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International Classification of Diseases, 10th Revision, Clinical Modification. The standard for documenting diagnoses in the United States. Maintained by the CDC and updated annually. Required for all US outpatient, inpatient, and physician billing.

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Overview

  • While the international version of ICD-10 has 14,000 codes, ICD-10-CM has over 70,000 codes covering diseases, symptoms, injuries, and health encounters
  • Alphanumeric codes: a letter followed by 2–7 characters (e.g., E11.649)
  • Only conditions that affect patient care should be coded.
  • The rules for ICD-10-CM coding is different for inpatient and outpatient settings. We, therefore, require the user to specify the setting.

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Encounter type

Encounter type is required. ICD-10-CM coding guidelines differ significantly between inpatient and outpatient settings. For instance, in the outpatient setting, one should only code established diagnoses. In the inpatient setting, one should also include all diagnoses that are uncertain, even those that are ruled out. Use icd10cm-inpatient for inpatient cases and icd10cm-outpatient for outpatient cases. The correct guideline set is applied automatically based on the suffix.