As of October 2015, International Classification of Diseases, 10th Revision (ICD-10) was published by the World Health Organization (WHO). The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings.
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. Diagnosis codes are to be used and reported at their highest level of specificity.