ICD-10-CM Instructional Notes ICD-10-CM
Instructional notes are the directions printed in the ICD-10-CM Tabular List under chapters, blocks, categories and codes. They say what a code includes, what it excludes, which second code to add and which condition goes first. The FY 2027 Tabular List carries 25,270 notes with 11,609 references to other codes. These pages index every one in both directions: the notes a code carries, and the notes elsewhere that point to it.
Browse by Note Type
Includes Notes
Includes notes appear under a category to further define, or give examples of, its content.
1,023 notes · 89 code references→Guidelines Section I.A.11Inclusion Terms (Applicable To)
Inclusion terms are the conditions a code is used for: synonyms of the code title or, for "other specified" codes, the conditions assigned to it.
12,629 notes · 223 code references→Guidelines Section I.A.12.aExcludes1 Notes
An Excludes1 note means "NOT CODED HERE": the excluded code should never be reported together with the code above the note.
5,411 notes · 5,710 code references→Guidelines Section I.A.12.bExcludes2 Notes
An Excludes2 note means "NOT INCLUDED HERE": the excluded condition is not part of this code, but a patient may have both, so both codes may be reported.
2,529 notes · 2,799 code references→Guidelines Section I.A.13Code First Notes
A Code First note means the underlying condition named in the note is sequenced before this code.
810 notes · 736 code references→Guidelines Section I.A.13Use Additional Code Notes
A Use Additional Code note means a second code should be added, after this one, to fully describe the condition.
1,491 notes · 1,438 code references→Guidelines Section I.A.17Code Also Notes
A Code Also note means two codes may be needed to fully describe a condition; it gives no sequencing direction.
689 notes · 538 code references→Tabular ListGeneral Notes
General notes in the Tabular List explain how a chapter, block or code is to be used.
180 notes · 76 code references→Coding Convention Guides
7th Character Values
Every category that requires a 7th character, grouped into 15 value sets: encounter (A, D, S), fracture healing, fetus, laterality, stage and more.
508 rules→Guidelines Section I.A.13Etiology and Manifestation Codes
The “in diseases classified elsewhere” codes that can never be listed first, each with the underlying conditions its Code First note names.
354 manifestation codes→What Each Note Tells You
| Note | What it means | Report both codes? | Which code goes first? |
|---|---|---|---|
| Includes | Further defines, or gives examples of, what the category covers. | — | — |
| Inclusion terms | Conditions the code is used for: synonyms, or the conditions assigned to an “other specified” code. | — | — |
| Excludes1 | “Not coded here”: the conditions cannot occur together. | No unless the conditions are unrelated | — |
| Excludes2 | “Not included here”: a separate condition the patient may also have. | Yes when both are present | Encounter circumstances |
| Code first | The underlying condition named in the note is coded before this one. | Yes | The code named in the note |
| Use additional code | Add a second code to describe the condition fully. | Yes when documented | The code carrying the note |
| Code also | Two codes may be needed to describe the condition. | Yes | No direction: depends on the encounter |
| 7th character | A required final character from the listed values, with X placeholders to fill empty positions. | — | — |
A note printed under a chapter, block or category heading applies to every code beneath it. Each ICD List code page shows its own notes together with the ones inherited from above, and lists the notes elsewhere that name the code.
Questions About Instructional Notes
What are instructional notes in ICD-10-CM?
Instructional notes are the conventions printed in the Tabular List (Includes, inclusion terms, Excludes1, Excludes2, Code first, Use additional code, Code also and 7th character notes) that tell coders how to use and combine codes. The Official Guidelines, Section I.A, define each one. The FY 2027 Tabular List has 25,270 of them.
What is the difference between Excludes1 and Excludes2?
Excludes1 means “not coded here”: the two codes are never reported together because the conditions cannot occur together (the one exception is when the conditions are unrelated). Excludes2 means “not included here”: the excluded condition is not part of the code, and the patient may have both, so both codes may be reported.
Does a note on a category apply to all the codes under it?
Yes. Notes are printed once, at the highest level they apply to: a chapter, a block, a category or a subcategory. Every code beneath inherits them. That is why a note naming E11 matters for E11.9, and why ICD List shows inherited notes on each code page.
What does a dash at the end of a code in a note mean?
A code ending in a dash, such as B36.- or T81.44-, stands for the whole category or subcategory: the note applies to every code in it, and the complete code has to be picked from the codes listed under it.
Can an “in diseases classified elsewhere” code be the principal diagnosis?
No. Under the etiology/manifestation convention (Section I.A.13), these manifestation codes are never permitted as the first-listed or principal diagnosis. They are reported after the code for the underlying condition, which their Code First note names.
Official Sources & Methodology
Every note on these pages is loaded verbatim from the FY 2027 ICD-10-CM Tabular List. Code references inside the notes are matched against the FY 2027 code set, so every link opens a valid code; scope counts (“applies to N codes”) count the billable codes under the note’s chapter, block or category.
- CMS ICD-10-CM FilesThe Tabular List (XML) that every note, note type and code reference on ICD List comes from.
- ICD-10-CM Official Guidelines for Coding and Reporting FY 2027Section I.A, Conventions for the ICD-10-CM, defines each note type; the definitions on these pages follow its wording.
ICD List is not affiliated with CMS or NCHS. These pages are a coding reference; the Tabular List and the Official Guidelines remain the authority.
Related References
Source: FY 2027 ICD-10-CM Tabular List (CMS and NCHS) and the ICD-10-CM Official Guidelines for Coding and Reporting FY 2027, Section I.A. ICD List is not affiliated with CMS or NCHS.
