Master ICD-10-CM diagnosis coding guidelines with our comprehensive resource. Learn about proper clinical documentation improvement, medical coding best practices, and official ICD-10 coding conventions. This guide covers key aspects of accurate diagnosis coding for healthcare professionals, including specificity, laterality, and combination codes. Improve your coding accuracy and compliance for optimized reimbursement and healthcare data quality. Explore ICD-10-CM coding examples, common coding errors, and practical tips for compliant medical coding in a clinical setting.
Also known as
Factors influencing health status
Codes for encounters with health services for reasons other than disease or injury.
Codes for special purposes
Classifies novel infectious diseases, contact with and suspected exposure.
External causes of morbidity
Supplementary classification of external causes of injury and poisoning.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis confirmed?
Yes
Is it acute or chronic?
No
Is it suspected, probable, or ruled out?
When to use each related code
| Description |
|---|
| Diabetes mellitus type 2 |
| Hypertension, unspecified |
| Hypertensive heart disease |
Using unspecified ICD-10-CM codes when more specific documentation is available, leading to lower reimbursement and inaccurate data.
Lack of proper documentation supporting the diagnosis code assigned, increasing risk of audits and denials. CDI crucial for validation.
Incorrect coding of complications or comorbidities (MCCs) and major complications or comorbidities (MCCs). Impacts MS-DRG assignment and reimbursement.
**ICD-10-CM Diagnosis: J45.909 Unspecified asthma, uncomplicated** Patient presents with complaints of recurrent wheezing, shortness of breath, and chest tightness. These symptoms are episodic and often worse at night or early morning. The patient reports symptom exacerbation with exercise and exposure to allergens such as dust mites and pet dander. Physical examination reveals diffuse expiratory wheezing and prolonged expiratory phase. Pulmonary function testing demonstrates reversible airway obstruction with significant improvement in FEV1 post-bronchodilator administration. The patient denies any history of smoking or occupational exposure to respiratory irritants. Diagnosis of uncomplicated asthma is made based on clinical presentation, symptom pattern, and spirometry findings. Treatment plan includes inhaled short-acting beta-agonist as needed for symptom relief, initiation of inhaled corticosteroid for long-term control, and patient education regarding asthma triggers and management. Differential diagnoses considered include acute bronchitis, viral respiratory infection, and chronic obstructive pulmonary disease. Asthma diagnosis ICD-10 code J45.909 is assigned. Medical coding and billing guidelines for asthma will be followed. The patient will be scheduled for follow-up to assess treatment response and adjust medications as needed. Keywords: Asthma, wheezing, shortness of breath, chest tightness, reversible airway obstruction, FEV1, bronchodilator, inhaled corticosteroid, ICD-10-CM, J45.909, medical coding, medical billing, healthcare, clinical documentation, EHR, electronic health records, diagnosis, treatment, symptoms, spirometry, pulmonary function test, respiratory, allergens, triggers, management, uncomplicated asthma. **ICD-10-CM Diagnosis: I10 Essential (primary) hypertension** Patient presents for routine follow-up of essential hypertension. The patient reports no new or worsening symptoms. Blood pressure today is 14288 mmHg. Review of systems is negative for headache, dizziness, chest pain, or shortness of breath. Current medications include lisinopril 20mg daily and hydrochlorothiazide 25mg daily. The patient reports good medication adherence. Physical examination reveals no significant abnormalities. Electrocardiogram shows normal sinus rhythm. Laboratory results, including serum electrolytes and renal function, are within normal limits. Diagnosis of essential hypertension is maintained. The patient is encouraged to continue lifestyle modifications including a low-sodium diet and regular exercise. Medication regimen is continued with no changes at this time. The importance of blood pressure control and medication adherence is emphasized. Follow-up is scheduled in three months to monitor blood pressure and assess treatment efficacy. Keywords: Hypertension, high blood pressure, essential hypertension, blood pressure control, lisinopril, hydrochlorothiazide, ICD-10-CM, I10, medical coding, medical billing, healthcare, clinical documentation, EHR, electronic health records, diagnosis, treatment, medication, cardiovascular, blood pressure monitoring, lifestyle modifications, follow-up, symptoms.