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ICD-10-CM Official Guidelines for Coding and Reporting FY 2016





ICD-10-CM Official Guidelines for Coding and Reporting

FY 2016



"The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).  These guidelines should be used as a companion document to the official version of the ICD-10CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings.  The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO). "

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself.  The instructions and conventions of the classification take precedence over guidelines.  These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction.

The guidelines are organized into sections. 
  • Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter specific guidelines that correspond to the chapters as they are arranged in the classification. 
  • Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. 
  • Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. 
  • Section IV is for outpatient coding and reporting.  It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.

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