🏥 ICD-10-CM Official Guidelines FY 2025 - Master Class

from reportlab.lib.pagesizes import letter
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import inch
from reportlab.lib import colors
from reportlab.platypus import (
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    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus.tableofcontents import TableOfContents
from reportlab.pdfgen import canvas

OUTPUT = "/home/daytona/workspace/icd10-guide/ICD10CM_Study_Guide.pdf"

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# ── Build story ───────────────────────────────────────────────────────────────

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        title="ICD-10-CM Guidelines Study Guide FY2025",
        author="Orris Medical Coding Tutor",
    )

    story = []

    # ══════════════════════════════════════════════════════════════════════════
    # COVER PAGE
    # ══════════════════════════════════════════════════════════════════════════
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        Paragraph("FY 2025 — Complete Study Guide", cover_sub),
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        Spacer(1, 0.1*inch),
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        Spacer(1, 0.3*inch),
        Paragraph("All 4 Sections + Present on Admission (POA)", cover_small),
    ]

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    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # BIG PICTURE TABLE
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("The Big Picture", "4 Sections You Must Know"))
    story.extend(make_table(
        ["Section", "What It Covers", "Setting"],
        [
            ["Section I",    "Conventions + General Rules + Chapter-Specific Guidelines", "All settings"],
            ["Section II",   "Selecting the PRINCIPAL diagnosis",                          "Inpatient only"],
            ["Section III",  "Reporting ADDITIONAL diagnoses",                             "Inpatient only"],
            ["Section IV",   "Coding rules for OUTPATIENT / office visits",                "Outpatient only"],
            ["Appendix I",   "Present on Admission (POA) reporting",                       "Inpatient billing"],
        ],
        col_widths=[1.0*inch, 4.2*inch, 1.8*inch]
    ))
    story.extend(highlight_box(
        "<b>Core principle:</b> Code what the documentation supports, at the highest level of "
        "specificity, in the correct order. When in doubt — query the provider."
    ))
    story.append(Spacer(1, 10))

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION I-A  CONVENTIONS
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section I-A: Conventions", "The Grammar Rules of ICD-10-CM"))

    # Two books
    story.extend(h2("1. The Two Books — Always Use Together"))
    story.extend(body(
        "The <b>Alphabetic Index</b> is your starting point — look up the condition by name. "
        "The <b>Tabular List</b> is your verification step — confirm and finalize the code. "
        "You MUST use both every time."
    ))
    story.extend(warn("Never code from the Alphabetic Index alone. The Tabular List contains "
                      "7th characters, laterality, instructional notes, and excludes that the Index may not show."))

    # Code structure
    story.extend(h2("2. Code Structure — Think of It Like a ZIP Code"))
    story.extend(code("  A 0 9 . 0 1 2 A"))
    story.extend(code("  │              └─ 7th character (encounter type: A/D/S)"))
    story.extend(code("  │          └──── 5th & 6th characters (specificity)"))
    story.extend(code("  │      └──────── 4th character (subcategory)"))
    story.extend(code("  │  └──────────── 2nd & 3rd (category detail)"))
    story.extend(code("  └────────────── 1st character = ALWAYS a letter (= chapter)"))
    story.extend(spacer(4))
    story.extend(make_table(
        ["Level", "Characters", "Example"],
        [
            ["Category",    "3 chars",   "J44 — COPD"],
            ["Subcategory", "4-5 chars", "J44.1 — COPD with acute exacerbation"],
            ["Full code",   "up to 7",   "S52.501A — fracture, radius, initial encounter"],
        ],
        col_widths=[2.0*inch, 1.8*inch, 3.2*inch]
    ))
    story.extend(body(
        "<b>Placeholder X:</b> If a code needs a 7th character but is only 5 characters long, "
        "insert <b>X</b> to fill empty positions. Example: <font name='Courier'>T14.90XA</font> — "
        "the X occupies position 6 so A can be the 7th character."
    ))

    # NEC / NOS
    story.extend(h2("3. Abbreviations — Only 2 to Memorize"))
    story.extend(make_table(
        ["Abbreviation", "Full Meaning", "Use When..."],
        [
            ["NEC", "Not Elsewhere Classifiable = Other Specified",
             "You know what it is, but no specific code exists"],
            ["NOS", "Not Otherwise Specified = Unspecified",
             "Documentation doesn't give enough detail"],
        ],
        col_widths=[1.0*inch, 2.6*inch, 3.4*inch]
    ))
    story.extend(mnem("NEC = 'Not Enough Code for this' (specific condition, no exact code). "
                      "NOS = 'Not On Sheet' (chart doesn't say enough)."))

    # Excludes
    story.extend(h2("4. The Two EXCLUDES Notes — Critical Distinction"))
    story.extend(make_table(
        ["Note", "Meaning", "Rule", "Memory Trick"],
        [
            ["Excludes1", "NOT CODED HERE",
             "These two codes NEVER appear together (same concept)",
             "1 code only — they're the same thing"],
            ["Excludes2", "Not included here",
             "Patient CAN have both conditions — use both codes if appropriate",
             "2 codes OK — they're different things"],
        ],
        col_widths=[0.9*inch, 1.4*inch, 2.8*inch, 1.9*inch]
    ))
    story.extend(tip("Exception to Excludes1: If the two conditions are clearly unrelated "
                     "(e.g., psychogenic dysmenorrhea + sleep teeth grinding), both codes may be assigned."))

    # Etiology/Manifestation
    story.extend(h2("5. Etiology / Manifestation Convention"))
    story.extend(body(
        "When a disease causes a complication in another body system, code the "
        "<b>underlying disease (etiology) FIRST</b>, then the <b>manifestation</b>."
    ))
    story.extend(highlight_box(
        "<b>Example — Diabetic neuropathy:</b><br/>"
        "1. <font name='Courier'>E11.40</font> — Type 2 DM with diabetic neuropathy (etiology)<br/>"
        "2. <font name='Courier'>G63</font> — Polyneuropathy in diseases classified elsewhere (manifestation)<br/><br/>"
        "Signals in the Tabular List: <b>\"Use additional code\"</b> at the etiology; "
        "<b>\"Code first\"</b> at the manifestation."
    ))

    # Key words
    story.extend(h2("6. Key Words with Special Meanings"))
    story.extend(make_table(
        ["Word in Classification", "What It Really Means"],
        [
            ['"and" in a title',        'Means "and" OR "or"'],
            ['"with" in title/index',   'Means "associated with" / "due to" — causal relationship is ASSUMED'],
            ['"see"',                   'Mandatory redirect — go there now'],
            ['"see also"',              'Optional redirect — additional info may exist'],
            ['"Code also"',             'Two codes may be needed; no sequencing direction given'],
            ['Default code',            'Code next to main term; used when no further info in the record'],
        ],
        col_widths=[2.5*inch, 4.5*inch]
    ))
    story.extend(highlight_box(
        '<b>"With" rule — huge in practice:</b> A patient has diabetes AND CKD. The word "with" '
        'in the classification means you ASSUME the diabetes caused the CKD. No explicit provider '
        'documentation linking them is required. Code: E11.65 + N18.x for the CKD stage.'
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION I-B  GENERAL CODING GUIDELINES
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section I-B: General Coding Guidelines"))

    story.extend(h2("The Step-by-Step Coding Process"))
    for step in [
        "1. Find the main term in the Alphabetic Index",
        "2. Review subterms and nonessential modifiers",
        "3. Note any cross-references (see, see also)",
        "4. Go to the Tabular List to verify the code",
        "5. Read ALL instructional notes (includes, excludes, code first, use additional)",
        "6. Assign the most specific code supported by documentation",
    ]:
        story.extend(bullet([step[3:]]))  # strip leading number + period + space already embedded

    story.extend(h2("The Most Important General Rules"))

    rules = [
        ("Signs & Symptoms", "Code them ONLY when no confirmed diagnosis has been established.",
         "Patient has chest pain — no diagnosis yet → R07.9 (chest pain). "
         "Once provider documents GERD, drop the chest pain (it is integral)."),
        ("Acute vs. Chronic", "When both exist at the same indentation level in the Index, "
         "code BOTH and sequence ACUTE first.",
         "Patient has acute and chronic sinusitis: code acute first, then chronic."),
        ("Combination Code", "When ONE code fully captures two diagnoses or a diagnosis + complication, "
         "use only that single code.",
         "K57.21 = Diverticulitis of large intestine with perforation and abscess with bleeding. Done."),
        ("Sequela (Late Effects)", "No time limit. Sequence: nature of the sequela FIRST, "
         "then the sequela code (7th char S) SECOND.",
         "Old burn scar: L90.5 (scar) first, then T22.xxxS (burn sequela) second."),
        ("Laterality", "Specify left/right. If bilateral but no bilateral code exists, "
         "assign two separate codes.",
         "Bilateral cataracts each treated in separate encounters: use bilateral code until "
         "first eye fully resolved, then unilateral code."),
        ("Impending / Threatened", "If it HAPPENED — code confirmed. If it did NOT happen — "
         "look up 'impending/threatened' in the Index; if no entry, code the underlying condition.",
         "Threatened MI that resolved: code underlying angina, not the threatened MI."),
    ]

    for title, rule_text, ex in rules:
        story.extend(h3(title))
        story.extend(body(rule_text))
        story.extend(highlight_box(f"<b>Example:</b> {ex}", bg=colors.HexColor("#eef7f0"), border=GREEN))

    # Uncertain diagnosis comparison
    story.extend(h2("Uncertain Diagnosis — Inpatient vs. Outpatient (Most Tested Rule!)"))
    story.extend(make_table(
        ["Setting", "Rule", "Example"],
        [
            ["INPATIENT",  "Code uncertain diagnoses AS IF confirmed\n(probable, suspected, likely, possible, rule out, consistent with)",
             '"Probable pneumonia" at discharge → Code the pneumonia'],
            ["OUTPATIENT", "Do NOT code uncertain diagnoses.\nCode signs & symptoms instead.",
             '"Possible GERD" in office note → Code heartburn (R12), not GERD'],
        ],
        col_widths=[1.2*inch, 3.4*inch, 2.4*inch]
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION I-C  CHAPTER-SPECIFIC GUIDELINES
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section I-C: Chapter-Specific Guidelines", "The High-Yield Chapters"))

    # ── Chapter 1: HIV ────────────────────────────────────────────────────────
    story.extend(h2("Chapter 1 — Infections (A00-B99)"))
    story.extend(h3("HIV — The Most Rule-Heavy Topic"))
    story.extend(make_table(
        ["Situation", "Code"],
        [
            ["HIV confirmed with illness / AIDS",        "B20"],
            ["HIV positive, NO symptoms",                "Z21"],
            ["Inconclusive HIV serology",                "R75"],
            ["Testing for HIV",                          "Z11.4"],
            ["Negative result / counseling only",        "Z71.7"],
            ["HIV pre-exposure prophylaxis (PrEP)",      "Z29.81"],
            ["HIV managed on antiretrovirals",           "B20 + Z79.899"],
            ["HIV + pregnancy (any trimester)",          "O98.7- FIRST, then B20"],
        ],
        col_widths=[4.5*inch, 2.5*inch]
    ))
    story.extend(bullet([
        "Code ONLY confirmed HIV cases (provider statement is sufficient — no lab required)",
        "Once a patient ever has an HIV-related illness, always use B20 going forward",
        "Chapter 15 codes ALWAYS take sequencing priority over B20 in pregnant patients",
    ]))

    # Sepsis
    story.extend(h3("Sepsis — The Most Complex Sequencing Topic"))
    story.extend(mnem("INFECTION FIRST — everything else follows"))
    story.extend(make_table(
        ["Scenario", "Sequencing Order"],
        [
            ["Simple sepsis",                               "Infection code (e.g., A41.9)"],
            ["Severe sepsis",                               "Infection → R65.2- → organ dysfunction codes"],
            ["Septic shock",                                "Infection → R65.21 (severe sepsis with septic shock)"],
            ["Sepsis from post-op wound",                   "T81.41-49 → T81.44 → R65.2 if severe"],
            ["Localized infection causing sepsis on admit", "Systemic infection first, localized infection second"],
            ["Admit for pneumonia, sepsis develops later",  "Pneumonia first, then sepsis codes"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))
    story.extend(warn("Septic shock can NEVER be the principal diagnosis. The underlying infection always leads."))

    # MRSA
    story.extend(h3("MRSA"))
    story.extend(make_table(
        ["Situation", "Code Strategy"],
        [
            ["MRSA infection WITH combination code (e.g., MRSA sepsis)",
             "Use combination code ONLY (e.g., A41.02). Do NOT add B95.62."],
            ["MRSA infection WITHOUT combination code (e.g., wound infection)",
             "Code the infection + B95.62 (MRSA as cause of disease)"],
            ["MRSA colonization (nasal swab positive, no illness)",
             "Z22.322"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))

    # COVID
    story.extend(h3("COVID-19 (U07.1)"))
    story.extend(bullet([
        "Code only confirmed cases (provider statement sufficient — no positive test required)",
        "U07.1 is always principal/first-listed when COVID is the reason for the encounter",
        "List manifestations (pneumonia J12.82, ARDS J80, acute resp failure J96.0-) as additional codes",
        "Suspected/possible COVID → code the symptoms instead (fever, cough, dyspnea)",
        "Post-COVID condition → code specific symptoms + U09.9",
        "COVID exposure, asymptomatic → Z20.822",
        "Vaping disorder → U07.0, always principal",
    ]))

    story.append(PageBreak())

    # ── Chapter 2: Neoplasms ──────────────────────────────────────────────────
    story.extend(h2("Chapter 2 — Neoplasms (C00-D49)"))
    story.extend(mnem("Spotlight rule: What are we treating TODAY? That goes first."))
    story.extend(make_table(
        ["Treatment Directed At...", "Principal/First-Listed Dx"],
        [
            ["Primary malignancy",               "Primary malignancy (e.g., C34.11)"],
            ["Secondary/metastatic site only",   "Secondary site (e.g., C78.01 secondary lung met)"],
            ["Chemo, radiation, immunotherapy",  "Z51.0 / Z51.11 / Z51.12 FIRST, then malignancy"],
            ["Anemia from malignancy",           "Malignancy FIRST, then D63.0"],
            ["Dehydration from chemo",           "Dehydration (E86.0) FIRST, then malignancy"],
            ["Previously excised, no evidence",  "Z85.x (personal history of malignancy)"],
            ["Malignancy in transplanted organ", "T86.- FIRST, then C80.2 + specific malignancy code"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))

    # ── Chapter 4: Diabetes ───────────────────────────────────────────────────
    story.extend(h2("Chapter 4 — Diabetes Mellitus (E08-E13)"))
    story.extend(make_table(
        ["Key Rule", "Details"],
        [
            ["Default type",        "If type NOT documented → assume Type 2 (E11.-)"],
            ["Insulin used, type unknown", "Still E11.- + Z79.4 (long-term insulin use)"],
            ['"With" rule',         "DM + CKD = assumed related. No explicit documentation needed."],
            ["Multiple codes",      "Assign as many E11.x codes as needed for all associated conditions"],
        ],
        col_widths=[2.5*inch, 4.5*inch]
    ))
    story.extend(make_table(
        ["Medication", "Z Code to Add"],
        [
            ["Insulin",                             "Z79.4"],
            ["Oral hypoglycemic (e.g., metformin)",  "Z79.84"],
            ["Injectable non-insulin (e.g., GLP-1)", "Z79.85"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))

    story.append(PageBreak())

    # ── Chapter 9: Cardiovascular ─────────────────────────────────────────────
    story.extend(h2("Chapter 9 — Cardiovascular (I00-I99)"))
    story.extend(h3("Hypertension"))
    story.extend(make_table(
        ["Combination", "Code"],
        [
            ["HTN alone",                             "I10"],
            ["HTN + heart disease",                   "I11.- (assumed related — no documentation needed)"],
            ["HTN + CKD",                             "I12.- + N18.x (add CKD stage)"],
            ["HTN + heart disease + CKD",             "I13.- + I50.- (if HF) + N18.x"],
            ["HTN + stroke/cerebrovascular disease",  "I60-I69 FIRST, then HTN code"],
            ["Secondary hypertension",                "Underlying cause FIRST, then I15.-"],
            ["Elevated BP, no HTN diagnosis",         "R03.0"],
            ["Resistant hypertension",                "Specific HTN code first + I1A.0"],
            ["Controlled or uncontrolled HTN",        "Still I10-I15 (hypertension is hypertension)"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))
    story.extend(tip("HTN + Heart Disease = always assumed related. The classification presumes causation. "
                     "No provider note linking them is required."))

    story.extend(h3("Acute Myocardial Infarction (AMI)"))
    story.extend(make_table(
        ["Type", "Code Range"],
        [
            ["STEMI (site-specific)",          "I21.0-I21.2"],
            ["STEMI (unspecified site)",        "I21.3"],
            ["NSTEMI",                          "I21.4"],
            ["Subsequent AMI within 4 weeks",  "I22.- USED WITH I21.-"],
            ["AMI + CAD at same encounter",    "AMI sequences first (acute event takes priority)"],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))

    # ── Chapter 10: Respiratory ───────────────────────────────────────────────
    story.extend(h2("Chapter 10 — Respiratory System (J00-J99)"))
    story.extend(bullet([
        "COPD + acute exacerbation vs. COPD + infection — these are different codes, do not confuse them",
        "VAP (Ventilator-Associated Pneumonia) = J95.851 — ONLY when provider explicitly documents VAP + add organism code",
        "COVID-19 (U07.1) = always principal; list respiratory manifestations after",
        "Vaping disorder (U07.0) = always principal",
    ]))

    # ── Chapter 15: OB ───────────────────────────────────────────────────────
    story.extend(h2("Chapter 15 — Obstetrics (O00-O9A)"))
    story.extend(warn("Chapter 15 codes ALWAYS have sequencing priority over all other chapters."))
    story.extend(make_table(
        ["Situation", "Rule"],
        [
            ["Routine prenatal, no complications",    "Z34.- (supervision of normal pregnancy) as first-listed"],
            ["Diabetes in pregnancy",                 "O24.- FIRST, then E08-E13"],
            ["HIV in pregnancy",                      "O98.7- FIRST, then B20"],
            ["Normal uncomplicated delivery",         "O80"],
            ["Outcome of delivery",                   "Z37.- always secondary; NEVER on newborn record"],
            ["Trimester character",                   "Assign based on when complication developed, NOT discharge trimester"],
        ],
        col_widths=[3.0*inch, 4.0*inch]
    ))

    story.append(PageBreak())

    # ── Chapter 19: Injuries / Adverse / Poisoning ───────────────────────────
    story.extend(h2("Chapter 19 — Injury, Poisoning & External Causes"))
    story.extend(h3("7th Character for Injuries"))
    story.extend(make_table(
        ["7th Char", "Meaning", "Use When..."],
        [
            ["A", "Initial encounter",    "Active treatment of the injury"],
            ["D", "Subsequent encounter", "Routine healing — follow-up visits"],
            ["S", "Sequela",              "Late effects after healing is complete"],
        ],
        col_widths=[0.8*inch, 2.0*inch, 4.2*inch]
    ))

    story.extend(h3("Adverse Effect vs. Poisoning vs. Underdosing"))
    story.extend(mnem("Correct = Adverse | Wrong/Too Much = Poisoning | Too Little = Underdosing"))
    story.extend(make_table(
        ["Situation", "Classification", "Sequencing"],
        [
            ["Drug correctly prescribed and given — bad reaction",
             "Adverse Effect",
             "Nature of reaction FIRST, then T code (5th/6th char = 5)"],
            ["Wrong drug, overdose, prescription error, drug + alcohol",
             "Poisoning",
             "Poisoning T code FIRST (with intent), then manifestations"],
            ["Taking less than prescribed (patient's own decision)",
             "Underdosing",
             "T code (char 6) + noncompliance Z91.12- or Z91.13-"],
            ["Harmful non-drug substance (bleach, venom, etc.)",
             "Toxic Effect",
             "Toxic effect code FIRST, then associated manifestations"],
        ],
        col_widths=[2.2*inch, 1.5*inch, 3.3*inch]
    ))

    # ── Chapter 20: External causes ──────────────────────────────────────────
    story.extend(h2("Chapter 20 — External Causes (V00-Y99)"))
    story.extend(bullet([
        "NEVER a principal or first-listed diagnosis",
        "Captures: HOW (cause) + WHY (intent) + WHERE (Y92 place) + WHAT activity (Y93)",
        "Intent unknown → default to ACCIDENTAL",
        "Terrorism → Y38.- (only when FBI officially designates it)",
        "Assign as many external cause codes as needed to fully explain the event",
    ]))

    # Z codes
    story.extend(h2("Chapter 21 — Z Codes (Z00-Z99)"))
    story.extend(body("Z codes are reasons for encounters that are not diseases — they provide context."))
    story.extend(make_table(
        ["Category", "Examples"],
        [
            ["Contact/Exposure",       "Z20.822 COVID exposure; Z20.821 Zika exposure"],
            ["Status codes",           "Z21 (HIV+); Z66 (DNR); Z87.310 (hx osteoporosis fracture)"],
            ["History",                "Z85.- (personal hx malignancy); Z86.73 (hx TIA)"],
            ["Screening",              "Z11.52 (COVID screen); Z12.31 (mammogram)"],
            ["Immunization status",    "Z23 (vaccine encounter); Z28.3 (underimmunized)"],
            ["Social determinants",    "Z59.0- (homelessness); Z59.41 (food insecurity)"],
            ["Long-term drug use",     "Z79.4 (insulin); Z79.84 (oral hypoglycemics)"],
        ],
        col_widths=[2.2*inch, 4.8*inch]
    ))
    story.extend(highlight_box(
        "<b>Z codes that can ONLY be principal/first-listed include:</b> Z00, Z01, Z02, Z34, Z38, Z39, "
        "Z40, Z51.0, Z51.1-, Z33.2, Z42, and others. Know these for the exam."
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION II
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section II: Selecting the Principal Diagnosis", "Inpatient Only"))
    story.extend(highlight_box(
        '<b>Definition:</b> "The condition established AFTER STUDY to be chiefly responsible for '
        'occasioning the admission of the patient to the hospital for care." — UHDDS<br/><br/>'
        '<b>Key words: "after study"</b> = you use what you know at DISCHARGE, not at admission.'
    ))

    story.extend(h2("Decision Framework"))
    story.extend(make_table(
        ["Situation", "Principal Dx Rule"],
        [
            ["Single clear reason for admission",            "Code that condition"],
            ["Two conditions equally responsible",           "Either may be principal — use circumstances"],
            ["Workup reveals a diagnosis (not just symptoms)", "Code the diagnosis (not the symptoms)"],
            ["Complication of surgery/medical care",         "Code the complication"],
            ["Uncertain diagnosis ('probable', 'suspected')", "Code AS IF confirmed (inpatient rule)"],
            ["Original treatment plan not carried out",      "Still code the original reason for admission"],
            ["Rehab admission",                              "Code the condition being rehabilitated"],
            ["Admission from outpatient surgery with complication", "Code the complication as principal"],
            ["Comparative diagnoses ('either GERD or angina')", "Code both as confirmed; sequence per circumstances"],
        ],
        col_widths=[3.0*inch, 4.0*inch]
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION III
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section III: Additional Diagnoses", "Inpatient Only"))
    story.extend(body("Report a condition as an additional diagnosis if it required ANY of the following:"))
    story.extend(make_table(
        ["Criterion", "Notes"],
        [
            ["Clinical evaluation",              "Provider assessed or monitored the condition"],
            ["Therapeutic treatment",            "Medication, procedure, or intervention given for it"],
            ["Diagnostic procedures",            "Tests ordered specifically for this condition"],
            ["Extended length of stay",          "Patient stayed longer because of this condition"],
            ["Increased nursing care/monitoring","More intensive nursing was needed because of it"],
        ],
        col_widths=[2.5*inch, 4.5*inch]
    ))
    story.extend(warn("Old conditions from previous episodes with NO bearing on the current stay = do NOT report."))
    story.extend(tip("Uncertain additional diagnoses (probable/suspected) in INPATIENT = code them as if confirmed."))

    # ══════════════════════════════════════════════════════════════════════════
    # SECTION IV
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Section IV: Outpatient Coding Rules"))
    story.extend(h2("Key Differences from Inpatient"))
    story.extend(make_table(
        ["Topic", "Inpatient (Sec II)", "Outpatient (Sec IV)"],
        [
            ["Uncertain diagnoses",  "Code as if confirmed",      "Do NOT code — use signs/symptoms"],
            ["First dx label",       '"Principal diagnosis"',      '"First-listed diagnosis"'],
            ["Abnormal test results","Can code abnormal findings",  "Code confirmed dx only when final report available"],
            ["Chronic diseases",     "Code if treated/monitored",  "Can code EVERY visit they are managed"],
            ["Same-day surgery",     "Inpatient principal rules",  "Reason for surgery = first-listed, even if not performed"],
        ],
        col_widths=[1.8*inch, 2.6*inch, 2.6*inch]
    ))
    story.extend(highlight_box(
        "<b>Outpatient surgery rule:</b> Code the REASON for surgery as first-listed, "
        "even if the surgery was not performed due to a contraindication."
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # APPENDIX I — POA
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Appendix I: Present on Admission (POA)", "Inpatient Billing"))
    story.extend(body(
        "POA indicates whether a condition was present when the inpatient admission order was written. "
        "It is assigned to all principal and secondary diagnoses on the UB-04/837I claim form."
    ))
    story.extend(make_table(
        ["Indicator", "Meaning"],
        [
            ["Y",     "YES — present at the time of inpatient admission"],
            ["N",     "NO — not present; developed after admission"],
            ["U",     "UNKNOWN — documentation unclear"],
            ["W",     "Clinically undetermined — provider cannot determine"],
            ["Blank", "Exempt from POA reporting"],
        ],
        col_widths=[1.0*inch, 6.0*inch]
    ))
    story.extend(highlight_box(
        "<b>Why it matters:</b> Conditions that are POA = N may be classified as hospital-acquired "
        "complications (HACs). Hospitals are NOT reimbursed for preventable complications they caused."
    ))
    story.extend(h2("Key POA Assignment Rules"))
    story.extend(make_table(
        ["Situation", "Assign"],
        [
            ["Condition explicitly documented as present on admission",    "Y"],
            ["Chronic conditions (hypertension, diabetes, asthma)",        "Y (always pre-existing)"],
            ["Condition develops during outpatient encounter before admit", "Y"],
            ["Condition develops during inpatient hospitalization",        "N"],
            ["Uncertain/possible dx present since admission symptoms",     "Y"],
            ["Uncertain/possible dx based on post-admission findings",     "N"],
            ["Documentation unclear whether present on admission",        "U"],
            ["Provider clinically cannot determine",                      "W"],
        ],
        col_widths=[4.5*inch, 2.5*inch]
    ))

    story.append(PageBreak())

    # ══════════════════════════════════════════════════════════════════════════
    # MASTER CHEAT SHEET
    # ══════════════════════════════════════════════════════════════════════════
    story.extend(section_header("Master Memory Cheat Sheet", "Quick Reference for Exams & Practice"))

    story.extend(make_table(
        ["Rule", "Remember It As"],
        [
            ["Always use Index + Tabular List together",   '"Look it up, then check it out"'],
            ["Excludes1",                                  '"1 code only — they are the same thing"'],
            ["Excludes2",                                  '"2 codes OK — they are different things"'],
            ["Etiology/manifestation",                     '"Root cause first, effect second"'],
            ['"With" in classification',                   '"Assume they are related — no documentation needed"'],
            ["Inpatient uncertain diagnosis",              '"Probable = code it"'],
            ["Outpatient uncertain diagnosis",             '"Probable = do NOT code it — use symptoms"'],
            ["Septic shock",                               '"Never principal dx — infection always leads"'],
            ["Chapter 15 obstetrics",                      '"Always wins the sequencing race"'],
            ["Principal diagnosis definition",             '"Responsible AFTER study = at discharge, not admission"'],
            ["Adverse vs. Poisoning",                      '"Correct drug bad reaction = adverse; wrong/too much = poisoning"'],
            ["AMI within 4 weeks",                         '"Use I22 WITH I21"'],
            ["HIV with illness",                           '"Always B20"'],
            ["HIV positive, no symptoms",                  '"Z21"'],
            ["POA = N",                                    '"Happened during the stay = hospital pays"'],
            ["Default diabetes type",                      '"No type documented = Type 2 (E11.-)"'],
            ["External cause codes",                       '"Never principal — always supporting info"'],
        ],
        col_widths=[3.5*inch, 3.5*inch]
    ))

    story.extend(h2("High-Yield Codes to Know"))
    story.extend(make_table(
        ["Code", "Condition"],
        [
            ["B20",    "HIV disease (with illness / AIDS)"],
            ["Z21",    "Asymptomatic HIV positive status"],
            ["A41.9",  "Sepsis, unspecified organism"],
            ["R65.21", "Severe sepsis with septic shock"],
            ["U07.1",  "COVID-19"],
            ["U07.0",  "Vaping-related disorder"],
            ["U09.9",  "Post-COVID condition, unspecified"],
            ["I10",    "Essential hypertension"],
            ["I1A.0",  "Resistant hypertension"],
            ["I21.4",  "NSTEMI"],
            ["E11.-",  "Type 2 diabetes mellitus"],
            ["O80",    "Normal uncomplicated delivery"],
            ["Z37.-",  "Outcome of delivery (always secondary on maternal record)"],
            ["Z38.-",  "Liveborn infant (always principal on newborn record)"],
            ["Z85.-",  "Personal history of malignant neoplasm"],
            ["Z79.4",  "Long-term (current) use of insulin"],
        ],
        col_widths=[1.2*inch, 5.8*inch]
    ))

    story.append(Spacer(1, 0.3*inch))
    footer_note = Table([[
        Paragraph(
            "ICD-10-CM Official Guidelines FY 2025 | Study Guide prepared by Orris Medical Coding Tutor | "
            "For educational purposes. Always refer to the official CMS/NCHS guidelines for clinical use.",
            ParagraphStyle("fn", fontSize=7.5, textColor=colors.gray,
                           fontName="Helvetica-Oblique", alignment=TA_CENTER))
    ]], colWidths=[7.0*inch])
    footer_note.setStyle(TableStyle([
        ("TOPPADDING",   (0,0),(-1,-1), 8),
        ("BOTTOMPADDING",(0,0),(-1,-1), 8),
        ("LINEABOVE",    (0,0),(-1,0),  0.5, MGRAY),
    ]))
    story.append(footer_note)

    # ── Build ─────────────────────────────────────────────────────────────────
    doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
    print(f"PDF created: {OUTPUT}")


if __name__ == "__main__":
    build()

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/icd10-guide/build_pdf.py'