Transcript ICD-10: A call to Action Documentation Improvement

Transition to ICD-10
for Coding Professionals
Kathy Pride, RHIT, CPC, CCS-P
Barbara Oviatt, CPC, CCS-P
Who Are We?
Complete Practice Resources, LLC was formed
specifically to assist providers in addressing the ICD10 transition.
We are dedicated to improving healthcare delivery
by providing innovative healthcare information
technology and services.
From clinical and patient access management, to
revenue cycle and health information management,
Complete Practice Resources delivers real-world
solutions that assist healthcare professionals in
delivering outstanding patient care with optimum
efficiency.
Purpose of this Workshop
To understand the differences
between the ICD-9 and ICD-10
guidelines and data elements,
and how to kick start your
transition by performing a gap
analysis of your current
documentation.
Part I - Course Objectives
• Understand the coding guideline
variations between ICD-9 and ICD-10
• Understand how to crosswalk your ICD9 codes using GEMs and other tools
• Understand the documentation impact
for ICD-10 by comparing documentation
elements between ICD-9 and ICD-10
Part II Course Objectives
• Know how to formulate a strategy for
conducting chart reviews
• Become comfortable evaluating
documentation for ICD-10 coding
• Develop strategies for implementing ICD10 documentation education
Regulatory Background
• 1996 – HIPAA - Regulations for privacy,
security, unique identifiers and electronic
transactions and code sets.
• 2000 – HHS final rule names standard
transactions to be used by covered entities
Covered entities are providers, payers and
clearinghouses who conduct specific
administrative transactions electronically
Regulatory Background, cont.
• January 16, 2009 HHS Final Rule
– Replace inflexible, ambiguous version 4010
electronic format with version 5010 with
mandatory use by January 1, 2012
– Adopt ICD-10 as the new code set to replace ICD9- CM with mandatory use by October 1, 2013
• August 24, 2012 HHS announces
October 1, 2013 deadline will be
pushed back to October 1, 2014
New Deadline:
Oct. 1, 2014
• Re-adjust your implementation
timelines
• This is not a time to relax, it is a time
to catch up
Kick Start Your Transition
• Awareness training for you and your
staff
• Familiarize yourself with the new
structure
• Documentation Improvement Program
– Perform gap analysis
– Provide feedback to providers
Overall Coding process is the same!
1. Capture the required encounter
documentation
2. Choose the correct code
 Alphabetic Index
 Tabular List
 Read instructional notations
Differences between
ICD-9-CM and ICD-10-CM
ICD-9-CM diagnosis codes
ICD-10-CM diagnosis codes
 3-5 numeric digits in length
 3-7 Alpha-Numeric
characters in length
 First digit may be alpha (E or  Digit one is alpha; Digits
V) or numeric;
two and three are Numeric;
 Digits 2-5 are numeric
Digits 4-7 are alpha or
numeric
 Lacks detail
 Very specific
 Lacks laterality
 Has laterality
 Approximately 14,000 codes  Approximately 69,000
available codes
ICD-10-CM Code Structure
ICD-9-CM Code Format
ICD-10-CM Code Format
Asthma, unspecified type
with acute exacerbation
Unspecified asthma with
acute exacerbation
ICD-9
ICD-10
493.92
J45.901
ICD-10 Structural Changes
ICD – 9 – CM
•
•
•
•
17 Chapters
V codes
E codes
Maximum 5 character
codes
ICD – 10 – CM
21 Chapters
Z codes
V, W, X and Y codes
Addition of 6th and 7th
characters
• Addition of “placeholder”
•
•
•
•
New Features of ICD-10-CM
• Combination codes for conditions and
common symptoms or manifestations
E20.21 Type I diabetes mellitus with diabetic
nephropathy
I25.110 Atherosclerotic heart disease of native
coronary artery with unstable angina pectoris
K50.112 Crohn’s disease of large intestine with
intestinal obstruction
New Features in ICD-10-CM
• Combination codes for poisonings and
external causes
T36.0x1A Poisoning by penicillin, accidental
(unintentional), initial encounter
T42.4x5A Adverse effect of benzodiazepines,
initial encounter
5th digit is a place holder
6th digit indicates external cause
7th digit indicates episode of care
New Features in ICD-10-CM
• Added laterality
H60.332 Swimmer’s ear, left ear
S63.411A Sprain of carpal joint of right
wrist, initial encounter
H65.06 Acute serous otitis media,
recurrent, bilateral
Changes to General Coding
Guidelines
• Laterality
– Use a bilateral code if available
– Assign separate codes for a bilateral
condition when no bilateral code is
available
New Features in ICD-10-CM
• Added 7th character extensions for
episode of care
M80.08A Age related osteoporosis with current
pathological fracture, vertebra(e), initial
encounter
S61.421D Laceration with foreign body of right
hand, subsequent encounter
T21.31xS Burn of third degree of chest, sequela
Placeholder Character
• Dummy placeholder is always the letter “x”
• Used as the 5th character for certain 6
character codes to provide future expansion
• When a code has <6 characters and a 7th
character extension is needed – “x” is
assigned for all characters less than 7 to
meet the number of characters need to add
the 7th character extension
Changes to General Coding
Guidelines
• Initial encounter
– First visit to provider
• Subsequent encounter
– Under active treatment
• Sequela
– New name for Late Effects, same rules
– No time limit
– Not under active treatment for acute
condition
Episode of Care - Fracture
• A - initial encounter for closed fracture
• B - initial encounter for open fracture
• D - subsequent encounter for fracture with
routine healing
• G - subsequent encounter for fracture with
delayed healing
• K - subsequent encounter for fracture with
nonunion
• S - sequela
Episode of Care - Open Fracture
A - initial encounter for closed fracture
B - initial encounter for open fracture type I or II and
initial encounter for open fracture NOS
C - initial encounter for open fracture type IIIA, IIIB, or IIIC
D - subsequent encounter for closed fracture with routine
healing
E - subsequent encounter for open fracture type I or II
with routine healing
F - subsequent encounter for open fracture type IIIA, IIIB,
or IIIC with routine healing
Episode of Care - Open Fracture, Cont.
G - subsequent encounter for closed fracture with delayed
healing
H - subsequent encounter for open fracture type I or II
with delayed healing
J - subsequent encounter for open fracture type IIIA, IIIB,
or IIIC with delayed healing
K - subsequent encounter for closed fracture with
nonunion
M - subsequent encounter for open fracture type I or II
with nonunion
N - subsequent encounter for open fracture type IIIA, IIIB,
or IIIC with nonunion
Episode of Care - Open Fracture, Cont
P - subsequent encounter for closed fracture with
malunion
Q - subsequent encounter for open fracture type I or II
with malunion
R - subsequent encounter for open fracture type IIIA, IIIB,
or IIIC with malunion
S - sequela
7th Character for Obstetrics
•
•
•
•
•
•
•
0 - not applicable or unspecified
1 - fetus 1
2 - fetus 2
3 - fetus 3
4 - fetus 4
5 - fetus 5
9 - other fetus
New Features in ICD-10-CM
• Inclusion of trimesters in obstetrics
codes and elimination of 5th digits for
episode of care
O10.012 Pre-existing essential hypertension
complicating pregnancy, second trimester
O99.013 Anemia complicating pregnancy, third
trimester
Remember the first digit is the
letter “O” not the number zero
Classification Changes
• Certain diseases have been reclassified
to a more appropriate chapter – Example
gout was reclassified from endocrine to
musculoskeletal
• Postoperative complications have been
moved to procedure–specific body
system chapters
• Eyes and ears have their own chapters
Injury, Poisoning, and Certain Other
Consequences of External Causes
• Added “ Certain Other Consequences of
External Causes”
• Significant modifications made
– Arranged by body region beginning with the
head and concluding with ankle/foot vs.
arranged by injury in ICD-9
– Includes codes that begin with S and T
Classification Changes
• Injuries classified by site and then by
injury
Head
• Scalp
• Eyelid
• Nose
• Ear
• Cheek
• Lip
• Other
Injury Type
• Fracture
• Dislocation/Sprain
• Nerve injury
• Contusion
• Superficial Injury
• Laceration/wound
• Traumatic
Injury, Poisoning, and Certain Other
Consequences of External Causes
• Injuries including
lacerations,
fractures, sprains,
foreign body, etc.
• Burns and
corrosions
• Frost bite
• Poisoning
• Toxic effects of
nonmedicinal
substances
• Certain early
complications of
trauma
• Complications of
surgical and medical
care
Classification Changes
Chapter 5 – Mental and Behavioral
Disorders
This chapter contains more subchapters,
categories, subcategories, and codes than
ID-9-CM. Consequently when comparing
ICD-10-CM to ICD-9-CM some disorders are
classified differently with greater clinical
detail.
Mental and Behavioral Disorders
• F10.10 – Alcohol abuse, uncomplicated
• F10.120 – Alcohol abuse with intoxication,
uncomplicated (305.00 – 305.03)
• F10.121 – Alcohol abuse with intoxication
delirium (291.0)
• F10.129 – Alcohol abuse with intoxication,
unspecified (305.00 – 305.03)
External Causes of Morbidity
• Formerly E-Codes, located in a
supplemental classification
• Capture the cause of the injury or health
condition, the intent, the place, activity,
and the person’s status (civilian or
military)
• V, W, X, Y codes in ICD-10
• More detailed than the E-Codes in ICD-9
W56.02XA Struck by a Dolphin,
Initial Encounter
W56.02XD Struck by a Dolphin,
Subsequent Encounter
W56.02XS Struck by a Dolphin,
Sequela with F32.8 Depressive
Episode
Coding Conventions
• Most coding conventions remain the
same
– Abbreviations
• NEC, NOS
– Punctuation
• ( ) Parentheses, : Colon, [] Bracket
– “Includes” instructional notes
New Features in ICD-10-CM
• Two types of exclusion notes:
– Excludes 1 – indicates not coded here - The
code excluded is never used with the code
– Excludes 2 – indicates not included here –
The excluded condition is not part of the
condition represented by the code and it is
acceptable to use both codes together if the
patient has both conditions
Changes to Coding Guidelines
for Timeframes
• Changes in timeframes specified in
certain codes
– Acute myocardial infarction – time period
for classification of “acute” changed from 8
weeks to 4 weeks
– Timeframe for abortion versus fetal death
changed from 22 weeks to 20 weeks
Mental, Behavioral and
Neurodevelopment disorders
• Selection of codes for “in remission” for
categories F10-F19 Mental and
behavioral disorders requires the
provider’s clinical judgment.
– The appropriate codes for “in remission”
are assigned only on the basis of provider
documentation
Psychoactive Substance Use,
Abuse And Dependence
• When the provider documentation refers to use, abuse
and dependence of the same substance, only one code
should be assigned to identify the pattern of use based
on the following hierarchy:
– If both use and abuse are documented, assign only the code
for abuse
– If both abuse and dependence are documented, assign only
the code for dependence
– If use, abuse and dependence are all documented, assign only
the code for dependence
– If both use and dependence are documented, assign only the
code for dependence.
Diseases of the Nervous System
• Document - Dominant/Non-dominant
in addition to Left or Right
• If dominant side is not documented use
the following default guidelines:
– For ambidextrous patients, the default should
be dominant.
– If the left side is affected, the default is nondominant.
– If the right side is affected, the default is
dominant.
Exposure to Tobacco Smoke
• Z77.22 Contact with and exposure to
environmental tobacco smoke
• P96.81 Exposure to tobacco smoke in
perinatal period
• Z57.31 Occupational exposure to
environmental tobacco smoke
Other Tobacco Use Codes
•
•
•
•
Z87.891 History of Tobacco Use
F17.xxx Tobacco Dependence
Z72.0 Tobacco Use (non-dependent)
O99.33- Smoking (tobacco)
complicating pregnancy, childbirth, and
the puerperium
Tobacco Use Disorder –
Nicotine Dependence
ICD-9-CM = 305.1
ICD-10-CM = F17
• Current smoker
• Terminology change to
Nicotine dependence
• Type of nicotine (cigarette,
chewing tobacco, cigar, pipe,
etc.)
• Remission/Withdrawal/
Uncomplicated
• Use Z87.891 for History of
nicotine dependence
• Use Z72.0 Tobacco Use
(non-dependent)
Additional documentation
required
Nicotine Dependence
• Documentation for ICD-9:
– Tobacco Use disorder vs. History of tobacco
use disorder
• Documentation elements for ICD-10:
– Cigarettes, Chewing tobacco, Other tobacco
– Uncomplicated, remission, withdrawal, or
other nicotine-induced disorder
– History of nicotine dependence
Using GEMs
•
•
•
•
Create awareness
Compile documentation requirements
Determine educational needs
Review frequently used diagnoses and
create reference documents
Asthma, Unspecified
•
•
•
•
•
•
ICD-9-CM = 493.90
Extrinsic vs. intrinsic
Chronic obstructive asthma
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
•
•
•
•
•
•
•
•
•
 Additional documentation
required
•
ICD-10-CM = J45.909
Mild intermittent 
Mild persistent 
Moderate persistent 
Severe persistent 
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
Tobacco use or exposure
(additional code required) 
Excludes chronic obstructive
asthma
Diabetes with Complications
ICD-9-CM = 250.20 – 250.90
• Type I or Type II
• With coma
• Controlled or Uncontrolled
• Manifestation or
Complication – Additional
code required
• Long term (current) insulin
use – Additional code
required
 Additional
documentation required
ICD-10-CM = E11.8
•
•
•
•
•
•
•
•
•
•
•
Type I or Type II
Manifestation or Complication –
additional code no longer
required – New Combination
codes
Details of complication:
Arthropathy
Site of Ulcer
Severity of retinopathy 
With/without macular edema
Stage of CKD
Gangrene 
Hyperglycemia 
Long term (current) insulin use
– Additional code required
Otitis Media
ICD-9-CM = 381.00 – 382.9
• Acute vs. Chronic
• Type of otitis (serous,
allergic, suppurative, etc.)
• Eardrum rupture (if
applicable)
 Additional
documentation required
ICD-10-CM = H65 – H66
• Acute/Subacute vs. Chronic
• Type of otitis (serous, allergic,
suppurative, etc.)
• Eardrum rupture (if
applicable)
• Left/Right/Bilateral 
• Recurrent 
• Tobacco use or exposure
(additional code required) 
• Perforation of tympanic
membrane (additional code
required) 
Depressive Disorder
ICD-9-CM = 296.xx and 311
• Single episode vs. recurrent
• Major Depressive vs. NEC
• Mild/Moderate/Severe
• Psychotic behavior
• Remission
 Additional
documentation required
ICD-10-CM = H32 – H33
• Single episode vs. recurrent
• Major Depressive vs. NEC
• Note: No code for “Not
Elsewhere Classified”
(formerly code 311)
• Mild/Moderate/Severe
• Psychotic behavior
• Partial remission vs. full
remission 
Attention Deficit Hyperactivity Disorder
ICD-9-CM = 314.xx
ICD-10-CM = F90.x
• Developmental delay
• Conduct disorder
• With/without
hyperactivity
• Predominantly
inattentive type 
• Predominantly
hyperactive type 
• Combined type 
• Use additional code for
developmental delay
• Use additional code for
conduct disorder
Additional
documentation required
Part II - Chart Reviews
“A joint effort between the healthcare provider and
the coder is essential to achieve complete and
accurate documentation, code assignment, and
reporting of diagnoses and procedures.… The
importance of consistent, complete documentation
in the medical record cannot be overemphasized.
Without such documentation accurate coding cannot
be achieved.”
ICD-9-CM and ICD-10-CM
Practice Vignette - Angina
A 45 year old woman presents with chest
pain following her exercise class. She says
the pain subsided during the ride to the
physician’s office, but increased when she
walked in from the car.
Diagnosis: Angina
ICD-9 Code Assigned: 413.9
ICD-9
Assigned primary ICD-9 Code: 413.9
Audited ICD-9 code:
413.9
ICD-10
Mapped ICD-10 Code: I20.8
I20.9
Audited ICD-10 Code: I20.9
Was documentation sufficient to
support assigned / audited primary ICD9 code?
X Yes
No
Documentation suggestions for primary
ICD-9 code:
413.9 is unspecified. Specify type of
angina, such as unstable, preinfarction,
decubitus or prinzmetal.
Was documentation sufficient to assign a
primary ICD-10 code?
Assigned secondary ICD-9 code(s): N/A
Mapped secondary ICD-10 code(s): N/A
X Yes
No
Documentation suggestions for primary
ICD-10 code:
I20.9 is an unspecified code, indicate
unstable, pectoris with spasm, other,
etc. Include HTN if present and tobacco
use, exposure, or dependence.
ICD-9 to ICD-10 GEMs Inclusion Term Comparison
411.1 Intermediate coronary syndrome
Impending infarction
Preinfarction angina
Preinfarction syndrome
Unstable angina
I20.0 Unstable Angina
Accelerated
Crescendo
De novo effort angina
Intermediate coronary syndrome
Preinfarction syndrome
Worsening effort angina
413.0 Angina decubitus
Nocturnal angina
I20.8 Other forms of angina pectoris
Angina equivalent
Angina of effort
Coronary slow flow syndrome
Stenocardia
413.1 Prinzmetal angina
Variant angina pectoris
I20.1 Angina pectoris with documented spasm
Angiospastic angina
Prinzmetal angina
Spasm-induced angina
Variant
413.9 Other and unspecified angina pectoris
NOS
Cardiac
Equivalent
Of effort
Anginal syndrome
Status anginosus
Stenocardia
Syncope anginosa
I20.8 Other forms of angina pectoris
Angina equivalent
Angina of effort
Coronary slow flow syndrome
Stenocardia
120.9 Angina pectoris, unspecified
Angina NOS
Anginal syndrome
Cardiac angina
Ischemic chest pain
Practice Vignette - Acute MI
Patient presents with crescendo angina
with rapid progression of his symptoms
without stabilization. All efforts to avert the
pending inferior wall MI failed.
Diagnosis: Acute MI, inferolateral wall
initial episode
ICD-9 Code Assigned: 410.21
Acute MI
ICD-9-CM = 410.xx
ICD-10-CM = I21.x
• Site of MI
• Episode of care
• Episode of care
– Subsequent <8 weeks
– New/Subsequent =
New MI < 4 weeks
• Type of MI 
• Site of STEMI for initial
episode or subsequent
episode
Additional
documentation required • Non STEMI - site not
required
• Current complications
• Postinfarction angina 
• Current complications
ICD-9
Assigned primary ICD-9 Code: 410.21
ICD-10
Mapped ICD-10 Code: I21.19
Audited ICD-9 code: 410.21
Audited ICD-10 Code: Can’t be coded
Was documentation sufficient to
support assigned / audited primary
ICD-9 code?
X Yes
No
Documentation suggestions for primary
ICD-9 code:
Was documentation sufficient to
assign a primary ICD-10 code?
Assigned secondary ICD-9 code(s): N/A
Mapped secondary ICD-10 code(s): N/A
Yes
X No
Documentation suggestions for primary
ICD-10 code:
Type of MI - STEMI or NSTEMI not
indicated. Indicate tobacco use,
exposure, or dependence
Acute MI – Guideline Changes
ICD-9-CM = 410.xx
• Subsequent episode of
care for AMI are used
for an episode of care
following the initial
episode for MI > 8
weeks old
ICD-10-CM = I21.x
• Subsequent episode of
care for AMI are used
only when the patient
suffers a new AMI
during the initial 4
week treatment period
of a new AMI
• Subsequent visits for an
initial MI < 4 weeks –
use the initial episode
codes
• Subsequent visit for
initial MI > 4 weeks use
Code additional code for Tobacco Use
after care code
Practice Vignette – Pressure Ulcer
Patient is a 76 year old male who fell three weeks ago and fractured
his ankle. He is in poor health with steroid-induced diabetes due to
long term use for his Crohn’s Disease and ASHD. He is partially bedridden and has been in bed most of the past three weeks with his foot
elevated. For the past two of those three weeks, he’s had severe pain
in his heel. In addition, he hasn’t been eating well the past few days.
X-rays of the ankle revealed that the fracture fragments are in good
alignment; however, it was decided to replace the cast due to the
patient’s pain. When the cast was removed, a large decubitus ulcer of
the heel was found. The cast was replaced by a splint and the patient
was sent to PT for treatment of the ulcer.
Diagnoses: pressure ulcer of the heel, steroid induced diabetes, and
malnutrition. (Code only for the ulcer, diabetes and malnutrition)
ICD-9 Codes Assigned: 707.07, 263.0, 249.00
ICD-9
Assigned primary ICD-9 Code: 707.07
Audited ICD-9 code: 707.07
ICD-10
Mapped ICD-10 Code: L89.609
Audited ICD-10 Code: L89.609
Documentation sufficient to support
primary ICD-9 code?
Documentation sufficient to assign a
primary ICD-10 code?
X Yes  Unspecified
 No
Documentation suggestions:
Yes X Unspecified
No
Documentation suggestions:
Indicate laterality and stage of ulcer
Assigned secondary ICD-9 code(s):
263.0, 249.00
Audited secondary ICD-9 code(s):
263.9, 249.00
Mapped secondary ICD-10 code(s):
E44.0, E08.9, E09.9, E13.9
Audited secondary ICD-10 code(s):
E46, T38.0X5D, E09.0
Documentation sufficient to support
assigned secondary codes?
Yes  No
Documentation Suggestions:
Identify DM as controlled or uncontrolled
Indicate stage of ulcer
Document degree of malnutrition: mild,
moderate, arrested development, etc.
Documentation sufficient to support
secondary codes?
 Yes X Unspecified  No
Documentation Suggestions:
Document degree of malnutrition: mild,
moderate, retarded development, etc.
Indicate use of insulin as appropriate.
Pressure Ulcer
ICD-9 – 707.07
ICD-10 – L89.609
• Need two codes, one for
ulcer and one for stage
• Site
• Stage
• One combination code
for ulcer and stage
• Site
• Laterality 
• Stage
Additional
documentation required
Pressure Ulcer Coding Tip
• Pressure ulcer and non-pressure ulcer sites
also specify laterality in ICD-10
• Combination codes in ICD-10 that identify the
site as well as the stage of the ulcer
• Difference between a pressure ulcer and a
diabetic ulcer
• Unstageable vs. Unspecified
• If ulcer is healed no code assigned
• If ulcer is healing assign code as appropriate
Practice Vignette – Asthmatic Bronchitis
CHIEF COMPLAINT: This 5-year-old male presents to the practice with the
mother with "he has asthma." Mother states he has been wheezing and has
productive coughing. He has had some vomiting and some abdominal pain.
His peak flows the prior evening were normal at 150, but in the morning,
they were down to 100 and subsequently decreased to 75 over the course of
the day… day…Lives at home, here with the mother and there is no smoking
in the home.
MEDICAL DECISION MAKING: Chest x-ray reveals bronchial thickening,
otherwise no definite infiltrate. She received breathing treatments at home
and in the office and has continued tight wheezes with saturations 99%, but
sats are 92% with coughing spells. Based on the above, the hospitalist was
consulted and accepts this patient for admission to the hospital.
Diagnosis: Acute exacerbation of asthmatic bronchitis.
ICD-9 Code Assigned: 493.92
ICD-9
Assigned primary ICD-9 Code:
Audited ICD-9 code:
493.92
493.92
Documentation sufficient to support primary
ICD-9 code?
X Yes
X Unspecified
 No
Documentation suggestions:
Include extrinsic, intrinsic, chronic
obstructive, etc
ICD-10
Mapped ICD-10 Code: J45.901
Audited ICD-10 Code: J45.901
Documentation sufficient to assign a primary
ICD-10 code?
Yes
X Unspecified
No
Documentation suggestions:
Specify uncomplicated, with acute
exacerbation, or with status asthmaticus and
mild intermittent, mild persistent, moderate
persistent, severe persistent or other such as
exercise and cough induced.
This record indicates no smoking in the home, pertinent
information when coding asthma for ICD-10.
ICD-10 Guidelines: Code any exposure to, history of use,
current use or dependency on tobacco.
Asthmatic Bronchitis
•
•
•
•
•
•
ICD-9-CM = 493.92
Extrinsic vs. intrinsic
Chronic obstructive
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
•
•
•
•
•
•
•
•
•
 Additional documentation
required
•
ICD-10-CM = J45.901
Mild intermittent 
Mild persistent 
Moderate persistent 
Severe persistent 
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
Tobacco use or exposure
(additional code required) 
Excludes chronic obstructive
asthma
Practice Vignette – Asthma F/U
SUBJECTIVE: This is a 42-year-old white female who comes in today for a
follow up on asthma. She says her asthma has been worse over the last three
months. She has been using her inhaler daily. Her allergies seem to be a little
bit worse as well. Her husband has been hauling corn and this seems to
aggravate things. She has not been taking Allegra daily but when she does
take it, it seems to help somewhat. She has not been taking her Flonase which
has helped her in the past. She also notes that in the past she was on Advair
but she got some vaginal irritation with that.
ASSESSMENT/PLAN:
1. Intrinsic asthma. Seems to be worse than in the past. She is just using her
Proventil inhaler but is using it daily. We will add Flovent 44 mcg two puffs
p.o. b.i.d. May need to increase the dose. She is to call me if she is not
improving. We will plan on following up for reevaluation in one month.
2. Allergic rhinitis. We will plan on restarting Allegra and Flonase daily for the
time being.
ICD-9 Codes Assigned: 493.10, 477.9
ICD-9
Assigned primary ICD-9 Code:
Audited ICD-9 code:
493.10
493.10
ICD-10
Mapped ICD-10 Code:
Audited ICD-10 Code:
J45.20
J45.909
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary ICD10 code?
 Yes
X Unspecified
 No
Documentation suggestions:
Specify with status asthmaticus or with
acute exacerbation.
Yes
X Unspecified
No
Documentation suggestions:
Specify with status asthmaticus or with acute
exacerbation. Additional detail (as
appropriate) includes: mild intermittent, mild
persistent, moderate persistent, severe
persistent or other such as exercise and
cough induced.
Mapped secondary ICD-10 code(s): J30.0 /
J30.9
Audited secondary ICD-10 code(s): J30.9
Assigned secondary ICD-9 code(s): 477.9
Audited secondary ICD-9 code(s): 477.9
Documentation sufficient to support assigned
secondary codes?
Yes
X Unspecified
No
Documentation Suggestions:
Specify cause: pollen, food, animal, other
allergen
Documentation sufficient to support secondary
codes?
Yes
X Unspecified
No
Documentation Suggestions:
Specify cause: pollen, seasonal allergic
rhinitis, food, animal, other. Indicate any
tobacco use, exposure, or dependence.
Asthma
•
•
•
•
•
•
ICD-9-CM = 493.xx
Extrinsic vs. intrinsic
Chronic obstructive
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
•
•
•
•
•
•
•
•
•
 Additional documentation
required
•
ICD-10-CM = Category J45
Mild intermittent 
Mild persistent 
Moderate persistent 
Severe persistent 
With status asthmaticus
With exacerbation
Exercise induced
bronchospasm
Cough variant asthma
Tobacco use or exposure
(additional code required) 
Excludes chronic obstructive
asthma
Practice Vignette – Major Depressive Disorder
CHIEF COMPLAINT: Mr. T presented with significant
muscle tremor, constant headaches, excessive
nervousness, poor concentration, and poor ability to
focus. His confidence and self-esteem are significantly low.
He stated he has excessive somnolence, his energy level is
extremely low, motivation is low, and he has a lack for
personal interests. Furthermore, he continues to have
hopeless thoughts and crying spells. Mr. T stated these
symptoms appeared approximately two months ago.
Impression: Major Depressive Disorder, single episode
ICD-9 Code Assigned: 296.20
ICD-9
Assigned primary ICD-9 Code: 296.20
Audited ICD-9 code: 296.20
ICD-10
Mapped ICD-10 Code: F32.9
Audited ICD-10 Code: F32.9
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
Yes
X Unspecified
 No
Documentation suggestions:
Specify: mild, moderate, severe with /
without psychotic behavior, in partial or full
remission
Assigned secondary ICD-9 code(s): N/A
X Unspecified
No
Documentation suggestions:
Specify: mild, moderate, severe with /
without psychotic behavior, in partial or full
remission
Mapped secondary ICD-10 code(s): N/A
The record specifies major depressive disorder, single
episode, but results in the assignment of an unspecified
code without the details indicated above. Providers
should be aware that the same information is required
in both code sets to accurately assign an appropriate
code.
Depressive Disorder
ICD-9-CM = 296.xx and 311
•
•
•
•
•
Single episode vs. recurrent
Major Depressive vs. NEC
Mild/Moderate/Severe
Psychotic behavior
Remission
 Additional documentation
required
ICD-10-CM = Category F32
• Single episode vs. recurrent
• Major Depressive vs. NEC
• Note: No code for “NEC”
(formerly code 311) 
• Mild/Moderate/Severe
• Psychotic behavior
• Partial remission vs. full
remission 
Practice Vignette – Recurring Depression
CC: “Five years ago, I stopped drinking and since that time, I have had
severe depression. I was doing okay when I stopped my medications
in December for a few weeks, but then I got depressed again. I started
lithium three weeks ago."
HPI: The patient is a 45-year-old married white female with one
psychiatric hospitalization for seven days in April of 2007. The patient
now presents with recurrent depressive symptoms for approximately
four months. The patient gives a substantial history of alcohol abuse
lasting up to about five years ago when she was hospitalized. The
patient has attended AA but at present going once a week; and when
asked if she may be in early relapse, she indicates that yes that is a
very real possibility.
Diagnosis: Dysthymia. Major depression, moderate severity,
recurrent
ICD-9 Code Assigned: 300.4, 296.32
ICD-9
ICD-10
Assigned primary ICD-9 Code: 300.4
Mapped ICD-10 Code: F34.1
Audited ICD-9 code: 300.4
Audited ICD-10 Code: F34.1
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
X Yes
 Unspecified
 No
Documentation suggestions: N/A
X Yes
 Unspecified
No
Documentation suggestions: N/A
Assigned secondary ICD-9 code(s): 296.32
Mapped secondary ICD-10 code(s): F33.1
Audited secondary ICD-9 code(s): 296.32
Not coded: 305.03
Audited secondary ICD-10 code(s): F33.1
F10.10
Documentation sufficient to support assigned
secondary codes?
X Yes
 Unspecified
 No
Documentation sufficient to support secondary
codes?
X Yes
 Unspecified
 No
The diagnostic statement for major depressive order remains the same between
the ICD-9 and ICD-10 code sets and includes: single or recurrent episode, mild,
moderate, severe, in full or partial remission, with and without mention of
psychotic features or symptoms. Providers should be aware that the same
information is required in both code sets to accurately assign an appropriate
code.
Practice Vignette – Chronic Otitis Media
HPI: This is a 14-month-old with history of chronic
recurrent episodes of otitis media, totaling 6 bouts,
requiring antibiotics since birth. There is also associated
chronic nasal congestion. There had been no bouts of
spontaneous tympanic membrane perforation, but there
had been elevations of temperature up to 102 during the
acute infection…The patient is not in daycare.
Social: There are no pets in the home. Parents both
smoke.
Diagnosis: Chronic eustachian tube dysfunction, chronic
otitis media with effusion, recurrent acute otitis media,
and wax accumulation.
ICD-9 Code Assigned: 381.81, 381.3, 380.4
ICD-9
ICD-10
Assigned primary ICD-9 Code: 381.81
Mapped ICD-10 Code: H69.80
Audited ICD-9 code: 381.81
Audited ICD-10 Code: H69.80
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
X Yes
 Unspecified
 No
 Yes
X Unspecified
 No
Documentation suggestions: N/A
Documentation suggestions:
Indicate laterality for tube dysfunction
Assigned secondary ICD-9 code(s):
381.3, 380.4
Mapped secondary ICD-10 code(s):
H65.499, H61.23
Audited secondary ICD-9 code(s):
381.3, 380.4, 382.9
Audited secondary ICD-10 code(s):
H65.499, H61.20, H66.90, Z77.22
Documentation sufficient to support assigned
secondary codes?
X Yes
 No
Documentation sufficient to support secondary
codes?
 Yes
X Unspecified
 No
Documentation Suggestions:
Specify nonsuppurative, suppurative,
allergic, serous, mucoid, sanguinois, etc.
Documentation Suggestions:
Specify nonsuppurative, suppurative, allergic,
serous, mucoid, sanguinois, etc.
Clarify the presence of each condition as R, L,
or bilateral
Chronic Otitis Media
ICD-9-CM = 381.3
ICD-10-CM = Category H65
Other and Unspecified Chronic
Nonsuppurative Otitis
Media Includes:
• Allergic
• Exudative
• Secretory
• Seromucinous
• Transudative
• With Effusion
Must state “chronic”
• Chronic allergic otitis media
• Chronic exudative
• Chronic nonsuppurative NEC
• Chronic with effusion
• Identify laterality 
• Use additional code to
identify tobacco use or
exposure 
• Use additional code for an
associated perforated
tympanic membrane 
 Additional documentation required
Practice Vignette - Otitis Media
HPI: 13 year old, comes in with his mother complaining of waking during
the night with severe ear pain. Mom states this is the third time this year.
Mom reports he has been afebrile with each earache episode, and he has
had no upper respiratory symptoms. Patient has recently started on the
wrestling team and denies any head trauma associated with wrestling
practice.
Family/Social: …Dad has hypertension and frequent heartburn
symptoms that he treats with over-the-counter (OTC) medications. Mom
is healthy and has asthma. Patient and mother both deny smoking
PMH: …He takes no prescribed medications but admits to taking his dad's
OTC Pepcid AE sometimes when he gets heartburn. He complains of sore
throats and often feels burning in his throat when he goes to sleep at
night after a late evening snack. He reports no epigastric tenderness but
states that heartburn begins in epigastric area and rises to throat.
Diagnosis: Chronic Otitis Media, GERD
ICD-9 Code Assigned: 382.9, 530.81
ICD-9
ICD-10
Assigned primary ICD-9 Code: 382.9
Mapped ICD-10 Code: H66.90
Audited ICD-9 code: 382.9
Audited ICD-10 Code: H66.93
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
Yes
X Unspecified
 No
X Unspecified
No
Documentation suggestions:
Specify nonsuppurative, suppurative,
allergic, serous, mucoid, sanguinois, etc.
Documentation suggestions: Indicate laterality
and specify nonsuppurative, suppurative,
allergic, serous, mucoid, sanguinois, etc.
Assigned secondary ICD-9 code(s): 530.81
Mapped secondary ICD-10 code(s): K21.9
Audited secondary ICD-9 code(s): 530.81
Audited secondary ICD-10 code(s): K21.9
Documentation sufficient to support assigned
secondary codes?
X Yes
 No
Documentation sufficient to support secondary
codes?
X Yes
 No
Code any exposure to, history of use, current use or dependency on tobacco when
reporting otitis media.
Practice Vignette - ADHD
Subjective: This is a 6-year-old male who comes in rechecking
his ADHD medicines. We placed him on Adderall last month.
Mother said the next day, he had a wonderful improvement, and
he has been doing very well with the medicine. She has two
concerns. It seems like first thing in the morning after he takes
the medicine and it seems like it takes a while for the medicine
to kick in. It wears off about 2 and they have problems in the
evening with him. His teachers have seen a dramatic
improvement and she did miss a dose this past weekend and
said he was just horrible. The patient even commented that he
thought he needed his medication.
Diagnosis: Attention deficit hyperactivity disorder
ICD-9 Code Assigned: 314.01
ICD-9
Assigned primary ICD-9 Code: 314.01
Audited ICD-9 code: 314.01
ICD-10
Mapped ICD-10 Code: F90.0 , F90.1, F90.2,
F90.9
Audited ICD-10 Code: F90.9
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
X Yes
 Unspecified
 No
Yes
X Unspecified
No
Documentation suggestions: N/A
Documentation suggestions: Indicate if
condition is predominantly inattentive,
hyperactive, or combined
Assigned secondary ICD-9 code(s): N/A
Mapped secondary ICD-10 code(s): N/A
Attention Deficit Disorder
ICD-9-CM = Category 314
•
•
•
•
Hyperactivity
Development delay
Conduct disorder
Other specified
manifestation
 Additional documentation
required
ICD-10-CM = Category F90
• Predominantly
hyperactivity 
• Predominantly
inattentive
• Combined type
Practice Vignette – ADHD / Depression
HPI: The patient has been receiving services at this facility, under the
care of ABC, M.D. Historically, he has found it very easy to be
distracted in the "cubicle" office setting where he sometimes works.
He first remembers having difficulty with concentration in college,
Symptoms have included difficulty sustaining attention (especially in
reading), not seeming to listen when spoken to directly, failure to
finish tasks, difficulty with organization…The patient has never been
hospitalized for psychiatric purposes. He tried Adderall for a time, and
it helped, but he became hypertensive…Patient's blood pressure is
high today, 140/94. However, he is experiencing a considerable
amount of back pain at this time, which likely contributes to this. We
discussed some of the treatment options, and the patient will return
within the next few days to have his blood pressure checked again.
Diagnosis: Major depression, recurrent, moderate. Attention-deficit
hyperactivity disorder, inattentive type.
ICD-9 Code Assigned: 296.32, 314.01, 796.2
ICD-9
Assigned primary ICD-9 Code: 296.32
Audited ICD-9 code: 296.32
ICD-10
Mapped ICD-10 Code: F33.1
Audited ICD-10 Code: F33.1
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
X Yes
 Unspecified
 No
X Yes
 Unspecified
No
Documentation suggestions: N/A
Documentation suggestions: N/A
Assigned secondary ICD-9 code(s): 314.01
Mapped secondary ICD-10 code(s): F90.0,
F90.1, F90.2, F90.9
Audited secondary ICD-9 code(s): 314.01,
796.2, 724.5
Audited secondary ICD-10 code(s): F90.0,
R03.0, M54.9
Documentation sufficient to support assigned
secondary codes?
X Yes  No
Documentation sufficient to support secondary
codes?
X Yes  No
Documentation Suggestions:
Specify location of back pain
Documentation Suggestions:
Specify location of back pain
Practice Vignette – Diabetes Mellitus
CC: Followup diabetes mellitus.
Subjective: Patient is a 34-year-old male with diabetic neuropathy. He
has been using NPH and Regular insulin to maintain his blood sugars.
States he is afraid of having a low blood sugar due to a motor vehicle
accident several years ago. Says his blood sugar dropped too low which
caused the accident he has been unwilling to let his blood sugars fall
within a normal range for fear of hypoglycemia. Reports that at one
point, he was on Lantus which worked well and he was able to get his
hemoglobin A1C down to 7. He denies alcohol or drug use and is a non
smoker. Patient also has a history of gastroparesis. Patient requests
Nexium.
Diagnosis: Diabetes mellitus, with significant diabetic neuropathy and
positive microalbuminuria. Elevated alkaline phosphatase, etiology
unclear…Prescription given for Prilosec OTC for GERD symptoms.
ICD-9 Codes Assigned: 250.60, 357.2, 791.0, V58.67
ICD-9
Assigned primary ICD-9 Code: 250.60
Audited ICD-9 code: 250.60
ICD-10
Mapped ICD-10 Code: E11.40
Audited ICD-10 Code: E11.40
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
Yes
X Unspecified
 No
Documentation suggestions:
Indicate type 1 or 2, controlled or
uncontrolled
Assigned secondary ICD-9 code(s): 357.2,
791.0, V58.67
X Unspecified
No
Documentation suggestions:
Indicate type 1 or 2 diabetes mellitus and
mononeuropathy, polyneuropathy,
autonomic (poly)neuropathy, amyotrophy
or other neurological condition
Mapped secondary ICD-10 code(s): R80.3,
R80.9, Z79.4
Audited secondary ICD-9 code(s): 357.2, 791.0, Audited secondary ICD-10 code(s):
790.5, V58.67
R80.9, R74.8, Z79.4
Documentation sufficient to support assigned
secondary codes?
X Yes (with some exceptions)
 No
Documentation sufficient to support secondary
codes?
 Yes X Unspecified  No
Documentation Suggestions:
Documentation Suggestions:
Indicate type of proteinuria – Isolate,
persistent, Bence Jones, etc.
Diabetes Mellitus
ICD-9-CM = Category 250
•
•
•
•
•
•
•
•
•
Type 1 or Type 2
Secondary
Hyperosmolarity
Ketoacidosis
Neurological manifestation
Coma
Ophthalmic manifestation
Peripheral circulatory disorder
Renal manifestations
 Additional documentation required
ICD-10-CM = Category E10
•
•
•
•
•
•
Type 1 or Type 2
Due to underlying condition
Drug or chemical induced
Ketoacidosis
– With/without coma 
Kidney complications
– Diabetic nephropathy 
– Chronic kidney disease 
Neurological complications
– Amyotrophy 
– Autonomic (poly) neuropathy

– Mononeuropathy 
– Polyneuropathy 
Diabetes Mellitus, Cont.
ICD-10-CM = Category E10
•
Ophthalmic complications 
– Diabetic Retinopathy 
– Nonproliferative 
• Mild/Moderate/Severe 
• W/wo Macular Edema 
– Proliferative 
• W/wo Macular Edema 
– Diabetic Cataract 
•
•
•
•
•
Peripheral angiopathy 
– W/wo gangrene 
Neuropathic arthropathy 
Skin complication 
– Dermatitis 
– Foot ulcer 
Periodontal disease 
Hypoglycemia w/wo coma 
Practice Vignette - Diabetes
Subjective: I am asked to see the patient today with ongoing
issues around her diabetic control. We have been fairly
aggressively, downwardly adjusting her insulins, both the Lantus
insulin, which we had been giving at night as well as her sliding
scale Humalog insulin prior to meals. Despite frequent decreases
in her insulin regimen, she continues to have somewhat low blood
glucoses, most notably in the morning when the glucoses have
been in the 70s despite decreasing her Lantus insulin from around
84 units down to 60 units, which is a considerable change. What I
cannot explain is why her glucoses have not really climbed at all
despite the decrease in insulin. The staff reports to me that her
appetite is good and that she is eating as well as ever.
Diagnosis: Type 1, Diabetes, still with some problematic
hypoglycemia
ICD-9 Code Assigned: 250.81, V58.67
ICD-9
Assigned primary ICD-9 Code: 250.81
Audited ICD-9 code: 250.81
ICD-10
Mapped ICD-10 Code: E10.618 – E10.638,
E10.649, E10.65-E10.69
Audited ICD-10 Code: E10.69
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
X Yes
 Unspecified
 No
X Yes
 Unspecified
No
Documentation suggestions:
Provider indicates problematic
hypoglycemia, but it is important to specify
controlled or uncontrolled diabetes.
Assigned secondary ICD-9 code(s): V58.67
Documentation suggestions:
Continue to specify type 1 or 2
Mapped secondary ICD-10 code(s): Z79.4
Audited secondary ICD-9 code(s): V58.67
Audited secondary ICD-10 code(s): Z79.4
Documentation sufficient to support assigned
secondary codes?
X Yes  No
Documentation sufficient to support secondary
codes?
X Yes  No
Documentation Suggestions: N/A
Documentation Suggestions: N/A
Practice Vignette – DM and Hyperlipidemia
HPI: The patient is a 39-year-old woman returns for follow-up
management of type 2 diabetes mellitus. Her last visit was
approximately 4 months ago. Since that time, the patient states her
health had been good and her glycemic control had been good,
however, within the past 2 weeks she had a pump malfunction, had
to get a new pump and was not certain of her pump settings and
has been having some difficulty with glycemic control over the
past 2 weeks. She is not reporting polyuria, polydipsia or
polyphagia. She is not exercising, is working on a full-time basis
and has little time for physical activity. She had lab work done at
her previous visit and this revealed persistent hyperlipidemic
state with a LDL of 144.
Diagnosis: Pump related hyperinsulinemic hypoglycemia,
hyperlipidemia.
ICD-9 Code Assigned: 250.80, 962.3, 272.4
ICD-9
Assigned primary ICD-9 Code: 250.80
Audited ICD-9 code: 250.80
ICD-10
Mapped ICD-10 Code: E11.649
Audited ICD-10 Code: E11.649
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
XYes
X Unspecified
 No
 Unspecified
No
Documentation suggestions:
Specify DM as controlled or uncontrolled
Documentation suggestions:
Assigned secondary ICD-9 code(s): 962.3,
272.4
Mapped secondary ICD-10 code(s): T38.3X1A,
E78.4, E78.5
Audited secondary ICD-9 code(s): 962.3,
272.4, V58.67
Audited secondary ICD-10 code(s): E11.9.
E78.5, Z79.4
Documentation sufficient to support assigned
secondary codes?
X Yes X Unspecified  No
Documentation sufficient to support secondary
codes?
X Yes X Unspecified
 No
Documentation Suggestions: Indicate
Documentation Suggestions: Specify type of
controlled or uncontrolled diabetes mellitus. hyperlipidemia if known (combined, familial,
Specify type of hyperlipidemia if known
group A-D, mixed etc. (See category E78.)
(pure, mixed, exogenous, endogenous,
group A-D, etc.)
Practice Vignette – Marginal Zone Lymphoma
HPI: This is a very pleasant 46-year-old woman
with newly diagnosed marginal zone lymphoma
(MALT-type lymphoma)
Social: She has rare alcohol use. She has no
illicit drug use. She has a history of tobacco
use. She is in the process of getting divorced.
She has a 24-year-old son in the area and 22year-old daughter.
Diagnosis: MALT lymphoma.
ICD-9 Code Assigned: 200.30
ICD-9
Assigned primary ICD-9 Code: 200.30
Audited ICD-9 code: 200.30
ICD-10
Mapped ICD-10 Code: C83.80, C83.89
Audited ICD-10 Code: C88.4
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
X Yes
X Unspecified
 No
 Unspecified
No
Documentation suggestions:
Indicate affected lymph node(s) or spleen.
Documentation suggestions:
Assigned secondary ICD-9 code(s): 305.1
Mapped secondary ICD-10 code(s): F17.200
Audited secondary ICD-9 code(s): V15.82
Audited secondary ICD-10 code(s): Z87.891
Documentation sufficient to support assigned
secondary codes?
X Yes
 No
Documentation sufficient to support secondary
codes?
X Yes
 No
Documentation Suggestions:
Distinguish between history of (past use)
and current use of tobacco.
Documentation Suggestions:
Distinguish between history of (past use)
and current use of tobacco.
GEMs Mapping for Unspecified
Marginal Zone Lymphoma
Practice Vignette - Angina
CC: This 62 year old female presents today
with chest pain, nausea, pain radiating to the
arm and pain radiating to the jaw. The pain is
described by the patient as crushing and
unchanged since sudden onset during
exercise 5 hours ago
Social: Patient admits tobacco use. She
relates a smoking history of 40 pack years.
Diagnosis: Angina pectoris
ICD-9 Code Assigned: 413.9, 305.1
ICD-9
Assigned primary ICD-9 Code: 413.9
Audited ICD-9 code: 413.9
ICD-10
Mapped ICD-10 Code: I20.8, I20.9
Audited ICD-10 Code: I20.9
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
Yes
X Unspecified
 No
Documentation suggestions:
413.9 is unspecified, Specify type of angina,
such as unstable, preinfarction, decubitus
or prinzmetal.
X Unspecified
No
Assigned secondary ICD-9 code(s): 305.1
Documentation suggestions:
I20.9 is an unspecified code, be specific in
the type of angina. Indicate instability,
pectoris with identified spasm, etc.
Document HTN if present.
Mapped secondary ICD-10 code(s): F17.200
Audited secondary ICD-9 code(s): 305.1
Audited secondary ICD-10 code(s): F17.200
Documentation sufficient to support assigned
secondary codes?
X Yes
 Unspecified  No
Documentation sufficient to support secondary
codes?
 Yes
X Unspecified
 No
Documentation Suggestions:
Documentation Suggestions:
Indicate if cigarette dependence is
uncomplicated, in remission, withdrawal, in
the presence of other nicotine induced
disorders
Practice Vignette – Open Wound with MRSA
CC: The patient is a 52-year-old male her for follow-up of complex
open wound right lower extremity complicated by a methicillinresistant staphylococcus aureus cellulitis. He is here following a
prolonged hospitalization for this problem. The patient was admitted
and started on IV antibiotics elevation, and was also counseled to
minimizing the cigarette smoking. The patient had edema of his
bilateral lower extremities. The patient eventually grew MRSA in a
moderate amount. He was treated with IV vancomycin. Local wound
care and elevation. The patient had slow progress. He was started on
compression, and by 04/03 his leg got much improved, minimal
redness and swelling was down with compression. The patient was
thought safe to discharge home.
Impression: Complex open wound right lower extremity complicated
by a methicillin-resistant staphylococcus aureus cellulitis, resolving.
Continued tobacco use despite counseling.
ICD-9 Code Assigned: 894.1
ICD-9
Assigned primary ICD-9 Code: 894.1
Audited ICD-9 code: 894.1
ICD-10
Mapped ICD-10 Code: S71.029A
Audited ICD-10 Code: No code
Documentation sufficient to support primary
ICD-9 code?
Documentation sufficient to assign a primary
ICD-10 code?
 Yes
Yes
X Unspecified
 No
Documentation suggestions:
Indicate location such as hip, thigh, knee,
ankle, foot, toes
 Unspecified
X No
Assigned secondary ICD-9 code(s): 682.6,
041.12, 305.1
Documentation suggestions:
Indicate type of wound (i.e. puncture,
laceration or bite) and location (hip, thigh,
knee, etc.) No code for “lower extremity”
Mapped secondary ICD-10 code(s): L03.119,
L03.129, B95.62, F17.200
Audited secondary ICD-9 code(s): 682.6,
041.12, 305.1
Audited secondary ICD-10 code(s): L03.115,
B95.62, F17.210
Documentation sufficient to support assigned
secondary codes?
X Yes
 No
Documentation sufficient to support secondary
codes?
X Yes
 No
Documentation Suggestions:
Documentation Suggestions:
Indicate if cigarette dependence is
uncomplicated, in remission, withdrawal, in
the presence of other nicotine induced
disorders.
Open Wound of Lower Extremity
ICD-9-CM = Category 894
ICD-10-CM = Categories S71, S81,
S91
• Location
• With or without
complications
• With tendon involvement
• Location (can not use general
locations such as “lower or
upper” extremity) 
• Type of wound
– Laceration 
– Puncture 
– Open bite 
• Presence of foreign body 
• Laterality 
• Encounter type (initial, etc) 
 Additional documentation required
Questions…
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