Section I.

Conventions, general coding guidelines and

chapter specific guidelines

The conventions, general guidelines and chapter-specific guidelines are applicable to all health care
settings unless otherwise indicated. The conventions and instructions of the classification take
precedence over guidelines.

A. Conventions for the ICD-10-CM

The conventions for the ICD-10-CM are the general rules for use of the classification independent of
the guidelines. These conventions are incorporated within the Alphabetic Index and Tabular List of
the ICD-10-CM as instructional notes.

1. The Alphabetic Index and Tabular List

The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their
corresponding code, and the Tabular List, a structured list of codes divided into chapters based on
body system or condition. The Alphabetic Index consists of the following parts: the Index of
Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of
Drugs and Chemicals.

2. Format and Structure:

The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for
categories, subcategories and codes may be either a letter or a number. All categories are 3
characters. A three-character category that has no further subdivision is equivalent to a code.
Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level
of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that
have applicable 7th characters are still referred to as codes, not subcategories. A code that has an
applicable 7th character is considered invalid without the 7th character.
The ICD-10-CM uses an indented format for ease in reference.

3. Use of codes for reporting purposes

For reporting purposes only codes are permissible, not categories or subcategories, and any
applicable 7th character is required.

4. Placeholder character
The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain
codes to allow for future expansion. An example of this is at the poisoning, adverse effect and under
dosing codes, categories T36-T50.

Where a placeholder exists, the X must be used in order for the code to be considered a valid code.

5. 7th Characters
Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required
for all codes within the category, or as the notes in the Tabular List instruct. The 7 th character must
always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a
placeholder X must be used to fill in the empty characters.

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6. Abbreviations
a. Alphabetic Index abbreviations
NEC “Not elsewhere classifiable”
This abbreviation in the Alphabetic Index represents “other specified.” When a specific code is not
available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the
Tabular List.
NOS “Not otherwise specified”
This abbreviation is the equivalent of unspecified.

b. Tabular List abbreviations

NEC “Not elsewhere classifiable”
This abbreviation in the Tabular List represents “other specified”. When a specific code is not
available for a condition, the Tabular List includes an NEC entry under a code to identify the code as
the “other specified” code.
NOS “Not otherwise specified”
This abbreviation is the equivalent of unspecified.

7. Punctuation
[ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory
phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary
words that may be present or absent in the statement of a disease or procedure without affecting the
code number to which it is assigned. The terms within the parentheses are referred to as nonessential
modifiers. The nonessential modifiers in the Alphabetic Index to Diseases apply to sub terms
following a main term except when a nonessential modifier and a subentry are mutually exclusive,
the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index under the main
term Enteritis, “acute” is a nonessential modifier and “chronic” is a subentry. In this case, the
nonessential modifier “acute” does not apply to the subentry “chronic”.
: Colons are used in the Tabular List after an incomplete term which needs one or more of the
modifiers following the colon to make it assignable to a given category.

8. Use of “and”.
See Section I.A.14. Use of the term “And”

9. Other and Unspecified codes

a. “Other” codes
Codes titled “other” or “other specified” are for use when the information in the medical record
provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the
line designate “other” codes in the Tabular List. These Alphabetic Index entries represent specific
disease entities for which no specific code exists so the term is included within an “other” code.
b. “Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical record is insufficient to
assign a more specific code. For those categories for which an unspecified code is not provided, the
“other specified” code may represent both other and unspecified.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

10. Includes Notes

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This note appears immediately under a three character code title to further define, or give examples
of, the content of the category.

11. Inclusion terms

List of terms is included under some codes. These terms are the conditions for which that code is to
be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the
terms are a list of the various conditions assigned to that code. The inclusion terms are not
necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to
a code.

12. Excludes Notes

The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use
but they are all similar in that they indicate that codes excluded from each other are independent of
each other.

a. Excludes1
A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note
indicates that the code excluded should never be used at the same time as the code above the
Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a
congenital form versus an acquired form of the same condition.
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated
to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or
not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1
note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under
F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic
dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and
sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so
it would be appropriate to report F45.8 and G47.63 together.

b. Excludes2
A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the
condition excluded is not part of the condition represented by the code, but a patient may have both
conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use
both the code and the excluded code together, when appropriate.

13. Etiology/manifestation convention (“code first”, “use additional code”

and “in diseases classified elsewhere” notes)
Certain conditions have both an underlying etiology and multiple body system manifestations due to
the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires
the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever
such a combination exists, there is a “use additional code” note at the etiology code, and a “code
first” note at the manifestation code. These instructional notes indicate the proper sequencing order
of the codes, etiology followed by manifestation.
In most cases the manifestation codes will have in the code title, “in diseases classified elsewhere.”
Codes with this title are a component of the etiology/ manifestation convention. The code title
indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted

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to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an
underlying condition code and they must be listed following the
underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an
example of this convention.

There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such
codes, there is a “use additional code” note at the etiology code and a “code first” note at the
manifestation code, and the rules for sequencing apply.
In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index
entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first
followed by the manifestation codes in brackets. The code in brackets is always to be sequenced
second.

An example of the etiology/manifestation convention is dementia in Parkinson’s disease. In the

Alphabetic Index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20
represents the underlying etiology, Parkinson’s disease, and must be sequenced first, whereas code
F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or
without behavioral disturbance.
“Code first” and “Use additional code” notes are also used as sequencing rules in the classification
for certain codes that are not part of an etiology/ manifestation combination.
See Section I.B.7. Multiple coding for a single condition.

14. “And”
The word “and” should be interpreted to mean either “and” or “or” when it appears in a title.
For example, cases of “tuberculosis of bones”, “tuberculosis of joints” and “tuberculosis of bones
and joints” are classified to subcategory A18.0, Tuberculosis of bones and joints.

15. “With”
The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears
in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification
presumes a causal relationship between the two conditions linked by these terms in the Alphabetic
Index or Tabular List. These conditions should be coded as related even in the absence of provider
documentation explicitly linking them, unless the documentation clearly states the conditions are
unrelated or when another guideline exists that specifically requires a documented linkage
between two conditions (e.g., sepsis guideline for “acute organ dysfunction that is not clearly
associated with the sepsis”).

For conditions not specifically linked by these relational terms in the classification or when a
guideline requires that a linkage between two conditions be explicitly documented, provider
documentation must link the conditions in order to code them as related.
The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in
alphabetical order.

16. “See” and “See Also”

The “see” instruction following a main term in the Alphabetic Index indicates that another term
should be referenced. It is necessary to go to the main term referenced with the “see” note to locate
the correct code.

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A “see also” instruction following a main term in the Alphabetic Index instructs that there is another
main term that may also be referenced that may provide additional Alphabetic Index entries that may
be useful. It is not necessary to follow the “see also” note when the original main term provides the
necessary code.

17. “Code also” 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.

18. Default codes

A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default
code. The default code represents that condition that is most commonly associated with the main
term, or is the unspecified code for the condition. If a condition is documented in a medical record
(for example, appendicitis) without any additional information, such as acute or chronic, the default
code should be assigned.

19. Code assignment and Clinical Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition
exists. The provider’s statement that the patient has a particular condition is sufficient. Code
assignment is not based on clinical criteria used by the provider to establish the diagnosis.