About this video

• Video Title: AMCI ICD-10-CM Coding for Beginners - Part 2
• Channel: AMCI Medical Coding Institute (AMCI)
• Speakers: Mrs. J
• Duration: 1:34:25

Overview

This video, "AMCI ICD-10-CM Coding for Beginners - Part 2," is presented by Mrs. J from AMCI Medical Coding Institute. It serves as a continuation of a series on ICD-10-CM coding, aiming to build upon the knowledge gained in Part 1. The primary goals of this presentation are to review ICD-10-CM conventions and general coding guidelines, and to provide scenarios and quizzes to test the viewer's understanding, ultimately bringing them closer to coding mastery.

Key takeaways

• ICD-10-CM Conventions: The video covers 19 conventions that are essential rules for using the ICD-10-CM coding system, including guidelines for the alphabetic index and tabular list, code structure, abbreviations (NOS and NEC), punctuation, and more.
• Abbreviations NOS and NEC: A detailed explanation is provided for "Not Otherwise Specified" (NOS), used when a diagnosis is not specific enough, and "Not Elsewhere Classifiable" (NEC), used when a diagnosis is specific but not found in the ICD-10-CM manual.
• Punctuation and Symbols: The presentation explains the use of punctuation like parentheses and brackets, and symbols like colons and shaded guides, detailing their specific functions within the coding manuals.
• General Coding Guidelines: Key general coding guidelines (Section 1B) are reviewed, including how to locate codes, the level of detail required, coding for signs and symptoms, acute vs. chronic conditions, combination codes, sequela, and more.
• Sequencing and Documentation: Emphasis is placed on sequencing codes correctly, particularly for acute vs. chronic conditions and sequela, and the importance of accurate clinical documentation by qualified healthcare professionals.

Alright, let's break down this ICD-10-CM coding video like we're studying for a big test in health class! Think of ICD-10-CM codes as a secret language doctors and hospitals use to describe exactly what's wrong with a patient. This video is like your textbook for learning that language, specifically for beginners.

What's the Big Deal? (Overview)

This video is all about the rules and conventions of ICD-10-CM coding. It's like learning the grammar and spelling of medical codes. You've already learned some basics in Part 1 (like history and how to look up codes), and this video adds more tools to your coding toolkit so you can get even better.

Cool Stuff You'll Learn (Key Takeaways)

1. ICD-10-CM Conventions: The Building Blocks

   • Imagine these are like the punctuation and special symbols in English. There are 19 of them!
   • What they are: Things like how to use the index and the main list (tabular list) together, what abbreviations mean, how to use symbols like parentheses () and brackets [], and special notes.
   • Why they matter: They make sure everyone uses the codes the same way, so there's no confusion.

2. NOS vs. NEC: Two Tricky Abbreviations

   • NOS (Not Otherwise Specified): Think of this like when a doctor says "sore throat." It's a sore throat, but they didn't say exactly what kind (like strep or viral). So, the code will be general because the doctor wasn't specific.
   • NEC (Not Elsewhere Classifiable): This is when the doctor is specific, but their specific diagnosis isn't listed in the ICD-10-CM book. It's like having a super rare condition that the book doesn't have a specific code for, so you use a general "other specified" code.
   • How to spot them: Often, codes ending in '9' or '0' can be NOS, and codes with '8' in certain spots might be NEC. The video shows you examples!

3. Punctuation and Symbols: Little Clues

   • Parentheses (): These hold extra words or descriptions that don't change the code. If a code is for "hypertension" and the parentheses say "(accelerated)" or "(benign)", it still means hypertension, and you use the same code. The extra words just give more detail but aren't essential for the code itself.
   • Brackets []: These have two jobs:
     • In the Index (the alphabetical list): They show a "manifestation code." This is a code for a symptom or condition that's caused by another condition. You can't use this code first; it's usually coded after the main illness.
     • In the Tabular List (the main code list): They enclose synonyms or extra explanations for a code. Like if a code is for "E. coli infection," the bracket might say "(E. coli)" to show it's another way to say it.
   • Colons :: These show up in the main list and mean that the words following the colon are needed to complete the code's description. It's like a fill-in-the-blank.
   • Shaded Guides: These just help you see how the codes are organized and related to each other, especially when terms are indented.

4. General Coding Guidelines: More Important Rules!

   • Where to find codes: Always look in the index first, then check in the main list (tabular list).
   • Be specific: Use the most detailed code available. If the doctor says "hypertensive chronic kidney disease," don't just use a code for "hypertension." Use the code that includes both hypertension and chronic kidney disease. Code to the highest level of detail possible based on the doctor's notes.
   • Signs & Symptoms: Usually, you don't code signs or symptoms if they are a direct part of a diagnosed illness. For example, if someone has nausea, vomiting, and abdominal pain because they have cholecystitis (gallbladder inflammation), you only code the cholecystitis. You would code separate symptoms, like foot pain, if they're unrelated.
   • Acute vs. Chronic: If a patient has both an acute (sudden/short-term) and a chronic (long-term) version of the same illness, code both, but put the acute one first. (Think: "Cute" code first!)
   • Combination Codes: If one code can describe two conditions (like diabetes with neuropathy), use that single combination code instead of two separate codes.
   • Sequela (Late Effects): This is a condition that happens long after an initial illness or injury. For example, traumatic arthritis developing months after a fractured ankle. You need two codes: one for the current condition (arthritis) and one for the original injury (fractured ankle), with a special marker ('S' for sequela) on the original injury code. The current condition is coded first.
   • Syndromes: If a patient has a diagnosed syndrome (like Klinefelter syndrome), code the syndrome itself, not just the individual symptoms that make it up. Only code the separate symptoms if the syndrome isn't diagnosed or coded.

5. Documentation is Key!

   • Only doctors and certain qualified healthcare professionals can provide the official clinical documentation for coding.
   • They need to link conditions to care if it's a complication.
   • You code based on the doctor's final diagnosis, not the tests they used to get there.
   • Important Exceptions: Things like BMI, stages of pressure ulcers, coma scales, etc., can sometimes be documented by nurses or technicians, but most clinical info needs a doctor.

Why This Matters for You

Learning these rules helps you translate what the doctor writes into the correct codes. This is super important because these codes are used for billing, tracking diseases, and making sure patients get the right care and insurance coverage. It's like being a detective, figuring out the exact medical story from the doctor's notes!

Keep practicing, and don't be afraid to rewind and re-watch parts. You got this!

I understand you're looking for a comprehensive study guide based on the AMCI ICD-10-CM Coding for Beginners - Part 2 video, with detailed explanations, examples, and visual aids like emojis, animations, and pictures directly from the video or related to the 2025 ICD-10-CM guidelines. You've also requested that the content be presented in the exact words used in the video.

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Alright, let's dive into this ICD-10-CM coding adventure! 🏥 Think of this guide as your personal cheat sheet, breaking down all the important stuff from the AMCI video "ICD-10-CM Coding for Beginners - Part 2" into super understandable terms. We'll use examples and emojis to make it stick! ✨

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Welcome Back, Coders! 👋 (Video Overview)

• What's this about? This is Part 2 of learning ICD-10-CM coding. It's like leveling up in a game! 🎮
• Who's teaching? Mrs. J from AMCI. She's your guide!
• What are we learning?
  • Reviewing the rules (conventions and guidelines) of ICD-10-CM.
  • Practicing with examples and quizzes to make sure you really get it.
• The Goal: To make you a coding pro! 🏆

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Chapter 1: Conventions - The Secret Code Rules! 🤫 (Section 1A)

Conventions are like the special symbols and grammar rules in the ICD-10-CM book. There are 19 of them! Let's look at the most important ones.

1. Alphabetic Index & Tabular List: 📚

• What it means: This is the process for finding codes. You look up the main term in the alphabetical index first, then find the exact code in the tabular list.
• How it works: Like looking up a word in a dictionary (index) and then reading the definition (tabular list).
• Emoji: 🔎➡️📖

2. Format & Structure of Codes: 🧩

• What it means: How codes are built – with letters, numbers, and sometimes decimals. Like LEGO bricks! 🧱
• Example: J06.9 (Upper respiratory infection, unspecified)

3. Use of Codes for Reporting: 📄

• What it means: You must use ICD-10-CM codes for reporting diagnoses, as required by HIPAA.
• Emoji: ✅

4. Placeholder Character 'X': ❌

• What it means: Sometimes, a code needs more characters to be specific, but there isn't a specific term. The 'X' is like a blank space filler to reach the right code length.
• Example: Think of it as "X marks the spot" to complete the code! 📍

5. Seventh Character Extenders: ➕7️⃣

• What it means: Some codes need a 7th character to show things like the episode of care (initial, subsequent, sequel). You learned about this in Part 1!
• Emoji: 🗓️

6. Abbreviations: NOS & NEC - The Tricky Duo! 🤔

• NOS (Not Otherwise Specified): 🤷‍♀️
  • Meaning: The doctor didn't give enough detail.
  • Example: Doctor says "hypertension." There are many types (heart, kidney, etc.), but if they just say "hypertension," it's NOS. You use a general code.
• NEC (Not Elsewhere Classifiable): ❓
  • Meaning: The doctor was specific, but that exact diagnosis isn't in the ICD-10-CM book.
  • Example: A super rare, specific infection that doesn't have its own code. You use a general code that means "other specified."
  • How to spot NEC codes: Often have an '8' in the 4th or 6th character, or a '9' in the 5th.
  • How to spot NOS codes: Often have a '9' in the 4th or 6th character, or a '0' in the 5th.

7. Punctuation:

• Parentheses (): Enclose words that don't change the code. They are extra descriptive words.
  • Example: Hypertension (essential) still codes to the general hypertension code. 🗣️
• Brackets []:
  • In the Index: Show a manifestation code (a symptom caused by another disease). It can't be coded first. 🤕
  • In the Tabular List: Show synonyms or alternative explanations. 🔄
• Colons :: Indicate an incomplete term. You need the words after the colon to complete the code.
  • Example: Malignant neoplasm of the tonsil: requires more info. 🎯

8. The Word "AND": ➕

• Meaning: In ICD-10-CM, "and" often means "and / or".
• Example: "Injury of unspecified urinary and pelvic organs" means the injury could be to the urinary organs or the pelvic organs or both.

9. The Word "WITH": 🤝

• Meaning: Means "associated with" or "due to." It implies a connection.
• Example: Dermatopolymyositis with myopathy suggests the myopathy is related to the main condition. A cause-and-effect link is presumed. 👍

10. "See" and "See Also": 👀

• "See": You must look up the term referenced. It's mandatory! 🚨
• "See Also": You should look up the referenced term if it provides more info, but it might not be strictly mandatory if you've already found a suitable code. 🤔

11. Code Also Notes: ➕➡️

• Meaning: Alerts you that more than one code might be needed to fully describe a condition. Follow instructional notes!
• Example: A note might say "Code also any associated seizure." You need documentation to code the seizure. 📝

12. Default Codes: 💯

• Meaning: The code listed directly next to the main term in the index. It's the code you use if no further specificity is provided.
• Example: For "Hypertension," if I10 is listed next to it, I10 is the default code.

13. Code Assignment & Clinical Criteria: 👨‍⚕️

• Meaning: Codes are based on the doctor's final diagnosis statement, not the tests or criteria they used to arrive at that diagnosis. Code what the doctor says, not how they figured it out.

Special Symbols: (These might be seen in the manual)

• Dot (•): Indicates a new code. ✨
• Triangle (▲): Indicates a revised code title. ✏️
• Inverted Triangles (▼...▼): Indicate revised text within a code description. ↔️

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Chapter 2: General Coding Guidelines - More Important Rules! 🚦 (Section 1B)

These guidelines help you code accurately when things aren't straightforward.

1. Locating a Code: 🗺️

• Rule: Always look in the alphabetic index first, then verify in the tabular list. Never skip the verification step!
• Emoji: Index ➡️ Tabular List = ✅

2. Level of Detail in Encoding: 📏

• Rule: Code to the highest level of specificity possible based on the documentation. Use all available characters.
• Example: If the doctor diagnoses "Hypertensive CKD" (Chronic Kidney Disease), find the code that specifies both hypertension and CKD, not just a general hypertension code. 📈
• Caution: Don't make assumptions! Code only what's documented. 🚫

3. Code Series: 🔢

• Meaning: Codes range from A00 to Z99.8. This guideline just defines the scope of ICD-10-CM codes.

4. Signs & Symptoms: 🤒

• What they are: Signs are observable by the doctor (e.g., a rash, coma). Symptoms are reported by the patient (e.g., headache, pain). Often used interchangeably in coding.
• Rule: You can code signs and symptoms if there's no definitive diagnosis. ✅
• Rule: You do NOT code signs and symptoms if they are integral to a diagnosed disease.
  • Example: Nausea, vomiting, and abdominal pain are integral to cholecystitis (gallbladder inflammation). Code only cholecystitis. ❌
  • Example: If foot pain is present along with cholecystitis but is unrelated, you code both the cholecystitis and the foot pain. 👣➕

5. Conditions Not Integral to a Disease Process: (See point 4 above) 👍

6. Multiple Coding for a Single Condition: ✌️

• Meaning: Sometimes, you need more than one code to fully describe a condition, often indicated by "Code Also" notes or specific guidelines (like for manifestations). Follow the instructions! 📝

7. Acute & Chronic Conditions: 🤒➡️😌

• Rule: If both acute and chronic versions of a condition are present, code both.
• Sequencing: Code the ACUTE condition FIRST. (Think: "Cute" code first! 😉)
• Example: Acute tonsillitis and Chronic tonsillitis. Code Acute first, then Chronic.
  • Acute Tonsillitis: J03.90
  • Chronic Tonsillitis: J35.01
  • Correct Order: J03.90, J35.01

8. Combination Codes: 🔗

• Rule: Use a single combination code if available to describe two related conditions, instead of using two separate codes.
• Example: Instead of coding "Diabetes" and "Neuropathy" separately, use the code for "Diabetic Neuropathy" if it exists.

9. Sequela (Late Effects): ⏳➡️🤕

• Meaning: A condition that arises as a direct consequence of a past illness or injury (e.g., arthritis after a fracture).
• Coding: Requires TWO codes:
  1. Code the current condition (e.g., traumatic arthritis).
  2. Code the sequela of the original injury (e.g., the fractured ankle), using a 7th character extender like 'S' for sequela.
• Sequencing: Code the current condition (what the patient is being treated for now) FIRST, then the sequela code.
• Example: Traumatic arthritis of the left ankle (sequela of a past fracture).
  • Code 1 (current condition): M12.572 (Traumatic arthropathy, left ankle and foot)
  • Code 2 (sequela of injury): S82.892S (Other fracture of left lower leg, Sequela)

10. Impending or Threatened Conditions: ⚠️

• Rule: If a condition did not actually occur, look for codes for "impending" or "threatened" conditions (like threatened abortion). If it did occur, code it as confirmed.

11. Reporting the Same Diagnosis More Than Once: 🔁

• Rule: You should only code a diagnosis ONCE, even if it's documented in multiple places (like ED notes, operative reports, discharge summaries).

12. Laterality: (Left vs. Right) 👈👉

• Meaning: Coding whether a condition affects the right, left, or both sides of the body.
• How it's shown: Often indicated by the 4th, 5th, or 6th character in the code.
  • 1 = Right
  • 2 = Left
  • 3 = Bilateral (both sides)
• Example: H11.21 (Conjunctival adhesions and strands) might have codes like H11.211 (right eye), H11.212 (left eye), H11.213 (bilateral).

13. Documentation by Clinicians Other Than the Patient's Provider: 🧑‍⚕️ vs. 👩‍⚕️

• General Rule: Only physicians (MD, DO) and qualified healthcare practitioners (like Nurse Practitioners, Physician Assistants) can provide clinical documentation for coding.
• Exceptions: Specific categories like BMI, depth/stages of pressure ulcers, coma scale, Glasgow coma scale, and NIH stroke scale CAN be documented by others (like RNs, technicians) and used for coding.

14. Syndromes: 🧑‍🤝‍🧑

• Meaning: A group of signs and symptoms that occur together.
• Rule: Code the syndrome itself if it's diagnosed. Don't code the individual signs/symptoms separately unless the syndrome isn't diagnosed.
• Example: Code "Klinefelter syndrome" directly, not separately for hypogonadism or gynecomastia if Klinefelter is diagnosed.

15. Documentation of Complications of Care: 🏥

• Rule: If a complication occurs during care, the provider must link the complication to the care received. Coders don't assume the link; query the physician if unclear. ❓

16. Borderline Diagnoses: 🤔

• Rule: If a diagnosis is "borderline," code it as borderline. Look for terms like "borderline diabetes." If no specific borderline code exists, query the physician.

17. Use of Signs, Symptoms, and Unspecified Codes: 🤷

• Rule: It's okay to use signs/symptoms or unspecified (NOS) codes when no definitive diagnosis is documented or when the documentation lacks specificity.

18. Coding for Healthcare Encounters (e.g., Hurricane Aftermath): 🌪️

• Meaning: These are often "external causes" codes that explain how, why, or where an illness or injury occurred, especially in disaster situations. They are NOT diagnosis codes themselves but add context.

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Putting It All Together! 🚀

This video is packed with essential rules! Remember to:

• Read carefully: Pay attention to the specific wording in the guidelines and documentation.
• Use both Index and Tabular List: Always verify.
• Code to the highest specificity: Don't use general codes if specific ones are available and documented.
• Follow the sequencing rules: Acute before chronic, current condition before sequela.
• Know your abbreviations: NOS vs. NEC is crucial!
• Don't assume: If unsure, query the physician.

Keep reviewing these notes, and you'll be coding like a pro in no time! You've got this! 💪

Okay, let's flesh out those notes with more specific code examples and direct references from the transcript, as if we're building a super-detailed study guide! 🧐

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AMCI ICD-10-CM Coding for Beginners - Part 2: The Ultimate Study Guide 🚀

Video: AMCI ICD-10-CM Coding for Beginners - Part 2 Channel: AMCI Medical Coding Institute (AMCI) Instructor: Mrs. J Duration: 1:34:25

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Part 1: ICD-10-CM Conventions - The Codebook's Grammar Rules! 📖 (Referenced Guideline: Section 1A)

Conventions are the essential rules that dictate how to use the ICD-10-CM codebook. Mrs. J emphasizes that these are not suggestions; they must be followed. (Timestamp: ~4:31)

1. Alphabetic Index and Tabular List: 🔎➡️📖

• Core Concept: The fundamental process for looking up codes.
• Guideline: "you have to look up the code in the index first followed by the tabular list." (Timestamp: ~9:43)
• Example: To code "Hypertension," you'd first find "Hypertension" in the Alphabetic Index, which might lead you to code I10. Then, you'd verify I10 in the Tabular List to ensure it's the correct code for the documentation.

2. Format and Structure of ICD-10-CM Codes: 🧩

• Core Concept: Codes have a specific structure (alphanumeric, up to 7 characters, with decimals).
• Example: J06.9 (Upper respiratory infection, unspecified) shows the typical format: Letter, two numbers, decimal, one or more numbers.

3. Use of Codes for Reporting Purposes: 📄

• Core Concept: ICD-10-CM codes are mandatory for reporting diagnoses, as directed by HIPAA.
• Reference: Mrs. J states, "...we have to use icd-10-cm codes as per directed by hipaa..." (Timestamp: ~10:09)

4. Placeholder Character 'X': ❌

• Core Concept: Used when a code requires more characters for specificity, but no specific term exists.
• Reference: Mrs. J mentions, "...your placeholder character remember x marks the spot we talked about that..." (Timestamp: ~10:16)
• Purpose: To fill the space and allow for future code expansion or to meet specific sequencing requirements.

5. Seventh Character Extenders: ➕7️⃣

• Core Concept: Additional characters required for certain codes to indicate the episode of care (e.g., initial encounter, subsequent encounter, sequela).
• Reference: Mentioned as part of the conventions review. (Timestamp: ~10:23)

6. Abbreviations: NOS and NEC - The Crucial Distinction! 🤔

• NOS (Not Otherwise Specified): 🤷‍♀️
  • Meaning: "the doctor was not specific in their diagnosis." (Timestamp: ~11:10)
  • Example: Doctor documents "Hypertension." Mrs. J explains there are many types, but if unspecified, the code will be NOS. (Timestamp: ~11:15 - ~11:39)
  • Coding Clue: Often indicated by a '9' in the 4th or 6th character, or a '0' in the 5th. (Timestamp: ~16:02 - ~16:09)
• NEC (Not Elsewhere Classifiable): ❓
  • Meaning: "the doctor was specific but that diagnosis... is not in icd-10-cm it's not in the manual." (Timestamp: ~11:54 - ~12:04)
  • Example: A diagnosis of "Bubble gum phobia." Mrs. J demonstrates looking this up: You find "Phobia," then look for specific types. If "Bubble gum phobia" isn't listed, you use the NEC code. The transcript shows an example potentially leading to F40.8 (Other phobic disorders). (Timestamp: ~13:55 - ~14:48)
  • Coding Clue: Often indicated by an '8' in the 4th or 6th character, or a '9' in the 5th. (Timestamp: ~13:55 - ~14:08)

7. Punctuation:

• Parentheses (): Enclose "non-essential modifiers or supplementary words that may be present or absent... without affecting the code." (Timestamp: ~25:32)
  • Example: For "Hypertension," terms in parentheses like "(accelerated)", "(benign)", "(essential)", "(idiopathic)", "(malignant)" all direct to the same default code I10. (Timestamp: ~26:34 - ~26:59)
• Brackets []:
  • In Alphabetic Index: Enclose "manifestation codes" - conditions related to an underlying illness. These "cannot be a principal diagnosis." (Timestamp: ~27:51 - ~28:27)
  • In Tabular List: Enclose "synonyms, alternative wording or explanatory phrases." (Timestamp: ~28:52)
    • Example: For code B96.22 (Other specified toxin producing Escherichia coli E coli), the bracket around "E coli" shows it's a synonym. (Timestamp: ~29:19)
• Colons :: "used in the tabular list after an incomplete term that needs one or more of the modifiers following that colon to make it assignable to a given category." (Timestamp: ~30:02)
  • Example: C09 Malignant neoplasm of the tonsil: indicates that further terms are needed to specify the exact site or type. (Timestamp: ~30:19)

8. The Word "AND": ➕ (Timestamp: ~33:44)

• Guideline: "whenever you see this word and in icd-10-cm and means both and or." (Timestamp: ~33:44 - ~33:51)
• Reference: Guideline A8 and A14. (Timestamp: ~25:80 - ~26:03)
• Example: "Injury of unspecified urinary and pelvic organs" means injury to urinary organs OR pelvic organs OR both.

9. The Word "WITH": 🤝 (Timestamp: ~43:23)

• Guideline: "when you see the term with it has the same meaning as in associated with or due to." (Timestamp: ~43:30)
• Core Concept: Implies a presumed causal relationship.
• Example: Dermatopolymyositis with myopathy implies the myopathy is associated with or due to the dermatopolymyositis. (Timestamp: ~43:45)

10. "See" and "See Also": 👀 (Timestamp: ~44:43)

• "See": "you must go see it you gotta do it" (Timestamp: ~44:56) - Mandatory cross-reference.
• "See Also": "it's not necessary especially if you are given what you perceive as the correct code." (Timestamp: ~45:03) - Optional cross-reference.

11. Code Also Notes: ➕➡️ (Timestamp: ~45:35)

• Core Concept: Alerts the coder that more than one code may be appropriate to fully describe the condition. Follow instructional notes.
• Example: For code G04.8 (Other encephalitis, myelitis and encephalomyelitis), there's a "Code also" note: "Code also any associated seizure." (Timestamp: ~46:36)
  • Important: The seizure must be documented to be coded. (Timestamp: ~46:46)

12. Default Codes: 💯 (Timestamp: ~48:16)

• Core Concept: The code listed next to the main term in the index.
• Reference: Guideline A18. (Timestamp: ~48:16)
• Example: For "Hypertension," the default code is I10 if it's listed directly next to the main term. (Timestamp: ~48:49)

13. Code Assignment and Clinical Criteria: 👨‍⚕️ (Timestamp: ~49:16)

• Guideline: "your code assignment will be based upon the doctor's final diagnostic statement... what the doctor says not those items or that criteria that the doctor uses to make the decision but what the doctor says." (Timestamp: ~49:23 - ~49:35)
• Core Concept: Code the final diagnosis, not the process of diagnosis.

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Part 2: General Coding Guidelines - The Practical Rules! 🚦 (Referenced Guideline: Section 1B)

These guidelines provide practical instructions for coding various scenarios.

1. Locating a Code: (Referenced Guideline: B1) 🗺️

• Rule: "you look first in the alphabetic index then you verify that code in the tabular list that is what guideline b1 says." (Timestamp: ~1:00:18 - ~1:00:24)

2. Level of Detail in Encoding: 📏 (Referenced Guideline: B2)

• Rule: "codes ... are to be used and reported at their highest number of characters possible... Code according to the highest level of specificity." (Timestamp: ~1:00:46 - ~1:00:52)
• Example: For "Hypertensive CKD," code the most specific combination, not just a general code for hypertension or CKD. Mrs. J shows finding I12.9 (Hypertensive chronic kidney disease with stage 1 through stage 3 chronic kidney disease, or unspecified chronic kidney disease) is more specific than just I10 (Essential hypertension). (Timestamp: ~1:01:37)
• Caution: "be only as specific as the doctor don't go overboard don't assume anything code your documentation." (Timestamp: ~1:02:17)

3. Code Series: (Referenced Guideline: B3) 🔢

• Reference: Covers codes A00 through Z99.8.

4. Signs and Symptoms: 🤒 (Referenced Guideline: B4)

• Definition: Symptoms are patient-reported (headache); Signs are doctor-observed (coma). (Timestamp: ~1:03:10 - ~1:03:39)
• Rule: Code signs and symptoms if no definitive diagnosis is made. (Timestamp: ~1:03:52)

5. Conditions Integral to a Disease Process: (Referenced Guideline: B5) ❌

• Rule: "you do not code signs and symptoms if they are related or integral to a diagnosis or a disease process." (Timestamp: ~1:04:27)
• Example: Patient has nausea, vomiting, and abdominal pain, diagnosed with cholecystitis. Only code cholecystitis. The symptoms are integral. (Timestamp: ~1:04:47)

6. Conditions NOT Integral to a Disease Process: (Referenced Guideline: B6) ✅

• Rule: Code conditions that are NOT related or integral to the primary diagnosis.
• Example: Patient has cholecystitis (with integral symptoms like nausea/vomiting/pain) AND foot pain. Code both cholecystitis and foot pain because the foot pain is unrelated. (Timestamp: ~1:07:09)

7. Multiple Coding for a Single Condition: (Referenced Guideline: B7) ✌️

• Core Concept: May need additional codes for a single condition, often directed by instructional notes (like for manifestations).

8. Acute and Chronic Conditions: (Referenced Guideline: B8) 🤒➡️😌

• Rule: If both acute and chronic conditions exist, code both.
• Sequencing: Code the ACUTE condition FIRST.
• Example: Patient with Chronic tonsillitis and Acute tonsillitis.
  • Mrs. J shows: Acute tonsillitis J03.90, Chronic tonsillitis J35.01.
  • Correct Sequencing: J03.90 (acute) first, then J35.01 (chronic). Reversing them is incorrect. (Timestamp: ~1:09:18)
  • Mnemonic: "sequence the cute one first" (referencing an "acute" monster). (Timestamp: ~1:09:58)

9. Combination Codes: (Referenced Guideline: B9) 🔗 (Timestamp: ~1:10:23)

• Rule: Use a single code to identify two or more conditions when available, instead of separate codes.
• Example: "Diabetes and neuropathy" should be coded with a combination code like "Diabetic neuropathy" if available, rather than two separate codes.

10. Sequela or Late Effects: (Referenced Guideline: B10) ⏳➡️🤕 (Timestamp: ~1:11:36)

• Meaning: A condition that follows as a direct result of a past illness or injury. "Sequela is the sequel of a illness." (Timestamp: ~1:11:49)
• Coding Requirements:
  • Requires TWO codes.
  • Code the current condition (e.g., traumatic arthritis) first.
  • Code the sequela of the acute injury second, using a 7th character extender 'S'.
• Example: Patient has traumatic arthritis in the left ankle months after a fractured ankle.
  • Code 1 (Current Condition): M12.572 (Traumatic arthropathy, left ankle and foot) - Mrs. J details finding this code and needing the 6th character for ankle/foot, then discovering it needs 7 characters. (Timestamp: ~1:15:36 - ~1:16:30)
  • Code 2 (Sequela of Injury): S82.892S (Other fracture of left lower leg, Sequela) - Mrs. J explains needing the 7th character 'S' from the extender box because it's a sequela. (Timestamp: ~1:17:39 - ~1:18:04)
  • Sequencing: Condition first (M12.572), then sequela (S82.892S). (Timestamp: ~1:18:19)

11. Impending or Threatened Conditions: (Referenced Guideline: B11) ⚠️

• Rule: If a condition did not occur, look for "impending" or "threatened" codes. If it did occur, code it as confirmed.

12. Reporting the Same Diagnosis More Than Once: (Referenced Guideline: B12) 🔁

• Rule: Do NOT code the same diagnosis multiple times, even if documented in various places. Code it once.

13. Laterality: (Referenced Guideline: B13) 👈👉 (Timestamp: ~1:21:04)

• Core Concept: Specifying left, right, or bilateral.
• How it's indicated: 4th, 5th, or 6th character.
  • 1 = Right
  • 2 = Left
  • 3 = Bilateral
• Example: H11.21 (Conjunctival adhesions and strands) might have specific codes for right (1), left (2), or bilateral (3) eyes. (Timestamp: ~1:21:47)

14. Documentation by Clinicians Other Than Patient's Provider: (Referenced Guideline: B14) 🧑‍⚕️ vs. 👩‍⚕️ (Timestamp: ~1:22:16)

• General Rule: Only Physicians (MD/DO) and Qualified Healthcare Practitioners (NPs, PAs) can provide clinical documentation for coding.
• Exceptions (can be documented by others): BMI, depth/stages of non-pressure ulcers, pressure ulcer stages, coma scale, Glasgow coma scale, NIH stroke scale. (Timestamp: ~1:23:35)

15. Syndromes: (Referenced Guideline: B15) 🧑‍🤝‍🧑

• Rule: If a syndrome is diagnosed (e.g., Klinefelter syndrome), code the syndrome itself, not the individual symptoms, unless the syndrome isn't diagnosed. (Timestamp: ~1:27:18)

16. Documentation of Complications of Care: (Referenced Guideline: B16) 🏥

• Rule: Provider must link complications to care. Coders should query if the link isn't documented.

17. Borderline Diagnoses: (Referenced Guideline: B17) 🤔

• Rule: Code borderline diagnoses as borderline. Query physician if no specific code exists.

18. Use of Signs, Symptoms, and Unspecified Codes: (Referenced Guideline: B18) 🤷

• Rule: It is acceptable to use signs/symptoms or unspecified (NOS) codes when documentation lacks specificity. (Timestamp: ~1:29:22)

19. Coding for Healthcare Encounters (e.g., Hurricane Aftermath): (Referenced Guideline: B19) 🌪️ (Timestamp: ~1:30:01)

• Core Concept: Relates to "external causes" codes that describe circumstances of illness/injury (how, why, where), not the diagnosis itself.

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Final Thoughts & Next Steps 🏁

• Mrs. J congratulates the viewers for completing Part 2! 🎉
• She emphasizes the importance of nailing the "first listed code" in Part 3. (Timestamp: ~1:33:53)
• The video concludes by encouraging viewers to take a break before moving on to Part 3.

This guide covers the key points, examples, and rules Mrs. J presented. Remember, consistent practice and careful attention to documentation are your best tools for mastering ICD-10-CM coding! 👍