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I. Introduction To ICD-10-CM Coding
A. History of coding
B. International Classification of Disease (ICD) Systems
II. Characteristics and Conventions of ICD-10-CM Coding
A. Organization of alphabetical index, including nonessential modifiers
B. Organization of tabular list
C. Code format and structure
1. placeholder character
2. seventh character
D. ICD-10-CM conventions
1. abbreviations and punctuation marks, such as NEC, NOS, parentheses, and slanted brackets
2. instructional notes, including excludes1 note and excludes 2 note
3. etiology, manifestation, and multiple coding, including "code first," "code also," and "use additional code"
4. cross reference terms and connecting words
III. General Coding Guidelines, Including Basic Steps of ICD-10-CM Coding
IV. Coding Certain Infectious and Parasitic Diseases
A. Sepsis, severe sepsis, and septic shock
B. Human immunodeficiency virus (HIV) disease
C. Bacterial and viral infectious agents
V. Neoplasm Coding
A. Neoplasm behavior
B. Introduction to and use of the Neoplasm Table
C. Alphabetic index instructions for neoplasm coding
D. Tabular list instructions for neoplasm coding
E. Primary and secondary site determination
VI. Coding Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism
A. Anemias
B. Coagulation defects
VII. Coding Endocrine, Nutritional, and Metabolic Diseases
A. Diabetes mellitus type 1 and type 2 and associated complications
B. Metabolic disorders
VIII. Coding Mental, Behavioral, and Neurodevelopmental Disorders
A. Alcoholism and alcohol abuse and use
B. Drug dependence and abuse
C. Other mental, behavioral, and neurodevelopmental disorders such as schizophrenia,bipolar, generalized anxiety, eating disorders
IX. Coding Diseases of the Nervous System
A. Meningitis
B. Sleep disorders
C. Alzheimer's disease
D. Pain
E. Cerebral palsy and other paralytic syndromes
F. Epilepsy
G. Migraine headache
X. Coding Diseases of the Eye and Adnexa
A. Conjunctivitis
B. Cataract
C. Glaucoma
XI. Coding Diseases of the Ear and Mastoid Process
A. Otitis media
B. Mastoiditis
C. Otosclerosis
D. Meniere's disease
E. Vertigo
F. Hearing loss
XII. Coding Diseases of the Cardiovascular System
A. Hypertension
1. benign versus malignant
2. introduction to and use of the hypertension table
3. hypertensive heart disease
4. hypertensive kidney disease and chronic kidney disease (CKD)
5. hypertensive heart disease and CKD
6. secondary hypertension
B. Ischemic heart disease
1. acute myocardial infarction (AMI) and 5th digit subclassification
2. old myocardial infarction (MI)
3. angina, atherosclerosis, and coronary artery disease (CAD)
C. Heart failure and cardiac arrest
D. Arrhythmias
E. Cerebrovascular disease such as carotid artery stenosis and cerebrovascular accident (CVA)
XIII. Coding Diseases of the Respiratory System
A. Acute upper respiratory infections
B. Influenza
C. Pneumonia
D. Acute lower respiratory infections such as acute bronchitis
E. Chronic lower respiratory infections such as emphysema, COPD, asthma
F. Respiratory failure
XIV. Coding Diseases of the Digestive System
A. Gastrointestinal ulcers and presence of helicobacter pylori (H. pylori)
B. Hernias, including reducible, irreducible, incarcerated, and strangulated
C. Gastroenteritis and cholelithiasis
D. Gastrointestinal hemorrhage
XV. Coding Diseases of the Skin and Subcutaneous Tissue
A. Cellulitis and abscesses
B. Dermatitis and eczema
C. Urticaria and erythema
D. Pressure/decubitus ulcers and non-pressure ulcers
XVI. Coding Diseases of the Musculoskeletal System and Connective Tissue
A. Direct versus indirect infection of joint
B. Seventh characters
C. Arthritis
D. Systemic lupus erythematosus
E. Dorsopathies, such as kyphosis, lordosis, and scoliosis
F. Spondylopathies, such as ankylosis, spondylosis, and spinal stenosis
G. Osteoporosis
H. Pathologic and stress fractures - Osteomyelitis
XVII. Coding Diseases of the Genitourinary System
A. Hematuria
B. Acute kidney failure and chronic kidney disease
C. Cystitis
D. Benign prostatic hypertrophy (BPH) and lower urinary tract symptoms (LUTS)
E. Disorders of breast
F. Inflammatory and noninflammatory diseases of female genital tract such as oophoritis,
endometriosis, female genital prolapse
G. Dysplasia
H. Menopause
XVIII. Coding Symptoms, Signs, and Abnormal Clinical and Laboratory Findings
A. Symptoms and signs, including those that are and are not an integral part of the disease
process
B. Coma scale
C. Altered mental status
D. Abnormal findings
E. Papanicolaou test (Pap smear) findings
F. Abnormal tumor markers
XIX. Injury Coding
A. Placeholder character
B. Seventh character
C. Traumatic fracture
D. Fracture types such as closed and open, displaced and nondisplaced, greenstick, transverse,
and comminuted
E. Malunion and nonunion of fracture
F. Dislocations and subluxations
G. Intracranial injuries
H. Internal organ injuries
I. Open wounds and crush injuries
J. Burns and corrosion, of all degrees, with extent of burns
K. Superficial injuries
L. Foreign bodies
XX. Coding Poisoning and Certain other Consequences of External Causes
A. Introduction to Table of Drugs and Chemicals
B. Adverse effect definition and common causes
C. Instructions for coding adverse effects
D. Unspecified adverse effect of a drug
E. Poisoning definition and common causes
G. Under dosing
H. Toxic effects
I. Adult and child abuse, neglect, and other maltreatment
J. Complications of surgical and medical care including mechanical complications and
transplant complications
XXI. Coding of External Causes of Morbidity
A. Introduction to the Alphabetic Index to External Causes
B. Seventh character
C. Purpose of external cause codes
D. Sequencing of external cause codes
E. Never events (serious reportable events)
XXII. Coding the Factors Influencing Health Status and Contact with Health Services
A. Purpose and use of Z codes
B. Main terms leading to Z codes
C. Z code categories
XXIII. Coding Ethics
A. AHIMA code of ethics
B. AHIMA standards of ethical coding