AMA CPT® Assistant - 2014 Issue 8 (August)
The ICD-10-CM Diagnosis Coding Process (August 2014)
August 2014 pages 10-12 The ICD-10-CM Diagnosis Coding Process The International Classification of Diseases has undergone numerous modifications over the years in an effort to remain current with the ever-changing medical field. The International Classification of Diseases, Tenth Revision (ICD-10) was completed by the World Health Organization (WHO) in 1992 and implemented in the United States for mortality coding and classification of death certificates in 1999. The US developed a Clinical Modification (CM) of the ICD-10 codes for medical diagnoses based on the WHO's ICD-10 and it is known as the ICD-10-CM. The ICD-10-CM code set has the ability...
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Article Overview
This article explains the structure and general diagnosis-coding workflow associated with ICD-10-CM and compares it with earlier ICD-9-CM conventions at a high level. It is aimed at coders and other health information professionals who need a practical understanding of how to approach diagnosis code lookup, cross-references, notes, and tabular verification in ICD-10-CM. The discussion focuses on broad process steps, general coding principles, and the importance of code specificity without substituting for the full article’s detailed guidance.
Why This Topic Matters
ICD-10-CM introduced more detailed diagnosis coding, so understanding the overall process helps readers evaluate how coding workflows change and why verification in the tabular list matters for accuracy and completeness.
Article Sections
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August 2014 pages 10-12
Introductory material placing the article in context and summarizing the shift from earlier diagnosis coding conventions to ICD-10-CM.
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The ICD-10-CM Diagnosis Coding Process
An overview of the diagnosis-coding workflow and the purpose of using ICD-10-CM for more detailed clinical classification.
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Essential Steps in the Diagnosis Coding Process
A stepwise outline of the general approach to finding, reviewing, and validating diagnosis information within ICD-10-CM resources.
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Step 1: Identify the Main Term in the Diagnostic Statement
Discussion of how diagnostic language is reduced to a primary term for index searching, with broad illustrative examples.
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Step 2: Locate the Main Term in the Alphabetic Index
Overview of index searching considerations such as condition, anatomy, manifestations, modifiers, and laterality.
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Step 3: Refer to Any Cross-References and Notes under the Main Term
Explanation of the role of cross-references and notes in supporting more precise code selection.
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Step 4: Refer to Any Modifiers of the Main Term
General discussion of modifiers in the Alphabetic Index and how they are organized conceptually.
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Step 5: Verify the Code Number in the Tabular List
Review of the verification step using the Tabular List and the importance of complete coding detail.
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Step 6: Code to the Highest Level of Specificity
Summary of the final specificity check and the role of complete code structure in ICD-10-CM.
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General Coding Guidelines
Broad guidance on ICD-10-CM code length, subdivision, and structural conventions, including placeholder and extension concepts.
What You Will Learn
- How ICD-10-CM differs from earlier diagnosis coding structures at a general level.
- The main stages in the ICD-10-CM diagnosis coding process.
- How coders use the Alphabetic Index and Tabular List together.
- Why cross-references, notes, and specificity review are important in diagnosis coding.
- How ICD-10-CM code structure supports more detailed classification.
Who Should Read This
- Medical coders
- Health information management professionals
- Coding educators
- Clinical documentation staff
- Revenue cycle and billing teams
Codes Discussed
Modifiers Discussed
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