ICD-10-CMExpert for Physicians

The Complete Official Code Set

2016

ITPB.book Page 1 Tuesday, July 8, 2014 2:13 PM

Illustrations

Illustrations–10 ICD-10-CM 2016

Muscles

Platysma m.

Splenius m.

Frontalis m.

Biceps brachii m. (short head)

Masseter m.

Rectus abdominis m.

Latissimus dorsi m.

Brachioradialis m.

Vastus lateralis m.

Gracilis m.

Rectus femoris m.

Gastrocnemius m.

Orbicularis oculi m.

Temporalis m.

Mentalis m.

Extensor carpi radialis longus m.

Brachialis m.

Deltoid m.

Levator scapulae m.

Pectineus m.Pudendal n.

Flexor carpi ulnaris m.

Flexor digitorum superficialis m.

Patella

Flexor carpi radialis m.

Pectoralis major m.

Serratus anterior m.

Omohyoid m.Sternocleidomastoid m. (Clavicular head)

Brachioradialis m.

Iliopsoas m.

Extensor carpi radialis longus m.

Extensor digiti minimi m.

Sartorius m.

Tibialis anterior m.

Zygomaticus major m.

Biceps brachii m.

Coracobrachialis m.

Palmaris longus m.

Adductor longus m.

Sternocleidomastoid m. (Sternal head)

Orbicularis oris m.

Depressor labii inferioris m.

Extensor carpi radialis brevis m.

Extensor digitorum m.

Extensor retinaculum

Triceps m.

Biceps brachii m. (long head)

Pronator teres m.

Flexor carpi radialis m.

Extensor retinaculum

Bicipital aponeurosis

External oblique m.

Vastus medialis m.

AnteriorSuperior

Iliac Spine

Tensor fascia latae m.

Soleus m.

Tensor fascia latae m.

Peroneus longus m.

Extensor digitorum longus m.

Linea alba

Superior extensor retinaculum

Tibia

Pubictubercle

Lateral maleolusMedial maleolus

ITENH.book Page 10 M onday, August 27, 2012 4:07 PM

Diseases of the N

ervous SystemG83.8–G92

S Additional Character Required g Xtension Alert Unspecified Code Other Specified Code Manifestation Code wx Revised Text l New Code s Revised Code TitleICD-10-CM 2014 551

c1 paralytic syndromes due to current spinal cord

injury—code to spinal cord injury (S14, S24, S34)

Other disorders of the nervous system (G89-G99)

b G89 Pain, not elsewhere classifiedCode also related psychological factors associated with pain (F45.42)1 generalized pain NOS (R52)

pain disorders exclusively related to psychological factors (F45.41)

pain NOS (R52)2 atypical face pain (G50.1)

headache syndromes (G44.-)localized pain, unspecified type—code to pain by site, such as:

abdomen pain (R10.-)back pain (M54.9)breast pain (N64.4)chest pain (R07.1-R07.9)ear pain (H92.0-)eye pain (H57.1)headache (R51)joint pain (M25.5-)limb pain (M79.6-)lumbar region pain (M54.5)painful urination (R30.9)pelvic and perineal pain (R10.2)renal colic (N23)shoulder pain (M25.51-)spine pain (M54.-)throat pain (R07.0)tongue pain (K14.6)tooth pain (K08.8)

migraines (G43.-)myalgia (M79.1)pain from prosthetic devices, implants, and grafts (T82.84,

T83.84, T84.84, T85.84)phantom limb syndrome with pain (G54.6)vulvar vestibulitis (N94.810)vulvodynia (N94.81-)

Déjérine-Roussy syndromeMyelopathic pain syndromeThalamic pain syndrome (hyperesthetic)

c

Post-thoracotomy pain NOS

Postoperative pain NOSPostprocedural pain NOS

c1 causalgia, lower limb (G57.7-)

causalgia, upper limb (G56.4-)central pain syndrome (G89.0)chronic pain syndrome (G89.4)complex regional pain syndrome II, lower limb (G57.7-)complex regional pain syndrome II, upper limb (G56.4-)neoplasm related chronic pain (G89.3)reflex sympathetic dystrophy (G90.5-)

Other chronic postoperative pain

Cancer associated painPain due to malignancy (primary) (secondary)Tumor associated pain

Chronic pain associated with significant psychosocial dysfunction

b G90 Disorders of autonomic nervous system 1 dysfunction of the autonomic nervous system due to alcohol

(G31.2)

c

Carotid sinus syndrome

Idiopathic peripheral autonomic neuropathy NOS

Bernard(-Horner) syndromeCervical sympathetic dystrophy or paralysis

Neurogenic orthostatic hypotension [Shy-Drager]1 orthostatic hypotension NOS (I95.1)

Use additional code to identify the cause, such as:fecal impaction (K56.41)pressure ulcer (pressure area) (L89.-)urinary tract infection (N39.0)

cReflex sympathetic dystrophy1 causalgia of lower limb (G57.7-)

causalgia of upper limb (G56.4-)complex regional pain syndrome II of lower limb

(G57.7-)complex regional pain syndrome II of upper limb

(G56.4-)

d

d

b G91 Hydrocephalus1 acquired hydrocephalus1 Arnold-Chiari syndrome with hydrocephalus (Q07.-)

congenital hydrocephalus (Q03.-)spina bifida with hydrocephalus (Q05.-)

Secondary normal pressure hydrocephalus

Normal pressure hydrocephalus NOS

G91.4 Hydrocephalus in diseases classified elsewhereCode first underlying condition, such as:

congenital syphilis (A50.4-)neoplasm (C00-D49)

1 hydrocephalus due to congenital toxoplasmosis (P37.1)

G92 Toxic encephalopathyToxic encephalitisToxic metabolic encephalopathyCode first (T51-T65) to identify toxic agent

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1 Not coded 2 Not included 8 Newborn Age: 0 9 Pediatric Age: 0-17 x Maternity Age: 12-55 y Adult Age: 15-124 662 ICD-10-CM 2016

L75.

9–L8

9.00

4D

isea

ses o

f the

Ski

n an

d Su

bcut

aneo

us T

issu

e

Intraoperative and postprocedural complications of skin and subcutaneous tissue (L76)

b L76 Intraoperative and postprocedural complications of skin and subcutaneous tissue

c

1 intraoperative hemorrhage and hematoma of skin and subcutaneous tissue due to accidental puncture and laceration during a procedure (L76.1-)

c

c

c

Use additional code, if applicable, to further specify disorder

Other disorders of the skin and subcutaneous tissue (L80-L99)

L80 Vitiligo2 vitiligo of eyelids (H02.73-)

vitiligo of vulva (N90.89)

b L81 Other disorders of pigmentation1 birthmark NOS (Q82.5)

Peutz-Jeghers syndrome (Q85.8)2 nevus—see Alphabetical Index

Lentigo

Angioma serpiginosum

Iron pigmentationTattoo pigmentation

b L82 Seborrheic keratosis1 dermatosis papulosa nigra

Leser-Trélat disease2 seborrheic dermatitis (L21.-)

Seborrheic keratosis NOS

L83 Acanthosis nigricansConfluent and reticulated papillomatosis

L84 Corns and callositiesCallusClavus

b L85 Other epidermal thickening2 hypertrophic disorders of the skin (L91.-)

1 congenital ichthyosis (Q80.-)

1 inherited keratosis palmaris et plantaris (Q82.8)

Dry skin dermatitis

Cutaneous horn

L86 Keratoderma in diseases classified elsewhereCode first underlying disease, such as:

Reiter's disease (M02.3-)1 gonococcal keratoderma (A54.89)

gonococcal keratosis (A54.89)keratoderma due to vitamin A deficiency (E50.8)keratosis due to vitamin A deficiency (E50.8)xeroderma due to vitamin A deficiency (E50.8)

b L87 Transepidermal elimination disorders1 granuloma annulare (perforating) (L92.0)

Kyrle diseaseHyperkeratosis follicularis penetrans

L88 Pyoderma gangrenosumPhagedenic pyoderma1 dermatitis gangrenosa (L08.0)

L89 Pressure ulcerBed soreDecubitus ulcerPlaster ulcerPressure areaPressure soreCode first any associated gangrene (I96)2 decubitus (trophic) ulcer of cervix (uteri) (N86)

diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)

non-pressure chronic ulcer of skin (L97.-)skin infections (L00-L08)varicose ulcer (I83.0, I83.2)

c

d

Healing pressure ulcer of unspecified elbow, stage 1

Pressure pre-ulcer skin changes limited to persistent focal edema, unspecified elbow

Healing pressure ulcer of unspecified elbow, stage 2

Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis, unspecified elbow

Healing pressure ulcer of unspecified elbow, stage 3

Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue, unspecified elbow

Healing pressure ulcer of unspecified elbow, stage 4

Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone, unspecified elbow

ITEN.book Page 662 Thursday, August 9, 2012 1:52 PM

1 Not coded 2 Not included 8 Newborn Age: 0 9 Pediatric Age: 0-17 x Maternity Age: 12-55 y Adult Age: 15-124 776 ICD-10-CM 2016

O35

.4–O

36.7

2Pr

egna

ncy,

Chi

ldbi

rth

and

the

Puer

peri

um g x;

g x;

Maternal care for damage to fetus from drug addictiong x;

g x;

Maternal care for damage to fetus by amniocentesisMaternal care for damage to fetus by biopsy proceduresMaternal care for damage to fetus by hematological

investigationMaternal care for damage to fetus by intrauterine contraceptive

deviceMaternal care for damage to fetus by intrauterine surgery

g x;

Maternal care for damage to fetus from maternal listeriosisMaternal care for damage to fetus from maternal toxoplasmosis

g x;

b O36 Maternal care for other fetal problems1 the listed conditions in the fetus as a reason for

hospitalization or other obstetric care of the mother, or for termination of pregnancy

1 encounter for suspected maternal and fetal conditions ruled out (Z03.7-)

placental transfusion syndromes (O43.0-)2 labor and delivery complicated by fetal stress (O77.-)

cMaternal care for Rh incompatibility (with hydrops fetalis)

d

e x;

e x;

e x;

e x;

d

e x;

e x;

e x;

e x;

cMaternal care for ABO isoimmunization

dMaternal care for isoimmunization NOS (with hydrops

fetalis)e x;

e x;

e x;

e x;

dMaternal care for Anti-B sensitization

e x;

e x;

e x;

e x;

cMaternal care for hydrops fetalis NOSMaternal care for hydrops fetalis not associated with

isoimmunization1 hydrops fetalis associated with ABO isoimmunization

(O36.1-)hydrops fetalis associated with rhesus isoimmunization

(O36.0-)

g x;

g x;

g x;

g x;

g x;

Maternal care for intrauterine fetal death NOSMaternal care for intrauterine fetal death after completion of 20

weeks of gestationMaternal care for late fetal deathMaternal care for missed delivery1 missed abortion (O02.1)

stillbirth (P95)

c

d

e x;

e x;

e x;

e x;

d

Maternal care for known or suspected light-for-dates NOS

Maternal care for known or suspected small-for-dates NOS

e x;

e x;

e x;

e x;

cMaternal care for known or suspected large-for-dates

g x;

g x;

g x;

g x;

c

g x;

g x;

g x;

One of the following 7th characters is to be assigned to each code under category O36. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O36 that has a 7th character of 1 through 9.0 not applicable or unspecified 4 fetus 41 fetus 1 5 fetus 52 fetus 2 9 other fetus3 fetus 3

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1 Not coded 2 Not included PDx Primary Diagnosis Only 8 Newborn Age: 0 9 Pediatric Age: 0-17 x Maternity Age: 12-55 y Adult Age: 15-124 1098 ICD-10-CM 2016

Z72.

6–Z7

7.01

1Fa

ctor

s Inf

luen

cing

Hea

lth

Stat

us a

nd C

onta

ct W

ith

Hea

lth

Serv

ices

1 compulsive or pathological gambling (F63.0)

c

d1 conduct disorders (F91.-)

9

Antisocial behavior (child) (adolescent) without manifest psychiatric disorder

Delinquency NOSGroup delinquency Offenses in the context of gang

membershipStealing in company with others Truancy from school

yAdult antisocial behavior without manifest

psychiatric disorderd

Lack of adequate sleep1 insomnia (G47.0-)

Bad sleep habitsIrregular sleep habitsUnhealthy sleep wake schedule1 insomnia (F51.0-, G47.0-)

Self-damaging behavior

b Z73 Problems related to life management difficulty2 problems related to socioeconomic and psychosocial

circumstances (Z55-Z65)

Physical and mental strain NOS1 stress related to employment or unemployment (Z56.-)

1 care-provider dependency (Z74.-)

c

d

9

9

9

9

b Z74 Problems related to care provider dependency2 dependence on enabling machines or devices NEC (Z99.-)

c

Bedridden

Chair riddenReduced mobility NOS2 wheelchair dependence (Z99.3)

b Z75 Problems related to medical facilities and other health care

1 no other household member able to render care (Z74.2)

1 bed unavailable (Z75.1)

b Z76 Persons encountering health services in other circumstances

Encounter for issue of repeat prescription for applianceEncounter for issue of repeat prescription for medicamentsEncounter for issue of repeat prescription for spectacles2 issue of medical certificate (Z02.7)

repeat prescription for contraceptive (Z30.4-)PDx

9 PDx

Encounter for medical or nursing care or supervision of healthy infant under circumstances such as adverse socioeconomic conditions at home

Encounter for medical or nursing care or supervision of healthy infant under circumstances such as awaiting foster or adoptive placement

Encounter for medical or nursing care or supervision of healthy infant under circumstances such as maternal illness

Encounter for medical or nursing care or supervision of healthy infant under circumstances such as number of children at home preventing or interfering with normal care

1 homelessness (Z59.0)

Person feigning illness (with obvious motivation)1 factitious disorder (F68.1-)

peregrinating patient (F68.1-)

c

Pre-adoption pediatrician visit for adoptive parent(s)

Patient waiting for organ availability

Persons encountering health services NOS

Persons with potential health hazards related to family and personal history and certain conditions influencing health status

(Z77-Z99)Code also any follow-up examination (Z08-Z09)

b Z77 Other contact with and (suspected) exposures hazardous to health

1 contact with and (suspected) exposures to potential hazards to health

2 contact with and (suspected) exposure to communicable diseases (Z20.-)

exposure to (parental) (environmental) tobacco smoke in the perinatal period (P96.81)

newborn (suspected to be) affected by noxious substances transmitted via placenta or breast milk (P04.-)

occupational exposure to risk factors (Z57.-)retained foreign body (Z18.-)retained foreign body fully removed (Z87.821)toxic effects of substances chiefly nonmedicinal as to source

(T51-T65)

c

d

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