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    1. Use of Both Alphabetic Index and Tabular List
    2. [eICD.com Note: the search feature in the both the online and stand-alone versions of the eICD obviate the need to examine the Alphabetic Index]

      1. Use both the Alphabetic Index and the Tabular List when locating and assigning a code. Reliance on only the Alphabetic Index or the Tabular List leads to errors in code assignments and less specificity in code selection.
      2. Locate each term in the Alphabetic Index and verify the code selected in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.


    3. Level of Specificity in Coding

      Diagnostic and procedure codes are to be used at their highest level of specificity:

      Assign three-digit codes only if there are no four-digit codes within that code category.

      Assign four-digit codes only if there is no fifth-digit subclassification for that category.

      Assign the fifth-digit subclassification code for those categories where it exists.


    5. Other (NEC) and Unspecified (NOS) Code Titles
    6. Codes labeled "other specified" (NEC not elsewhere classified) or "unspecified" (NOS not otherwise specified) are used only when neither the diagnostic statement nor a thorough review of the medical record provides adequate information to permit assignment of a more specific code.

      Use the code assignment for "other" or NEC when the information at hand

      specifies a condition but no separate code for that condition is provided.

      Use "unspecified" (NOS) when the information at hand does not permit either a more specific or "other" code assignment.

      When the Alphabetic Index assigns a code to a category labeled "other (NEC)" or to a category labeled "unspecified (NOS)", refer to the Tabular List and review the titles and inclusion terms in the subdivisions under that particular three-digit category (or subdivision under the four-digit code) to determine if the information at hand can be appropriately assigned to a more specific code.


    7. Acute and Chronic Conditions
    8. If the same condition is described as both acute (subacute) and chronic and

      separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

    9. Combination Code
    10. A single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or an associated complication is called a combination code. Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.


        1. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code may be used as a secondary code.
    11. Multiple Coding of Diagnoses
    12. Multiple coding is required for certain conditions not subject to the rules for combination codes.

      Instruction for conditions that require multiple coding appear in the Alphabetic Index and the Tabular List.

      1. Alphabetic Index:
      2. Codes for both etiology and manifestation of a disease appear following the subentry term, with the second code in brackets.

        Assign both codes in the same sequence in which they appear in the Alphabetic Index.

      3. Tabular List:
      4. Instructional terms, such as "Code first...," "Use additional

        code for any...," and "Note...," indicate when to use more than one code.

        "Code first underlying disease" - Assign the codes for both the

        manifestation and underlying cause. The codes for manifestations cannot be used (designated) as principal diagnosis.

        "Use additional code, to identify manifestation, as ..." - Assign also the code that identifies the manifestation, such as, but not limited to, the examples listed. The codes for manifestations cannot be used (designated) as principal diagnosis.


      5. Apply multiple coding instructions throughout the classification

      Where appropriate, whether or not multiple coding directions appear in the Alphabetic Index or the Tabular List. Avoid indiscriminate multiple coding or irrelevant information, such as symptoms or signs characteristic of the diagnosis.

    13. Late Effect
    14. A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury.

      Coding of late effects requires two codes:

      The residual condition or nature of the late effect

      The cause of the late effect

      The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect, except in those few instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title or the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s).

      The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the cause of the late effect.

      1. Late Effects of Cerebrovascular Disease

      Category 438 is used to indicate conditions classifiable to categories 430-437 as the causes of late effects (neurologic deficits), themselves classified elsewhere. These "late effects" include neurologic deficits that persist after initial onset of conditions classifiable to 430-437. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to 430-437.

      Codes from category 438 may be assigned on a health care record with codes from 430-437, if the patient has a current CVA and deficits from an old CVA.

      Assign code V12.59 (and not a code from category 438) as an additional code for history of cerebrovascular disease when no neurologic deficits are present.

    15. Uncertain Diagnosis
    16. If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", code the condition as if it existed or was established. The bases for this guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

    17. Impending or Threatened Condition

Code any condition described at the time of discharge as "impending" or

"threatened" as follows:

If it did occur, code as confirmed diagnosis.

If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for Impending and for Threatened.

If the subterms are listed, assign the given code.

If the subterms are not listed, code the existing forerunner condition(s) and

not the condition described as impending or threatened.

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ICD-10 codes, terms, and text World Health Organization, 1992-94