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| 11503947463 | The Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS) provide guidelines for coding and reporting using | the International 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-10-CM as published on the NCHS website. | 0 | |
| 11503911542 | ICD-10-CM | is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO). | 1 | |
| 11503962696 | These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: | The American Hospital Association (AHA) The American Health Information Management Association (AHIMA) CMS NCHS | 2 | |
| 11503994257 | 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. | 3 | |
| 11504015377 | What are the guidelines based on? | the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. | 4 | |
| 11504034493 | Adherence to these guidelines when assigning ICD-10 CM diagnosis codes is required by? | Health Insurance Portability and Accountability Act (HIPAA). Note: The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. | 5 | |
| 11504100306 | Encounter | is used for all settings, including hospital admissions. | 6 | |
| 11504188045 | Section I - Conventions, General Coding Guidelines, and Chapter Specific Guidelines | includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. This section is the largest section of the guidelines. Note: The conventions, general guidelines, and chapter-specific guidelines in Section I are applicable to all healthcare settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines. | 7 | |
| 11504233773 | Section II - Selection of Principal Diagnosis | includes guidelines for selection of principal diagnosis for non-outpatient settings. In determining principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines. | 8 | |
| 11504374647 | Section III - Reporting Additional Diagnosis | includes guidelines for reporting additional diagnoses in non-outpatient settings. Note: The guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider. | 9 | |
| 11504388298 | General Rules for Other (Additional) Diagnoses: | For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring | 10 | |
| 11504562976 | Section IV - Diagnostic Coding and Reporting Guidelines for Outpatient Services | is for outpatient coding and reporting. These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits (this means outpatient settings and physician settings.) | 11 | |
| 11504604559 | Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that: | The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care, and psychiatric hospitals. Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients. | 12 | |
| 11504742576 | Appendix I - Present on Admission Reporting Guidelines | These guidelines are to be used as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each diagnosis and external cause of injury code reported on claim forms (UB-04 and 837 Institutional). Note: These guidelines are not intended to replace any guidelines in the main body of the ICD-10-CM Official Guidelines for Coding and Reporting. The POA guidelines are not intended to provide guidance on when a condition should be coded, but rather, how to apply the POA indicator to the final set of diagnosis codes that have been assigned in accordance with Sections I, II, and III of the official coding guidelines. Subsequent to the assignment of the ICD-10-CM codes, the POA indicator should then be assigned to those conditions that have been coded | 13 | |
| 11504931900 | ICD-10-PCS | is a procedure classification published by the United States for classifying procedures performed in hospital inpatient health care settings. | 14 | |
| 11504949362 | The parts of the ICD-10-PCS Guidelines are listed: | A. Conventions B. Medical and Surgical Section Guidelines Body System Root Operation Body Part Approach Device C. Obstetrics Section Guidelines | 15 |
