American Medical Association - ICD-10-CM 2020 The Complete Official Codebook

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.

The AMA is committed to producing accurate and reliable materials.

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Marianne Randall, CPC, Product Manager

Karen Schmidt, BSN, Technical Director

Anita Schmidt, BS, RHIA, AHIMA-approved ICD-10-CM/PCS Trainer, Clinical Technical Editor

Leanne Patterson, CPC, Clinical Technical Editor

Karen Krawzik, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS Trainer, Clinical Technical Editor

LaJuana Green, RHIA, CCS, Clinical Technical Editor

Peggy Willard, CCS, AHIMA-approved ICD-10-CM/PCS Trainer, Clinical Technical Editor

Dr. Vikas Kumar, BHMS, CPC, CPC-H, Clinical Technical Editor

Stacy Perry, Manager, Desktop Publishing

Lisa Singley, Project Manager

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. Schmidt has expertise in ICD-10-CM/PCS, DRG, and CPT with more than 15 years experience in coding in multiple settings, including inpatient, observation, and same-day surgery. Her experience includes analysis of medical record documentation, assignment of ICD-10-CM and PCS codes, and DRG validation. She has conducted training for ICD-10-CM/PCS and electronic health record. She has also collaborated with clinical documentation specialists to identify documentation needs and potential areas for physician education. Most recently she has been developing content for resource and educational products related to ICD-10-CM, ICD-10-PCS, DRG, and CPT. Ms. Schmidt is an AHIMA-approved ICD-10-CM/PCS trainer and is an active member of the American Health Information Management Association (AHIMA) and the Minnesota Health Information Management Association.

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).

This FY 2020 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, 2019) 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 2020 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.