Conventions and General Coding Guidelines - PART 2

Continuation of PART 1 

Includes Notes 

This note appears immediately under a three-character code title to further define, or give examples of,  the content of the category. 

Inclusion Terms

A list of terms is included under some codes. These terms are the conditions for which that code is to be used.  The terms may be synonyms of the code title, or, in the case of “other specified” codes,  the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the  Alphabetic Index may also be assigned to a code. 

Excludes Notes 

The  ICD-10-CM  has two types of excludes notes. Each type of note has a  different definition for use,  but they are all similar in that they indicate that codes excluded from each other are independent of each other. 

Excludes1 

A type1 Excludes note is pure excludes note. It means “NOT  CODED HERE!”  An  Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1  note.

Excludes2 

A type 2 Excludes note represents “Not  included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

Code Assignment and Clinical  Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a  particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.