American Medical Association - ICD-10-CM 2021

The ICD-10-CM: The Complete Official Codebook is designed to be an accurate and authoritative source regarding coding and every reasonable effort has been made to ensure accuracy and completeness of the content. However, the American Medical Association (AMA) makes no guarantee, warranty, or representation that this publication is accurate, complete, or without errors. It is understood that the AMA is not rendering any legal or other professional services or advice in this publication and that the AMA bears no liability for any results or consequences that may arise from the use of this book.

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Marianne Randall, CPC, Product Manager

Anita Schmidt, BS, RHIA, AHIMA-approved ICD-10-CM/PCS Trainer, Subject Matter Expert

Leanne Patterson, CPC, Subject Matter Expert

Karen Krawzik, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS Trainer, Subject Matter Expert

LaJuana Green, RHIA, CCS, Subject Matter Expert

Jacqueline R. Petersen, RHIA, CHDA, CPC, Subject Matter Expert

Stacy Perry, Manager, Desktop Publishing

Tracy Betzler, Senior Desktop Publishing Specialist

Hope M. Dunn, Senior Desktop Publishing Specialist

Katie Russell, Desktop Publishing Specialist

Kate Holden, Editor

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Ms. Patterson has more than 15 years of experience in the healthcare profession. She has an extensive background in professional component coding, with expertise in E/M coding and auditing, and HIPAA compliance. Her experience includes general surgery coding, serving as Director of Compliance, conducting chart-to-claim audits, and physician education. She has been responsible for coding and denial management in large multi-specialty physician practices, and most recently has been part of a team developing content for educational products related to ICD-10-CM. Ms. Patterson is credentialed by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC).

Ms. Green is a Registered Health Information Administrator with over 35 years of experience in multiple areas of information management. She has proven expertise in the analysis of medical record documentation, assignment of ICD-10-CM and PCS codes, DRG validation, and CPT code assignment in ambulatory surgery units and the hospital outpatient setting. Her experience includes serving as a director of a health information management department, clinical technical editing, new technology research and writing, medical record management, utilization review activities, quality assurance, tumor registry, medical library services, and chargemaster maintenance. Ms. Green is an active member of the American Health Information Management Association (AHIMA).

This FY 2021 update of the International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification (ICD-10-CM) is being published by the United States government in recognition of its responsibility to promulgate this classification throughout the United States for morbidity coding. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), published by the World Health Organization (WHO), is the foundation of ICD-10-CM. ICD-10 continues to be the classification used in cause-of-death coding in the United States. The ICD-10-CM is comparable with the ICD-10. The WHO Collaborating Center for the Family of International Classifications in North America, housed at the Centers for Disease Control and Preventions National Center for Health Statistics (NCHS), has responsibility for the implementation of ICD and other WHO-FIC classifications and serves as a liaison with the WHO, fulfilling international obligations for comparable classifications and the national health data needs of the United States. The historical background of ICD and ICD-10 can be found in the Introduction to the International Classification of Diseases and Related Health Problems (ICD-10), 2010, World Health Organization, Geneva, Switzerland.

ICD-10-CM is the United States clinical modification of the World Health Organizations ICD-10. The term clinical is used to emphasize the modifications intent: to serve as a useful tool in the area of classification of morbidity data for indexing of health records, medical care review, and ambulatory and other health care programs, as well as for basic health statistics. To describe the clinical picture of the patient the codes must be more precise than those needed only for statistical groupings and trend analysis.

ICD-10-CM far exceeds its predecessors in the number of concepts and codes provided. The disease classification has been expanded to include health-related conditions and to provide greater specificity at the sixth and seventh character level. The sixth and seventh characters are not optional and are intended for use in recording the information documented in the clinical record.

ICD-10-CM extensions, interpretations, modifications, addenda, or errata other than those approved by the Centers for Disease Control and Prevention are not to be considered official and should not be utilized. Continuous maintenance of the ICD-10-CM is the responsibility of the aforementioned agencies. However, because the ICD-10-CM represents the best in contemporary thinking of clinicians, nosologists, epidemiologists, and statisticians from both public and private sectors, when future modifications are considered, advice will be sought from all stakeholders.

All official authorized addenda since the last complete update (October 1, 2020) have been included in this revision. For more detailed information please see the complete official authorized addenda to ICD-10-CM, including the ICD-10-CM Official Guidelines for Coding and Reporting, and a description of the ICD-10-CM updating and maintenance process.

ICD-10-CM: The Complete Official Codebook 2021 is your definitive coding resource, combining the work of the National Center for Health Statistics (NCHS), Centers for Medicare and Medicaid Services (CMS), American Hospital Association (AHA), and Publisher experts to provide the information you need for coding accuracy.

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), is an adaptation of ICD-10, copyrighted by the World Health Organization (WHO). The development and maintenance of this clinical modification (CM) is the responsibility of the NCHS as authorized by WHO. Any new concepts added to ICD-10-CM are based on an established update process through the collaboration of WHOs Update and Revision Committee and the ICD-10-CM Coordination and Maintenance Committee.