In some places, the ICD-10-CM code set uses words we think we are familiar with. However, a review of the guidelines shows that some of these words have very specific definitions. Here are a few important ones to remember.
The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. Take a look at the category S33- Dislocation and sprain of joints and ligaments of lumbar spine and pelvis. This category title might be more correctly read as “dislocation and/or sprain of joints and/or ligaments of lumbar spine and/or pelvis.” So, this category works just as well for sprains of the lumbar spine as it does for dislocations of the pelvis.
The word “with” should be interpreted to mean “associated with” or “due to” when it appears anywhere in ICD-10-CM. The fourth character of the code is often designated with the number “1,” when the code description includes the word "with", while the “0” or “9” is used
to designate “without.” When this information is not included in the documentation, the default code would be “without.” For example the subcategory G43.1- Migraine with aura uses the "1" when an aura is present. G43.0- Migraine without aura uses the "0" when to designate "without" when there is no aura.
“See” and “See also”
When using the Alphabetic Index, the “see” instruction means that another term should be referenced. “See also” means that another term may be referenced, but it is not necessary. For example this is what you will see if you look up "strain" in the Alphabetic Index:
Strain, postural - see also Disorder, soft tissue, due to use
The “code also” instructional note indicates that two codes may be required to fully describe a condition, but, unlike “Code first” or “Use additional code,” the sequence depends on whichever condition is the primary reason for the encounter. A second code is not required if the other condition does not exist. If you were to look up M41.4- in the Tabular List, you would see the following:
M41.4- Neuromuscular scoliosis
Code also underlying condition
Just remember to apply the proper guidelines whenever coding with ICD-10-CM. Chapter 1 of the 2016 ICD-10 Coding for Chiropractic book covers all the important guidelines for DCs and gives examples of each. Make sure to get your copy today.