b. Without Written Instructions:
(1) Late effects (cause of) with residual. The residual code is sequenced before
the late effect code.
(2) Etiology (underlying cause) with manifestations/ complications. Code first
the underlying cause, then the manifestation/complication.
both codes be used and sequenced with the reaction first followed by the E code.
(4) Any other conditions in the main classification that can be more completely
identified by the use of multiple coding.
NUMBER OF CODES REQUIRED
2. The number of codes to be used depends upon the needs of the user. Avoid
indiscriminate coding of all signs and symptoms with their accompanying definitive
diagnoses, laboratory test results, social factors and other personal, nonmedical data
mentioned in the record. Code only those conditions that require treatment or
management during the current episode of hospitalization. DO NOT CODE conditions
stated as "history of," "status post," etc., not treated or managed during current
EXCEPTION: Personal history of malignant neoplasm V10.00-V10.9 for a previously
treated malignant neoplasm with no evidence of recurrence in the primary site. (See
principle VIII ( Neoplasms.)*
3. Diseases/conditions that are treated in one facility before transfer to another are not
coded by the receiving facility unless that disease/condition is still present and being
EXCEPTION: When coding underlying cause of death/separation, the receiving facility
will code the actual disease/condition that caused the death/separation, even if not
treated by that facility.
1. Written Instruction:
a. Code also . . . .
DIAGNOSIS: Acute myocarditis, secondary to tuberculosis.
Code also underlying disease as: