ICD-10-CM Official Guidelines for Coding and Reporting FY 2026
Section I. Conventions, general coding guidelines and chapter specific guidelines

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Section I. Conventions, General Coding Guidelines and Chapter Specific Guidelines
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines.
A. Conventions for the ICD-10-CM
The conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes.

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1. The Alphabetic Index and Tabular List
The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their corresponding code, and the Tabular List, a structured list of codes divided into chapters based on body system or condition. The Alphabetic Index consists of the following parts: the Index of Diseases and Injury, the Index of External Causes of Injury, the Table of Neoplasms and the Table of Drugs and Chemicals.
Index of Diseases and Injury
Alphabetical listing of medical conditions and their codes
Index of External Causes
Codes for injuries and their external causes
Table of Neoplasms
Specialized table for cancer coding
Table of Drugs and Chemicals
Reference for poisoning and adverse effects
See Section I.C.2. Neoplasms
See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects

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2. Format and Structure: The ICD-10-CM Tabular List
The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character. The ICD-10-CM uses an indented format for ease in reference.
01
Categories
3 characters - broadest classification level
02
Subcategories
4 or 5 characters - more specific detail
03
Codes
3, 4, 5, 6 or 7 characters - final level of specificity

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3. Use of Codes for Reporting Purposes
For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.

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4. Placeholder Character
The ICD-10-CM utilizes a placeholder character "X". The "X" is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and underdosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code.
The "X" Placeholder
Used to fill empty character positions in codes that require 7 characters
Example: T36-T50 categories for poisoning and adverse effects
ICD-10-CM Official Guidelines for Coding and Reporting FY 2026 Page 8 of 121

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5. 7th Characters
Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.
1
Identify Required 7th Character
Check if the category requires a 7th character per Tabular List notes
2
Count Existing Characters
Determine if the code has fewer than 6 characters
3
Add Placeholder X if Needed
Use X to fill empty positions before adding 7th character
4
Add 7th Character
Place the required 7th character in the 7th position

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6. Abbreviations
a. Alphabetic Index abbreviations
NEC
"Not elsewhere classifiable"
This abbreviation in the Alphabetic Index represents "other specified." When a specific code is not available for a condition, the Alphabetic Index directs the coder to the "other specified" code in the Tabular List.
NOS
"Not otherwise specified"
This abbreviation is the equivalent of unspecified.
b. Tabular List abbreviations
NEC
"Not elsewhere classifiable"
This abbreviation in the Tabular List represents "other specified". When a specific code is not available for a condition, the Tabular List includes an NEC entry under a code to identify the code as the "other specified" code.
NOS
"Not otherwise specified"
This abbreviation is the equivalent of unspecified.

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7. Punctuation
The nonessential modifiers in the Alphabetic Index to Diseases apply to subterms following a main term except when a nonessential modifier and a subentry are mutually exclusive, the subentry takes precedence. For example, in the ICD-10-CM Alphabetic Index under the main term Enteritis, "acute" is a nonessential modifier and "chronic" is a subentry. In this case, the nonessential modifier "acute" does not apply to the subentry "chronic".
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8. Use of "and"
See Section I.A.14. Use of the term "And"

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9. Other and Unspecified Codes
a. "Other" codes
Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate "other" codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists, so the term is included within an "other" code.
b. "Unspecified" codes
Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the "other specified" code may represent both other and unspecified.

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10. Includes Notes
This note appears immediately under a three-character code title to further define, or give examples of, the content of the category.

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11. Inclusion Terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
Purpose of Inclusion Terms
Provide specific examples of conditions that should be coded to a particular code
Types of Terms
May be synonyms of the code title or a list of various conditions for "other specified" codes
Not Exhaustive
Additional terms found in the Alphabetic Index may also be assigned to the code

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12. Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are independent of each other.
Excludes1
"NOT CODED HERE!"
A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
Excludes2
"Not included here"
A type 2 Excludes note represents "Not included here." An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
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An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.

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13. Etiology/Manifestation Convention
("code first", "use additional code" and "in diseases classified elsewhere" notes)
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention.
There are manifestation codes that do not have "in diseases classified elsewhere" in the title. For such codes, there is a "use additional code" note at the etiology code and a "code first" note at the manifestation code, and the rules for sequencing apply.
In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.
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"Code first" and "Use additional code" notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. See Section I.B.7. Multiple coding for a single condition.

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14. "And"
The word "and" = "and" OR "or"
The word "and" should be interpreted to mean either "and" or "or" when it appears in a title.
Example
Cases of "tuberculosis of bones", "tuberculosis of joints" and "tuberculosis of bones and joints" are classified to subcategory A18.0, Tuberculosis of bones and joints.

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15. "With"
The word "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index (either under a main term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions (e.g., sepsis guideline for "acute organ dysfunction that is not clearly associated with the sepsis").
Presumed Causal Relationship
When "with" or "in" appears in the classification, code the conditions as related even without explicit provider documentation linking them
Exceptions
  • Documentation clearly states conditions are unrelated
  • Specific guideline requires documented linkage
  • Provider must link conditions when not specifically linked by classification terms
For conditions not specifically linked by these relational terms in the classification or when a guideline requires that a linkage between two conditions be explicitly documented, provider documentation must link the conditions in order to code them as related.

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16. "See" and "See Also"
"See" Instruction
The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the "see" note to locate the correct code.
"See Also" Instruction
A "see also" instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the "see also" note when the original main term provides the necessary code.
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17. "Code also" Note
A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.

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18. Default Codes
A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.
Most Common Association
The default code represents the condition most commonly associated with the main term
Unspecified Code
When no additional details are provided, the default code serves as the unspecified code
When to Use
Assign the default code when documentation lacks specific details like acute or chronic

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19. Code Assignment and Clinical Criteria
Provider's Diagnostic Statement
The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
If there is conflicting medical record documentation, query the provider.
B. General Coding Guidelines

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20. Locating a Code in the ICD-10-CM
To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.
Step 1: Alphabetic Index
Locate the term in the Alphabetic Index to find the preliminary code
Step 2: Tabular List
Verify the code in the Tabular List and read all instructional notes
Step 3: Complete the Code
Add laterality and any applicable 7th character as required
It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

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21. Level of Detail in Coding
Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record.
ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail.
1
2
3
4
5
1
7 Characters
Highest specificity
2
6 Characters
3
5 Characters
4
4 Characters
5
3 Characters
Category level
A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
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22. Code or Codes from A00.0 through T88.9, Z00-Z99.8, U00-U85
The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8, and U00-U85 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit.
A00.0 - T88.9
Disease and injury codes
Z00 - Z99.8
Factors influencing health status
U00 - U85
Provisional assignment codes

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23. Signs and Symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for symptoms.

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24. Conditions that are an Integral Part of a Disease Process
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Do Not Code Separately
When a sign or symptom is an integral part of the disease, it should not be coded separately
Example: Fever with pneumonia - fever is integral to pneumonia and should not be coded separately
Exception
Code separately only when the classification specifically instructs to do so

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25. Conditions that are Not an Integral Part of a Disease Process
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
Code These Separately
When signs and symptoms are not routinely associated with the disease, they provide additional important clinical information and should be coded.
Example: A patient with diabetes who also presents with chest pain - the chest pain is not an integral part of diabetes and should be coded separately.

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26. Multiple Coding for a Single Condition
In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. "Use additional code" notes are found in the Tabular List at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, "use additional code" indicates that a secondary code should be added, if known.
For example, for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, Staphylococcus, and Enterococcus, as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A "use additional code" note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code.
01
"Use additional code"
Indicates a secondary code should be added to fully describe the condition
02
"Code first"
The underlying condition should be sequenced first when present
03
"Code, if applicable, any causal condition first"
May be used as principal diagnosis when causal condition is unknown or not applicable
"Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first, if known.
"Code, if applicable, any causal condition first" notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis.
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Multiple codes may be needed for sequela, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction.

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27. Acute and Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.
1
Acute/Subacute Code
Sequence first
2
Chronic Code
Sequence second

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28. Combination Code
A combination code is a single code used to classify:
  • Two diagnoses, or
  • A diagnosis with an associated secondary process (manifestation)
  • A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.
When to Use
Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs.
When Not to Use
Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis.
Additional Codes
When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

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29. Sequela (Late Effects)
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis.
Code the Residual Effect First
The condition or nature of the sequela is sequenced first
Code the Sequela Second
The sequela code is sequenced second
Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.
See Section I.C.9. Sequelae of cerebrovascular disease
See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium
See Section I.C.19. Application of 7th characters for Chapter 19
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30. Impending or Threatened Condition
Code any condition described at the time of discharge as "impending" or "threatened" as follows:
If it Did Occur
Code as confirmed diagnosis
If it Did Not Occur
Reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened."
If Subterms are Listed
Assign the given code
If Subterms are Not Listed
Code the existing underlying condition(s) and not the condition described as impending or threatened

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31. Reporting Same Diagnosis Code More than Once
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code.

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32. Laterality
Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.
Left Side
Specific code for left-sided conditions
Bilateral
Single code for both sides when available
Right Side
Specific code for right-sided conditions
Unspecified
Use when side is not documented
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.
When laterality is not documented by the patient's provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient's provider should be queried for clarification.

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33. Documentation by Clinicians Other than the Patient's Provider
Code assignment is based on the documentation by the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis).
In this context, "clinicians" other than the patient's provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient's official medical record.
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These exceptions include codes for:
  • Body Mass Index (BMI)
  • Depth of non-pressure chronic ulcers
  • Pressure ulcer stage
  • Coma scale
  • NIH stroke scale (NIHSS)
  • Social determinants of health (SDOH) classified to Chapter 21
  • Laterality
  • Blood alcohol level
  • Underimmunization status
  • Firearm injury intent
This information is typically, or may be, documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, pressure ulcer, or a condition classifiable to category F10, Alcohol related disorders) must be documented by the patient's provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's provider should be queried for clarification.

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34. Syndromes
Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.
01
Check Alphabetic Index
Follow the guidance provided in the Alphabetic Index for the specific syndrome
02
Code Manifestations
If no specific guidance exists, code the documented manifestations of the syndrome
03
Add Additional Codes
Code manifestations that are not integral to the disease process when no unique code exists

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35. Documentation of Complications of Care
Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term "complication."
Requirements for Complication Coding
  • Cause-and-effect relationship between care and condition
  • Documentation supports clinical significance
  • Term "complication" not required
For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2026 Page 17 of 121

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36. Borderline Diagnosis
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.
General Rule
Code borderline diagnosis as confirmed unless a specific entry exists
Specific Entry Exists
Use the specific borderline code when available in the classification
All Settings
No distinction between inpatient and outpatient settings
When Unclear
Query the provider for clarification

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37. Use of Sign/Symptom/Unspecified Codes
Sign/symptom and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.
Each healthcare encounter should be coded to the level of certainty known for that encounter. As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
When Definitive Diagnosis Not Established
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.
When Information is Insufficient
When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).
Reflect What is Known
Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter.
It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

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38. Coding for Healthcare Encounters in Hurricane Aftermath
a. Use of External Cause of Morbidity Codes
An external cause of morbidity code should be assigned to identify the cause of the injury(ies) incurred as a result of the hurricane. The use of external cause of morbidity codes is supplemental to the application of ICD-10-CM codes. External cause of morbidity codes are never to be recorded as a principal diagnosis (first-listed in non-inpatient settings). The appropriate injury code should be sequenced before any external cause codes. The external cause of morbidity codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person's status (e.g., civilian, military). They should not be assigned for encounters to treat hurricane victims' medical conditions when no injury, adverse effect or poisoning is involved. External cause of morbidity codes should be assigned for each encounter for care and treatment of the injury. External cause of morbidity codes may be assigned in all health care settings.
ICD-10-CM Official Guidelines for Coding and Reporting FY 2026 Page 18 of 121
For the purpose of capturing complete and accurate ICD-10-CM data in the aftermath of the hurricane, a healthcare setting should be considered as any location where medical care is provided by licensed healthcare professionals.

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Hurricane Aftermath Coding (continued)
b. Sequencing of External Causes of Morbidity Codes
Codes for cataclysmic events, such as a hurricane, take priority over all other external cause codes except child and adult abuse and terrorism and should be sequenced before other external cause of injury codes. Assign as many external cause of morbidity codes as necessary to fully explain each cause. For example, if an injury occurs as a result of a building collapse during the hurricane, external cause codes for both the hurricane and the building collapse should be assigned, with the external causes code for hurricane being sequenced as the first external cause code.
For injuries incurred as a direct result of the hurricane, assign the appropriate code(s) for the injuries, followed by the code X37.0-, Hurricane (with the appropriate 7th character), and any other applicable external cause of injury codes. Code X37.0- also should be assigned when an injury is incurred as a result of flooding caused by a levee breaking related to the hurricane. Code X38.-, Flood (with the appropriate 7th character), should be assigned when an injury is from flooding resulting directly from the storm. Code X36.0.-, Collapse of dam or manmade structure, should not be assigned when the cause of the collapse is due to the hurricane. Use of code X36.0- is limited to collapses of man-made structures due to earth surface movements, not due to storm surges directly from a hurricane.
c. Other External Causes of Morbidity Code Issues
For injuries that are not a direct result of the hurricane, such as an evacuee that has incurred an injury as a result of a motor vehicle accident, assign the appropriate external cause of morbidity code(s) to describe the cause of the injury, but do not assign code X37.0-, Hurricane. If it is not clear whether the injury was a direct result of the hurricane, assume the injury is due to the hurricane and assign code X37.0-, Hurricane, as well as any other applicable external cause of morbidity codes. In addition to code X37.0-, Hurricane, other possible applicable external cause of morbidity codes include:
  • X30-, Exposure to excessive natural heat
  • X31-, Exposure to excessive natural cold
  • X38-, Flood
d. Use of Z codes
Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter. The ICD-10-CM Official Guidelines for Coding and Reporting identify which codes may be assigned as principal or first-listed diagnosis only, secondary diagnosis only, or principal/first-listed or secondary (depending on the circumstances). Possible applicable Z codes include:
  • Z59.0-, Homelessness
  • Z59.1, Inadequate housing
  • Z59.5, Extreme poverty
  • Z75.1, Person awaiting admission to adequate facility elsewhere
  • Z75.3, Unavailability and inaccessibility of health-care facilities
  • Z75.4, Unavailability and inaccessibility of other helping agencies
  • Z76.2, Encounter for health supervision and care of other healthy infant and child
  • Z99.12, Encounter for respirator [ventilator] dependence during power failure
ICD-10-CM Official Guidelines for Coding and Reporting FY 2026 Page 19 of 121
The external cause of morbidity codes and the Z codes listed above are not an all-inclusive list. Other codes may be applicable to the encounter based upon the documentation. Assign as many codes as necessary to fully explain each healthcare encounter. Since patient history information may be very limited, use any available documentation to assign the appropriate external cause of morbidity and Z codes.

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39. Multiple Sites Coding
The classification defines "multiple" as involving two or more sites. Follow chapter specific guidelines for assigning codes for "multiple sites." In the absence of chapter specific guidelines, assign codes describing specified sites individually when documented. When the specified site(s) are not documented, assign the appropriate code for "multiple sites."
2+
Definition of Multiple
Involving two or more sites
1st
Priority
Follow chapter-specific guidelines first
100%
Documentation
Code all specified sites when documented

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