other T codes, some of the complications of care
documented as suspected (T76.-). codes have the external cause included in the code. The code
For cases of confirmed abuse or neglect an external cause code from includes the nature of the complication as well as the type of
the assault section (X92-Y09) should be added to identify the cause procedure that caused the complication. No external cause
of any physical injuries. A perpetrator code (Y07) should be added code indicating the type of procedure is necessary for these
when the perpetrator of the abuse is known. For suspected cases of codes.
abuse or neglect, do not report external cause or perpetrator code. 5) Complications of care codes within the body system
If a suspected case of abuse, neglect or mistreatment is ruled out chapters
during an encounter code Z04.71, Encounter for examination and Intraoperative and postprocedural complication codes are
observation following alleged physical adult abuse, ruled out, or found within the body system chapters with codes specific to
code Z04.72, Encounter for examination and observation following the organs and structures of that body system. These codes
alleged child physical abuse, ruled out, should be used, not a code should be sequenced first, followed by a code(s) for the specific
from T76. complication, if applicable.
If a suspected case of alleged rape or sexual abuse is ruled out 20. Chapter 20: External Causes of Morbidity (V00-Y99)
during an encounter code Z04.41, Encounter for examination and The external causes of morbidity codes should never be sequenced as
observation following alleged adult rape or code Z04.42, Encounter the first-listed or principal diagnosis.
for examination and observation following alleged child rape, External cause codes are intended to provide data for injury research and
should be used, not a code from T76. evaluation of injury prevention strategies. These codes capture how the
See Section I.C.15. Abuse in a pregnant patient. injury or health condition happened (cause), the intent (unintentional or
g. Complications of care accidental; or intentional, such as suicide or assault), the place where the
1) General guidelines for complications of care event occurred the activity of the patient at the time of the event, and
the person’s status (e.g., civilian, military).
(a) Documentation of complications of care
See Section I.B.16. for information on documentation of There is no national requirement for mandatory ICD-10-CM external
complications of care. cause code reporting. Unless a provider is subject to a state-based
external cause code reporting mandate or these codes are required by a
2) Pain due to medical devices particular payer, reporting of ICD-10-CM codes in Chapter 20, External
Pain associated with devices, implants or grafts left in a surgical Causes of Morbidity, is not required. In the absence of a mandatory
site (for example painful hip prosthesis) is assigned to the reporting requirement, providers are encouraged to voluntarily report
appropriate code(s) found in Chapter 19, Injury, poisoning, and external cause codes, as they provide valuable data for injury research
certain other consequences of external causes. Specific codes and evaluation of injury prevention strategies.
for pain due to medical devices are found in the T code section
of the ICD-10-CM. Use additional code(s) from category G89 to a. General External Cause Coding Guidelines
identify acute or chronic pain due to presence of the device, 1) Used with any code in the range of A00.0-T88.9 Z00-Z99
implant or graft (G89.18 or G89.28). An external cause code may be used with any code in the range
3) Transplant complications of A00.0-T88.9, Z00-Z99, classification that represents a health
condition due to an external cause. Though they are most
(a) Transplant complications other than kidney applicable to injuries, they are also valid for use with such
Codes under category T86, Complications of transplanted things as infections or diseases due to an external source, and
organs and tissues, are for use for both complications and other health conditions, such as a heart attack that occurs
rejection of transplanted organs. A transplant complication during strenuous physical activity.
code is only assigned if the complication affects the
function of the transplanted organ. Two codes are required 2) External cause code used for length of treatment
to fully describe a transplant complication: the appropriate Assign the external cause code, with the appropriate 7th
code from category T86 and a secondary code that character (initial encounter, subsequent encounter or sequela)
identifies the complication. for each encounter for which the injury or condition is being
treated.
Pre-existing conditions or conditions that develop after the
transplant are not coded as complications unless they Most categories in chapter 20 have a 7th character requirement
affect the function of the transplanted organs. for each applicable code. Most categories in this chapter have
three 7th character values: A, initial encounter, D, subsequent
See I.C.21. for transplant organ removal status encounter and S, sequela. While the patient may be seen by a
See I.C.2. for malignant neoplasm associated with new or different provider over the course of treatment for an
transplanted organ. injury or condition, assignment of the 7th character for external
(b) Kidney transplant complications cause should match the 7th character of the code assigned for
Patients who have undergone kidney transplant may still the associated injury or condition for the encounter.
have some form of chronic kidney disease (CKD) because
the kidney transplant may not fully restore kidney function.


3) Use the full range of external cause codes events should be reported rather than the codes for place, activity,
Use the full range of external cause codes to completely or external status.
describe the cause, the intent, the place of occurrence, and if f. Multiple External Cause Coding Guidelines
applicable, the activity of the patient at the time of the event, More than one external cause code is required to fully describe the
and the patient’s status, for all injuries, and other health external cause of an illness or injury. The assignment of external
conditions due to an external cause. cause codes should be sequenced in the following priority:
4) Assign as many external cause codes as necessary If two or more events cause separate injuries, an external cause code
Assign as many external cause codes as necessary to fully should be assigned for each cause. The first-listed external cause
explain each cause. If only one external code can be recorded, code will be selected in the following order:
assign the code most related to the principal diagnosis.
External codes for child and adult abuse take priority over all other
5) The selection of the appropriate external cause code external cause codes.
The selection of the appropriate external cause code is guided
by the Alphabetic Index of External Causes and by Inclusion and See Section I.C.19., Child and Adult abuse guidelines.
Exclusion notes in the Tabular List. External cause codes for terrorism events take priority over all other
6) External cause code can never be a principal diagnosis external cause codes except child and adult abuse.
An external cause code can never be a principal (first-listed) External cause codes for cataclysmic events take priority over all
diagnosis. other external cause codes except child and adult abuse and
7) Combination external cause codes terrorism.
Certain of the external cause codes are combination codes that External cause codes for transport accidents take priority over all
identify sequential events that result in an injury, such as a fall other external cause codes except cataclysmic events, child and
which results in striking against an object. The injury may be adult abuse and terrorism.
due to either event or both. The combination external cause Activity and external cause status codes are assigned following all
code used should correspond to the sequence of events causal (intent) external cause codes.
regardless of which caused the most serious injury.
The first-listed external cause code should correspond to the cause
8) No external cause code needed in certain circumstances of the most serious diagnosis due to an assault, accident, or
No external cause code from Chapter 20 is needed if the self-harm, following the order of hierarchy listed above.
external cause and intent are included in a code from another
g. Child and Adult Abuse Guideline
chapter (e.g. T36.0X1- Poisoning by penicillins, accidental
(unintentional)). Adult and child abuse, neglect and maltreatment are classified as
assault. Any of the assault codes may be used to indicate the
b. Place of Occurrence Guideline external cause of any injury resulting from the confirmed abuse.
Codes from category Y92, Place of occurrence of the external cause,
For confirmed cases of abuse, neglect and maltreatment, when the
are secondary codes for use after other external cause codes to
perpetrator is known, a code from Y07, Perpetrator of maltreatment
identify the location of the patient at the time of injury or other
and neglect, should accompany any other assault codes.
condition.
See Section I.C.19. Adult and child abuse, neglect and other
Generally, a place of occurrence code is assigned only once, at the
maltreatment
initial encounter for treatment. However, in the rare instance that a
new injury occurs during hospitalization, an additional place of h. Unknown or Undetermined Intent Guideline
occurrence code may be assigned. No 7th characters are used for If the intent (accident, self-harm, assault) of the cause of an injury or
Y92. other condition is unknown or unspecified, code the intent as
Do not use place of occurrence code Y92.9 if the place is not stated accidental intent. All transport accident categories assume
or is not applicable. accidental intent.
c. Activity Code 1) Use of undetermined intent
Assign a code from category Y93, Activity code, to describe the External cause codes for events of undetermined intent are only
activity of the patient at the time the injury or other health for use if the documentation in the record specifies that the
condition occurred. intent cannot be determined.
An activity code is used only once, at the initial encounter for i. Sequelae (Late Effects) of External Cause Guidelines
treatment. Only one code from Y93 should be recorded on a medical 1) Sequelae external cause codes
record. Sequela are reported using the external cause code with the
7th character “S” for sequela. These codes should be used with
The activity codes are not applicable to poisonings, adverse effects, any report of a late effect or sequela resulting from a previous
misadventures or sequela. injury.
Do not assign Y93.9, Unspecified activity, if the activity is not stated. See Section I.B.10 Sequela (Late Effects)
A code from category Y93 is appropriate for use with external cause 2) Sequela external cause code with a related current injury
and intent codes if identifying the activity provides additional A sequela external cause code should never be used with a
information about the event. related current nature of injury code.
d. Place of Occurrence, Activity, and Status Codes Used with other 3) Use of sequela external cause codes for subsequent visits
External Cause Code Use a late effect external cause code for subsequent visits when
When applicable, place of occurrence, activity, and external cause a late effect of the initial injury is being treated. Do not use a
status codes are sequenced after the main external cause code(s). late effect external cause code for subsequent visits for
Regardless of the number of external cause codes assigned, follow-up care (e.g., to assess healing, to receive rehabilitative
generally there should be only one place of occurrence code, one therapy) of the injury when no late effect of the injury has been
activity code, and one external cause status code assigned to an documented.
encounter. However, in the rare instance that a new injury occurs
during hospitalization, an additional place of occurrence code may j. Terrorism Guidelines
be assigned. 1) Cause of injury identified by the Federal Government (FBI)
e. If the Reporting Format Limits the Number of External Cause as terrorism
Codes When the cause of an injury is identified by the Federal
Government (FBI) as terrorism, the first-listed external cause
If the reporting format limits the number of external cause codes
code should be a code from category Y38, Terrorism. The
that can be used in reporting clinical data, report the code for the
definition of terrorism employed by the FBI is found at the
cause/intent most related to the principal diagnosis. If the format
inclusion note at the beginning of category Y38. Use additional
permits capture of additional external cause codes, the
code for place of occurrence (Y92.-). More than one Y38 code
cause/intent, including medical misadventures, of the additional

may be assigned if the injury is the result of more than one 3) Status
mechanism of terrorism. Status codes indicate that a patient is either a carrier of a
2) Cause of an injury is suspected to be the result of terrorism disease or has the sequelae or residual of a past disease or
When the cause of an injury is suspected to be the result of condition. This includes such things as the presence of
terrorism a code from category Y38 should not be assigned. prosthetic or mechanical devices resulting from past treatment.
Suspected cases should be classified as assault. A status code is informative, because the status may affect the
course of treatment and its outcome. A status code is distinct
3) Code Y38.9, Terrorism, secondary effects from a history code. The history code indicates that the patient
Assign code Y38.9, Terrorism, secondary effects, for conditions no longer has the condition.
occurring subsequent to the terrorist event. This code should
not be assigned for conditions that are due to the initial terrorist A status code should not be used with a diagnosis code from
act. one of the body system chapters, if the diagnosis code includes
the information provided by the status code. For example, code
It is acceptable to assign code Y38.9 with another code from Z94.1, Heart transplant status, should not be used with a code
Y38 if there is an injury due to the initial terrorist event and an from subcategory T86.2, Complications of heart transplant. The
injury that is a subsequent result of the terrorist event. status code does not provide additional information. The
k. External cause status complication code indicates that the patient is a heart
A code from category Y99, External cause status, should be assigned transplant patient.
whenever any other external cause code is assigned for an For encounters for weaning from a mechanical ventilator,
encounter, including an Activity code, except for the events noted assign a code from subcategory J96.1, Chronic respiratory
below. Assign a code from category Y99, External cause status, to failure, followed by code Z99.11, Dependence on respirator
indicate the work status of the person at the time the event [ventilator] status.
occurred. The status code indicates whether the event occurred
during military activity, whether a non-military person was at work, The status Z codes/categories are:
whether an individual including a student or volunteer was involved Z14 Genetic carrier
in a non-work activity at the time of the causal event. Genetic carrier status indicates that a person carries a
A code from Y99, External cause status, should be assigned, when gene, associated with a particular disease, which may
applicable, with other external cause codes, such as transport be passed to offspring who may develop that disease.
accidents and falls. The external cause status codes are not The person does not have the disease and is not at risk
applicable to poisonings, adverse effects, misadventures or late of developing the disease.
effects. Z15 Genetic susceptibility to disease
Do not assign a code from category Y99 if no other external cause Genetic susceptibility indicates that a person has a gene
codes (cause, activity) are applicable for the encounter. that increases the risk of that person developing the
An external cause status code is used only once, at the initial disease.
encounter for treatment. Only one code from Y99 should be Codes from category Z15 should not be used as
recorded on a medical record. principal or first-listed codes. If the patient has the
Do not assign code Y99.9, Unspecified external cause status, if the condition to which he/she is susceptible, and that
status is not stated. condition is the reason for the encounter, the code for
21. Chapter 21: Factors influencing health status and contact with the current condition should be sequenced first. If the
health services (Z00-Z99) patient is being seen for follow-up after completed
Note: The chapter specific guidelines provide additional information treatment for this condition, and the condition no
about the use of Z codes for specified encounters. longer exists, a follow-up code should be sequenced
first, followed by the appropriate personal history and
a. Use of Z codes in any healthcare setting genetic susceptibility codes. If the purpose of the
Z codes are for use in any healthcare setting. Z codes may be used as encounter is genetic counseling associated with
either a first-listed (principal diagnosis code in the inpatient setting) procreative management, code Z31.5, Encounter for
or secondary code, depending on the circumstances of the genetic counseling, should be assigned as the
encounter. Certain Z codes may only be used as first-listed or first-listed code, followed by a code from category Z15.
principal diagnosis. Additional codes should be assigned for any applicable
b. Z Codes indicate a reason for an encounter family or personal history.
Z codes are not procedure codes. A corresponding procedure code Z16 Resistance to antimicrobial drugs
must accompany a Z code to describe any procedure performed.
This code indicates that a patient has a condition that is
c. Categories of Z Codes resistant to antimicrobial drug treatment. Sequence the
1) Contact/Exposure infection code first.
Category Z20 indicates contact with, and suspected exposure Z17 Estrogen receptor status
to, communicable diseases. These codes are for patients who do
not show any sign or symptom of a disease but are suspected to Z18 Retained foreign body fragments
have been exposed to it by close personal contact with an Z19 Hormone sensitivity malignancy status
infected individual or are in an area where a disease is Z21 Asymptomatic HIV infection status
epidemic.
This code indicates that a patient has tested positive for
Category Z77, Other contact with and (suspected) exposures HIV but has manifested no signs or symptoms of the
hazardous to health, indicates contact with and suspected disease.
exposures hazardous to health.
Z22 Carrier of infectious disease
Contact/exposure codes may be used as a first-listed code to
explain an encounter for testing, or, more commonly, as a Carrier status indicates that a person harbors the
secondary code to identify a potential risk. specific organisms of a disease without manifest
symptoms and is capable of transmitting the infection.
2) Inoculations and vaccinations
Code Z23 is for encounters for inoculations and vaccinations. It Z28.3 Underimmunization status
indicates that a patient is being seen to receive a prophylactic Z33.1 Pregnant state, incidental
inoculation against a disease. Procedure codes are required to This code is a secondary code only for use when the
identify the actual administration of the injection and the pregnancy is in no way complicating the reason for visit.
type(s) of immunizations given. Code Z23 may be used as a Otherwise, a code from the obstetric chapter is
secondary code if the inoculation is given as a routine part of required.
preventive health care, such as a well-baby visit.
Z66 Do not resuscitate


This code may be used when it is documented by the Z97 Presence of other devices
provider that a patient is on do not resuscitate status at Z98 Other postprocedural states
any time during the stay.
Assign code Z98.85, Transplanted organ removal status,
Z67 Blood type to indicate that a transplanted organ has been
Z68 Body mass index (BMI) previously removed. This code should not be assigned
As with all other secondary diagnosis codes, the BMI for the encounter in which the transplanted organ is
codes should only be assigned when they meet the removed. The complication necessitating removal of
definition of a reportable diagnosis (see Section III, the transplant organ should be assigned for that
Reporting Additional Diagnoses). encounter.
Z74.01 Bed confinement status See section I.C19. for information on the coding of organ
transplant complications.
Z76.82 Awaiting organ transplant status
Z99 Dependence on enabling machines and devices, not
Z78 Other specified health status elsewhere classified
Code Z78.1, Physical restraint status, may be used when Note: Categories Z89-Z90 and Z93-Z99 are for use only
it is documented by the provider that a patient has if there are no complications or malfunctions of the
been put in restraints during the current encounter. organ or tissue replaced, the amputation site or the
Please note that this code should not be reported when equipment on which the patient is dependent.
it is documented by the provider that a patient is
temporarily restrained during a procedure. 4) History (of)
There are two types of history Z codes, personal and family.
Z79 Long-term (current) drug therapy Personal history codes explain a patient’s past medical
Codes from this category indicate a patient’s condition that no longer exists and is not receiving any
continuous use of a prescribed drug (including such treatment, but that has the potential for recurrence, and
things as aspirin therapy) for the long-term treatment therefore may require continued monitoring.
of a condition or for prophylactic use. It is not for use for Family history codes are for use when a patient has a family
patients who have addictions to drugs. This member(s) who has had a particular disease that causes the
subcategory is not for use of medications for patient to be at higher risk of also contracting the disease.
detoxification or maintenance programs to prevent
withdrawal symptoms in patients with drug Personal history codes may be used in conjunction with
dependence (e.g., methadone maintenance for opiate follow-up codes and family history codes may be used in
dependence). Assign the appropriate code for the drug conjunction with screening codes to explain the need for a test
dependence instead. or procedure. History codes are also acceptable on any medical
record regardless of the reason for visit. A history of an illness,
Assign a code from Z79 if the patient is receiving a even if no longer present, is important information that may
medication for an extended period as a prophylactic alter the type of treatment ordered.
measure (such as for the prevention of deep vein
thrombosis) or as treatment of a chronic condition The history Z code categories are:
(such as arthritis) or a disease requiring a lengthy course Z80 Family history of primary malignant neoplasm
of treatment (such as cancer). Do not assign a code from Z81 Family history of mental and behavioral disorders
category Z79 for medication being administered for a
brief period of time to treat an acute illness or injury Z82 Family history of certain disabilities and chronic
(such as a course of antibiotics to treat acute bronchitis). diseases (leading to disablement)
Z88 Allergy status to drugs, medicaments and biological Z83 Family history of other specific disorders
substances Z84 Family history of other conditions
Except: Z88.9, Allergy status to unspecified drugs, Z85 Personal history of malignant neoplasm
medicaments and biological substances status Z86 Personal history of certain other diseases
Z89 Acquired absence of limb Z87 Personal history of other diseases and conditions
Z90 Acquired absence of organs, not elsewhere classified Z91.4- Personal history of psychological trauma, not elsewhere
Z91.0- Allergy status, other than to drugs and biological classified
substances Z91.5 Personal history of self-harm
Z92.82 Status post administration of tPA (rtPA) in a different Z91.81 History of falling
facility within the last 24 hours prior to admission to a
current facility Z91.82 Personal history of military deployment
Assign code Z92.82, Status post administration of tPA Z92 Personal history of medical treatment
(rtPA) in a different facility within the last 24 hours prior Except: Z92.0, Personal history of contraception
to admission to current facility, as a secondary diagnosis Except: Z92.82, Status post administration of tPA (rtPA)
when a patient is received by transfer into a facility and in a different facility within the last 24 hours prior to
documentation indicates they were administered tissue admission to a current facility
plasminogen activator (tPA) within the last 24 hours
prior to admission to the current facility. 5) Screening
Screening is the testing for disease or disease precursors in
This guideline applies even if the patient is still seemingly well individuals so that early detection and
receiving the tPA at the time they are received into the treatment can be provided for those who test positive for the
current facility. disease (e.g., screening mammogram).
The appropriate code for the condition for which the The testing of a person to rule out or confirm a suspected
tPA was administered (such as cerebrovascular disease diagnosis because the patient has some sign or symptom is a
or myocardial infarction) should be assigned first. diagnostic examination, not a screening. In these cases, the sign
Code Z92.82 is only applicable to the receiving facility or symptom is used to explain the reason for the test.
record and not to the transferring facility record. A screening code may be a first-listed code if the reason for the
Z93 Artificial opening status visit is specifically the screening exam. It may also be used as an
Z94 Transplanted organ and tissue status additional code if the screening is done during an office visit for
other health problems. A screening code is not necessary if the
Z95 Presence of cardiac and vascular implants and grafts screening is inherent to a routine examination, such as a pap
Z96 Presence of other functional implants smear done during a routine pelvic examination.

Should a condition be discovered during the screening then the immunotherapy. These codes are to be first-listed, followed by
code for the condition may be assigned as an additional the diagnosis code when a patient’s encounter is solely to
diagnosis. receive radiation therapy, chemotherapy, or immunotherapy for
The Z code indicates that a screening exam is planned. A the treatment of a neoplasm. If the reason for the encounter is
procedure code is required to confirm that the screening was more than one type of antineoplastic therapy, code Z51.0 and a
performed. code from subcategory Z51.1 may be assigned together, in
which case one of these codes would be reported as a
The screening Z codes/categories: secondary diagnosis.
Z11 Encounter for screening for infectious and parasitic The aftercare Z codes should also not be used for aftercare for
diseases injuries. For aftercare of an injury, assign the acute injury code
Z12 Encounter for screening for malignant neoplasms with the appropriate 7th character (for subsequent encounter).
Z13 Encounter for screening for other diseases and The aftercare codes are generally first-listed to explain the
disorders specific reason for the encounter. An aftercare code may be
Except: Z13.9, Encounter for screening, unspecified used as an additional code when some type of aftercare is
provided in addition to the reason for admission and no
Z36 Encounter for antenatal screening for mother diagnosis code is applicable. An example of this would be the
6) Observation closure of a colostomy during an encounter for treatment of
There are three observation Z code categories. They are for use another condition.
in very limited circumstances when a person is being observed Aftercare codes should be used in conjunction with other
for a suspected condition that is ruled out. The observation aftercare codes or diagnosis codes to provide better detail on
codes are not for use if an injury or illness or any signs or the specifics of an aftercare encounter visit, unless otherwise
symptoms related to the suspected condition are present. In directed by the classification. Should a patient receive multiple
such cases the diagnosis/symptom code is used with the types of antineoplastic therapy during the same encounter,
corresponding external cause code. code Z51.0, Encounter for antineoplastic radiation therapy, and
The observation codes are to be used as principal diagnosis codes from subcategory Z51.1, Encounter for antineoplastic
only. The only exception to this is when the principal diagnosis chemotherapy and immunotherapy, may be used together on a
is required to be a code from category Z38, Liveborn infants record. The sequencing of multiple aftercare codes depends on
according to place of birth and type of delivery. Then a code the circumstances of the encounter.
from category Z05, Encounter for observation and evaluation of Certain aftercare Z code categories need a secondary diagnosis
newborn for suspected diseases and conditions ruled out, is code to describe the resolving condition or sequelae. For
sequenced after the Z38 code. Additional codes may be used in others, the condition is included in the code title.
addition to the observation code, but only if they are unrelated
to the suspected condition being observed. Additional Z code aftercare category terms include fitting and
adjustment, and attention to artificial openings.
Codes from subcategory Z03.7, Encounter for suspected
maternal and fetal conditions ruled out, may either be used as a Status Z codes may be used with aftercare Z codes to indicate
first-listed or as an additional code assignment depending on the nature of the aftercare. For example code Z95.1, Presence of
the case. They are for use in very limited circumstances on a aortocoronary bypass graft, may be used with code Z48.812,
maternal record when an encounter is for a suspected maternal Encounter for surgical aftercare following surgery on the
or fetal condition that is ruled out during that encounter (for circulatory system, to indicate the surgery for which the
example, a maternal or fetal condition may be suspected due to aftercare is being performed. A status code should not be used
an abnormal test result). These codes should not be used when when the aftercare code indicates the type of status, such as
the condition is confirmed. In those cases, the confirmed using Z43.0, Encounter for attention to tracheostomy, with
condition should be coded. In addition, these codes are not for Z93.0, Tracheostomy status.
use if an illness or any signs or symptoms related to the The aftercare Z category/codes:
suspected condition or problem are present. In such cases the Z42 Encounter for plastic and reconstructive surgery
diagnosis/symptom code is used. following medical procedure or healed injury
Additional codes may be used in addition to the code from Z43 Encounter for attention to artificial openings
subcategory Z03.7, but only if they are unrelated to the
suspected condition being evaluated. Z44 Encounter for fitting and adjustment of external
prosthetic device
Codes from subcategory Z03.7 may not be used for encounters
for antenatal screening of mother. See Section I.C.21. Screening. Z45 Encounter for adjustment and management of
implanted device
For encounters for suspected fetal condition that are
inconclusive following testing and evaluation, assign the Z46 Encounter for fitting and adjustment of other devices
appropriate code from category O35, O36, O40 or O41. Z47 Orthopedic aftercare
The observation Z code categories: Z48 Encounter for other postprocedural aftercare
Z03 Encounter for medical observation for suspected Z49 Encounter for care involving renal dialysis
diseases and conditions ruled out Z51 Encounter for other aftercare and medical care
Z04 Encounter for examination and observation for other 8) Follow-up
reasons The follow-up codes are used to explain continuing surveillance
Except: Z04.9, Encounter for examination and following completed treatment of a disease, condition, or
observation for unspecified reason injury. They imply that the condition has been fully treated and
Z05 Encounter for observation and evaluation of newborn no longer exists. They should not be confused with aftercare
for suspected diseases and conditions ruled out codes, or injury codes with a 7th character for subsequent
encounter, that explain ongoing care of a healing condition or
7) Aftercare its sequelae. Follow-up codes may be used in conjunction with
Aftercare visit codes cover situations when the initial treatment history codes to provide the full picture of the healed condition
of a disease has been performed and the patient requires and its treatment. The follow-up code is sequenced first,
continued care during the healing or recovery phase, or for the followed by the history code.
long-term consequences of the disease. The aftercare Z code
should not be used if treatment is directed at a current, acute A follow-up code may be used to explain multiple visits. Should
disease. The diagnosis code is to be used in these cases. a condition be found to have recurred on the follow-up visit,
Exceptions to this rule are codes Z51.0, Encounter for then the diagnosis code for the condition should be assigned in
antineoplastic radiation therapy, and codes from subcategory place of the follow-up code.
Z51.1, Encounter for antineoplastic chemotherapy and The follow-up Z code categories:


Z08 Encounter for follow-up examination after completed Z37 Outcome of delivery
treatment for malignant neoplasm Z39 Encounter for maternal postpartum care and
Z09 Encounter for follow-up examination after completed examination
treatment for conditions other than malignant Z76.81 Expectant mother prebirth pediatrician visit
neoplasm
12) Newborns and Infants
Z39 Encounter for maternal postpartum care and See Section I.C.16. Newborn (Perinatal) Guidelines, for further
examination instruction on the use of these codes.
9) Donor Newborn Z codes/categories:
Codes in category Z52, Donors of organs and tissues, are used
for living individuals who are donating blood or other body Z76.1 Encounter for health supervision and care of foundling
tissue. These codes are only for individuals donating for others, Z00.1- Encounter for routine child health examination
not for self-donations. They are not used to identify cadaveric Z38‘ Liveborn infants according to place of birth and type of
donations. delivery
10) Counseling 13) Routine and administrative examinations
Counseling Z codes are used when a patient or family member The Z codes allow for the description of encounters for routine
receives assistance in the aftermath of an illness or injury, or examinations, such as, a general check-up, or, examinations for
when support is required in coping with family or social administrative purposes, such as, a pre-employment physical.
problems. The codes are not to be used if the examination is for diagnosis
The counseling Z codes/categories: of a suspected condition or for treatment purposes. In such
Z30.0- Encounter for general counseling and advice on cases the diagnosis code is used. During a routine exam, should
contraception a diagnosis or condition be discovered, it should be coded as an
additional code. Pre-existing and chronic conditions and
Z31.5 Encounter for procreative genetic counseling history codes may also be included as additional codes as long
Z31.6- Encounter for general counseling and advice on as the examination is for administrative purposes and not
procreation focused on any particular condition.
Z32.2 Encounter for childbirth instruction Some of the codes for routine health examinations distinguish
Z32.3 Encounter for childcare instruction between “with” and “without” abnormal findings. Code
assignment depends on the information that is known at the
Z69 Encounter for mental health services for victim and time the encounter is being coded. For example, if no abnormal
perpetrator of abuse findings were found during the examination, but the encounter
Z70 Counseling related to sexual attitude, behavior and is being coded before test results are back, it is acceptable to
orientation assign the code for “without abnormal findings.” When
Z71 Persons encountering health services for other assigning a code for “with abnormal findings,” additional
counseling and medical advice, not elsewhere classified code(s) should be assigned to identify the specific abnormal
finding(s).
Z76.81 Expectant mother prebirth pediatrician visit
Pre-operative examination and pre-procedural laboratory
11) Encounters for Obstetrical and Reproductive Services examination Z codes are for use only in those situations when a
See Section I.C.15. Pregnancy, Childbirth, and the Puerperium, for patient is being cleared for a procedure or surgery and no
further instruction on the use of these codes. treatment is given.
Z codes for pregnancy are for use in those circumstances when The Z codes/categories for routine and administrative
none of the problems or complications included in the codes examinations:
from the Obstetrics chapter exist (a routine prenatal visit or
postpartum care). Codes in category Z34, Encounter for Z00 Encounter for general examination without complaint,
supervision of normal pregnancy, are always first-listed and are suspected or reported diagnosis
not to be used with any other code from the OB chapter. Z01 Encounter for other special examination without
Codes in category Z3A, Weeks of gestation, may be assigned to complaint, suspected or reported diagnosis
provide additional information about the pregnancy. Category Z02 Encounter for administrative examination
Z3A codes should not be assigned for pregnancies with Except: Z02.9, Encounter for administrative
abortive outcomes (categories O00-O08), elective termination examinations, unspecified
of pregnancy (code Z33.2), nor for postpartum conditions, as
category Z3A is not applicable to these conditions. The date of Z32.0- Encounter for pregnancy test
the admission should be used to determine weeks of gestation 14) Miscellaneous Z codes
for inpatient admissions that encompass more than one The miscellaneous Z codes capture a number of other health
gestational week. care encounters that do not fall into one of the other categories.
The outcome of delivery, category Z37, should be included on Certain of these codes identify the reason for the encounter;
all maternal delivery records. It is always a secondary code. others are for use as additional codes that provide useful
Codes in category Z37 should not be used on the newborn information on circumstances that may affect a patient’s care
record. and treatment.
Z codes for family planning (contraceptive) or procreative Prophylactic Organ Removal
management and counseling should be included on an For encounters specifically for prophylactic removal of an organ
obstetric record either during the pregnancy or the postpartum (such as prophylactic removal of breasts due to a genetic
stage, if applicable. susceptibility to cancer or a family history of cancer), the
Z codes/categories for obstetrical and reproductive services: principal or first-listed code should be a code from category
Z30 Encounter for contraceptive management Z40, Encounter for prophylactic surgery, followed by the
appropriate codes to identify the associated risk factor (such as
Z31 Encounter for procreative management genetic susceptibility or family history).
Z32.2 Encounter for childbirth instruction If the patient has a malignancy of one site and is having
Z32.3 Encounter for childcare instruction prophylactic removal at another site to prevent either a new
Z33 Pregnant state primary malignancy or metastatic disease, a code for the
malignancy should also be assigned in addition to a code from
Z34 Encounter for supervision of normal pregnancy subcategory Z40.0, Encounter for prophylactic surgery for risk
Z36 Encounter for antenatal screening of mother factors related to malignant neoplasms. A Z40.0 code should
Z3A Weeks of gestation not be assigned if the patient is having organ removal for

treatment of a malignancy, such as the removal of the testes for Z88.9 Allergy status to unspecified drugs, medicaments and
the treatment of prostate cancer. biological substances status
Miscellaneous Z codes/categories: Z92.0 Personal history of contraception
Z28 Immunization not carried out 16) Z Codes That May Only be Principal/First-Listed Diagnosis
Except: Z28.3, Underimmunization status The following Z codes/categories may only be reported as the
principal/first-listed diagnosis, except when there are multiple
Z29 Encounter for other prophylactic measures encounters on the same day and the medical records for the
Z40 Encounter for prophylactic surgery encounters are combined:
Z41 Encounter for procedures for purposes other than Z00 Encounter for general examination without complaint,
remedying health state suspected or reported diagnosis
Except: Z41.9, Encounter for procedure for purposes Except: Z00.6
other than remedying health state, unspecified Z01 Encounter for other special examination without
Z53 Persons encountering health services for specific complaint, suspected or reported diagnosis
procedures and treatment, not carried out Z02 Encounter for administrative examination
Z55 Problems related to education and literacy Z03 Encounter for medical observation for suspected
Z56 Problems related to employment and unemployment diseases and conditions ruled out
Z57 Occupational exposure to risk factors Z04 Encounter for examination and observation for other
Z58 Problems related to physical environment reasons
Z59 Problems related to housing and economic Z33.2 Encounter for elective termination of pregnancy
circumstances Z31.81 Encounter for male factor infertility in female patient
Z60 Problems related to social environment Z31.83 Encounter for assisted reproductive fertility procedure
Z62 Problems related to upbringing cycle
Z63 Other problems related to primary support group, Z31.84 Encounter for fertility preservation procedure
including family circumstances Z34 Encounter for supervision of normal pregnancy
Z64 Problems related to certain psychosocial circumstances Z39 Encounter for maternal postpartum care and
Z65 Problems related to other psychosocial circumstances examination
Z72 Problems related to lifestyle Z38 Liveborn infants according to place of birth and type of
delivery
Note: These codes should be assigned only when the
documentation specifies that the patient has an Z40 Encounter for prophylactic surgery
associated problem Z42 Encounter for plastic and reconstructive surgery
Z73 Problems related to life management difficulty following medical procedure or healed injury
Z74 Problems related to care provider dependency Z51.0 Encounter for antineoplastic radiation therapy
Except: Z74.01, Bed confinement status Z51.1- Encounter for antineoplastic chemotherapy and
immunotherapy
Z75 Problems related to medical facilities and other health
care Z52 Donors of organs and tissues
Z76.0 Encounter for issue of repeat prescription Except: Z52.9, Donor of unspecified organ or tissue
Z76.3 Healthy person accompanying sick person Z76.1 Encounter for health supervision and care of foundling
Z76.4 Other boarder to healthcare facility Z76.2 Encounter for health supervision and care of other
healthy infant and child
Z76.5 Malingerer [conscious simulation]
Z99.12 Encounter for respirator [ventilator] dependence during
Z91.1- Patient’s noncompliance with medical treatment and power failure
regimen
Z91.83 Wandering in diseases classified elsewhere
Z91.84-Oral health risk factors Section II. Selection of Principal Diagnosis
Z91.89 Other specified personal risk factors, not elsewhere The circumstances of inpatient admission always govern the selection of
classified principal diagnosis. The principal diagnosis is defined in the Uniform Hospital
Discharge Data Set (UHDDS) as “that condition established after study to be
15) Nonspecific Z codes chiefly responsible for occasioning the admission of the patient to the hospital
Certain Z codes are so non-specific, or potentially redundant for care.”
with other codes in the classification, that there can be little
justification for their use in the inpatient setting. Their use in The UHDDS definitions are used by hospitals to report inpatient data elements
the outpatient setting should be limited to those instances in a standardized manner. These data elements and their definitions can be
when there is no further documentation to permit more precise found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.
coding. Otherwise, any sign or symptom or any other reason for Since that time the application of the UHDDS definitions has been expanded
visit that is captured in another code should be used. to include all non-outpatient settings (acute care, short term, long term care
Nonspecific Z codes/categories: and psychiatric hospitals; home health agencies; rehab facilities; nursing
homes, etc). The UHDDS definitions also apply to hospice services (all levels of
Z02.9 Encounter for administrative examinations, unspecified care).
Z04.9 Encounter for examination and observation for In determining principal diagnosis, coding conventions in the ICD-10-CM, the
unspecified reason Tabular List and Alphabetic Index take precedence over these official coding
Z13.9 Encounter for screening, unspecified guidelines.
Z41.9 Encounter for procedure for purposes other than (See Section I.A., Conventions for the ICD-10-CM)
remedying health state, unspecified The importance of consistent, complete documentation in the medical record
Z52.9 Donor of unspecified organ or tissue cannot be overemphasized. Without such documentation the application of
Z86.59 Personal history of other mental and behavioral all coding guidelines is a difficult, if not impossible, task.
disorders


A. Codes for symptoms, signs, and ill-defined conditions • If no complication, or other condition, is documented as the reason
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 for the inpatient admission, assign the reason for the outpatient
are not to be used as principal diagnosis when a related definitive surgery as the principal diagnosis.
diagnosis has been established. • If the reason for the inpatient admission is another condition
B. Two or more interrelated conditions, each potentially meeting the unrelated to the surgery, assign the unrelated condition as the
definition for principal diagnosis. principal diagnosis.
When there are two or more interrelated conditions (such as diseases in K. Admissions/Encounters for Rehabilitation
the same ICD-10-CM chapter or manifestations characteristically When the purpose for the admission/encounter is rehabilitation,
associated with a certain disease) potentially meeting the definition of sequence first the code for the condition for which the service is being
principal diagnosis, either condition may be sequenced first, unless the performed. For example, for an admission/encounter for rehabilitation
circumstances of the admission, the therapy provided, the Tabular List, for right-sided dominant hemiplegia following a cerebrovascular
or the Alphabetic Index indicate otherwise. infarction, report code I69.351, Hemiplegia and hemiparesis following
C. Two or more diagnoses that equally meet the definition for cerebral infarction affecting right dominant side, as the first-listed or
principal diagnosis principal diagnosis.
In the unusual instance when two or more diagnoses equally meet the If the condition for which the rehabilitation service is no longer present,
criteria for principal diagnosis as determined by the circumstances of report the appropriate aftercare code as the first-listed or principal
admission, diagnostic workup and/or therapy provided, and the diagnosis, unless the rehabilitation service is being provided
Alphabetic Index, Tabular List, or another coding guidelines does not following an injury. For rehabilitation services following active
provide sequencing direction, any one of the diagnoses may be treatment of an injury, assign the injury code with the appropriate
sequenced first. seventh character for subsequent encounter as the first-listed or
D. Two or more comparative or contrasting conditions principal diagnosis. For example, if a patient with severe degenerative
In those rare instances when two or more contrasting or comparative osteoarthritis of the hip, underwent hip replacement and the current
diagnoses are documented as “either/or” (or similar terminology), they encounter/admission is for rehabilitation, report code Z47.1, Aftercare
are coded as if the diagnoses were confirmed and the diagnoses are following joint replacement surgery, as the first-listed or principal
sequenced according to the circumstances of the admission. If no further diagnosis. If the patient requires rehabilitation post hip
determination can be made as to which diagnosis should be principal, replacement for right intertrochanteric femur fracture, report code
either diagnosis may be sequenced first. S72.141D, Displaced intertrochanteric fracture of right femur,
subsequent encounter for closed fracture with routine healing, as
E. A symptom(s) followed by contrasting/comparative diagnoses the first-listed or principal diagnosis.
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014
See Section I.C.21.c.7, Factors influencing health states and contact with
F. Original treatment plan not carried out health services, Aftercare.
Sequence as the principal diagnosis the condition, which after study
occasioned the admission to the hospital, even though treatment may See Section I.C.19.a for additional information about the use of 7th
not have been carried out due to unforeseen circumstances. characters for injury codes.
G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from
surgery or other medical care, the complication code is sequenced as the
Section III. Reporting Additional
principal diagnosis. If the complication is classified to the T80-T88 series Diagnoses
and the code lacks the necessary specificity in describing the GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
complication, an additional code for the specific complication should be
For reporting purposes the definition for “other diagnoses” is interpreted as
assigned.
additional conditions that affect patient care in terms of requiring:
H. Uncertain Diagnosis
clinical evaluation; or
If the diagnosis documented at the time of discharge is qualified as
“probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be therapeutic treatment; or
ruled out”, or other similar terms indicating uncertainty, code the diagnostic procedures; or
condition as if it existed or was established. The bases for these extended length of hospital stay; or
guidelines are the diagnostic workup, arrangements for further workup increased nursing care and/or monitoring.
or observation, and initial therapeutic approach that correspond most The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist
closely with the established diagnosis. at the time of admission, that develop subsequently, or that affect the
Note: This guideline is applicable only to inpatient admissions to treatment received and/or the length of stay. Diagnoses that relate to an
short-term, acute, long-term care and psychiatric hospitals. earlier episode which have no bearing on the current hospital stay are to be
excluded.” UHDDS definitions apply to inpatients in acute care, short-term,
I. Admission from Observation Unit long term care and psychiatric hospital setting. The UHDDS definitions are
1. Admission Following Medical Observation used by acute care short-term hospitals to report inpatient data elements in a
When a patient is admitted to an observation unit for a medical standardized manner. These data elements and their definitions can be found
condition, which either worsens or does not improve, and is in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.
subsequently admitted as an inpatient of the same hospital for this
same medical condition, the principal diagnosis would be the Since that time the application of the UHDDS definitions has been expanded
medical condition which led to the hospital admission. to include all non-outpatient settings (acute care, short term, long term care
and psychiatric hospitals; home health agencies; rehab facilities; nursing
2. Admission Following Post-Operative Observation homes, etc). The UHDDS definitions also apply to hospice services (all levels of
When a patient is admitted to an observation unit to monitor a care).
condition (or complication) that develops following outpatient
surgery, and then is subsequently admitted as an inpatient of the The following guidelines are to be applied in designating “other diagnoses”
same hospital, hospitals should apply the Uniform Hospital when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide
Discharge Data Set (UHDDS) definition of principal diagnosis as direction. The listing of the diagnoses in the patient record is the responsibility
“that condition established after study to be chiefly responsible for of the attending provider.
occasioning the admission of the patient to the hospital for care.” A. Previous conditions
J. Admission from Outpatient Surgery If the provider has included a diagnosis in the final diagnostic statement,
When a patient receives surgery in the hospital's outpatient surgery such as the discharge summary or the face sheet, it should ordinarily be
department and is subsequently admitted for continuing inpatient care coded. Some providers include in the diagnostic statement resolved
at the same hospital, the following guidelines should be followed in conditions or diagnoses and status-post procedures from previous
selecting the principal diagnosis for the inpatient admission: admission that have no bearing on the current stay. Such conditions are
not to be reported and are coded only if required by hospital policy.
• If the reason for the inpatient admission is a complication, assign
the complication as the principal diagnosis.

However, history codes (categories Z80-Z87) may be used as secondary 2. Observation Stay
codes if the historical condition or family history has an impact on When a patient is admitted for observation for a medical condition,
current care or influences treatment. assign a code for the medical condition as the first-listed diagnosis.
B. Abnormal findings When a patient presents for outpatient surgery and develops
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic complications requiring admission to observation, code the reason
results) are not coded and reported unless the provider indicates their for the surgery as the first reported diagnosis (reason for the
clinical significance. If the findings are outside the normal range and the encounter), followed by codes for the complications as secondary
attending provider has ordered other tests to evaluate the condition or diagnoses.
prescribed treatment, it is appropriate to ask the provider whether the B. Codes from A00.0 through T88.9, Z00-Z99
abnormal finding should be added. The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be
Please note: This differs from the coding practices in the outpatient used to identify diagnoses, symptoms, conditions, problems, complaints,
setting for coding encounters for diagnostic tests that have been or other reason(s) for the encounter/visit.
interpreted by a provider. C. Accurate reporting of ICD-10-CM diagnosis codes
C. Uncertain Diagnosis For accurate reporting of ICD-10-CM diagnosis codes, the
If the diagnosis documented at the time of discharge is qualified as documentation should describe the patient’s condition, using
“probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be terminology which includes specific diagnoses as well as symptoms,
ruled out” or other similar terms indicating uncertainty, code the problems, or reasons for the encounter. There are ICD-10-CM codes to
condition as if it existed or was established. The bases for these describe all of these.
guidelines are the diagnostic workup, arrangements for further workup D. Codes that describe symptoms and signs
or observation, and initial therapeutic approach that correspond most Codes that describe symptoms and signs, as opposed to diagnoses, are
closely with the established diagnosis. acceptable for reporting purposes when a diagnosis has not been
Note: This guideline is applicable only to inpatient admissions to established (confirmed) by the provider. Chapter 18 of ICD-10-CM,
short-term, acute, long-term care and psychiatric hospitals. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not
Elsewhere Classified (codes R00-R99) contain many, but not all codes for
symptoms.
Section IV.Diagnostic Coding and E. Encounters for circumstances other than a disease or injury
Reporting Guidelines for Outpatient ICD-10-CM provides codes to deal with encounters for circumstances
other than a disease or injury. The Factors Influencing Health Status and
Services Contact with Health Services codes (Z00-Z99) are provided to deal with
These coding guidelines for outpatient diagnoses have been approved for use occasions when circumstances other than a disease or injury are
by hospitals/ providers in coding and reporting hospital-based outpatient recorded as diagnosis or problems.
services and provider-based office visits. Guidelines in Section I, Conventions, See Section I.C.21. Factors influencing health status and contact with health
general coding guidelines and chapter-specific guidelines, should also be services.
applied for outpatient services and office visits.
F. Level of Detail in Coding
Information about the use of certain abbreviations, punctuation, symbols, and 1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
other conventions used in the ICD-10-CM Tabular List (code numbers and ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters.
titles), can be found in Section IA of these guidelines, under “Conventions Codes with three characters are included in ICD-10-CM as the
Used in the Tabular List.” Section I.B. contains general guidelines that apply to heading of a category of codes that may be further subdivided by
the entire classification. Section I.C. contains chapter-specific guidelines that the use of fourth, fifth, sixth or seventh characters to provide greater
correspond to the chapters as they are arranged in the classification. specificity.
Information about the correct sequence to use in finding a code is also
described in Section I. 2. Use of full number of characters required for a code
A three-character code is to be used only if it is not further
The terms encounter and visit are often used interchangeably in describing subdivided. A code is invalid if it has not been coded to the full
outpatient service contacts and, therefore, appear together in these number of characters required for that code, including the 7th
guidelines without distinguishing one from the other. character, if applicable.
Though the conventions and general guidelines apply to all settings, coding G. ICD-10-CM code for the diagnosis, condition, problem, or other
guidelines for outpatient and provider reporting of diagnoses will vary in a reason for encounter/visit
number of instances from those for inpatient diagnoses, recognizing that: List first the ICD-10-CM code for the diagnosis, condition, problem, or
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal other reason for encounter/visit shown in the medical record to be
diagnosis does not apply to hospital-based outpatient services and chiefly responsible for the services provided. List additional codes that
provider-based office visits. describe any coexisting conditions. In some cases the first-listed
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, diagnosis may be a symptom when a diagnosis has not been established
etc.) were developed for inpatient reporting and do not apply to outpatients. (confirmed) by the physician.
A. Selection of first-listed condition H. Uncertain diagnosis
In the outpatient setting, the term first-listed diagnosis is used in lieu of Do not code diagnoses documented as “probable”, “suspected,”
principal diagnosis. “questionable,” “rule out,” or “working diagnosis” or other similar terms
indicating uncertainty. Rather, code the condition(s) to the highest
In determining the first-listed diagnosis the coding conventions of degree of certainty for that encounter/visit, such as symptoms, signs,
ICD-10-CM, as well as the general and disease specific guidelines take abnormal test results, or other reason for the visit.
precedence over the outpatient guidelines.
Please note: This differs from the coding practices used by short-term,
Diagnoses often are not established at the time of the initial acute care, long-term care and psychiatric hospitals.
encounter/visit. It may take two or more visits before the diagnosis is
confirmed. I. Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and
The most critical rule involves beginning the search for the correct code reported as many times as the patient receives treatment and care for
assignment through the Alphabetic Index. Never begin searching the condition(s)
initially in the Tabular List as this will lead to coding errors.
J. Code all documented conditions that coexist
1. Outpatient Surgery Code all documented conditions that coexist at the time of the
When a patient presents for outpatient surgery (same day surgery), encounter/visit, and require or affect patient care treatment or
code the reason for the surgery as the first-listed diagnosis (reason management. Do not code conditions that were previously treated and
for the encounter), even if the surgery is not performed due to a no longer exist. However, history codes (categories Z80-Z87) may be
contraindication. used as secondary codes if the historical condition or family history has
an impact on current care or influences treatment.


K. Patients receiving diagnostic services only be coded, but rather, how to apply the POA indicator to the final set of
For patients receiving diagnostic services only during an encounter/visit, diagnosis codes that have been assigned in accordance with Sections I, II, and
sequence first the diagnosis, condition, problem, or other reason for III of the official coding guidelines. Subsequent to the assignment of the
encounter/visit shown in the medical record to be chiefly responsible for ICD-10-CM codes, the POA indicator should then be assigned to those
the outpatient services provided during the encounter/visit. Codes for conditions that have been coded.
other diagnoses (e.g., chronic conditions) may be sequenced as As stated in the Introduction to the ICD-10-CM Official Guidelines for Coding
additional diagnoses. and Reporting, a joint effort between the healthcare provider and the coder is
For encounters for routine laboratory/radiology testing in the absence of essential to achieve complete and accurate documentation, code assignment,
any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter and reporting of diagnoses and procedures. The importance of consistent,
for other specified special examinations. If routine testing is performed complete documentation in the medical record cannot be overemphasized.
during the same encounter as a test to evaluate a sign, symptom, or Medical record documentation from any provider involved in the care and
diagnosis, it is appropriate to assign both the Z code and the code treatment of the patient may be used to support the determination of
describing the reason for the non-routine test. whether a condition was present on admission or not. In the context of the
For outpatient encounters for diagnostic tests that have been official coding guidelines, the term “provider” means a physician or any
interpreted by a physician, and the final report is available at the time of qualified healthcare practitioner who is legally accountable for establishing
coding, code any confirmed or definitive diagnosis(es) documented in the patient’s diagnosis.
the interpretation. Do not code related signs and symptoms as These guidelines are not a substitute for the provider’s clinical judgment as to
additional diagnoses. the determination of whether a condition was/was not present on admission.
Please note: This differs from the coding practice in the hospital The provider should be queried regarding issues related to the linking of
inpatient setting regarding abnormal findings on test results. signs/symptoms, timing of test results, and the timing of findings.
L. Patients receiving therapeutic services only Please see the CDC website for the detailed list of ICD-10-CM codes that do
For patients receiving therapeutic services only during an not require the use of a POA indicator
encounter/visit, sequence first the diagnosis, condition, problem, or (https://www.cdc.gov/nchs/icd/icd10cm.htm)
other reason for encounter/visit shown in the medical record to be (https://www.cms.gov/Medicare/Coding/ICD10/2018-ICD-10-CM-and-GEMs.
chiefly responsible for the outpatient services provided during the html). The codes and categories on this exempt list are for circumstances
encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may regarding the healthcare encounter or factors influencing health status that
be sequenced as additional diagnoses. do not represent a current disease or injury or that describe conditions that
are always present on admission.
The only exception to this rule is that when the primary reason for the
admission/encounter is chemotherapy or radiation therapy, the General Reporting Requirements
appropriate Z code for the service is listed first, and the diagnosis or All claims involving inpatient admissions to general acute care hospitals or
problem for which the service is being performed listed second. other facilities that are subject to a law or regulation mandating collection of
M. Patients receiving preoperative evaluations only present on admission information.
For patients receiving preoperative evaluations only, sequence first a Present on admission is defined as present at the time the order for inpatient
code from subcategory Z01.81, Encounter for pre-procedural admission occurs -- conditions that develop during an outpatient encounter,
examinations, to describe the pre-op consultations. Assign a code for the including emergency department, observation, or outpatient surgery, are
condition to describe the reason for the surgery as an additional considered as present on admission.
diagnosis. Code also any findings related to the pre-op evaluation.
POA indicator is assigned to principal and secondary diagnoses (as defined in
N. Ambulatory surgery Section II of the Official Guidelines for Coding and Reporting) and the external
For ambulatory surgery, code the diagnosis for which the surgery was cause of injury codes.
performed. If the postoperative diagnosis is known to be different from
the preoperative diagnosis at the time the diagnosis is confirmed, select Issues related to inconsistent, missing, conflicting or unclear documentation
the postoperative diagnosis for coding, since it is the most definitive. must still be resolved by the provider.
O. Routine outpatient prenatal visits If a condition would not be coded and reported based on UHDDS definitions
See Section I.C.15. Routine outpatient prenatal visits. and current official coding guidelines, then the POA indicator would not be
reported.
P. Encounters for general medical examinations with abnormal
Reporting Options
findings
The subcategories for encounters for general medical examinations, Y - Yes
Z00.0- and encounter for routine child health examination, Z00.12-, N - No
provide codes for with and without abnormal findings. Should a general
U - Unknown
medical examination result in an abnormal finding, the code for general
medical examination with abnormal finding should be assigned as the W – Clinically undetermined
first-listed diagnosis. An examination with abnormal findings refers to a Unreported/Not used – (Exempt from POA reporting)
condition/diagnosis that is newly identified or a change in severity of a
Reporting Definitions
chronic condition (such as uncontrolled hypertension, or an acute
exacerbation of chronic obstructive pulmonary disease) during a routine Y = present at the time of inpatient admission
physical examination. A secondary code for the abnormal finding should N = not present at the time of inpatient admission
also be coded.
U = documentation is insufficient to determine if condition is present on
Q. Encounters for routine health screenings admission
See Section I.C.21. Factors influencing health status and contact with health W = provider is unable to clinically determine whether condition was
services, Screening present on admission or not
Appendix I. Present on Admission Reporting Timeframe for POA Identification and Documentation
Guidelines There is no required timeframe as to when a provider (per the definition of
“provider” used in these guidelines) must identify or document a condition to
be present on admission. In some clinical situations, it may not be possible for
Introduction a provider to make a definitive diagnosis (or a condition may not be
These guidelines are to be used as a supplement to the ICD-10-CM Official recognized or reported by the patient) for a period of time after admission. In
Guidelines for Coding and Reporting to facilitate the assignment of the Present some cases it may be several days before the provider arrives at a definitive
on Admission (POA) indicator for each diagnosis and external cause of injury diagnosis. This does not mean that the condition was not present on
code reported on claim forms (UB-04 and 837 Institutional). admission. Determination of whether the condition was present on admission
These guidelines are not intended to replace any guidelines in the main body or not will be based on the applicable POA guideline as identified in this
of the ICD-10-CM Official Guidelines for Coding and Reporting. The POA document, or on the provider’s best clinical judgment.
guidelines are not intended to provide guidance on when a condition should

If at the time of code assignment the documentation is unclear as to whether Codes That Contain Multiple Clinical Concepts
a condition was present on admission or not, it is appropriate to query the Assign “N” if at least one of the clinical concepts included in the code
provider for clarification. was not present on admission (e.g., COPD with acute exacerbation and
the exacerbation was not present on admission; gastric ulcer that does
Assigning the POA Indicator not start bleeding until after admission; asthma patient develops status
Condition is on the “Exempt from Reporting” list asthmaticus after admission).
Leave the “present on admission” field blank if the condition is on the list Assign “Y” if all of the clinical concepts included in the code were present
of ICD-10-CM codes for which this field is not applicable. This is the only on admission (e.g., duodenal ulcer that perforates prior to admission).
circumstance in which the field may be left blank.
For infection codes that include the causal organism, assign “Y” if the
POA Explicitly Documented infection (or signs of the infection) were present on admission, even
Assign Y for any condition the provider explicitly documents as being though the culture results may not be known until after admission (e.g.,
present on admission. patient is admitted with pneumonia and the provider documents
Assign N for any condition the provider explicitly documents as not Pseudomonas as the causal organism a few days later).
present at the time of admission. Same Diagnosis Code for Two or More Conditions
Conditions diagnosed prior to inpatient admission When the same ICD-10-CM diagnosis code applies to two or more
Assign “Y” for conditions that were diagnosed prior to admission conditions during the same encounter (e.g. two separate conditions
(example: hypertension, diabetes mellitus, asthma) classified to the same ICD-10-CM diagnosis code):
Conditions diagnosed during the admission but clearly present before Assign “Y” if all conditions represented by the single ICD-10-CM code
admission were present on admission (e.g. bilateral unspecified age-related
cataracts).
Assign “Y” for conditions diagnosed during the admission that were
clearly present but not diagnosed until after admission occurred. Assign “N” if any of the conditions represented by the single ICD-10-CM
code was not present on admission (e.g. traumatic secondary and
Diagnoses subsequently confirmed after admission are considered recurrent hemorrhage and seroma is assigned to a single code T79.2, but
present on admission if at the time of admission they are documented as only one of the conditions was present on admission).
suspected, possible, rule out, differential diagnosis, or constitute an
underlying cause of a symptom that is present at the time of admission. Obstetrical conditions
Condition develops during outpatient encounter prior to inpatient admission Whether or not the patient delivers during the current hospitalization
does not affect assignment of the POA indicator. The determining factor
Assign Y for any condition that develops during an outpatient encounter for POA assignment is whether the pregnancy complication or
prior to a written order for inpatient admission. obstetrical condition described by the code was present at the time of
Documentation does not indicate whether condition was present on admission or not.
admission If the pregnancy complication or obstetrical condition was present on
Assign “U” when the medical record documentation is unclear as to admission (e.g., patient admitted in preterm labor), assign “Y”.
whether the condition was present on admission. “U” should not be If the pregnancy complication or obstetrical condition was not present
routinely assigned and used only in very limited circumstances. Coders on admission (e.g., 2nd degree laceration during delivery, postpartum
are encouraged to query the providers when the documentation is hemorrhage that occurred during current hospitalization, fetal distress
unclear. develops after admission), assign “N”.
Documentation states that it cannot be determined whether the condition If the obstetrical code includes more than one diagnosis and any of the
was or was not present on admission diagnoses identified by the code were not present on admission assign
Assign “W” when the medical record documentation indicates that it “N”. (e.g., Category O11, Pre-existing hypertension with pre-eclampsia)
cannot be clinically determined whether or not the condition was Perinatal conditions
present on admission.
Newborns are not considered to be admitted until after birth. Therefore,
Chronic condition with acute exacerbation during the admission any condition present at birth or that developed in utero is considered
If a single code identifies both the chronic condition and the acute present at admission and should be assigned “Y”. This includes
exacerbation, see POA guidelines pertaining to codes that contain conditions that occur during delivery (e.g., injury during delivery,
multiple clinical concepts. meconium aspiration, exposure to streptococcus B in the vaginal canal).
If a single code only identifies the chronic condition and not the acute Congenital conditions and anomalies
exacerbation (e.g., acute exacerbation of chronic leukemia), assign “Y.” Assign “Y” for congenital conditions and anomalies except for categories
Conditions documented as possible, probable, suspected, or rule out at the Q00-Q99, Congenital anomalies, which are on the exempt list.
time of discharge Congenital conditions are always considered present on admission.
If the final diagnosis contains a possible, probable, suspected, or rule out External cause of injury codes
diagnosis, and this diagnosis was based on signs, symptoms or clinical Assign “Y” for any external cause code representing an external cause of
findings suspected at the time of inpatient admission, assign “Y.” morbidity that occurred prior to inpatient admission (e.g., patient fell out
If the final diagnosis contains a possible, probable, suspected, or rule out of bed at home, patient fell out of bed in emergency room prior to
diagnosis, and this diagnosis was based on signs, symptoms or clinical admission)
findings that were not present on admission, assign “N”. Assign “N” for any external cause code representing an external cause of
Conditions documented as impending or threatened at the time of discharge morbidity that occurred during inpatient hospitalization (e.g., patient fell
If the final diagnosis contains an impending or threatened diagnosis, out of hospital bed during hospital stay, patient experienced an adverse
and this diagnosis is based on symptoms or clinical findings that were reaction to a medication administered after inpatient admission)
present on admission, assign “Y”.
If the final diagnosis contains an impending or threatened diagnosis,
and this diagnosis is based on symptoms or clinical findings that were
not present on admission, assign “N”.
Acute and Chronic Conditions
Assign “Y” for acute conditions that are present at time of admission and
N for acute conditions that are not present at time of admission.
Assign “Y” for chronic conditions, even though the condition may not be
diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the
POA guidelines for codes that contain multiple clinical concepts.

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ICD-10-CM Official Guidelines for Coding and Reporting

ICD-10-CM Official Guidelines for Coding and Reporting 2018

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