{"id":16155,"date":"2023-01-03T07:49:00","date_gmt":"2023-01-03T07:49:00","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=16155"},"modified":"2026-11-02T19:06:57","modified_gmt":"2026-11-02T13:36:57","slug":"general-coding-guidelines-for-icd-10-cm","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/","title":{"rendered":"General Coding Guidelines for ICD-10-CM"},"content":{"rendered":"<nav class=\"mbc-breadcrumb\" style=\"font-size: 14px; margin: 0 0 16px;\" aria-label=\"Breadcrumb\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/\">Home<\/a> \u00bb <a href=\"https:\/\/www.medicalbillersandcoders.com\/blog\/\">Blog<\/a> \u00bb <a href=\"https:\/\/www.medicalbillersandcoders.com\/blog\/category\/medical-coding-services\/\">Medical Coding Services<\/a> \u00bb <span aria-current=\"page\">General Coding Guidelines for ICD-10-CM<\/span><\/nav>\r\n<p class=\"wp-block-paragraph\">The general coding guidelines for ICD-10-CM come down to two rules: locate the diagnosis in the Alphabetic Index and verify it in the Tabular List, then report the code at the highest number of characters and level of specificity the record supports. The remaining guidelines cover combination codes, sequela, laterality, and when sign, symptom, or unspecified codes are acceptable.<\/p>\r\n\r\n\r\n\r\n<div class=\"wp-block-yoast-seo-ai-summarize yoast-ai-summarize\">\r\n<h2>Key Takeaways<\/h2>\r\n\r\n<ul class=\"wp-block-list yoast-ai-summarize-list\">\r\n<li>ICD-10-CM coding requires locating a diagnosis code in the Alphabetic Index and verifying it in the Tabular List for accuracy.<\/li>\r\n\r\n\r\n\r\n<li>Select codes at the highest level of specificity, using 3 to 7 characters as necessary for detailed reporting.<\/li>\r\n\r\n\r\n\r\n<li>Combination codes classify two diagnoses, but use them only when they fully identify the condition.<\/li>\r\n\r\n\r\n\r\n<li>Sign, symptom, or unspecified codes are acceptable when the record does not support a specific diagnosis.<\/li>\r\n\r\n\r\n\r\n<li>Follow additional guidelines regarding laterality, sequela, and coding for impending conditions to ensure compliance.<\/li>\r\n<\/ul>\r\n<\/div>\r\n\r\n<h2><strong>ICD-10-CM Basics<\/strong><\/h2>\r\n<p><span style=\"font-weight: 400;\">Selecting accurate diagnosis codes using ICD-10-CM is challenging due to the availability of more than 68,000 codes. In this blog, we shared general coding guidelines for ICD-10-CM, which will help you select accurate diagnosis codes. First, you\u2019ll need access to two lists in ICD-10 CM: the Alphabetical Index of diagnostic terms and the Tabular List of ICD-10 codes.<\/span><\/p>\r\n<p><span style=\"font-weight: 400;\"> The Alphabetical Index of diagnostic terms lists thousands of \u2018main terms\u2019 alphabetically. Under each of those main terms, there is often a sub-list of more detailed terms; for instance, \u2018Cataract\u2019 has a sub-list of 84 terms. The Tabular List of ICD-10 codes runs alphanumerically from A00.0 to Z99.89. Its chapters group codes by body system or condition.<\/span><\/p>\r\n<table style=\"border-collapse: collapse; width: 100%;\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/family-practice-medical-billing-services.html\">Family Practice Billing<\/a><\/td>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/ob-gyn-medical-billing-services.html\">Ob-Gyn Billing<\/a><\/td>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/dermatology-medical-billing-services.html\">Dermatology Billing<\/a><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/wound-care-medical-billing-services.html\">Wound Care Billing<\/a><\/td>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/orthopedic-medical-billing-services.html\">Orthopedic Billing<\/a><\/td>\r\n<td style=\"width: 33.3333%; text-align: center;\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/speciality\/optometry-medical-billing-services.html\">Optometry Billing<\/a><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h2><strong>General Coding Guidelines for ICD-10-CM<\/strong><\/h2>\r\n<h3><strong>Locating a code in the ICD-10-CM\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">To select a code, find the diagnosis or reason for the visit in the Alphabetic Index. Then verify that code in the Tabular List. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">Read and follow the instructional notes in both the Alphabetic Index and the Tabular List. Always use both resources when you locate and assign a code.<\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">The Alphabetic Index does not always provide the complete code. Only the Tabular List shows the entire code, including laterality and any applicable 7th character.<\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">A dash (-) at the end of an Alphabetic Index entry indicates that the code needs additional characters. Even without a dash, check the Tabular List to confirm the code needs no 7th character.<\/span><\/p>\r\n<h3><strong>Level of Detail in Coding\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">Report diagnosis codes at the highest number of characters available and the highest level of specificity in the medical record. ICD-10-CM diagnosis codes contain 3, 4, 5, 6, or 7 characters. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">Three-character codes serve as category headings in ICD-10-CM. Fourth, fifth, or sixth characters can subdivide these categories to add greater detail. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">Use a three-character code only when the category has no further subdivisions. A code is invalid if it lacks any required character, including the 7th character.<\/span><\/p>\r\n<h3><strong>Multiple Coding for a Single Condition\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">The etiology\/manifestation convention requires two codes for a single condition that affects multiple body systems. Other single conditions also need more than one code. \u2018Use additional code\u2019 notes appear in the Tabular List for codes outside an etiology\/manifestation pair. They flag cases where a secondary code helps fully describe the condition. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">The sequencing rule is the same as the etiology\/manifestation pair. &#8216; Use additional code\u2019 tells you to add a secondary code if known. <\/span><\/p>\r\n<h3><strong>Combination Code\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">A combination code is a single code that classifies two diagnoses: a diagnosis with an associated secondary process (manifestation) or an associated complication. To identify combination codes, refer to sub-term entries in the Alphabetic Index and read the inclusion and exclusion notes in the Tabular List. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index directs. <\/span><span style=\"font-weight: 400;\">Do not use multiple codes when one combination code captures every element the provider documents in the diagnosis. <\/span><\/p>\r\n<p><span style=\"font-weight: 400;\">When the combination code lacks specificity in describing the manifestation or complication, add a secondary code.<\/span><\/p>\r\n<h3><strong>Sequela (Late Effects)\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">A sequela is a residual effect that remains after the acute phase of an illness or injury ends. No time limit applies to sequela codes. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later due to a previous injury.<\/span><\/p>\r\n<p><span style=\"font-weight: 400;\"> Examples of sequela include scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding sequela generally requires two codes. List the condition or nature of the sequela first, and the sequela code second.<\/span><\/p>\r\n<h3><strong>Use of Sign\/Symptom\/Unspecified Codes\u00a0<\/strong><\/h3>\r\n<p><span style=\"font-weight: 400;\">Sign\/symptom and \u2018unspecified\u2019 codes have acceptable, even necessary, uses. Report specific diagnosis codes when the medical record and clinical knowledge of the patient\u2019s health condition support them. In some encounters, though, signs\/symptoms or unspecified codes reflect the visit most accurately. Code each healthcare encounter to the level of certainty known at that visit. <\/span><\/p>\r\n<h2><strong>Impending or Threatened Condition\u00a0<\/strong><\/h2>\r\n<p style=\"text-align: left;\"><strong>Code any condition described at the time of discharge as \u2018impending\u2019 or \u2018threatened\u2019 as follows:\u00a0<\/strong><\/p>\r\n<ul>\r\n<li style=\"font-weight: 400; text-align: left;\" aria-level=\"1\"><span style=\"font-weight: 400;\">When the condition did occur, code it as the confirmed diagnosis. <\/span><\/li>\r\n<li style=\"font-weight: 400; text-align: left;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for \u2018impending\u2019 or \u2018threatened\u2019 and also reference primary term entries for \u201cImpending\u201d and \u2018Threatened.\u2019<\/span><\/li>\r\n<li style=\"font-weight: 400; text-align: left;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Where the Index lists the sub-terms, assign the given code. <\/span><\/li>\r\n<li style=\"font-weight: 400; text-align: left;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Without listed sub-terms, code the existing underlying condition(s), not the condition described as impending or threatened.<\/span><\/li>\r\n<\/ul>\r\n<h2 style=\"text-align: left;\"><strong>Remaining Coding Guidelines for ICD-10-CM<\/strong><\/h2>\r\n<p><strong>Here are some additional important guidelines to keep in mind when coding with ICD-10-CM:<\/strong><\/p>\r\n<ul>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Use the appropriate codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85 to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter\/visit.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Symptom and sign codes are acceptable when the provider has not established a related definitive diagnosis.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Do not assign signs and symptoms that routinely accompany a disease process as additional codes, unless the classification instructs otherwise.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Code additional signs and symptoms that do not routinely accompany a disease process when they are present.<\/span><\/li>\r\n<\/ul>\r\n<h3>Acute, Bilateral, and Borderline Conditions<\/h3>\r\n<ul>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If the same condition is described as acute (sub-acute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (sub-acute) code first.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Report each unique ICD-10-CM diagnosis code only once per encounter. This applies to bilateral conditions without distinct laterality codes, and to two different conditions that share the same ICD-10-CM code.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right, or is bilateral. If the condition is bilateral and no bilateral code exists, assign separate codes for both the left and right sides. When the medical record does not identify the side, assign the code for the unspecified side.<\/span><\/li>\r\n<li style=\"font-weight: 400;\" aria-level=\"1\"><span style=\"font-weight: 400;\">If the provider documents a \u2018borderline\u2019 diagnosis at discharge, code it as confirmed unless the classification provides a specific entry (e.g., borderline diabetes). When a borderline condition has its own index entry in ICD-10-CM, code it accordingly. Because borderline conditions are not uncertain diagnoses, the rule applies the same way in inpatient and outpatient settings. <\/span><\/li>\r\n<\/ul>\r\n<p class=\"isSelectedEnd\"><a href=\"https:\/\/www.medicalbillersandcoders.com\/medical-billing-services.aspx\"><strong>Medical Billers and Coders (MBC)<\/strong> is a leading medical billing company<\/a> that provides comprehensive medical billing and coding services to healthcare providers across various specialties. For provider education purposes, we have shared general coding guidelines for ICD-10-CM.\u00a0<\/p>\r\n<p>If you need assistance with medical billing and coding services for your practice, contact us at <a href=\"tel:888-357-3226\"><strong>888-357-3226<\/strong><\/a> or <strong><a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a><\/strong>.<\/p>\r\n<p class=\"mbc-quote-cta\">Want accurate ICD-10-CM coding that holds up to payer scrutiny? <a href=\"https:\/\/www.medicalbillersandcoders.com\/request-a-billing-quote.aspx?utm_source=request-a-billing-quote-sab&amp;utm_medium=submission%28sab%29&amp;utm_campaign=submission%28sab%29&amp;utm_id=request-a-billing-quote-sab&amp;utm_term=02%2F11%2F2026SAB&amp;utm_content=SAB\"><strong>Request a Billing Quote<\/strong><\/a>, and our coding team will review your specialty, payer mix, and claim volume to build a custom plan for your practice.<\/p>\r\n<h2><strong>FAQs<\/strong><\/h2>\r\n\r\n<div class=\"schema-faq wp-block-yoast-faq-block\">\r\n<div id=\"faq-question-1744961786417\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>1. What is ICD-10-CM?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a system healthcare providers use to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961807729\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>2. How do I use the Alphabetical Index and Tabular List in ICD-10-CM?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">First, locate the diagnostic term in the Alphabetical Index to select a code. After identifying the code, verify it in the Tabular List, which organizes codes by body systems and conditions. This ensures you assign the correct and complete code.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961823198\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>3. What is the importance of laterality in ICD-10-CM coding?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">Laterality specifies whether a condition affects the body&#8217;s left, right, or both sides. If no bilateral code exists, you must assign separate codes for each side or use an &#8220;unspecified&#8221; code if the documentation lacks details.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961835384\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>4. What is a combination code in ICD-10-CM?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">A combination code classifies two diagnoses: a diagnosis with a secondary manifestation or a diagnosis with a complication. Use it only when it fully identifies the condition. If it does not, add secondary codes.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961852066\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>5. Can multiple codes be used for a single condition in ICD-10-CM?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">Yes, some conditions may require multiple codes to describe the diagnosis and its effects fully. This often happens with conditions that affect various body systems, where &#8216;use additional code&#8217; notes in the Tabular List guide the selection of secondary codes.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961866156\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>6. What is meant by &#8220;sequela&#8221; in ICD-10-CM coding?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">Sequela refers to a residual condition resulting from a previous illness or injury. Coding typically requires two codes: one for the current condition and another for the sequela.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961879245\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>7. How detailed should ICD-10-CM coding be?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">Report diagnosis codes with as many characters as available to achieve the highest specificity. Codes may contain 3 to 7 characters, with three-character codes acting as general categories unless further details are available.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961891481\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>8. When should unspecified or symptom codes be used in ICD-10-CM?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">Use unspecified or symptom codes when the provider has not confirmed the diagnosis or the medical record lacks sufficient information to assign a more specific code. These codes are acceptable when necessary to accurately reflect the healthcare encounter.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961902936\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>9. What should I do if a condition is described as &#8220;impending&#8221; or &#8220;threatened&#8221;?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">When the condition occurred, code it as a confirmed diagnosis. If it did not, use the Alphabetic Index to determine if &#8220;impending&#8221; or &#8220;threatened&#8221; terms have specific codes. Without a specific code, code the underlying condition instead.<\/p>\r\n<\/div>\r\n<div id=\"faq-question-1744961916755\" class=\"schema-faq-section\"><strong class=\"schema-faq-question\"><strong>10. How can Medical Billers and Coders (MBC) assist with ICD-10-CM coding?<\/strong><\/strong>\r\n<p class=\"schema-faq-answer\">MBC provides comprehensive medical billing and coding services, including assistance with ICD-10-CM coding and ensuring compliance with coding guidelines. For more information, contact MBC at <a href=\"tel:888-357-3226\">888-357-3226<\/a> or <a href=\"mailto:info@medicalbillersandcoders.com\">info@medicalbillersandcoders.com<\/a><br \/><br \/><strong>Reference:<\/strong> <a href=\"https:\/\/www.cms.gov\/files\/document\/fy-2023-icd-10-cm-coding-guidelines.pdf\">ICD-10-CM Official Guidelines for Coding and Reporting FY 2023<\/a><br \/><strong>ICD-10 CM Copyright<\/strong> @<a href=\"https:\/\/www.who.int\/classifications\/classification-of-diseases\">World Health Organization (WHO)<\/a>\u00a0<\/p>\r\n<\/div>\r\n<\/div>\r\n","protected":false},"excerpt":{"rendered":"<p>Home \u00bb Blog \u00bb Medical Coding Services \u00bb General Coding Guidelines for ICD-10-CM The general coding guidelines for ICD-10-CM come down to two rules: locate the diagnosis in the Alphabetic Index and verify it in the Tabular List, then report the code at the highest number of characters and level of specificity the record supports. [&hellip;]<\/p>\n","protected":false},"author":9,"featured_media":32607,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6569],"tags":[568,1746,4767,3792,97,3566,3102,4078,20],"class_list":["post-16155","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-coding-services","tag-billing-and-coding-services","tag-coding-guidelines","tag-coding-guidelines-for-icd-10-cm","tag-general-coding-guidelines","tag-icd-10-2","tag-icd-10-cm-code","tag-leading-medical-billing-company","tag-medical-billers-and-coders-mbc","tag-medical-billing-and-coding"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.8 (Yoast SEO v28.8) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>General Coding Guidelines for ICD-10-CM<\/title>\n<meta name=\"description\" content=\"Mastering the coding guidelines for ICD-10-CM is crucial for accurate diagnosis coding. 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Learn the tips and tricks to select the right codes.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/\" \/>\n<meta property=\"og:site_name\" content=\"Medical Billing and RCM Blogs\" \/>\n<meta property=\"article:published_time\" content=\"2023-01-03T07:49:00+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-11-02T13:36:57+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.medicalbillersandcoders.com\/blog\/wp-content\/uploads\/2023\/01\/general-coding-guidelines-for-icd-10-cm.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"1148\" \/>\n\t<meta property=\"og:image:height\" content=\"442\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Alex Peter\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Alex Peter\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"8 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":[\"Article\",\"BlogPosting\"],\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/\"},\"author\":{\"name\":\"Alex Peter\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/#\\\/schema\\\/person\\\/797b3e03da28649c3a2975caca332e13\"},\"headline\":\"General Coding Guidelines for ICD-10-CM\",\"datePublished\":\"2023-01-03T07:49:00+00:00\",\"dateModified\":\"2026-11-02T13:36:57+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/\"},\"wordCount\":1773,\"publisher\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/wp-content\\\/uploads\\\/2023\\\/01\\\/general-coding-guidelines-for-icd-10-cm.jpg\",\"keywords\":[\"billing and coding services\",\"Coding Guidelines\",\"Coding Guidelines for ICD-10-CM\",\"General Coding Guidelines\",\"icd-10\",\"ICD-10-CM code\",\"leading medical billing company\",\"Medical Billers and Coders (MBC)\",\"medical billing and coding\"],\"articleSection\":[\"Medical Coding Services\"],\"inLanguage\":\"en-US\",\"copyrightYear\":\"2023\",\"copyrightHolder\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/#organization\"}},{\"@type\":[\"WebPage\",\"FAQPage\"],\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/\",\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/\",\"name\":\"General Coding Guidelines for ICD-10-CM\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/wp-content\\\/uploads\\\/2023\\\/01\\\/general-coding-guidelines-for-icd-10-cm.jpg\",\"datePublished\":\"2023-01-03T07:49:00+00:00\",\"dateModified\":\"2026-11-02T13:36:57+00:00\",\"description\":\"Mastering the coding guidelines for ICD-10-CM is crucial for accurate diagnosis coding. Learn the tips and tricks to select the right 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What is ICD-10-CM?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a system healthcare providers use to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961807729\",\"position\":2,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961807729\",\"name\":\"2. How do I use the Alphabetical Index and Tabular List in ICD-10-CM?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"First, locate the diagnostic term in the Alphabetical Index to select a code. 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If not, additional codes may be required.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961852066\",\"position\":5,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961852066\",\"name\":\"5. Can multiple codes be used for a single condition in ICD-10-CM?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"Yes, some conditions may require multiple codes to describe the diagnosis and its effects fully. 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Two codes are typically required in coding: one for the current condition and another for the sequela.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961879245\",\"position\":7,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961879245\",\"name\":\"7. How detailed should ICD-10-CM coding be?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"Diagnosis codes should be reported with as many characters as available to achieve the highest specificity. Codes may contain 3 to 7 characters, with three-character codes acting as general categories unless further details are available.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961891481\",\"position\":8,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961891481\",\"name\":\"8. When should unspecified or symptom codes be used in ICD-10-CM?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"Unspecified or symptom codes should be used when the diagnosis is not confirmed, or the medical record lacks sufficient information to assign a more specific code. These codes are acceptable when necessary to accurately reflect the healthcare encounter.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961902936\",\"position\":9,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961902936\",\"name\":\"9. What should I do if a condition is described as \\\"impending\\\" or \\\"threatened\\\"?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"If the condition occurred, code it as a confirmed diagnosis. If it did not, use the Alphabetic Index to determine if \\\"impending\\\" or \\\"threatened\\\" terms have specific codes. If no code is available, document the underlying condition instead.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961916755\",\"position\":10,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/general-coding-guidelines-for-icd-10-cm\\\/#faq-question-1744961916755\",\"name\":\"10. How can Medical Billers and Coders (MBC) assist with ICD-10-CM coding?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"MBC provides comprehensive medical billing and coding services, including assistance with ICD-10-CM coding and ensuring compliance with coding guidelines. For more information, contact MBC at 888-357-3226 or info@medicalbillersandcoders.com.<br\\\/><br\\\/><strong>Reference:<\\\/strong> <a href=\\\"https:\\\/\\\/www.cms.gov\\\/files\\\/document\\\/fy-2023-icd-10-cm-coding-guidelines.pdf\\\">ICD-10-CM Official Guidelines for Coding and Reporting FY 2023<\\\/a><br\\\/><strong>ICD-10 CM Copyright<\\\/strong> @<a href=\\\"https:\\\/\\\/www.who.int\\\/classifications\\\/classification-of-diseases\\\">World Health Organization (WHO)<\\\/a>\u00a0\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO Premium plugin. -->","yoast_head_json":{"title":"General Coding Guidelines for ICD-10-CM","description":"Mastering the coding guidelines for ICD-10-CM is crucial for accurate diagnosis coding. 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What is ICD-10-CM?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a system healthcare providers use to classify and code all diagnoses, symptoms, and procedures recorded in conjunction with hospital care.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961807729","position":2,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961807729","name":"2. How do I use the Alphabetical Index and Tabular List in ICD-10-CM?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"First, locate the diagnostic term in the Alphabetical Index to select a code. After identifying the code, verify it in the Tabular List, which organizes codes by body systems and conditions. This ensures you assign the correct and complete code.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961823198","position":3,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961823198","name":"3. What is the importance of laterality in ICD-10-CM coding?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Laterality specifies whether a condition affects the body's left, right, or both sides. If a code for laterality is not specified, you must assign separate codes for each side or use an \"unspecified\" code if the documentation lacks details.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961835384","position":4,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961835384","name":"4. What is a combination code in ICD-10-CM?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"A combination code classifies two diagnoses: a diagnosis with a secondary manifestation or a diagnosis with a complication. It should be used when it fully identifies the condition. If not, additional codes may be required.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961852066","position":5,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961852066","name":"5. Can multiple codes be used for a single condition in ICD-10-CM?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Yes, some conditions may require multiple codes to describe the diagnosis and its effects fully. This often happens with conditions that affect various body systems, where 'use additional code' notes in the Tabular List guide the selection of secondary codes.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961866156","position":6,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961866156","name":"6. What is meant by \"sequela\" in ICD-10-CM coding?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Sequela refers to a residual condition resulting from a previous illness or injury. Two codes are typically required in coding: one for the current condition and another for the sequela.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961879245","position":7,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961879245","name":"7. How detailed should ICD-10-CM coding be?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Diagnosis codes should be reported with as many characters as available to achieve the highest specificity. Codes may contain 3 to 7 characters, with three-character codes acting as general categories unless further details are available.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961891481","position":8,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961891481","name":"8. When should unspecified or symptom codes be used in ICD-10-CM?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"Unspecified or symptom codes should be used when the diagnosis is not confirmed, or the medical record lacks sufficient information to assign a more specific code. These codes are acceptable when necessary to accurately reflect the healthcare encounter.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961902936","position":9,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961902936","name":"9. What should I do if a condition is described as \"impending\" or \"threatened\"?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"If the condition occurred, code it as a confirmed diagnosis. If it did not, use the Alphabetic Index to determine if \"impending\" or \"threatened\" terms have specific codes. If no code is available, document the underlying condition instead.","inLanguage":"en-US"},"inLanguage":"en-US"},{"@type":"Question","@id":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961916755","position":10,"url":"https:\/\/www.medicalbillersandcoders.com\/blog\/general-coding-guidelines-for-icd-10-cm\/#faq-question-1744961916755","name":"10. How can Medical Billers and Coders (MBC) assist with ICD-10-CM coding?","answerCount":1,"acceptedAnswer":{"@type":"Answer","text":"MBC provides comprehensive medical billing and coding services, including assistance with ICD-10-CM coding and ensuring compliance with coding guidelines. 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