In coding, what does the note "Use additional code" indicate?

The phrase "Use additional code" in ICD-10-CM coding signifies that two codes are necessary to fully capture the clinical picture of a patient's condition. This instruction implies that the primary code alone does not encompass all relevant aspects of the diagnosis or condition being reported; therefore, an additional code is necessary to provide more complete information.

In practice, this is often seen in scenarios where a primary diagnosis may not include all relevant details about the patient's health situation, such as complications, secondary conditions, or specific details that affect treatment and prognosis. An additional code enhances the specificity of the diagnosis and ensures that all relevant clinical information is captured for accurate coding, billing, and health data reporting. This practice supports proper treatment planning and enhances the quality of patient care.