The ICD-10-CM coding manual

The ICD-10-CM coding manual teaches coders step-by-step how to process and find the correct code, it helps the coder to locate the code in the official indexes and verify the code in the tabular. The ICD-10-CM coding manual also follows conventions, guidelines, and instructional notes. There are 10 steps to correctly coding they are as follows: identify the reason for the patient visit, after identifying reason for visit, consult the alphabetic index, locate the main term entry, scan subterm entries, pay close attention to index instructions, choose a potential code and locate it in the tabular list, read all instructional material in the tabular section, consult the official ICD-10-CM conventions and guidelines, confirm and assign the code, and sequence codes correctly.

When selecting the ICD-10-CM codes from the alphabetic index and tabular list there are guidelines for specific diagnoses and/or any condition. The guidelines are to be applied to all healthcare settings unless there is another stated. Instructional notes such as “and,” “includes,” “see also,” etc. mean that the initial diagnosis can also include something else or that there may be another explain for it.

Two methods I would use to build good coding habits is to break down the steps into terms I could easily remember, and practice using them for conditions that are most often seen in a health care setting. My biggest challenge with the codes would be remembering which step goes when. I plan to overcome this by learning each step and relating them to something I am familiar with just as I did in high school math. We used “please excuse my dear aunt sally” to remember “parenthesis, exponents, multiplication, division, addition, subtraction,”(PEMDAS) in order to solve math problems. If the instructional notes and guidelines are not followed correctly it could result in the misdiagnosis of a patient.

What would be a good potential negative impact of not using the guidelines to select a code?