Diagnosis Guidelines & Reporting Rules
The diagnosis must exist at the time of the visit and meet this second condition to be coded.
What is it must affect patient care, treatment, or management?
This part of the ICD-10 Index helps you identify conditions known by a person’s name.
What are eponyms?
You should never assign a code unless you have verified it in this part of the ICD-10 book.
What is the Tabular List?
If a code requires a 7th character but only has five characters, this is inserted.
What is the placeholder “X”?
This Z code is used when a patient donates an organ or tissue.
What is Z52?
This type of note from the physician allows coders to assign a code, even without lab confirmation.
What is a provider's diagnostic statement?
These main terms may be used when coding visits related to history or current health status.
What are general terms like history, status, or presence?
These instructions tell you to report additional conditions for a more complete picture.
What are "Use additional code" notes?
Three-character codes can be used alone only if the category is not further divided into these.
What are subcategories?
This code is used to indicate vaccine refusal.
What is Z28?
These codes are assigned for visits when the condition has been treated and the purpose is to check for recurrence.
What are follow-up codes (Z08–Z09)?
In the index, these words appear in italics and direct you to check another entry.
What are "See" and "See also"?
These are examples under a code that show what it can be used for, though they’re not exhaustive.
What are inclusion terms?
The ICD-10-CM has how many maximum characters per code?
What is 7 characters?
Codes starting with this letter are for public health emergencies and other special cases.
What is “U”?
This chapter covers diagnosis codes for signs and abnormal findings when no confirmed diagnosis is available.
What is Chapter 18 (R00–R99)?
These kinds of modifiers are in parentheses and don’t affect code assignment.
What are nonessential modifiers?
This section groups like diagnoses and helps reveal more specific codes.
What is the benefit of using the Tabular List?
This character must always be included if required at the category level.
What is the 7th character?
This Z code is used for travel-related counseling before a trip.
What is Z71.84?
You must reference these two guideline sections when determining how to properly sequence inpatient diagnoses.
What are Sections II and III of the Official Guidelines?
These subterms, listed out of alphabetical order, indicate a presumed relationship between conditions.
What is “with”?
These punctuation marks are used to introduce inclusion terms that require more words after them.
What are colons (:)?
A code without all the required characters is this.
What is invalid?
Social determinants like homelessness and food insecurity are coded using this Z code range.
What are Z55–Z65?