30 AAP News •
www.aapnews.org • September 2015
from the AAP Division of Health Care Finance
Editor’s note: This is the first of two articles that addresses
International Classification of Diseases, Tenth Revision,
Clinical Modification (ICD-10-CM) coding conventions
As the Oct. 1 implementation date for ICD-10-
CM approaches, it is important to understand some
basic rules for applying the code set appropriately,
including how to locate a code, use of 7th characters
Locating a code
It is essential to use both the Alphabetic Index
and the Tabular List to locate and assign a code that
corresponds to a diagnosis or reason for visit.
First, locate the term in the Alphabetic Index and
then verify the code in the Tabular List. Instructional
notations serve as guides.
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
ICD-10-CM: back to the basics
AAP staff are available to assist members with the transition to ICD-10-CM. Email questions to the AAP Coding
Hotline at email@example.com.
The newest program in the Helping Babies Survive
(HBS) suite rolled out to educate those who will go on
to train others in small baby care in resource-limited areas. Essential Care for Small Babies (ECSB), which focuses on premature and low birthweight (under 2,000
grams) infants, builds on Essential Care for Every Baby
and Helping Babies Breathe (HBB).
About 60 people were trained in July in Washington, D.C. Among attendees were representatives from
partner organizations, with plans to extend training
abroad. Countries represented at the workshop included Canada, Ethiopia, Mexico, Nigeria and the U.S.
The first 90 minutes of life are the focus of the HBS
programs, which target countries considered by the
World Health Organization to have high mortality
rates for children under age 5.
A big emphasis of ECSB is skin-to-skin care, which
is designed to keep the small baby warm. Skin-to-skin
care also facilitates breastfeeding to improve weight
gain and aids maternal bonding with the newborn.
Compared to the grassroots approach of HBB,
ECSB’s clinically focused technical material appeals
to midwives, doctors and nurses. Most small babies
have trouble breastfeeding, so ECSB training involves
a specialized small baby simulator that aids in teaching how to insert a feeding tube. Another simulator
teaches how to express and measure breastmilk. The
training program also stresses continual assessment to
determine whether more care is needed, recognition of
danger zones and determining when the infant is ready
to go home. A single-page parent handout accompanies
the learning materials so providers can offer care tips
and remind parents about immunizing their children.
The Academy worked with partners to beta test
ECSB in Nepal and Uganda. A regional training then
was conducted in Bangladesh with participants from
nine surrounding countries. Evaluations and feedback
from all locations led to adjustments to the curriculum.
Groups represented at the ECSB training included
Save the Children, American College of Nurse Midwives, the Bill and Melinda Gates Foundation, the
Even if a dash is not included in the Alphabetic Index
entry, it is necessary to refer to the Tabular List to verify
whether a 7th character is required.
Level of detail
ICD-10-CM diagnosis codes are comprised of three
to seven characters. They should be reported with the
highest number of characters available, including the 7th
character, if applicable. Otherwise, the code is invalid.
Codes with three characters are included as the
heading of a category of codes that may be subdivided
by the use of fourth, fifth and/or sixth characters, which
provide greater detail. Use a three-character code only
if it is not subdivided.
Format and structure
The ICD-10-CM Tabular List contains categories,
subcategories and codes. Characters for categories,
subcategories and codes may be either a letter or a
• Categories are three characters. A three-character
category that has no further subdivision is
equivalent to a code and may be reported as such.
• Subcategories are either four or five characters.
• Codes may have three, four, five, six or seven
characters. Each level of subdivision after a category
is a subcategory. The final level of subdivision is a
code. A code that has an applicable 7th character is
considered invalid without the 7th character.
ICD-10-CM uses “X” as a placeholder character in
certain codes to allow for future expansion (e.g., poisoning,
adverse effect and underdosing codes, categories
T36-T50). Where a placeholder exists, the X must be
used for the code to be considered valid. This holds true
specifically for codes that require a 7th character.
Certain ICD-10-CM categories have 7th characters,
which are required for all codes in 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 six characters, a placeholder
X must be used to fill in the empty characters.
• Brackets [ ] are used in the Tabular List to enclose
synonyms, alternative wording or explanatory
phrases. Brackets are used in the Alphabetic Index
to identify manifestation codes.
• Parentheses ( ) are used in both the Alphabetic Index
and Tabular List to enclose supplementary words
that may be present or absent in the statement of
a disease or procedure without affecting the code
number to which it is assigned. Terms within the
parentheses are referred to as nonessential modifiers.
• Colons are used in the Tabular List after an
incomplete term that needs one or more of the
modifiers following the colon to make it assignable
to a given category.
• “And”: The word “and” means either “and” or “or”
when it appears in a title. For 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
• “With”: The word “with” means “associated with”
or “due to” when it appears in a code title, the
Alphabetic Index or an instructional note in the
• “See”: The “see” instruction following a main term
in the Alphabetic Index indicates that another term
should be referenced to locate the correct code.
• “See Also”: A “see also” instruction following a main
term in the Alphabetic Index indicates that another
main term 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.
First workshop held on small baby essential care
• Helping Babies Breathe, www.helpingbabiesbreathe.org
• AAP Global, http://www2.aap.org/international
Janna Patterson, M.D., FAAP, of the Bill and
Melinda Gates Foundation (left), learns about
skin-to-skin care from Nalini Singhal, M.D.,
FAAP, editor of Essential Care for Small Babies,
while Michael K. Visick, M.D., FAAP, of LDS