The International Classification of Diseases, Tenth Revision, Clinical Modification, known as ICD-10-CM, is the required standard for reporting diagnoses or condition codes on all healthcare claims, including Medicare. When attending an ICD-10-CM course, one of the first instructions is to obtain and use the current ICD-10-CM Coding Manual, which is updated every October. It is emphasized NOT to search for code(s) from the internet, the phone, or a list of codes. Yes, use the actual coding manual. There are ICD-10-CM manuals available in a digital format. In my opinion, subscribing or purchasing the software is a quicker way to locate the code(s) than to use a physical coding manual.

What to look for?

It is crucial to first identify the active diagnoses or conditions by reviewing the provider-documented medical records, such as the history and physical, recent hospital discharge summary, signed physician’s orders, provider consults, progress notes, and pertinent diagnostic reports. This process would assist in determining the correct and specific ICD-10-CM code(s). When the provider documentation does not have sufficient information, querying the provider to have the necessary details documented in the medical record is recommended.

The Default Code:

If the needed information from the provider cannot be obtained timely i.e. before the Assessment Reference Date (ARD), the ICD-10- Coding Guidelines provide information on how to code specific diagnoses or conditions. In particular, knowledge of the use of Default Codes is required. A Default Code corresponds to the diagnosis or condition most commonly associated with the main term or the unspecified code for the diagnosis or condition. First, what is the main term? The main term represents diseases or injuries. For example, Peripheral Vascular Disease – disease is the main term.

Here are instances when the Default Codes could be used:

  • If the type of Diabetes Mellitus (DM) is not documented:
    • The Default Code category is E11, Type 2 DM.

For fractures:

  • If the medical record does not indicate Displaced or Non-Displaced –
    • code as DISPLACED.
  • If the medical record does not indicate an Open or Closed fracture –
    • code it CLOSED.

For Cerebrovascular disease:

  • If the affected side is documented but not specified as dominant or non-dominant, and the classification system does not have a default code, the selection is as follows:
    • If the right side is affected, the default is dominant;
    • If the left side is affected, the default is non-dominant;
    • For ambidextrous patients, the default should be dominant.

Like laterality, the specific information may often be embedded in the therapy or nursing notes. Keep an eye out and ensure coding is at its highest level of specificity. It is essential to check and follow the ICD-10-CM Coding Guidelines when assigning ICD-10-CM codes for accuracy, or issues with the payer can occur when reporting incorrect codes.

LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training,  or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!