Diagnosis coding can seem daunting at first but with practice you can navigate the diagnosis coding process with ease.
1. Find the documented diagnosis
2. Determine the main term
3. Look up the main term in the Index to Diseases and Injuries (alphabetic index)
4. Verify code in the tabular list
5. Review all conventions and notes
Determining “the main term” can be difficult at times, try these tips to help you determine what part of the diagnostic phrase is the “main term”. Once you have the main term you can more accurately find your ICD-10-CM code.
When determining the main term, ask yourself these 3 questions:
1. What is the disease?
2. What is the illness?
3. What is the symptom?
There will be descriptive terms/words in the diagnostic statement and as a medical coder it is up to you to determine the main term within that diagnostic statement to begin your code lookup.
Practice differentiating between descriptive terms and main terms. Descriptive terms describe location, severity, chronic/acute, state/status, and so on.
For example, abdominal pain, pain is the main term and abdominal describes where the pain is, therefore you would begin your code lookup with pain.
Necrotizing fasciitis, necrotizing is a descriptive term therefore the main term is fasciitis.
Transitional cell carcinoma in the bladder, Transitional cell is describing the type and bladder is the location therefore the main term is carcinoma.
Descriptive terms are important and crucial to specific and accurate diagnostic coding, so do not neglect those details in your code lookup. However, knowing where to start sets you up to select the most accurate ICD-10-CM code possible and helps save you as a coder time and headache.
Always remember to verify your code choice in the tabular list, make sure you have all the characters required to be a complete code and read all instructional notes relevant to the code.
(Disclaimer: This is not a comprehensive ICD-10-CM coding article, this is intended to be helpful and to be taken as advice and not to replace comprehensive training. It is always up to you to use your professional judgement.)