Lean on This Guidance When Reporting Multiple Codes for a Single Condition
Question: In what situations might it be appropriate to report multiple diagnosis codes for a single condition? North Carolina Subscriber Answer: There are several situations in which you may need multiple ICD-10-CM codes to report a single condition. Some conditions require two codes to fully describe etiology or manifestation, especially if they affect multiple body systems. Or, when you look up a code in the Tabular List, you may see guidance like a “Use additional code” note to report another code to fully describe a condition. In the Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS) ICD-10-CM Official Guidelines for Coding and Reporting, the agencies provide this example: “… for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, Staphylococcus, and Enterococcus, as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A ‘use additional code’ note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code.” Don’t forget, too, that you may see a Code first note, which can show that a condition may be due to a different underlying cause. The guidelines say if you see a note to “Code, if applicable, any causal condition first” note, then “If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.” In some code categories, like sequela or those covering obstetrics or denoting complications, you may need to use multiple codes, but make sure you check with the specific guidelines for those respective conditions to follow the exact instructions. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC 
