How to find perfect ICD 10 code without using Google

Medical coders have always in search of correct ICD 10 codes and CPT codes. Medical coding is all about finding the right diagnosis codes and procedures codes. If you are into medical coding, you will know the importance of these codes.

ICD 10 codes are the most important ones to be coded perfectly, because the ICD 10 diagnosis should be able fulfill the medical necessity requirement for procedure codes. When the diagnosis or ICD 10 codes fulfill the medical necessity for CPT codes, then only the payer or insurance companies give the correct and proper reimbursement.

Now, coming to ICD 10 codes, we know while coding diagnosis we are always in double mind for finding the correct ICD 10 codes. But, nowadays many medical coders have find a shortcut method to find a correct ICD 10 code in few seconds. Yes, Google search is the option for everyone to find the correct ICD 10 code.

But, you should always remember Google does not follow ICD 10 coding guidelines, it follows its own alogrithm. Hence, it will be good not to use this step to find the ICD 10 codes.

Today, I will share some easy methods to find the correct ICD 10 codes if you have a ICD 10 code-book or any coding software like Trucode, 3M etc.

Follow the main “keyword”

Here, the keyword represent the main term to find the correct ICD 10 code. For example, in Chest pain, pain is the keyword in the index. When you search ICD 10 code book, you will see different main terms like disease, disorder, syndrome etc. in each aphabetic index. Now, if you have want search for COPD (Chronic Pulmonary Obstructive disease) ICD 10 code, you have to go to the search main term “disease” and then below disease you have to look for pulmonary and then chronic obstructive word. Always go with main term first and then look for the anatomic region for disease.

If you have a coding software, you can directly type the disease name and find the correct ICD 10 code.

Avoid coding Manifestation codes Primary

Their are certain ICD 10 coding guidelines which needs to be followed strictly. For example, the manifestation codes as per coding guidelines should not be reported primary diagnosis. The manifestation needs a primary diagnosis which needs to be coded first followed by the manifestation codes.

For example, the D63.0 describes the manifestation of an underlying disease, not the disease itself, but while coding this code it asks to code the Neoplasm (C00-D49) first note is given below this code. Around 395 manifestation codes have been added on October 2019. Below are few manifestation ICD 10 codes which requires a main primary diagnosis to code first. Most of them are diabetes codes added newly this year. The keyword “due to underlying condition” will be mostly present in the manifestation codes.  The note below this manifestation codes will guide you to the primary diagnosis followed by the manifestation ICD 10 code.

D63.0 Anemia in neoplastic disease
D63.1 Anemia in chronic kidney disease
D63.8 Anemia in other chronic diseases classified elsewhere
D64.1 Secondary sideroblastic anemia due to disease
D75.81 Myelofibrosis
D77 Other disorders of blood and blood-forming organs in diseases classified elsewhere
E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma
E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma
E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma
E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy
E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease
E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication
E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema

Read also: Top common ICD 10 coding errors by medical coders

Search for “Encounter” “Aftercare” “Status” & “history” for Finding Z codes

Z codes are the main problems for medical coders, because you will not find Z codes directly in software. Hence, many coders use google to find the perfect Z ICD 10 codes.

But, it is easy to find the Z code if you search with main term Encounter, aftercare, status or History, depending on the documentation in the medical report. 

But remember, Encounter Z codes should be always primary and First listed diagnosis, while status and history codes should be always secondary diagnosis.

Personal or family history codes should be coded with Follow up ICD 10 code Z08 or Z09 as primary diagnosis as per coding Guidelines.

Look for “with” ,”complicated by”, “complicating” or “due to” keywords

While searching for ICD 10 diagnosis codes, you have to remember that their are many combination codes which represent two or more diagnosis. As per ICD 10 coding guidelines, coders need to use a combination code when the documentation support coding two diagnosis with a single ICD 10 combination codes. 

For example, hypertension and Chronic kidney disease when documented in the medical report, should be coded as combination code. As per coding guidelines coders can assume a relationship between hypertension and chronic kidney disease and use I12 series code for Hypertensive chronic kidney disease.

Look for keyword “with” to find a combination code for two or more disease.  For Hypertensive chronic kidney disease, you can go through “disease” or “hypertension” main term and see the “chronic ” & “with” term under which you will get renal or kidney term. You can even code the combination code for hypertensive heart renal disease like this. 

Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10
           with
                      heart failure (congestive) I11.0
                       heart involvement (conditions in I50.-, I51.4- I51.9 due to hypertension)
                       kidney involvement – see Hypertension, kidney

To search a combination code you will come across either “with” or “complicated by” keyword to find the perfect ICD 10 codes. Pregnancy complication codes are also a combination code indirectly including the diagnosis and the trimester.

Pregnancy (single) (uterine)

       complicated by (care of) (management affected by)
               abnormal, abnormality
               cervix O34.4-
               causing obstructed labor O65.5
               cord (umbilical) O69.9
               fetal heart rate or rhythm O36.83-