Q&A: 'Code first' versus 'in diseases classified elsewhere'

Q: I can't distinguish between "code first" and "in diseases classified elsewhere.” Both are used with manifestations and both can't be sequenced as principal diagnosis, and both need etiology codes so what is the difference?

A: Technically, not all “code first” notes are mandatory, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HCPro’s Certified Coder Boot Camp® programs, based in Middleton, Massachusetts. For example, ICD-10-CM category I50 includes a “code first” note but it is only used if applicable since heart failure can be a principal diagnosis.

The “code first” note informs us of two things, says Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist at ACDIS. First, it informs you that two codes may be required. Second, it provides sequencing direction.

There are some “code first” notes that are only applicable in certain instances, such as McCall mentions, at “heart failure,” the note talks about assigning codes for hypertensive heart failure, pregnancy related heart failure etc., first, if applicable. Secondly, if, for example, the CDI specialist reviews a Parkinson’s manifestation, such as a dementia, and they see “code first Parkinson’s,” in the tabular list then first code Parkinson’s disease (G20) followed by the code for dementia (F02.80). In this example, the “code first” note is positioned next to the manifestation code to remind you to code the etiology first.

In contrast, the phrase “in diseases classified elsewhere” informs coders that two codes are required and means this code must be sequenced as the second code. If you see “in diseases classified elsewhere” in a code description, then you know you are looking at a manifestation code. These codes should never be used as a principal diagnosis and must be reported in conjunction with a code for the underlying cause/diagnosis.

While these terms may seem very similar, Frady says, the “code first” terminology represents an instructional note while “in diseases classified elsewhere” is actually a part of the code title itself. You would only see the “code first” note if you look up the code in the tabular list and review the instructional notes, whereas you would see “in diseases classified elsewhere” if you were simply reading the code title or description in the alphabetic index.

Interestingly enough, if you index Dementia in a current 2017 code book, these conventions are not used. The index entry is Dementia (with) Parkinson’s disease: G20 [F02.80]. In this case, the formatting of code first [bracketed code second] provides the sequencing.

Caution is warranted, if you index this condition by looking up the keyword “Parkinson’s,” you get an entirely different code as you get an instructional note to “See Parkinsonism” and following that pathway in either a book or an encoder you will arrive at codes G31.83 and F02.80.

Editor’s note: This answer was provided based on limited information submitted to ACDIS. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. For information regarding coding or CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.