This article provides general information about collecting and coding a ICD10 Diagnosis.
There are some ICD10 Diagnoses and CCI Codes that need to be coded together, and ICD10 coding guidelines apply to some diagnoses.
Determining which diagnosis to code
To find an ICD10 Diagnosis to code, try the following:
- search wiki for the dx name
- search wiki for a different name for the diagnosis, or an acronym
- find a related article and check it's
- alternate diagnosis links
- related articles links
Entering the diagnosis into CCMDB.mdb
Some diagnoses are coded as several lines of data as combined ICD10 codes.
To enter one line of data,
- If not already there, in Patient Viewer, click the ICD10 tab
- click the dropdown for type and chose one of the following
- if you know the diagnosis name verbatim, you can click into the Dx field and start typing; else, use the ICD10 Chooser form
- if you are entering an Acquired Diagnosis / Complication, enter the Dx_Date
- if the date is unavailable, check the Dx Date unknown checkbox.
- you can use the *, +, - buttons to set the date
- enter a Dx_Priority to group together combined ICD10 codes
- We will NOT code things as suspected until we have confirmation (however that's done clinically) that it's actually present.
- Instead, code the manifestation:
- Which could be a symptom, a sign, a diagnostic test abnormality
- For a tumor which isn't known yet whether it's malignant or not, then you can use (as long as it remains unknown) Neoplasm of uncertain behavior (i.e. not clear if benign or malignant), NOS
- If you know that there is a tumor in an organ, but don't yet know whether or not it's malignant, then code the clinical manifestation (as above) AND Neoplasm of uncertain behavior (i.e. not clear if benign or malignant), NOS
- If the patient dies or otherwise leaves your unit before you figure out the true cause/diagnosis, then don't try to go beyond coding the manifestation(s).
Co-coding CCI procedures and ICD10 diagnoses
There are some ICD10 Diagnoses and CCI Codes that need to be coded together.