Medical Coding — ICD-10-CM Conventions & General Guidelines flashcards
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ICD-10-CM Index and Tabular conventions, Excludes notes, sequencing instructions, the general coding guidelines, principal and first-listed diagnosis rules for inpatient and outpatient settings, and POA indicators (FY 2027).
Learn deck · part of Medical coding: AAPC CPC and AHIMA CCA · written against: ICD-10-CM Official Guidelines and code set FY 2027 (effective 1 October 2026); CPT structure and E/M guidelines described in our own words; HCPCS Level II, NCCI and ICD-10-PCS per CMS. Updated 2026-10-10.
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Which four parts make up the ICD-10-CM Alphabetic Index?The Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals.ICD-10-CM Conventions › Index and Tabular
The Tabular List, the chaptered list of codes, is the other half of the classification (Section I.A.1). -
Where should every ICD-10-CM code search begin, and where must it end?Begin in the Alphabetic Index and confirm the code in the Tabular List.ICD-10-CM Conventions › Index and Tabular
Section IV.A warns that starting in the Tabular List leads to coding errors, and Section I.B.1 requires both parts for every code. -
An Index entry ends in a dash. What does that tell you, and why check the Tabular List even when there is no dash?The dash means more characters are required.ICD-10-CM Conventions › Index and Tabular
Laterality and any required 7th character can only be selected in the Tabular List, so even an entry without a dash must be checked there (Section I.B.1). -
A coder looks up "fracture of the femur" by starting at "Femur" in the Alphabetic Index. What is the mistake?Main terms in the Index are usually conditions, not body sites, so the search starts at Fracture.ICD-10-CM Conventions › Index and Tabular
The anatomic site is then found as a subterm under the condition. -
When are sign and symptom codes acceptable instead of a diagnosis?When the provider has not established (confirmed) a related definitive diagnosis.ICD-10-CM General Guidelines
Chapter 18 (R00–R99) holds many, but not all, of the symptom codes (Section I.B.4). -
A patient with confirmed pneumonia also has a cough and fever. Are the cough and fever coded?No: signs and symptoms that routinely accompany a disease are not coded separately.ICD-10-CM General Guidelines
Add a symptom only when it is not routinely part of the disease, or when the classification instructs you to (Sections I.B.5–6). -
The same condition is documented as both acute and chronic. How is it coded?Code both, acute (or subacute) first, when the Index lists acute and chronic as separate subentries at the same indentation level.ICD-10-CM General Guidelines
If the classification offers one combination code for both, use that instead (Sections I.B.8–9). -
How does the UHDDS define the principal diagnosis?The condition established after study to be chiefly responsible for occasioning the admission.Outpatient and Inpatient Selection › Inpatient
"After study" means the workup during the stay decides it, not just the reason first suspected at admission (Section II). -
Do the UHDDS principal diagnosis rules apply only to acute care hospitals?No: they cover all non-outpatient settings, including long-term care and psychiatric hospitals, home health, rehabilitation facilities, nursing homes and hospice.Outpatient and Inpatient Selection › Inpatient
They do not apply to hospital outpatient services or provider office visits (Sections II and IV). -
A patient admitted with abdominal pain is found to have acute appendicitis. Can the pain be the principal diagnosis?No: a Chapter 18 symptom is not principal once a related definitive diagnosis is established.Outpatient and Inpatient Selection › Inpatient
The appendicitis is principal, and the pain is integral to it (Section II.A).
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About these cards
Review status: Second-reader reviewed, with corrections applied.
Checked against:
- ICD-10-CM codes and rules checked against the ICD-10-CM Official Guidelines for Coding and Reporting FY 2027 and the FY 2027 code files (CDC/NCHS and CMS, effective 1 October 2026; public domain). Code sets change every 1 October; check the current year's books.
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