When a code first note is present?

This chapter will discuss the ICD-10-CM coding conventions and the steps in the coding process.

ICD-10-CM Coding Conventions

These types of conventions are discussed in your textbook, and explanations of the conventions appear in the ICD-10-CM Official Coding Guidelines for Coding and Reporting as follows:

1. Conventions for the ICD-10-CM The ICD-10-CM conventions are the general rules for use of the classification system, independent of the guidelines. These conventions are incorporated within the Index and Tabular List as instructional notes and are applicable regardless of the health care setting.

   A summary of the use of the conventions are as follows:

1. Instructional Notations
   The following instructional notations are used within ICD-10-CM:
1. Includes Notes
   This note appears immediately under a three-digit code title to further define, or give examples of, the content of the category.
2. Excludes Notes
   The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are independent of each other.
• Excludes1
  A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
• Excludes2
  A type 2 excludes note represents “Not included here.” An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
3. “See” and “See Also” Instructional Notes
• The “see” instruction following a main term in the Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code.
• A “see also” instruction following a main term in the index instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.
4. “Code first”, “use additional code,” and “in diseases classified elsewhere” Notes.
• Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes: etiology followed by manifestation.
• In most cases the manifestation codes will have in the code title “in diseases classified elsewhere.” Codes with this title are a component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code, and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention.
• There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such codes a “use additional code” note will still be present and the rules for sequencing apply.
• In addition to the notes in the Tabular, these conditions also have a specific Index entry structure. In the Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.
• An example of the etiology/manifestation convention is dementia in Parkinson's disease. In the index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiology, Parkinson's disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance.
• “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination.
5. “Code also” Note
   A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.
2. Punctuation
1. [ ] Brackets are used in the Tabular list to enclose synonyms, alternative wording, or explanatory phrases. Brackets are used in the Index to identify manifestation codes.
2. ( ) Parentheses are used in both the Index and Tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.
3. : Colons are used in the Tabular List after an incomplete term that needs one or more of the modifiers following the colon to make it assignable to a given category.
3. Abbreviations
1. Index abbreviations
• NEC “Not elsewhere classifiable”
  This abbreviation in the Index represents “other specified.” When a specific code is not available for a condition, the Index directs the coder to the “other specified” code in the Tabular.
2. Tabular abbreviations
• NEC “Not elsewhere classifiable”
  This abbreviation in the Tabular represents “other specified.” When a specific code is not available for a condition, the Tabular includes an NEC entry under a code to identify the code as the “other specified” code.
• NOS “Not otherwise specified”
  This abbreviation is the equivalent of unspecified.
4. Symbols
1. Point Dash (.-) This symbol tells the coder that the code listed contains a list of options at a level of specificity past the three-character category.

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Under ICD-10 coding rules, in the outpatient setting, if you note your patient’s diagnosis as “probable” or use any other term that means you haven’t established a diagnosis, you are not allowed to report the code for the suspected condition. However, you may report codes for symptoms, signs, or test results.

Here are three general guidelines to follow when reporting signs and symptoms in ICD-10:

1.    When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reasons for the visit.

2.    If the signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.

3.    If the signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.

ICD-10 then offers four types of notes to further direct you to the correct codes:

1.    Excludes1 notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code from which it is excluded. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported. However, there is an exception to this approach if the two conditions are present but unrelated to each other.

2.    Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. For example, category R07 for pain in the throat and chest has an exclusive2 note indicating that jaw pain and pain in the breast are not included with this code but may be reported separately.

3.    Code-first notes instruct you to report another code first. For example, R53.0, “Neoplastic (malignant) related fatigue,” is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis.

4.    Inclusion notes are also provided under some codes, giving you a list of terms to help identify conditions reported with the code. For example, R73.09, “Other abnormal glucose,” has the following inclusion terms: “abnormal glucose NOS, abnormal nonfasting glucose tolerance, latent diabetes, and prediabetes.” Inclusion terms are also helpful in confirming the correct code for specific indications. For example, code R75, “Inconclusive laboratory evidence of human immunodeficiency virus (HIV),” is followed with this inclusion term: “nonconclusive HIV-test finding in infants.”

Read the full FPM article: “ICD-10 Coding for the Undiagnosed Problem.”

ICD 10 coding guidelines has many different instructional notes which help us to follow general coding guidelines. For example, the Excludes 1 and Excludes 2 notes which are newly introduced in ICD 10, tells us whether to code these codes together or not. The same way, we have lot of codes in ICD 10 code book which should not be used as primary diagnosis. Manifestation codes are the ones which should not be reported as primary diagnosis. In ICD 10 coding guidelines, we have an instructional note “Code First” with the manifestation codes, which tells to code first the mentioned and then code the manifestation codes. We will go through few ICD 10 codes which are having these instructional notes, so that you become perfect in ICD 10 coding.

Read also: When to code Z codes in ICD 10 coding

Since, we are discussing about notes “Code First”, we can come across few ICD 10 codes with instruction notes “Code first, if applicable”. Do not get confused with these two notes, there is a minute difference between these two instructional nodes. In simple terms I will define below notes as:

Code First: Must be used Primary Diagnosis with Manifestation codes

Code First, if Applicable: Can be used as Primary diagnosis. if present.

So, you can easily differentiate between the above two instructional notes. For “Code First, if applicable” note you can code the manifestation code as primary, if any of the mentioned diagnosis in the notes are not present along with the manifestation. While for “Code first” note it is mandatory to use the ICD 10 codes as primary diagnosis mentioned along with the notes.

Read also: How to become perfect in coding Medical report

F02-Dementia in other diseases classified elsewhere
Code first the underlying physiological condition, such as:
Alzheimer’s (G30.-)
cerebral lipidosis (E75.4)
Creutzfeldt-Jakob disease (A81.0-)
dementia with Lewy bodies (G31.83)
epilepsy and recurrent seizures (G40.-)
frontotemporal dementia (G31.09)
hepatolenticular degeneration (E83.0)
human immunodeficiency virus [HIV] disease (B20)
hypercalcemia (E83.52)
hypothyroidism, acquired (E00-E03.-)
intoxications (T36-T65)
Jakob-Creutzfeldt disease (A81.0-)
multiple sclerosis (G35)
neurosyphilis (A52.17)
niacin deficiency [pellagra] (E52)
Parkinson’s disease (G20)
Pick’s disease (G31.01)
polyarteritis nodosa (M30.0)
systemic lupus erythematosus (M32.-)
trypanosomiasis (B56.-, B57.-)
vitamin B deficiency (E53.8)

I43-Cardiomyopathy in diseases classified elsewhere
Code first underlying disease, such as:
amyloidosis (E85.-)
glycogen storage disease (E74.0)
gout (M10.0-)
thyrotoxicosis (E05.0-E05.9-)

H32-Chorioretinal disorders in diseases classified elsewhere
Code first underlying disease, such as:
congenital toxoplasmosis (P37.1)
histoplasmosis (B39.-)
leprosy (A30.-)

G32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhere
Dana-Putnam syndrome
Sclerosis of spinal cord (combined) (dorsolateral) (posterolateral)
Code first underlying disease, such as:
anemia (D51.9)
dietary (D51.3)
pernicious (D51.0)
vitamin B12 deficiency (E53.8)

H62.4O titis externa in other diseases classified elsewhere
Code first underlying disease, such as:
erysipelas (A46)
impetigo (L01.0)

H28 Cataract in diseases classified elsewhere
Code first underlying disease, such as:
hypoparathyroidism (E20.-)
myotonia (G71.1-)
myxedema (E03.-)
protein-calorie malnutrition (E40-E46)