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Principles of Pediatric ICD-10-CM Coding

Principles of Pediatric ICD-10-CM Coding

by AAP, Jeffrey F. Linzer (Editor)
Start preparing your practice for migration to ICD-10-CM with this all-new AAP guidebook. Designed to complement the complete ICD-10- CM code set, it provides the pediatric-specific knowledge and know-how your staff will need to successfully implement the new code set as soon as it goes "live." Chapters devoted to individual disease categories or organ systems offer


Start preparing your practice for migration to ICD-10-CM with this all-new AAP guidebook. Designed to complement the complete ICD-10- CM code set, it provides the pediatric-specific knowledge and know-how your staff will need to successfully implement the new code set as soon as it goes "live." Chapters devoted to individual disease categories or organ systems offer expert guidance for appropriate ICD-10-CM code selection. Separate sections in each chapter include guideline instructions with step-by-step ICD-10-CM how-tos, coding scenarios illustrating real-life applications of the new codes, and practical chapter reviews to reinforce new knowledge and skill sets. The guidebook's clear, concise text is complemented by multiple features that enhance learning and comprehension. These features include key terms highlighted for help with improved understanding, highlighted text boxes to call attention to important difference between the ICD-9-CM and ICD-10-CM code structure and applications, practical opportunities to apply knowledge learned, and more. Custom-built to streamline ICD-10-CM migration, contents include
• Guidelines and Conventions of ICD-10 Coding
• Certain Infectious and Parasitic Diseases (A00-B99)
• Neoplasms (C00-D49)
• Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)
• Endocrine, Nutritional and Metabolic Diseases (E00-E89)
• Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)
• Diseases of the Nervous System (G00-G99)
• Diseases of the Eye and Adnexa (H00-H59)
• Diseases of the Ear and Mastoid Process (H60-H95)
• Diseases of the Circulatory System (I00-I99)
• Diseases of the Respiratory System (J00-J99)
• Diseases of the Digestive System (K00-K95)
• Diseases of the Skin and Subcutaneous Tissue (L00-L99)
• Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
• Diseases of the Genitourinary System (N00-N99)
• Pregnancy, Childbirth

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American Academy of Pediatrics
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Read an Excerpt

Principles of Pediatric ICD-10-CM Coding

By Jeffrey F. Linzer

American Academy of Pediatrics

Copyright © 2013 American Academy of Pediatrics
All rights reserved.
ISBN: 978-1-58110-738-8


Guidelines and Conventions of ICD-10 Coding

Like its predecessor, International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-10-CM has 3 main steps for selection of an accurate code

1. Look up a diagnosis or condition in the alphabetic index first and then in the tabular list.

2. Read all instructional notes in both the alphabetic index and the tabular list.

3. When in the tabular list, be sure to check for instructions at the 3-digit category level in addition to the code level.

Beyond these 3 steps are the official guidelines and conventions of ICD-10-CM as established by the Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) and approved by the cooperating parties for ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS, and NCHS. The guidelines provide additional instruction beyond the conventions (general rules) contained directly within the alphabetic index and tabular list of the code set. Use of the official guidelines of ICD-10-CM is required under the Health Insurance Portability and Accountability Act when using the code set. However, conventions take precedence over the guidelines.

In this chapter, we will look at the structure of ICD-10-CM codes and review of some key guidelines and conventions that apply to the overall code set. Chapter- and diagnosis-specific guidelines of ICD-10-CM will be included later in reviews of each associated chapter.

First, let's note a few key definitions associated with the general conventions and guidelines of ICD-10-CM.

Character — a letter or number that serves as the building block of ICD-10-CM codes, sometimes referred to as digits

Category — a 3-character unit that may be a complete code when no further subcategories exist but often serves as the base for building a 4- to 7-character code, categories are the main entries of the tabular list

Subcategory — a further defined category of 4 to 6 characters that is not a complete code

Code — a complete set of characters for which there are no further subdivisions, 3 to 7 characters long, describing a condition or reason for an encounter or related factors such as external causes

And — means "and/or" in ICD-10-CM

With — means "with" or "due to" in ICD-10-CM

Principal diagnosis — in a non-outpatient setting, that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital or other non-outpatient setting for care (including home health agencies)

First-listed diagnosis — in an outpatient facility or office setting, the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided

Combination code — a single code that represents either multiple conditions or a single condition and an associated secondary process or complication

PlaceholderICD-10-CM uses the letter "X" as a placeholder. Where a subcategory of less than 6 characters requires 7 characters for a complete code, an "X" must be used as a placeholder filling in any undefined characters.

Sequela — a late effect of an illness or injury that is no longer in the acute phase

These terms are used throughout the ICD-10-CM code set and the guidelines for its use.

Code Structure

As shown by the definition above, codes in ICD-10-CM are alphanumeric and may be from 3 to 7 characters long. All alphabetic characters except the letter U are used. The pattern of the code structure is 3 characters before a decimal followed by up to 4 more characters.

Pattern: XXX.XXXX

The first 3 characters form the code category. The first character is an alphabetic. The second character is numeric. Remaining characters may be alphabetic or numeric. Alphabetic characters are not case sensitive. The code category may then be further expanded on with etiology, severity, site, manifestations, or intent within the fourth through sixth characters. The seventh character is an extension required in some categories to further define the episode of care, status of fracture healing, the number of the fetus in obstetrical conditions, or the site of recording of the Glasgow coma scale.

Examples of complete codes

R05 Cough R06.2 Wheezing

G43.C0 Periodic headache syndromes in child or adult, not intractable

G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus

S52.311D Greenstick fracture of shaft of radius, right arm, subsequent encounter for fracture with routine healing

T37.5X5A Adverse effect of antiviral drugs, initial encounter

The letter "X" is used as a placeholder embedded in some codes to either provide for future expansion of a code category or where a seventh character is required but a code is less than 6 characters long, the placeholder must be added to fill the those spaces between the end of the code and the seventh character.


H60.8X1 Other otitis externa, right ear

H60.8X2 Other otitis externa, left ear

M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter

X32.XXXA Exposure to sunlight, first encounter

The codes H60.8X1 and H60.8X2 are examples of the placeholder used to maintain the sixth character structure while leaving room for expansion. Codes M48.52XA and X32.XXXA are examples of codes completed by addition of placeholders to fill the characters between the end of the subcategory listing and a required seventh character.

Guidelines and Conventions of the Alphabetic Index

The alphabetic index of ICD-10-CM consists of an alphabetic list of terms for diseases, injuries, and other reasons for encounters with their corresponding codes or code categories. It also includes an index to external causes of injuries, a table of neoplasms, and a table of drugs and chemicals. The alphabetic index contains main terms followed by a listing of terms that add specificity, such as acute or chronic. When a code appears next to a main term in the index, the code is a default code representing the condition most commonly associated with that term. This is often an "unspecified" code and should be reported only when information needed to arrive at a more specific code is not available.

Each main term in the index may be followed by a listing of subterms that further define the condition. The indents in the alphabetic index serve to guide the reader through the list of subterms, keeping each level of granularity connected back to the main term. Note that "with" is the first subterm in categories where it applies. The remaining subterms are in alphabetic order.

Example Adenoiditis (chronic) J35.02

– with tonsillitis J35.03

– acute J03.90

– recurrent J03.91

– specified organism NEC J03.80

– recurrent J03.81

– staphylococcal J03.80

– recurrent J03.81

In the example above, adenoiditis is the main term with an initial first subterm "with tonsillitis" followed by a second subterm "acute" followed by further levels of subterms to specify the organism involved and whether or not the acute adenoiditis is recurrent.

When consulting the alphabetic index, terms or subterms may be followed by a series of terms enclosed in parentheses. These are nonessential modifiers that may or may not be present in the documentation and do not affect the code number assigned.

ExamplesAsthma, asthmatic (bronchial) (catarrh) (spasmodic) J45.909 Agenesis

– adrenal (gland) Q89.1

Brackets are used in the alphabetic index to identify manifestation codes.

ExampleAmyloidosis (generalized) (primary) E85.9

– with lung involvement E85.4 [J99]

– familial E85.2

– genetic E85.2

– heart E85.4 [I43]

Manifestation codes are always sequenced second to the etiology codes. In the example above, code E85.4 represents organ-limited amyloidosis and secondary codes J99 or I43 indicate the manifestation in the lungs or heart. The descriptors for codes J99 and I43 include the phrase "in diseases classified elsewhere," indicating they are manifestation codes. In the tabular list, these codes appear with an instruction to code first the underlying disease.

Example 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-)

A dash (-) following a code in the alphabetic index indicates that the code is incomplete and that further characters must be located in the tabular list. Even where the dash is not present at the end of a code in the alphabetic index, the tabular list should be consulted for further instructions and possible seventh character requirements.

Example Index entry — Kearns-Sayre syndrome H49.81-

Tabular list — H49.81 Kearns-Sayre syndrome

Progressive external ophthalmoplegia with pigmentary retinopathy

Use additional code for other manifestation, such as: heart block (I45.9)

H49.811 Kearns-Sayre syndrome, right eye

H49.812 Kearns-Sayre syndrome, left eye

H49.813 Kearns-Sayre syndrome, bilateral

H49.819 Kearns-Sayre syndrome, unspecified eye

In the above example, the dash at the end of the index entry for Kearns-Sayre syndrome indicates that H49.81 is not a complete code. The tabular list provides the necessary sixth characters, indicating the involvement of one or both eyes and instruction to additionally report any manifestation such as heart block. ICD-10-CM captures laterality where it applies.

Terms in the index that include the abbreviation NEC for not elsewhere classified correspond to codes representing documented conditions other than those specified in ICD-10-CM. Think of NEC in the index as meaning other or other specified.

Example of NECAberrant (congenital) — see also Malposition, congenital

– artery (peripheral) Q27.8

– basilar NEC Q28.1

Q28.1 Other malformations of precerebral vessels

Congenital malformation of precerebral vessels NOS

Congenital precerebral aneurysm (nonruptured)

The abbreviation NOS for not otherwise specified corresponds to unspecified codes representing conditions for which documentation does not support a more specific code selection.

Example of NOSBirth

– compression during NOS P15.9

P15.9 Birth injury, unspecified

When an unspecified code is not provided in a category, the "other" code option represents both other and unspecified.

The alphabetic index also contains the instructions to "see" and "see also." The instruction "see" will be followed by another term that should be referenced in the index to arrive at the correct code. A "see also" instruction indicates that there is another main term that may provide additional alphabetic index entries related to the condition. It is not necessary to follow the see also note when the original main term provides the necessary code.

ExamplesAbandonmentsee Maltreatment

Abnormal, abnormality, abnormalities — see also Anomaly

It is necessary to follow the instruction to "see Maltreatment" in the first example above. However, if the abnormality to be reported is represented in the subterms of the second example, the "see also Anomaly" instruction can be disregarded.

The instruction "see also" is used to guide selection of the correct column in the neoplasm table and to use of the table of drugs and chemicals for adverse effect, poisoning, underdosing, or toxic effects of drugs or chemicals. These tables are important references to code selection but, as with the alphabetic index, the tabular list remains the final step in code selection.

The neoplasm table lists the codes or code subcategories for neoplasms by anatomical site. For each site, 6 columns provide for selection by type of neoplasm: malignant primary, malignant secondary, carcinoma in situ, benign, uncertain behavior, or unspecified behavior. The alphabetic index provides the "see also" instructions referencing the correct column for the morphological varieties of neoplasms.

Example Diagnosis documented is neuroblastoma of right adrenal gland

Alphabetic index Neuroblastoma

– olfactory C30.0

– specified site — see Neoplasm, malignant, by site

Neoplasm table Site — Adrenal, gland

Malignant column C74.9-

Tabular list C74.9 Malignant neoplasm of unspecified part of adrenal gland

C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland

C74.91 Malignant neoplasm of unspecified part of right adrenal gland

C74.92 Malignant neoplasm of unspecified part of left adrenal gland

The alphabetic index provides direction to the malignant column of the neoplasm table. The neoplasm table provides the subcategory for the code but indicates the code is incomplete with a dash following the code number, C74.9-. The tabular list provides the choices for complete code selection, with C74.91 representing the right adrenal gland. (Further documentation of the site as capsule, cortex, or medulla of the adrenal gland would have resulted in a more specific code in this example.)

Similarly, the table of drugs and chemicals provides a list of codes or subcategories of codes by substance with columns indicating accidental poisoning, intentional self-harm poisoning, poisoning by assault, undetermined poisoning, adverse effect, and underdosing.

Example Documentation states overdose of amoxicillin due to parent error in administering dose

Alphabetic index Overdose, overdosage (drug) — see table of drugs and chemicals, by drug, poisoning

Table of drugs Drug — Amoxicillin, Poisoning, accidental T36.0X1

Tabular list T36 Poisoning by, adverse effect of and underdosing of systemic antibiotics

The appropriate seventh character is to be added to each code from category T36.

A — initial encounter

D — subsequent encounter

S — sequela

T36.0X Poisoning by, adverse effect of and underdosing of penicillins

T36.0X1 Poisoning by penicillins, accidental (unintentional)

Note that the index listing for overdose refers to the table of drugs and chemicals with a "see" instruction. The table of drugs and chemicals provides subcategory T36.0X1 but does not provide a complete code. The tabular list instructions at category T36 note that a seventh character must be added to indicate the type of encounter as initial, subsequent, or sequela to the poisoning. Selection of a code from the table alone would result in an invalid code.

The final part of the alphabetic index is the external cause of injuries index. External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture the cause, intent, place of occurrence, activity of the patient at the time of the event, and patient status (eg, civilian, military). The selection of the appropriate external cause code is guided by the alphabetic index of external causes and by inclusion and exclusion notes in the tabular list. These codes are not required when the external cause is included in the code for the related condition, as in our example above for accidental poisoning by overdosing of ampicillin.

Example Documentation states this is the initial encounter with a patient who was injured due to being run over by a giraffe while cleaning its pen at the zoo. Codes for injuries sustained would be reported first followed by external cause codes.


Excerpted from Principles of Pediatric ICD-10-CM Coding by Jeffrey F. Linzer. Copyright © 2013 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Meet the Author

Jeffry Linzer Sr, MD, FAAP, FACEP, is the associate medical director for compliance for the Emergency Pediatric Group/Division of Pediatric Emergency Medicine, Children’s Healthcare of Atlanta and associate professor in the Departments of Pediatrics and Emergency Medicine at Emory University School of Medicine. Dr Linzer has been a member of the American Academy of Pediatrics (AAP) since 1987 and is active in the AAP sections on Emergency Medicine and Transport Medicine. He is also a member of the AAP Committee on Coding and Nomenclature and serves as the AAP representative to the ICD-9-CM Editorial Advisory Board.

Additionally, Dr Linzer has taken on the role as chair of the first ever pediatric topical advisory group (TAG) as ICD undergoes its 11th revision under the auspice of the World Health Organization. Dr Linzer is an expert in ICD guidelines and implementation and has been actively involved in the ICD-10-CM transition in the United States

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