129 terms

Chapter 11, 12, 13, 14, 15

For example, Tracheobronchitis is classified to bronchitis in J40, Bronchitis, not specified as acute or chronic
When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.
Intermittent: symptoms less than or equal to 2 times a week
asthma severity
Mild Persistent: symptoms more than 2 times a week
asthma severity
Moderate Persistent: symptoms daily, may restrict activity
asthma severity
Severe Persistent: symptoms throughout the day, frequent severe attacks limiting ability to breathe
asthma severity
Use additional code to identify the infectious agent
Use additional code to identify the virus
Code first any associated lung abscess
Code first the underlying disease
Use additional code to identify other conditions such as tobacco use or exposure
Diseases of the Respiratory System are:
Diseases of oral cavity and salivary glands
Disease of esophagus, stomach and duodenum
Diseases of appendix
Noninfective enteritis and colitis
Diseases of peritoneum and retroperitoneum
Diseases of liver
Disorders of gallbladder, biliary tract and pancreas
Other diseases of digestive system
Diseases of the Digestive System, K00-K94
when referring to ulcers
Term "hemorrhage" is used
used when classifying gastritis, duodenitis, diverticulosis and diverticulitis
Term "bleeding" is used
Fourth character specifies the site
Fifth character indicates whether or not a complication is present
Sixth character classifies the specific complication
Category K50, Crohn's disease, expanded to the fourth, fifth, and sixth character level
for example, use additional code to identify manifestations with ulcerative colitis
Use additional code notes are used
for associated conditions and external causes
Additional codes should be assigned
underlying conditions
Instructions added to code first
the accompanying complications within each code
Ulcerative colitis and regional enteritis codes include
bilateral and unilateral conditions, with or without obstruction and gangrene
New codes for hernias of the abdominal cavity include
with and without hemorrhage and performation
ICD-10-CM include codes for acute and chronic types of ulcers
the diagnosis of "obstruction" for digestive system ulcer codes
ICD-10-CM codes do not include
intraoperative and postprocedural complications as well as hemorrhage, hematoma, and accidental puncture and laceration
Codes exist for
state that chronic kidney disease and kidney transplant status can be coded for the same patient
Coding guidelines state
the complications of a kidney transplant
Guidelines address coding
to identify the presence of an infection with or without hematuria
Combination codes exist
Code also any associated underlying condition
N17, Acute kidney failure
Code first any associated diabetic chronic kidney disease, hypertensive chronic kidney disease with a use additional code to identify kidney transplant status, if applicable
N18, Chronic kidney failure
N30, Cystitis—Use additional code to identify infectious agent
Notes are available to indicate an additional code should be used, for example:
N31, Neuromuscular dysfunction of bladder, NEC—Use additional code to identify any associated urinary incontinence
Notes are available to indicate an additional code should be used, for example:
N33, Bladder disorders in diseases classified elsewhere—Code first underlying disease
Notes are available to indicate an additional code should be used, for example:
N40, Enlarged prostate with lower urinary tract symptoms (LUTS)—Use additional code for associated symptoms, when specified
Notes are available to indicate an additional code should be used, for example:
which the condition occurred at the 5th and 6th character level
ICD-10-CM codes identifies the trimester in
code Z33.2, Encounter for elective termination of pregnancy, in Chapter 21 of ICD-10-CM.
Codes for elective (legal or therapeutic) abortion has been moved to code
are found in Chapter 21 of ICD-10-CM
Complications of induced termination of pregnancy
to identify the fetus to which certain complication codes apply, including a seventh character for unspecified when the fetus affected cannot be identified
ICD-10-CM requires the use of a seventh character extension
when multiple fetuses are involved
The seventh character is only used
when there is only 1 fetus
0" is used
includes the reason for the obstruction into the code so that only one code is required.
ICD-10-CM codes for obstructed labor
immediately after delivery and continues for six weeks following delivery
Postpartum period begins
is any complication occurring within the six-week period
A postpartum complication
less than 14 weeks 0 days
1st trimester
14 weeks 0 days to less than 28 weeks 0 days
2nd trimester
28 weeks 0 days until delivery
3rd trimester
Outcome of delivery, is used on every maternal record when a delivery occurs
A code from category Z37
when the woman has no complications during the antepartum period, during delivery, or postpartum during the delivery episode, and delivers a single, healthy infant. Category O80 is used for normal delivery and is not used with any other code from chapter 15.
A full-term normal delivery occurs
the principal diagnosis should correspond to the main circumstances or complication of the delivery.
When a delivery occurs
the principal diagnosis should be the condition established after study that was responsible for the patient's admission. It may or may not be the reason for the cesarean delivery, depending on the individual patient
In cases of cesarean delivery
not all conditions include codes for all three trimesters.
Because certain OB conditions occur during certain trimesters
at all because the condition always occur in a specific trimester or the trimester is not applicable
Some codes do not include the trimester classification
the fetus in a multiple gestation that is affected by the condition being coded.
Certain codes in Chapter 15 require a 7th character extension to identify
single gestations or multiple gestations where the affected fetus is unspecified
The 7th character extension of "0" is for
of multiple gestation to identify the fetus for which the code applies
Characters 1-9 are for cases
Z30, Encounter for contraceptive management
Z31, Encounter for procreative management
Z32, Encounter for pregnancy test and childbirth and childcare instructions
Z33, Pregnant state
Z34, Encounter for supervision of normal pregnancy
Z36, Encounter for antenatal screening of mother
Z3A, Weeks of gestation
Z37, Outcome of delivery
Z39, Encounter for maternal postpartum care and examination
Chapter 21, Factors influencing health status and contact with health services, contain several categories related to the pregnant female:
as an additional code to identify the outcome of delivery on the mother's record
Outcome of delivery codes (Z37.0-Z37.9) are used
Always used as additional code
Majority of these codes end with the last two digits that match the gestation of the pregnancy
Codes for weeks of gestation are used for all pregnancy patients, not exclusively for the patients who delivery during the current encounter
The date of admission is used to determine weeks of gestation when the inpatient admission extends more than one gestational week
Category Z3A, Weeks of gestation, are for use only on the maternal record to indicate the weeks of gestation of pregnancy.
that the drug or substance, underlying disease, or associated underlying conditions should be coded first
Other notes indicate
to identify the organism or infectious agent
An additional code is used
Non-pressure chronic ulcers of lower limbs are specifically identified by site, laterality and severity
Code L97
can be a principal or first listed code if no underlying condition is documented as the cause of the ulcer
Code L97
, a causal condition should be assumed
If an underlying condition is documented with a lower extremity ulcer,
Atherosclerosis of the lower extremities
Chronic venous hypertension
Diabetic ulcers
Postphlebitic syndrome
Postthrombotic syndrome
Varicose ulcer
Code first any associated underlying condition
any associated gangrene
Code first
J69.0, I69.391, R13.19, L89.211, L89.221
The patient has aspiration pneumonia because of his difficulty in swallowing (neurogenic) due to a previous cerebral infarction. The patient also has stage 1 decubitus ulcers on both his left and right hip.
J44.1, F17.200
Acute respiratory insufficiency due to acute exacerbation of COPD and tobacco dependence
Patient has high fever, cough and chest pain. Gram stain of the sputum showed numerous small gram-negative coccobacilli. Diagnosis: H. influenzae pneumonia.
J96.00, J44.0, J44.1, J20.9
Acute respiratory failure, acute bronchitis with acute exacerbation of COPD. The patient was admitted to treat the acute respiratory failure and treated mechanical ventilation after intubation in the ER.
Severe persistent asthma with acute exacerbation
Novel H1N1 influenza with upper respiratory tract infection.
J45.42, J44.1
Moderate persistent asthma with status asthmaticus. Acute exacerbation of chronic obstructive pulmonary disease (COPD).
J69.0, K21.9
Aspiration pneumonia treated with respiratory therapy and antibiotics. Patient has severe gastroesphageal reflux causing him to aspirate food.
Chronic mucopurulent chronic bronchitis
Acute pulmonary insufficiency following thoracic surgery (confirmed by the physician as being a postoperative complication)
K94.22, L03.311, C15.4, B95.61
This patient has extensive cellulitis of the abdominal wall due to an infection of the existing gastostomy site. A feeding tube was inserted four months ago because of the patient's carcinoma of the middle esophagus. The physician confirmed that the responsible organism for the infection is Staph aureus.
Acute gastric ulcer with hemorrhage
Recurrent right inguinal hernia with gangrene and obstruction.
Crohn's disease of the small intestine with a small bowel as the result of an exacerbation of the Crohn's disease
Choledocholilithiasis with acute cholangitis and obstruction
K40.20, R07.2, J44.9, M54.5, I10, Z53.09
A 68-year-old man was admitted to the hospital for bilateral inguinal hernia repair. The patient also had evaluation and treatment of COPD, chronic low back pain and hypertension while in the hospital. After being prepared for surgery, the patient complained of precordial chest pain. The surgery was canceled. Cardiac studies failed to find a reason for the chest pain which resolved later that day
K25.4, I50.9, I48.91
The patient came to the emergency department with the symptoms of vomiting blood and having very dark stools that appeared to be bloody. The patient is also being treated for congestive heart failure and atrial fibrillation. After study, it was determined the patient had a chronic gastric ulcer with bleeding.
Generalized chronic periodontitis
Diverticulitis of large intestine with perforation and peritonitis
K70.31, F10.20
Alcoholic cirrhosis of liver with ascites
Patient was evaluated for proteinurea and hematuria and the final diagnosis established as chronic nephritis syndrome with diffuse membranous glomerulonephritis.
N30.01, B96.20
Patient complained of frequent urination with pain and was diagnosed with acute suppurative cystitis, with hematuria due to E coli.
N18.3, Z94.0, E89.0, Z85.850
Patient is currently being treated for chronic kidney disease (CKD), stage 3. She has previously undergone a kidney transplant but still suffers from chronic kidney disease. This patient is also treated for hypothyroidism following removal of the thyroid for thyroid carcinoma. At this time, there is no longer evidence of an existing thyroid malignancy.
N17.0, N40.1, N13.8
The male patient complained of lower abdominal pain and the inability to urinate over the past 24 hours. After study, the patient was diagnosed as having acute kidney failure due to acute tubular necrosis, caused by a urinary obstruction. The urinary obstruction was a result of the patient's benign prostatic hypertrophy. The patient was treated with medication and the acute kidney failure was resolved prior to discharge.
Premenopausal menorrhagia
N39.0, B96.4, Z87.440
A patient complaining of fever, malaise and left flank pain has a urinalysis performed that showed bacteria of more than 100,000/ml present and subsequent culture shows Proteus growth as the cause of the urinary tract infection. The patient was treated with IV antibiotics. The patient also has a history of repeated UTIs over the past several years. The final diagnosis is urinary tract infection due to Proteus.
N80.0, N80.2, N80.1
Endometriosis of uterus, bilateral fallopian tubes and ovaries
Fibrocystic disease of right breast
Prolapse of cervix (female)
Female infertility due to fallopian tube blockage
O98.712, B20, B59, Z3A.21
This 25-year-old patient was admitted with difficulty breathing. She has AIDS and is 21 weeks pregnant. Workup reveals Pneumocystis carinii pneumonia due to the AIDS. What is/are the correct diagnosis code(s)?
O21.0, O23.42, B96.20, Z3A.16
16-week pregnancy with mild hyperemesis and urinary tract infection which grew out E. coli
O13.2, O09.522, Z3A.26
The patient is a 40-year-old G2 P1 woman who is 26-weeks pregnant and being seen for gestational hypertension. Other than being an elderly, multigravid patient, she is not having any other problems during this pregnancy.
O30.003, O69.81x2, Z37.2, Z3A.39
Patient is a woman who is G1 P0 at 39 weeks with twin gestation. The delivery complicated by nuchal cord, without compression, of fetus 2. Both infants were liveborn and healthy.
Patient returns to the office with breast pain. The patient is a 24-year-old woman who is 3 weeks postpartum. Final diagnosis documented as nonpurulent postpartum mastitis.
O26.12, O10.012, Z3A.20
20-week pregnancy with low weight gain and pre-existing essential hypertension complicating the pregnancy.
O24.419, Z3A.28
Patient is a woman, who is G4, P3, 28 weeks, and seen today for continued follow-up of her gestational diabetes. Her diabetes has been well controlled on oral medications.
O70.1, Z37.0, Z3A.38
The patient, G1, P0, was admitted in active labor at 38 completed weeks of gestation. The patient was dilated to 6 cm approximately 7 hours following admission. Pitocin augmentation was started and she progressed to complete dilation. A second degree perineal laceration occurred during delivery and was repaired. A female infant was delivered with Apgar scores of 9 and 9. Code diagnoses only.
O80, Z37.0, Z3A.39
The patient is admitted in active labor during week 39 of pregnancy. The patient experienced no complications during her pregnancy. The patient labored for 8 hours and delivered a liveborn male over an intact perineum.
O60.14x2, O36.4xx2, O30.103, O41.1030, Z37.61, Z3A.34
The patient, G3 P2, was admitted in premature labor at approximately 34 weeks' gestation with a history of contractions for the last 24 hours. She was experiencing contractions every 5 to 8 minutes. An ultrasound showed an intrauterine fetal death of triplet 2 but the other two were progressing normally. The contractions stopped for approximately 24 hours then started again. It was noted by the physician that the continued contractions were due to fetus2. The patient was given magnesium sulfate for tocolysis which was unsuccessful. The patient also developed a fever with an infection of the amniotic sac. The patient continued to be in active labor and due to the infection was allowed to spontaneously deliver the three infants, two liveborn and one fetal death. The patient experienced no postpartum complications.
L24.3, T49.8x5A, H01.114, H01.111, L70.0
Irritant contact dermatitis due to cosmetics; Cystic acne

The patient was seen with extensive inflammation and irritation of the skin of both upper eyelids and under her eyebrows that was spreading to her temples and forehead. Upon questioning the patient, the physician learned that she had recently used new eye cosmetics. The physician had examined the patient during a prior visit for cystic acne. During this visit, the physician also examined the patient's cystic acne on her forehead and jawline. The patient was advised to continue using the medication previously prescribed. The patient was also advised to immediately discontinue use of any make-up on the face ans was given a topical medication to resolve the inflammation which was an adverse effect of the cosmetics that came in contact with the skin of her face.
I96, L89.213, L89.152
Gangrenous pressure ulcer of the right hip and a pressure ulcer of the sacrum documented by the physician. The nursing assessment indicates a stage 2 pressure ulcer of the sacrum with a stage 3 decubitus ulcer of the right hip.
L27.0, T36.0x5A
Dermatitis covering entire body due to antibiotics (penicillin) taken correctly as prescribed
Abscess of the entire left big toe
I70.233, L97.311
Athersclerosis of the native arteries of the right ankle region, with non-healing ulcer, with breakdown of the skin on right ankle
L27.1, T46.4x5A, I10
The patient was seen for treatment of a fine rash that developed on the patient's trunk and upper extremities over the last three or four days. The patient was diagnosed with hypertension seven days ago and started on Ramipril 10 mg daily. The physician determined the localized rash to be dermatitis due to the Ramipril. The Ramipril was discontinued and the patient was prescribed a new antihypertensive medication, Captopril. In addition, the physician prescribed a topical cream for the localized dermatitis.
L03.115, B95.1, L89.312, L89.321
Cellulitis in the right lower extremity with streptococcus B organism documented by the physician as the cause of t he cellulitis. The patient also has a stage 1 decubitus ulcer of the left buttock and stage 2 decubitus in the right gluteal region.
L03.221, F11.10, Z72.89
Cellulitis of the right anterior neck treated with IV antibiotics. The patient is also a know morphine drug abuser and exhibited considerable drug-seeking behavior and continuously requested morphine. All narcotics were discontinued and the patient exhibited no drug withdrawal symptoms.
Discoid lupus erythematosus
Psoriatic arthritis
Chapter 8 H60-H95
Diseases of the Ear and Mastoid
Chapter 9 I00-I99
Diseases of the circulatory system
Chapter 10 J00-J99
Diseases of the respiratory system
Chapter 11 K00-K95
Diseases of the Digestive System
Chapter 12 L00-l99
Diseases of the Skin and Subcutaneous Tissue
Chapter 13 M00-M99
Diseases of the Musculoskeletal Ssystem
Chapter 14 N00-N99
Diseases of the Genitourinary System
Chapter 15 O00-O9A
Pregnancy, Childbirth, and the Puerperium
Chapter 16 P00-P96
Certain Conditions Originating in the Perinatal Period
Chapter 17 Q00-Q99
Congenital Malformation, Deformations, and Chromosomal Abnormalties Q00-Q099
Chapter 18 R00-R99
Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere classified
Chapter 19 S00-T88
Injury, Poisoning, and Certain Other Consequences of External Cause
Chapter 20 V00-Y99
External Cause of Morbidity
Chapter 21 Z00-Z99
Factors Influencing Health Status and Contact with Health Services
Chapter 1 A00-B99
Certain Infectious and Parasitic Diseases
Chapter 2 C00-D49
Chapter 3 D50-D89
Diseases of the blood and blood-forming organs and Disorders involving the immune mechanism
Chapter 4 E00-E89
Endocrine, Nutritional, and Metabolic Diseases
Chapter 5 F01-F99
Mental, Behavioral and neurodevelopmental Disorders
Chapter 6 G00-G99
Diseases of the Nervous System
Chapter 7 H00-H59
Diseases of the Eye and Adnexa