Health Information Management

Become familiar with structure, organization, and unique features of ICD-10-CM

JustCoding News: Inpatient, April 28, 2010

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It may be too early to start intensive ICD-10-CM training for your coding team, but now is a good time for your coders to at least become familiar with features of the new coding system.

On March 23, CMS hosted a Basic Introduction to ICD-10-CM National Provider Call, during which Sue Bowman, RHIA, CCS, director of coding policy and compliance at the American Health Information Management Association addressed features of ICD-10 codes and gave examples to illustrate the significant detail this new system will be provide. (Note: You can access CMS’ Web site to view the presentation and transcript for this call.)

Combination codes

“One of the great new features of ICD-10-CM is the creation of combination codes for conditions and common associated symptoms or manifestations,” Bowman said during the call. “This allows one code to be assigned rather than multiple codes and provides a clear linkage between the underlying condition and the associated symptom or manifestation.”

For example, ICD-10-CM codes combine poisonings and associated external causes. Consider these additional examples of combination codes:

  • I25.110 (atherosclerotic heart disease of native coronary artery with unstable angina pectoris)
  • E11.311 (type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema)
  • K71.51 (toxic liver disease with chronic active hepatitis with ascites)
  • K50.012 (Crohn’s disease of small intestine with intestinal obstruction)
  • N41.01 (acute prostatitis with hematuria)

Seventh digit

When a code has an applicable seventh character, coders must report this code with the appropriate seventh character for the code to be valid, Bowman said. When the code doesn’t have a sixth character, for example, coders still need to report an ‘x’ as a placeholder in the sixth position and report the appropriate seventh character.

The seventh digit often conveys information about the patient encounter, Bowman said. For example the seventh digit of injury codes identifies whether this is the initial encounter for the injury, a subsequent encounter, or sequelae (i.e., late effect).

For obstetric codes, the seventh digit may be used in cases of multiple gestations to identify the fetus to which the code applies. For fractures, the seventh character can be used to specify routine versus delayed healing or malunion versus nonunion.
Note the following seventh character values for fracture codes in ICD-10-CM:

  • A: Initial encounter for closed fracture
  • B: Initial encounter for open fracture
  • D: Subsequent encounter for fracture with routine healing
  • G: Subsequent encounter for fracture with delayed healing
  • K: Subsequent encounter for fracture with nonunion
  • P: Subsequent encounter for fracture with malunion
  • S: Sequela

Code organization

ICD-10-CM also shuffles around various codes, so the organization might be different from what coders are accustomed.

Injuries in ICD-9-CM are grouped according to the type of injury (e.g., fractures, dislocations, sprains and strains). However, ICD-10-CM organizes injury codes according to the anatomical site (e.g., head, neck, thorax). To illustrate this point, note the following codes:


  • Fractures (codes 800–829)
  • Dislocations (codes 830–839)
  • Sprains and strains (codes 840–848)


  • Injuries to the head (codes S00–S09)
  • Injuries to the neck (codes S10–S19)
  • Injuries to the thorax (codes S20–S29)

Increased specificity

By now you’ve probably heard coding experts touting ICD-10-CM’s increased specificity, but have you had an opportunity to actually look at some of the code descriptions? With just a brief glance, you can see the degree of detail contained in code descriptions is significant.

For example, code S72.044G is the ICD-10-CM code for a nondisplaced fracture at the base of the neck of the right femur, subsequent encounter for closed fracture with delayed healing.

“You can see how much more information is in that code that you know about the patient that you don't get from many of the current ICD-9-CM diagnosis codes,” Bowman said during the call.

Likewise, consider the following codes that also illustrate the greater specificity ICD-10-CM provides:

  • I69.351 (sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side)
  • Z47.81 (encounter for orthopedic aftercare following surgical amputation)
  • Z48.21 (encounter for aftercare following heart transplant)

Coding example

To help illustrate the similarities between the processes for coding with ICD-9-CM and ICD-10-CM, Bowman took a step-by-step approach in explaining how coders would arrive at certain ICD-10-CM codes.

For example, how would you find the code for dislocation, jaw, subsequent encounter?

First, you would look up the term “dislocation” in the Alphabetic Index, where you would see:

Dislocation (articular)

jaw (cartilage) (meniscus) S03.0

Then you would verify the code in the Tabular Index, where you would see:

S03 Dislocation and sprain of joints and ligaments of head

The appropriate 7th character is to be added to each code from category S03:

A (initial encounter)
D (subsequent encounter)
S (sequela)

S03.0 Dislocation of jaw

Dislocation of jaw (cartilage) (meniscus)
Dislocation of mandible
Dislocation of temporomandibular (joint)

After confirming that code S03.0 is the correct code, it’s important to note that this code requires a seventh character.

“S03.0 is only four digits long. So it requires a placeholder ‘x’ in both the fifth and the sixth character positions in order to put the ‘D,’ for the subsequent encounter, in the seventh character position,” Bowman said.

Coder training

According to the CMS call, intensive coder training should begin six to nine months prior to the October 1, 2013 implementation date. And according to the presentation, 16 hours of ICD-10-CM training will likely be adequate for most coders:

  • Six hours learning the fundamentals of ICD-10-CM to understand the code structure conventions, related coding guidelines, and how ICD-10-CM is different from ICD-9-CM
  • Six hours of more intensive training applying ICD-10-CM coding conventions and guidelines
  • Four hours practicing applying the ICD-10-CM codes to typical encounters in their organization to gain proficiency in code assignments

“Acquiring knowledge months or years before it’s applied is not efficient, as this inevitably results in varying amounts of follow-up and retraining that consumes additional training resources,” said Bowman, who emphasized that right now coders should focus on learning about the structure, organization, and unique features of ICD-10-CM.

Bowman also suggests providers use assessment tools to identify strengths and weaknesses among staff members regarding anatomy, physiology, pathophysiology, pharmacology, and medical terminology.

“Assessing individual competence allows the organization to focus on prioritized training resources, and provide training where it is most needed, and tailor the training plan to the individual,” Bowman said.

Editor’s note: E-mail your questions to Managing Editor Doreen Bentley at To learn more about ICD-10 or to read about recent ICD-10 news, including reports from the 2010 ICD-10 Summit in Washington, DC, April 12–13, subscribe to the ICD-10 Watch blog by JustCoding.

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