Transcript Slides

ICD-10-CM
FY2017 CHANGES
Sally Phillips, RHIA
NIHIMA Fall Seminar
October 2016
2017 FY ICD-10-CM CODING UPDATE
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1,974 NEW codes
311 Deleted codes
425 Revised codes
Most Impact by Chapter:
• Chapter 4 – Endocrine, nutritional and metabolic diseases
• Chapter 13 – Diseases of the musculoskeletal system and connective tissue
• Chapter 19 – Injury, poisoning and certain other consequences of external causes
• Numerous Tabular Instruction Changes (Excludes 1 Corrections!)
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Coding Guideline Updates
FY 2017 MAJOR Changes ONLY Presented
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2017 FY ICD-10-CM Coding Guidelines Changes
Continuation of the interim advice from NCHS
posted 10/19/2015 and updated 10/26/2015
regarding the Excludes 1 note application
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Section I.A.12. Excludes Notes
a. Excludes 1
An exception to the Excludes 1 definition is the circumstance when the two
conditions are unrelated to each other. If it is not clear whether the two
conditions involving an Excludes 1 note are related or not, query the provider.
For example, code F45.8, Other somatoform disorders, has an Excludes 1 note for
“sleep related teeth grinding (G47.63),” because “teeth grinding” is an inclusion
term under F45.8. Only one of these two codes should be assigned for teeth
grinding. However psychogenic dysmenorrhea is also an inclusion term under
F45.8, and a patient could have both this condition and sleep related teeth
grinding. In this case, the two conditions are clearly unrelated to each other,
and so it would be appropriate to report F45.8 and G47.63 together.
2017 FY ICD-10-CM Coding Guidelines Changes
Section 1.A.15. “With”
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NEW! NEW! NEW!
Change in interpretation of Hypertension and
Heart Disease due to re-interpreting “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 classification presumes a causal relationship between the two conditions linked by
these terms in the Alphabetic Index or Tabular List. These conditions should be coded as
related even in the absence of provider documentation explicitly linking them, unless
the documentation clearly states the conditions are unrelated. For conditions not
specifically linked by these relational terms in the classification, provider
documentation must link the conditions in order to code them as related. The word
“with” in the Alphabetical Index is sequenced immediately following the main term, not
in alphabetical order.
WATCH FOR ANY “WITH” STATEMENTS!
2017 FY ICD-10-CM Coding Guidelines Changes
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Section I.A.19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic
statement that the condition exists. The providers’ statement that the patient
has a particular condition is sufficient. Code assignment is not based on clinical
criteria used by the provider to establish the diagnosis.
NEW! NEW! NEW!
Potential conflict with CDI and also auditors who expect
validation of codes (clinical criteria/indicators) be
documented!
VERY CONTROVERSIAL CHANGE!
2017 FY ICD-10-CM Coding Guidelines Changes
Section I.B.13. Laterality
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CLARIFICATION!
Helpful guidance on use of “bilateral” vs specific
laterality when sites are previously treated
When a patient has a bilateral condition and each side is treated during separate
encounters, assign the “bilateral” code (as the condition still exists on both sides),
including for the encounter to treat the first side. For the second encounter for
treatment after one side has previously been treated and the condition no longer exists
on that side, assign the appropriate unilateral code for the side where the condition still
exists (e.g., cataract surgery performed on each eye in separate encounters). The
bilateral code would not be assigned for the subsequent encounter, as the patient no
longer has the condition in the previously-treated site. If the treatment on the first side
did not completely resolve the condition, then the bilateral code would still be
appropriate.
2017 FY ICD-10-CM Coding Guidelines Changes
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Coma scale (GCS) and NIHSS added to list that
doesn’t require provider to document
Section I.B.14. Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer
Stages, Coma Scale, and NIH Stroke Scale
For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer
stages, coma scale, and NIH stroke scale (NIHSS) 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, a nurse
often documents the pressure ulcer stages, and an emergency medical technician often
documents the coma scale). However, the associated diagnosis (such as overweight,
obesity, acute stroke, 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, coma scale, and NIHSS codes should only be reported as secondary diagnoses.
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.1.f. Zika virus infections
Comparable to guideline on HIV infection/illness
1) Code only confirmed cases
Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as
documented by the provider. This is an exception to the hospital inpatient
guideline Section II.H. In this context, “confirmation” does not require
documentation of the type of test performed; the physician’s diagnostic
statement that the condition is confirmed is sufficient. This code should be
assigned regardless of the stated mode of transmission.
If the provider documents “suspected,” “possible” or “probable” Zika, do not
assign coded A92.5. Assign a code(s) explaining the reason for encounter (such as
fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to
other viral communicable diseases.
New Z79.84 Long-term (current) use of oral
hypoglycemic drugs code
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.4.a.(3) Diabetes mellitus and the use of insulin and oral hypoglycemics
If the documentation in a medical record does not indicate the type of diabetes
but does indicate that the patient uses insulin, code E11, Type 2 diabetes
mellitus, should be assigned. Code Z79.4, Long-term (current) use of insulin, or
Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be
assigned to indicate that the patient uses insulin or hypoglycemic drugs. Code
Z79.4 should not be assigned if insulin is given temporarily to bring a type 2
patient’s blood sugar under control during an encounter.
I.C.4.a.(6)(a) Secondary diabetes mellitus and the use of insulin or hypoglycemic
drugs
For patient who routinely use insulin or hypoglycemic drugs, code Z79.4, Longterm (current) use of insulin, or Z79.84, Long-term (current) use of oral
hypoglycemic drugs should also be assigned. . . .
2017 FY ICD-10-CM Coding Guidelines Changes
NEW! NEW! NEW!
Change in interpretation of Hypertension and
Heart Disease due to re-interpreting “with”
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I.C.9.a. Hypertension
The classification presumes a causal relationship between hypertension and heart
involvement and between hypertension and kidney involvement, as the two conditions
are linked by the term “with” in the Alphabetic Index. These conditions should be coded
as related even in the absence of provider documentation explicitly linking them, unless
the documentation clearly states the conditions are unrelated.
For hypertension and conditions not specifically linked by relational terms such as
“with,” “associated with” or “due to” in the classification, provider documentation must
link the conditions in order to code them as related.
1) Hypertension with Heart Disease
Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a
code from category I11, Hypertensive heart disease. Use an additional code from
category I50, Heart failure, to identify the type of heart failure in those patients with
heart failure.
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.9.a.(10) Hypertensive Crisis
Assign a code from category I16, Hypertensive crisis, for documented hypertensive
urgency, hypertensive emergency or unspecified hypertensive crisis. Code also
any identified hypertensive disease (I10-I15). The sequencing is based on the
reason for the encounter.
More information with chapter-specific review
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.12.a(5) Patients admitted with pressure ulcers documented as healing
...
Coding/Guideline Clarification!
For ulcers that were present on admission but healed at the time of discharge,
assign the code for the site and stage of the pressure ulcer at the time of
admission.
I.C.12.a(6) Patient admitted with pressure ulcer evolving into another stage during
the admission
If a patient is admitted with a pressure ulcer at one stage and it progresses to a
higher stage, assign the code for the highest stage reported for that site. two
separate codes should be assigned: one code for the site and stage of the ulcer on
admission and a second code for the same ulcer site and the highest stage
reported during the stay.
Coding/Guideline Change!
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.15.b.(2) Supervision of High-Risk Pregnancy
Codes from category O09, Supervision of high-risk pregnancy, are intended for use
only during the prenatal period. For complications during the labor or delivery
episode as a result of a high-risk pregnancy, assign the applicable complication
codes from Chapter 15. If there are no complications during the labor or delivery
episode, assign code O80, Encounter for full-term uncomplicated delivery.
...
Coding/Guideline Clarification!
2017 FY ICD-10-CM Coding Guidelines Changes
Sequencing Clarification!
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I.C.15.b.(4) When a delivery occurs
When a delivery occurs, the principal diagnosis should correspond to the main
circumstances or complication of the delivery. When an obstetric patient is
admitted and delivers during that admission, the condition that prompted the
admission should be sequenced as the principal diagnosis. If multiple conditions
prompted the admission, sequence the one most related to the delivery as the
principal diagnosis. A code for any complication of the delivery should be assigned
as an additional diagnosis. In cases of cesarean delivery, the selection of the
principal diagnosis should be the condition established after study that was
responsible for the patient’s admission. if the patient was admitted with a
condition that resulted in the performance of a cesarean procedure, that condition
should be selected as the principal diagnosis. If the reason for the admission was
unrelated to the condition resulting in the cesarean delivery, the condition related
to the reason for the admission should be selected as the principal diagnosis.
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.15.h. Long term use of insulin and oral hyopglycemics
Code Z79.4, Long-term (current) use of insulin, or code Z79.84, Long-term
(current) use of oral hypoglycemic drugs, should also be assigned if the diabetes
mellitus is being treated with insulin or oral medications. If the patient is
treated with both oral medications and insulin, only the code for insulincontrolled should be assigned.
New Z79.84 Long-term (current) use of oral
hypoglycemic drugs code
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.15.i. Gestational (pregnancy induced) diabetes
...
The codes under subcategory O24.4 include diet controlled, and insulin
controlled, and controlled by oral hypoglycemic drugs. If a patient with
gestational diabetes is treated with both diet and insulin, only the code for
insulin-controlled is required. If a patient with gestational diabetes is treated
with both diet and oral hypoglycemic medications, only the code for “controlled
by oral hypoglycemic drugs” is required. Code Z79.4, Long-term (current) use
of insulin or code Z79.84, Long-term (current) use of oral hypoglycemic drugs,
should not be assigned with subcategory O24.4.
...
New Z79.84 Long-term (current) use of oral
hypoglycemic drugs code
New Z05 Observation and evaluation of newborns
and infants for suspected conditions ruled out
2017 FY ICD-10-CM Coding Guidelines Changes
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I.16.b. Observation and Evaluation of Newborns for Suspected Conditions not Found
1) Assign a code from category Z05, Observation and evaluation of newborns and infants
for suspected conditions ruled out, to identify those instances when a healthy newborn
is evaluated for a suspected condition that is determined after study not to be present.
Do not use a code from category Z05 when the patient has identified signs or symptoms
of a suspected problem; in such cases code the sign or symptom.
2) A code from category Z05 may also be assigned as a principal or first-listed code for
readmissions or encounters when the code from category Z38 code no longer applies.
Codes from category Z05 are for use only for healthy newborns and infants for which no
condition after study is found to be present.
3) Z05 on a birth record
A code from category Z05 is to be used as a secondary code after the code from
category Z38, Liveborn infants according to place of birth and type of delivery.
2017 FY ICD-10-CM Coding Guidelines Changes
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New R29.7- NIH Stroke Scale codes
I.C.18.i. NIHSS Stroke Scale
The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in conjunction with
acute stroke codes (I63) to identify the patient’s neurological status and the
severity of the stroke. The stroke scale codes should be sequenced after the
acute stroke diagnosis code(s).
At a minimum, report the initial score documented. If desired, a facility may
choose to capture multiple stroke scale scores.
See Section I.B.14. for information concerning the medical record documentation
that may be used for assignment of NIHSS codes.
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.19.a. Application of 7th Characters in Chapter 19
Attempt to clarify use of 7th Character initial, subsequent encounter; REMOVED EXAMPLES!
...
7th character “A,” initial encounter is used for each encounter where while the
patient is receiveding active treatment for the condition. Examples of active
treatment are: surgical treatment, emergency department encounter, and
evaluation and continuing treatment by the same or a different physician.
7th character “D” subsequent encounter is used for encounters after the patient
has completed received active treatment of the condition and is receiving routine
care for the condition during the healing or recovery phase. Examples of
subsequent care are: cast change or removal, an x-ray to check healing status of
fracture, removal of external or internal fixation device, medication adjustment,
other aftercare and follow up visits following treatment of the injury or condition.
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.19.c(1) Initial vs. Subsequent Encounters for Fractures
...
Malunion/nonunion: The appropriate 7th character for initial encounter should
also be assigned for a patient who delayed seeking treatment for the fracture or
nonunion.
The open fracture designations in the assignment of the 7th character for
fractures of the forearm, femur and lower leg, including ankle are based on the
Gustilo open fracture classification. When the Gustilo classification type is not
specified for an open fracture, the 7th character for open fracture type I or II
should be assigned (B, E, H, M, Q).
...
Attempt to clarify use of 7th Character for open fractures
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.19.e. Adverse Effects, Poisoning, Underdosing and Toxic Effects
5) (b) Poisoning
When coding a poisoning or reaction to the improper use of a medication (e.g.
overdose, wrong route of administration), first assign the appropriate code from
categories T36-T50. The poisoning codes have an associated intent as their 5th or
6th character (accidental, intentional self-harm, assault and undetermined. If the
intent of the poisoning is unknown or unspecified, code the intent as accidental
intent. The undetermined intent is only for use if the documentation in the
record specifies that the intent cannot be determined. Use additional code(s) for
all manifestations of poisonings.
POISONING default defined: accidental
2017 FY ICD-10-CM Coding Guidelines Changes
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New Z05 Observation and evaluation of newborns
and infants for suspected conditions ruled out
I.C.21.b.(6) Observation
There are two three observation Z code categories. . . .
The observation codes are to be used as principal diagnosis only. The only exception to
this is when the principal diagnosis is required to be a code from category Z38, Liveborn
infants according to place of birth and type of delivery. Then a code from category Z05,
Encounter for observation and evaluation of newborn for suspected diseases and
conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in
addition to the observation code but only if they are unrelated to the suspected
condition being observed.
...
Z03
Z04
Z05
Encounter for medical observation for suspected diseases and conditions ruled out
Encounter for examination and observation for other reasons
Except: Z04.9, Encounter for examination and observation for unspecified reason
Encounter for observation and evaluation of newborn for suspected diseases and conditions
ruled out
2017 FY ICD-10-CM Coding Guidelines Changes
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I.C.21.b.(7) Aftercare
...
Z51
Encounter for other aftercare and medical care
I.C.21.b.(11) Encounters for Obstetrical and Reproductive Services
...
Coding/Guideline CHANGE for Z3A
Codes in category Z3A, Weeks of gestation, may be assigned to provide additional
information about the pregnancy. Category Z3A codes should not be assigned for
pregnancies with abortive outcomes (categories O00-O08), elective termination of
pregnancy (code Z33.32), nor for postpartum conditions, as category Z3A is not applicable
to these conditions. The date of the admission should be used to determine weeks of
gestation for inpatient admissions that encompass more than one gestational week.
2017 FY ICD-10-CM Coding Guidelines Changes
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Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
These 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. Guidelines in Section I, Conventions, general
coding guidelines, and chapter-specific guidelines, should also be applied for
outpatient services and office visits.
Guideline clarified
...
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.does not apply to hospital-based outpatient services and
provider-based office visits.
2017 FY ICD-10-CM Coding Guidelines Changes
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IV.P. Encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations, Z00.0-,
provide codes for with and without abnormal findings. Should a general
medical examination result in an abnormal finding, the code for general
medical examination with abnormal finding should be assigned as the firstlisted diagnosis. An examination with abnormal findings refers to a condition/
diagnosis that is newly identified or a change in severity of a chronic
condition (such as uncontrolled hypertension, or an acute exacerbation of
chronic obstructive pulmonary disease) during a routine physical examination.
A secondary code for the abnormal finding should also be coded.
Guideline clarification
Changed “combination codes” to “codes that
contain multiple clinical concepts”
2017 FY ICD-10-CM Coding Guidelines Changes
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Appendix I. Present on Admission
Chronic condition with acute exacerbation during the admission
If a single code identifies both the chronic condition and the acute
exacerbation, see POA guidelines pertaining to combination codes
codes that contain multiple clinical concepts.
Combination Codes That Contain Multiple Clinical Concepts
Assign “N” if at least one of the clinical concepts included in the any part of the
combination code was not present on admission (e.g., COPD with acute exacerbation
and the exacerbation was not present on admission; gastric ulcer that does not start
bleeding until after admission; asthma patient develops status asthmaticus after
admission).
Assign “Y” if all parts of the combination clinical concepts included in the code were
present on admission (e.g., patient with acute prostatitis admitted with hematuria
duodenal ulcer that perforates prior to admission).
Chapter Specific Changes
FY 2017 MAJOR/SIGNIFICANT Changes ONLY Presented
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Multiple Chapters:
29
• Title REVISIONS:
Postprocedural hemorrhage and hematoma of [system/organ/structure] following
a/an [system] procedure
Postprocedural hemorrhage and hematoma of [system/organ/structure] following
other procedure
• NEW CODES:
Postprocedural
Postprocedural
Postprocedural
Postprocedural
hematoma of a/an [system/organ/structure] following a/an [system] procedure
hematoma of a/an [system/organ/structure] following other procedure
seroma of a/an [system/organ/structure] following a/an [system procedure
seroma of a/an [system/organ/structure] following other procedure
• Carved out hematoma and added seroma (a pocket of clear, serous fluid that
sometimes develops after surgery) for postprocedural complications in the following
chapters:
• Chapter 3 – Diseases of the blood and blood-forming organs . . . (D50-D89)
• Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89)
• Chapter 6 – Diseases of the nervous system (G00-G99)
Multiple Chapters:
• Carve out continued in the following chapters:
•
•
•
•
•
•
•
•
Chapter 7 – Diseases of the eye and adnexa (H00-H59)
Chapter 8 – Diseases of the ear and mastoid process (H60-H95)
Chapter 9 – Diseases of the circulatory system (I00-I99)
Chapter 10 – Diseases of the respiratory system (J00-J99)
Chapter 11 – Diseases of the digestive system (K00-K95)
Chapter 12 – Diseases of the skin and subcutaneous tissue (L00-L99)
Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99)
Chapter 14 – Diseases of the genitourinary system (N00-N99)
30
Chapter 1 – Certain infectious and parasitic
diseases (A00-B99)
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NEW code:
Zika Virus Disease A92.5
• Spreads primarily through the bite of an infected Aedes species mosquito.
Can be passed from a pregnant woman to her fetus.
• Symptoms: fever, rash, joint pain, conjunctivitis
• Mild symptoms, short duration (several days to a week), low mortality
• Serious/Severe birth defects: microcephaly, fetal brain defects
• Treat symptoms: rest, hydration, fever reduction and analgesic medications
(acetaminophen)
• Human testing of Zika vaccine approved in mid-June 2016
Chapter 2 – Neoplasms (C00-D49)
• Excludes 1 corrected to Excludes 2:
C78 Secondary malignant neoplasm of respiratory and digestive organs
• Lymph node metastases (C77.0)
C79 Secondary malignant neoplasm of other and unspecified sites
• Lymph node metastases (C77.0)
D16.4 Benign neoplasm of bones of skull and face
• Benign neoplasm of lower jaw bone (D16.5)
• Code title revisions:
C81- Classical Hodgkin lymphoma
32
Chapter 2 – Neoplasms (00-D49)
33
New codes:
• C49.A- Gastrointestinal stromal tumor
GIST: uncommon tumors of the GI tract, most originate in the stomach, some are benign,
start from different cells than other GI cancers so need different types of treatment and
have a different prognosis
• D47.Z2 Castleman disease
A rare disease of lymph nodes and related tissues. AKA Giant lymph node hyperplasia or
angiofollicular lymph node hyperplasia (AFH). It’s a lymphoproliferative disorder that
results in an abnormal overgrowth of lymph cells
• D49.51- Neoplasm of unspecified behavior of kidney
• D49.59 Neoplasm of unspecified behavior of other genitourinary organ
Chapter 3 – Diseases of the blood and bloodforming organs and certain disorders involving the
immune mechanism (D50-D89)
34
• Instructional note code title revisions
• Excludes 1 corrected to Excludes 2:
D61.81 Pancytopenia
• Pancytopenia (due to) (with) myelodysplastic syndromes (D46.-)
D64.81 Anemia due to antineoplastic chemotherapy
• Anemia in neoplastic disease (D63.0)
• NEW CODES:
D89.4- Mast cell activation syndrome and related disorders
• AKA Mast cell activation disorder (MCAD) is an immunological condition in which mast
cells inappropriately and excessively release chemical mediators resulting in a range of
chronic symptoms such as dermatological, gastrointestinal, neurological, cardiovascular,
and respiratory
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
35
• New Diabetes Mellitus category codes (E08-, E09-, E10-, E11-, E13-) “use
additional” instructional notes related to new Z79.84 Long term (current)
use of oral hypoglycemic drugs:
Use additional code to identify control using:
Insulin (Z79.4)
Oral antidiabetic drugs (Z79.84)
Oral hypoglycemic drugs (Z79.84)
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
36
• New Diabetes Mellitus category codes’ (E08-, E09-, E10-, E11-, E13-) 7th characters
for laterality of ophthalmic complications:
-.32
-.33
-.34
-.35
-.37
Diabetes
Diabetes
Diabetes
Diabetes
Diabetes
mellitus
mellitus
mellitus
mellitus
mellitus
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
with
with
with
with
with
mild nonproliferative diabetic retinopathy
moderate nonproliferative diabetic retinopathy
severe nonproliferative diabetic retinopathy
proliferative retinopathy
diabetic macular edema, resolved following treatment
One of the following 7th characters is to be assigned to codes in subcategory _____ to
designate laterality of the disease:
1 right eye
2 left eye
3 bilateral
9 unspecified eye
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
37
New codes:
Diabetes mellitus category codes (E08-, E09-, E10-, E11-, E13-)
-.352 Diabetes mellitus . . .with proliferative diabetic retinopathy with traction retinal
detachment involving the macula
-.353 Diabetes mellitus . . . with proliferative diabetic retinopathy with traction retinal
detachment not involving the macula
-.354 Diabetes mellitus . . . with proliferative diabetic retinopathy with combined
traction retinal detachment and rhegmatogenous retinal detachment
-.355 Diabetes mellitus . . . with stable proliferative diabetic retinopathy
-.37X Diabetes mellitus . . . with diabetic macular edema, resolved following treatment
• (all of the above with the new 7th character for eye laterality)
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
• Proliferative retinopathy: new growth of small blood vessels from the
retina that bleed easily causing scar tissue that shrinks and pulls off
(detaches) the retina causing blindness. Treated with laser. Common
diabetic complication.
• Traction retinal detachment: scar tissue or other abnormal tissue grows
on the retina causing the retina to pull away from the layer below
(detachment); proliferative retinopathy is the most common cause of
this detachment
• Rhegmatogenous retinal detachment: most common type of
detachment; caused by holes or tears in the retina that allow fluid to
build up under the retina, pushing it away (detachment) from the layer
below
38
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
39
• New instructional notes
E16.0 Drug-induced hypoglycemia without coma
• Excludes 1: diabetes with hypoglycemia without coma (E09.692)
E16.1 Other hypoglycemia
• Excludes 1: diabetes with hypoglycemia (E08.649, E10.649, E11.649, E13.649
E16.2 Hypoglycemia, unspecified
• Excludes 1: diabetes with hypoglycemia (E08.649, E10.649, E11.649, E13.649
E66.2 Morbid (severe) obesity with alveolar hypoventilation
• Obesity hypoventilation syndrome (OHS)
E86 Volume depletion
• Use Additional code(s) for any associated disorders of electrolyte and acid-base balance (E87.-)
• Revised instructional notes
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
40
New codes:
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
• An autosomal dominant disorder that causes severe elevations in total cholesterol and
low-density lipoprotein cholesterol
Chapter 4 – Endocrine, nutritional and
metabolic diseases (E00-E89)
41
• Diabetes index addition:
uncontrolled
meaning
hyperglycemia – see Diabetes, by type, with, hyperglycemia
hypoglycemia – see Diabetes, by type, with hypoglycemia
NOT THE SAME AS: “inadequately controlled,” or “out of control” or “poorly controlled”:
code to Diabetes, by type, with hyperglycemia
• NOT ADDED:
Diabetes Mellitus, type 2, with ketoacidosis
• Continue to assign E13.10 Other specified diabetes mellitus with ketoacidosis without coma
• Above coding advice from Coding Clinic, 1Q2013, pp 26-27, and re-cited in Coding Clinic
2Q2016, p. 10
Chapter 5 – Mental, behavioral and
neurodevelopmental disorders (F01-F99)
• Added instructional notes
• For example:
F02 Dementia in other diseases classified elsewhere
Includes: Major neurocognitive disorder in other diseases classified elsewhere
Code first dementia with Parkinsonism (G31.83)
Huntington’s disease (G10)
Prion disease (A81.9)
Traumatic brain injury (S06.-)
F10.10 Alcohol abuse, uncomplicated
Alcohol use disorder, mild
F10.20 Alcohol dependence, uncomplicated
Alcohol use disorder, moderate
Alcohol use disorder, severe
42
Chapter 5 – Mental, behavioral and
neurodevelopmental disorders (F01-F99)
43
• Excludes 1 corrected to Excludes 2:
F10.22 Alcohol dependence with intoxication
• Alcohol dependence with withdrawal (F10.23-)
F10.23 Alcohol dependence with withdrawal
• Alcohol dependence with intoxication (F10.22-)
• Excludes 1 notes added:
F32.81 Premenstrual dysphoric disorder
• Excludes 1: premenstrual tension syndrome (N94.3)
F42.4 Excoriation (skin-picking) disorder
• Excludes 1: factitial dermatitis (L98.1)
• Other specified behavioral and emotional disorders with onset usually occurring in early
childhood and adolescence (F98.8)
F44.0 Dissociative amnesia
• Excludes 1: dissociative amnesia with dissociative fugue (F44.1)
Chapter 6 – Diseases of the nervous system
(G00-G99)
44
• Excludes 1 corrected to Excludes 2:
G40 Epilepsy and recurrent seizures
•
•
•
•
Hippocampal sclerosis (G93.81)
Mesial temporal sclerosis (G93.81)
Temporal sclerosis (G93.81)
Todd’s paralysis (G83.84)
New codes:
G61.82 Multifocal motor neuropathy
• MNN is a progressively worsening condition wherein muscles in the extremities gradually
weaken
Chapter 6 – Diseases of the nervous system
(G00-G99)
New codes for BILATERAL:
G56.03
G56.13
G56.23
G56.43
G56.83
G56.93
G57.03
G57.13
G57.23
G57.33
G57.43
G57.53
G57.63
G57.73
G57.83
G57.93
Carpal tunnel syndrome, bilateral upper limbs
Other lesions of median nerve, bilateral upper limbs
Lesion of ulnar nerve, bilateral upper limbs
Causalgia of bilateral upper limbs
Other specified mononeouropathies of bilateral upper limbs
Unspecified mononeuropathy of bilateral upper limbs
Lesion of sciatic nerve, bilateral lower limbs
Meralgia paresthetica, bilateral lower limbs
Lesion of femoral nerve, bilateral lower limbs
Lesion of lateral popliteal nerve, bilateral lower limbs
Lesion of medial popliteal nerve, bilateral lower limbs
Tarsal tunnel syndrome, bilateral lower limbs
Lesion of plantar nerve, bilateral lower limbs
Causalgia of bilateral lower limbs
Other specified mononeuropathies of bilateral lower limbs
Unspecified mononeuropathy of bilateral lower limbs
45
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
• Excludes 1 revised to Excludes 2:
H42 Glaucoma in diseases classified elsewhere
• Glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39)
46
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
47
• 7th characters added to codes:
H34.81 Central retinal vein occlusion
H34.83 Tributary (branch) retinal vein occlusion
• 0 with macular edema
• 1 with retinal neovascularization
• 2 stable
H35.31 Nonexudative age-related macular degeneration
H35.32 Exudative age-related macular degeneration
•
•
•
•
0 stage unspecified
1 with active choroidal neovascularization
2 with inactive choroidal neovascularization with involuted or regressed neovascularization
3 with inactive scar
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
48
New codes:
H35.311 Nonexudative age-related macular degeneration, right eye
H35.312 Nonexudative age-related macular degeneration, left eye
H35.313 Nonexudative age-related macular degeneration, bilateral
H35.319 Nonexudative age-related macular degeneration, unspecified eye
• Or “dry,” is associated with the presence of drusen [yellow deposits under the retina
made up of lipids] and is generally much slower to progress to visual loss compared to
exudative age-related macular degeneration
• Age-related macular degeneration (ARMD) signs and symptoms:
•
•
•
•
Difficulty with night vision and changing light conditions
Visual fluctuation
Difficulty with reading and making out faces
Distortion of visual images
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
49
New codes:
H35.321 Exudative age-related macular degeneration, right eye
H35.322 Exudative age-related macular degeneration, left eye
H35.323 Exudative age-related macular degeneration, bilateral
H35.329 Exudative age-related macular degeneration, unspecified eye
• In “wet,” (exudative) form, pathologic choroidal neovascular membranes (CNVM) develop
under the retina causing fluid and blood leakage. Faster progression to visual loss than the
“dry” form.
• Signs and symptoms:
• Subretinal fluid
• Retinal pigment epithelial (RPE) detachments
• Subretinal hemorrhage
• Subretinal lipid deposits (occasionally)
• Painless, progressive blurring of central visual acuity
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
50
New codes:
H40.111 Primary open-angle glaucoma, right eye
H40.112 Primary open-angle glaucoma, left eye
H40.113 Primary open-angle glaucoma, bilateral
H40.119 Primary open-angle glaucoma, unspecified eye
• A multifactorial optic neuropathy that is chronic and progressive; includes an acquired loss
of optic nerve fibers that develops in the presence of open anterior chamber angles.
Chapter 7 – Diseases of the eye and adnexa
(H00-H59)
51
New codes:
H53.041 Amblyopia suspect, right eye
H53.042 Amblyopia suspect, left eye
H53.043 Amblyopia suspect, bilateral
H53.049 Amblyopia suspect, unspecified eye
• Vision in one of the eyes is reduced because the eye and brain are not working together
properly; also called “lazy eye.” Occurs in any condition that prevents the eye from
focusing clearly such as with misalignment of the two eyes in strabismus or with the
clouding caused by cataracts.
Chapter 8 – Diseases of the ear and mastoid
process (H60-H95)
52
• Instructional note revisions
• NEW codes:
H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side
H90.A21 Sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A22 Sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side
H90.A31 Mixed conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A32 Mixed conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side
Chapter 8 – Diseases of the ear and mastoid
process (H60-H95)
53
New Codes:
H93.A1 Pulsatile tinnitus, right ear
H93.A2 Pulsatile tinnitus, left ear
H93.A3 Pulsatile tinnitus, bilateral
H93.A9 Pulsatile tinnitus, unspecified ear
• Pulsatile tinnitus: ear noise perceived as a rhythmic pulsing, often in time with the heartbeat.
Can be a thumping or whooshing sound. Also called vascular tinnitus as it originates within the
blood vessels in the head or neck region when blood flow is disturbed either as an increase in
flow or due to narrowing of the blood vessel. It is unrelated to continuous tinnitus which
results from damage to the cochlea and/or hearing nerve.
Chapter 9 – Diseases of the circulatory system
(I00-I99)
54
• Corrections to instructional notes:
• Excludes 1 to Excludes 2:
Hypertensive diseases (I10-I16)
• Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16)
I42 Cardiomyopathy
• Ischemic cardiomyopathy (I25.5)
• Peripartum cardiomyopathy (O90.3)
I50 Heart failure
• Cardiac arrest (I46.-)
I50.9 Heart failure, unspecified
• Fluid overload (E87.10)
I60 Nontraumatic subarachnoid hemorrhage
• Sequelae of subarachnoid hemorrhage (I69.0-)
I61 Nontraumatic intracerebral hemorrhage
• Sequelae of intracerebral hemorrhage (I69.1-)
Chapter 9 – Diseases of the circulatory system
(I00-I99)
• Corrections to instructional notes:
• Excludes 1 to Excludes 2:
I62 Other and unspecified nontraumatic intracranial hemorrhage
• Sequelae of intracranial hemorrhage (I69.2)
I63 Cerebral infarction
• Sequelae of cerebral infarction (I69.3-)
I67 Other cerebrovascular diseases
• Sequelae of the listed conditions (I69.8)
• Correction:
I96 Gangrene, not elsewhere classified
• Now: gangrene in diabetes mellitus (E08-E13 with .52)
55
Chapter 9 – Diseases of the circulatory system
(I00-I99)
56
• New instructional notes:
• I20.8 Other forms of angina pectoris
Stable angina
• I63 Cerebral infarction
Use Additional code, if known, to indicate National Institutes of Health Stroke Scale (NIHSS)
score (R29.7-)
• I72- Other aneurysm
Excludes 2: dissection of precerebral artery, congenital (nonruptured) Q28.1)
• I72.5 Aneurysm of other precerebral arteries
Aneurysm of basilar artery (trunk)
Excludes 2: aneurysm of carotid artery (I72.0)
aneurysm of vertebral artery (I72.6)
dissection of carotid artery (I77.71)
dissection of other precerebral arteries (I77.75)
dissection of vertebral artery (I77.74)
Chapter 9 – Diseases of the circulatory system
(I00-I99)
• New instructional notes:
I72.6 Aneurysm of vertebral artery
• Excludes 2: dissection of vertebral artery (I77.74)
I87.2 Venous insufficiency (chronic)(peripheral)
• Excludes 1: stasis dermatitis with varicose veins of lower extremities (I83.1-, I83.2-)
• Deleted instructional notes:
I83.1 Varicose veins of lower extremities with inflammation
I87.2 Venous insufficiency (chronic)(peripheral)
Stasis dermatitis
57
Chapter 9 – Diseases of the circulatory system
(I00-I99)
58
NEW Codes:
I16 Hypertensive crisis
Code also any identified hypertensive disease (I10-I15)
I16.0 Hypertensive urgency
I16.1 Hypertensive emergency
I16.9 Hypertensive crisis, unspecified
• Hypertensive crisis: severe increase in blood pressure (BP); urgency or emergency
• Hypertensive urgency: severely elevated blood pressure (≥ 180 systolic (top) or ≥ 110 diastolic (bottom)
but no associated organ damage. Potential symptoms: severe headache, shortness of breath,
nosebleed, severe anxiety. Treatment: immediate evaluation and readjustment and/or additional
dosing of oral medications.
• Hypertensive emergency: blood pressure levels resulting in damage to organs. BP > 180 systolic OR >
120 diastolic but may be less in patients whose blood pressure had not been previously high.
Complications include: stroke, loss of consciousness, memory loss, heart attack, damage to eyes and
kidneys, loss of kidney function, aortic dissection, angina (unstable chest pain), pulmonary edema (fluid
backup in the lungs), eclampsia
Chapter 9 – Diseases of the circulatory system
(I00-I99)
59
NEW Codes:
• Bilateral Cerebral Infarction Sites:
I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries
I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries
I63.133 Cerebral infarction due to embolism of bilateral carotid arteries
I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral
arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries
I63.323 Cerebral infarction due to thrombosis of bilateral anterior arteries
I63.333 Cerebral infarction due to thrombosis of bilateral posterior arteries
I63.343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries
Chapter 9 – Diseases of the circulatory system
(I00-I99)
60
NEW Codes:
• Bilateral Cerebral Infarction Sites (continued):
I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries
I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries
I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries
I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries
I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior
arteries
I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar
arteries
Chapter 9 – Diseases of the circulatory system
(I00-I99)
61
NEW Codes: different types of cognitive deficits
Attention and
concentration
deficit
Memory deficit
Visuospatial
deficit and
spatial neglect
Psychomotor
deficit
Frontal lobe
and executive
function deficit
Cognitive social
or emotional
deficit
Sequelae
following:
Other
symptoms and
signs involving
cognitive
functions
Unspecified
symptoms and
signs involving
cognitive
functions
Subarachnoid
hemorrhage
I69.010
I69.011
I69.012
I69.013
I69.014
I69.015
I69.018
I69.019
Intracerebral
hemorrhage
I69.110
I69.111
I69.112
I69.113
I69.114
I69.115
I69.118
I69.119
Other
nontraumatic
intracranial
hemorrhage
I69.210
I69.211
I69.212
I69.213
I69.214
I69.215
I69.218
I69.219
Cerebral
infarction
I69.310
I69.311
I69.312
I69.313
I69.314
I69.315
I69.318
I69.319
Other
cerebrovascular
disease
I69.810
I69.811
I69.812
I69.813
I69.814
I69.815
I69.818
I69.819
Unspecified
cerebrovascular
disease
I69.910
I69.911
I69.912
I69.913
I69.914
I69.915
I69.918
I69.919
Chapter 9 – Diseases of the circulatory system
(I00-I99)
62
NEW Codes:
I77.70 Dissection of unspecified artery
I77.75 Dissection of other precerebral artery
I77.76 Dissection of artery of upper extremity
I77.77 Dissection of artery of lower extremity
• Dissection: separation of the layers of the artery wall resulting from a tear or daage to the inner wall
or lining of the artery
Chapter 10 – Diseases of the respiratory
system (J00-J99)
• Excludes 1 corrected to Excludes 2:
J44 Other chronic obstructive pulmonary disease
Lung diseases due to external agents (J60-J70)
• New instructional notes:
J47.0 Bronchiectasis with acute lower respiratory infection
Use additional code to identify the infection
• Deleted instructional notes:
J84.89 Other specified interstitial pulmonary diseases
Organizing pneumonia due to known underlying cause
• MAPPING (Index) CHANGE:
Distress
acute respiratory J80
J80 Acute Respiratory distress syndrome
Distress
acute respiratory R06.00
syndrome J80
R06.00 Dyspnea, unspecified
63
Chapter 10 – Diseases of the respiratory
system (J00-J99)
64
NEW codes:
J98.51 Mediastinitis
Code first underlying condition, if applicable, such as postoperative mediastinitis (T81.1-)
A life-threatening infection with a high mortality most often associated with cardiac surgery.
Symptoms include chest pain, shortness of breath and fever. Diagnosis made from CXR or
CT. Treated with antibiotics
J98.59 Other diseases of mediastinum, not elsewhere classified
Fibrosis of mediastinum: a rare, late complication of histoplasmosis
Hernia of mediastinum: congenital or due to aspiration of the mediastinum into the left
hemithorax caused by lack of re-expansion of the left lung in patients with bilateral
pneumothorax
Retraction of mediastinum
Chapter 11 – Diseases of the digestive system
(K00-K95)
• New instructional notes:
K02 Dental caries
Includes: caries of dentine
Early childhood caries
Pre-eruptive caries
Recurrent caries (dentino enamel junction) (enamel) (to the pulp)
K02.52 Dental caries on pit and fissure surface penetrating into dentin
Primary dental caries, cervical origin
K52.2 Allergic and dietetic gastroenteritis and colitis
Excludes 2: allergic eosinophilic colitis (K52.82), Allergic eosinophilic esophagitis (K20.0),
Allergic eosinophilic gastritis (K52.81), Allergic eosinophilic gastroenteritis (K52.81), Food
protein-induced proctocolitis (K52.82)
65
Chapter 11 – Diseases of the digestive system
(K00-K95)
• New instructional notes:
K52.82 Eosinophilic colitis
Allergic proctocolitis
Food-induced eosinophilic proctocolitis
Food protein-induced proctocolitis
Milk protein-induced proctocolitis
• Excludes 1 corrected to Excludes 2:
K52.81 Eosinophilic gastritis or gastroenteritis
Eosinophilic esophagitis (K20.0)
66
Chapter 11 – Diseases of the digestive system
(K00-K95)
67
NEW codes:
K04.01 Reversible pulpitis
• pulp is inflamed and is responding to an irritant, such as dental caries. Symptoms include
transient pain or sensitivity to hot/cold/sweet. Removal of the irritant restores pulp to a
healthy state
K04.02 Irreversible pulpitis
• pulp is irreversibly damaged and results in necrosis of the tissue. Symptoms include dull
aching, pain fro hot/cold
K05.211 Aggressive periodontitis, localized, slight
K05.212 Aggressive periodontitis, localized, moderate
K05.213 Aggressive periodontitis, localized, severe
K05.219 Aggressive periodontitis, localized, unspecified severity
• Rapid loss of attachment and bone destruction
Chapter 11 – Diseases of the digestive system
(K00-K95)
68
NEW codes:
K05.221 Aggressive periodontitis, generalized, slight
K05.222 Aggressive periodontitis, generalized, moderate
K05.223 Aggressive periodontitis, generalized, severe
K05.229 Aggressive periodontitis, generalized, unspecified severity
This is a form of periodontal disease. Aggressive periodontitis is less common than chronic
periodontitis, generally affects younger patients. Results in the rapid loss of attachment of
the teeth and bone destruction. Includes depressed neutrophil function. Localized and
generalized are distinct forms of this disease.
Chapter 11 – Diseases of the digestive system
(K00-K95)
69
NEW codes:
K05.311 Chronic periodontitis, localized, slight.
K05.312 Chronic periodontitis, localized, moderate
K05.313 Chronic periodontitis, localized, severe
K05.319 Chronic periodontitis, localized, unspecified severity
K05.321 Chronic periodontitis, generalized, slight
K05.322 Chronic periodontitis, generalized, moderate
K05.323 Chronic periodontitis, generalized, severe
K05.329 Chronic periodontitis, generalized, unspecified severity
A common disease of the oral cavity, involves chronic inflammation of the periodontal tissues
caused by accumulation of profuse amounts of dental plaque. Symptoms may included redness or
bleeding gums while brushing teeth, using dental floss or biting into hard food, recurrent gum
swelling, halitosis (bad breath) and persistent metallic taste in the mouth, gingival recession,
loose teeth; however, it may be painless.
Chapter 11 – Diseases of the digestive system
(K00-K95)
70
NEW codes:
K08.81 Primary occlusal trauma
K08.82 Secondary occlusal trauma
Occlusal trauma results when the occlusal (biting) surface of any of the teeth is altered to
the detriment of the teeth. Primary occlusal trauma occurs when greater than normal
occlusal forces are placed on the teeth such as with bruxism or other chewing/biting habits
involving fingernails, pencils and pens. Secondary occlusal trauma occurs when normal
occlusal forces are placed on teeth with compromised periodontal attachment.
Chapter 11 – Diseases of the digestive system
(K00-K95)
71
NEW codes:
K52.21 Food protein-induced enterocolitis syndrome
• FPIES is a type of food allergy which involves a non-IgE mediated immune reaction in the GI system to
one or more specific foods. Most common foods are cow’s milk and soy. Symptoms include profuse
vomiting and diarrhea. Prolonged exposure to these foods results in poor growth.
K52.22 Food protein-induced enteropathy
• an uncommon malabsorption syndrome of chronic diarrhea, weight loss, and failure to thrive. Most
commonly due to cow’s milk protein intolerance.
K52.29 Other allergic and dietetic gastroenteritis and colitis
• food-related hypersensitivity GI disorders. Symptoms include vomiting, diarrhea, blood in stools, weight
loss, abdominal pain, failure to thrive.
Chapter 11 – Diseases of the digestive system
(K00-K95)
72
NEW codes:
K52.831 Collagenous colitis
K52.832 Lymphocytic colitis
K52.838 Other microscopic colitis
K52.839 Microscopic colitis, unspecified
Relatively rare conditions that are diagnosed when a patient with chronic watery nonbloody diarrhea
with normal radiographic or endoscopic colon but mucosal biopsies show inflammatory changes.
Lymphocytic colitis is characterized by an infiltration of lymphocytes in the colonic epithelium.
Collagenous colitis has the same lymphocytic infiltration but also has a distinctive thickening of the
subepithelial collagen table.
Chapter 11 – Diseases of the digestive system
(K00-K95)
73
NEW codes:
K55.011 Focal (segmental) acute (reversible) ischemia of small intestine
K55.012 Diffuse acute (reversible) ischemia of small intestine
K55.019 Acute (reversible) ischemia of small intestine, extent unspecified
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.039 Acute (reversible) ischemia of large intestine, extent unspecified
K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified
K55.052 diffuse acute (reversible) ischemia of intestine, part unspecified
K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified
Reduced blood flow to the small or large intestine. More common in the elderly. Causes can include
circulation disorders such as low blood pressure or blood vessel stricture or blood clot. Mild to moderate
ischemia is treated with IV fluids, analgesia and bowel rest (no food or water by mouth).
Chapter 11 – Diseases of the digestive system
(K00-K95)
74
NEW codes:
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.029 Acute infarction of small intestine, extent unspecified
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K55.049 Acute infarction of large intestine, extent unspecified
K55.061 Focal (segmental) acute infarction of intestine, part unspecified
K55.062 Diffuse acute infarction of intestine, part unspecified
K55.069 Acute infarction of intestine, part and extent unspecified
Severe ischemia can progress to infarction of the small or large intestine resulting in sepsis, intestinal
gangrene or bowel perforation. Surgery and intensive care are often required.
Chapter 11 – Diseases of the digestive system
(K00-K95)
75
NEW codes:
K55.30 Necrotizing enterocolitis, unspecified
K55.31 Stage 1 necrotizing enterocolitis
K55.32 Stage 2 necrotizing enterocolitis
K55.33 Stage 3 necrotizing enterocolitis
NEC typically occurs in the 2nd-3rd week of life in premature, formula-fed infants. It’s
characterized by variable damage to the intestinal tract ranging from mucosal injury to fullthickness necrosis and perforation. Symptoms include abdominal distention and tenderness,
feeding residuals, gross or occult blood in stool, absent bowel sounds, temperature
instability, glucose instability, lethargy, apnea, bradycardia. Stage 1= suspected NEC, Stage
2 = definite NEC. Stage 3 = Advanced NEC.
Chapter 11 – Diseases of the digestive system
(K00-K95)
76
NEW codes:
K58.1 Irritable bowel syndrome with constipation
K58.2 Mixed irritable bowel syndrome
K58.8 Other irritable bowel syndrome
Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine.
Commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation. It is a
chronic condition. It doesn’t cause changes in bowel tissue or increase colorectal cancer
risk. Symptoms range from mild to severe and it’s managed by diet, lifestyle changes, stress
reduction. Medication and counseling are also used to managed the disorder. Can be IBS-D
(with Diarrhea) or IBS-C (with constipation) or mixed. IBS-D specific codes already defined.
Chapter 11 – Diseases of the digestive system
(K00-K95)
77
NEW codes:
K59.03 Drug induced constipation
Use Additional code for adverse effect, if applicable, to identify drug
K59.04 Chronic idiopathic constipation (CIC)
AKA functional constipation
Constipation can be a side effect (adverse effect) of many drugs, including antacids,
antihistamines, antipsychotic drugs, aspirin, beta blockers, blood pressure medications,
calcium channel blockers, iron or calcium supplements, narcotics (especially opioids),
NSAIDS, and tricyclic antidepressants. Stimulant (e.g. Senna, bisacodyl) and Osmotic (e.g.
Lactulose, glycerin, polyethylene glycol) are more effective than emollient (e.g. docusate or
mineral oil) laxatives for treating drug induced constipation.
CIC is simply defined as the chronic presence of constipation without a defined underlying
cause.
Chapter 11 – Diseases of the digestive system
(K00-K95)
NEW codes:
K85.00 Idiopathic acute pancreatitis without necrosis or infection
K85.01 Idiopathic acute pancreatitis with uninfected necrosis
K85.02 Idiopathic acute pancreatitis with infected necrosis
K85.10 Biliary acute pancreatitis without necrosis or infection
K85.11 Biliary acute pancreatitis with uninfected necrosis
K85.12 Biliary acute pancreatitis with infected necrosis
K85.20 Alcohol induced acute pancreatitis without necrosis or infection
K85.21 Alcohol induced acute pancreatitis with uninfected necrosis
K85.22 Alcohol induced acute pancreatitis with infected necrosis
78
Chapter 11 – Diseases of the digestive system
(K00-K95)
NEW codes (continued):
K85.30 Drug induced acute pancreatitis without necrosis or infection
K85.31 Drug induced acute pancreatitis with uninfected necrosis
K85.32 Drug induced acute pancreatitis with infected necrosis
K85.80 Other acute pancreatitis without necrosis or infection
K85.81 Other acute pancreatitis with uninfected necrosis
K85.82 Other acute pancreatitis with infected necrosis
K85.90 Acute pancreatitis without necrosis or infection, unspecified
K85.91 Acute pancreatitis with uninfected necrosis, unspecified
K85.92 Acute pancreatitis with infected necrosis, unspecified
79
Chapter 11 – Diseases of the digestive system
(K00-K95)
80
NEW codes (continued):
Idiopathic pancreatitis: no cause is identified for the pancreatitis
Acute Biliary pancreatitis: a serious complication of biliary calculous disease
Alcohol induced pancreatitis: pancreatitis related to heavy alcohol consumption
Drug-induced pancreatitis: there is a long list of drugs associated with or found
to be contributing factors to acute pancreatitis
AKA acute necrotizing pancreatitis, acute pancreatitis with necrosis is a serious
related condition. Pancreatic cells die or necrotize during recurring attacks of
pancreatitis. Pancreas can then become invaded with bacteria (infection).
Pancreatic abscess is a late complication of acute necrotizing pancreatitis.
Chapter 11 – Diseases of the digestive system
(K00-K95)
81
NEW codes:
K86.81 Exocrine pancreatitic insufficiency
K86.89 Other specified diseases of pancreas
Exocrine pancreatic insufficiency (EPI) is characterized by the deficiency of the exocrine
pancreatitic enzymes and results in the inability to digest food properly. Signs and symptoms of
this condition are not always evident or similar to those of other GI diseases or are due to dietary
restrictions
K90.41 Non-celiac gluten sensitivity
Gluten sensitivity NOS
Gluten sensitivity describes individuals who can’t tolerate gluten and experience symptoms
similar to that of celiac disease but lack the same antibodies and intestinal damage that’s
present in celiac disease.
K90.49 Malabsorption due to intolerance, not elsewhere classified
Malabsorption (prevention of absorption of nutrients and fluids in the bowel) due to other types
of intolerance such as lactose or fructose intolerance.
Chapter 12 – Diseases of the skin and
subcutaneous tissue (L00-L99)
82
REVISIONS to and Additions to instructional and excludes notes
Mostly technical corrections (e.g., stasis dermatitis (I83.1-.2) to (I87.2)
NEW CODES:
L98.7 Excessive and redundant skin and subcutaneous tissue
Loose or sagging skin following bariatric surgery weight loss
Loose or sagging skin following dietary weight loss
Loose or sagging skin, NOS
• Typically excessive and redundant skin and subcutaneous tissue occurs after massive weight loss
• Might also be used with cosmetic procedures
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
• Excludes 1 corrected to Excludes 2:
M1A Chronic Gout: acute gout (M10.-)
M10 Gout: chronic gout (M1A.-)
• Instructional Note Added: M62.84 Sarcopenia (Code first underlying disease, if
applicable)
• Includes note added:
M48.5 Collapsed vertebra, not elsewhere classified
Compression fracture of vertebra NOS
• Excludes 1 note added:
M62.5 Muscle wasting and atrophy, not elsewhere classified
Excludes 1: muscle weakness in sarcopenia (M62.84)
83
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
84
• Excludes 2 note added:
M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system,
not elsewhere classified
Excludes 2: periprosthethic fracture around internal prosthetic joint (M97.-)
M97 Periprosthetic fracture around internal prosthetic joint
Excludes 2: fracture of bone following insertion of orthopedic implant, joint prosthesis or bone plate
(M96.6-); breakage (fracture of prosthetic joint (T84.01-)
• REVISIONS to and ADDITIONS to instructional and excludes notes
Technical corrections
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
85
NEW codes:
M04.1 Periodic fever syndromes
Includes Familial Mediterranean fever, Hyperimmunoglobulin D syndrome, Mevalonate kinase
deficiency, and Tumor necrosis factor receptor associated periodic syndrome (TRAPS)
M04.2 Cryoprin-associated periodic syndromes
Includes Chronic infantile neurological, cutaneous and articular syndrome (CINCA), Familial
cold autoinflammatory syndrome, Familial cold urticaria, Muckle-Wells syndrome, and Neonatal onset
multisystemic inflammatory disorder (NOMID)
M04.8 Other autoinflammatory sydnromes
Includes Blau syndrome, Deficiency of interleukin 1 receptor antagonist (DIRA), Majeed
syndrome, Periodic fever, apthous stomatitis, pharyngitis, and adenopathy syndrome (PFAPA),
Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (PAPA)
M04.9 Autoinflammatory syndrome, unspecified
Autoinflammatory syndromes have frequent recurring, often cyclic, fevers with affects on a number of
organs and tissues; rash, headache, vomiting, diarrhea, mouth ulcers, swollen lymph nodes, abdominal and joint
pains and fatigue are common
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
86
NEW codes:
M21.61 Bunion
with laterality (right/left/unspecified), M21.611, M21.612, M21.619
M21.62 Bunionette
•
•
•
•
•
with laterality (right/left/unspecified), M21.621, M21.622, M21.629
“Bunion” removed as an includes term from Hallux valgus (M20.1)
“Bunion” is a bump on the side of the foot with the big toe
“Bunion” is the deformity known as a hallux abducto valgus that is characterized by a medial
deviation of the first metatarsal bone and lateral deviation of the hallux (ie, big toe)
“Bunionette” or Tailor’s bunion is found on the little toe on the outside (contralateral from
the bunion) of the foot
“Bunionette” is a prominence on the lateral aspect of the fifth metatarsal head
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
87
NEW Codes:
M25.54 Pain in joints of hand
with laterality (right, left, unspecified) (M25.541, M25.542, M25.549)
• Hand joint pain not present; currently just assigned to hand pain (not specific to joint)
M26.60 Temporomandibular joint disorder, unspecified
M26.61 Adhesions and ankyloses of temporomandibular joint
M26.62 Arthralgia of temporomandibular joint
M26.63 Articular disc disorder of temporomandibular joint
added laterality to all of the above (right, left, bilateral, unspecified)
M26.601, M26.602, M26.603, M26.609, M26.611, M26.612, M26.613, M26.619, M26.621,
M26.622, M26.623, M26.629, M26.631, M26.632, M26.633, M26.639
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
NEW codes:
• Increased specificity for levels:
M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level
M50.021 Cervical disc disorder at C4-C5 level with myelopathy
M50.022 Cervical disc disorder at C5-C6 level with myelopathy
M50.023 Cervical disc disorder at C6-C7 level with myelopathy
M50.120 Mid-cervical disc disorder, unspecified
M50.121 Cervical disc disorder at C4-C5 level with radiculopathy
M50.122 Cervical disc disorder at C5-C6 level with radiculopathy
M50.123 Cervical disc disorder at C6-C7 level with radiculopathy
88
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
NEW codes:
• Increased specificity for levels:
M50.220 Other cervical disc displacement, mid-cervical region, unspecified level
M50.221 Other cervical disc displacement at C4-C5 level
M50.222 Other cervical disc displacement at C5-C6 level
M50.223 Other cervical disc displacement at C6-C7 level
M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level
M50.321 Other cervical disc degeneration at C4-C5 level
M50.322 Other cervical disc degeneration at C5-C6 level
M50.323 Other cervical disc degeneration at C6-C7 level
89
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
NEW codes:
• Increased specificity for levels:
M50.820 Other cervical disc disorders, mid-cervical region, unspecified level
M50.821 Other cervical disc disorders at C4-C5 level
M50.822 Other cervical disc disorders at C5-C6 level
M50.823 Other cervical disc disorders at C6-C7 level
M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level
M50.921 Unspecified cervical disc disorder at C4-C5 level
M50.922 Unspecified cervical disc disorder at C5-C6 level
M50.923 Unspecified cervical disc disorder at C6-C7 level
90
Chapter 13 – Diseases of the musculoskeletal
system and connective tissue (M00-M99)
91
NEW codes:
M84.75 Atypical femoral fracture
with laterality (right, left, unspecified) and specificity (incomplete, complete transverse,
complete oblique) and 7th characters for fractures (A, D, G, K, P, S)
M84.750, M84.751, M84.752, M84.753, M84.754, M84.755, M84.756, M84.757, M84.758,
M84.759
M97.- Periprosthetic fracture around internal prosthetic joint
with laterality (right, left) and specificity (hip, knee, ankle, shoulder, elbow, other and
unspecified) and 7th characters for fractures (A, D, S)
M97.01, M97.02, M97.11, M97.12, M97.21, M97.22, M97.31, M97.32, M97.41, M97.42, M97.8,
M97.9
Chapter 14: Diseases of the genitourinary
system (N00-N99)
92
• Revised code titles:
N10 Acute tubulo-interstitial nephritis pyelonephritis
N40.0 Enlarged prostate Benign prostatic hyperplasia without lower urinary tract symptoms
N40.1 Enlarged prostate Benign prostatic hyperplasia with lower urinary tract symptoms
N52.39 Other post-surgical and unspecified postprocedural erectile dysfunction
N99.113 Postprocedural anterior bulbous urethral stricture
N99.520 Hemorrhage of other incontinent external stoma of urinary tract
N99.521 Infection of other incontinent external stoma of urinary tract
N99.522 Malfunction of other incontinent external stoma of urinary tract
N99.528 Other complication of other incontinent external stoma of urinary tract
N99.530 Hemorrhage of other continent stoma of urinary tract
N99.531 Infection of other continent stoma of urinary tract
N99.532 Malfunction of other continent stoma of urinary tract
N99.538 Other complication of other continent stoma of urinary tract
Chapter 14: Diseases of the genitourinary
system (N00-N99)
• REVISIONS to and ADDITIONS to instructional and excludes notes
Technical corrections (e.g. urethroscrotal fistula (N50.8) to (N50.89)
• Instructional Note Added:
N39.42 Incontinence without sensory awareness
Insensible (urinary) incontinence
• Excludes 1 note Added:
M36.8 Other specified disorders of urethra
Excludes 1: congenital urethrocele (Q64.7); female urethrocele (N81.0)
93
Chapter 14: Diseases of the genitourinary
system (N00-N99)
94
NEW codes:
N13.0 Hydronephrosis with ureteropelvic junction obstruction
Hydronephrosis due to acquired occlusion of ureteropelvic junction
Excludes 2: Hydronephrosis with ureteropevlic junction obstruction due to calculus (N13.2)
N39.491 Coital incontinence
N39.492 Postural (urinary) incontinence
• Coital incontinence: involuntary loss of urine with sexual intercourse
• Postural incontinence: involuntary loss of urine with change of body position (eg. Rising from a seated or lying
position)
N42.30 Unspecified dysplasia of prostate
N42.31 Prostatic intraepithelial neoplasia
N42.32 Atypical small acinar proliferation of prostate
N42.39 Other dysplasia of prostate
• Precancerous forms of prostate tissue
Chapter 14: Diseases of the genitourinary
system (N00-N99)
NEW codes:
N50.81 Testicular pain
with laterality (right, left, unspecified) N50.811, N50.812, N50.819
N50.82 Scrotal pain
N50.89 Other specified disorders of the male genital organs
• Increased specificity for sites of male genital organ pain
95
Chapter 14: Diseases of the genitourinary
system (N00-N99)
NEW codes:
N52.35 Erectile dysfunction following radiation therapy
N52.36 Erectile dysfunction following interstitial seed therapy
N52.37 Erectile dysfunction following prostate ablative therapy
• Increased specificity for types of postprocedural erectile dysfunction
N61.0 Mastitis without abscess
N61.1 Abscess of the breast and nipple
• Increased specificity for abscess of breast/nipple
96
Chapter 14: Diseases of the genitourinary
system (N00-N99)
97
NEW codes:
N83.0- Follicular cyst of ovary
N83.1- Corpus luteum cyst of ovary
N83.20- Unspecified ovarian cyst
N83.29- Other ovarian cysts
N83.31- Acquired atrophy of ovary
N83.32- Acquired atrophy of fallopian tube
N83.33- Acquired atrophy of ovary and fallopian tube
N83.4- Proplase and hernia of ovary and fallopian tube
N83.51- Torsion of ovary and ovarian pedicle
N83.52- Torsion of fallopian tube
laterality added (right, left, unspecified)
N83.00, N83.01, N83.02, N83.10, N83.11, N83.12, N83.201, N83.202, N83.209, N83.291, N83.292,
N83.299, N83.311, N83.312, N83.319, N83.321, N83.322, N83.329, N83.331, N83.332, N83.339, N83.40,
N83.41, N83.42, N83.511, N83.512, N83.519, N83.521, N83.522, N83.529
Chapter 14: Diseases of the genitourinary
system (N00-N99)
98
NEW codes:
N90.60 Unspecified hypertrophy of vulva
N90.61 Childhood asymmetric labium majus enlargement
N90.69 Other specified hypertrophy of vulva
• Enlargement of the labia
• Usually affects the inner labia (labia minora) but can also affect the outer labia (labia majora)
• Can be asymetrical, affecting only one side
• Symptoms range from none to irritation
Chapter 14: Diseases of the genitourinary
system (N00-N99)
99
NEW codes:
N93.1 Pre-pubertal vaginal bleeding
• Can be associated with genital redness, itching, discharge, and pain
• Must be distinguished from injury due to sexual abuse
N94.10 Unspecified dyspareunia
N94.11 Superficial (introtial) dyspareunia
N94.12 Deep dyspareunia
N94.19 Other specified dyspareunia
• Increased specificity
• “Painful intercourse” – persistent or recurrent genital pain before/during/after intercourse
• Causes range from structural to psychological
Chapter 14: Diseases of the genitourinary
system (N00-N99)
NEW codes:
N99.115 Postprocedural fossa navicularis urethral stricture
N99.523 Herniation of incontinent stoma of urinary tract
N99.524 Stenosis of incontinent stoma of urinary tract
N99.533 Herniation of continent stoma of urinary tract
N99.534 Stenosis of continent stoma of urinary tract
• Increased specificity
100
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
101
• Instructional note revisions:
Use addition code from category Z3A, Weeks of gestation, to identify the
specific week of the pregnancy, if known.
O24.0- Premature rupture of membranes, onset of labor within 24 hours of rupture
Premature rupture of membranes at or after 37 completed weeks of gestation, onset
of labor within 24 hours of rupture
• Excludes 2 note additions/revisions:
O09.81 Supervision of pregnancy resulting from assisted reproductive technology
Excludes 2: gestational carrier status (Z33.3)
• Excludes 1 note additions/revisions:
O99.82 Streptococcus B carrier state complicating pregnancy, childbirth and the puerperium
Excludes 1: Carrier of streptococcus group B (GBS) in a nonpregnant woman (Z22.330)
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
102
• Code title revisions:
O09.1- Supervision of pregnancy with history of ectopic or molar pregnancy
O15.0- Eclampsia in complicating pregnancy
O15.1 Eclampsia in complicating labor
O15.2 Eclampsia in complicating the puerperium
O24.0- Pre-existing type 1 diabetes mellitus, type 1, in pregnancy, childbirth and the
puerperium
O24.1- Pre-existing type 2 diabetes mellitus, type 2, in pregnancy, childbirth and the
puerperium
O44.0- Complete Placenta previa specified as NOS or without hemorrhage
O44.1- Complete Placenta previa with hemorrhage
O99.33- Tobacco use disorder Smoking (tobacco) complicating pregnancy, childbirth, and the
puerperium
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
• 7th characters Added:
O33.7 Maternal care for disproportion due to other fetal deformities
0-5, 9 for single gestation and multiple gestations where the fetus is specified
• Includes notes added:
O34.0 Maternal care for congenital malformation of uterus
Maternal care for double uterus, Maternal care for uterus bicornis
O34.29 Maternal care due to uterine scar from other previous surgery
Maternal care due to uterine scar from other transmural uterine incision
103
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
NEW codes:
O00.00 Abdominal pregnancy without intrauterine pregnancy
O00.01 Abdominal pregnancy with intrauterine pregnancy
O00.10 Tubal pregnancy without intrauterine pregnancy
O00.11 Tubal pregnancy with intrauterine pregnancy
O00.20 Ovarian pregnancy without intrauterine pregnancy
O00.21 Ovarian pregnancy with intrauterine pregnancy
O00.80 Other ectopic pregnancy without intrauterine pregnancy
O00.81 Other ectopic pregnancy with intrauterine pregnancy
O00.90 Unspecified ectopic pregnancy without intrauterine pregnancy
O00.91 Unspecified ectopic pregnancy with intrauterine pregnancy
• Codes added to distinguish ectopic pregnancies with or without intrauterine pregnancy
104
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
NEW codes:
105
O09.A- Supervision of pregnancy with history of molar pregnancy
with specificity for trimester (first, second, third, unspecified)
Code O09.1- Revised to remove “molar” from code description
O11.4 Pre-existing hypertension with pre-eclampsia, complicating childbirth
O11.5 Pre-existing hypertension with pre-eclampsia, complicating the puerperium
O12.04 Gestational edema, complicating childbirth
O12.05 Gestational edema, complicating the puerperium
O12.14 Gestational proteinuria, complicating childbirth
O12.15 Gestational proteinuria, complicating the puerperium
O12.24 Gestational edema with proteinuria, complicating childbirth
O12.25 Gestational edema with proteinuria, complicating the puerperium
O13.4 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating
childbirth
O13.5 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating
the puerperium
• Added time periods for childbirth and puerperium complications
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
NEW codes:
O14.04 Mild to moderate pre-eclampsia, complicating childbirth
O14.05 Mild to moderate pre-eclampsia, complicating the puerperium
O14.14 Severe pre-eclampsia complicating childbirth
O14.15 Severe pre-eclampsia complicating the puerperium
O14.24 HELLP syndrome, complicating childbirth
O14.25 HELLP syndrome, complicating the puerperium
O14.94 Unspecified pre-eclampsia, complicating childbirth
O14.95 Unspecified pre-eclampsia, complicating the puerperium
O16.4 Unspecified maternal hypertension, complicating childbirth
O16.5 Unspecified maternal hypertension, complicating the puerperium
• Added time periods for childbirth and puerperal complications
106
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
NEW codes:
107
O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs
O24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs
O24.435 Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs
• See Coding Guideline I.C.15.i. Gestational (pregnancy induced) diabetes
O33.7xx- Maternal care for disproportion due to other fetal deformities
added 7th character for single and multiple gestations where the fetus is specified
O44.2- Partial placenta previa without hemorrhage
O44.3- Partial placenta previa with hemorrhage
O44.4- Low lying placenta NOS or without hemorrhage
O44.5- Low lying placenta with hemorrhage
• Placenta previa is distinguished between partial and total coverage of the
cervix, either can be accompanied or not by hemorrhage. Low lying
placenta is a placenta attached to the lower part of the uterus near to but
not covering the cervix, also may/may not be associated with hemorrhage
Chapter 15 – Pregnancy, childbirth and the
puerperium (O00-O9A)
NEW codes:
O70.20 Third degree perineal laceration during delivery, unspecified
O70.21 Third degree perineal laceration during delivery, IIIa
O70.22 Third degree perineal laceration during delivery IIIb
O70.23 Third degree perineal laceration during delivery III
• Three subcategories of third-degree tear or laceration are now specified:
• 3a: partial tear of the external anal sphincter involving less than 50% thickness
• 3b: greater than 50% tear of the external anal sphincter
• 3c: internal sphincter is torn
108
Chapter 16 – Certain conditions originating in
the perinatal period (P00-P96)
109
Code REVISIONS:
P00- Newborn (suspected to be) affected by maternal conditions that may be unrelated to present
pregnancy
P01- Newborn (suspected to be) affected by maternal complications of pregnancy
P02- Newborn (suspected to be) affected by complications of placenta, cord and membranes
P03- newborn (suspected to be) affected by other complications of labor and delivery
P04- newborn (suspected to be) affected by noxious substances transmitted via placenta or breast
milk
Explanation: new code created to capture the newborns with suspected conditions ruled out:
Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions
rule out
Chapter 16 – Certain conditions originating in
the perinatal period (P00-P96)
110
• Excludes 1 additions:
P07.0 Extremely low birth weight newborn
P07.1 Other low birth weight newborn
Excludes 1: low birth weight due to slow fetal growth and fetal malnutrition (P05.-)
NEW codes:
P05.09 Newborn light for gestational age, 2500 grams and over
P05.19 Newborn small for gestation age, other
• Returned the 2,500 gram and over code option to this category
Chapter 17 – Congenital malformations, deformations
and chromosomal abnormalities (Q00-Q99)
111
• Includes note additions/revisions:
Q25.1 Coarctation of aorta
Stenosis of aorta
Q82.6 Congenital sacral dimple
Parasacral dimple
• Excludes 2 note additions/revisions:
Q82.6 Congenital sacral dimple
Excludes 2: pilonidal cyst with abscess (L05.01); pilonidal cyst without abscess (L05.91)
Chapter 17 – Congenital malformations, deformations
and chromosomal abnormalities (Q00-Q99)
NEW codes:
Q25.21 Interruption of aortic arch
Q25.29 Other atresia of aorta
Q25.40 Congenital malformation of aorta unspecified
Q25.41 Absence and aplasia of aorta
Q25.42 Hypoplasia of aorta
Q25.43 Congenital aneurysm of aorta
Q25.44 Congenital dilation of aorta
Q25.45 double aortic arch
Q25.46 Tortuous aortic arch
Q25.47 Right aortic arch
Q25.48 Anomalous origin of subclavian artery
Q25.49 Other congenital malformations of artery
• Specific abnormalities (congenital) of the aorta
112
Chapter 17 – Congenital malformations, deformations
and chromosomal abnormalities (Q00-Q99)
113
NEW codes:
Q52.120 Longitudinal vaginal septum, nonobstructing
Q52.121 Longitudinal vaginal septum, obstructing, right side
Q52.122 Longitudinal vaginal septum, obstructing, left side
Q52.123 Longitudinal vaginal septum, microperforate, right side
Q52.124 Longitudinal vaginal septum, microperforate, left side
Q52.129 Other and unspecified longitudinal vaginal septum
• A vaginal septum occurs when the female reproductive tract does not develop and merge
correctly, creating a dividing wall of tissue inside the vagina
• The condition may block normal menstrual flow, may cause pain during intercourse, or be
asymptomatic
Chapter 17 – Congenital malformations, deformations
and chromosomal abnormalities (Q00-Q99)
114
NEW codes:
Q66.21 Congenital metatarsus primus varus
• A congenital deformity of the foot in which the forepart rotates inward toward the midline of the
body and the heel remains straight
Q66.22 Congenital metatarsus adductus
Congenital metatarsus varus
• A congenital deformity with adduction of the forefoot at the tarsometatarsal joint
Q87.82 Arterial tortuosity syndrome
• A disorder that affects connective tissue; it is characterized by blood vessel abnormalities that carry
blood from the heart to the rest of the body; tortuosity arises from abnormal elongation of the arteries;
the extra length twists and curves and may result in constriction (stenosis) and bulging (aneurysms) of
the vessels, as well as small clusters of enlarged blood vessels just under the skin (telangiectasia).
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
115
• Excludes 1 corrected to Excludes 2:
R00 Abnormalities of heart beat: I47-I49
R01 Cardiac murmur, unspecified: Q40.0, K92.0-K92.2, K56.-, P54.0-P54.3,
K31.3, R30-R39, N94.-, N48-N50
Symptoms and signs involving the digestive system and abdomen (R10-R19)
Q40.0, K92.0-K92.2, K56.-, P54.0-P54.3, P76.-, K31.3, R30-R39, N94.-, N48-N50
Symptoms and signs involving cognition, perception, emotional state and
behavior (R40-R46)
Symptoms and signs constituting part of a pattern of mental disorder
F01-F99
Abnormal findings on examination of blood, without diagnosis (R70-R79):
O28.-, D69.-, D70-D72, D65-D68, P50-P61
R93.4 Abnormal findings on diagnostic imaging of urinary organs: N28.81
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
116
• Includes terms additions/revisions:
R01.1 Cardiac murmur, unspecified
Systolic murmur NOS
• Instructional note change to “Note”
R40.24 Glasgow coma scale, total score
NOTE: Assign a code from subcategory R40.24 when only the total coma score is documented
• Excludes 1 note additions/revisions:
R41.84 Other specified cognitive deficit
Excludes 1: cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-,
I69.21-, I69.31-, I69.81-, I69.91-)
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
117
NEW codes:
R29.70 NIHSS score 0-9
R29.71 NIHSS score 10-19
R29.72 NIHSS score 20-29
R29.73 NIHSS score 30-39
R29.74 NIHSS score 40-42
with specificity to assign exact NIHSS score R29.700, R29.701, R29.702, R29.703, R29.704,
R29.705, R29.706, R29.707, R29.708, R29.709, R29.710, R29.711, R29.712, R29.713, R29.714, R29.715,
R29.716, R29.717, R29.718, R29.719, R29.720, R29.721, R29.722, R29.723, R29.724, R29.725, R29.726,
R29.727, R29.728, R29.729, R29.730, R29.731, R29.732, R29.733, R29.734, R29.735, R29.736, R29.737,
R29.738, R29.739, R29.740, R29.741, R29.742
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
118
NEW codes:
R31.21 Asymptomatic microscopic hematuria
• Presence of three or more red blood cells per HPF visible in a urine specimen
• No symptoms: common causes include urinary tract infection, benign prostatic hyperplasia,
urinary calculi; 5% found to have urologic malignancy
R31.29 Other microscopic hematuria
R39.191 Need to immediately re-void
R39.192 Position dependent micturition
R39.198 Other difficulties with micturition
• Increased specificity for urination/micturition difficulties
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
NEW codes:
R39.82 Chronic bladder pain
R40.24-Glasgow coma scale, total score
Added 7th character:
0
1
2
3
4
unspecified
in the field [EMT or ambulance]
at arrival to emergency department
at hospital admission
24 hours or more after hospital admission
R73.03 Prediabetes
• Higher than normal blood sugar but not high enough to be classified as diabetes
• A1c 5.7%-6.4%; fasting plasma glucose (FPG) 100-125 mg/dl; GTT 140-199 mg/dl
• AKA impaired glucose tolerance or impaired fasting glucose
119
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
NEW codes:
R82.71 Bacteriuria
R82.79 Other abnormal findings on microbiological examination of urine
• Bacteriuria: presence of bacteria in urine
R93.41 Abnormal radiologic findings on imaging of renal pelvis, ureter or bladder
R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
R93.422 Abnormal radiologic findings on diagnostic imaging of left kidney
R93.429 Abnormal radiologic findings on diagnostic imaging of unspecified kidney
R93.49 Abnormal radiologic findings on diagnostic imaging of other urinary organs
120
Chapter 18 – Symptoms, signs and abnormal
clinical findings, not elsewhere classified (R00-R99)
NEW codes:
R97.20 Elevated prostate specific antigen [PSA]
R97.21 Rising PSA following treatment for malignant neoplasm of prostate
121
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
• Excludes 1 changed to Excludes 2:
T78.05 Anaphylactic reaction due to tree nuts and seeds: T78.01
• NEW includes note:
T82.855 Stenosis of coronary artery stent
In-stent stenosis (restenosis) of coronary artery stent
Restenosis of coronary artery stent
T82.856 Stenosis of peripheral vascular stent
In-stent stenosis (restenosis) of peripheral vascular stent
Restenosis of peripheral vascular stent
122
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
123
LATERALITY ADDED:
S02.10- Unspecified fracture of base of skull
S02.3- Fracture of orbital floor
S02.40- Fracture of malar, maxillary, and zygoma bones
S02.6- Fracture of mandible
S03.0- Dislocation of jaw
S03.4- Sprain of jaw
LATERALITY AND SPECIFICITY ADDED:
S02.11- Fracture of occiput
• Type I, II, and III occipital condyle fractures (Anderson and Montesano classification Type I =
impaction, Type II = basilar skull, Type III = occipital condyle avulsion)
S99.0- Physeal fracture of calcaneus
S99.1- Physeal fracture of metatarsal
S99.2- Physeal fracture of phalanx of toe
• Salter-Harris Types I, II, III, and IV, and other and unspecified physeal fractures
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
CODES DELETED:
124
S06.0x2 to S06.0x8 Concussion with loss of consciousness of 31 minutes to 59 minutes to Concussion
with loss of consciousness of any duration with death due to other cause prior to regaining
consciousness
T84.04- Periprosthetic fracture around internal prosthetic joint
CODE TITLES REVISED:
T82.81- Embolism due to of cardiac and vascular prosthetic devices, implants and grafts
T82.82- Fibrosis due to of cardiac and vascular prosthetic devices, implants and grafts
T82.83- Hemorrhage due to of cardiac and vascular prosthetic devices, implants and grafts
T82.84- Pain due to from cardiac and vascular prosthetic devices, implants and grafts
T82.85- Stenosis due to of cardiac and vascular prosthetic devices, implants and grafts
T82.857 Stenosis of other vascular prosthetic devices, implants and grafts
T82.858 Stenosis of other vascular prosthetic devices, implants and grafts
T82.867 Thrombosis due to of cardiac prosthetic devices, implants and grafts
T82.868 Thrombosis due to of vascular prosthetic devices, implants and grafts
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
125
CODE TITLES REVISED:
T83.711 Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or
tissue
T83.718 Erosion of other implanted mesh and other prosthetic materials to surrounding organ or
tissue
T83.721 Exposure of implanted vaginal mesh and other prosthetic materials into vagina
T83.728 Exposure of other implanted mesh and other prosthetic materials to surrounding organ or
tissue
T83.81 Embolism due to of genitourinary prosthetic devices, implants and grafts
T83.82 Fibrosis due to of genitourinary prosthetic devices, implants and grafts
T83.83 Hemorrhage due to of genitourinary prosthetic devices, implants and grafts
T83.84 Pain due to from genitourinary prosthetic devices, implants and grafts
T83.85 Stenosis due to of genitourinary prosthetic devices, implants and grafts
T83.86 Thrombosis due to of genitourinary prosthetic devices, implants and grafts
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
126
CODE TITLES REVISED:
T85.110 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of brain
electrode (lead)
T85.111 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of
peripheral nerve electrode (lead)
T85.112 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of spinal
cord electrode (lead)
T85.120 Displacement of implanted electronic neurostimulator (electrode) of brain electrode
(lead)
T85.121 Displacement of implanted electronic neurostimulator (electrode) of peripheral nerve
electrode (lead)
T85.122 Displacement of implanted electronic neurostimulator (electrode) of spinal cord electrode
(lead)
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
127
CODE TITLES REVISED:
T85.190 Other mechanical complication of implanted electronic neurostimulator (electrode) of
brain electrode (lead)
T85.191 Other mechanical complication of implanted electronic neurostimulator (electrode) of
peripheral nerve electrode (lead)
T85.192 Other mechanical complication of implanted electronic neurostimulator (electrode) of
spinal cord electrode (lead)
T85.610 Breakdown (mechanical) of epidural and subdural cranial or spinal infusion catheter
T85.620 Displacement of epidural and subdural cranial or spinal infusion catheter
T85.630 Leakage of epidural and subdural cranial or spinal infusion catheter
T85.690 Other mechanical complication of epidural and subdural cranial or spinal infusion catheter
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
NEW codes:
S92.81- Other fracture of foot
with laterality (right, left, unspecified)
T83.011 Breakdown (mechanical) of indwelling urethral catheter
T83.012 Breakdown (mechanical) of nephrostomy catheter
T83.021 Displacement of indwelling urethral catheter
T83.022 Displacement of nephrostomy catheter
T83.031 Leakage of indwelling urethral catheter
T83.032 Leakage of nephrostomy catheter
T83.091 Other mechanical complication of indwelling urethral catheter
T83.092 Other mechanical complication of nephrostomy catheter
T83.24 Erosion of graft of urinary organ
T83.25 Exposure of graft of urinary organ
• Added specificity for catheter and graft complications
128
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
NEW codes:
129
T83.510 Infection and inflammatory reaction due to cystostomy catheter
T83.511 Infection and inflammatory reaction due to indwelling urethral catheter
T83.512 Infection and inflammatory reaction due to nephrostomy catheter
T83.518 Infection and inflammatory reaction due to other urinary catheter
T83.590 Infection and inflammatory reaction due to implanted urinary neurostimulation device
T83.591 Infection and inflammatory reaction due to implanted urinary sphincter
T83.592 Infection and inflammatory reaction due to indwelling ureteral stent
T83.593 Infection and inflammatory reaction due to other urinary stents
T83.598 Infection and inflammatory reaction due to other prosthetic device, implant and graft in
urinary system
T83.61 Infection and inflammatory reaction due to implanted penile prosthesis
T83.62 Infection and inflammatory reaction due to implanted testicular prosthesis
T83.69 Infection and inflammatory reaction due to other prosthetic device, implant and graft in
genital tract
• Added specificity for catheters, stents, prostheses, implants, devices complications
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
130
NEW codes:
T83.712 Erosion of implanted urethral mesh to surrounding organ or tissue
T83.713 Erosion of implanted urethral bulking agent to surrounding organ or tissue
T83.719 Erosion of other prosthetic materials to surrounding organ or tissue
T83.722 Exposure of implanted urethral mesh into urethra
T83.723 Exposure of implanted urethral bulking agent into urethra
T83.724 Exposure of implanted ureteral bulking agent into ureter
T83.729 Exposure of other prosthetic materials into organ or tissue
T83.79 Other specified complication due to other genitourinary prosthetic materials
T85.123 Displacement of implanted electronic neurostimulator, generator
T85.193 Other mechanical complication of implanted electronic neurostimulator,
generator
• Added specificity implant complications
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
NEW codes:
131
T85.615 Breakdown (mechanical) of other nervous system device, implant or graft
T85.625 Displacement of other nervous system device, implant or graft
T85.635 Leakage of other nervous system device, implant or graft
T85.695 Other mechanical complication of other nervous system device, implant or graft
T85.730 Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt
T85.731 Infection and inflammatory reaction due to implanted electronic neurostimulator of brain,
electrode (lead)
T85.732 Infection and inflammatory reaction due to implanted electronic neurostimulator of
peripheral nerve, electrode (lead)
T85.733 Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal
cord, electrode (lead)
T85.734 Infection and inflammatory reaction due to implanted electronic neurostimulator,
generator
T85.735 Infection and inflammatory reaction due to cranial or spinal infusion catheter
T85.738 Infection and inflammatory reaction due to other nervous system device, implant or graft
• Added specificity for complications
Chapter 19 – Injury, poisoning and certain other
consequences of external causes (S00-T88)
NEW codes:
132
T85.810 Embolism due to nervous system prosthetic devices, implants and grafts
T85.818 Embolism due to other internal prosthetic devices, implants and grafts
T85.820 Fibrosis due to nervous system prosthetic devices, implants and grafts
T85.828 Fibrosis due to other internal prosthetic devices, implants and grafts
T85.830 Hemorrhage due to nervous system prosthetic devices, implants and grafts
T85.838 Hemorrhage due to other internal prosthetic devices, implants and grafts
T85.840 Pain due to nervous system prosthetic devices, implants and grafts
T85.848 Pain due to other internal prosthetic devices, implants and grafts
T85.850 Stenosis due to nervous system prosthetic devices, implants and grafts
T85.858 Stenosis due to other internal prosthetic devices, implants and grafts
T85.860 Thrombosis due to nervous system prosthetic devices, implants and grafts
T85.868 Thrombosis due to other internal prosthetic devices, implants and grafts
T85.890 Other specified complication of nervous system prosthetic devices, implants and grafts
T85.898 Other specified complication of other internal prosthetic devices, implants and grafts
T85.53 Unintended awareness under general anesthesia during procedure
• Added specificity for complications
Chapter 20 – External causes of morbidity
(V00-Y99): HIGHLIGHTS ONLY
133
NEW CODES
W26.2 Contact with edge of stiff paper
Paper cut
W26.8 Contact with other sharp object(s), not elsewhere classified
Contact with tin can lid
W26.9 Contact with unspecified sharp object(s)
• DELETED: W45.1 Paper entering through skin (Paper cut) and W45.2 Lid of can entering through
skin
X50.0 Overexertion from strenuous movement or load
X50.1 Overexertion from prolonged static or awkward postures
X50.3 Overexertion from repetitive movements
X50.9 Other and unspecified overexertion or strenuous movements or postures
• Added missing overexertion code(s)
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
134
• Excludes 1 corrected to Excludes 2:
Z12.4 Encounter for screening for malignant neoplasm of cervix: Z11.51
Z99.2 Dependence on renal dialysis: Z91.15
• Includes note added:
Z45.01 Encounter for adjustment and management of cardiac pacemaker
Encounter for adjustment and management of cardiac resynchronization therapy
pacemaker (CRT-P)
Z45.02 encounter for adjustment and management of automatic implantable cardiac
defibrillator
Encounter for adjustment and management of cardiac resynchronization therapy
defibrillator (CRT-D)
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
135
NEW codes:
Z05.0 Observation and evaluation of newborn for suspected cardiac condition ruled out
Z05.1 Observation and evaluation of newborn for suspected infectious condition ruled out
Z05.2 Observation and evaluation of newborn for suspected neurological condition ruled out
Z05.3 Observation and evaluation of newborn for suspected respiratory condition ruled out
Z05.41 Observation and evaluation of newborn for suspected genetic condition ruled out
Z05.42 Observation and evaluation of newborn for suspected metabolic condition ruled out
Z05.43 Observation and evaluation of newborn for suspected immunologic condition ruled out
Z05.5 Observation and evaluation of newborn for suspected gastrointestinal condition ruled out
Z05.6 Observation and evaluation of newborn for suspected genitourinary condition ruled out
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
136
NEW codes:
Z05.71 Observation and evaluation of newborn for suspected skin and subcutaneous tissue
condition ruled out
Z05.72 Observation and evaluation of newborn for suspected musculoskeletal condition ruled out
Z05.73 Observation and evaluation of newborn for suspected connective tissue condition ruled
out
Z05.8 Observation and evaluation of newborn for other specified suspected condition ruled out
Z05.9 Observation and evaluation of newborn for unspecified condition ruled out
• See Coding Guidelines I.C.16.b. Observation and Evaluation of Newborns for Suspected
Conditions not Found and I.C.21.c(6) Observation for specific usage and sequencing guidance.
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
137
NEW codes:
Z19.1 Hormone sensitivity malignancy status
Z19.2 Hormone resistant malignancy status
• Certain cancers are hormone sensitive or dependent, ie, they need hormones to grow or
develop. Hormone therapies can slow or stop the growth of these cancers
Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV)
Z29.12 Encounter for prophylactic antivenim
Z29.13 Encounter for prophylactic Rho(D) immune globulin
Z29.14 Encounter for prophylactic rabies immune globin
Z29.3 Encounter for prophylactic fluoride administration
Z29.8 Encounter for other specified prophylactic measures
Z29.9 Encounter for prophylactic measures, unspecified
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
138
NEW codes:
Z30.015 Encounter for initial prescription of vaginal ring hormonal contraceptive
Z30.016 Encounter for initial prescription of transferal patch hormonal contraceptive device
Z30.017 encounter for initial prescription of implantable subdermal contraceptive
Z30.018 Encounter for initial prescription of other contraceptives
Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device
Z30.45 Encounter for surveillance of transdermal patch hormonal contraceptive device
Z30.46 Encounter for surveillance of implantable subdermal contraceptive
Z30.49 Encounter for surveillance of other contraceptives
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
139
NEW codes:
Z31.7 Encounter for procreative management and counseling for gestational carrier
Z33.3 Pregnant state, gestational carrier
• Codes for gestational surrogate added
Z53.31 Laparoscopic surgical procedure converted to open procedure
Z53.32 Thoracoscopic surgical procedure converted to open procedure
Z53.33 Arthroscopic surgical procedure converted to open procedure
Z53.39 Other specified procedure converted to open procedure
• Added codes to explain two PCS codes with endoscopic procedure converted to open procedure
Chapter 21 – Factors influencing health status
and contact with health services (Z00-Z99)
140
New codes:
Z79.84 Long term (current) use of oral hypoglycemic drugs
• See Coding Guideline I.C.4.a(3) Diabetes mellitus and the use of insulin and oral
hypoglycemic and I.C.4.a(6)(a) Secondary diabetes mellitus and the use of insulin or
hypoglycemic drugs and I.C.15.h. Long term use of insulin and oral hypoglycemic and
I.C.15.i. Gestational (pregnancy induced) diabetes
Z83.42 Family history of familial hypercholesterolemia
Z84.82 Family history of sudden infant death syndrome
Z98.890 Other specified postpocedural states
Z98.891 History of uterine scar from previous surgery
Excludes 1: Maternal care due to uterine scar from previous surgery (O34.2-)
141