ICD10CM

ICD-10-CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification. It is a medical classification used in the United States to code and classify diagnoses and reasons for patient encounters in clinical settings.

ICD-10-CM is a US clinical modification of the World Health Organization’s ICD-10. It is developed and maintained by the National Center for Health Statistics (NCHS) in coordination with the Centers for Medicare and Medicaid Services (CMS). It replaced the ICD-9-CM diagnosis coding system for most purposes, with ICD-10-PCS used for inpatient procedure coding. The ICD-10-CM system operates alongside ICD-10-PCS in hospital and outpatient coding.

Codes are alphanumeric and can be up to seven characters in length. The structure allows detailed documentation of diagnoses and conditions, with features such as laterality and encounter type incorporated in many codes. The coding set is updated annually to reflect medical advances, new diseases, and changes in clinical practice.

Common uses include documentation of diagnoses for patient records, billing and reimbursement, public health surveillance, epidemiology, quality measurement, and clinical research. Federal agencies, health plans, and healthcare providers rely on ICD-10-CM data for statistics, reporting, and decision making.

Governance and adoption: the code set is maintained by NCHS with CMS oversight, and updates are released annually. Compliance with ICD-10-CM guidelines is required for HIPAA-standard electronic health transactions in the United States. When transitioning from ICD-9-CM, mappings exist between the two systems to support conversion.