ICD-10 in Action: “Code Also” instructional note

October 30, 2017

This Independence series, ICD-10 in Action, features articles to recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and/or communicate updates to ICD-10 coding conventions.

The ICD-10-CM Manual contains official guidelines for coding and reporting, including:

  • Coding conventions. A set of rules for use of the classification independent of the guidelines. Coding conventions and instructions of the classification take precedence over guidelines (e.g., Code First).
  • General guidelines. A set of rules and sequencing instructions for using the Tabular List and Alphabetic Index. These guidelines provide rules such as how to locate a code and obtain level of detail.
  • Chapter-specific guidelines. A set of rules for specific diagnoses and conditions in a particular classification.
These conventions and guidelines must be followed to classify and assign the most appropriate code. Understanding these guidelines and conventions is key to reaching the most appropriate code assignment.

As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

Coding convention ? "Code Also" instructional 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. The sequencing depends on the circumstances of the encounter and is at the discretion of the provider. Sequencing can be based on the severity of the conditions and reason for the patient encounter.

Guideline update: This updated guideline of "The sequencing depends on the circumstances of the encounter" was released in the Official Guidelines for Coding and Reporting for FY2018.

Stay tuned

We will continue to communicate ICD-10-specific information through this article series to review some of the ICD-10 diagnosis code changes. We encourage you to keep up with the latest news and information by visiting the ICD-10 section of our website.

Test Your Knowledge: Coding Scenarios

Code the following scenarios. Provide both codes, including the ICD-10 "Code Also" instructional note code.

Scenario 1:

Jack, a 40-year-old male, presented to his provider for his weekly IV treatment of Rituximab (Rituxan®). He was diagnosed with HHV-8-associated Multicentric Castleman Disease after a compromised organ transplantation.

Scenario 2:

John is scheduled in two weeks for a corneal pachymetry using ultrasound procedure to assess and manage his intraocular pressure and suspected glaucoma of his right eye. The results confirmed moderate stage glaucoma secondary to acute primary iridocyclitis.

Scenario 3:

Jane's chief complaint to her physician was her constant urge to urinate. Her physician informed her that she has what is referred to as a spastic or overactive bladder. The treatment plan for Jane is four weeks of a regimen of pelvic muscle exercise training to increase periurethral muscle strength. The physician informed her that if this treatment plan failed to improve, the next line of treatment in urinary continence may be Biofeedback.

Scenario 4:

After several weeks of difficulty falling asleep, Tina decided to consult her physician. She explained that not only was she not able to fall asleep, but once asleep she would wake constantly. After examining Tina and reviewing her records, the physician determined that Tina?s insomnia was due to her attention-deficit hyperactivity disorder of childhood.

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