The ICD-10-CM stands for the International Classification of Diseases, Tenth Revision, Clinical Modification. The ICD-10-CM is one of four major coding manuals used by medical coders. It provides codes for diagnoses, signs, symptoms, and other reasons a patient may visit a healthcare organization. In the United States, the ICD-10-CM is maintained by the National Center for Health Statistics (NCHS) and published every October.
Uses in the medical field
The ICD-10-CM is used by both outpatient and inpatient medical coders. If you are thinking about becoming a medical coder in an outpatient setting, such as, a doctor’s office, or an inpatient setting (i.e., hospital), then you will need to be proficient in ICD-10-CM coding. Proficiency starts with obtaining a certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA). These are the two most recognized medical coding certifying bodies. I encourage you to visit their website for more information on the certifications they offer.
Examples of ICD-10-CM codes
As mentioned above, the ICD-10-CM provides the codes for multiple reasons a patient may seek medical services. For example, Jane decides to go to the doctor due to daily headaches and dizziness. Then towards the end of the visit, the doctor notifies Jane, that she has been diagnosed with hypertension. After the patient checks out, the medical record is reviewed by a medical coder. Instead of sending a claim to the insurance company with the patient’s written diagnosis of hypertension, the medical coder will assign the appropriate ICD-10-CM code for the condition. In this example, the ICD-10-CM code for Jane’s diagnosis is I10.
What about a patient who comes in for a routine physical examination, and he has no medical problems? The ICD-10-CM has codes for this situation as well. For instance, Paul is described as a healthy male in his 20s with no significant medical history. Paul decides to visit his primary care doctor for a routine physical. At the end of the visit, the provider will document his findings in the medical record. Then the coder will review and see the written diagnosis of “Encounter for preventive maintenance exam”. Subsequently, the medical coder will assign a diagnosis of Z00.00, Encounter for general adult medical examination without abnormal findings. Remember patients are also seen for reasons other than illnesses and injuries.
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References
Centers for Disease Control and Prevention. (2023, June) National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). https://www.cdc.gov/nchs/icd/icd-10-cm.htm. Accessed on August 18, 2023.
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