Guided Notes

ICD-10-CM Official Guidelines

The rules that decide which diagnoses to code and in what order — first-listed diagnosis, signs and symptoms, uncertain diagnoses, combination codes, and chronic conditions.

The Official Guidelines

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The ICD-10-CM Official Guidelines for Coding and Reporting are published each year with the code set. HIPAA requires them — following them isn't optional.

Sections: • I — conventions and general + chapter-specific rules • II — selecting the principal diagnosis (inpatient) • III — reporting additional diagnoses (inpatient) • IV — outpatient services

The biggest difference between settings is how uncertain diagnoses are handled.

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