ICD-10-CM Conventions & Notes
This note means two codes are needed to fully report a condition and its manifestation.
What is “Code first” / “Use additional code” (etiology/manifestation pairing)?
In the outpatient setting, diagnoses documented as “rule out” should be coded as this instead.
What are signs/symptoms and/or reason for visit?
POA “Y” means this.
What is present at the time of inpatient admission?
Chapter 1 (Certain Infectious & Parasitic Diseases)
When sepsis is documented, this condition is sequenced first if present.
What is the underlying systemic infection?
Chapter 9 (Diseases of the Circulatory System)
Hypertensive heart and kidney disease codes often require an additional code for this.
What is heart failure type and/or CKD stage?
This convention means the coder should not code both conditions together because one includes the other.
What is “Excludes1”?
In the inpatient setting, “probable,” “suspected,” or “likely” diagnoses are coded as if this.
What is established/confirmed?
POA “N” means this.
What is not present at admission (developed after admission)?
Chapter 2 (Neoplasms)
This type of neoplasm is coded based on the site of origin, not the metastatic site.
What is a primary malignant neoplasm?
Chapter 10 (Respiratory System)
An acute respiratory condition with a chronic condition may require coding both due to this guideline.
What is multiple coding to fully describe the condition?
This note means both conditions may exist together, and both may be coded if documented.
What is “Excludes2”?
The inpatient diagnosis chiefly responsible for admission is called this.
What is the principal diagnosis?
POA “U” means this.
What is documentation is insufficient to determine POA?
Chapter 3 (Blood & Immune Disorders)
Anemia due to chronic disease requires sequencing this condition first.
What is the underlying condition causing the anemia?
Chapter 18 (Signs & Symptoms)
Signs and symptoms are coded when this has not been established.
What is a definitive diagnosis?
This punctuation in the Alphabetic Index indicates that additional characters are required.
What is a dash (-)?
The outpatient diagnosis chiefly responsible for the encounter is called this.
What is the first-listed diagnosis?
POA “W” means this.
What is clinically undetermined (provider can’t determine POA)?
Chapter 4 (Endocrine, Nutritional, Metabolic)
Diabetes codes require identification of this to fully describe the condition.
What are complications and manifestations?
Chapter 15 (Pregnancy, Childbirth & Puerperium)
When a condition is related to pregnancy, codes are assigned from this chapter first.
What is Chapter 15 takes sequencing priority?
This term indicates a diagnosis is uncertain and may be coded differently depending on the inpatient vs. the outpatient setting.
What is “probable / suspected / likely / rule out”?
his is assigned on inpatient claims and communicates whether a condition was present at admission.
What is the POA indicator?
POA “1” (or “blank” depending on payer/system) typically means this type of code.
What is POA exempt (exempt from POA reporting)?
Chapter 5 (Mental, Behavioral & Neurodevelopmental Disorders)
Substance-related disorders require coding both the substance and this level of use.
What is use, abuse, or dependence?
Chapter 19–21 (Injury, External Causes, Z Codes)
Injury codes require a 7th character to identify this, while Z codes capture this type of encounter information.
What is episode of care and factors influencing health status or encounters for services?