The first step to finding the most accurate code is to confirm that you are working with the correct version of the ICD-10-CM Official Guidelines for Coding and Reporting. The correct version may be the most recent update, or – in the context of retrospective coding– it may need to be a previous version that corresponds to the date of service, says Adrienne Commeree, MLS, RHIA, CPC, CPMA, CCS, CEMC, CPIP, professor at Tacoma Community College in Tacoma, Washington.

Either way, the CMS website includes PDFs of current guidelines, previous years’ guidelines, updates, and other helpful links. While it is highly recommended to reference the physical ICD-10-CM codebook, there are also convenient, free code look-up tools, such as ICD10Data.com.

Assessing Section I.B, General Coding Guidelines

Section I.B of the ICD-10-CM manual contains general guidelines that apply to the entire classification. These instructions, plus the conventions mentioned in Section I.A, take precedence over the coding guidelines in the Tabular and Alphabetic Index. Included are 19 headings. They range from the basic process of locating the proper code set to documenting complications of care.

This article will go through each section in detail.

1. Locating a code in the ICD-10-CM
2. Level of Detail in Coding
3. Code or codes from A00.0 through T88.9, Z00-Z99.8, U00-U85
4. Signs and symptoms
5. Conditions that are an integral part of a disease process
6. Conditions that are not an integral part of a disease process
7. Multiple coding for a single condition
8. Acute and Chronic Conditions
9. Combination Code
10. Sequela (Late Effects)
11. Impending or Threatened Condition
12. Reporting Same Diagnosis Code More than Once
13. Laterality
14. Documentation by Clinicians Other than the Patient’s Provider
15. Syndromes
16. Documentation of Complications of Care
17. Borderline Diagnosis
18. Use of Sign/Symptom/Unspecified Codes
19. Coding for Healthcare Encounters in Hurricane Aftermath