Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. 2 is a valid billable ICD-10 diagnosis code for Pelvic and perineal pain . 011, Postthrombotic syndrome with ulcer of right lower extremity, and L97. In the Alphabetic Index, following the main term “sequela,” is the direction term “see also condition” to remind the coder that other entries in the Alphabetic Index are. Use additional code for adverse effect, if applicable, to identify adverse effect of drug (T36-T50 with fifth or six. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. A postcoordination instructional note labeled “Has manifestation (use additional code, if desired)” is a reminder to the user that, depending on the case being coded, it is allowable to post-coordinate any manifestations with the underlying condition. 9. ICD-10-CM guideline I. -)" instructional note under category K70. Group of answer choices. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. Correctly use instructional terms and symbols as defined in the ICD-9-CM. N52. Use Additional Code. In most cases the manifestation codes will include “in diseases classified elsewhere” in the. Introduction to ICD-10-CM. e. 01 Conn’s syndrome. There is an instructional note to code also the type of asthma, if applicable (J45. In most cases the manifestation codes will have in the code title, "in diseases. The instructional notes to code first the underlying physiological condition are found at the category level. 9. The 7th character must always be the 7th character in the data field. A note under category J01 Acute sinusitis states that an additional code (B95-B97) is used to identify the infectious agent, if known. 00, N30. a. c. Laterality and 7 thCategory J32. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Verify the codes in the tabular list and assign codes in this order: I87. Location. When it applies, codes missing this character are. E66. What is the ICD-10-CM code for nausea? R11. Z71. Diseases of the Eye and Adnexa. A "use additional code" note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code. Category O02 Use additional code note and excludes1 note 10. The note, however, does not provide sequencing. The principal diagnosis for this case is reported with code _____. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Relating to Use Additional Code and Code First Instructional Notes: The CODE FIRST note _____. These items provide guidelines for using the code set. You are directed to R11. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 5 Chronic kidney disease, stage 5 states that this code excludes “chronic kidney disease, stage 5 requiring chronic dialysis (N18. There is advice at the beginning of this chapter to use an additional code to identify resistance to antimicrobial drugs using. detail to ensure the code assignment is not affected. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. This notation indicates that use of an additional code. What is the instruction provided in the note below code E10. If the coder sees a "see" note, they should follow the cross-reference to where it tells you to go to review extra entries in the index. Question 1. 1 - N18. You will also find instructional notes that say code first or use additional code. Answer: The Use Additional Code note instructs the coder to use an additional code to identify the manifestation that is present. general notes, inclusion and exclusion notes, code first notes, use additional code notes, and code also notes. In most cases, the manifestation codes will have in the code title “in diseases classified elsewhere. The abbreviation NEC appears with main terms for which no specific code exists. g. 0 also applies to the following:Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. 15. ↓ See below for any exclusions, inclusions or special notations. Wherever such a combination exists, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code. R14. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. The "use additional code" note will be found under the associated condition code in the "Tabular List of Diseases. Which is not an instructional note under Transport Accidents? Use additional code to identify: failure to use seatbelt. (See Appendix A, Section I. and more. The ICD-10-CM Index does have instructional notes to code first the underlying infection. 8- directing to “Code first underlying disease when associated fever is present such as with: neutropenia (D70. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Excludes2 means that the condition is not a part of the condition that is being represented by the code, but the patient can have both conditions at the same time. NEC means not elsewhere classifiable 2. The SEE ALSO instructional note. [Brackets] are an ICD-10-CM convention indicating the enclosed code is. "Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. True The "Excludes 1" note _____. Some people are interpreting a "use additional code" note to mean that the secondary code must always appear in the diagnosis field immediately following the. when the note appears under a code, it is acceptable. The location of the includes note determines the category or block of category codes that the note governs. A portion of the body part is being removed. 3. ↓ See below for any exclusions,. 1. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 1 0 Instructional note appears at beginning of chapter, "when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site" Use additional codes, where applicable, to identify o Exposure. instructional notes, and may also require coding to a higher degree of specificity than indicated here. 0) 11 Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. " ICD-10-CM Coding Conventions The conventions for ICD-10-CM are the general rules for using the classification independent of the guidelines. 1 is a valid billable ICD-10 diagnosis code for Major depressive disorder, recurrent, moderate . It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . When there is a “code first” note and an underlying condition is present, the underlying condition is sequenced first. Use additional code. QUESTION 1 4 points Sa In the ICD 10 CM manual which type of instructional note is used in the Tabular List of Diseases to identify a. " In the "Index to Diseases," the multiple coding requirement is indicated by the use of the slanted brackets. Thromboarteritis - see arteritis. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. Make sure to review pairs of ‘Use additional code’ notes at the etiology code, and ‘Code first’ notes at the manifestation code to ensure proper sequencing order in the guidance,” Blanchard adds. The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. Wherever such a combination exists there is a "Use Additional Code" note at the etiology code, and a "Code First" note at the manifestation code. ICD-10-CM: type 2 DM with diabetic CKD (E11. In this case, the PDX of hypertensive heart disease with CHF (I11. Codes First and Use Additional Code Notes Coding convention used in ICD-10-CM that directs the coder as to which condition is coded first is known as a “code first” note. Expert tip: “Tab your copy of ICD-10 with reminders. [Brackets] are an ICD-10-CM convention indicating the enclosed code is a manifestation code INSTRUCTIONAL NOTES Excludes1&2 Tip: Excludes1: Only 1 code can be used Excludes2: 2 codes can be use if both are appropriate and there is proper documentation for both 11/19/2015 17 INSTRUCTIONAL NOTES • “Code First” & “Use Additional Code” • Used for Sequencing Priority – Found in Tabular Use of "Code also" or "Use Additional code" Instructions in ICD 10 coding for medical coders. Example: E10. In most cases the manifestation codes will have in the code title, "in diseases. Used to signify that the conditions listed are not assigned to the category or block of category. The "use additional code" note will be found under the associated condition code in the "Tabular List of Diseases. Some categories of codes (e. 1 - N18. Select one: True False. The “Use additional” code note is found below the underlying condition code. In most cases the manifestation codes will have in the code title, 'in diseases. CODING CONVENTIONS. In the tabular, code G31. , The instructional note "INCLUDES" ________. Square brackets are used in the Tabular List of Diseases to: To enclose alternative wordings, abbreviations, and explanatory phrases. Additional terms found only in the Alphabetic Index may also be assigned to a code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. locate main term in index. " In the "Index to Diseases," the multiple coding requirement is. 01 Conn’s syndrome. There is no information of the infectious agent and no additional code is reported. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. Chronic sinusitis (includes abscess, empyema, infection, suppuration) There are several instructional notes you must consider when applying the sinusitis codes. A combination code is used to classify? Two diagnosis, a diagnosis w/ an associated secondary process ( manifestation) , a diagnosis w/ an associated complication. Hypertension With Heart Disease. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ICD-10-CM Tabular Instructional Notes . -). instructional notes, and may also require coding to a higher degree of. xxxx Drug or chemical-induced diabetes mellitus Code first a dx from (T36-T65) Use additional code for adverse effect (T36-T50) E10. 10. The words indicate an instructional note that directs the coder to sequence the underlying condition before the manifestation. K90. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . 83)ICD 10 Code Description Notes E08. tracheobronchitis to bronchitis in. Wherever an etiology and manifestation combination of codes exists, the manifestation code contains an instructional note to: use of an additional code The International Classification of Diseases (ICD) is published by the World Health Organization (WHO) and is used to classify: At the beginning of Chapter 10, Diseases of the Respiratory System (J00-J99) there is an instructional note to Use additional code, where applicable, to identify tobacco dependence (F17. ) Assign codes to the highest possible level of detail. Instructional notes indicate the proper sequencing order of these conditions-etiology (underlying condition) followed by manifestation. This is step number __ when coding: Assign the code to the highest level of specificity. Diseases of the Digestive System. In the tabular list, code first and use additional code instructional notes indicate the proper sequencing order of what conditions Certain conditions that have both an underlying etiology and multiple body system manifestations due to the underlying etiology instructional notes indicate a proper sequencing order of these conditions etiology. b. 4-I51. In disease classified else. The instructional note “Use additional code, where applicable, to identify exposure to environmental tobacco smoke (Z77. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ICD-10-CM assumes a causal relationship and this is coded as hypertensive heart disease with CHF and an additional code for the specific type of heart failure. Found at the etiology code as a clue to identify the manifestations commonly associated with the disease. These instructional notes indicate that the etiology code should be listed first followed by the manifestation code. Excludes 1: fever and chills. In most cases the manifestation codes will have in the code title, "in diseases. ↓ See below for any exclusions, inclusions or special notations. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . These instructional notes indicate the proper sequencing order of the codes: etiology, followed by manifestation. With: The words "with" or "in" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, either under a main term or subterm, or an instructional note in the Tabular List. Study with Quizlet and memorize flashcards containing terms like combination codes for. According to the instructional notes for the category code, are the codes for use on the maternal or fetal record, or both? Maternal. * Because in ICD-10-CM coding coder first assi. 4-)Study with Quizlet and memorize flashcards containing terms like These _____ are incorporated within the Alphabetic Index and Tabular List of the ICD--CM as instructional notes, The conventions and instructions of the classification take precedence over _____, The _____ _____ is an alphabetical list of terms and their corresponding code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. E78. Parallel ICD-9-CM Code Guidelines Increased Instruction Notes (Code first; Use Additional Code) Enhanced Combination Codes Updated Terminology to Reflect Current Medical Practices COPD (J44-J45) Acute exacerbation is a worsening or decompensation of a chronic condition An acute exacerbation is NOT equivalent to an infectionin ICD-10-CM/PCS uses an indented arrangement. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . listed below certain codes in the index. *Instructional note in ICD-10-CM indicates to use additional code, if applicable, to identify coronary atherosclerosis due to lipid rich plaque (I25. Learn your Medical Coding Conventions and Guidelines. Instructional notes appear in both the Tabular List and Alphabetic Index of ICD-10-CM. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. 8. ICD 10 CM ___________ include the following: Instructional notes, Abbreviations, Cross-reference notes, Punctuation marks, and Relational terms. Wherever such a combination exists there is a "Use Additional Code" note at the etiology code, and a "Code First" note at the manifestation code. In most cases the manifestation codes will have in the code title, "in diseases. There are also instructional notes to use additional code to identify specific organ dysfunction. ICD-10-CM Coding Tips Instructional Notes and Common Coding Mistakes . These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 414, Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone. instructs the coder to use an additional code to identify the manifestation that is present. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. 2x-3y=-2 x+y=-6. Explain the use of V and E codes. Pseudocyst of pancreas Billable Code. 5. Code Also –A “code also” note instructs that two codes may be required to fully describe a condition, but the sequencing of the two codes depends on the severity of the conditions and the reason for the encounter. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ICD-10-CM Instructional Notes, Chapter 3 Two instructional notes appear with a code if the type of anemia is produced by either a poisoning or an adverse effect of a drug, such as-Code first _____ due to drug or toxin, if applicable (T36-T65), with fifth or sixth character 1-4 or 6-Use additional code for adverse effect, if applicable, to. These items provide guidelines for using the code set. 11, and reads: “A type 1 Excludes note is a pure excludes note. As a result, it is crucial to follow the symbols, conventions, instructional notes, and guidelines mentioned throughout the book. CPC Prep Course Chapter 3 Notes. In most cases the manifestation codes will have in the code title, "in diseases. The other instructional note is under category code I85 which says to use an additional code to report alcohol abuse and dependence. Instructional notes Punctuation marks Abbreviations Symbols. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. In most cases the manifestation codes will have in the code title, "in diseases. In this case the patient has end stage renal disease so N18. ↓ See below for any exclusions, inclusions or special notations. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Some codes in chapter 10 have been expanded to include notes indicating that an additional code should be assigned or an associated condition should be sequenced first. ↓ See below for any exclusions, inclusions or special notations. There is a "Use Additional Code" notation at the etiology code and a "Code First" note at the manifestation code whenever such a combination exists. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . I am currently coding. Code First. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . However, if the coder also sees the instructional note of "Use an Additional Code" in the ICD 10 CM Code Book in the Tabular List, the coder would then also provide an additional code to provide. Correctly use instructional terms and symbols as defined in the ICD-9-CM. In most cases the manifestation codes will have in the code title, “in. There is an instructional note under category code K70 to use additional code to identify alcohol abuse and dependence. 7, I51. infection. 4. 0. 23 is a valid billable ICD-10 diagnosis code for Adjustment disorder with mixed anxiety and depressed mood . 22) and CKD, stage 3 (N18. Some categories of codes (e. The notes also remind the code to use an additional (secondary) code to show the dialysis status (Z99. True. 11, there is a “Code first” instruction for complications of bone marrow transplant and stem cell transplant complication. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. 0 also applies to the following: Inclusion term. An instructional note with category Z16 says to code first the infection. There is no information of the infectious agent and no additional code is reported. There are multiple additional codes for identified influenza virus infections, including novel A types (avian, swine. These instructional note indicate the proper sequencing order of the codes, etiology followed by manifestation, if applicable Underlying condition. true. c. ” (See Reference 1) For instance, if a patient has a diabetes, the coder may use the code E11. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . When the term “and” is used in a statement, it may be interpreted as, “and/or”. When there is a "code first" note and an underlying. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. 621 Type 1 diabetes mellitus with foot ulcerConventions of ICD-10: The general rules for use of the classification independent of guidelines. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . - or I51. A) when the note appears under a code, it is acceptable to use both the code and the excluded code together when applicable. ( True/False) Question. Use the code(s) in brackets in addition to the disease or condition to identity an associated manifestation. 0. At the beginning of Chapter 10, Diseases of the Respiratory System (J00-J99) there is an instructional note to Use additional code, where applicable, to identify tobacco dependence (F17. You must use the applicable 7th character for all ICD-10-CM codes within the category or as notes in the Tabular List instruct. xxx Diabetes mellitus due to underlying condition Include the underlying condition diagnosis E09. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Notes provide information on code selection. 22) •History of tobacco use (Z87. R11. In most cases the manifestation codes will have in the code title, "in diseases. There is an instructional note use additional code to identify organism. 2x-3y=-2. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. A list of abbreviations, punctuation, symbols, typefaces, and instructional notes appears at the beginning of the ICD-9-CM. In most cases the manifestation codes will have in the code title, "in diseases. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. Use additional code for any associated fecal incontinence ( R15 . The additions for FY 2021 presently pushing the number of codes to over 70,000. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Instructional Notes General notes Inclusion and exclusion notes Code first notes Use additional code notes, and Etiology/manifestation convention (code first, use additional code and in diseases classified elsewhere notes): Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. An instructional note in ICD-10-CM for intellectual disabilities (F70 through F79) directs coders to: a. For such codes, a "use additional code" note will still be present and the rules for sequencing still apply. An instructional note in the Tabular List instructs us to use an additional code to identify alcohol and/or tobacco use and/or dependence, history of tobacco dependence, and/or exposure to tobacco smoke. N30. followed by the manifestation. 89, I51. In the Tabular List, an instructional note may appear under these category codes to “code first condition resulting from (sequela of)” that particular category. Explain the use of V and E codes. but provide additional instruction. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 9) Under the Category I50 in the ICD-10-CM. Patient is admitted to the hospital with pneumonia due to bacteriodes fragilis, J15. ICD 10 CM ___________ include the following: Instructional notes, Abbreviations, Cross-reference notes, Punctuation marks, and Relational terms. 1 states: Hypertension with heart conditions classified to I50. Chronic kidney disease, stage 3b Billable Code. There is a. false. 22) history of tobacco use (Z87. 3 According to the instructional notes for the category code, are the codes for use on the maternal or fetal record,. the use of ICD 9 codes is mandated by HIPAA for. These instructional notes. 001. Codes B95-B97 are secondary codes to. If coded incorrectly and missing the instructional notations, it could result in a claim denial or medical record review. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 96. In most cases the manifestation codes will have in the code title, "in diseases. A. It is found in the 2024 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2023 - Sep 30, 2024 . These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. ↓ See below for any exclusions, inclusions or special notations. In most cases the manifestation codes will have in the code title, "in diseases. -)It is important to use both the Alphabetic Index and the Tabular list when assigning ICD-10-CM codes because we do not code from the Alphabetic Index, the alphabetic index doesn’t provide the full code and you must refer to the Tabular List to get the full code 2 how instructional notes in both the Alphabetic Index and the Tabular List guide. Square brackets are used: In the Alphabetic Index to enclose the manifestation of a disease. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Correct Answer: Add an additional character to the code. 891) •Occupational exposure to environmental tobacco smoke (Z57. These notes are used to signal that, when there is an underlying etiology and multiple body system manifestation due to the underlying etiology, two codes are needed. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Learn Test Match Q-Chat Created by chubut Chapter 3 Terms in this set (20) Conventions include: Instructional notes, Abbreviations, Cross-reference notes, Punctuation marks, and Relational terms ("and," "with," "without," "due to"). true false Appendix C contains coding examples to assist in the selection of. ↓ See below for any exclusions, inclusions or special notations. ICD-10-CM guideline I. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. 4. When an Excludes _____ note appears under a code, it is acceptable to use both the code and the excluded code together. c. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. g. and more. 10. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. #1. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. Wherever such a combination exists there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. Two “use additional code” notes appear to remind the coder to use an additional code to identify the infectious agent. Use an additional code to identify the infectious agent. 4. 1. " d. In the ICD-10-CM tabular, the coder will see notes under the Category J91. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. Code if applicable, any casual condition. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). Laterality and 7 thfollowed by the manifestation. Pay attention to the instructional notes in the tabular list (see yellow highlighted areas). 1, C34. N18. Examples of these notes include: Use additional code to identify the infectious agent; Use additional code to identify the virus; Code first any associated lung abscessCode First/Use additional code These instructional notes provide sequencing instruction. In most cases the manifestation codes will have in the code title, "in diseases. In most cases the manifestation codes will have in the code title, "in diseases. code first underlying disease. The use of ICD-10 code E86. The instructional note “Use additional code” (B95–B97) is found in the Tabular List of ICD- 10-CM under Code N39. The additional code is always listed after the primary code. but provide additional instruction. Additional Instructional Notes Excludes -1 Under a three digit category code, an Excludes 1 designation means that the code is NOT CODED HERE and indicates that two codes are mutually exclusive and therefore cannot be coded as separate codes in same encounter (example E66). Notice the instructional notes tell the coder to assign a code for diabetes first (code first any associated diabetic chronic kidney disease). instructional notes. They may appear independently of each other or to designate certain etiology/manifestation paired codes. Brackets enclose all but which one of the following? essential modifiers. 4 , N18. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. The additional code is always listed after the primary code.