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ICD-10-CM Structure
ICD-9-CM
ICD-10-CM
• 3-5 characters
• First character is numeric or
alpha (E or V)
• Characters 2-5 are numeric
• Always at least 3 characters
• Use of decimal after 3
characters
• 3-7 characters
– 3 characters before the decimal and up to 4
characters after the decimal
• 1
st
character is alpha (all letters except U are used)
• 2
nd
character is numeric
• Characters 3-7 are alpha or numeric
• Alpha characters are not case-sensitive
(e.g., Right ankle sprain, initial encounter:
S93.401A, S93.401a, s93.401A, s93.401a)
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Similarities to ICD-9-CM
• Tabular List
– Chronological list of codes divided into chapters based on
body system or condition
– Same hierarchical structure
– Chapters in Tabular structured similarly to ICD-9-CM, with
minor exceptions
• A few chapters have been restructured
• Sense organs (eye and ear) separated from Nervous
System chapter and moved to their own chapters
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Similarities to ICD-9-CM
• Index
– Alphabetical list of terms and their corresponding codes
– Indented subterms appear under main terms
– Same structure as ICD-9-CM
• Alphabetic Index of Diseases and Injuries
• Alphabetic Index of External Causes
• Table of Neoplasms
• Table of Drugs and Chemicals
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Similarities to ICD-9-CM
• Many conventions have same meaning
– Abbreviations, punctuation, symbols, notes such as “code
first” and “use additional code”
• Nonspecific codes (“unspecified” or “not otherwise specified”)
are available to use when detailed documentation to support
more specific code is not available
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Similarities to ICD-9-CM
• Codes are looked up the same way
– Look up diagnostic terms in Alphabetic Index, then
– Verify code number in Tabular List
• Codes are invalid if they are missing an applicable character
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Similarities to ICD-9-CM
• ICD-10-CM Official Guidelines for Coding and Reporting
accompany and complement ICD-10-CM conventions and
instructions
• Adherence to the official coding guidelines in all healthcare
settings is required under the Health Insurance Portability and
Accountability Act (HIPAA)
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Differences from ICD-9-CM
• Expanded detail and specificity
• Codes reflect modern medicine and updated medical
terminology
• Laterality (side of the body affected) has been added to
relevant codes
• Expanded use of combination codes
– Certain conditions and associated common symptoms
or manifestations
– Poisonings and associated external cause
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Combination Codes – Examples
• I25.110 Atherosclerotic heart disease of native coronary artery
with unstable angina pectoris
• E11.311 Type 2 diabetes mellitus with unspecified diabetic
retinopathy with macular edema
• K71.51 Toxic liver disease with chronic active hepatitis with
ascites
• K50.012 Crohn’s disease of small intestine with intestinal
obstruction
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Differences from ICD-9-CM
• In Tabular, injuries grouped by anatomical site rather
than type of injury
ICD-9-CM
Fractures (800-829)
Dislocations (830-839)
Sprains and strains (840-848)
ICD-10-CM
Injuries to the head (S00-S09)
Injuries to the neck (S10-S19)
Injuries to the thorax (S20-S29)
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Addition of 7th Character
• 7
th
character used in certain chapters (e.g., Musculoskeletal,
Obstetrics, Injuries, External Causes)
• Different meaning depending on section where it is being used
• Must always be used in the 7
th
character position
• When 7
th
character applies, codes missing 7
th
character are
invalid
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7th Character Describing Encounter
Initial encounter: As long as patient is receiving active treatment for the condition.
Examples of active treatment are: surgical treatment, emergency department encounter,
and evaluation and treatment by a new physician.
Subsequent encounter: After patient has received active treatment of the condition and
is receiving routine care for the condition during the healing or recovery phase.
Examples of subsequent care are: cast change or removal, removal of external or internal
fixation device, medication adjustment, other aftercare and follow up visits following
treatment of the injury or condition.
Sequela: Complications or conditions that arise as a direct result of a condition (e.g., scar
formation after a burn).
Note: For aftercare of injury, assign acute injury code with 7
th
character for
subsequent encounter.
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7th Character – Fractures
A Initial encounter for closed fracture
B Initial encounter for open fracture
D Subsequent encounter for fracture with routine healing
G Subsequent encounter for fracture with delayed healing
K Subsequent encounter for fracture with nonunion
P Subsequent encounter for fracture with malunion
S Sequela
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Placeholder “X”
• Addition of dummy placeholder “X” (or “x”) is used in certain
codes to:
– Allow for future expansion
– Fill in empty characters when a code contains fewer than 6 characters and a 7
th
character applies
• “X” is not case-sensitive
– T46.1x5A or T46.1X5A– Adverse effect of calcium-channel blockers, initial encounter
– T15.02xD or T15.02XD– Foreign body in cornea, left eye, subsequent encounter
• When the placeholder character applies, it must be used
in order for the code to be valid
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Excludes Notes
• Excludes1 note
– Indicates that code identified in the note and code where the note appears
cannot be reported together because the 2 conditions cannot occur together
Example:
E10 Type 1 Diabetes mellitus
Excludes1: diabetes mellitus due to underlying condition (E08.-)
drug or chemical induced diabetes mellitus (E09.-)
gestational diabetes (O24.4-)
hyperglycemia NOS (R73.9)
neonatal diabetes mellitus (P70.2)
postpancreatectomy diabetes mellitus (E13.-)
postprocedural diabetes mellitus (E13.-)
secondary diabetes mellitus NEC (E13.-)
type 2 diabetes mellitus (E11.-)
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Excludes Notes
• Excludes2 note
– Indicates that condition identified in the note is not part of the condition
represented by the code where the note appears, so both codes may be
reported together if the patient has both conditions
Example:
L89 Pressure ulcer
Excludes2: decubitus (trophic) ulcer of cervix (uteri) (N86)
diabetic ulcers (E08.621, E08.622, E09.621,
E09.622, E10.621, E10.622, E11.621, E11.622,
E13.621, E13.622)
non-pressure chronic ulcer of skin (L97.-)
skin infections (L00-L08)
varicose ulcer (I83.0, I83.2)
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ICD-10-CM Specificity Examples
• Increased specificity
– S72.044G Nondisplaced fracture of base of neck of right
femur, subsequent encounter for closed fracture with
delayed healing
– I69.351 Sequelae of cerebral infarction, Hemiplegia and
hemiparesis following cerebral infarction affecting right
dominant side
– Z47.81 Encounter for orthopedic aftercare following surgical
amputation
– Z48.21 Encounter for aftercare following heart
transplant
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ICD-10-CM Laterality Examples
• Laterality
– C50.511 Malignant neoplasm of lower-outer quadrant of
right female breast
– H01.111 Allergic dermatitis of right upper eyelid
– L89.223 Pressure ulcer of left hip, stage 3
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ICD-10-CM Coding Examples
Type 1 diabetes mellitus with diabetic nephropathy
Step 1
Look up term in Alphabetic Index:
Diabetes, diabetic (mellitus) (sugar) E11.9
type 1 E10.9
with
nephropathy E10.21
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ICD-10-CM Coding Examples
Type I diabetes mellitus with diabetic nephropathy
Step 2
Verify code in Tabular:
E10 Type 1 diabetes mellitus
E10.2 Type 1 diabetes mellitus with kidney complications
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
Type 1 diabetes mellitus with intercapillary glomerulosclerosis
Type 1 diabetes mellitus with intracapillary glomerulonephrosis
Type 1 diabetes mellitus with Kimmelstiel-Wilson disease
Code Assignment: E10.21
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ICD-10-CM Coding Examples
Acute cystitis with hematuria
Step 1
Look up term in Alphabetic Index:
Cystitis (exudative) (hemorrhagic) (septic) (suppurative) N30.90
acute N30.00
with hematuria N30.01
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ICD-10-CM Coding Examples
Acute cystitis with hematuria
Step 2
Verify code in Tabular:
N30 Cystitis
Use additional code to identify infectious agent (B95-B97)
N30.0 Acute cystitis
Excludes1: irradiation cystitis (N30.4-)
trigonitis (N30.3-)
N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
Code Assignment: N30.01
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ICD-10-CM Coding Examples
Fracture (traumatic) of proximal third of scaphoid bone, left
wrist, initial encounter
Step 1
Look up term in Alphabetic Index:
Fracture, traumatic
scaphoid (hand) – see also Fracture, carpal, navicular
carpal bone(s) S62.10-
navicular S62.00 –
proximal third (displaced) S62.03-
nondisplaced S62.03-
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ICD-10-CM Coding Examples
Fracture (traumatic) of proximal third of scaphoid bone, left wrist, initial encounter
Step 2
Verify code in Tabular:
S62 Fracture at wrist and hand level
Note: A fracture not indicated as displaced or nondisplaced should be coded to displaced
Note: A fracture not indicated as open or closed should be coded to closed
The appropriate 7
th
character is to be added to each code from category S62:
A Initial encounter for closed fracture
B Initial encounter for open fracture
D Subsequent encounter for fracture with routine healing
G Subsequent encounter for fracture with delayed healing
K Subsequent encounter for fracture with nonunion
P Subsequent encounter for fracture with malunion
S Sequela
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ICD-10-CM Coding Examples
Fracture (traumatic) of proximal third of scaphoid bone, left wrist, initial encounter
Step 2 Continued
Verify code in Tabular:
S62.03 Fracture of proximal third of navicular [scaphoid] bone of wrist
S62.031 Displaced fracture of proximal third of navicular [scaphoid] bone of right wrist
S62.032 Displaced fracture of proximal third of navicular [scaphoid] bone of left wrist
S62.033 Displaced fracture of proximal third of navicular [scaphoid] bone of unspecified wrist
S62.034 Nondisplaced fracture of proximal third of navicular [scaphoid] bone of right wrist
S62.035 Nondisplaced fracture of proximal third of navicular [scaphoid’ bone of left wrist
S62.036 Nondisplaced fracture of proximal third of navicular [scaphoid] bone of
unspecified wrist
Code Assignment: S62.032A
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ICD-10-CM Coding Examples
Admission to rehabilitation facility for physical and occupational therapy
following hospitalization for a left hip (femoral neck) fracture
Step 1
Look up term in Alphabetic Index:
Fracture, femur, femoral, neck – see Fracture, femur, upper end, neck
Fracture, femur, upper end, neck S72.00-
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ICD-10-CM Coding Examples
Admission to rehabilitation facility for physical and occupational therapy following
hospitalization for a left hip (femoral neck) fracture
Step 2
Verify code in Tabular:
S72- Fracture of femur
Note: A fracture not indicated as open or closed should be coded to closed
A fracture not indicated as open or closed should be coded to closed
The open fracture designations are based on the Gustilo open fracture classification
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ICD-10-CM Coding Examples
Step 2 continued
Verify code in Tabular continued: The appropriate 7th character is to be added to all codes from category S72
A - initial encounter for closed fracture
B - initial encounter for open fracture type I or II
initial encounter for open fracture NOS
C - initial encounter for open fracture type IIIA, IIIB, or IIIC
D - subsequent encounter for closed fracture with routine healing
E - subsequent encounter for open fracture type I or II with routine healing
F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G - subsequent encounter for closed fracture with delayed healing
H - subsequent encounter for open fracture type I or II with delayed healing
J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K - subsequent encounter for closed fracture with nonunion
M - subsequent encounter for open fracture type I or II with nonunion
N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P - subsequent encounter for closed fracture with malunion
Q - subsequent encounter for open fracture type I or II with malunion
R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S - sequela
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ICD-10-CM Coding Examples
Admission to rehabilitation facility for physical and occupational therapy
following hospitalization for a left hip (femoral neck) fracture
Step 2 continued
Verify code in Tabular:
S72.00- Fracture of unspecified part of neck of femur
Fracture of hip NOS
Fracture of neck of femur NOS
S72.001- Fracture of unspecified part of neck of right femur
S72.002- Fracture of unspecified part of neck of left femur
S72.009- Fracture of unspecified part of neck of unspecified femur
Code Assignment: S72.002D
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ICD-10-CM Coding Examples
Placenta previa with hemorrhage, second trimester
Step 1
Look up term in Alphabetic Index:
Placenta, placental – see Pregnancy, complicated by (care of) (management affected
by), specified condition
Pregnancy, complicated by (care of) (management affected by)
placenta previa O44.1-
without hemorrhage O44.0-
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ICD-10-CM Coding Examples
Step 2
Verify code in Tabular:
O44- Placenta previa
O44.1- Placenta previa with hemorrhage
Low implantation of placenta, NOS or with hemorrhage
Marginal placenta previa, NOS or with hemorrhage
Partial placenta previa, NOS or with hemorrhage
Total placenta previa, NOS or with hemorrhage
O44.10 Placenta previa with hemorrhage, unspecified trimester
O44.11 Placenta previa with hemorrhage, first trimester
O44.12 Placenta previa with hemorrhage, second trimester
O44.13 Placenta previa with hemorrhage, third trimester
Code Assignment: O44.12
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ICD-10-CM Coding Examples
Morbid obesity, Body Mass Index (BMI) of 46
Step 1
Look up term in Alphabetic Index:
Obesity E66.9
morbid E66.01
with alveolar hypoventilation E66.2
due to excess calories E66.01
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ICD-10-CM Coding Examples
Morbid obesity, Body Mass Index (BMI) of 46
Step 2
Verify code in Tabular:
E66- Overweight and obesity
Use additional code to identify body mass index (BMI), if known (Z68.-)
E66.0- Obesity to excess calories
E66.01 Morbid (severe) obesity due to excess calories
E66.09 Other obesity due to excess calories
Z68- Body Mass Index (BMI)
Z68.4- Body mass index 40 or greater, adult
Z68.42 Body mass index (BMI) 45.0-49.9, adult
Code Assignment: E66.01, Z68.42
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ICD-10-CM Coding Examples
Examination for admission to preschool
Step 1
Look up term in Alphabetic Index:
Examination, medical Z00.00
preschool children
for admission to school Z02.0
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ICD-10-CM Coding Examples
Examination for admission to preschool
Step 2
Verify code in Tabular:
Z02- Encounter for administrative examination
Z02.0 Encounter for examination for admission to educational institution
Encounter for examination for admission to preschool (education)
Encounter for examination for re-admission to school following illness or
medical treatment
Code Assignment: Z02.0
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Unspecified Codes
• Unspecified codes have acceptable, even necessary, uses
• Unspecified codes should be reported when they most
accurately reflect what is known about the patient’s condition
at the time of that particular encounter
• It would be inappropriate to select a specific code that is not
supported by the medical record documentation or conduct
medically unnecessary diagnostic testing in order to determine
a more specific code
• Avoid excessive use of non-specific codes
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Unspecified Code Examples
Fracture of left wrist, follow-up visit, fracture healing well
Step 1
Look up term in Alphabetic Index:
Fracture, traumatic
wrist S62.10-
carpal – see Fracture, carpal bone
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Unspecified Code Examples
Step 2
Verify code in Tabular:
S62 Fracture at wrist and hand level
Note: A fracture not indicated as displaced or nondisplaced should be coded to
displaced
Note: A fracture not indicated as open or closed should be coded to closed
The appropriate 7
th
character is to be added to each code from category S62:
A Initial encounter for closed fracture
B Initial encounter for open fracture
D Subsequent encounter for fracture with routine healing
G Subsequent encounter for fracture with delayed healing
K Subsequent encounter for fracture with nonunion
P Subsequent encounter for fracture with malunion
S Sequela
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Unspecified Code Examples
Fracture of left wrist, follow-up visit, fracture healing well
Step 2 Continued
Verify code in Tabular:
S62.10 Fracture of unspecified carpal bone
Fracture of wrist NOS
S62.101 Fracture of unspecified carpal bone, right wrist
S62.102 Fracture of unspecified carpal bone, left wrist
S62.109 Fracture of unspecified carpal bone, unspecified wrist
Code Assignment: S62.102D
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Unspecified Code Examples
Pneumonia
Step 1
Look up term in Alphabetic Index:
Pneumonia (acute) (double) (migratory) (purulent) (septic)
(unresolved) J18.9
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Unspecified Code Examples
Pneumonia
Step 2
Verify code in Tabular:
J18 Pneumonia, unspecified organism
Code first associated influenza, if applicable (J09.X1, J10.0-, J11.0-)
J18.9 Pneumonia, unspecified organism
Code Assignment: J18.9
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External Causes of Morbidity
• No national requirement for mandatory ICD-10-CM external
cause code reporting
• Reporting of ICD-10-CM codes in Chapter 20, External Causes of
Morbidity, is only required for providers subject to a state-based
external cause code reporting mandate or payer requirement
• In the absence of a mandatory reporting requirement, providers
are encouraged to voluntarily report external cause codes
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What is The Value of Reporting External Cause of Injury
Codes?
• Provide valuable data for injury research and evaluation of
injury prevention strategies
• External cause of injury data are used at the national, state, and
local levels to identify high-risk populations, set priorities, and
plan and evaluate injury prevention programs and policies, and
are potentially useful for evaluating emergency medical services
(EMS) and trauma care systems
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External Cause Code Example
Injury sustained from falling down ice-covered steps, initial
encounter
Step 1
Look up term in the Index to External Causes:
Fall, falling (accidental) W19
from, off, out of
stairs, steps W10.9
due to ice or snow W00.1
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External Cause Code Example
Injury sustained from falling down ice-covered steps, initial encounter
Step 2
Verify code in Tabular:
W00 Fall due to ice and snow
Includes: pedestrian on foot falling (slipping) on ice and snow
The appropriate 7th character is to be added to each code from category W00
A - initial encounter
D - subsequent encounter
S – sequela
W00.1 Fall from stairs and steps due to ice and snow
Code Assignment: W00.1xxA
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External Cause Code Example
Solo bicyclist (pedal cyclist) sustained injuries from a collision
with a car in an intersection (initial encounter)
Step 1
Look up term in External Cause of Injury Index:
Accident, pedal cycle – see Accident, transport, pedal cyclist
Accident, transport (involving injury to) V99
pedal cyclist V19.9
driver
collision (with)
car (traffic) V13.4
nontraffic V13.0
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External Cause Code Example
Solo bicyclist (pedal cyclist) sustained injuries from a collision with a car in an
intersection (initial encounter)
Step 2
Verify code in Tabular:
V13 Pedal cycle rider injured in collision with car, pick-up truck or van
The appropriate 7th character is to be added to each code from category V13:
A - initial encounter
D - subsequent encounter
S – sequela
V13.4xx- Pedal cycle driver injured in collision with car, pick-up truck or van in traffic
accident
Code Assignment: V13.4xxA
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