Use additional/code also notes in code book

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Good morning,

I am wanting to clarify some red instructional notes in the code book. I am currently coding Metabolic syndrome and there is a note stating to use additional code for associated manifestations such as Obesity. The provider did not document for Obesity and I know as a coder, I cannot assume, so I will query him. With that being said, some notes say "use additional code "or "use additional code if applicable". What is the difference between these? Also, codes in brackets for instance Alzheimer's G30.9 [F02.80]. If the doctor didn't document Dementia in other diseases classified elsewhere without behavioral disturbance, can that code still be used? These are questions in case I am unable to query the provider.
 

kimberlywatson

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Good idea to query the provider. Regarding the Alzheimer's, if you go to G30.9 in the Tabular List, you'll see a note that says to code Dementia with it regardless of the provider explicitly stating it - which is obviously a rare instance due to our requirement of only coding what is documented.
 
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Thank you for the feedback and I do see where it says to use an additional code to identify ,but I don't see in the book where it states to use regardless of the provider explicitly stating it. The only guideline I see for that would be anything under the term "with". The "code also" note states that two codes MAY BE required to fully describe a condition...Am I missing this somewhere? I am using the AAPC ICD-10 CM EXPERT Diagnosis codes for Providers and Facilities 2021.
 

kimberlywatson

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Thank you for the feedback and I do see where it says to use an additional code to identify ,but I don't see in the book where it states to use regardless of the provider explicitly stating it. The only guideline I see for that would be anything under the term "with". The "code also" note states that two codes MAY BE required to fully describe a condition...Am I missing this somewhere? I am using the AAPC ICD-10 CM EXPERT Diagnosis codes for Providers and Facilities 2021.
Hmm that's odd! I'm using the Optum360 book. They must differ a bit because the tip I referenced is listed right under that code so you definitely would have seen it. Sorry about that! :(
 
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Hmm that's odd! I'm using the Optum360 book. They must differ a bit because the tip I referenced is listed right under that code so you definitely would have seen it. Sorry about that! :(
Don't be sorry! I appreciate your feedback. Would it be too much trouble to send me a snippet of that guideline in your book? Maybe I can talk the providers into buying another code book? Thanks again!
 

sls314

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Don't be sorry! I appreciate your feedback. Would it be too much trouble to send me a snippet of that guideline in your book? Maybe I can talk the providers into buying another code book? Thanks again!

You don't need a new book. The information is part of the ICD-10 Guidelines - it's a standard rule that applies whenever brackets appear with a code in the alphabetic index.

In your copy of the book, the coding convention is on page G4. (I have the same book and double-checked the page reference.)

Here's a portion of the information from the guidelines, but I'd recommend reading the whole paragraph for the full information. It's in Section I. A.13 (Etiology/Manifestation Convention)


"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."
 

kimberlywatson

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You don't need a new book. The information is part of the ICD-10 Guidelines - it's a standard rule that applies whenever brackets appear with a code in the alphabetic index.

In your copy of the book, the coding convention is on page G4. (I have the same book and double-checked the page reference.)

Here's a portion of the information from the guidelines, but I'd recommend reading the whole paragraph for the full information. It's in Section I. A.13 (Etiology/Manifestation Convention)


"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."
Thanks for including this Susan!
 
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