2021 ICD-10-CM Guidelines

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ICD-10-CM Official Guidelines for Coding and ReportingFY 2021(October 1, 2020 - September 30, 2021)Narrative changes appear in bold textItems underlined have been moved within the guidelines since the FY 2020 versionItalics are used to indicate revisions to heading changesThe Centers for Medicare and Medicaid Services (CMS) and the National Center for HealthStatistics (NCHS), two departments within the U.S. Federal Government’s Department of Healthand Human Services (DHHS) provide the following guidelines for coding and reporting using theInternational Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).These guidelines should be used as a companion document to the official version of the ICD-10CM as published on the NCHS website. The ICD-10-CM is a morbidity classification publishedby the United States for classifying diagnoses and reason for visits in all health care settings. TheICD-10-CM is based on the ICD-10, the statistical classification of disease published by the WorldHealth Organization (WHO).These guidelines have been approved by the four organizations that make up the CooperatingParties for the ICD-10-CM: the American Hospital Association (AHA), the American HealthInformation Management Association (AHIMA), CMS, and NCHS.These guidelines are a set of rules that have been developed to accompany and complement theofficial conventions and instructions provided within the ICD-10-CM itself. The instructions andconventions of the classification take precedence over guidelines. These guidelines are based onthe coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM,but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CMdiagnosis codes is required under the Health Insurance Portability and Accountability Act(HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted underHIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder isessential to achieve complete and accurate documentation, code assignment, and reporting ofdiagnoses and procedures. These guidelines have been developed to assist both the healthcareprovider and the coder in identifying those diagnoses that are to be reported. The importance ofconsistent, complete documentation in the medical record cannot be overemphasized. Withoutsuch documentation accurate coding cannot be achieved. The entire record should be reviewed todetermine the specific reason for the encounter and the conditions treated.The term encounter is used for all settings, including hospital admissions. In the context of theseguidelines, the term provider is used throughout the guidelines to mean physician or any qualifiedhealth care practitioner who is legally accountable for establishing the patient’s diagnosis. Onlythis set of guidelines, approved by the Cooperating Parties, is official.The guidelines are organized into sections. Section I includes the structure and conventions of theclassification and general guidelines that apply to the entire classification, and chapter-specificguidelines that correspond to the chapters as they are arranged in the classification. Section IIincludes guidelines for selection of principal diagnosis for non-outpatient settings. Section IIIincludes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is foroutpatient coding and reporting. It is necessary to review all sections of the guidelines to fullyunderstand all of the rules and instructions needed to code properly.

ICD-10-CM Official Guidelines for Coding and Reporting . 1Section I. Conventions, general coding guidelines and chapter specific guidelines . 7A. Conventions for the ICD-10-CM . 71.The Alphabetic Index and Tabular List . 72.Format and Structure: . 73.Use of codes for reporting purposes . 74.Placeholder character . 75.7th Characters . 86.Abbreviations . 8a. Alphabetic Index abbreviations . 8b. Tabular List abbreviations . 87.Punctuation . 88.Use of “and”. . 99.Other and Unspecified codes . 9a. “Other” codes . 9b. “Unspecified” codes. 910. Includes Notes . 911. Inclusion terms . 912. Excludes Notes. 9a. Excludes1 . 10b. Excludes2 . 1013. Etiology/manifestation convention (“code first”, “use additional code” and “in diseasesclassified elsewhere” notes) . 1014. “And” . 1115. “With” . 1116. “See” and “See Also”. 1217. “Code also” note . 1218. Default codes . 1219. Code assignment and Clinical Criteria . 12B. General Coding Guidelines . 121.Locating a code in the ICD-10-CM . 122.Level of Detail in Coding . 133.Code or codes from A00.0 through T88.9, Z00-Z99.8 . 134.Signs and symptoms . 135.Conditions that are an integral part of a disease process . 136.Conditions that are not an integral part of a disease process . 137.Multiple coding for a single condition . 148.Acute and Chronic Conditions . 149.Combination Code . 1410. Sequela (Late Effects) . 1511. Impending or Threatened Condition . 1512. Reporting Same Diagnosis Code More than Once . 1513. Laterality . 1614. Documentation by Clinicians Other than the Patient's Provider . 1615. Syndromes. 1716. Documentation of Complications of Care . 17ICD-10-CM Official Guidelines for Coding and ReportingFY 2021Page 2 of 126

17. Borderline Diagnosis . 1718. Use of Sign/Symptom/Unspecified Codes. 1719. Coding for Healthcare Encounters in Hurricane Aftermath . 18a. Use of External Cause of Morbidity Codes . 18b. Sequencing of External Causes of Morbidity Codes . 18c. Other External Causes of Morbidity Code Issues . 19d. Use of Z codes . 19C. Chapter-Specific Coding Guidelines . 201.Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99), U07.1 . 20a. Human Immunodeficiency Virus (HIV) Infections . 20b. Infectious agents as the cause of diseases classified to other chapters . 22c. Infections resistant to antibiotics . 22d. Sepsis, Severe Sepsis, and Septic Shock . 23e. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions . 27f. Zika virus infections . 28g. Coronavirus infections. 282.Chapter 2: Neoplasms (C00-D49) . 32a. Treatment directed at the malignancy . 33b. Treatment of secondary site . 34c. Coding and sequencing of complications . 34d. Primary malignancy previously excised . 35e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy . 35f. Admission/encounter to determine extent of malignancy . 36g. Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms . 36h. Admission/encounter for pain control/management . 36i. Malignancy in two or more noncontiguous sites . 37j. Disseminated malignant neoplasm, unspecified . 37k. Malignant neoplasm without specification of site . 37l. Sequencing of neoplasm codes . 37m. Current malignancy versus personal history of malignancy . 38n. Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versuspersonal history . 39o. Aftercare following surgery for neoplasm . 39p. Follow-up care for completed treatment of a malignancy . 39q. Prophylactic organ removal for prevention of malignancy . 39r. Malignant neoplasm associated with transplanted organ. 393.Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving theimmune mechanism (D50-D89) . 394.Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) . 40a. Diabetes mellitus . 405.Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99) . 42a. Pain disorders related to psychological factors . 42b. Mental and behavioral disorders due to psychoactive substance use . 43c. Factitious Disorder . 446.Chapter 6: Diseases of the Nervous System (G00-G99) . 44a. Dominant/nondominant side . 44b. Pain - Category G89. 44ICD-10-CM Official Guidelines for Coding and ReportingFY 2021Page 3 of 126

Chapter 7: Diseases of the Eye and Adnexa (H00-H59) . 48Glaucoma . 48Blindness . 49Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95) . 50Chapter 9: Diseases of the Circulatory System (I00-I99) . 50Hypertension . 50Atherosclerotic Coronary Artery Disease and Angina . 52Intraoperative and Postprocedural Cerebrovascular Accident . 53Sequelae of Cerebrovascular Disease . 53Acute myocardial infarction (AMI) . 54Chapter 10: Diseases of the Respiratory System (J00-J99), U07.0 . 56Chronic Obstructive Pulmonary Disease [COPD] and Asthma . 56Acute Respiratory Failure . 56Influenza due to certain identified influenza viruses . 57Ventilator associated Pneumonia . 58Vaping-related disorders . 58Chapter 11: Diseases of the Digestive System (K00-K95) . 59Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) . 59Pressure ulcer stage codes . 59Non-Pressure Chronic Ulcers . 60Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) . 61Site and laterality . 61Acute traumatic versus chronic or recurrent musculoskeletal conditions . 62Coding of Pathologic Fractures . 62Osteoporosis . 62Chapter 14: Diseases of Genitourinary System (N00-N99) . 63Chronic kidney disease . 63Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) . 64General Rules for Obstetric Cases . 64Selection of OB Principal or First-listed Diagnosis . 65Pre-existing conditions versus conditions due to the pregnancy . 67Pre-existing hypertension in pregnancy . 67Fetal Conditions Affecting the Management of the Mother . 67HIV Infection in Pregnancy, Childbirth and the Puerperium . 68Diabetes mellitus in pregnancy . 68Long term use of insulin and oral hypoglycemics . 68Gestational (pregnancy induced) diabetes . 68Sepsis and septic shock complicating abortion, pregnancy, childbirth

Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on

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