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June 24, 2020

Training New or Inexperienced Coders

Written by: Amy WagnerMEd, CHA, CPC, ICDCT-CM


Educating new or inexperienced coders lets you share your wisdom and experience with others as you broaden your own training skills and expand your career in a new direction. Teaching can change lives! You can inspire your students to become better coders and master ICD-10 by demonstrating enthusiasm for your subject matter and promoting a passion for coding excellence.

Where to Begin?

As an experienced coder, you may be asked to present information to your co-workers or staff that are new to coding. Start with the basics – Like how to use the coding book! Everyone, even those institutions using CAC (computer-aided-coding) tools, should get their hands on a coding book to learn how to use it. As a trainer, provide a couple of coding books during class for the students to share.

Rule #1 – remind coders that the diagnosis data set is updated each fiscal year effective October 1st. 

Review the Alphabetic Index and Tabular List

ICD-10-CM is divided into the Alphabetic Index (an alphabetical list of terms and their corresponding code) and the Tabular List (a chronological list of codes divided into chapters based on body system or condition). The e-files for the Alphabetic Index of ICD-10-CM can be downloaded from the following CMS webpage:

The left-side column of this webpage lists links to the current FY and previous years. It is divided by “CM” versus “PCS”. Click on the link for the current (or future) FY data files to obtain the e-file zipped downloads.

Describe and Help Your New Coders Find These Parts of the Alpha Index

Alpha Index:

  • Index of Diseases and Injury;
  • Index of External Causes of Injury;
  • Table of Neoplasms; and
  • Table of Drugs and Chemicals.

Review each section of the Alpha Index and show your students how the sections are divided.  Briefly explain how each section is distinguished from the others and give them a chance to look at examples found in each section of the Alpha Index before moving on to explain the Tabular List.

Review How the Tabular List Is Organized Into Chapters

The ICD-10-CM Tabular List is referenced after locating the term in the Alpha Index (index). The index will provide a code which requires confirmation and completion in the Tabular List. 


This is one of the most important rules of coding and a common mistake made by new or inexperienced coders. The tabular contains categories, subcategories and codes. As a coder, you MUST complete the code from the tabular listing due to extensions, placeholders, excludes notes and other factors which are only provided in the tabular. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code.

Review the format and structure of the Tabular Index. Each level of subdivision after a category is a subcategory. Looking at the subcategories, they are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or even 7 characters. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. ICD-10-CM utilizes a placeholder character “X”. The X is used as a placeholder in certain codes to allow for future expansion. Where a placeholder exists, the X must be used in order for the code to be considered a valid code. A code that has an applicable 7th character is considered invalid without the 7th character. For reporting purposes only codes are permissible, not categories or subcategories. Using the X placeholder and adding any applicable 7th character is required.

Includes and Excludes Notes

Give your students examples of codes with Includes and Excludes Notes and review the rules regarding these notes when they appear in the Tabular List. The Includes Notes appear immediately under a three character code title to further define, or give examples of, the content of the category. It provides a list of terms included under some of the codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title or, in the case of “other specified” codes, a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

ICD-10-CM has two types of excludes notes, Excludes1 and Excludes2. Each type of note has a different definition for use but they are similar in that they indicate that codes excluded from each other are independent of each other. A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

A type 2 Excludes note represents “Not included here”. An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Extensions - A complicated subject to explain to new coders

Experienced coders realize that the extension is placed at the end of the code to complete the required number of characters and to report particular circumstances of the patient’s condition. Your review of the use of extensions in coding is a great time to also review the most common extensions for non-fracture encounters following injuries and to make sure your students understand the definition of sequela, the difference between a subsequent encounter and a sequela, and the sequencing guidelines for coding sequela. However, introducing the more complex extensions right from the beginning with a new coder is best.  It may also be a good review for you!. 


Extension A for initial encounter should be used while the patient is receiving active treatment for the condition.

Extension D for subsequent encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase (after care). 

Extension S for sequela is used for complications or conditions which arise as a direct result of a condition, such as a scar formation after a burn.

  • The use of 7th character S requires codes for the injury that precipitated the sequela and the sequela. The S is not added to the sequela code but only to the injury code indicating it is responsible for the sequela. The sequela is sequenced first followed by the injury code. “Sequela” replaces “late effect” terminology from ICD-9.

  • Remind your inexperienced coders not to confuse these definitions with CPT coding. The “new” or “subsequent” terms used in ICD-10 have NOTHING to do with New or Established patient definitions of CPT. 

Fracture-Related Extensions

Fracture Extensions to Know

G   subsequent encounter for fracture with delayed healing

K   subsequent encounter for fracture with nonunion

P   subsequent encounter for fracture with malunion

Gustilo Open Fracture Classifications & Extensions

the Gustilo open fracture classification groups open fractures into three main categories, designated as Type I, Type II and Type III (with Type III injuries being divided further into Type IIIA, Type IIIB and Type IIIC). The categories are defined by three characteristics, which include:

  • Mechanism of injury
  • Extent of soft tissue damage
  • Degree of bone injury or involvement

Type I

Type II

  • Wound less than one centimeter
  • Minimal soft tissue damage 
  • Wound bed clean
  • Typically low-energy injury
  • Fracture type typically one of the following:
  • Simple transverse
  • Short oblique
  • Minimally comminuted
  • Wound greater than one centimeter
  • Moderate soft-tissue damage
  • Minimal or no wound bed contamination
  • Typically low-energy injury
  • Fracture type typically one of the following:
  • Simple Transverse
  • Short oblique
  • Minimally comminuted

Type III


  • Wound less than one centimeter
  • Extensive soft tissue damage 
  • Typically a high-energy injury
  • Highly unstable fractures, often with multiple bone fragments 
  • Injury patterns resulting in fractures typically classified to this category include:
  • Open segmental fracture, regardless of wound size
  • Gunshot wounds with bone involvement
  • Open fractures with any type of neurovascular involvement
  • Severely contaminated open fractures
  • Traumatic amputations
  • Open fractures with delayed treatment (more than eight hours)
  • Adequate soft tissue coverage of open wound
  • No local or distant flap coverage required
  • Fracture open segmental or severely comminuted and still classified as Type IIIA


  • Extensive soft tissue loss
  • Local or distant flap coverage required
  • Wound bed contamination requiring serial irrigation and debridement to clean open fracture site


  • Major arterial injury
  • Extensive repair, usually requiring skills of a vascular surgeon, required for limb salvage.
  • Local or distant flap coverage required
  • Wound bed contamination requiring serial irrigation and debridement to clean open fracture site

These are the additional Gustilo extensions:

B          Initial encounter for open fracture type I or II

C          Initial encounter for open fracture type IIIA, IIIB, or IIIC

E          Subsequent encounter for open fracture type I or II with routine healing

F          Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

H          Subsequent encounter for open fracture type I or II with delayed healing

J           Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

M         Subsequent encounter for open fracture type I or II with nonunion

N          Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Q          Subsequent encounter for open fracture type I or II with malunion

R          Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Abbreviations and Punctuation

New coders can always benefit from a review of the abbreviations and punctuation rules found throughout the ICD-10 coding book. There are 2 main acronyms used in both the alphabetic and tabular index: NEC “Not elsewhere classifiable” and NOS “Not otherwise specified”. Quiz your students to see how many remember these acronyms and how they are used. Be ready with some instances from the book to show your students examples of the many times they will encounter these abbreviations in their coding careers.

The NEC “Not elsewhere classifiable” abbreviation in the Alphabetic Index represents “other specified”. When a specific code is not available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the Tabular List. When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the “other specified” code. While, the NOS “Not otherwise specified” abbreviation is the equivalent of unspecified. ICD-10-CM also uses specific punctuation to represent additional information. 

“[ ]” Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.


“( )” Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.

“:” Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. This presumes a causal relationship between the two conditions and these conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between two conditions. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.

The “see” instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code. A “see also” instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code. A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing of these codes depends on the reason for the encounter. Walk your students through some examples of conditions where they will have to follow these rules. Remember, students always benefit from seeing the rule in action with an opportunity to ask questions of you if they are confused by these rules.

Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate “other” codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an “other” code.

“Unspecified” titled codes are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the “other specified” code may represent both other and unspecified. When training new coders, start with basic review questions.


New or inexperienced coders may feel overwhelmed by the many rules and guidelines of ICD-10 coding and your positive attitude as an educator can make the difference. Make it fun! Provide positive feedback and encouragement to your learners with lots of opportunities to code simple case examples as you review the fundamental rules of coding. 

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