General coding standards
Specificity
Always code to the highest level of detail the clinical record supports.
Qué significa esto en la práctica
- Unspecified codes are a last resort. Where the record documents laterality, stage, acuity or organism, the specific code must be used.
- Diagnostic imaging, pathology and other test reports may be used to add specificity to a diagnosis the physician has already documented.
- The explorer flags unspecified codes so a coder can see immediately when a more specific alternative exists in the same category.
Dónde lo aplica el explorador
neoplasminflammatorytraumadegenerative
{# CIHI's licence requires acknowledgement AND prohibits implying endorsement.
Both obligations live here so every standards page carries them. #}
Source, copyright and permitted use.
This service indexes and cites the Canadian Coding Standards; it does not reproduce them. The summaries here are original text written for this product. The authoritative wording is CIHI's publication, and where the two differ the publication governs.
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022.
CIHI permits reproduction of its publications unaltered, in whole or in part, solely for non-commercial purposes with full acknowledgement of CIHI as copyright owner. Any reproduction or use for a commercial purpose requires CIHI's prior written authorization. Reproduction or use suggesting endorsement by, or affiliation with, CIHI is prohibited — Advanced Management Solutions is not affiliated with or endorsed by CIHI.
Production of the source publication was made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed in it do not necessarily represent the views of Health Canada or of any provincial or territorial government.
Códigos y clasificaciones del ICIS · All attributions & third-party rights
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022.
CIHI permits reproduction of its publications unaltered, in whole or in part, solely for non-commercial purposes with full acknowledgement of CIHI as copyright owner. Any reproduction or use for a commercial purpose requires CIHI's prior written authorization. Reproduction or use suggesting endorsement by, or affiliation with, CIHI is prohibited — Advanced Management Solutions is not affiliated with or endorsed by CIHI.
Production of the source publication was made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed in it do not necessarily represent the views of Health Canada or of any provincial or territorial government.
Códigos y clasificaciones del ICIS · All attributions & third-party rights