Transcript Chapter Review (con`t)

ICD-10-CM Code Set Education
and Training
Building Expert Diagnosis Coding 2014
Welcome
Introductions: Let’s go around the room and introduce
ourselves . . .
Then we’ll cover some housekeeping items.
Did you sign in?
Goals and Objectives
By the end of this education & training,
participants will be able to:
Define ICD-10-CM/PCS conventions
Apply ICD-10-CM/PCS guidelines
Apply correct coding to exercises and case
scenarios
Reinforce ICD-10 Code Set learnings
Have FUN
Review of the Agenda
Agenda
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Welcome and Introductions
Resources Review
ICD-10 History and Background
Understanding Alpha/Tabular and Tables
Orientation to your Codebook & Manual
Conventions and Guidelines Review with case examples
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Part I – Chapter Review
Chapter I: Certain Infectious and Parasitic Diseases (A00-B99)
• Overview: Case examples and Rationale
Chapter II: Neoplasms (C00-D49)
• Overview: Case examples and Rationale
Chapter III: Diseases of the Blood and Blood-Forming Organs and
Certain Disorders Involving the Immune Mechanism (D50-D89)
• Overview: Case examples and Rationale
Agenda (con’t)
Part II – Chapter Review (con’t)
Chapter IV: Endocrine, Nutritional and Metabolic Diseases (E00E89)
Overview: Case examples and Rationale
Chapter V: Mental, Behavioral and Neurodevelopmental
Disorders (F01-F99)
Overview: Case examples and Rationale
Chapter VI: Diseases of the Nervous System (G00-G99)
Overview: Case examples and Rationale
Chapter VII: Diseases of the Eye and Adnexa (H00-H59)
Overview: Case examples and Rationale
Chapter VIII Diseases of the Ear and Mastoid Process (H60-H95) Reserved for future guideline expansion
Agenda (con’t)
Part II – Chapter Review (con’t)
Chapter IX: Diseases of the Circulatory System (I00-I99)
Overview: Case examples and Rationale
Chapter X:Diseases of the Respiratory System (J00-J99)
Overview: Case examples and Rationale
Part III – Chapter Review
Chapter XI: Diseases of the Digestive System (K00-K95)
Reserved for future guideline expansion
Chapter XII Diseases of the Skin and Subcutaneous Tissue (L00L99)
Overview: Case examples and Rationale
Chapter XIII: Diseases of the Musculoskeletal System and
Connective Tissue (M00-M99)
Overview: Case examples and Rationale
Agenda (con’t)
Part III – Chapter Review (con’t)
Chapter XIV: Diseases of Genitourinary System (N00-N99)
Overview: Case examples and Rationale
Chapter XV Pregnancy, Childbirth, and the Puerperium
(O00-O9A)
Overview: Case examples and Rationale
Chapter XVI Certain Conditions Originating in the Perinatal
Period (P00-P96)
Overview: Case examples and Rationale
Chapter XVII: Congenital malformations, deformations, and
chromosomal abnormalities (Q00-Q99)
Overview: Case examples and Rationale
Agenda (con’t)
Part III – Chapter Review (con’t)
Chapter XVIII: Symptoms, signs, and abnormal clinical and laboratory
findings, not elsewhere classified (R00-R99)
Overview: Case examples and Rationale
Chapter XIX: Injury, poisoning, and certain other consequences of
external causes (S00-T88)
Overview: Case examples and Rationale
Chapter XX External Causes of Morbidity (V00-Y99)
Overview: Case examples and Rationale
Agenda (con’t)
Part III & IV (Day 3)
Chapter XXI: Factors Influencing Health Status
and Contract with Health Services (Z00-Z99)
Overview: Case examples and Rationale
Outpatient Cases
Physician Cases (Profee only)
Discussion
Final Review & Wrap Up
POA (Hospital) review
MS-DRGs (Hospital) overview
ICD-10-CM Resources
2014 ICD-10-CM is available:
2014 ICD-10-CM Index to Diseases and Injuries
2014 ICD-10-CM Tabular List of Diseases and Injuries
Instructional Notations
2014 Official Guidelines for Coding and Reporting
2014 Table of Drugs and Chemicals
2014 Neoplasm Table
2014 Index to External Causes
2014 Mapping Information ICD-9-CM to ICD-10-CM and ICD-10-CM to ICD-9-CM”
CMS: http://www.cdc.gov/nchs/icd/icd10cm.htm or
http://www.cms.hhs.gov/ICD10
WHO website
AHIMA.org
AAPC.org – Physician Services
ICD-10-CM: The Complete Official Draft
Code Set 2014 (Optum Code Book)
Introduction
ICD-10-CM Draft Conventions
ICD-10-CM Official Guidelines for Coding and Reporting (you can highlight
areas of importance): Illustrations
ICD-10-CM Index to Diseases and Injuries
ICD-10-CM Neoplasm Table
Table of Drugs and Chemicals
ICD-10-CM Index to External Causes
ICD-10-CM Tabular List of Diseases and Injuries
ICD-10 History and Background
ICD-10 History and Background (con’t)
The International Classification of Diseases (ICD) is the international
standard diagnostic classification for all general epidemiological purposes,
many health management purposes, and for clinical use.
Overseen by the World Health Organization
This includes the analysis of the general health situation of population
groups, as well as monitoring the incidence and prevalence of diseases
and other health problems in relation to other variables such as the
characteristics and circumstances of the individuals affected,
reimbursement, resource allocation, quality, and guidelines.
The design of the classification system was to have updates every 10
years, due to changes in medicine and medical technologies.
History/Background (con’t)
ICD-9 code set has been in use in the United States since 1979 with annual
revisions.
ICD-10 came into use in World Health Organization (WHO) in 1994.
ICD-10 classification is in various formats and are adjusted in different
countries.
In Canada ICD-10 is referred to as: ICD-10-CA
Implemented in 2001
In Australia ICD-10 is referred to as:
Implemented in 1998
ICD-10, Clinical Modification (ICD-10-CM) was developed by the U.S.
National Center for Health Statistics (NCHS) along with an advisory panel to
ensure accuracy and utility in 1993.
History (con’t)
The 43rd World Health Assembly endorsed the ICD-10 in May 1990,
and member states (countries) began implementation of the new
codes in 1994.
United Kingdom 1995
France
1997
Australia
1998
Germany
2000
Canada
2001
The WHO is currently crafting the 11th revision, which is expected
to be release in 2015/2016.
Why Change to ICD-10?
ICD-9 codes provide limited data about patients’ medical conditions and
hospital inpatient procedures.
ICD-9 is over 30 years old, it has outdated and obsolete terms, and is
inconsistent with current medical practices.
The structure of ICD-9 limits the number of new codes that can be created, and
many ICD-9 categories are full.
ICD-10 codes allow for greater specificity and exactness in describing a
patient’s diagnosis and in classifying inpatient procedures.
ICD-10 will also accommodate newly developed diagnoses and procedures,
innovations in technology and treatment, performance-based payment
systems, and more accurate billing.
ICD-10 coding will make the billing process more streamlined and efficient, and
this will also allow for more precise methods of detecting fraud.
Why Change to ICD-10?
Example: ICD-9-CM does not accurately reflect current
technology and medical treatment. Since ICD-9-CM does
not accurately describe advancements in technologies,
significantly different procedures are assigned to a single
ICD- 9-CM procedure code.
Limitations in the coding system translate directly into
limitations in coverage and reimbursement.
History/Background (con’t)
Benefits to ICD-10-CM include but are not limited to the
following:
Improving payment systems and reimbursement accuracy
Measuring the quality, safety and efficacy of care
Improve disease management
Conducting research, epidemiogical studies, and clinical trials
Setting health policy
Monitoring resource utilization
Preventing and detecting healthcare fraud and abuse
History/Background (con’t)
In August 2008, the Department of Health & Human Services
proposed that new code sets be used for reporting diagnoses and
procedures on health care transactions in the United States.
The Proposed Rule was published for review on August 22, 2008. On
January 15, 2009, the U.S. Department of Health and Human
Services (HHS) published a final rule establishing ICD-10 as the new
national coding standard. The implementation date has been set for
October 1, 2013.
A one-year delay was approved with the new implementation date
of 10/1/2014.
All HIPAA covered entities must comply with this date.
History/Background (con’t)
The new 5010 electronic transaction format for electronic health
care transactions was also published with an implementation of
January 1, 2012.
Version 5010 provides the framework needed to support ICD-10
diagnosis and procedure codes and is the prerequisite to
implementing ICD-10.
The 11th revision of the classification has already started and will
continue until 2015/2016
Estimates are that the US would be ready for ICD-11 in
2024/2025 (maybe).
History/Background (con’t)
ICD-10 Clinical Modification (ICD-10-CM) will be used for
diagnosis coding in the United States, and will replace
Volumes 1 and 2 of ICD-9-CM.
Besides the sheer number of codes, there are some other
major differences between ICD-9-CM and ICD-10-CM.
ICD-10-CM codes are all alphanumeric, starting with an
alpha character, as opposed to V and E codes in ICD-9-CM.
ICD-10-CM codes include laterality to show right, left, and
bilateral conditions.
CDC & NCHS
The National Center for Health Statistics (NCHS), the
Federal agency responsible for use of the International
Statistical Classification of Diseases and Related Health
Problems, 10th revision (ICD-10) in the United States, has
developed a clinical modification of the classification for
morbidity purposes.
The ICD-10 is used to code and classify mortality data
from death certificates, having replaced ICD-9 for this
purpose as of January 1, 1999. ICD-10-CM is planned as
the replacement for ICD-9-CM, volumes 1 and 2.
ICD-9 Code Freeze
The last regular, annual updates to both ICD-9-CM and ICD-10 code
sets were made on October 1, 2011.
On October 1, 2012 and October 1, 2013 there will be only limited
code updates to both the ICD-9-CM and ICD-10 code sets to capture
new technologies and diseases as required by section 503(a) of Pub.
L. 108-173.
On October 1, 2014, there will be only limited code updates to ICD10 code sets to capture new technologies and diagnoses as required
by section 503(a) of Pub. L. 108-173. There will be no updates to
ICD-9-CM, as it will no longer be used for reporting.
On October 1, 2015, regular updates to ICD-10 will begin.
Coordination and Maintenance Committee
The ICD-9-CM Coordination and Maintenance Committee
is a federal committee with responsibility for maintaining
the classification system divided between two parties:
The National Center for Health Statistics (NCHS) and
The Centers for Medicare and Medicaid Services (CMS)
The ICD-9-CM Coordination and Maintenance Committee
will continue to meet twice a year during the partial
freeze.
The Coordination and Maintenance Committee
(con’t)
These meetings are public and the public will be asked
to comment on whether or not requests for new
diagnosis or procedure codes should be created based
on the criteria of the need to capture a new technology
or disease.
Any code requests that do not meet the criteria will be
evaluated for implementation within ICD-10 on and
after October 1, 2015 once the partial freeze has
ended.
The Coordination and Maintenance
Committee (con’t)
Final decisions are made by the Director of NCHS and the Administrator
of CMS. The final decisions affecting changes to the classification system
are made at the end of the year for the code changes that will become
effective on October 1st of the following year.
The final addenda for procedural and diagnostic changes are posted
on the CMS and CDC webpages.
The Hospital Inpatient Prospective Payment System final rule is also
required by law to be published in the Federal Register to include all the
final codes to be implemented on October 1. The new and revised codes
go into effect on October 1st, along with the DRG changes.
Documentation
Clinical documentation is a vital component that
represents the medical condition of the patient and,
therefore, has always played a vital role in medical coding.
billing, medical research, hospital/physician outcome
studies, etc.
Complete, accuracy, specific and timely
Proper documentation is required to support the
submission of both CPT® and ICD-9-CM codes today and
ICD-10 in the future.
Documentation (con’t)
Medical Record Documentation Principles
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include: the date; the reason for the encounter;
appropriate history and physical exam in relationship to the patient’s chief complaint; review of lab, x-ray data,
and other ancillary services, where appropriate; assessment; and a plan for care (including discharge plan, if
appropriate)
3. Past and present diagnoses should be accessible to the treating and/or consulting physician.
4. The reasons for—and results of—x-rays, lab tests, and other ancillary services should be documented or
included in the medical record.
5. Relevant health risk factors should be identified.
6. The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient
noncompliance, should be documented.
7. The written plan for care should include, when appropriate: treatments and medications, specifying frequency
and dosage; any referrals and consultations; patient/family education; and specific instructions for follow-up.
8. The documentation should support the intensity of the patient evaluation and/or treatment, including thorough
processes and the complexity of medical decision-making as it relates to the patient’s chief complaint for the
encounter.
9. All entries to the medical record should be dated and authenticated.
10. The CPT/ICD-9-CM codes reported on the CMS-1500 claim form should reflect the documentation in the medical
record.
Source: CMS and TrailBlazer Health Enterprises, LLC.
Principles of Clinical Documentation
Major healthcare and insurance organizations have revealed some principles that should
be observed when keeping proper documentation:
A medical record should be kept clear and legible in compliance with the suggestions of
a medical record audit and in line with the established clinical documentation
improvement program.
For the documentation of each patient encounter, the following information should be
included: reason for the encounter, date, laboratory and tests data, physical
examinations, medical history, assessments, and plan of care.
The medical professional should make sure that previous and current diagnoses are
always accessible to whomever will handle the case.
Ancillary services should be clear, including the results and/or any intervention initiated.
All of the following should also be documented regarding patient response: reactions to
treatments, changes on the procedures, noncompliance on the part of the patient, and
any changes on the diagnosis.
(Source: Dr Robert Gold – DCBA Consulting)
CMS ICD-10 Basics
Understanding Alpha/Tabular and Tables
• Orientation to your codebook
alpha/tabular, tables & the manual
• You all know how to code already, so
we are not teaching coding, but
teaching ICD-10
Your Codebook
Alphabetic
Tabular
Tables: Drug
Table of Drugs
• In ICD-9-CM, we can choose a
code to represent:
• Poisoning
• Accident
• Therapeutic use
• Suicide attempt
• Assault
• Undetermined
• In ICD-10-CM, our choices are:
• Poisoning, accidental
(unintentional)
• Poisoning, intentional self-harm
• Poisoning, assault
• Poisoning, undetermined
• Adverse effect
• Underdosing
Also use additional code(s) to specify:
Manifestations of poisoning
Underdosing or failure in dosage during medical and surgical care (Y63.6, Y63.8-Y63.9)
Underdosing of medication regimen (Z91.12-, Z91.13-)
ICD-10 Quick Facts
Diagnosis
80,000
Procedure
70,000
60,000
50,000
Diagnosis
40,000
Procedure
30,000
20,000
10,000
0
ICD-9-CM
ICD-10-CM
ICD-10 (WHO)
ICD-9-CM
ICD-10-PCS
ICD-10 (WHO)
43
Manual
We will be using
the AHIMA ICD-10
Training “Manual”
in addition to the
codebook.
Coding in ICD-10-CM
ICD-9-CM
ICD-10-CM
Three to five characters
Three to seven characters
First digit is numeric but can be alpha
(E or V)
First character always alpha
2–5 are numeric
All letters used except U
Always at least three digits
Character 2 always numeric: 3–7 can
be alpha or numeric
Decimal placed after the first three
characters (or with E codes, placed
after the first four characters)
Always at least three digits
Alpha characters are not case-sensitive Decimal placed after the first three
characters
Alpha characters are not case-sensitive
ICD-10 CHANGES
CHANGES IN ICD-10-CM INCLUDE:
➤ Injuries are grouped by anatomical site rather than by type of injury;
➤ Category restructuring and code reorganization have occurred in a number of
ICD-10-CM chapters, resulting in the classification of certain diseases and
disorders that are different from ICD-9-CM;
➤ Certain diseases have been reclassified to different chapters or sections in
order to reflect current medical knowledge;
➤ New code definitions (e.g., definition of acute myocardial infarction is now 4
weeks rather than 8 weeks); and
➤ The codes corresponding to ICD-9-CM V codes (Factors Influencing Health
Status and Contact with Health Services) and E codes (External Causes of Injury
and Poisoning) are incorporated into the main classification rather than
separated into supplementary classifications as they were in ICD-9-CM.
ICD-10-CM New Features
Combination codes for conditions and common
symptoms or manifestations
Combination codes for poisonings and external causes
Added laterality
Expanded codes (injury, diabetes, alcohol/substance
abuse, postoperative complications)
Injuries grouped by anatomical site rather than injury
category
ICD-9-CM vs ICD-10-CM Abdominal Pain
Codes
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•
•
•
•
•
•
•
•
•
•
In ICD-9-CM, codes for abdominal
pain fall under 789.0.
Coders must assign one of the
following fifth digits to specify
the location of the pain:
0, unspecified NOS
1, right upper quadrant
2, left upper quadrant
3, right lower quadrant
4, left lower quadrant
5, periumbilic
6, epigastric
7, generalized
• 9, other specified site
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
In ICD-10-CM, codes for abdominal and pelvic pain are
located
in the R10- series of codes. Instead of adding a fifth
digit to specify the site of the pain, coders will use the
site of
the pain to locate the correct code series:
• R10.0, acute abdomen
• R10.1, pain localized to upper abdomen
–– R10.10, upper abdominal pain, unspecified
–– R10.11, right upper quadrant pain
–– R10.12, left upper quadrant pain
–– R10.13, epigastric pain
• R10.2, pelvic and perineal pain
• R10.3, pain localized to other parts of lower abdomen
R10.30, lower abdominal pain, unspecified
–– R10.31, right lower quadrant pain
–– R10.32, left lower quadrant pain
–– R10.33, periumbilical pain
ICD-10-CM: Abdominal Pain
The codes under subsection R10.8 (other abdominal
pain) are divided by site:
• R10.81, abdominal tenderness
–– R10.811, right upper quadrant abdominal tenderness
–– R10.812, left upper quadrant abdominal tenderness
–– R10.813, right lower quadrant abdominal tenderness
–– R10.814, left lower quadrant abdominal tenderness
–– R10.815, periumbilic abdominal tenderness
–– R10.816, epigastric abdominal tenderness
–– R10.817, generalized abdominal tenderness
–– R10.819, abdominal tenderness, unspecified site
Many Ask . . . Why Are There So Many
Diagnosis Codes?
• 34,250 (50%) of all ICD-10-CM codes are related to
the musculoskeletal system
• 17,045 (25%) of all ICD-10-CM codes are related to
fractures
– 10,582 (62%) of fracture codes to distinguish
‘right’ vs. ‘left’
• ~25,000(36%) of all ICD-10-CM codes to distinguish
‘right’ vs. ‘left’
Coding Characters
Alpha
(Except U)
M
X X
A
S
0 X
2
Category
2 Numeric
3-7 Numeric or Alpha
.
Additional
Characters
X
6 X
5 X
x
A
X
Etiology, anatomic
site, severity
Added 7th character for
obstetrics, injuries, and
external causes of injury
3–7 Characters
The meaning of each of the first
characters.
•
•
•
•
•
•
•
•
•
•
•
•
•
A & B = Certain Infectious and Parasitic Diseases
C & D = Neoplasms
D = Diseases of the Blood and Blood-forming
Organs
E = Endocrine Nutritional and Metabolic
Diseases
F = Mental, Behavioral, Neurodevelopmental
Disorders
G = Diseases of the Nervous System
H = Diseases of the Eye and Adnexa
H = Diseases of the Ear and Mastoid Process
I = Diseases of the Circulatory System
J = Diseases of the Respiratory System
K= Diseases of the Digestive System
L = Diseases of the Skin and Subcutaneous Tissue
M = Diseases of the Musculoskeletal System
•
•
•
•
•
•
•
•
•
•
•
N = Diseases of the Genitourinary System
O = Pregnancy, Childbirth and the Puerperium
P = Certain Conditions Originating in the
Perinatal Period
Q = Congenital Malformations, Deformations
and Chromosomal Abnormalities
R = Symptoms, Signs and Abnormal Clinical
and Laboratory Findings, Not Elsewhere
Classified
S & T = Injury, Poisoning and Certain Other
Consequences of External Causes
V = Transport accidents - External Causes of
Morbidity
W = Other External Causes of Accidental Injury
X = Exposure to smoke, fire and flames
X - Y = Assault
Z = Factors Influencing Health Status and
Contact With Health Services
5th Character “x”
Character “x” is used as a 5th character placeholder in certain 6
character codes to allow for future expansion and to fill in other
empty characters (e.g., character 5 and/or 6) when a code that is
less than 6 characters in length requires a 7th character
Examples:
T46.1x5A – Adverse effect of calcium-channel blockers, initial
encounter; and
T15.02xD – Foreign body in cornea, left eye, subsequent encounter.
Coding and Seventh Character
Alpha
(Except U)
M
X X
A
S
0 X
2
Category
2 Numeric
3-7 Numeric or Alpha
.
Additional
Characters
X
6 X
5 X
x
A
X
Etiology, anatomic
site, severity
Added 7th character for
obstetrics, injuries, and
external causes of injury
3–7 Characters
Coding and Use of Seventh Character
•Used in these
chapters:
•Obstetrics
•Injury
•External cause
•Musculoskeletal
•Either alpha or
numeric
•Placeholder X
•Meanings vary
Injury and External Cause Identifies Injury
Initial –
Receiving
active
treatment
Subsequent –
Sequela –
Receiving
Complications
routine care
or conditions
during healing
arising as
or recovery
result of a
(after active
condition
treatment)
ICD-10-CM Coding Conventions and Guidelines
ICD-10-CM Coding Conventions and Guidelines
The Centers for Medicare and Medicaid Services (CMS) and the
National Center for Health Statistics (NCHS), two departments
within the U.S. Federal Government’s Department of Health and
Human Services (DHHS) provide the following guidelines for coding
and reporting using the International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM). These guidelines
should be used as a companion document to the official version of
the ICD-10-CM as published on the NCHS website.
The ICD-10-CM is a morbidity classification published by the United
States for classifying diagnoses and reason for visits in all health
care settings. The ICD-10-CM is based on the ICD-10, the statistical
classification of disease published by the World Health Organization
(WHO).
ICD-10-CM Coding Conventions and Guidelines
These guidelines have been approved by the four
organizations that make up the Cooperating Parties for
the ICD-10-CM: the American Hospital Association (AHA),
the American Health Information Management
Association (AHIMA), CMS, and NCHS.
These guidelines are a set of rules that have been
developed to accompany and complement the official
conventions and instructions provided within the ICD-10CM itself. The instructions and conventions of the
classification take precedence over guidelines.
ICD-10-CM Coding Conventions and Guidelines
These guidelines are based on the coding and
sequencing instructions in the Tabular List and
Alphabetic Index of ICD-10-CM, but provide additional
instruction. Adherence to these guidelines when
assigning ICD-10-CM diagnosis codes is required under
the Health Insurance Portability and Accountability Act
(HIPAA).
ICD-10-CM Coding Conventions and Guidelines
The diagnosis codes (Tabular List and Alphabetic Index)
have been adopted under HIPAA for all healthcare settings.
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. These guidelines have been
developed to assist both the healthcare provider and the
coder in identifying those diagnoses that are to be
reported. The importance of consistent, complete
documentation in the medical record cannot be
overemphasized. Without such documentation accurate
coding cannot be achieved. The entire record/encounter
should be reviewed to determine the specific reason for
the encounter and the conditions treated.
ICD-10-CM Coding Conventions and Guidelines
The term “encounter” is used for all settings, including
hospital admissions. In the context of these guidelines,
the term provider is used throughout the guidelines to
mean physician or any qualified health care practitioner
who is legally accountable for establishing the patient’s
diagnosis.
Only this set of guidelines, is approved by the
Cooperating Parties, it is official.
ICD-10-CM Coding Conventions and Guidelines
The guidelines are organized into sections. Section I includes
the structure and conventions of the classification and general
guidelines that apply to the entire classification, and chapterspecific guidelines that correspond to the chapters as they are
arranged in the classification. Section II includes guidelines for
selection of principal diagnosis for non-outpatient settings.
Section III includes guidelines for reporting additional
diagnoses in non-outpatient settings. Section IV is for
outpatient coding and reporting.
It is necessary to review all sections of the guidelines to fully
understand all of the rules and instructions needed to code
properly.
Coding Convention Review
Section I. Conventions, general coding guidelines and chapter specific
guidelines
The conventions, general guidelines and chapter-specific guidelines are
applicable to all health care settings unless otherwise indicated. The
conventions and instructions of the classification take precedence over
guidelines.
A. Conventions for the ICD-10-CM
The conventions for the ICD-10-CM are the general rules for use of the
classification independent of the guidelines. These conventions are
incorporated within the Alphabetic Index and Tabular List of the ICD-10CM as instructional notes.
Coding Convention Review
Section I.
1. The Alphabetic Index and Tabular List
The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of
terms and their corresponding code, and the Tabular List, a structured list
of codes divided into chapters based on body system or condition. The
Alphabetic Index consists of the following parts: the Index of Diseases and
Injury, the Index of External Causes of Injury, the Table of Neoplasms and
the Table of Drugs and Chemicals.
See Section I.C2. General guidelines
See Section I.C.19. Adverse effects, poisoning, underdosing and toxic
effects
Coding Convention Review (con’t)
2. Format and Structure:
The ICD-10-CM Tabular List contains categories, subcategories and codes.
Characters for categories, subcategories and codes may be either a letter or a
number. All categories are 3 characters. A three-character category that has no
further subdivision is equivalent to a code. Subcategories are either 4 or 5
characters.
Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after
a category is a subcategory. The final level of subdivision is a code. Codes that
have applicable 7th characters are still referred to as codes, not subcategories.
A code that has an applicable 7th character is considered invalid without the
7th character.
The ICD-10-CM uses an indented format for ease in reference.
3. Use of codes for reporting purposes: For reporting purposes only codes are
permissible, not categories or subcategories, and any applicable 7th character is
required.
Coding Convention Review (con’t)
4. Placeholder character
The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a
placeholder at certain codes to allow for future expansion.
An example of this is at the poisoning, adverse effect and underdosing
codes, categories T36-T50.
Where a placeholder exists, the X must be used in order for the code to be
considered a valid code.
5. 7th Characters
Certain ICD-10-CM categories have applicable 7th characters. The applicable
7th character is required for all codes within the category, or as the notes in
the Tabular List instruct. The 7th character must always be the 7th character
in the data field. If a code that requires a 7th character is not 6 characters, a
placeholder X must be used to fill in the empty characters.
Coding Convention Review (con’t)
6. Abbreviations
a. Alphabetic Index abbreviations
NEC “Not elsewhere classifiable”
This abbreviation in the Alphabetic Index represents “other specified”. When a specific code is
not available for a condition, the Alphabetic Index directs the coder to the “other specified”
code in the Tabular List.
NOS “Not otherwise specified”
This abbreviation is the equivalent of unspecified.
b. Tabular List abbreviations
NEC “Not elsewhere classifiable”
This abbreviation in the Tabular List represents “other specified”. When a specific code is not
available for a condition the Tabular List includes an NEC entry under a code to identify the code
as the “other specified” code.
NOS “Not otherwise specified” : This abbreviation is the equivalent of unspecified.
Coding Convention Review (con’t)
7. Punctuation
[ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording
or explanatory phrases. Brackets are used in the Alphabetic Index to identify
manifestation codes.
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose
supplementary words that may be present or absent in the statement of a
disease or procedure without affecting the code number to which it is assigned.
The terms within the parentheses are referred to as nonessential modifiers.
: Colons are used in the Tabular List after an incomplete term which needs one or
more of the modifiers following the colon to make it assignable to a given
category.
8. Use of “and”.
See Section I.A.14. Use of the term “And”
Coding Convention Review (con’t)
9. Other and Unspecified codes
a. “Other” codes
Codes titled “other” or “other specified” are for use when the information in
the medical record provides detail for which a specific code does not exist.
Alphabetic Index entries with NEC in the line designate “other” codes in the
Tabular List. These Alphabetic Index entries represent specific disease entities
for which no specific code exists so the term is included within an “other”
code.
b. “Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical
record is insufficient to assign a more specific code. For those categories for
which an unspecified code is not provided, the “other specified” code may
represent both other and unspecified.
Coding Convention Review (con’t)
10. Includes Notes
This note appears immediately under a three character code title to
further define, or give examples of, the content of the category.
11. Inclusion terms
List of terms is included under some codes. These terms are the conditions for
which that code is to be used. The terms may be synonyms of the code title, or, in
the case of “other specified” codes, the terms are a list of the various conditions
assigned to that code. The inclusion terms are not necessarily exhaustive.
Additional terms found only in the Alphabetic Index may also be assigned to a
code.
Coding Convention Review (con’t)
12. Excludes Notes
The ICD-10-CM has two types of excludes notes. Each type of note has a different
definition for use but they are all similar in that they indicate that codes excluded
from each other are independent of each other.
a. Excludes1
A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!”
An Excludes1 note indicates that the code excluded should never be used at
the same time as the code above the Excludes1 note. An Excludes1 is used
when two conditions cannot occur together, such as a congenital form versus
an acquired form of the same condition.
b. Excludes2
A type 2 Excludes note represents “Not included here”. An excludes2 note
indicates that the condition excluded is not part of the condition represented
by the code, but a patient may have both conditions at the same time. When
an Excludes2 note appears under a code, it is acceptable to use both the
code and the excluded code together, when appropriate.
Coding Convention Review (con’t)
13. Etiology/manifestation convention (“code first”, “use additional code” and “in
diseases classified elsewhere” notes)
Certain conditions have both an underlying etiology and multiple body system
manifestations due to the underlying etiology. For such conditions, the ICD-10CM has a coding convention that requires the underlying condition be
sequenced first followed by the manifestation. Wherever such a combination
exists, there is a “use additional code” note at the etiology code, and a “code
first” note at the manifestation code. These instructional notes indicate the
proper sequencing order of the codes, etiology followed by manifestation.
In most cases the manifestation codes will have in the code title, “in diseases
classified elsewhere.” Codes with this title are a component of the etiology/
manifestation convention. The code title indicates that it is a manifestation code.
“In diseases classified elsewhere” codes are never permitted to be used as firstlisted or principal diagnosis codes. They must be used in conjunction with an
underlying condition code and they must be listed following the underlying
condition. See category F02, Dementia in other diseases classified elsewhere, for
an example of this convention.
Coding Convention Review (con’t)
There are manifestation codes that do not have “in diseases classified elsewhere”
in the title. For such codes, there is a “use additional code” note at the etiology
code and a “code first” note at the manifestation code and the rules for
sequencing apply.
In addition to the notes in the Tabular List, these conditions also have a specific
Alphabetic Index entry structure. In the Alphabetic Index both conditions are
listed together with the etiology code first followed by the manifestation codes in
brackets. The code in brackets is always to be sequenced second.
Coding Convention Review (con’t)
An example of the etiology/manifestation convention is dementia in
Parkinson’s disease. In the Alphabetic Index, code G20 is listed first, followed by
code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiology,
Parkinson’s disease, and must be sequenced first, whereas codes F02.80 and
F02.81 represent the manifestation of dementia in diseases classified elsewhere,
with or without behavioral disturbance.
“Code first” and “Use additional code” notes are also used as sequencing rules in
the classification for certain codes that are not part of an etiology/ manifestation
combination.
See Section I.B.7. Multiple coding for a single condition.
Coding Convention Review (con’t)
14. “And”
The word “and” should be interpreted to mean either “and” or “or” when it
appears in a title.
For example, cases of “tuberculosis of bones”, “tuberculosis of joints” and
“tuberculosis of bones and joints” are classified to subcategory A18.0,
Tuberculosis of bones and joints.
15. “With”
The word “with” should be interpreted to mean “associated with” or “due to” when
it appears in a code title, the Alphabetic Index, or an instructional note in the
Tabular List. The word “with” in the Alphabetic Index is sequenced immediately
following the main term, not in alphabetical order.
Coding Convention Review (con’t)
16. “See” and “See Also”
The “see” instruction following a main term in the Alphabetic Index indicates that
another term should be referenced. It is necessary to go to the main term
referenced with the “see” note to locate the correct code.
A “see also” instruction following a main term in the Alphabetic Index instructs
that there is another main term that may also be referenced that may provide
additional Alphabetic Index entries that may be useful. It is not necessary to
follow the “see also” note when the original main term provides the necessary
code.
17. “Code also note”
A “code also” note instructs that two codes may be required to fully
describe a condition, but this note does not provide sequencing direction.
Coding Convention Review (con’t)
18. Default codes
A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to
as a default code. The default code represents that condition that is most
commonly associated with the main term, or is the unspecified code for the
condition. If a condition is documented in a medical record (for example,
appendicitis) without any additional information, such as acute or chronic, the
default code should be assigned.
Questions?
Are there any questions about the “conventions”?
Section 1 - Manual
Please open your manuals and go to page 16 and
complete the 10 questions there.
Review Q&A
All done?
Let’s now go through the answers to the 10
questions…..
Coding Guideline Review
Section II.
Let’s walk through the coding guidelines
General Coding Guidelines
B. General Coding Guidelines
1. Locating a code in the ICD-10-CM
To select a code in the classification that corresponds to a diagnosis or reason for
visit documented in a medical record, first locate the term in the Alphabetic
Index, and then verify the code in the Tabular List. Read and be guided by
instructional notations that appear in both the Alphabetic Index and the Tabular
List.
It is essential to use both the Alphabetic Index and Tabular List when locating and
assigning a code. The Alphabetic Index does not always provide the full code.
Selection of the full code, including laterality and any applicable 7th character can
only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry
indicates that additional characters are required. Even if a dash is not included at
the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that
no 7th character is required.
General Coding Guidelines (con’t)
2. Level of Detail in Coding
Diagnosis codes are to be used and reported at their highest number of
characters available.
ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7
characters. Codes with three characters are included in ICD-10-CM as the
heading of a category of codes that may be further subdivided by the use
of fourth and/or fifth characters and/or sixth characters, which provide
greater detail.
A three-character code is to be used only if it is not further subdivided. A
code is invalid if it has not been coded to the full number of characters
required for that code, including the 7th character, if applicable.
General Coding Guidelines (con’t)
3. Code or codes from A00.0 through T88.9, Z00-Z99.8
The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8
must be used to identify diagnoses, symptoms, conditions, problems,
complaints or other reason(s) for the encounter/visit.
4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis
has not been established (confirmed) by the provider. Chapter 18 of
ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory
Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many,
but not all codes for symptoms.
General Coding Guidelines (con’t)
5. Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a
disease process should not be assigned as additional codes,
unless otherwise instructed by the classification.
6. Conditions that are not an integral part of a disease
process
Additional signs and symptoms that may not be associated
routinely with a disease process should be coded when
present.
General Coding Guidelines (con’t)
7. Multiple coding for a single condition
In addition to the etiology/manifestation convention that requires two codes to
fully describe a single condition that affects multiple body systems, there are
other single conditions that also require more than one code. “Use additional
code” notes are found in the Tabular List at codes that are not part of an
etiology/manifestation pair where a secondary code is useful to fully describe a
condition. The sequencing rule is the same as the etiology/manifestation pair,
“use additional code” indicates that a secondary code should be added.
General Coding Guidelines (con’t)
7. Multiple coding for a single condition
For example, for bacterial infections that are not included in chapter 1, a
secondary code from category B95, Streptococcus, Staphylococcus, and
Enterococcus, as the cause of diseases classified elsewhere, or B96, Other
bacterial agents as the cause of diseases classified elsewhere, may be required to
identify the bacterial organism causing the infection.
A “use additional code” note will normally be found at the infectious disease
code, indicating a need for the organism code to be added as a secondary code.
General Coding Guidelines (con’t)
“Code first” notes are also under certain codes that are not specifically
manifestation codes but may be due to an underlying cause. When there
is a “code first” note and an underlying condition is present, the
underlying condition should be sequenced first.
“Code, if applicable, any causal condition first”, notes indicate that this
code may be assigned as a principal diagnosis when the causal condition is
unknown or not applicable. If a causal condition is known, then the code
for that condition should be sequenced as the principal or first-listed
diagnosis.
Multiple codes may be needed for sequela, complication codes and
obstetric codes to more fully describe a condition. See the specific
guidelines for these conditions for further instruction.
General Coding Guidelines (con’t)
8. Acute and Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist
in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute)
code first.
9. Combination Code
A combination code is a single code used to classify:
Two diagnoses, or
A diagnosis with an associated secondary process (manifestation)
A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the Alphabetic Index and by
reading the inclusion and exclusion notes in the Tabular List.
Assign only the combination code when that code fully identifies the diagnostic conditions involved or
when the Alphabetic Index so directs. Multiple coding should not be used when the classification
provides a combination code that clearly identifies all of the elements documented in the diagnosis.
When the combination code lacks necessary specificity in describing the manifestation or
complication, an additional code should be used as a secondary code.
General Coding Guidelines (con’t)
10. Sequela (Late Effects)
A sequela is the residual effect (condition produced) after the acute phase of an
illness or injury has terminated. There is no time limit on when a sequela code
can be used. The residual may be apparent early, such as in cerebral infarction, or
it may occur months or years later, such as that due to a previous injury. Coding
of sequela generally requires two codes sequenced in the following order: The
condition or nature of the sequela is sequenced first. The sequela code is
sequenced second.
An exception to the above guidelines are those instances where the code for the
sequela is followed by a manifestation code identified in the Tabular List and title,
or the sequela code has been expanded (at the fourth, fifth or sixth character
levels) to include the manifestation(s). The code for the acute phase of an illness
or injury that led to the sequela is never used with a code for the late effect.
See Section I.C.9. Sequelae of cerebrovascular disease
See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium
See Section I.C.19. Application of 7th characters for Chapter 19
General Coding Guidelines (con’t)
11. Impending or Threatened Condition
Code any condition described at the time of discharge as “impending” or
“threatened” as follows:
If it did occur, code as confirmed diagnosis.
If it did not occur, reference the Alphabetic Index to determine if the
condition has a subentry term for “impending” or “threatened” and also
reference main term entries for “Impending” and for “Threatened.”
If the subterms are listed, assign the given code.
If the subterms are not listed, code the existing underlying condition(s) and
not the condition described as impending or threatened.
12. Reporting Same Diagnosis Code More than Once
Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.
This applies to bilateral conditions when there are no distinct codes identifying
laterality or two different conditions classified to the same ICD-10-CM diagnosis code.
General Coding Guidelines (con’t)
13. Laterality
Some ICD-10-CM codes indicate laterality, specifying whether the
condition occurs on the left, right or is bilateral. If no bilateral code
is provided and the condition is bilateral, assign separate codes for
both the left and right side. If the side is not identified in the
medical record, assign the code for the unspecified side.
General Coding Guidelines (con’t)
14. Documentation for BMI, Non-pressure ulcers and Pressure Ulcer Stages
For the Body Mass Index (BMI), depth of non-pressure chronic ulcers and pressure ulcer
stage codes, code assignment may be based on medical record documentation from
clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare
practitioner legally accountable for establishing the patient’s diagnosis), since this
information is typically documented by other clinicians involved in the care of the patient
(e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer
stages).
However, the associated diagnosis (such as overweight, obesity, or pressure ulcer) must be
documented by the patient’s provider. If there is conflicting medical record documentation,
either from the same clinician or different clinicians, the patient’s attending provider
should be queried for clarification.
The BMI codes should only be reported as secondary diagnoses. As with all other
secondary diagnosis codes, the BMI codes should only be assigned when they meet the
definition of a reportable additional diagnosis (see Section III, Reporting Additional
Diagnoses).
General Coding Guidelines (con’t)
15. Syndromes
Follow the Alphabetic Index guidance when coding syndromes. In the absence of
Alphabetic Index guidance, assign codes for the documented manifestations of
the syndrome. Additional codes for manifestations that are not an integral part
of the disease process may also be assigned when the condition does not have
a unique code.
16. Documentation of Complications of Care
Code assignment is based on the provider’s documentation of the relationship
between the condition and the care or procedure. The guideline extends to any
complications of care, regardless of the chapter the code is located in. It is
important to note that not all conditions that occur during or following medical
care or surgery are classified as complications. There must be a cause-and-effect
relationship between the care provided and the condition, and an indication in
the documentation that it is a complication. Query the provider for clarification, if
the complication is not clearly documented.
General Coding Guidelines (con’t)
17. Borderline Diagnosis
If the provider documents a "borderline" diagnosis at the time of
discharge, the diagnosis is coded as confirmed, unless the
classification provides a specific entry (e.g., borderline diabetes). If
a borderline condition has a specific index entry in ICD-10-CM, it
should be coded as such.
Since borderline conditions are not uncertain diagnoses, no
distinction is made between the care setting (inpatient versus
outpatient). Whenever the documentation is unclear regarding a
borderline condition, coders are encouraged to query for
clarification.
General Coding Guidelines (con’t)
18. Use of Sign/Symptom/Unspecified Codes
Sign/symptom and “unspecified” codes have acceptable,
even necessary, uses. While specific diagnosis codes should
be reported when they are supported by the available
medical record documentation and clinical knowledge of the
patient’s health condition, there are instances when
signs/symptoms or unspecified codes are the best choices for
accurately reflecting the healthcare encounter. Each
healthcare encounter should be coded to the level of
certainty known for that encounter.
General Coding Guidelines (con’t)
#18 con’t
If a definitive diagnosis has not been established by the end of the
encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in
lieu of a definitive diagnosis. When sufficient clinical information isn’t
known or available about a particular health condition to assign a more
specific code, it is acceptable to report the appropriate “unspecified” code
(e.g., a diagnosis of pneumonia has been determined, but not the specific
type). Unspecified codes should be reported when they are the codes that
most accurately reflects what is known about the patient’s condition at the
time of that particular encounter. It would be inappropriate to select a
specific code that is not supported by the medical record documentation or
conduct medically unnecessary diagnostic testing in order to determine a
more specific code.
Questions?
Are there any questions about the General Coding
Guidelines?
Section 2 - Manual
Please Go to page 25 in your manual and answer the 10
questions.
Review Q&A
Let’s now go through the answers to the 10
questions…..
Questions?
Section IV. Diagnostic Coding and
Reporting Guidelines for Outpatient Services
These coding guidelines for outpatient diagnoses have been approved for
use by hospitals/ providers in coding and reporting hospital-based
outpatient services and provider-based office visits.
Information about the use of certain abbreviations, punctuation, symbols,
and other conventions used in the ICD-10-CM Tabular List (code numbers
and titles), can be found in Section IA of these guidelines, under
“Conventions Used in the Tabular List.” Section I.B. contains general
guidelines that apply to the entire classification. Section I.C. contains
chapter-specific guidelines that correspond to the chapters as they are
arranged in the classification. Information about the correct sequence to
use in finding a code is also described in Section I.
The terms encounter and visit are often used interchangeably in describing
outpatient service contacts and, therefore, appear together in these guidelines
without distinguishing one from the other.
Though the conventions and general guidelines apply to all settings, coding
guidelines for outpatient and provider reporting of diagnoses will vary in a
number of instances from those for inpatient diagnoses, recognizing that:
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal
diagnosis applies only to inpatients in acute, short-term, long-term care and
psychiatric hospitals.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.)
were developed for inpatient reporting and do not apply to outpatients.
A. Selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of
principal diagnosis.
In determining the first-listed diagnosis the coding conventions of ICD-10CM, as well as the general and disease specific guidelines take precedence
over the outpatient guidelines.
Diagnoses often are not established at the time of the initial
encounter/visit. It may take two or more visits before the diagnosis is
confirmed.
The most critical rule involves beginning the search for the correct code
assignment through the Alphabetic Index. Never begin searching initially
in the Tabular List as this will lead to coding errors.
Accurate reporting of ICD-10-CM diagnosis codes
For accurate reporting of ICD-10-CM diagnosis codes, the
documentation should describe the patient’s condition,
using terminology which includes specific diagnoses as
well as symptoms, problems, or reasons for the
encounter. There are ICD-10-CM codes to describe all of
these.
Level of Detail in Coding
1. ICD-10-CM codes with 3, 4, 5, 6 or 7 characters
ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes
with three characters are included in ICD-10-CM as the heading of a
category of codes that may be further subdivided by the use of fourth,
fifth, sixth or seventh characters to provide greater specificity.
2. Use of full number of characters required for a code
A three-character code is to be used only if it is not further subdivided. A
code is invalid if it has not been coded to the full number of characters
required for that code, including the 7th character, if applicable.
ICD-10-CM code for the diagnosis, condition, problem, or
other reason for encounter/visit
List first the ICD-10-CM code for the diagnosis, condition,
problem, or other reason for encounter/visit shown in the
medical record to be chiefly responsible for the services
provided. List additional codes that describe any coexisting
conditions. In some cases the first-listed diagnosis may be a
symptom when a diagnosis has not been established
(confirmed) by the physician.
Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and
reported as many times as the patient receives treatment and care
for the condition(s)
J. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the
encounter/visit, and require or affect patient care treatment or
management. Do not code conditions that were previously treated
and no longer exist. However, history codes (categories Z80-Z87)
may be used as secondary codes if the historical condition or family
history has an impact on current care or influences treatment.
Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence
first the diagnosis, condition, problem, or other reason for encounter/visit shown in
the medical record to be chiefly responsible for the outpatient services provided
during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may
be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs,
symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified
special examinations. If routine testing is performed during the same encounter as a
test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z
code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a
physician, and the final report is available at the time of coding, code any confirmed
or definitive diagnosis(es) documented in the interpretation. Do not code related
signs and symptoms as additional diagnoses.
Diagnostic Coding and Reporting
Guidelines for Outpatient Services
Any Questions?
Check Your Understanding
… Coding Conventions
Review
1–10
1. The ICD-10-CM code for electrocution is T75.4 and
requires the use of a seventh character to identify the
encounter. Which of the following is the correct code
for an initial encounter to treat the electrocution?
a. T75.4A
b. T75.4XA
c. T75.4XXA
d. T75.4
#1. Answer: c. T75.4XXA
Rationale: ICD-10-CM Coding Guideline I.A.5 states that
the seventh character must always be the seventh character in
the data field. If a code that requires a seventh character is not
six characters long, a placeholder X must be used to fill in the
empty characters. Additionally, Guideline A.4 indicates that ICD10-CM utilizes a placeholder character X and where
a placeholder exists, the X must be used in order for the
code to be considered a valid code. All alpha characters in ICD10-CM are not case sensitive, which means that if the
placeholder X is entered in either the upper- or lowercase
format, the meaning would not change.
#2 Nonessential modifiers are enclosed in:
______________
#2.
Nonessential modifiers are enclosed in:
Answer: Parentheses
Rationale: Parentheses are used in ICD-10-CM in both the
Alphabetic Index and Tabular to enclose supplementary words that may be
present or absent in the statement of a disease without affecting the code
number to which it is assigned. The terms within the parentheses are
referred to as nonessential modifiers. Boxes are not a defined convention of
ICD-10-CM. Square brackets in ICD-10-CM in the Tabular List are used to
enclose synonyms, alternative wordings, abbreviations, and explanatory
phrases. Brackets are used in the Index to identify manifestation codes.
Colons are used in the Tabular List after an incomplete term that needs one
or more of the modifiers following the colon to make it assignable to a given
category.
3.
True or false? When an Excludes2 note appears
under a code, it is acceptable to use both the code and
the excluded code together.
#3. Answer: True
Rationale: An Excludes2 note indicates that the
condition excluded is not part of the condition
represented, but a patient may have both conditions at
the same time. When an Excludes2 note appears under a
code, it is acceptable to use both the code and the
excluded code together if
the documentation indicates that the patient has both
conditions (ICD-10-CM Coding Guideline I.A.12.b).
4.
The first character of an ICD-10-CM code is:
___________________
#4 Answer: Always a letter
Rationale: This is an ICD-10-CM convention with all
codes beginning with a letter of the alphabet except the
letter U.
5.
A(n) ________ note means “not coded here.”
#5. Answer: Excludes1
Rationale: ICD-10-CM has two types of “excludes”
notes. An Excludes1 note indicates that the code excluded
should never be used at the same time as the code above the
Excludes1 note (ICD-10-CM Coding Guideline I.A.12.a). An
Excludes2 note represents “not included here” and it is
acceptable to use both the code and the excluded code
together when both are documented (ICD-10-CM Coding
Guideline I.A.12.b).
6.
Codes titled “other” or “other specified” are to
be used when: ________________
#6. Answer: When the information in the medical record
provides detail for which a specific code does not exist.
Rationale: Codes titled “other” or “other specified” are
for use when the information in the medical record provides
detail for which a specific code does not exist (ICD-10-CM Coding
Guideline I.A.9.a). This can be contrasted with “unspecified”
codes when the information in the medical record is insufficient
to assign a more specific code (ICD-10-CM Coding Guideline
I.A.9.b).
#7. True or false? Similar to ICD-9-CM, in ICD-10-CM all
categories are three characters.
#7. Answer: True
Rationale: All categories in ICD-10-CM are three
characters. A three-character category that has no further
subdivision is equivalent to a code. Subcategories are
either four or five characters. Codes may be three, four,
five, six, or seven characters.
8.
True or false? When the term “and” is used in
a narrative statement it is interpreted to mean
only “and.”
9.
True or false? In ICD-10-CM all inclusion notes
contain all conditions for which a particular code number
is to be used and are considered to be “exhaustive.”
#9. Answer: False
Rationale: Inclusion notes contain terms that are the
condition for which that code number is to be used. The
terms may be synonyms of the code title, or in the case
of “other specified” codes, the terms are a list of various
conditions assigned to that code. The inclusion terms
are not necessarily exhaustive (ICD-10-CM Coding
Guideline I.A.11).
10. True or false? In ICD-10-CM a “code also” note
provides sequencing guidance to the coding professional.
.
#10. Answer: False
Rationale: ICD-10-CM Coding Guideline I.A.17
states a “code also” note instructs that two codes
may be required to fully describe a condition, but
this note does not provide sequencing direction. In
contrast, the “code first” and “use additional code”
notes provide sequencing order of the codes
Any Questions?
Chapter Specific Coding Guidelines
Chapter-Specific Coding Guidelines
In addition to general coding guidelines, there are
guidelines for specific diagnoses and/or conditions in the
classification. Unless otherwise indicated, these guidelines
apply to all health care settings. Please refer to Section II
for guidelines on the selection of principal diagnosis.
As we move through the chapters we’ll cover the chapterspecific guidelines.
ICD-10-CM
Chapter 1 Certain Infectious and Parasitic Diseases
• Includes diseases generally
recognized as communicable
or transmissible
• Use additional code to identify
resistance to antimicrobial
drugs (Z16)
• New section called infections
with a predominantly sexual
mode of transmission
(A50–A64)
• Code only confirmed cases
• Code only confirmed cases of HIV
infection/illness. This is an exception
to the hospital inpatient guideline
Section II, H.
• In this context, “confirmation” does
not require documentation of
positive serology or culture for HIV;
the provider’s diagnostic statement
that the patient is HIV positive, or
has an HIV-related illness is
sufficient.
•
•
•
•
Patients with inconclusive HIV serology
Patients with inconclusive HIV serology, but
no definitive diagnosis or manifestations of
the illness, may be assigned code R75,
Inconclusive laboratory evidence of human
immunodeficiency virus [HIV].
(f) Previously diagnosed HIV-related illness
Patients with any known prior diagnosis of
an HIV-related illness should be coded to
B20. Once a patient has developed an HIVrelated illness, the patient should always
be assigned code B20 on every subsequent
admission/encounter.
•
•
•
•
•
Selection and sequencing of HIV codes
(a) Patient admitted for HIV-related condition
If a patient is admitted for an HIV-related
condition, the principal diagnosis should be
B20, Human immunodeficiency virus [HIV]
disease followed by additional diagnosis codes
for all reported HIV-related conditions.
(b) Patient with HIV disease admitted for
unrelated condition
If a patient with HIV disease is admitted for an
unrelated condition (such as a traumatic
injury), the code for the unrelated condition
(e.g., the nature of injury code) should be the
principal diagnosis. Other diagnoses would be
B20 followed by additional diagnosis codes for
all reported HIV-related conditions.
•
•
•
•
Whether the patient is newly diagnosed
Whether the patient is newly diagnosed or
has had previous admissions/encounters for
HIV conditions is irrelevant to the sequencing
decision.
(d) Asymptomatic human immunodeficiency
virus
Z21, Asymptomatic human
immunodeficiency virus [HIV] infection
status, is to be applied when the patient
without any documentation of symptoms is
listed as being “HIV positive,” “known HIV,”
“HIV test positive,” or similar terminology.
Do not use this code if the term “AIDS” is
used or if the patient is treated for any HIVrelated illness or is described as having any
condition(s) resulting from his/her HIV
positive status; use B20 in these cases.
• When coding sepsis or AIDS,
it is important to review the Coding
Guidelines and the notes at the
category level of ICD-10-CM
• Categories B90-B94 are to be used to
indicate conditions in categories A00B89 as the cause of sequelae, which
are themselves classified elsewhere.
• Check your State specific guidelines
regarding the reporting of HIV status
via coding (ie Z21)
What are some
different types of
opportunistic infections seen
in AIDS?
The CDC developed a list of more than 20 OIs that are considered AIDSdefining conditions—if you have HIV and one or more of these OIs, you will
be diagnosed with AIDS, no matter what your CD4 count happens to be:
Candidiasis of bronchi, trachea, esophagus, or lungs
Invasive cervical cancer
Coccidioidomycosis
Cryptococcosis
Cryptosporidiosis, chronic intestinal (greater than 1 month's duration)
Cytomegalovirus disease (particularly CMV retinitis)
Encephalopathy, HIV-related
Herpes simplex: chronic ulcer(s) (greater than 1 month's duration); or bronchitis, pneumonitis, or esophagitis
Histoplasmosis
Isosporiasis, chronic intestinal (greater than 1 month's duration)
Kaposi's sarcomav
Lymphoma, multiple forms
Mycobacterium avium complex
Tuberculosis
Pneumocystis carinii pneumonia
Pneumonia, recurrent
• Code first condition resulting
from (sequela) the infectious
or parasitic disease
• Bacterial and viral infectious
agents (B95-B97) are provided
for use as supplementary or
additional codes
to identify the infectious
agent(s)
in diseases classified elsewhere
– Index
• Infection
• Organism (Streptococcus)
• Other Bacterial Diseases: Sepsis
Urosepsis
• Urosepsis Guideline: Urosepsis
cannot be coded in ICD-10-CM.
• Guideline states: “The term
urosepsis a nonspecific term. It is
not to be considered synonymous
with sepsis. It has no default code
in the Alphabetic Index. Should a
provider use this term, he/she
must be queried for clarification.”
• ICD-9-CM Alpha Index
Urosepsis = 599.0 meaning
sepsis = 995.91 meaning
urinary tract infection =
599.0
• ICD-10-CM Alpha Index
Urosepsis – code to the
condition
Coding Note: ICD-10-CM has
created a range of codes to identify
infections with a predominantly sexual
mode of transmission
(A50-A64). It is important to note that
human immunodeficiency virus (HIV)
disease is excluded from this range of
codes.
Differentiate
between the types
of hepatitis.
Gray’s Anatomy 1918
Coding Hepatitis is based
upon:
• Acute, chronic, &
unspecified
• With or without hepatic
coma
•
•
•
•
•
Ready… Set?... Let’s Code!
Cases to Code –
Go to page 93 in Your Manual
1.1
1.2
1.6
1.8
1.11
Check Your Understanding
1.1–1.11
Case 1.1 ANSWER
N39.0
Infection, infected, infective
(opportunistic), urinary (tract)
B96.20
Infection, infected, infective
(opportunistic), bacterial NOS, as cause of
disease classified elsewhere, Escherichia
coli [E. coli] (see also Escherichia coli)
Rationale: The symptoms associated with the UTI
should not be coded. The “use additional code” note
under N39.0 instructs the coder to an additional code
(B95-B97) to identify the infectious agent.
Case 1.2 ANSWER
A04.7
Colitis (acute) (catarrhal) (chronic)
(noninfective) (hemorrhagic), Clostridium
difficile
Z16.39
Resistance, resistant (to), organism(s), to
drug, antimicrobial (single), specified NEC
Rationale: ICD-10-CM provides a code to identify
resistance to antimicrobial drugs (Z16._). The “use
additional code” note is found at the beginning of
Chapter 1.
Case 1.6 ANSWER
B20
B59
AIDS (related complex)
Pneumonia, Pneumocystis (carinii)
(jiroveci)
Rationale: Per the Official Coding Guidelines, if
a patient is admitted for an HIV-related condition,
the principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease, followed by
additional diagnosis codes for all reported HIV-related
conditions.
Case 1.8 ANSWER
A41.50
Sepsis (generalized), gram-negative
(organism)
R65.20
Sepsis, with organ dysfunction (acute)
(multiple)
J96.00Failure, respiration, respiratory, acute
Rationale: Under the R65.2 subcategory, there is a “code first underlying
infection“ note; therefore, A41.50 should be listed as the principal diagnosis
followed by R65.20 as a secondary diagnosis. Coding Guideline C.1.d.1.b
provides sequencing guidance for severe sepsis: “the coding of severe sepsis
requires a minimum of two codes: first a code for the underlying systemic
infection, followed by a code from subcategory R65.2, Severe sepsis. Code
J96.00 is used to identify the acute respiratory failure.
Case 1.11 ANSWER
B18.1 Hepatitis, viral, virus, chronic, type B
Rationale: In ICD-10-CM chronic (viral) hepatitis B without
delta-agent is coded B18.1. Delta agent is a type
of virus called hepatitis D that causes symptoms only in
people who have hepatitis B infection. Because of this
there are no other hepatitis D codes (in the Index or
Tabular List). It is a combination code available for use
with hepatitis B codes. The Delta-agent can be shown
with or without hepatic coma by individual codes.
Any Questions?
ICD-10-CM
Chapter 2 Neoplasms
I.C.2 General Neoplasm Guidelines
• The Neoplasm Table in the
Alphabetic Index should be
referenced first. However,
if the histological term is
documented, that term should
be referenced first, rather than
going immediately to the
Neoplasm Table, in order to
determine which column in the
Neoplasm Table is appropriate.
• A primary malignant neoplasm
overlapping two or more contiguous
(next to each other) sites should be
classified to the subcategory/code .8
(overlapping lesion), unless the
combination is specifically indexed
elsewhere.
• For multiple neoplasms of the same
site that are not contiguous, such as
tumors in different quadrants of the
same breast, codes for each site should
be assigned.
•
•
•
Treatment directed at the malignancy
If the treatment is directed at the
malignancy, designate the malignancy •
as the principal diagnosis.
•
The only exception to this guideline is if
a patient admission/encounter is solely
for the administration of chemotherapy,
immunotherapy or radiation therapy,
assign the appropriate Z51.-- code as
the first-listed or principal diagnosis,
and the diagnosis or problem for which
the service is being performed as a
secondary diagnosis.
Treatment of secondary site
When a patient is admitted
because of a primary neoplasm
with metastasis and treatment is
directed toward the secondary site
only, the secondary neoplasm is
designated as the principal
diagnosis even though the primary
malignancy is still present.
Coding and sequencing of complications
Coding and sequencing of complications associated with the malignancies
or with the therapy thereof are subject to the following guidelines:
1) Anemia associated with malignancy
When admission/encounter is for management of an anemia associated
with the malignancy, and the treatment is only for anemia, the
appropriate code for the malignancy is sequenced as the principal or firstlisted diagnosis followed by the appropriate code for the anemia (such as
code D63.0, Anemia in neoplastic disease).
This guideline is the same in ICD-10: Anemia associated with
chemotherapy, immunotherapy and radiation
Cases to Code –
Go to your Manual - Start on page 97
•
•
•
•
1.12
1.13
1.16
1.18
Check Your Understanding
1.12–1.18
Case 1.12 ANSWER
C34.31
Carcinoma, see also Neoplasm, by site,
malignant. Refer to Neoplasm Table, by site
(lung), malignant, primary site, lower lobe
C77.1
Refer to Neoplasm Table, by site, lymph
gland, malignant, intrathoracic,
secondary site
C79.31
Refer to Neoplasm Table, by site, brain,
malignant, secondary site
C79.51
Refer to Neoplasm Table, by site, bone,
malignant, rib, secondary site
Case 1.12 (continued):
Rationale: The primary site is the small cell
carcinoma of the right lower lobe of the lung.
The intrathoracic lymph nodes, brain, and rib are
secondary sites. Index the term Carcinoma because the
histological term is documented. This refers you to the
Neoplasm Table, by site, malignant. It is correct to list
each metastatic site.
Case 1.13 ANSWER
D3A.021
Carcinoid, see Tumor, carcinoid,
benign, cecum
Rationale: When indexing carcinoid, the note directs to Tumor.
It is not necessary to use the Neoplasm Table to code this tumor.
Under carcinoid, there is a differentiation between benign or
malignant, with specific sites listed. Benign carcinoid tumors fall
into category D3A, Benign neuroendocrine tumors. The
following notes are present: Code also any associated multiple
endocrine neoplasia [MEN] syndromes; and Use additional code
to identify any associate endocrine syndrome, such as carcinoid
syndrome (E34.0).
Case 1.16 ANSWER
E86.0
Dehydration
G89.3
Pain(s) (see also Painful), chronic,
neoplasm related
C50.111
Carcinoma, see also Neoplasm, by site,
malignant. Refer to Neoplasm Table,
by site (breast), malignant, primary site,
central portion
C79.31
Refer to Neoplasm Table, by site, brain,
malignant, secondary site
C78.7
Refer to Neoplasm Table, by site, liver,
malignant, secondary site
Case 1.16 (continued):
Rationale: ICD-10-CM chapter-specific guideline
for neoplasms states that when the encounter is for management of
dehydration due to the malignancy
or the therapy, or a combination of both, and only the dehydration is
being treated, the dehydration is sequenced first, followed by the
code(s) for the malignancy. An additional ICD-10-CM Coding Guideline
states that when the reason for the encounter is for neoplasm-related
pain control or pain management, the pain code may be assigned as
the first-listed diagnosis. Because the focus
of this encounter was both the dehydration and the intractable pain,
either may be sequenced first.
Case 1.18 ANSWER
Z51.11
Chemotherapy (session) (for), cancer
C17.8Carcinoma, see also Neoplasm, by
site, malignant. Refer to Neoplasm
Table, by site, intestine, small,
overlapping lesion, malignant,
primary site
Z90.49
Absence (of) (organ or part)
(complete or partial), intestine
(acquired) (small)
Case 1.18 (continued):
Rationale: The reason for the encounter
(chemotherapy) is the first listed diagnosis. The
neoplasm is coded as current (even though it was
excised) because the patient is still receiving
chemotherapy. The overlapping sites code is used
because the cancer is part in the duodenum and part in
the jejunum. The acquired absence of the small
intestine may be coded because the category includes
the organ or part, complete or partial.
Questions?
Any questions on Chapter 2?
ICD-10-CM
Chapter 3 Disease of the Blood and Blood-Forming
Organs and Certain Disorders Involving The Immune
Mechanism – Reserved for Future Expansion
See your Student Manual page 29
Read over the first paragraph……
Cases to Code
Go to your Manual to page 99
•
•
•
•
1.19
1.22
1.23
1.24
Check Your Understanding
1.19–1.24
What codes did you get?
• Case 1.19
Case 1.19 ANSWER
C50.912
Carcinoma, see also Neoplasm, by site,
malignant. Neoplasm, breast (connective tissue)
(glandular tissue) (soft parts)
D63.0
Anemia (essential) (general) (hemoglobin
deficiency) (infantile) (primary) (profound),
in (due to) (with), neoplastic disease (see also
Neoplasm)
Rationale: When the patient is treated for anemia due to a
malignancy, Coding Guideline I.C.2.c.1 directs the coding
professional to sequence the malignancy as principal or first listed
diagnosis followed by a code for the anemia. There is
a “code first neoplasm” note under code D63.0.
Case 1.22 ANSWER
D56.3 Thalassemia (anemia) (disease), minor
Rationale: ICD-10-CM has provided greater specificity in
the coding of Thalassemia.
Case 1.23 ANSWER
D57.01
Anemia, sickle-cell – See Disease,
sickle-cell, with crisis (vasoocclusive
pain), with, acute chest syndrome
Rationale: In some cases, combination codes are
used for sickle-cell crisis with manifestation.
Case 1.24 ANSWER
D81.1 Immunodeficiency, combined, severe
(SCID), with, low T- and B-cell
numbers
Rationale: ICD-10-CM has added additional specificity to
the severe combined immunodeficiency subcategory.
SCID is a genetic disorder in which B and T cells are
crippled due to a defect in genes. It is also known as
“bubble boy” disease, and patients are extremely
vulnerable to infectious diseases.
Check Your Understanding
Guideline Review
11–15
(Start on page xx of your
Student Manual)
# 11. If an encounter is solely for chemotherapy,
immunotherapy, or radiation therapy for a neoplastic
condition, the first reported diagnosis is:
____________________________________
#11 Answer: The appropriate Z51 code
Rationale: If a patient admission or encounter is solely for the
administration of chemotherapy, immunotherapy, or radiation
therapy assign code Z51.0, Encounter for antineoplastic radiation
therapy; or Z51.11, Encounter for antineoplastic chemotherapy; or
Z51.12, Encounter for antineoplastic immunotherapy as the firstlisted or principal diagnosis. If a patient receives more than one of
these therapies during the same admission more than one of these
codes may be assigned, in any sequence (ICD-10-CM Coding
Guideline I.C.2.e.2). An encounter for chemotherapy and
immunotherapy for a nonneoplastic condition should be coded to
the condition.
12. True or false? When assigning the principal diagnosis
for a patient with AIDS, the AIDS code would always
be sequenced before any other conditions.
#12. Answer: False
Rationale: When a patient is admitted with an HIV-related
condition, the principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease, followed by
additional diagnosis codes for all reported HIV-related
conditions (ICD-10-CM Coding Guideline I.C.1.a.2.a).
When a patient with HIV disease is admitted for an
unrelated condition, for example, trauma, the code for
the unrelated condition should be the principal diagnosis
with B20 listed as an additional code (ICD-10-CM Coding
Guideline I.C.1.a.2.b).
#13. A patient has liver metastasis due to adenocarcinoma
of the rectum which was resected two years ago. The
patient has been receiving radiotherapy to the liver with
some relief of pain. The patient is being seen at this time
for management of severe anemia due to the malignancy.
The principal (first listed) diagnosis listed on this encounter
is?: ___________
13. Answer: Liver metastasis
Rationale: When an admission or encounter is for
the management of an anemia associated with the
malignancy, and the treatment is only for anemia, the
appropriate code for the malignancy is sequenced as the
principal or first listed diagnosis followed by the
appropriate code for the anemia (such as D63.0, Anemia in
neoplastic disease) (ICD-10-CM Coding Guideline I.C.2.c.1).
In addition, in the Tabular, the note under D63.0 states to
code first neoplasm (C00-D49).
14. True or False? Patients with a prior diagnosis
of an HIV-related illness should be assigned the code
for AIDS (B20) on every subsequent admission.
#14 Answer: True
Rationale: Patients with any known prior diagnosis of
an HIV-related illness should be coded to B20. Once a
patient has developed an HIV-related illness, the patient
should always
be assigned code B20 on every subsequent admission or
encounter. Patients previously diagnosed with any HIV
illness (B20) should never be assigned to R75 or Z21,
Asymptomatic human immunodeficiency virus [HIV]
infection status (ICD-10-CM Coding Guideline I.C.1.a.2.f).
15. When reporting an encounter for a patient who
is HIV positive but has never had any symptoms,
the following code is assigned: ______________
#15 Answer: Z21, Asymptomatic HIV infection status
Rationale: Z21, Asymptomatic HIV infection status
is to be used when the patient without any
documentation of symptoms is listed as being “HIV
positive,” “known HIV,” “HIV test positive,” or similar
terminology. Do not use this code if the term “AIDS” is
used or if the patient is treated for any HIV-related illness
or is described as having any condition(s) resulting from
HIV positive status; use B20 in these cases (ICD-10-CM
Coding Guideline I.C.1.a.2.d).
Any Questions?
ICD-10-CM
Chapter 4: Endocrine, Nutritional and Metabolic Diseases
ICD-10-CM
International
Classification of
Diseases
10th Revision
Clinical Modification
Diabetes mellitus
• Combination codes
• No longer classified as controlled or
uncontrolled
• Inadequately, out of control or poorly
controlled coded by type with
hyperglycemia
• Same as in ICD-9:
• Type of diabetes mellitus not
documented
• If the type of diabetes mellitus is not
documented in the medical record the
default is E11.-, Type 2 diabetes mellitus.
• Type of diabetes
• Type of diabetes mellitus
not documented
• The age of a patient is
not the sole determining • If the type of diabetes
factor, though most type
mellitus is not
1 diabetics develop the
documented in the
condition before
medical record the
reaching puberty. For this
default is E11.-, Type 2
reason type 1 diabetes
diabetes mellitus.
mellitus is also referred
to as juvenile diabetes.
Diabetes mellitus and the use of
insulin
• Secondary diabetes mellitus
If the documentation in a medical
record does not indicate the type of
and the use of insulin
diabetes but does indicate that the
• For patients who routinely use
patient uses insulin, code E11, Type 2
insulin, code Z79.4, Long-term
diabetes mellitus, should be assigned.
(current) use of insulin, should
Code Z79.4, Long-term (current) use of
insulin, should also be assigned to
also be assigned. Code Z79.4
indicate that the patient uses insulin.
should not be assigned if insulin
Code Z79.4 should not be assigned if
is given temporarily to bring a
insulin is given temporarily to bring a
patient’s blood sugar under
type 2 patient’s blood sugar under
control during an encounter.
control during an encounter.
Note: Code Z79.4 is not assigned with Type I
Coding Note: A note appears in the
Tabular under category E09 instructing
to “Use additional code for adverse
effect, if applicable, to identify drug
(T36-T65 with fifth or sixth character 5).”
Use the Drugs and Chemical Table to
locate this code. An additional note
appears in the Tabular under category
E09 instructing to “Use additional code
to identify any insulin use (Z79.4).”
The difference
between type 1 and
type 2 diabetes.
Type 1 and Type 2 Diabetes
•
•
•
Type 1 formerly called juvenile onset
diabetes occurs typically before the
age of 20 but now we see Type I
occur at later ages also.
The cause of type 1 diabetes is that
the pancreas, the organ that secretes
insulin, is destroyed by
autoantibodies, that's why people
with type 1 diabetes always need
insulin, either injected or through an
insulin pump.
Type 1 diabetes occurs in about 1015 percent of all the diabetics in the
country.
•
•
•
Type 2 diabetics usually diagnosed after
the age of 35.
The cause of type 2 diabetes is quite
different from type 1. The cause of type 2
diabetes is primarily a complicated
medical condition called 'insulin
resistance.' In fact, in the early stages of
type 2 diabetes, there's plenty of insulin
around, it just doesn't work well.
To treat type 2 diabetes, we typically use
lifestyle, and that may work alone -- just
diet and exercise -- then we may need oral
medications, and it is not uncommon for
someone with type 2 diabetes to
eventually need insulin, either with or
without the oral medications.
Cases to Code
Go to page 101 of your Manual
•
•
•
•
•
•
1.25
1.28
1.29
1.30
1.31
1.34
Check Your Understanding
1.25–1.34
Case 1.25 ANSWER
E11.321
E11.36
Z79.4
Diabetes, diabetic (mellitus) (sugar),
type 2, with, retinopathy,
nonproliferative, mild, with
macular edema
Diabetes, diabetic (mellitus) (sugar),
type 2, with, cataract
Long-term (current) (prophylactic)
drug therapy (use of), insulin
Case 1.25 (continued):
Rationale: There is a combination code for the type
2 diabetes with nonproliferative diabetic retinopathy with
macular edema. The diabetic cataract was documented
and should be coded, but it requires a separate code.
Since the patient has type 2 DM, and is on insulin, code
Z79.4 should be assigned to indicate that as indicated by
the note at category E11: Use additional code to identify
any insulin use (Z79.4).
Case 1.28 ANSWER
E66.01 Obesity, morbid
Z68.41 Body, bodies, mass index (BMI), adult,
40.0 – 44.9
Rationale: The Index indicates that morbid obesity is assigned
code E66.01. When consulting the Tabular, the subcategory is Obesity
due to excess calories. This is the correct code even though it is not
documented that excess calories caused the obesity. This is the
default code per the classification. The note at category E66 indicates
that an additional code should be assigned for BMI when known
(Z68.-).
NOTE: Be sure to code all reportable conditions to
capture patient severity; capture revenue.
Case 1.29 ANSWER
F50.2
E44.0
Bulimia (nervosa)
Malnutrition, protein, calorie,
moderate
Rationale: Protein-calorie malnutrition codes
differentiate between mild and moderate levels.
Case 1.30 ANSWER
E86.0 Dehydration
A02.0 Gastroenteritis (acute) (chronic)
(noninfectious), Salmonella or
Infection, Salmonella, with
(gastro)enteritis
Rationale: The dehydration would be the first listed code
because it is the reason for the encounter and is the diagnosis that
was treated. The gastroenteritis due to salmonella would be coded
as an additional code. The symptoms (abdominal cramping, nausea,
vomiting, diarrhea) are integral to the gastroenteritis and are not
separately coded.
Case 1.31 ANSWER
E10.10
Diabetes, diabetic (mellitus) (sugar),
type 1, with, ketoacidosis
E86.0
Dehydration
Rationale: The reason for the encounter is the
diabetic ketoacidosis which would be sequenced first.
The symptoms of nausea and vomiting, frequency of
urination, and polydipsia would not be coded.
Case 1.34 ANSWER
E10.621
L97.521
E10.51
E10.22
N18.2
Diabetes, diabetic (mellitus) (sugar), type 1, with
foot ulcer
Ulcer, foot, see Ulcer, lower limb, lower limb, foot,
left, with skin breakdown only
Diabetes, diabetic (mellitus) (sugar), type 1, with
peripheral angiopathy
Diabetes, diabetic (mellitus) (sugar), type 1, with
chronic kidney disease
Disease, diseased, kidney (functional) (pelvis),
chronic, stage 2 (mild)
Case 1.34 (continued):
Rationale: The diabetic ulcer is listed first because this
appears to be the reason for treatment. The note under
code E10.621 states to “Use additional code to identify
site of ulcer (L97.4-, L97.5-)”. It is correct to list as many
diabetic conditions as are present, and the stage 2 chronic
kidney disease and the peripheral angiopathy are coded.
An additional code, N18.2, is added to identify the stage 2
chronic kidney disease. It is not correct to assign Z79.4
because type 1 diabetics must use insulin to sustain life,
and this is inherent in the Category E10 codes.
Any Questions?