ICD-10 Coding and Clinical Documentation Resources
As with ICD-9, ample resources are available to assist you with coding and clinical documentation for ICD-10.
Official government coding guidelines cover:
- Diagnosis coding: ICD-10-CM Official Guidelines for Coding and Reporting 2016
- Inpatient procedure coding: ICD-10-PCS Official Guidelines for Coding and Reporting 2016
CMS offers documentation and coding basics for clinicians in the Road to 10 Clinical Concepts Series with tailored guidance for:
Free lists of codes and ICD-9/ICD-10 mappings are available from CMS as well as vendors and trade associations, for example:
- 2016 ICD-10-CM and GEMs (CMS)
- 2016 ICD-10-PCS and GEMs (CMS)
- CMS ICD-10 Code Lookup
- ICD-10 Charts
- ICD-10 Central Coding Guidance (RelayHealth)
- ICD-10 Code Translator (AAPC)
Several free and low-cost smartphone apps are available, and ICD10Data.com is a mobile-friendly website.
Many electronic health record (EHR) products and practice management systems prompt users for required documentation and feature computer-assisted coding.
Some system vendors and clearinghouses offer training to customers and potential customers.
Some health care trade associations and medical societies provide coding resources at no or little cost to their members, with premium costs sometimes charged to nonmembers.
Membership is not required to submit coding questions to the American Hospital Association’s codingclinicadvisor.com or view AHA’s free webinars (registration is required). When contacting the Coding Clinic Advisor for free assistance, include documentation and specify whether your question refers to a specific setting like a skilled nursing facility or home health services. Please note that the Coding Clinic Advisor will not respond to inquiries that include personal health information (PHI) or the names of providers or health care facilities. Please see the Coding Clinic Advisor FAQs for more, including a list of topics that are out of scope for this service.
Remember: The process for looking up an ICD-10 code—whether in a book or in an electronic product—remains essentially the same as the process for looking up an ICD-9 code.