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ICD-10-CM Guidelines

Terms in this set (389)

Confirmed
Code only _____ cases of HIV. Lab work is not required only the physician documents.
B20
When a patient is admitted for an HIV related condition, _____ is sequenced first followed by additional diagnoses codes for all reported HIV related conditions.
First
If a patient with HIV disease is admitted for an unrelated condition such as a fracture, the code for the unrelated condition is coded _______. B20 is used as an additional diagnosis.
Z21
Asymptomatic human immunodeficiency virus (HIV) infection is applied when the patient is HIV positive and does not have any documented symptoms of an HIV related illness. What is the code?
Chapter 15
ICD-10-CM _______ ______ codes always take sequencing priority and should be listed first.
Signs and symptoms
Should a patient with signs and symptoms is being seen for HIV testing, what should be coded while waiting on the results?
B20
If a patient test results come back positive for HIV and the patient is symptomatic, what code should be used?
Systematic infection
Sepsis and severe sepsis require a code to identify the ________ _________. If documentation does not include the casual organism, report A41.9 Sepsis, unspecified organism.
R65.2
Severe sepsis is associated with acute organ dysfunction. A minimum of two codes are required. Code underlying condition first, followed by a code from subcategory ______ depending on what is documented.
R65.2
Code ____ can never be used as principal diagnosis.
Organ function
When coding septic shock, first code the systemic infection followed by R65.21 or
Malignancy, anemia
When the patient develops anemia because of the neoplasm and presents for treatment of the anemia, the code for the ________ is listed first, followed by the code for the ______.
Anemia, neoplasm and the adverse effect
If the anemia is caused by chemotherapy or radiotherapy, the _______ code is reported first, followed by the appropriate codes for the _____________________.
Z codes, malignant neoplasm
When coding an encounter for chemotherapy, immunotherapy, and radiotherapy, report the ___________ first, followed by the active code for the ___________________________, even if that neoplasm has already been removed.
Secondary diabetes
_______________ is a type of diabetes caused by something other than genetics or environmental factors. It is always caused by another condition or event.
Paraplegia
_________ is the paralysis of both lower limbs.
Quadriplegia
_________ is paralysis of all four limbs.
Hemiplegia
_________ is paralysis on one vertical half of the body.
Monoplegia
__________ is paralysis of one limb.
Glaucoma
__________ is a condition when the optic nerve is damaged, causing vision loss.
Otitis media (OM)
________________ is any inflammation of the middle ear without reference to etiology or pathogenesis.
Z38
What code should be used to report weeks of gestation?
Throughout life of the patient
Should a condition originate in the perinatal period, and continue throughout the life of the patient, should the Perinatal code be used throughout the life of the patient of or should the perinatal code be discontinued after delivery.
the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
Coding of sequela generally requires two codes sequenced in the following order: _____________________________________________.
Signs and/or symptoms of an underlying disease, not the disease itself, and therefore, cannot be a principal diagnosis.
Manifestation
It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. If two conditions are not related to one another, it is possible to report both codes despite the presence of an Exclude note 1. Ex: Mental disorder (F01-F99) cannot be assigned with the R40-R46 codes but if dizziness (R42) is not component if mental health condition then we can code it separately.
Excludes 1
A type 2 Excludes note represents "Not included here." An excludes2
note indicates that the condition excluded is not part of the condition
represented by the code, but a patient may have both conditions at the
same time. When an Excludes2 note appears under a code, it is
acceptable to use both the code and the excluded code together, when
appropriate.
Excludes2
Sepsis
Sepsis For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
acute organ dysfunction
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated __________________ is documented
urosepsis
The term _____________ is a nonspecific term. It has no default code in the Alphabetic Index. It is not to be considered synonymous with sepsis.
severe sepsis
If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding ________________.
R65.2, Severe sepsis
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory ____________________. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code.
2, underlying systemic infection, R65.2Severe sepsis
The coding of severe sepsis requires a minimum of ____ codes: first a code for the _________________, followed by a code from subcategory _________________________.
circulatory failure
Septic shock generally refers to ______________________ associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction
first, secondary diagnosis
If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned ____________ and the code for the localized infection should be assigned as a _____________________.
first
If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned _________, followed by the appropriate sepsis/severe sepsis codes.
first, specific infection, R65.2
For such cases, the postprocedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded ________, followed by the code for the ______________. If the patient has severe sepsis, the appropriate code from subcategory _________ should also be assigned with the additional code(s) for any acute organ dysfunction.
STEMI and NSTEMI
Types of MI
Anterolateral wall or true posterior wall
The ICD-10-CM codes for type 1 acute myocardial infarction (AMI) identify the site, such as _________________________.
I21.0-I21.2 and code I21.3
Codes for type 1 STEMI are _________________________.
I21.4
Codes for type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs
STEMI, STEMI
If a type 1 NSTEMI evolves to STEMI, assign the _______ code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as ________.
I21
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for "other diagnoses" codes from category _______ may continue to be reported.
aftercare code
For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate ___________ should be assigned, rather than a code from category I21.
I25.2
For old or healed myocardial infarctions not requiring further care, code _________, Old myocardial infarction, may be assigned.
I21.9
Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type.
I21.3
If only type 1 STEMI or transmural MI without the site is documented, assign code ________, ST elevation (STEMI) myocardial infarction of unspecified site.
subendocardial AMI
If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a _________________.
I22 (Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction)
When a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI.
I21.0-I21.4
Type 1 myocardial infarctions are assigned to codes
I21.A1, Myocardial infarction type 2 with a code for the underlying cause
Type 2 myocardial infarction, and myocardial infarction due to demand ischemia or secondary to ischemic balance, is assigned to code _____________________.
I21.A9, Other myocardial infarction type
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code ___________________.
Hypertension coding
1) Hypertension with Heart Disease ( I50.- or I51.4I51.9)
2) Hypertensive Chronic Kidney Disease ( I12 and type of Kidney disease N18)
3) Hypertensive Heart and Chronic Kidney Disease ( I13, Type of Kidney disease and type of heart failure)
4) Hypertensive Cerebrovascular Disease ( I60-I69)
5) Hypertensive Retinopathy
6) Hypertension, Secondary
7) Hypertension, Transient
8) Hypertension, Controlled (I10-I15)
9) Hypertension, Uncontrolled (I10-I15)
10) Hypertensive Crisis (I16)
11) Pulmonary Hypertension (I27.1, I27.2-)
CKD Types
The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD;
stage 3, code N18.3, equates to moderate CKD; stage 4, code N18.4, equates to severe CKD.
Code N18.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD).

If both a stage of CKD and ESRD are documented, assign code N18.6 only.
Etiology/manifestation convention
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
should not be coded
Signs and symptoms that are associated routinely with a disease process _____________, unless otherwise instructed by the classification.
should be coded
Additional signs and symptoms that may not be associated routinely with a disease process _____________ when present.
acute (subacute) code first
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the _________________.
Two diagnoses, A diagnosis with an associated secondary process (manifestation), A diagnosis with an associated complication
A combination code is a single code used to classify: ____________________________, , or _________________________, and _______________________.
left and right side, unspecified side
If no bilateral code is provided and the condition is bilateral, assign separate codes for both the ______________. If the side is not identified in the medical record, assign the code for the _______________.
confirmed
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as ___________, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient).
overlapping malignant lesion
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.
principal diagnosis
If the treatment is directed at the malignancy, designate the malignancy as the ______________.
principal diagnosis
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the _____________________ even though the primary malignancy is still present.
sequenced first
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is ____________________, followed by the code(s) for the malignancy.
Z codes should be given. Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

* principal or first-listed
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category _________________________________.

* Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the ______________________ with the Z85 code used as a secondary code.
sequenced as the principal or first-listed diagnosis. Code Z51.0 should not be assigned
If a patient admission/encounter is for the insertion or implantation of radioactive elements (e.g., brachytherapy) the appropriate code for the malignancy is ________________________.
malignancy
When a patient is admitted for the purpose of insertion or implantation of radioactive elements (e.g., brachytherapy) and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is the appropriate code for the ______________________ followed by any codes for the complications.
sequenced first, sequenced first
When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be _______________________, followed by the code for the neoplasm.

*If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be ___________________,, followed by a code from M84.5 for the pathological fracture.
Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category ____________________________.
IMP Point Malignancy
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
Type 2 diabetes mellitus
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, _________________.
Type 2 diabetes mellitus, should be assigned, Z79
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11-, _____________________. An additional code should be assigned from category ____________________ to identify the long-term (current) use of insulin or oral hypoglycemic drugs.
insulin
If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of _____________ should be assigned.
Z79.4
Code ___________ should not be assigned if insulin is given temporarily to bring a type 2 patient's blood sugar under control during an encounter.
Mechanical complication of other specified internal and external prosthetic devices, implants and grafts
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory _________________________.,
* T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts.
* T38.3X1, Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional). 6
The principal or first-listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin, should also be ___________________________ followed by code ___________________________.
Secondary diabetes mellitus
Codes under categories E08, Diabetes mellitus due to underlying condition, E09, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
Z79
For patients with secondary diabetes mellitus who routinely use insulin or oral hypoglycemic drugs, an additional code from category _______________ should be assigned to identify the long-term (current) use of insulin or oral hypoglycemic drugs.
Z79.4
If the patient is treated with both oral medications and insulin, only the code for long-term (current) use of insulin should be assigned. Code ____________ should not be assigned if insulin is given temporarily to bring a secondary diabetic patient's blood sugar under control during an encounter.
Good
Good
When assigning Diabetes Diagnosis remember what 2 things?
Review definition of 5th digits in category;
Understand the difference between type 1 & 2 and the patho of each type.
When coding Respiratory what things should you look for?
Specific type of Pneu
Know criteria for recognizing gram negative and other types of pneu;
review the various types of COPD and how ACUTE exacerbation of each is coded. (AHA coding Clinic);
Review criteria for coding respiratory failure and when it is sequenced.
How do you code an excisional debridement?
Do not code it unless there is documention that the excis debridement was performed. Check AHA CC.
When a dx of Gastrointestinal is aparent, what rule should you follow?
Use a combination code whenever available that incorporates a hemorrhage and the specific disorder. Use the 578.x category as an additional code when no combo code has been created or when the cause of the hemorrhage is unknown.
Delivery and Pregnancy Dx - what digit is only used for a postpartum complication?
The 5th digit of 4
What is the definition of a Normal Delivery?
Code 650; Delivery is entirely normal w/single liveborn outcome; No postpartum complications, and any antepartum comp experienced during pregnancy must have been resolved before the time of delivery.
What 3 codes do delivery patients always have to have?
Delivery Dx code (6xx)
Outcome of Delivery (V2x.xx)
Px code (73.59 if not other px was performed)
This type of Abortion occurs wo any instrument or chemical intervention.
Spontaneous (634)
This type of Abortion performed for either therapeutic or elective termination of pregnancy (elective abortion, induced, artificial, termination of pregnancy)
Legally induced (635)
This type of Abortion is not performed in a accordance w/provisions of state law or not meeting regulartory requirements . Performed outside of the hospital.
Illegally Induced (636)
This type of Abortion is one in which an elective abortion px has failed to evacuate or expel the fetus and the patient is sitll pregnant.
Failed (638)
What is the 5th digit sub classification used for when coding an abortion?
To indicate whether the abortion is complete or incomplete.
If a patient goes in for surgery and planned having a laparoscopic px but has to an open px, what type of code would you assign?
V codes; ex: V64.41 ( Laparoscopic surgical procedure converted to open procedure )
Chronic kidney disease stage 5
Code to N18.6 (ESRD) and dialysis status Z99.2
Severe sepsis
Underlying infection + R65.2
Septic shock
Underlying infection + R65.1
Nosocomial infections
Additional code of Y95
HIV infections
Code only confirmed cases (diagnosis sufficient)
Sequencing HIV codes
Admitted for HIV- B20
A/D unrelated- unrelated first then B20
Asymptomatic HIV- Z21
Inconclusive HIV- R75
Previously diagnosed- B20
HIV in pregnancy- O98.7
Asymptomatic HIV in pregnancy- O98.7 + Z21
Encounters for testing of HIV- Z11.4
Return visit for negative test results- Z71.7
Labor pneumonia
Has a unique category
Respiratory condition occurring in more than one place
Coded to the lower anatomic location
Respiratory condition
Code exposure to tobacco
Gastrointestinal term hemmorrhage
Means ulcers
Gastrointestinal term bleeding
Means gastritis, duodenitis, diverticulosis, diverticulitis
Delivery and pregnancy
5th or 6th digit represents trimester
Trimesters
1- less than 14 wks
2- less than 28 wks, more than 14
3- 28 wks thru delivery
Delivery chart codes should include
a) Delivery diagnosis code
b) Outcome of delivery
c)Weeks of gestation
d) Procedure code
Normal delivery code
O80
Weeks of gestation code
Z3A
Complications of ectopic pregnancy and abortions
Require additional codes
Anemia
Code also the cause
Code first the poisoning and under-dosing of medications
If associated with malignancy, code malignancy first
MI documented as nontransmural or subendocardial with a site provided
Code as a subenocardial MI
Subsequent MI within 4 weeks of initial
Code from I22 and I21
Primary site of neoplasm
Is where the cancer arises
Secondary neoplasm
When cancer leaves the original site
Morphology can lead to primary site
For example: renal cell carcinoma arises in the kidney
Steps for coding neoplasms
1. Look up morphology
2. No primary site code- use neoplasm table
3. If the term metastatic is used assume these are secondary sites:
Bones, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, spinal cord, and sites from C76
Injuries and burns
Use code from ch. 20 to indicate cause of injury
Burns on different body parts
Use only the degree of greatest severity along with the additional codes for burns of other anatomic sites
Adverse effect of a drug
Allergic reaction
Cumulative effect
Hypersensitivity
Idiosyncratic reaction
Paradoxical reaction
Synergistic
Poisoning
Administered, taken or prescribed incorrectly
Alcohol in conjunction with a drug
Street drugs resulting in overdose
Street drugs in addition to OTC or prescription meds.
Two OTC drugs used together
POA
a) Present at the time the order for inpatient admission occurs
b) Develop during outpatient encounter (emergency, observation, surgery)
POA Definitions
Y= present at time of inpatient admission
N= not present at the time of admission
U= documentation is insufficient to determine if condition is present on admission
W= provider is unable to clinically determine whether condition was present on admission or not
Alphabetic Index PCS
To locate the appropriate table that contains all information necessary to construct a procedure code
And
When used in a code description means and/or
Upper and lower body parts
Specifies body parts above or below the diaphragm respectively
Multiple procedures during the same operative episode
a) if the same root operation is performed on different body parts
b) the same root operation is repeated at different body sites that are included in the same body part value
c) multiple root operations with distinct objectives are performed on the same body part
d) the intended root operation is attempted using one approach, but is converted to a different approach.
Intended procedure discontinued
Code the procedure to the root operation performed
Procedure discontinued before root operation is performed
Code the root operation inspection of the body part or anatomical region inspected
Biopsy procedure
Coded using; excision, extraction, or drainage + the qualifier diagnostic
(qualifier diagnostic is used only for biopsies)
Biopsy + more definitive procedures
Both are coded
Overlapping layers
The body part with the deepest layer is coded
Bypass procedures
The body part bypassed from and to. The fourth character is the from and the qualifier is the to
Coronary arteries
Classified by number of distinct sites treated
Multiple coronary artery sites bypassed
A separate procedure is coded for each coronary artery site that uses a different device and/or qualifier
Root operation Control
Stopping or attempt to stop post-procedural bleeding; if unsuccessful and another more definitive root operation is performed code that instead of control
Resection
All of a specific body part is cut out or off
Excision
Cutting out of a less specific body part
Autograph obtained from a different body part
A separate procedure is coded
Fusion of spine
Classified by the level of the spine
Multiple vertebral joints fused
Separate procedure is coded for each vertebral joint that uses a different device and/or qualifier
Interbody fusion
Coded with the device value inter-body device
Bone graft
Device value no autologous tissue substitute or autologous tissue substitute
Mixture of autologous and non autologous bone graft
Code with device value autologous tissue subsitute
Inspection
Not coded separately if used to achieve the objective of the procedure
Multiple tubular parts inspected
Code the most distal part inspected
Multiple non-tubular parts inspected in a region
Body part that specifies the entire area inspected is coded
Inspection and another procedure performed at the same time
If using a different approach the inspection is coded seperately
Occlusion
Embolization to completely close a vessel
Restriction
Embolization to narrow the lumen of a vessel
Release procedure
Body part being freed is coded not the tissue being manipulated
Relaease
Freeing a body part without cutting
Division
Separating or transecting a body part
Reduction
a) Of displaced fracture; coded to the root operation
b) reposition and the application of a cast or splint; reposition is not coded separately
c) non displaced fracture is coded to the root operation immobilization in the placement section
Transplantation
a) Putting in a mature and functioning living body part taken from another individual or animal
b) putting in autologous or non-autologous cells is coded to the administration section
DISEASES AND THEIR MEDS...
...
AIDS
Retrovir, AZT, Videx
Allergies
Claritin, Phenergan, Allegra, Zyrtec, Benadryl
Anemia
Feosol, Feriron, Fergom, Procrut, Epigen, Neupogen
Angina pectoris
Verpamil, diltiazem, nifedipine
Anxiety
Ativan, Xanax, Valium, lorazepam, diazepam
Arrhythmia
Verapamil, digoxin Lanoxin, quinidine,
Arthritis
Ibuprofen, Lodine, naproxen, prednisone, Deltasone, Relafen
Use additional code
Note is found at the etiology code or underlying condition
Code first
Note is found at the manifestation code to provide instruction that the underlying condition should sequenced first
Code also
Indicate two code may be require
Manifestation code
Usually have the phrase in disease classified elsewhere never use as first listed or principal diagnosis
See"
Instruction for See" is mandatory you cannot code without following
Excludes1
Note means not code here two condition cannot occur together
Exclude2
Not include here but patient may have both condition
Congenital condition
Under the main anomaly
Condition that complicate pregnancy, childbirth
Are found under delivery, pregnancy, puerperal
Complication of medical or surgical
Are found under complication
Late effect
Found under Sequelae
Chapter
21 chapterwaa
ICD-10-CM/PCS
Are closed classification provide one and only one place to classify condition and procedure
Condition that occur infrequently or low importance
Are often grouped together in residual code labeled not elsewhere classified
AHA coding clonics
Published by American Hospital Association
Chapter 19
Seen place holder X
Main term
Identify disease condition or injuries
Subterms
Indicate site, type, or etiology
Parentheses
Are used to enclosed supplementary words or explanatory information that may either present or absent without affecting the code (non essential
Square brackets
To enclosed synonyms , alternative wording, abbreviation and explanatory that provide additional information or can also be used to indicate that the number in the bracket can only be a manifestation
Colon
Are used in the tabular list in both inclusion note and exclusion note after an incomplete
And
Interpret as either and or Or
With
Mean as associate with or due to
Due to
Casual relationship between condition is present
Symptoms followed by contrasting / comparative diagnoses
The symptom code is code first
Chronic condition such as hypertension, Parkinson's disease, chronic obstructive pulmonary disease, diabetes mellitus
Are systemic disease that are ordinarily should be coded even in the absence of documented intervention
Admitting diagnosis
Is not an element of the UHDDS (uniform hospital discharge data set
Uniform hospital discharge data set
Does not apply to the coding of outpatient
Discharge diagnoses
Usually recorded on the face sheet, final progress sheet or discharge summary
It is appropriate to base Code assignment on the documentation of other physician
As long as there is no conflict information between from the information from the attending if conflict queried the the attending physician
Z code section
Encounter, admission , examination
Rule out
Indicate that a diagnosis is still possible code as confirmed
Ruled out
Indicates that a diagnosis once considered likely is no longer possible never code
Dual coding
Two code that provide info about both a manifestation and the associate underlying condition the first code identifies the underlying condition and the second identifies the manifestation
No bilateral
Code left and right
No side identified assign the code for unspecified
Possible, probable, suspected, likely, questionable or rule out
Condition should be code as established diagnosis
Do not Code unconfirmed condition such as HIV, multiple sclerosis, epilepsy
As if they were established
Borderline condition
Should code only as confirm unless the classification provide a specific index entry
Threatened / impending
No entry in the index code the presenting condition if there is an entry code it
Sequelae or late effect
May occur at any time require two code, condition or nature of late effect or late effect code (second second)
Z code
Factor influencing Heath status and contact (Z codes: Z00-Z99)
External codes
V00-Y99
Z codes
Some can be used as principal or fist listed diagnosis
External codes
Are assigned as additional code
Locate z code & external
Admission, examination, history, observation, aftercare, problem, status
External code are not used to report the intent for poisoning toxic effect adverse effect underdosing of drug
Used T36-T65
Z codes are used as principal
For specific after care such as removal of internal fixation, sole purpose of special therapy radiotherapy chemotherapy
After care visit
Z42-Z51
After care code
Should not be used for aftercare injuries
Locating Z codes and external cause
Admission. Examination history observation aftercare problem status
Chapter 18
Can be designated followed by two or more contrasting comparative condition
Z08,Z09, Z39
Is assigned principal diagnosis when the reason is admitted for the purpose of surveillance after the initial treatment has been completed
Z03
Encountered for medical observation for suspected disease and condition ruled out
Z04
Encountered for examination and observation for other disease and c
Z04, Z03
Only as principal not secondary
Z04.41 cover collection of specimen advice given & counseling
Only for encounter for rape if no physical finding if physical finding is found do not assigned Z04.41
A diagnostic expressed status post
Refers to an earlier surgery injury illness no significance for the episode of care no code for the condition is assogn
Z79
Are assigned for long termed of a condition not to treat acute illness or brief period
Sign and symptom
Chapter 18
Glasgow coma scale
Assessing the degree of consciousness 3 factors amout of eye opening, verbal responsiveness motor responsiveness
Ill-defined condition
R99 patient who has already died is brought into an emergeny
Bacteremia
Presence of bacteria in the bloodstream after a trauma or an infection
Sepsis
SIRS due to infection a severe case indicates organ dysfunction
Septic shock
Circulatory failure associated with severe sepsis
Septicemia
Systemic disease associate with pathological microorganism or toxins in the bloodstream
SIRS
Systemic inflammatory response syndrome a systemic response to infection or trauma with such symptoms as fever and tachycardia
Chapter 1
Infection and parasites disease and Take precedence over other chapter for the same condition
For a chronic cystitis due to gonococcus
The index provides Subterms for both but the Subterms for the organism takes precedence over the Subterms chronic
If the organic is specified but not indexed under main term
Go to infection
Severe acuterespiratory syndrome (SARS)
Respiratory illness caused by a corona virus begin with fever may include chills headache malaise Z20.828,B97.21, J12.81
West Nile virus fever
Bite of mosquitos fever, headache, body ache elderly patient or those weakened immune system the virus may cause encephalitis meningitis or permanent neurological damage A92.3
Tuberculosis
Caused by Mycobacterium tuberculosis and mycobacterium bovis spread through the air A15-A19
R65.2
Can never be assigned principal diagnosis
Severe sepsis
Coding require a minimum of two code underlying infection first followed by a code from subcategory R65.2 severe sepsis additional code for the organisms should be code
Sepsis and severe sepsis with a localized on admission
Code first underlying condition follow by localized followed by localized infection,
Sepsis and severe sepsis with a localized not present on admission
Code first localized infection follow if severe sepsis develop after admission code it second
Toxic shock syndrome
Caused by bacteria infection, symptoms include high fever vomiting watery diarrhea myalgia hypotension
Nosocomial infection
MedicAl treatment develop during hospitALIZation
B20
For all positive diagnosis HIV positive Or HIV related is sufficient
Borderline diabetes
Without further provider should be assign a code R73.0 abnormal glucose
Tumor lysis syndrome
To a group of serious life threatening metabolic, can occur after antineoplastic therapy leukemia and lymphomas when cancer cell is destroy they can release intra cellular ions and metabolic into the circulation
Mental disorders
Is code to F01-F09
If use and abuse
Assign code for abuse
Abuse and dependence
Assign only code for dependence
Use, dependence, abuse
Assign code for dependence
Use, dependence
Assign code for dependence
Anemia
Code first the underlying condition follow by anemia code
F01-F09
Code first underlying condition
Aplastic anemia
Failure of the bone marrow to produce red blood cell maybe congenital but usually idiopathic or acquired
Sickle cell anemia or disease
The disease is passed to a child when both parents carry the genetic trait
Sickle cell trait
The disease is passed to a child when one parent carry the genetic trait
Sickle cell trait
Do not generally develop sickle cell disease they carry the trait
Medical record both sickle cell disease and sickle cell trait
Assign only sickle cell disease
Acute blood loss anemia
May occur following surgery but not necessarily a complication of the procedure and should not be coded as a postoperative complication unless the physician identifies it as such
Anemia chronic kidney disease
Code first the underlying kidney disease N18 follow by anemia code D63.1
Anemia in neoplastic
Code the neoplasm C00-D49
Anemia of other chronic disease
Code first the underlying chronic disease
Anemia with adverse effect of chemotherapy and the trea men is for anemia
Anemia code sequence first follow by the adverse effect
Aplastic anemia
Caused by failure of the bone marrow to produce red blood cells
Pancytopenia
Type of aplastic anemia that represent a deficiency of all three elements of the blood
Hemiplegia/hemiparesis
Paralysis of one side of the body. What side is dominant or nondominant. For ambidextrous patient default should be dominant, left side is affected non dominant, right side dominant
If hemiplegia occurring with cerebrovascular accident(CVA)
Often clear quickly code from categoryG81 event without treatment
Pain in category G89
Maybe used in conjunction with pain other pain code maybe used as principal diagnosis
Do not assign code G89
If the pain is specified as acute chronic post thoracotomy postpocedural or neoplasm related or the underlying diagnosis is known
Code influenza to category J09
Only confirm diagnosis do not code if stat men indicate suspected possible likely
Supraglottitis
Acute life threatening upper respiratory infection
Atelectasis
Alveoli are deflated
Pleural effision
Accumulation of fluid within the pleural may principal diagnosis if treatment is for pleural effusion
Biopsies to the root
Excision
Ablation
Using extreme heat freezing chemical (cryoablation) microwaves radiofrequency under the root destruction
Mechanical ventilation non invasive
Classifies to the extracorporeal assistant and performance
Invasive mechanical ventilation
Performance
Removal of biliary ducts
Root operation extirpation
Extracorporeal shock wave lithotripsy
Destroy biliary stones root fragmentation approach external
Adhesion of lysis
To the root release should not be coded unless is required before operation
Incisional hernia
Classified as a ventral hernia
Incarcerated or strsngulated
Classified as obstructed
Hernia with both grangrene and obstruction
Classified to hernia with gangrene
Peritoneal
If using per cutaneous approach it is coded as bypass
Hemodialysis
Is coded to extracorporeal assistance and performance
Implantable venous access device
Require two code one for insertion and another one for insertion of reservoir
Arteriovenous graft
Tubular graft used to connect the artery and vein( creation of arteriovenous graft root operation is bypass
Cystoscopic approach
Via natural or artificial opening endoscopic
Procedure describe as transurethral
Approach is via natural or artificial opening
Transurethral endoscopic
Is code to via natural or artificial opening endoscopic
Lithotripsy with removal of fragments
Is coded to the root operation extirpation
Per cutaneous nephrostomy
Is coded to the root operation extirpation
A total hysterectomy remove the whole uterus and cervix
Two code one for the removal uterus and for cervix
Endometrial ablation
Is code to destruction
Biopsies of breast
Root operation drainage (fluid removal)or excision (removal of a mass or lump) Seventh character X for diagnostic
Surgery of breast is performed for neoplasm
It is customary to perform a biopsy first before the definitive surgery. Definitive surgery is sequence first follow by biopsie
Ulcer
Code first underlying condition (gangrene etc)
T36-T65
Condition is due to poisoning (T36-T65) is sequence first if for adverse effect (T36-T65) sequence second
Cellulitis
Treatment to the cellulitis is code first treatment to the open wound open wound is code first
Grangrene code
Always code first if present
If a person is read mitt because
Code infection following procedure T81.4
Excisional debridements
To the root excision
Non-excisional debridements
To the extraction or to the root irrigation when perform by irrigating
Example of nonexcisional debridements
Versajet and ultrasonic debridements
Code only the deepest
Layer of excision
Pathological fracture
Bones that are weakened by disease
Spontaneous fracture
Are always pathological
Fracture sequence
Treatment to fracture first treatment to neoplasm neoplasm first
Never code traumatic and pathological
Fracture together
Coding for percutaneous vertebroasty or percutaneous vertebral augmentation
Require two codes one for root operation reposition and another for root supplement same for arcuplasty, kyphoplasty, skyphoplasty, spineoplasty
Vertebroasty
One code supplement root code
Do not use Z34
With chapter 15
Normal routine pregnancy
Z34 no code from chapter 15
High risk patient prenatal
O09
O80
Always first diagnosis no complication can be present
Cystoscopic approach
Via natural or artificial opening endoscopic
Procedure describe as transurethral
Approach is via natural or artificial opening
Transurethral endoscopic
Is code to via natural or artificial opening endoscopic
Lithotripsy with removal of fragments
Is coded to the root operation extirpation
Per cutaneous nephrostomy
Is coded to the root operation extirpation
A total hysterectomy remove the whole uterus and cervix
Two code one for the removal uterus and for cervix
Endometrial ablation
Is code to destruction
Biopsies of breast
Root operation drainage (fluid removal)or excision (removal of a mass or lump) Seventh character X for diagnostic
Surgery of breast is performed for neoplasm
It is customary to perform a biopsy first before the definitive surgery. Definitive surgery is sequence first follow by biopsie
Ulcer
Code first underlying condition (gangrene etc)
T36-T65
Condition is due to poisoning (T36-T65) is sequence first if for adverse effect (T36-T65) sequence second
Cellulitis
Treatment to the cellulitis is code first treatment to the open wound open wound is code first
Grangrene code
Always code first if present
If a person is read mitt because
Code infection following procedure T81.4
Excisional debridements
To the root excision
Non-excisional debridements
To the extraction or to the root irrigation when perform by irrigating
Example of nonexcisional debridements
Versajet and ultrasonic debridements
Code only the deepest
Layer of excision
Pathological fracture
Bones that are weakened by disease
Spontaneous fracture
Are always pathological
Fracture sequence
Treatment to fracture first treatment to neoplasm neoplasm first
Never code traumatic and pathological
Fracture together
Coding for percutaneous vertebroasty or percutaneous vertebral augmentation
Require two codes one for root operation reposition and another for root supplement same for arcuplasty, kyphoplasty, skyphoplasty, spineoplasty
Vertebroasty
One code supplement root code
Do not use Z34
With chapter 15
Normal routine pregnancy
Z34 no code from chapter 15
High risk patient prenatal
O09
O80
Always first diagnosis no complication can be present
Cesarean deliver
Extraction root operation
Vaginal delivery assistance with forceps vacuum internal version
Extraction
A
initial encounter for fracture
D
subsequent encounter for fracture with routine healing
G
subsequent encounter for fracture with delayed healing
S
sequela of fracture
NEC
Not elsewhere classifiable - ICD-10-CM system does not provide a code specific for patient's condition
NOS
Not elsewhere specified - equivalent to "unspecified"
[ ]
Brackets are used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Brackets are used in the Index of Diseases and Injuries to identify manifestation codes in which multiple coding and sequencing rules will apply
( )
Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure. They do not affect the code (nonessential modifiers)
:
Colon is used in the Tabular List after an incomplete term that needs one or more of the modifiers that follow to make it assignable to a given category
Other
are used when the information in the medical record provides detail for which a specific code does not exist
Unspecified
are used when the information in the medical record is not available for coding more specifically
EXCLUDES1
"Not coded here" This note indicates that the code should not be used at the same time as the code above (two conditions that cannot occur together)
EXCLUDES2
"Not included here" This note indicates that the condition excluded is not part of the condition represented by the code (patient may have both conditions at the same time)
INCLUDES
This note appears directly under a there-character code title to define further
Use additional code
An additional code should be used after a primary code to provide a more complete picture of the diagnosis
Code first
This note indicates two codes are needed to report a condition and requires that the underlying disease (etiology) be coded first, and the manifestation be coded second
Use additional code, if applicable
This code may be assigned as a diagnosis when the causal condition is unknown or not applicable
Which coding convention is used in the description of an ICD-10-CM code when the information in the medical record provides detail, but no specific code exists? Refer to ICD-10-CM guidelines, section I.A.6.
NEC
Cyclic neutropenia is coded with D70.0 Cyclic neurtopenia. There are additional coding instructions for this code listed under the category D70 Neutropenia. Using those instructions, how would you report a patient with cyclic neutropenia with an associated fever?
D70.4, R50.81
Supplementary words enclosed in parentheses in the ICD-10-CM codebook have what effect on the coding? Refer to ICD-10-CM guidelines, section I.A.7.
They do not affect code assignment
What is a default code? Refer to ICD-10-CM guidelines, section 1.A.18.
The code that represents the condition most commonly associated with the main term
Three-character ICD-10-CM codes represent what level of code in the ICD-10-CM?
Category
Notes
Used to define terms, clarify information, or list choices for additional characters in the Tabular List
And
can mean "and" or "or"
With
can mean "associated with" or "due to"
See
directs you to a more specific term where correct code can be found
See also
indicates additional information is available that may provide an additional diagnostic code
.- Point Dash
indicates the code is incomplete
Applying the coding concept from ICD-10-CM guidelines, section 1.B.1, which of the following is the recommended method for using your ICD-10-CM codebook?
Always consult the Alphabetic Index first. Refer to the Tabular List to locate the selected code.
What is the ICD-10-CM code for a bruised left knee?
S80-02XA
What is the ICD-10-CM code for prostate hyperplasia with urinary retention?
N40.1, R33.8 (listed as an additional code to report urinary retention)
What is the ICD-10-CM code for essential hypertension?
I10
What is/are the ICD-10-CM code(s) for bilateral hip pain?
M25.551 (right hip pain), M25.552 (left hip pain)
What is ICD-10-CM code for COPD?
J44.9 Chronic obstruction pulmonary disease, unspecified
When trying to determine the main term, it is helpful to read the diagnosis right to left.
...
G
subsequent encounter for fracture with NONunion
P
subsequent encounter for fracture with MALunion
Instructional notes that indicated when to use more than one code:
code first
code, if applicable, any causal condition first
code also
use additional code
acute and chronic
acute is sequenced first
Sequelae (Late Effects)
The residual condition (sequela) is coded first, and the code(s) for the cause of the sequela are coded secondary.
A patient visits the primary care physician for complaints of nausea and vomiting. Which option is appropriate to report a diagnosis of nausea and vomiting? Apply the coding concept from ICD-10-CM guidelines, section I.B.9.
R11.2 (combines the nausea and vomiting conditions)
Referencing ICD-10-CM guidelines, section I.B.10, what is the time limit when assigning codes as "sequela?"
There is no time limit on sequelae
Referencing ICD-10-guidelnes, section I.B.8, when a patient presents with an acute and chronic condition, and no single code captures both the chronic and acute nature of the illness, how are the codes sequenced?
Code the acute condition first, followed by the chronic condition
Referencing ICD-10-CM guidelines, section I.B.11, what is the appropriate action with a physician documents an impending condition that had not occurred by the time of discharge?
Check the ICD-10-CM Index to Diseases and Injuries to see if there are listings under "threatened" or "impending" and if not, code the existing underlying condition(s) rather than the condition described as impending.
A patient is brought to the ED with right and left ankle fractures. Applying the coding concepts from ICD-10-CM guidelines, section I.B.12, which ICD-10-CM code selection should you report?
S82.891A (right ankle), S82.892A (left ankle)
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