xviii PEDIATRIC ICD-10-CM 2017: A MANUAL FOR PROVIDER-BASED CODING
B. Codes from A00.0 through t88.9, Z00 – Z99
The appropriate code(s) from A00.0 through T88.9, Z00 – Z99 must be used to identify diagnoses, symptoms, conditions, problems,
complaints, or other reason(s) for the encounter/visit.
C. Accurate reporting of ICD-10-CM diagnosis codes
For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology
which includes speciﬁc diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to
describe all of these.
D. Codes that describe symptoms and signs
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis
has not been established (conﬁrmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings Not Elsewhere Classiﬁed (codes R00 – R99) contain many, but not all codes for symptoms.
e. encounters for circumstances other than a disease or injury
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health
Status and Contact with Health Services codes (Z00 – Z99) are provided to deal with occasions when circumstances other than a
disease or injury are recorded as diagnosis or problems.
See Chapter 21, Factors influencing health status and contact with health services.
F. Level of Detail in Coding
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the
heading of a category of codes that may be further subdivided by the use of fourth, ﬁfth, sixth or seventh characters to provide
2. Use of full number of characters required for a code
A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full
number of characters required for that code, including the 7th character, if applicable.
G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
List ﬁrst the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record
to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the
ﬁrst-listed diagnosis may be a symptom when a diagnosis has not been established (conﬁrmed) by the physician.
H. Uncertain diagnosis
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar
terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as
symptoms, signs, abnormal test results, or other reason for the visit.
I. Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care
for the condition(s)
J. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or
management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80 – Z87)
may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
K. Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence ﬁrst the diagnosis, condition, problem, or other
reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the
encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign
Z01.89, Encounter for other speciﬁed special examinations. If routine testing is performed during the same encounter as a test to
evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-