Top Medical Diagnoses with Detailed ICD-10 Codes and Clinical

Justifications

Symptoms & Acute Conditions

1. Heartburn

• R12 – Pyrosis (standard code covering all heartburn cases)

2. Abdominal Pain, NOS

• R10.0 – Pain localized to upper abdomen

• R10.2 – Pain localized to lower abdomen
• R10.3 – Generalized abdominal pain
• R10.9 – Abdominal pain, unspecified

Justification: Use most specific quadrant code when known; otherwise use NOS.

3. Epigastric Pain

• R10.13 – Epigastric pain

• R10.11 – RUQ pain if overlapping
• R10.4 – Used when truly generalized

4. Abdominal Pain, Generalized

• R10.4 – Generalized abdominal pain

• R10.9 – Unspecified if further detail is unavailable

5. LUQ Pain

• R10.12 – Left upper quadrant pain

• R10.9 – Use unspecified if quadrant not documented
6. LLQ Pain

• R10.32 – Left lower quadrant pain

• R10.9 – Unspecified

7. RUQ Pain

• R10.11 – Right upper quadrant pain

• R10.9 – Unspecified

8. RLQ Pain

• R10.31 – Right lower quadrant pain

• R10.9 – Unspecified

9. Fever

• R50.0 – Subfebrile fever (99–100.3°F)

• R50.1 – Fever with raised temperature unspecified
• R50.9 – Fever, unspecified

10. Cough

• R05.0 – Acute cough

• R05.1 – Chronic cough
• R05.2 – Paroxysmal cough
• R05.9 – Cough, unspecified

11. Headache

• R51 – Headache, unspecified

• G44.1 – Tension-type headache
• G43.0–G43.9 – Migraine variants

12. Weight Loss

• R63.4 – Abnormal weight loss
• R63.3 – Anorexia-related weight loss (if appropriate)

13. Obesity

• E66.01 – Morbid (severe) obesity

• E66.09 – Other obesity
• E66.1 – Vomiting-related
• E66.2 – BMI 35–39.9
• E66.8 – Other specified
• E66.9 – Obesity, unspecified

14. Weight Gain

• R63.5 – Abnormal weight gain

• E66.9 – Secondary obesity if BMI elevated

15. Nausea

• R11.0 – Nausea only

• R11.1 – Nausea with vomiting
• R11.2 – Nausea unspecified

16. Vomiting

• R11.10 – Vomiting, unspecified

• R11.11 – Vomiting with dehydration
• R11.12 – Projectile vomiting

17. Depression

• F32.0–F32.3 – Single episode severity (mild → severe with psychosis)

• F33.0–F33.2 – Recurrent depressive episodes (mild → severe)
• F34.1 – Persistent depressive disorder (dysthymia)
18. Internal Hemorrhoids

• I84.0–I84.1 – With complications (bleeding, thrombosis)

• I84.2 – Without complications
• I84.3–I84.4 – Other internal hemorrhoid types

19. External Hemorrhoids

• I84.5 – Without complications

• I84.6–I84.7 – With bleeding or thrombosis
• I84.8 – Other external types

20. Pharyngitis

• J02.0 – Streptococcal pharyngitis

• J02.8 – Pharyngitis from other specified organisms
• J02.9 – Pharyngitis, unspecified

Respiratory & Musculoskeletal Symptoms

21. Pneumonia

• J18.0 – Bronchopneumonia, unspecified organism

• J18.1 – Lobar pneumonia, unspecified organism
• J18.9 – Pneumonia, unspecified organism
• J12.0–J12.9 – Viral pneumonias (e.g., adenovirus, RSV)

22. Pain in Chest

• R07.1 – Chest pain on breathing

• R07.2 – Precordial pain
• R07.89 – Other chest pain
• R07.9 – Chest pain, unspecified

23. Pain in Right Leg

• M79.601 – Pain in right leg
• M25.561 – Pain in right knee
• M54.41 – Lumbago with sciatica, right side (if radiating)

24. Pain in Left Leg

• M79.602 – Pain in left leg

• M25.562 – Pain in left knee
• M54.42 – Lumbago with sciatica, left side (if radiating)

25. Pain in Right Hand

• M79.641 – Pain in right hand

• M25.541 – Pain in right wrist
• M79.641 – Myalgia or joint-related symptoms in right hand

26. Pain in Left Hand

• M79.642 – Pain in left hand

• M25.542 – Pain in left wrist
• M79.642 – Myalgia or arthropathy

27. Ear Pain NOS

• H92.09 – Otalgia, unspecified ear

• H92.00 – Otalgia, unspecified
• H92.01 – Otalgia, right ear
• H92.02 – Otalgia, left ear

28. Ear Pain Left

• H92.02 – Otalgia, left ear

• H61.23 – Impacted cerumen left ear (if cause is cerumen)

29. Ear Pain Right

• H92.01 – Otalgia, right ear
• H61.22 – Impacted cerumen right ear (if relevant)

30. Elevated Liver Enzymes

• R74.01 – Elevation of levels of liver transaminase and lactic acid dehydrogenase

• R74.8 – Abnormal liver function studies
• K76.9 – Liver disease, unspecified (if chronic)

31. Fall

• Z91.81 – History of falling

• R29.6 – Repeated falls
• W19.XXXA – Unspecified fall, initial encounter
• W19.XXXD – Unspecified fall, subsequent encounter

32. Facial Pain

• R51.9 – Facial pain, unspecified

• G50.1 – Atypical facial pain
• G50.0 – Trigeminal neuralgia

33. Streptococcal Pharyngitis

• J02.0 – Streptococcal pharyngitis

• B95.0 – Streptococcus, group A as the cause of diseases classified elsewhere (secondary code)

34. Acute Bronchitis

• J20.9 – Acute bronchitis, unspecified

• J20.8 – Acute bronchitis due to other specified organisms
• J20.3 – Acute bronchitis due to coxsackievirus

35. Allergic Rhinitis

• J30.1 – Allergic rhinitis due to pollen (seasonal)
• J30.2 – Other seasonal allergic rhinitis
• J30.9 – Allergic rhinitis, unspecified

36. Bronchospasm

• J98.01 – Acute bronchospasm

• J45.909 – Unspecified asthma, uncomplicated (if asthma-related)

37. URI (Upper Respiratory Infection)

• J06.9 – Acute upper respiratory infection, unspecified

• J06.0 – Acute laryngopharyngitis
• J00 – Acute nasopharyngitis (common cold)

38. Chronic Cough

• R05.3 – Chronic cough

• R05.1 – Cough variant asthma (if applicable)

39. Acute Cough

• R05.0 – Acute cough

• J00 – Common cold (as a cause)
• J20.9 – Acute bronchitis (if associated)

40. Adenoviral Pneumonia

• J12.0 – Adenoviral pneumonia

• B34.0 – Adenovirus infection, unspecified (if systemic)

41. Sore Throat

• J02.9 – Acute pharyngitis, unspecified

• J03.90 – Acute tonsillitis, unspecified

 • R07.0 – Pain in throat
Used for general sore throat symptoms when specific etiology is unclear or tonsillitis is
suspected.

42. Bronchopneumonia

• J18.0 – Bronchopneumonia, unspecified organism

• J15.9 – Unspecified bacterial pneumonia

• J44.0 – COPD with acute lower respiratory infection (if comorbid COPD)
Use for lower respiratory tract infections presenting with diffuse infiltrates and
productive cough.

43. COPD (Chronic Obstructive Pulmonary Disease)

• J44.9 – COPD, unspecified

• J44.0 – COPD with acute lower respiratory infection

• J44.1 – COPD with (acute) exacerbation

Applies to patients with emphysema/chronic bronchitis or acute flare-ups.

44. CAD (Coronary Artery Disease)

• I25.10 – Atherosclerotic heart disease of native coronary artery without angina

• I25.110 – With unstable angina

• I25.119 – With other forms of angina pectoris

Used depending on the presence and type of angina.

45. HTN (Hypertension)

• I10 – Essential (primary) hypertension

• I11.9 – Hypertensive heart disease without heart failure

• I15.0 – Renovascular hypertension

Use based on associated complications or origin.
46. HTN + ESRD

• I12.0 – HTN with CKD stage 5 or ESRD

• N18.6 – End-stage renal disease

• Z99.2 – Dependence on renal dialysis

Used together to show the systemic effect of HTN on renal failure.

47. HTN + CHF

• I11.0 – Hypertensive heart disease with heart failure

• I50.9 – Heart failure, unspecified

• I50.22 – Chronic systolic heart failure (if known type)

Documents combined cardiac strain and failure.

48. HTN + CHF SYS

• I50.22 – Chronic systolic heart failure

• I11.0 – Hypertensive heart disease with heart failure

Use for patients with systolic dysfunction due to hypertension.

49. HTN + CHF DIA

• I50.32 – Chronic diastolic heart failure

• I11.0 – Hypertensive heart disease with heart failure

Used when diastolic dysfunction is confirmed.

50. HTN + CKD

• I12.9 – HTN with CKD, unspecified stage

• N18.9 – CKD, unspecified

Use when the chronic kidney disease stage isn’t detailed.
51. HTN + CKD Stage 1

• I12.9 – Hypertension with CKD

• N18.1 – CKD stage 1

Early renal involvement due to hypertension.

52. HTN + CKD Stage 2

• I12.9 – Hypertension with CKD

• N18.2 – CKD stage 2

Denotes mild kidney damage with hypertension.

53. Diabetes Mellitus

• E11.9 – Type 2 diabetes mellitus without complications

• E11.21 – T2DM with nephropathy

• E11.29 – T2DM with other specified complications

• E11.65 – T2DM with hyperglycemia

Choose based on patient’s complication profile.

54. Chest Discomfort

• R07.89 – Other chest pain

• R07.82 – Intercostal pain

• R07.1 – Chest pain on breathing

Non-specific symptoms; evaluate for cardiac, musculoskeletal, or respiratory cause.

55. Rib Pain

• R07.89 – Other chest pain

• S22.39XA – Multiple fractures of ribs, initial encounter (if trauma-related)

 • M79.1 – Myalgia (muscle strain)
Choose based on injury vs. soft tissue origin.

56. Palpitations

• R00.2 – Palpitations

• I49.3 – Ventricular premature depolarization

• I49.8 – Other specified cardiac arrhythmias

Code depends on underlying arrhythmia type if known.

57. Bradycardia

• R00.1 – Bradycardia, unspecified

• I49.8 – Other specified cardiac arrhythmias

• I49.5 – Sick sinus syndrome (if confirmed)

Used for low heart rate; evaluate for sinus or AV node dysfunction.

58. Tachycardia

• R00.0 – Tachycardia, unspecified

• I47.1 – Supraventricular tachycardia

• I47.2 – Ventricular tachycardia

Use depending on rhythm origin and documentation.

59. Atrial Fibrillation

• I48.0 – Paroxysmal atrial fibrillation

• I48.1 – Persistent atrial fibrillation

• I48.91 – Unspecified atrial fibrillation

Differentiated by chronicity and documentation.
60. Paroxysmal Atrial Fibrillation

• I48.0 – Paroxysmal atrial fibrillation

• I48.92 – Other specified atrial fibrillation

Use when episodes are self-terminating or intermittent.

61. Cardiomegaly

• I51.7 – Cardiomegaly

• I42.9 – Cardiomyopathy, unspecified (if due to structural dysfunction)

• R93.1 – Abnormal findings on diagnostic imaging of heart and great vessels

Used when heart enlargement is noted via imaging or linked to dysfunction.

62. Cardiomyopathy

• I42.0 – Dilated cardiomyopathy

• I42.1 – Obstructive hypertrophic cardiomyopathy

• I42.9 – Cardiomyopathy, unspecified

Use based on echocardiographic findings or documented type.

63. Hyperlipidemia

• E78.5 – Hyperlipidemia, unspecified

• E78.0 – Pure hypercholesterolemia

• E78.2 – Mixed hyperlipidemia

Apply codes depending on which lipid levels are elevated.

64. Vitamin D Deficiency

• E55.9 – Vitamin D deficiency, unspecified

• E55.0 – Rickets, active (if pediatric or bone abnormalities present)

Code reflects nutritional or metabolic causes.
65. Diarrhea

• R19.7 – Diarrhea, unspecified

• K52.9 – Noninfective gastroenteritis and colitis, unspecified

• A09 – Infectious gastroenteritis, unspecified

Choose based on infectious vs noninfectious etiology.

66. Colitis

• K52.9 – Noninfective gastroenteritis and colitis, unspecified

• K51.90 – Ulcerative colitis, without complications

• K52.2 – Allergic and dietetic gastroenteritis and colitis

ICD code depends on the cause and chronicity.

67. CHF (Congestive Heart Failure)

• I50.9 – Heart failure, unspecified

• I50.22 – Chronic systolic (congestive) heart failure

• I50.32 – Chronic diastolic (congestive) heart failure

Used depending on heart failure type and documentation.

68. CKD Stage 1

• N18.1 – Chronic kidney disease, stage 1

• Z13.6 – Encounter for screening for kidney disorders (if screening basis)
Early-stage kidney damage; often asymptomatic.

69. CKD Stage 2

• N18.2 – Chronic kidney disease, stage 2 (mild)

• Z13.6 – Screening code if incidentally detected

Indicates mild loss of kidney function.
70. CKD Stage 3

• N18.30 – CKD stage 3, unspecified

• N18.31 – Stage 3a (GFR 45–59)

• N18.32 – Stage 3b (GFR 30–44)

Stage-specific based on glomerular filtration rate (GFR).

71. CKD Stage 4

• N18.4 – Chronic kidney disease, stage 4 (severe)

Significant loss of renal function, often precursor to ESRD.

72. ESRD (End-Stage Renal Disease)

• N18.6 – End-stage renal disease

• Z99.2 – Dependence on renal dialysis (if on dialysis)

Used for patients with permanent loss of kidney function.

73. CKD (Chronic Kidney Disease, Unspecified)

• N18.9 – Chronic kidney disease, unspecified

• N18.3 – Stage 3 if probable but not clearly documented

Used when staging is not specified.

74. CHF – Systolic

• I50.22 – Chronic systolic heart failure

• I50.21 – Acute systolic heart failure

• I50.20 – Systolic heart failure, unspecified

Specific to reduced ejection fraction (HFrEF).
75. CHF – Diastolic

• I50.32 – Chronic diastolic heart failure

• I50.31 – Acute diastolic heart failure

• I50.30 – Diastolic heart failure, unspecified

Applies to preserved ejection fraction (HFpEF).

76. CHF – Acute

• I50.21 – Acute systolic heart failure

• I50.31 – Acute diastolic heart failure

• I50.41 – Acute combined systolic and diastolic heart failure

Choose based on documented acute decompensation type.

77. CHF – Chronic

• I50.22 – Chronic systolic heart failure

• I50.32 – Chronic diastolic heart failure

• I50.43 – Chronic combined systolic and diastolic heart failure

Applies to long-standing, stable heart failure conditions.

Key ICD-10 Coding Guidelines to Avoid Non-Billable or Rejected

Claims

To avoid using non-billable or rejected ICD-10 codes, here are the most important points to
consider:

Use these best practices to ensure accuracy, compliance, and reimbursement success in clinical
documentation and diagnosis coding.

1. Use the Most Specific Code Available

• Avoid unspecified codes when detailed documentation exists.

 o J18.9 – Pneumonia, unspecified

o J18.1 – Lobar pneumonia if known

• Specificity improves reimbursement and minimizes denials.

2. Verify Code is Billable

• Some codes (often ending in .x or placeholders like .XXX) are category headers and not
billable.

o I50 – Heart failure → Not billable

o I50.9 – Heart failure, unspecified → Billable

• Use an ICD-10 lookup or EHR validation tool to check billability.

3. Don’t Use Codes That Require Additional Details

• If a code requires laterality or clinical detail (e.g., type, site, severity), it won’t be billable
unless provided.

o H66 – Otitis media

o H66.91 – Otitis media, right ear, unspecified

4. Watch for Combination Codes

• Use combination codes when applicable (e.g., HTN with CKD), instead of listing separate
ones.

o I12.9 – Hypertensive CKD

o Using I10 + N18.9 separately may be incorrect in some scenarios

5. Match Code to Provider Documentation

• Codes must match exactly what’s documented in the provider’s note.

 o Do not assume or infer details not written explicitly (e.g., type of diabetes, stage
of CKD).

6. Avoid “NOS” or “Unspecified” When Possible

• NOS (Not Otherwise Specified) and unspecified codes are a red flag for payers.

o M79.60 – Pain, unspecified site

o M79.641 – Pain in right hand

7. Validate with Coding Software or Crosswalks

• Use billing software, EHRs, or online tools like CMS, AAPC, or ICD10Data.com to confirm:

o Code is billable

o Code has no missing characters or extensions

8. Stay Updated with Annual ICD-10 Revisions

• Codes can change every October 1st—new codes are added, some deleted or
restructured.

o Always use current-year ICD-10-CM manual or tools.

9. Pay Attention to Placeholder Characters ("X")

• Some ICD-10 codes require a 7th character extension (like for injuries, fractures,
obstetrics).

• If the 7th character is needed, but the code has fewer than 6 characters, use "X" as
placeholders.

o S01.01A ➝ Missing placeholder

o S01.01XA – Laceration without foreign body, initial encounter

10. Don’t Use Codes from Incomplete Categories

• Codes like E11 (Type 2 diabetes) or I10 (Essential hypertension) are sometimes used
alone when complications are also present.

o E11 – Too broad

o E11.65 – T2DM with hyperglycemia (if documented)

11. Use Codes That Reflect Patient Status

• For visits like follow-ups or check-ins, Z-codes are often appropriate if no new diagnosis
exists.

o Z09 – Encounter for follow-up exam after treatment

o Z13.1 – Encounter for screening for diabetes mellitus

12. Don’t Use Symptoms When a Diagnosis Exists

• If a confirmed diagnosis is present, avoid coding the symptom separately unless it's
unrelated.

o R05 – Cough when J20.9 – Acute bronchitis is documented

o Use only the diagnosis unless symptom is distinct and separate

13. Choose Codes That Match Encounter Type

• Initial vs. subsequent vs. sequela encounters matter, especially for injuries:

o S72.001A – Fracture, initial encounter

o S72.001D – Subsequent encounter for healing

o Omitting "A" or "D" leads to non-billable code

14. Avoid Coding Diagnoses Not Addressed

• Only assign diagnoses that were evaluated, treated, or impacted care during the visit.

o Coding HTN when not mentioned or managed in the note

 o Document and code only what’s clinically relevant

15. Use Complete Laterality Codes

• Many musculoskeletal and eye/ear codes require left/right/bilateral specification:

o M25.5 – Joint pain, unspecified

o M25.562 – Pain in left knee

16. Combine Etiology and Manifestation (If Required)

• Some conditions require two linked codes — one for the underlying cause, one for the
manifestation.

o E11.21 – T2DM with nephropathy (etiology)

o N18.9 – CKD, stage unknown (manifestation)

17. Use Official Coding Guidelines

• Refer to ICD-10-CM Official Guidelines for Coding and Reporting (updated annually).

• Ensures compliance with CMS, payers, and auditors.

18. Educate Clinical Staff on Documentation Needs

• Missing documentation = non-billable code.

• The clinician should document:

o Severity

o Laterality

o Relationship (e.g., DM with neuropathy)

o Stage or episode (especially in CKD, CHF, fractures)

19. Be Specific with Disease Stage and Type

• Many chronic diseases require staging or classification to be billable:

o N18 – CKD, unspecified

o N18.3 – CKD Stage 3 (moderate)

o E11.40 – T2DM with diabetic neuropathy, unspecified

20. Link Conditions When Guidelines Require

• Some codes need a cause-and-effect relationship clearly documented:

o I13.0 – HTN heart disease with CHF

o Using I10 (essential hypertension) + I50.9 (CHF) separately without linkage

21. Don’t Use “Unspecified” Codes When More Detail Exists

• Try to avoid codes ending in “.9” when documentation supports more specificity:

o J18.9 – Pneumonia, unspecified

o J18.0 – Bronchopneumonia, unspecified organism

22. Use Combination Codes When Available

• Use a single code that reflects multiple conditions when it exists:

o E11.65 – T2DM with hyperglycemia (instead of separate codes for diabetes +

hyperglycemia)

o I13.10 – HTN with heart and kidney disease

23. Confirm Laterality in Diagnosis

• Codes for limbs, eyes, ears, etc., often require left/right/bilateral details:

o H91.90 – Hearing loss, unspecified ear

o H91.91 – Hearing loss, right ear

24. Don’t Use Codes Marked “Excludes1” Together

• ICD-10 has “Excludes1” rules: two mutually exclusive codes should not be billed
together.

o E10.9 (Type 1 DM) and E11.9 (Type 2 DM)

o Choose the appropriate diabetes type

25. Use External Cause Codes When Required

• For injuries, include external cause codes if relevant:

o W19.XXXA – Fall, initial encounter

o Y92.009 – Place of occurrence (e.g., home, work)

26. Watch for “Includes” and “Excludes” Notes

• Always read the coding notes in the ICD-10 book or system:

o Helps you determine if a code includes subtypes or excludes related diagnoses

27. Ensure 7th Characters Are Used Correctly

• Especially for fractures, injuries, and obstetrics, missing the 7th character = denial.

o S52.501A – Unspecified fracture of right radius, initial encounter

28. Don’t Code “History Of” as Active Disease

• Use Z-codes when referring to past conditions no longer active:

o C50.911 – Breast cancer (active)

o Z85.3 – Personal history of breast cancer (inactive)

29. Code to the Highest Level of Detail

• ICD-10 codes can have up to 7 characters. Using only 3 or 4 digits may be insufficient:

o M54 – Dorsalgia

o M54.5 – Low back pain or M54.41 – Lumbago with sciatica, right side

30. Do Not Use Placeholder Codes Without the Final Character

• Some codes require 7 characters, and missing the final placeholder ("X") or character
makes them non-billable:

o S06.0 (Too short)

o S06.0X0A – Concussion without loss of consciousness, initial encounter

31. Avoid Using Only Symptom Codes When a Diagnosis Is Known

• If the cause is known, code the condition, not just symptoms:

o R11.0 – Nausea

o K21.0 – GERD with esophagitis (if GERD is documented)

32. Include Laterality for Paired Organs

• Always specify right, left, or bilateral:

o H25.031 – Age-related cataract, right eye

o H25.032 – …left eye

33. Differentiate Between Initial, Subsequent, and Sequela Encounters

• Injury and trauma codes often require 7th character for encounter type:

o S82.101A – Fracture of tibia, initial encounter

o S82.101D – …subsequent encounter with routine healing

34. Avoid Redundant Codes

• Don’t code separately for things already captured in a combo code:

o I50.9 + I10

o I13.0 – HTN heart disease with CHF

35. Confirm if "Unspecified" Code is Reimbursable

• Not all unspecified codes are payable unless justified:

o N39.0 – Urinary tract infection, site not specified

o N30.00 – Acute cystitis without hematuria (if site is known)

36. Differentiate Between Acute and Chronic

• Use separate codes if condition has both forms:

o J44.1 – COPD with acute exacerbation

o J45.40 – Moderate persistent asthma, uncomplicated

37. Don’t Use Diagnosis Codes for Screening

• Use Z-codes when performing routine screening:

o Z12.11 – Screening for colon cancer

o C18.9 – Malignant neoplasm of colon (unless confirmed)

38. Verify if Combination Codes Exist for Comorbidities

• Use one code that includes both conditions when available:

o E11.22 – T2DM with diabetic CKD (instead of separate E11.9 + N18.3)

39. Never Use “History of” Codes for Active Conditions

• Use Z-codes (e.g., Z86.73) only if the condition is resolved and not being treated.

o Z86.73 – Personal history of TIA (if the patient is actively treated)

o I67.89 – Other cerebrovascular disease (if residuals or follow-up)

40. Include the Cause of the Symptom, When Known

• Use the underlying etiology, not just vague symptom codes:

o R05 – Cough

o J20.9 – Acute bronchitis (if known)

41. Use Combination Codes Instead of Multiple Separate Codes

• Many ICD-10 codes combine diagnoses + complications.

o I50.32 – Chronic diastolic heart failure

o Avoid coding I50.9 + I10 when a combo exists like I13.2

42. Use External Cause Codes for Injuries (if payer requires)

• Especially in trauma cases:

o W01.0XXA – Fall on same level from slipping

o Y92.009 – Place of occurrence, unspecified home

43. Clarify Diagnoses Labeled "Likely," "Rule Out," or "Probable"

• In inpatient settings: can code suspected conditions.

• In outpatient settings: code only confirmed diagnoses or symptoms.

o Code “probable pneumonia” as J18.9 (outpatient)

o R06.02 – Shortness of breath + R05 – Cough

44. Do Not Confuse Signs of a Condition With the Condition Itself

• If the diagnosis is documented, avoid redundant signs:

o R60.0 – Localized edema if you’re already using:

o I50.9 – Heart failure (edema is part of the condition)

45. Include All Documented Chronic Conditions That Impact Care

• Don’t omit stable comorbidities that affect decisions:

o E78.5 – Hyperlipidemia

o E66.9 – Obesity

46. Don’t Code Temporarily Elevated Labs Without Diagnosis

• Only code lab abnormalities if clinically significant or addressed:

o R79.1 – Elevated blood glucose (unless interpreted by provider)

o E11.65 – T2DM with hyperglycemia (if documented)

47. Always Use the Most Specific Anatomic Site

• Specify laterality and exact location when possible:

o M25.562 – Pain in left knee

o L03.115 – Cellulitis of right lower limb

48. Avoid Duplicate Coding

• Don’t repeat the same diagnosis using multiple synonymous codes:

o E11.9 + R73.9

o E11.9 – T2DM without complications (don’t add prediabetes or

hyperglycemia separately if already captured)
49. Code Manifestations Only With the Underlying Condition

• Never code a complication without linking it to the main diagnosis:

o N18.3 + I10 (separately)

o I12.9 – Hypertensive CKD stage 1–4 with heart involvement

50. Watch for Excludes1 Notes

• Excludes1 means never use both codes together:

o F32.9 – Depression NOS + F33.1 – MDD, recurrent, moderate

o Use only one appropriate diagnosis (in this case: F33.1)

51. Clarify Whether Pain Is Acute, Chronic, or Postprocedural

• Many pain codes vary by duration and cause:

o G89.18 – Other acute postprocedural pain

o G89.29 – Other chronic pain

52. Avoid "NOS" (Not Otherwise Specified) if More Specific Codes Exist

• R51.9 – Headache, unspecified

• G43.909 – Migraine, unspecified, not intractable (if applicable)

53. Combine Mental Health & Physical Conditions When Linked

• Use both when mental health affects physical disease management:

o E11.69 – T2DM with other complications

o F32.9 – Depression (if impacting care)

54. Do Not Code Symptoms If They’re Integral to the Diagnosis

• Avoid listing symptoms that are part of the condition:

o R63.5 – Abnormal weight gain + E66.9 – Obesity

o E66.9 – Obesity (only)

55. Be Careful with "Screening" Codes (Z Codes)

• Only use if no symptoms or diagnosis is present:

o Z12.11 – Colon cancer screening

o If symptoms are present, code the symptom (e.g., R19.5 – Other fecal
abnormalities)

56. Avoid Acute/Chronic Conflicts

• Don’t use acute and chronic codes together unless documentation supports both:

o I50.31 – Acute diastolic heart failure

o I50.32 – Chronic diastolic heart failure (only if both are documented)

57. Do Not Use Unconfirmed Lab Results as Diagnoses

• Wait for provider interpretation:

o E87.5 – Hyperkalemia if lab value is high but not addressed

o R79.89 – Abnormal blood chemistry if noted without formal diagnosis

58. Differentiate Between Adverse Effects and Poisoning

• For side effects of correctly used drugs:

o T88.7XXA – Unspecified adverse effect of drug, initial

• For overdose or misuse:

o T40.2X1A – Poisoning by opioids, accidental

 59. Avoid Using “Unspecified” Codes Repeatedly

• Frequent use of unspecified codes (e.g., .9 or NOS) can trigger audits.

o I10 – Essential hypertension (if specific type is known)

o I13.0 – Hypertensive heart and CKD with heart failure

60. Use "With" and "Due to" Relationships Based on Provider Documentation

• Only link conditions if explicitly stated or clinically inferred:

o E11.22 – T2DM with diabetic CKD (if provider links them)

o Don’t assume CKD is from diabetes without confirmation

61. Avoid Using R-Codes Without Follow-Up or Diagnosis

• Only use R-codes (signs/symptoms) when no definitive diagnosis is known or
documented:
o M79.1 – Myalgia (if muscle pain is identified)
o R53.83 – Other fatigue (if a cause is documented but not coded)

62. Do Not Use Symptom Codes If They Are Explained by a Diagnosis

• Avoid coding symptoms separately when they are inherent to a diagnosed condition:
o K21.0 – GERD (includes related nausea)
o R11.0 – Nausea + K21.0 – GERD (redundant coding)

63. Use Laterality Whenever Possible

• Always code the side of the body (right, left, or bilateral) when available:
o M25.562 – Pain in left knee
o M25.569 – Pain in unspecified knee

64. Confirm If the Condition Is Acute, Chronic, or Both

• Use codes that reflect the acuity and chronicity of the condition as documented:
o I50.21 – Acute systolic heart failure
o I50.22 – Chronic systolic heart failure
o I50.23 – Acute on chronic systolic heart failure

65. Don’t Code “History Of” for Active Conditions

• Z-codes for “history of” are only used for resolved conditions with no current
treatment:
o K63.5 – Polyp of colon (if still present)
o Z86.010 – History of colonic polyps (if polyps remain)

66. Include Associated Conditions When Linked and Addressed

• Only code linked diagnoses when documented by the provider:
o E11.22 – T2DM with diabetic CKD
o I12.0 – HTN with CKD stage 5
o I10 + N18.5 – (do not code separately if linkage is stated)

67. Don’t Use Symptom Codes for Conditions Already Diagnosed

• Avoid redundant coding of symptoms already attributed to a condition:
o J44.9 – COPD (includes SOB if due to COPD)
o R06.02 – Shortness of breath + J44.9 – COPD

68. Avoid Using Z Codes for Existing Conditions Needing Treatment

• Z-codes indicate history or screening, not active conditions needing care:
o F17.210 – Nicotine dependence, cigarettes
o Z87.891 – History of tobacco use (if currently smoking)

69. Use the Correct 7th Character for Injury/Poisoning Codes

• Ensure use of “A”, “D”, or “S” for initial, subsequent, or sequelae encounters:
o S61.201A – Open wound, right hand, initial encounter
o S61.201D – … subsequent encounter
o S61.201S – … sequela

70. Document Provider Confirmation for Suspected Conditions

• Only assign a diagnosis code if confirmed by the provider in documentation:
o R06.02 – Shortness of breath (until diagnosis confirmed)
o J18.9 – Pneumonia (if only “rule out pneumonia” without confirmation)

71. Never Use "Rule Out" Diagnoses as Final Codes

• Only assign a diagnosis if confirmed by the provider in documentation:
o R07.9 – Chest pain, unspecified (until diagnosis confirmed)
o I21.3 – Acute MI (if only “rule out” or unconfirmed)
 72. Clarify Infection Type and Site When Coding
• Always specify the organism and site of infection if documented:
o N39.0 – UTI, site not specified
o B96.20 – E. coli as cause of diseases classified elsewhere
o B96.20 – Alone, without linking it to the primary infection

73. Use External Cause Codes with Injury Diagnoses

• Add cause-of-injury codes (e.g., fall, assault) when appropriate:
o S72.001A – Fracture of femur, initial encounter
o W19.XXXA – Unspecified fall, initial encounter
o S72.001A – Without documenting how injury occurred (if required)

74. Distinguish Between Acute and Chronic Diagnoses

• Don’t code both unless clearly documented as coexisting:
o I10 – Essential hypertension (chronic)
o I16.0 – Hypertensive urgency (acute)
o I10 + I16.0 – Together without proper documentation

75. Don’t Code Symptoms Separately if Included in Diagnosis

• If the cause of a symptom is diagnosed, don’t list the symptom again:
o G43.909 – Migraine, not intractable
o R51.9 – Headache + G43.909 – (Headache is part of migraine)
 76. Match Laterality Across All Related Diagnoses
• Ensure the same side (right/left) is coded across conditions:
o H92.01 – Otalgia, right ear
o H61.22 – Impacted cerumen, right ear
o H92.00 – Otalgia, unspecified + H61.22 – Right ear

77. Use Combination Codes When Available

• Don’t break apart a condition that has a combination code:
o I13.0 – Hypertensive heart and CKD with heart failure
o I10 + I50.9 + N18.3 – Separately, when combination code exists

78. Avoid Z Codes for Active Conditions

• Z codes are for history or follow-up, not for current illness or treatment:
o C34.91 – Malignant neoplasm of right lung
o Z85.118 – History of lung cancer (if still being treated)

79. Use Sequela Codes Only for Residual Conditions

• Use sequela (“S” extension) only when coding long-term effects:
o T81.4XXS – Infection following procedure, sequela
o T81.4XXA – For sequela stage (only for active phase)

80. Ensure the ICD Code Supports Procedure or Test

• The diagnosis must justify the medical necessity of tests performed:
o R10.9 – Abdominal pain (to support imaging/test)
o Z13.9 – Screening encounter (if patient has symptoms)

81. Confirm Status of Chronic Conditions Before Coding

• The condition must be current and relevant to the encounter:
o E11.9 – T2DM without complications (if actively managed or addressed)
o E11.9 – If diabetes is not documented as monitored, treated, or assessed

82. Verify That Encounter Codes Are Appropriately Used

• Z codes are for wellness or administrative visits without active issues:
o Z00.00 – General adult medical exam without abnormal findings
o Z00.00 – If the patient presents with symptoms or illness

83. Use Tobacco Use Codes When Relevant

• Include tobacco use if it affects diagnosis, treatment, or risk:
o Z72.0 – Tobacco use
o F17.210 – Nicotine dependence, cigarettes, uncomplicated
o Omitting tobacco use when managing COPD or hypertension

84. Avoid "History of" Codes for Active Illness

• Don’t use personal history codes if the condition is still active:
o C50.911 – Malignant neoplasm of right breast
o Z85.3 – History of breast cancer (if still under treatment)
 85. Check That Fracture Codes Include Episode of Care
• Use the correct extension for initial, subsequent, or sequela visits:
o S52.501A – Fracture of unspecified ulna, initial encounter
o S52.501 – Missing encounter type can result in claim denial

86. Review "In Remission" Mental Health Codes

• Only use remission codes if explicitly stated by the provider:
o F33.41 – MDD, in partial remission
o F33.41 – If remission status is not documented

87. Validate Site-Specific Cancer Codes

• Use the most specific cancer site and laterality when available:
o C18.7 – Malignant neoplasm of sigmoid colon
o C18.9 – Unspecified colon site if more detail is documented

88. Confirm Pregnancy Trimester and Type When Applicable

• OB codes must reflect the correct trimester and pregnancy details:
o O26.891 – Pregnancy-related condition, third trimester
o O26.899 – Without trimester detail can lead to rejection

89. Avoid Repeating Symptoms and Definitive Diagnoses

• Don’t list symptoms that are inherent to the confirmed condition:
o R05 – Cough (if chronic or treated separately)
o R05 + J18.9 – Cough is part of pneumonia unless separately addressed
 91. Don’t Use “Rule Out” Diagnoses Without Confirmation
• Include only diagnoses confirmed by the provider:
o R06.02 – Shortness of breath (until confirmed)
o J18.9 – Pneumonia (if only ruled out or suspected)

92. Avoid Using Symptom Codes When a Definitive Diagnosis Is Documented

• Use the confirmed condition instead of vague symptoms:
o K21.9 – GERD
o R10.13 – Epigastric pain (if GERD is diagnosed)

93. Code All Complications That Affect Care

• Include all documented complications that impact treatment:
o E11.40 – T2DM with diabetic neuropathy
o E11.9 – Without capturing the complication

94. Don’t Mix Acute and Chronic Codes Without Support

• Use both only when clearly documented:
o I50.21 + I50.22 – Acute and chronic systolic heart failure
o I50.9 + I50.22 – Non-specific combination without clarity

95. Link Anemia to Its Underlying Cause If Known

• Avoid unspecified anemia if the etiology is documented:

o D63.1 – Anemia in CKD
o D64.9 – Anemia, unspecified (if due to CKD)

96. Distinguish Between “In Remission” and “History Of”

• Use remission codes for active monitoring; history for resolved cases:
o F17.213 – Nicotine dependence, in remission
o Z87.891 – History of tobacco use (if still monitored)

97. Avoid Age-Inappropriate Codes

• Use codes relevant to patient age and clinical context:
o P07.30 – Prematurity (for newborns)
o N39.0 – UTI (in infants without supportive documentation)

98. Don’t Assume Causal Relationships Between Conditions

• Only link diagnoses when clearly stated in documentation:
o E11.21 – T2DM with nephropathy
o E11.9 + N18.9 – Coded separately without linkage

99. Use Status Z Codes to Support Risk and Treatment Decisions

• Document implanted devices, ongoing therapies, or chronic use:
o Z95.1 – Presence of coronary bypass graft
o Z79.4 – Long-term use of insulin
o Omitting these may reduce risk-adjustment accuracy
 100. Avoid Repetitive Use of “Unspecified” Codes
• Choose detailed codes when documentation allows:
o J45.40 – Moderate persistent asthma, uncomplicated
o J45.909 – Asthma, unspecified (if severity is documented)

Essential Things Medical Coders Must Consider

To ensure accurate, billable, and compliant ICD-10 coding, every medical coder should keep the
following points in mind:

1. Thorough Review of Documentation

o Always code based on provider-confirmed documentation, not assumptions.

o Look for specific diagnoses, laterality, acuity, and linked conditions.

2. Use the Most Specific Code Available

o Avoid using “NOS” (Not Otherwise Specified) or “Unspecified” codes if more

specific ones are documented.

o Use laterality and anatomical site codes when applicable.

3. Code to the Highest Level of Certainty

o Do not code suspected or rule-out diagnoses unless they are confirmed.

o Use symptom codes (e.g., R-codes) if a definitive diagnosis is not documented.

4. Respect ICD-10 Excludes Notes

o Excludes1: Never code together.

o Excludes2: Acceptable to report both if documentation supports it.

5. Link Conditions Appropriately

o Use terms like “due to,” “with,” or “secondary to” only when documented.
 o Don’t assume relationships (e.g., diabetes with CKD) unless stated by the
provider.

6. Avoid Duplicate or Contradictory Codes

o Never code both acute and chronic unless both are documented.

o Avoid redundant codes that describe the same issue differently.

7. Include Comorbidities and Chronic Conditions

o Code chronic illnesses even if stable, if they impact care or management

decisions.

8. Don’t Code Temporary or Incidental Findings

o Elevated labs, imaging abnormalities, or symptoms must be clinically addressed

to be coded.

9. Apply Correct Encounter Status and External Cause Codes

o Use initial, subsequent, or sequela extensions properly (e.g., “A,” “D,” or “S”).

o When required, include external cause codes (e.g., injuries or accidents).

10. Stay Updated on Coding Guidelines

• Refer to the ICD-10-CM Official Guidelines regularly.

• Stay current with payer-specific rules and billing policies.

Code Only: What Is Documented by the Provider s

• Never assume or infer diagnoses.
• Use only confirmed findings unless coding for symptoms.

Use the Most Specific ICD-10 Code Available

• Avoid unspecified (e.g., .9) or NOS codes when detail exists.
• Include laterality and anatomical specificity when applicable.

Respect “Excludes1” and “Excludes2” Guidelines

• Excludes 1: Never code both conditions together.
• Excludes 2: May code both when clinically appropriate.
 Link Related Conditions Properly
• Only connect conditions using terms like “due to” or “with” when documented.
• Example: E11.22 – Type 2 diabetes with diabetic CKD (when documented).

Avoid Redundant or Duplicate Codes

• Do not code similar conditions twice (e.g., E11.9 + R73.9).
• Use the most accurate, complete code that encompasses the condition.

Differentiate Between Acute and Chronic When Necessary

• Don’t code both unless clearly documented.
• Example: I50.31 – Acute diastolic heart failure,

I50.32 – Chronic diastolic heart failure (if both are documented).

Include All Relevant Chronic Conditions

• Code stable but relevant conditions that impact treatment or decision-making.
• Example: E78.5 – Hyperlipidemia,

E66.9 – Obesity

Don’t Code Lab Abnormalities Without Clinical Significance

• Only code abnormal labs if addressed by the provider.
• Example: R79.1 – Elevated glucose,

E11.65 – T2DM with hyperglycemia (if diagnosed)

Avoid Coding Symptoms Integral to the Diagnosis

• Don’t code symptoms separately if they are part of the diagnosis.
• Example: R51 – Headache with G43.909 – Migraine

Use External Cause Codes Fully

• For injuries, include cause, place, and activity.
• Example: W01.0XXA – Fall from tripping, initial encounter