ICD-9 to ICD-10 PrepPRESENTED BY:

Lizeth Flores, RHIT

Khaleelah Wagner, RHIA

Staci LePage, RHIT

Objectives

Participants will: ● Correctly assign diagnoses to ICD-9-CM codes● Correctly identify primary/secondary diagnoses ● Identify correct sequence of diagnoses for coding assignment ● Identify documentation needed for ICD-10-CM coding

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ICD-9 and ICD-10 History

The 9th revision was published in 1977. The U.S. National Center for Health Statistics (NCHS) and CMS are responsible for maintaining ICD-9-CM.

The World Health Organization (WHO) adopted ICD-10 (International Classification of Diseases, Tenth Revision) in 1990 and it came into use in 1994 by other countries.

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) was developed under the oversight of National Center for Health Statistics in 1997 and has undergone several modifications since then.

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2014 ICD-9-CM and ICD-10-CM Availability

http://www.cdc.gov/nchs/icd/icd9cm.htm

http://www.cdc.gov/nchs/icd/icd10cm.htm or http://www.cms.hhs.gov/ICD10● 2014 ICD-10-CM Index to Diseases and Injuries● 2014 ICD-10-CM Tabular List of Diseases and Injuries

o Instructional Notations

● 2014 Official Guidelines for Coding and Reporting ● 2014 Table of Drugs and Chemicals● 2014 Neoplasm Table ● 2014 Mapping ICD-9-CM to ICD-10-CM and

ICD-10-CM to ICD-9-CM”

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ICD-9-CM and ICD-10-CM Coding Guidelines

The guidelines are approved by four organizations:● American Hospital Association (AHA)● American Health Information Management Association

(AHIMA)● Centers for Medicare and Medicaid Services (CMS), and● National Center for Health Statistics (NCHS)

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Coding to Support Need for Medicare

The principal diagnosis and secondary top 8 diagnoses are entered onto the UB-04.

Accurate reporting of ICD-9 CM codes effect:● Medicare billing● Quality measures● Data collected● Overall accuracy of MDS/RUG categories

The main benefit of correct coding is validation of service delivered and reduced compliance risk.

The industry is using more checks and balances to reject claims and review for fraud and abuse.

Inaccurate codes will lead to rejection of claims and services.

Coding Conventionsand GuidelinesICD-9-CM

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Coding from ICD-9-CM to ICD-10-CMICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha (E or V)

First character always alpha

2–5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3–7 can be alpha or numeric

Decimal placed after the first three characters (or with E codes, placed after the first four characters)

Always at least three digits

Alpha characters are not case-sensitive Decimal placed after the first three characters

Alpha characters are not case-sensitive

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Alphabetic Index -2

Main terms in boldface font are listed in alphabetic order. Then, indented beneath the main term, any applicable subterm or essential modifier will be shown in alphabetical order. The indented subterm is always read in combination with the main term.

Pneumonia 486 (J18.9)

aspiration 507.0 (J69.0)

due to food

507.0(J69.0)

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Alphabetic Index -3

Nonessential modifiers appear in parentheses ( ) and do not affect the code number assigned.

The “-” at end of an index entry indicates that additional characters are required (ICD-10)

Amblyopia (congenital) (ex anopsia) (partial) (suppression) 368.00 (H53.00-)

deprivation 368.02 (H53.01-)

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Alphabetic Index -4

Manifestation codes are included in the alphabetic index by including a second code, shown in brackets [ ] directly after the underlying or etiology code which should always be reported first.

Chorioretinitis – see also inflammation chorioretinal

Tuberculosis 017.3 [363.13]

Egyptian B76.9 [D63.8]

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Tabular List

Most but not all categories are subdivided into four or five character subcategories, e.g. (496 COPD or I10 – Hypertension)

The fourth character when placed after the decimal point of:● 8 - (.8) is used to indicate “other specified”, and● 9 - (.9) is usually reserved for “unspecified”

365.89 Other specified glaucoma 365.9 Unspecified glaucomaK52.89 Other specified noninfective gastroenteritis and colitisK52.9 Noninfective gastroenteritis and colitis, unspecified

Tabular List -4

(NEC) – “not elsewhere classified”

(NOS) – “not otherwise specified”

Both NEC and NOS have their own codes

Five and six character codes provider greater specificity or more information about the condition

Codes must be assigned to the highest number of characters available or to the highest level of specificity, or bills will be rejected

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Coding Convention Abbreviations

Not Elsewhere Classified “NEC” – A residual category, subdivision, or subclassification that provides a location for “other” types of specified conditions that have not been classified anywhere else in the code set. These residual codes may also contain the term “NEC” as part of their descriptor.

276.9 Electrolyte and fluid disorders, not elsewhere classified

E87.8 Other Disorder of electrolyte and fluid balance, not elsewhere classified

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Tabular List Notes

Pertinent coding information is located at the beginning of chapters or any subdivisions that follow and apply to all the categories within it.

Beginning of the chapter – 780-799 or R00-R99 Beginning of a subchapter – 235-238 or D37-D48

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Coding Convention Abbreviations -2

Not Otherwise Specified “NOS” - for use when the documentation of the condition identified by the provider is insufficient to assign a more specific code.

294.20 Unspecified dementia without behavioral disturbance or Dementia, NOS

F03.90 Unspecified dementia without behavioral disturbance – Dementia, NOS

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Coding Conventions Punctuation

( ) Parentheses – supplemental words that may or may not be present.

[ ] - Brackets – synonyms, alternative workings or explanatory phrases.

401.9 Hypertension (essential) (primary)I10 – Essential (primary) hypertension

814.02 Fracture of lunate [semilunar]S62.12 Fracture of lunate [semilunar]

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Coding Conventions Punctuation -2

Colon ( : ) – used after an incomplete term which needs one or more of the modifiers following the colon. Used in both “includes” and “excludes” notes in which the words that precede the colon are not considered complete terms and therefore must be appended by one of the modifiers indented under the statement.

359.6 Symptomatic inflammatory myopathy in diseases classified elsewhereCode first underlying disease, as:

malignant neoplasm (140.0-208.9)rheumatoid arthritis (714.0)

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Coding Conventions Punctuation -3

Dashes ( - ) in the Alphabetic Index, dashes at the end of a code indicates an incomplete code *ICD-10 only

In the Tabular List, a dash preceded by a decimal point (.-) indicates an incomplete code *ICD-10 only

J43 EmphysemaExcludes 1: emphysematous (obstructive) bronchitis (J44.-)

Fracture, pathological ankle M84.47- carpus M84.44-

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Coding Convention Instructional Notes

Includes notes – used to clarify the condition included within a particular chapter, section, category, subcategory or code. They are not exhaustive and may include diagnoses not listed in the inclusion note. The word “includes” is not preceded by the list of terms at the code level.

531 Gastric ulcer Includes: ulcer, stomach

K25 Gastric ulcerIncludes: stomach ulcer (peptic)

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Coding Convention Instructional Notes -2

Excludes 1 – not coded here. Used when two codes cannot occur together *ICD-10

Excludes – terms excluded from the code are to be coded elsewhere *ICD-9

355.9 Mononeuritis of unspecified siteExcludes:

Causalgia, upper/lower limb (355.71/354.4)G59 Mononeuropathy in disease classified elsewhere Excludes 1:

Diabetic mononeuropathy (E09 – E14 with .41)

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Coding Convention Instructional Notes -3

Excludes 2 – not included here. Used when the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time *ICD-10 only

J01 Acute SinusitisExcludes 1 – Sinusitis NOS (J32.9)Excludes 2 – Chronic Sinusitis (J32.0 – J32.8)

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Coding ConventionsCode First & Use Additional Code

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The underlying condition is sequenced first followed by the manifestation. The “use additional code” note appears at the etiology and a “code first” note at the manifestation code.

Coding Convention Instructional Notes -3

331.0 Alzheimer’s diseaseUse additional code to identify…

294 Persistent mental disorders due to conditions classified elsewhere

Code first underlying conditionG30 Alzheimer’s disease Use additional code to identify:

dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance (F02.80)F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Alzheimer’s (G30.-)

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Coding ConventionsCross Reference Notes

Cross reference notes are used in the Alphabetic Index to advise the coding professional to look elsewhere before assigning a code. There are three terms used: see, see also, see condition

Hemorrhage, cranial – see Hemorrhage, intracranialLabyrinthitis (circumscribed) (destructive) (diffuse) (inner ear) (latent) (purulent) (suppurative)– see also subcategory H83.0 Hematoma (traumatic) (skin surface intact) (see also Contusion)

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Coding ConventionsRelational Terms

And – should be interpreted to mean “and/or” when it appears in the code title within the Tabular List.

451 Phlebitis and thrombophlebitisI80 Phlebitis and thrombophlebitis

453 Other venous embolism and thrombosisI82 Other venous embolism and thrombosis

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Coding ConventionsRelational Terms -2

With – should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetical Index, or an instructional note in the Tabular List. The term “with” in the Alphabetical Index is sequenced immediately following the main term, not in alphabetical order.

Asthma, asthmatic with chronic obstructive pulmonary disease 493.2/J44.9493.2 Chronic obstructive asthmaJ44 Other chronic obstructive pulmonary disease Includes asthma with COPD

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General Coding GuidelinesSigns and Symptoms

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider

Chapter 16 of ICD-9-CM contains many, but not all codes for symptoms

Chapter R00 – R99, for ICD-10-CM, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains many, but not all codes for symptoms

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General Coding GuidelinesIntegral Part of a Disease

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Examples:Altered Mental Status due to UTI -599.0/N39.0COPD with Shortness of Breath -496/J44.9

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General Coding GuidelinesNot an Integral Part of Disease -2

Signs and symptoms that may not be associated routinely with a disease process should be coded when present.

Resident has a culture that returned difficile. The resident has diarrhea with additional symptoms of malaise, low-grade fever and frequent diarrhea. The resident was started on Flagyl. The resident is weak, dehydrated, and needs IV fluids.

Infection, Clostridium, difficile, food borne (disease) 008.45/A04.7 Dehydration 276.51/E86.0

General Coding GuidelinesMultiple Coding

In addition to the etiology/manifestation convention that requires two codes, there are other single conditions that also require more than one code. See “Use additional code” notes in the Tabular List at the code level. These are sequenced secondary to the condition code.

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General Coding GuidelinesMultiple Coding -2

“Code first” notes are under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present, the underlying condition is sequenced first.

“Code if applicable, any causal condition” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable.

If the causal condition is known, then the code for that condition should be sequenced as the principal diagnosis or first-listed diagnosis.

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General Coding GuidelinesMultiple Coding Example

Multiple codes may be needed for sequela conditions. See Guideline #10.

E. coli urinary tract infection

Infection, Urinary (tract) 599.0/N39.0 Use additional code to identify infectious organism/agentInfection, bacterial, Escherichia coli [E. coli] (see also Escherichia coli) 041.04/B96.20

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General Coding GuidelinesAcute and Chronic Conditions

If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indention level, code both and sequence the acute (subacute) code first

Acute and chronic bronchitisBronchitis, acute or subacute (with bronchospasm or obstruction) 466.0/J20.9Bronchitis, chronic 491.9/J42

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General Coding GuidelinesCombination Code

A combination code is a single code used to classify:● Two diagnoses, or● A diagnosis with an associated secondary manifestation, or● Type 2 diabetes with other specified complication

250.80/E11.69o Use additional code to identify complication

● A diagnosis with an associated complication o Acute Bronchitis with COPD 491.22/J44.0

General Coding Guidelines Combination Code -2

Assign only the combination code that fully identifies the diagnostic conditions involved or when directed by the Alphabetical Index

Multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis

When a combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code

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General Coding GuidelinesLate Effects/Sequela

“A residual effect (condition produced) after the acute phase of an illness or injury has terminated.”

There is no time limit for the late effect or sequela code

The residual may be apparent early or years later

Generally requires two codes:● The condition or nature of the late effect/sequela – first

o 438.5/I69.16 Other paralytic syndrome following intracerebral hemorrhage

● The late effect/sequela code – secondo 344.00/G82.5- Quadriplegia

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General Coding GuidelinesSequela

Exceptions to above guideline.● In instances where the code for the late effect/sequela is

followed by a manifestation code identified in the Tabular List and title, or the late effect/sequela code has been to include the manifestation.

Example: 438/I69 Late Effects/Sequela of Cerebrovascular Disease

● The code for the acute phase of an illness or injury that led to the late effect/sequela is never used with a code for the late effect.

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General Coding GuidelinesReporting Same Dx More than Once

Each unique ICD-10-CM code may be reported only once for an encounter

This applies to bilateral conditions when there are no distinct codes for laterality or two different conditions classified to the same ICD-9-CM or ICD-10-CM diagnosis code

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General Coding GuidelinesLaterality *ICD-10 only

Laterality Guidelines● For bilateral sites, the final character of the codes indicates

laterality.● An unspecified site code is also provided should the side not be

identified in the medical record.● If no bilateral code is provided and the condition is bilateral,

assign separate codes for both the left and right side

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General Coding GuidelinesDocumentation of BMI and Pressure Ulcer Stages

Body Mass Index (BMI) and pressure ulcer stage codes may be based on the medical record documentation from clinicians who are not the patient’s provider, such as a dietician for BMI or licensed nurse for pressure ulcer staging.

Associated conditions (overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

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General Coding GuidelinesSyndromes

Follow the Alphabetical Index for guidance when coding syndromes

If there is no guidance in the Alphabetical Index assign codes for the documented manifestations of the syndrome

Look for the syndrome by its name in the alphabetical index first and then if not there, under syndrome

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Coding GuidelinesComplications

“Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure.”

The guideline extends to any complications of care, regardless of the chapter the code is located in.

Note: not all conditions that occur during or following medical care or surgery are classified as complications.

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Coding GuidelinesComplications -2

There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. If the complication is not clearly documented, query the provider for clarification.

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INFECTIOUS AND PARASITIC DISEASES

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HIV Infections Code Only Confirmed Cases

Code only confirmed cases of HIV

“Confirmation” does not require documentation of positive serology, the provider’s diagnostic statement that the patient is HIV positive is sufficient

Asymptomatic HIV is to be applied when the patient without documentation of symptoms is listed as being “HIV Positive”. Do not use this code if the terms AIDS is used or if the patient is treated for any HIV-related illness.

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Infectious Agents

Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code

An additional code from Chapter 1 should be used to identify the organism:● 041/B95 Streptococcus, Staphylococcus, and Enterococcus● 041.8/B96, Other bacterial agents● 079/B97 Viral agents

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Infectious Agents -2

An instructional note will be found at the infection code advising that an additional organism code is required

Use an additional code to identify infectious agent

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Examples

UTI with hematuria due to E.coli● 599.0, 599.70 UTI,

hematuria, orN30.91, Cystitis unspecified with hematuria

● 041.4 Escherichia coli, orB96.2, Escherichia coli [E. coli] as the cause of diseases classified elsewhere

Pneumonia due to streptococcus group B with sepsis● 482.32, or

J15.3, Pneumonia due to streptococcus, group B

● 995.91, orA41.9 Sepsis, unspecified organism Septicemia NOS

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Infections Resistant to Antibiotics

Infections Resistant to Antibiotics● Identify all infections documented as antibiotic resistant

Assign code V09.9-/Z16● Infection with drug-resistant microorganisms following the

infection code

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Septicemia, SIRS, Sepsis, Severe Sepsis, and Septic Shock

Septicemia and sepsis are often used interchangeably, but they are NOT considered synonymous terms.● Septicemia refers to a systemic disease associated with the

presence of toxins in the blood● Systemic inflammatory response syndrome/SIRS refers to

the systemic response to infection with symptoms of fever, tachycardia, tachypnea and leukocytosis

● Sepsis refers to SIRS d/t infection● Severe sepsis refers to sepsis with associated acute organ

dysfunction● Septic shock refers to circulatory failure associated w/severe

sepsis

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Coding of SIRS, Sepsis and Severe Sepsis

Requires a minimum of 2 codes:● A code for the underlying cause (such as infection; if

unspecified septicemia, code 038.9) *sequence first● And a code from subcategory 995.9- *sequence second

Severe sepsis requires an additional code for the associated acute organ dysfunction

Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9-

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Urosepsis Guidelines

Urosepsis cannot be coded in ICD-10-CM Guideline states: “The

term urosepsis is a nonspecific term. It is not to be considered

synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use

this term, he/she must be queried for clarification.”

ICD-9-CM Alpha Index

Urosepsis 599.0

meaning sepsis 995.91

meaning urinary tract

infection 599.0

ICD-10-CM Alpha Index

Urosepsis – code to

condition

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Sepsis documentation to look for…Or query MD for…

Streptococcal sepsis

Sepsis d/t Staphylococcus aureus

Sepsis d/t other Gram-negative organisms

Severe sepsis

Sepsis d/t MRSA

Sepsis d/t MSSA

d/t joint prosthesis (complication)

d/t catheter (complication)

Other organism??

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Severe Sepsis Coding Example

ICD-9-CM

• Severe sepsis due to hemophilus influenza with septic shock and acute renal failure

• 038.41 (Hemophilus influenza septicemia)

• 995.92 (Severe sepsis)• 785.52 (Septic shock)• 584.9 (Acute renal failure)

ICD-10-CM

• Severe sepsis due to hemophilus influenza with septic shock and acute renal failure

• A41.3 (Hemophilus influenza sepsis)

• R65.21 (Severe sepsis with septic shock)

• N17.9 (Acute renal failure)

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Coding Note: In ICD-10-CM, when coding an infection due

to an indwelling urinary catheter, the coding

professional is instructed to use an additional code to

identify the infection (besides coding the complication

996.31). Additionally, if the infectious agent is also known, this should be

assigned as an additional diagnosis.

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Methicillin Resistant Staphylococcus Aureus (MRSA) Conditions

Selection and sequencing of MRSA codes● (a) Combination codes for MRSA infection – when an infection

due to MRSA has a combination code that includes the causal organism assign the appropriate combination codeo Do not code B95.62 MRSA infection as the cause of diseases elsewhere

or Z16.11 Resistance to penicillin as additional codes

● (b) Other codes for MRSA infection – when there is a current infection and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62o Do not use Z16.11 Resistance to penicillin

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Methicillin Resistant Staphylococcus Aureus (MRSA) Conditions -2

Selection and sequencing of MRSA codes● c) Methicillin susceptible Staphylococcus aureus (MSSA) and

MRSA colonization- means that MSSA or MSRA is present on or in the body without necessarily causing illnesso Assign code Z22.322 Carrier or suspected carrier of MRSA, or

Z22.321 Carrier or suspected carrier of MSSA

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Neoplasms

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General Neoplasm Guidelines

The Neoplasm Table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.

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Neoplasm Table

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Neoplasm Table -2

Malignant – Primary● Original site of cancer● 2 primary sites may be coded, if indicated● Alphabetic Instructions will indicate if malignant● Primary site unknown or unspecified

o Use 199.1/C80.1, Malignant (primary) neoplasm, unspecified

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Neoplasm Table -3

Malignant – Secondary● The site where the cancer spreads to (metastasizes)● Primary cancer that spreads to a secondary site may be stated

as:o Primary site with metastasis to secondary siteo Secondary site with metastasis from primary siteo Secondary site due to metastatic primary site

● If secondary site unknown - use 199.1/C79.9, secondary malignant neoplasm of unspecified site

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Neoplasm Table -4

Ca in situ● Atypical malignancy; encapsulated – has not spread● Physician must indicate “in situ” or index will instruct you to

code this type

Benign● Not malignant● Does not metastasize

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Neoplasm Table -5

Uncertain ● Alphabetic index will instruct to use this type if appropriate –

See neoplasm, by site, uncertain behavior● Not used if it is the coder that is uncertain of the behavior

Unspecified Behavior● Not specified as malignant or benign● Index instructions will direct here as appropriate – See

neoplasm, by site, unspecified behavior

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Current vs. History of

Neoplasm is coded as a current condition if

being actively treated

• Diagnosed but no treatment administered

• Has been removed surgically but treatment is still being administered

(for example, chemotherapy/radiation)

Neoplasm is coded as a “history of” if

• Site has ben surgically removed and/or treatment has been completed AND

• There is no mention of recurrence

• Use V10/Z85 category to indicate a personal history of neoplasm

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Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

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Anemia Defined

A condition in which your blood has a reduced number of circulating red blood cells usually defined as an abnormally low hemoglobin or hematocrit level.

Caused by:● Disease (malignancy, kidney failure, immunity)● Blood loss● Decreased blood formation or destruction of cells● Nutritional Deficiency● Drug induced

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Anemia, Due to

D50.0 – Iron deficiency secondary to blood loss (chronic blood loss)

D50.9 – Iron deficiency Anemia

D51.0 – Vitamin B12 deficiency anemia

D53.0 – Protein deficiency anemia

D62 – Acute blood loss

D63.1 – Anemia in chronic kidney disease

D63.8 – Anemia in neoplastic disease

D64.81 – Anemia due to antineoplastic chemotherapy

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Anemia Associated with Malignancy

Coding Guideline I.C.2.c.1. Anemia Associated with Malignancy

When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as D63.0, Anemia in neoplastic disease).

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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES

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Diabetes Combination Codes

Documentation needs to include type of diabetes● Type I● Type II● Secondary● Other specified

Is there a body system affected:● Kidney ● Ophthalmic● Neurological● Circulatory● Other specified (diabetic ulcer, etc.)

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Diabetes Combination Codes -2

What is the specific complication affecting the system(s)?

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DIABETES

TYPE I

DIABETES

TYPE II

What’s the difference?

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Diabetes TypesAge Not Sole Factor Determining Type

Diabetes, Type I

• Cause: Absent or insufficient insulin production

• 10% of diabetics• Usually juvenile onset• Does not respond to oral

anti-glycemic agents• Always requires insulin

Diabetes, Type II

• Cause: Improper utilization of insulin

• 90% adult onset (age 40>, but being seen more in younger population)

• Responds to oral anti-glycemic agents

• May require insulin

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Secondary Diabetes

Due to another underlying condition● Cystic Fibrosis● Malignant Neoplasm of Pancreas● Pancreatectomy

Drug or chemical induced● Adverse effect of drug● Poisoning*Follow coding directions at the beginning of each category!

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Diabetes Type Not Documented?

Default = Type II DiabetesDEFAULT

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Q: Do I always use an additional code for

long term use of insulin when ordered?

A: No

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Diabetes and Use of Insulin

Type I: Do NOT code long term use of insulin

Type II: Code long term use of insulin

Secondary to underlying condition: Code use of insulin

Drug/Chemical induced: Code use of insulin

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CDAT Example for Diabetes 250.00

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Obesity

Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat, and/or body water. Both terms mean that a person's weight is greater than what's considered healthy for his or her height.

Type of obesity● Morbid/severe● Due to excess calories● Drug-induced obesity

Vs. Overweight (code for this too)

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Gout

Gout is a kind of arthritis. It can cause an attack of sudden burning pain, stiffness, and swelling in a joint, usually a big toe.

Types: acute, chronic or secondary● Idiopathic● Gouty bursitis● Drug-induced gout● Due to renal impairment● Other secondary gout

Specify joint site/laterality

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Dehydration

The excessive loss of body water with an accompanying disruption of metabolic processes

Note: make sure this is a current condition that is being actively treated upon admission to your facility, otherwise do NOT code

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Hypothyroidism

Often called underactive thyroid, it is a common endocrine disorder in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as tiredness, poor ability to tolerate cold, and weight gain

Acquired or congenital?

Due to:● Iodine deficiency● Post-irradiation therapy● Post-surgery● Other

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Hypercholesterolemia

Hypercholesterolemia is the presence of high levels of cholesterol in the blood. It is a form of “hyperlipidemia" (elevated levels of lipids in the blood) and "hyperlipoproteinemia" (elevated levels of lipoproteins in the blood).

Does documentation show:● With hyperglyceridemia (an elevated concentration of

glycerides in the blood), or● With dietary counseling (use additional code)

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Hyperlipidemia

Abnormally elevated levels of any or all lipids and/or lipoproteins in the blood. It is the most common form of dyslipidemia (which includes any abnormal lipid levels).

Specified type:● Combined (also known as "Multiple-type

hyperlipoproteinemia” )o Familial combined hyperlipidemia

● Group o A, B, C or D

● Mixed● Other specified type● Lipoprotein deficiency

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Anemia

ICD-9/Diseases of the blood – Anemia, NOS 285.9

ICD-10/Endocrine, Nut’l, Metabolic diseases D58-D64● Chapter change

Anemia has three main causes: blood loss, lack of red blood cell production, or high rates of red blood cell destruction.

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Anemia -2

Specified type● General = unspecified● Acquired hemolytic *caused by high rates of red blood cell

destruction● Chronic blood loss *such as chronic posthemorrhagic anemia● Iron *fewer red blood cells made or red blood cells that are too

small ● Nutritional *such as simple chronic anemia● In chronic diseases *such as neoplastic disease, CKD,

hypothyroidism

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Mental and Behavioral Disorders

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Dementia

Specific type● Vascular/multi-infarct *a result of infarction of the brain due to

vascular disease, including hypertensive cerebrovascular disease. Code 1st underlying condition (CVD, etc.)

● In diseases classified elsewhere code 1st underlying condition (Alzheimer’s, Parkinson’s, etc.)

● Senile *separate code in ICD-9, but dementia unspecified in ICD-10

● Delirium superimposed on dementia *ICD-10 only, code 1st underlying condition

● Unspecified

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Dementia -2

With or without behavioral disturbance● Aggressive, combative, violent behavior

Old code 294.8 *should NOT be using anymore, invalid

Additional code for wandering Z91.83 *ICD-10 only

If psychotherapeutic drugs given, check guidelines

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Episodic Mood Disorders/Bipolar Disorder*also known as Manic-depressive Illness

Bipolar and Major depression have separate categories in ICD-10

Bipolar disorder, severe *with or without psychotic features

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Episodic Mood Disorders/Bipolar Disorder*also known as Manic-Depressive Illness -2

Specify type

If psychotherapeutic drugs given, check guidelines

ICD-9 Single or Recurrent w/

• Subchronic• Chronic• Subchronic w/acute

exacerbation• Chronic w/acute

exacerbation• In remission

ICD-10

• Hypomanic• Manic• Depressed• Mixed• In remission• Other

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Major Depression

Has its own category in ICD-10

In ICD-10, Depression, NEC is coded to Major depressive disorder, single episode, unspecified

Specify type● Major depressive disorder, single episode● Major depressive disorder, recurrent ● Major depressive disorder, recurrent, in remission

Specify intensity: mild, moderate or severe

If severe: with or without psychotic features

If psychotherapeutic drugs given, check guidelines

94

Schizophrenia

Specify type● Paranoid● Disorganized● Catatonic● Undifferentiated *atypical● Residual● Schizophreniform disorder● Schizotypal disorder *borderline, latent, etc.● Schizoaffective disorder *bipolar, depressive, other – ICD-10● Other

In ICD-10, 5th digit of chronic, in remission, etc. is gone

If psychotherapeutic drugs given, check guidelines

95

Psychosis

If d/t a known mental disorder, code to that condition● Delusional disorder *includes paranoia, paranoid state● Mood disorder w/psychotic symptoms *includes Manic episode,

Bipolar disorder, Major depressive disorder● Brief psychotic disorder *includes paranoid reaction● Shared psychotic disorder *includes induced paranoid disorder● Unspecified mental disorder d/t known physiological condition

*includes OBS, NOS; mental disorder NOS , *code 1st underlying physiological condition

● Unspecified psychosis NOT d/t known physiological condition *includes Psychosis, NOS

96

Psychosis -2

If d/t a known mental disorder, code to that condition (cont.)● Other psychotic disorder NOT d/t known physiological

condition *includes chronic hallucinatory psychosis● Mental disorder, NOS *includes mental illness, NOS

If psychotherapeutic drugs given, check guidelines

97

Anxiety

Specify type● Panic disorder *includes panic attack, panic state● Generalized anxiety disorder *includes anxiety reaction,

anxiety state● Other mixed anxiety disorders *suffer from both anxiety and

depressive symptoms ● Other specified anxiety disorders *includes anxiety depression

If psychotherapeutic drugs given, check guidelines

98

Diseases of the Nervous System

99

Hemiplegia

These codes are only to be used when the paralytic syndrome is specified w/o further specification, or is stated to be old but unspecified cause

This category is also for use in multiple coding to identify the specific type of hemiplegia resulting from any cause *flaccid or spastic

*ICD-10 only

100

Hemiplegia -2

Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows: ● For ambidextrous (using both sides equally) patient, the default

should be dominant● If the left side is affected, the default is non dominant● If the right side is affected, the default is dominant

101

Dementia with Parkinson’s Disease vs. Parkinsonism

Parkinson's disease (PD) belongs to a group of conditions called motor system disorders, which are the result of the loss of dopamine-producing brain cells *code 332.0/G20, with dementia add 294.1-/F02.-

Parkinsonism shares symptoms found in Parkinson’s disease, from which it is named; but Parkinsonism is a symptom complex, and differs from Parkinson’s disease which is a progressive neurodegenerative illness*code 331.82/G31.83 *same as Lewy body dementia

*ICD-10 only

102

Alzheimer’s Disease

Identify type● Alzheimer’s disease with early onset● Alzheimer’s disease with late onset● Other Alzheimer’s disease● Alzheimer’s disease, unspecified

Use additional code to identify● Dementia w/behavioral disturbance● Dementia w/o behavioral disturbance● Delirium , if applicable

*ICD-10 requires the use of both the Alzheimer and dementia codes

103

Seizure Disorder vs. Convulsions

Epilepsy/seizure disorder is a spectrum of brain disorders ranging from severe, life-threatening and disabling, to ones that are much more benign

Convulsion is a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body

If seizures repeatedly continue after the underlying problem is treated, the condition is called epilepsy (resident is usually on a routine med for seizures)

104

Epilepsy, Recurrent Seizures and Migraines

The following terms are equivalent to

intractable: pharmacoresistent (pharmacologically resistant), treatment resistant, refractory

(medically), and poorly controlled.

105

Coding of Epilepsy

Identify if epilepsy or seizure disorder, or just convulsion, NOS

Specify type● Intractable● Not intractable● With status epilepticus● Without status epilepticus

106

Peripheral Neuropathy

Specify type● Polyneuropathy in diseases classified elsewhere

ICD-9

• Diabetes 250.6- + 357.2

• Malignant dx • CA code + 357.3

ICD-10

• Diabetes, type 2 E11.42

• Neoplasm• Code CA + G63

107

Diseases of the Eye and adnexa

108

Coding Note

Use additional external cause code, if applicable, to identify the cause of the eye condition

Glaucoma types:● Borderline glaucoma● Open-angle glaucoma● Primary angle-closure glaucoma ● Corticosteroid-induced glaucoma● Glaucoma asso w/congenital anomalies, dystrophies, and systemic

syndromes *includes glaucoma d/t diabetes 250.50, 365.44● Glaucoma associated with disorders of the lens● Glaucoma associated with other ocular disorders● Other specified forms of glaucoma*Where do you get this information from?

109

Combination Codes & Laterality

ICD-9-CM

• Diabetic Retinopathy with Macular Degeneration needs three codes: 250.50, 362.01, 362.50

• Cystic Macular Degeneration 362.54

ICD-10-CM

• Combination Code:• Diabetic Retinopathy with

Macular Degeneration uses a combination code: E08.351

• Laterality:• Macular cyst, hole, right

eye H35.341

110

ICD-10 Glaucoma Coding Changes

Identify the type of glaucoma, the affected eye, and the glaucoma stage.

A 7th character is to be assigned to designate the stage of glaucoma: mild, moderate, severe, indeterminate, or unspecified

111

ICD-10 Cataract Terms

ICD-10 CM uses the terms “age-related” cataract and “senile cataract” interchangeably.

There are also terms for “age-related”, “infantile & juvenile cataract”, “traumatic cataract”, “complicated cataract”, “drug-induced cataract”, and “secondary cataract”.

Within the age-related/senile category there are cortical, subcapsular, incipient, nuclear, and morgagnian cataracts.*Similar terminology to ICD-9

112

Blindness and Low Vision Definitions

Visual impairment refers to a functional limitation of the eye

Visual disability indicates a limitation of the abilities of the individual

For international reporting, WHO, defines blindness as profound impairment

The definition of legal blindness as a severe impairment is used in the USA

113

ICD-10 Terms for Blindness

In the case of blindness, the code H54 has a note: Code first any associated underlying cause of blindness.

Blindness codes include laterality.

Example: ● H54.52, which is low vision left eye, normal vision right eye.

114

Diseases of the Circulatory System

115

Cardiac dysrhythmias

427.0 Paroxysmal supraventricular tachycardia427.1 Paroxysmal ventricular tachycardia427.2 Paroxysmal tachycardia, unspecified427.3- Atrial fibrillation and flutter

*ICD-10 Includes a code for chronic a-fib

427.4- Ventricular fibrillation and flutter427.5 Cardiac arrest427.6- Premature beats427.8- Other specified cardiac dysrhythmias

● Sick sinus syndrome

116

Heart Failure

428.0 Congestive heart failure, unspecified

428.1 Left heart failure

428.2- Systolic heart failure **

428.3- Diastolic heart failure **

428.4- Combined systolic and diastolic heart failure **

Code, if applicable, heart failure d/t HTN 1st *if supporting MD documentation

**these codes also need to know if acute, chronic or acute on chronic (ICD-10 will need for CHF too)

117

Acute Myocardial Infarction (AMI)

Myocardial infarction or acute myocardial infarction (AMI) is the medical term for an event commonly known as a heart attack. It happens when blood stops flowing properly to part of the heart and the heart muscles are injured due to not receiving enough oxygen.

118

Acute Myocardial Infarction (AMI) -2

Usually this is because one of the coronary arteries that supplies blood to the heart develops a blockage due to a buildup of white blood cells, cholesterol and fat. The event is called "acute" if it is sudden and serious

119

Acute MI

STEMI or NSTEMI?

Occurred 8 weeks or less?

5th digit needed● 2 = Subsequent episode of care *appropriate

code for SNF, if treated 1st at hospital

ICD-10 Code changes:

I21 – Initial AMIs

I22 – Subsequent AMIs

*New for ICD-10

120

Atherosclerotic Coronary Artery Disease and Angina

Atherosclerosis (hardening of the arteries) ● can slowly narrow and harden the arteries throughout the body● when atherosclerosis affects the arteries of the heart, it’s

referred to as coronary artery disease

Coronary artery disease is the No. 1 killer of Americans. Most of these deaths are from heart attacks, caused by sudden blood clots in the heart’s arteries.

121

Atherosclerotic Coronary Artery Disease and Angina

Atherosclerosis is a blood clot causing an acute coronary syndrome.

Two things can happen:● Unstable angina - the clot doesn't totally

block the blood vessel and then dissolves without causing a heart attack

● Myocardial infarction (heart attack) - the coronary artery is blocked by the cloto the heart muscle, starved for nutrients and

oxygen, dies

122

Coding Coronary Artery Disease/CAD

Should be coding to 414.01, unless a CABG has been done or MD specifies otherwise

Differentiate between coding of coronary arteries 414 and of the extremities 440…

123

ICD-10 Coding of Arteriosclerosis

4th digit● Vessel: Native, bypass graft, autologous vein bypass graft, non-

autologous biological bypass graft, non-biological bypass graft

5th digit● Symptom: claudication, rest pain, ulcer and with gangrene.

6th digit● Extremities: right, left, bilateral, other, unspecified ● Site of leg: thigh, calf, ankle, heel, mid-foot, foot, other.

*ICD-10 will also have a combination code for CAD with angina

124

Cerebrovascular System

125

CVA Versus TIA

126

CVA

• Brain infarction or hemorrhage usually associated with permanent or temporary neurologic deficits; includes transient focal neurological deficits lasting longer than 24 hours

• Persistent neurological deficit >24 hours

• Positive image study (MRI/CT)

TIA

• A brief period of focal neurologic deficit lasting less than 24 hours (usually less than one hour) due to temporarily blocked blood flow to a specific area of the brain

• Symptoms resolve in 24 hours (usually < 1 hour)

• No infarction or hemorrhage• Negative MRI/CT

Coding Post CVA

Once cerebrovascular disease/CVD has been treated at the hospital, just the late effects/sequelae are being treated, if any.

Category 438 is used to indicate conditions/residuals that have occurred any time after the onset of CVD.

Use a separate code for each residual effect.

Should NOT be coding 436.

If no residual effects should code V12.54

127

Hypertension

Hypertension, also referred to as high blood pressure, it is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries.

128

ICD-10 Hypertension Coding Changes

Type of hypertension (benign, malignant, unspecified) is not used as an axis for the ICD-10-CM hypertension codes, there is only one code for essential hypertension (I10)

129

Types of Hypertension

401 Essential hypertension

402 Hypertensive heart disease*MD must document causal relationship

403 Hypertensive chronic kidney disease*implied relationship if both diagnoses documented, also need to code

CKD to indicate the stage 585.-

404 Hypertensive heart and chronic kidney disease*if resident has all three diagnoses/AKA cardiorenal – MD must still

indicate heart dx and hypertension have causal relationship

405 Secondary hypertension*is high blood pressure that's caused by another medical condition

130

CDAT Example for Hypertension 401.9

131

Peripheral Vascular Disease

443.81 Peripheral angiopathy in diseases classified elsewhere *code 1st underlying disease*ICD-10 will have a combo code for DM w/PVD

443.9 Peripheral/arterial/vascular disease

*Excludes atherosclerosis of the extremities

132

Venous Embolism and Thrombosis

453.40 DVT, NOS is coded to acute venous embolism and thrombosis of deep vessels of the lower extremity

453.41 DVT of proximal lower extremity

453.42 DVT of distal lower extremity

453.5- Chronic DVT *also code V58.61 for long term use of anticoagulants

*if vein specified, make sure have correct code

*make sure treatment is currently being given and is NOT for prophylactic measures (Coumadin tx)

*if no current treatment given, code V12.51 for hx of DVT

133

Diseases of the Respiratory System (J00-J99) National Cancer Institute

134

Asthma Terminology for ICD-10

Terminology used to describe asthma has been updated to reflect the current clinical classification of asthma

The following terms have been added to describe asthma:● Mild intermittent, and● Three degrees of persistent

o mild, moderate, severe

135

Symptoms

Stage 1: mild ● Possible chronic cough and sputum production

Stage 2: moderate ● Shortness of breath on exertion● Possible chronic cough and sputum production

Stage 3: Severe ● Shortness of breath● Fatigue● Multiple exacerbations● Reduced exercise tolerance

136

Symptoms -2

Stage IV: Very severe ● Respiratory failure ● Elevation of jugular venous pressure● Pitting ankle edema.

137

Current Asthma Coding

493.0- Extrinsic asthma

493.1- Intrinsic asthma

493.2- Chronic obstructive asthma

*includes asthma w/COPD and chronic asthmatic bronchitis

5th digit for:● Status asthmaticus, and● Acute exacerbation

138

Pneumonia

Remember, if you know the organism code it!

Default code = 486 Pneumonia, unspecified organism

480- Viral pneumonia

481 Pneumococcal pneumonia (includes lobar)

482- Other bacterial pneumonia

483- Pneumonia d/t other specified organism

484- Pneumonia in infectious disease classified elsewhere

485 Bronchopneumonia, organism unspecified

507.0 Aspiration pneumonia d/t inhalation food/vomitus

139

COPD - 496

This code is not to be used with any code from categories 491.- 493. (bronchitis, emphysema, asthma)

COPD w/emphysema 492.8

COPD w/bronchitis:● Acute 491.22● Chronic 491.20

COPD w/exacerbation 491.21

140

Other Diseases of the Lung – 518.8-

Acute respiratory failure - can develop quickly and may require emergency treatment and is usually treated in an intensive care unit

Acute respiratory insufficiency - condition in which the lungs cannot take in sufficient oxygen or expel sufficient carbon dioxide to meet the needs of the cells of the body.

Chronic respiratory failure - develops more slowly and lasts longer. Chronic respiratory failure can be treated at home or at a long-term care center

Acute on chronic respiratory failure – pt exhibits severe pulmonary impairment as a baseline characteristic which may require hospitalization and mechanical ventilation

141

Diseases of the Digestive System

National Cancer Institute

142

Esophageal Reflux Disease

530.81 Esophageal reflux/GERD● Includes acid reflux● Excludes reflux esophagitis 530.11● Excludes hemorrhage d/t esophageal varices 456

Esophageal w/esophagitis 530.11

143

Constipation

564.0- Constipation● Slow transit - there is a prolonged delay in the transit of stool

through the colon.● Outlet dysfunction - difficulty or inability to expel the stool● Other – atonic, neurogenic, spastic

564.1 Irritable bowel syndrome● sometimes alternating bouts of constipation and diarrhea

144

Gastrointestinal Hemorrhage

578.0 Hematemesis – vomiting of blood

578.1 Blood in stool – melena

578.9 Hemorrhage of GI tract, unspecified

Excludes: that with mention of:● diverticulitis of lg and sm intestine, ● diverticulosis of lg and sm intestine, ● gastritis and duodenitis, and ● stomach ulcers

145

Diseases of the Skin and SubcutaneousTissue

National Cancer Institute

146

Cellulitis and Abscess

682.0 Face

682.1 Neck

682.2 Trunk

682.3 Upper arm/forearm

682.4 Hand, except fingers and thumb (681.0-)

682.5 Buttock

682.6 Leg, except foot

682.7 Foot, except toes (681.1-)

682.8 Other specified sites

682.9 Unspecified site

Use additional code to identify organism

147

Chronic Ulcer of Skin

707.0- Pressure ulcer (elbow, upper back, lower back, hip, buttock, ankle, heel, other)

707.1- Ulcer of lower limb, except pressure ulcer (lower limb, thigh, calf, ankle, hell and midfoot, other part of ft)

*code any causal condition first

707.2- Pressure ulcer stages (I-IV, unstageable)

*must use this code after coding 707.0-

*should NOT be using an “unspecified site” code 707.9

148

149

VISUAL GUIDE TO SOME FREQUENTLY SEEN SKIN PROBLEMS

Pressure Ulcer Stage I

150

Pressure Ulcer Stage II

151

Pressure Ulcer Stage III

152

Pressure Ulcer Stage IV

153

Suspected Deep Tissue Injury

154

Unstageable Pressure Ulcer

155

Diabetic Ulcer

156

Vascular Ulcers

157

Cellulitis

158

Diseases of the Musculoskeletal System and Connective Tissue

159

Arthropathy vs. Arthritis vs. Osteoarthritis

Arthropathy = disease of the joints

Arthritis = inflammation of the joints

Osteoarthritis = degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth

*Arthritis is a form of Arthropathy

160

Osteoarthritis/OAArthropathy/DJD

715.0- Osteoarthrosis, generalized

715.1- Osteoarthrosis, localized, primary

715.2- Osteoarthrosis, localized, secondary

715.3- Osteoarthrosis, localized, not specified whetehr primary or secondary

715.8- Osteoarthrosis involving, or with mention of more than one site/polyarthritis

715.9- Osteoarthrosis, unspecified whether generalized or localized

161

5th digits for Osteoarthrosis

0 – site unspecified

1 – shoulder region

2 – upper arm *use for elbow

3 – forearm *use for wrist

4 – hand

5 – pelvic region and thigh *use for hip

6 – lower leg *use for knee

7 – ankle and foot

8 – other specified sites

9 – multiple sites

162

Other Derangement of Joint

718.1- Loose body in joint *Loose bodies are fragments of bone and/or cartilage that freely float in the joint space

718.3- Recurrent dislocation of joint

718.4- Contracture of joint *a permanent shortening of a joint

718.5- Ankylosis of joint *stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint, which may be the result of injury or disease

718.8- Other joint derangement, NEC *instability of joint

163

Osteoporosis

733.00 Osteoporosis, unspecified

733.01 Senile osteoporosis *a geriatric syndrome with a particular pathophysiology

733.03 Disuse osteoporosis *bone loss that results from not enough stress or pressure on the bones. Bones become brittle and weak, causing them to fracture easily.

Use additional code to identify personal hx of pathologic fracture V13.51

164

Definition of Terms

Spontaneous rupture● Occurs when normal force

is applied to tissues that are inferred to have less than normal strength

Fragility fracture● Sustained with trauma no more than a fall from a standing

height or less occurring under circumstances that would not cause a fracture in a normal healthy bone

165

Pathologic Fracture

733.11 Pathologic fracture of humerus

733.12 Pathologic fracture of distal radius/ulna

733.13 Pathologic fracture of vertebrae

733.14 Pathologic fracture of neck of femur

Includes chronic fracture, spontaneous fracture

Excludes stress fracture, traumatic fracture

166

Other and Unspecified Disorders of Joint/Gait disorders

719.7 Difficulty in walking

781.2 Abnormality of gait/ataxic/gait disturbance/paralytic/spastic/staggering gait

167

Other Disorders of the Back

724.1 Pain in thoracic spine

724.2 Lumbago/low back pain/lumbalgia

724.3 Sciatica *neuralgia or neuritis of sciatic nerve

724.5 Backache

168

Muscle Weakness/Muscle Wasting and Disuse Atrophy

728.87 Muscle weakness (generalized)

*different than generalized weakness/malaise and fatigue 780.79

728.2 Muscular wasting and disuse atrophy

728.3 Other specific muscle disorders

169

Diseases of the Genitourinary System National Cancer Institute Alan Hoofring

170

Acute and Chronic Kidney Failure

584.- Acute kidney failure - develops rapidly over a few hours or a few days, can be fatal and requires intensive treatment. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care.

585.- Chronic kidney disease/CKD● 4th digit for stage ● ESRD is 585.6 *includes stage V requiring dialysis

*code first any associated condition:diabetic chronic kidney disease 250.4-hypertensive chronic kidney disease 403.-, 404.-

586 Renal failure, unspecified

171

Stages of Chronic Kidney Disease/CKD

• CKD, Stage 1585.1/N18.1

• CKD, Stage 2 (mild)585.2/N18.2

• CKD, Stage 3 (moderate)585.3/N18.3• CKD, Stage 4 (severe)585.4/N18.4

• CKD, Stage 5 585.5/N18.5• End Stage Renal Disease (CKD

requiring chronic dialysis)585.6/N18.6

172

CKD and Kidney Transplant Status

Following kidney transplant, a patient may continue to have some form of CKD, because the kidney transplant may not fully restore kidney function.

The presence of CKD alone does not constitute a transplant complication.

Assign the appropriate code for the stage of CKD & code kidney transplant status.

173

Urinary Tract Infection

599.0 is the code for site not specified, if site is known this would be an incorrect code:

-bladder – see cystitis

-kidney – see infection, kidney

-urethra – see urethritis

• Use additional code to identify organism, if known

174

Hyperplasia/Enlarged Prostate

Includes BPH 600.0-

Subcategories for enlarged and nodular:● 600.00 Enlarged prostate without lower urinary tract

symptoms/LUTS (incomplete bladder emptying, nocturia, straining on urination, urinary freq, urinary hesitancy, urinary incont, urinary obstruction, urinary retention, urinary urgency weak urinary stream)

● 600.01 Enlarged prostate with LUTS● 600.10 Nodular prostate without LUTS *● 600.11 Nodular prostate with LUTS *

*a nodular = a "bump" that can be felt in the prostate

175

Symptoms, Signs and Abnormal Clinical and Laboratory Findings

176

Codes Used For

a

• No more specific diagnosis can be made even after all facts have been investigated

b

• Signs or symptoms existing at time of initial encounter - transient and causes not determined

c• Provisional diagnosis in patient failing to return

d• Referred elsewhere before diagnosis made

e• More precise diagnosis not available

f

• Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right

177

Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the code book.● Examples:

o SOB in COPDo Edema in CHFo Fever in strep throato Urinary urgency in UTI

In LTC, often symptoms are used as therapy treatment diagnoses. Code as long as therapy is treating.

178

Superficial injuries, such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

179

Coding from Lab/X-Ray Reports

Attending physician must document the significance of any abnormal finding

Can use lab/x-ray reports to further define documented diagnoses, but not to code a new diagnosis when the provider has not documented

180

Common Signs and Symptoms

780.2 Syncope and collapse/fainting

780.79 Other malaise and fatigue/gen. weakness

799.3 Debility *weak and feeble

780.96 Generalized pain *site?

780.97 Altered mental status *on ER report

780.99 Other general symptoms *??

783.7 Adult failure to thrive *a descriptive, non-specific term that encompasses "not doing well"

782.3 Edema

181

Common Signs and Symptoms -2

786.05 Shortness of breath

786.2 Cough

787.01 Nausea with vomiting

182

Insomnia

780.50 Sleep disturbance, unspecified

780.51 Insomnia with sleep apnea, unspecified

780.52 Insomnia, unspecified

780.57 Unspecified sleep apnea

327.01 Insomnia d/t medical condition classified elsewhere *code first underlying condition

183

Common Therapy Treatment Diagnoses

781.2 Abnormality of gait *excludes ataxic gait, difficulty walking

781.3 Lack of coordination/muscular incoordination

781.92 Abnormal posture

784.3 Aphasia *if following CVA, code 438.11

784.60 Symbolic dysfunction may experience a lack of ability to initiate and/or terminate a conversation, as well as difficulty with other forms of communication

787.2- Dysphagia *identify phase of dysphagia after eval

*if d/t CVA, code first 438.82

799.52 Cognitive communication deficit *and characteristic that acts as a barrier to the cognition process

184

Factors Influencing Health Status & Contact with Health Services

185

Amputations

Traumatic = due to an incident

An amputation not identified as partial or complete should be coded to complete

Use the appropriate 7th character:

“D” subsequent encounter

“S” sequela

If acquired amputation, go to Absence, by site, acquired (Z89)

186

Acute Fractures vs. Aftercare

Traumatic fractures are coded using the acute fracture codes (800-829) while the patient is receiving active treatment for the fracture.

Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

Fractures are coded using the aftercare codes (V54) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.

187

V Codes

Represent reasons for encounters● When person who may or may not be sick encounters health

services for some specific purpose, i.e. to receive limited care or service for current condition, donate an organ or tissue, receive prophylactic vaccination, discuss problem

● When some circumstance or problem is present which influences person’s health status but is not a current illness or injury

188

V Codes Represent Reasons for Encounters

Identify significant past health histories

Identify services provided following an acute care episode

Identify services related to the provision of aftercare

Identify delivery of specific healthcare services: screening, tests & vaccinations

Identify presence of problem influencing health status but which is not a current illness (history of)

189

Use of V Codes in any Healthcare Setting

V codes are for use in any healthcare setting

V codes may be used as either first-listed or secondary diagnosis, depending on the circumstances of the encounter

Certain V codes may only be used as first-listed or principal diagnosis ● *See the Official Coding Guidelines for a list of these codes

I.C.21.c.16.

190

Categories of V Codes

There are numerous categories for V Codes

We will define the categories most frequently seen in post-acute care

We will explore examples of the common codes from frequently used categories in LTC.

We will practice coding conditions found in this chapter.

191

V01 Contact / Exposure

These codes are for patients who do not show any signs or symptoms of a disease but are suspected to have been exposed to it by close personal contact or are in an area where a disease is epidemic.

This category also indicates contact with and suspected exposures hazardous to health

*may be used as a first-listed or secondary code

192

V03 – V06 Inoculations and Vaccinations

Codes are for encounters for inoculations and vaccinations

It indicates that a patient is being seen to receive a prophylactic inoculation against a disease

There is only one code for inoculations, and if coded, need an additional procedure code to identify the vaccine

193

Status Codes

Status codes indicate that a patient is either a carrier of a disease or has the residual of a past disease or condition

Includes presence of prosthetic or mechanical devices resulting from past treatment

A status code is informative, because the status may affect the course of treatment or its outcome

A status code is distinct from a history code (history code indicates that patient no longer has the condition)

194

Resistance to Antimicrobial Drugs V09

NOTE: The codes in this category are provided for use as additional codes to identify the resistance and non responsiveness of a condition to antimicrobial

drugs.

Exclude 1:Code first the infection:

MRSA infections (038.12)MSSA infections (038.11)MRSA pneumonia (482.42)

195

Carrier of Infectious Disease/V02

V02 Carrier of Infectious Disease

Colonization status

Suspected carrier

Example:

V02.54 Carrier or (suspected) carrier of Methicillin resistant Staphylococcus

aureus MRSA colonizationCarrier = person that harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection

196

Long Term (current) Drug Therapy V58.6-

Codes from this category indicate a patient’s continued use of a prescribed drug for the long term treatment of a condition or for prophylactic use.

Not used for patients with addictions to drugs

Used for patients receiving a medication for an extended period of time

197

Long Term (current) Drug Therapy

Includes: Long term (current) drug use for prophylactic purposes

Exclude 1: Code also any therapeutic drug level monitoring (V58.83)

V58.61 Long term (current) use of anticoagulants

V58.66 Long term (current) use of aspirin

V58.62 Long term (current) use of antibiotics

V58.67 Long term (current) use of insulin

198198

V49.- Acquired Absence of LimbV45.7 Acquired Absence of Organ

Examples:

V49.75 Amputation status below knee

V49.76 Amputation status above knee

V45.71 Acquired absence breast and nipple

V45.73 Acquired absence of kidney

199

V44 Artificial Opening StatusV42 Transplanted Organ Status

Examples:

V44.1Gastrostomy status

V44.3Colostomy status

V44.0Tracheostomy status

V42.0Kidney transplant status

V42.5Corneal transplant status

200

Organ Or Tissue Replaced By Other Means

Examples:

V43.1 Presence of intraocular lens

(s/p cataract removal surgery)

V43.64 Presence of artificial hip joint

(s/p joint replacement)

V43.21 Presence of heart assist device

(cardiac shunt, etc.)

201

V45.- Other Postprocedural Status

Examples:

V45.61 Cataract extraction status

V45.87 Transplant organ removal status

V45.11 Dependence on renal dialysis

V45.12 Noncompliance with renal dialysis

V45.01 Cardiac pacemaker status

202

History (of)

Two types, family and personal

A history codes indicate that a patient no longer has the condition, and is no longer receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring

History codes are acceptable on any medical record, as the history of an illness is important information that may alter the type of treatment ordered

203

History (of), Personal

V10.3 Personal history breast cancer

V12.04 Personal history MRSA infection

V12.51 Personal hx of venous thrombosis/embolism

V13.51 Personal hx pathological fx

V15.51 Personal hx traumatic fracture (healed)

V15.88 Personal history of falling

*at risk for falling

204

History Allergy to Drugs and Other Substances

Examples:

V14.0Allergy status to penicillin

V14.5Allergy status to narcotic drugs

V15.01 Peanut allergy status

V15.06 Insect allergy status

V15.07 Latex allergy status

V15.08 Radiographic dye allergy status

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Personal History of Medical Treatment

V87.41 Personal history of antineoplastic chemotherapy

V87.43 Personal history of estrogen therapy

V87.44 Personal history of inhaled steroid therapy

V87.45 Personal history of systemic steroid therapy

V15.3 Personal history of irradiation

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Aftercare

Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.

The aftercare V code should not be used if treatment is directed at a current, acute disease or injury.

Aftercare codes are generally first listed to explain the specific reason for the encounter.

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Aftercare + Status Codes

Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare or to indicate the surgery for which the aftercare is being performed

Example:● V58.73 Encounter for surgical aftercare following surgery on

the circulatory system ● V45.81 Aortocoronary bypass status – “CABG” status

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Aftercare Categories

V55 Attention to artificial openings

V54 Orthopedic aftercare

V57 Care involving the use of rehabilitation procedures

*code that may only be principal/first-listed dx

*only use one code in this category (if > one therapy, code multiple therapy V57.89)

V58 Aftercare following surgery

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V55 Attention to Artificial OpeningsV58 Encounter for Other Aftercare

V55.0 Attention to tracheostomy

V55.3 Attention to colostomy*includes toileting/cleansing

V58.31 Attention to surgical dressings

V58.32 Attention to sutures

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V54 Orthopedic Aftercare

V54.13 Aftercare for healing traumatic fracture of hip

V54.81 Aftercare following joint replacement*Use additional code to identify the joint (V43.-)

V54.82 Aftercare following explanation of joint prosthesis

V54.09 Other aftercare involving internal fixationdevice

V54.89 Other orthopedic aftercare

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Aftercare Following Surgery for Neoplasm

V58.42 Aftercare following surgery for Neoplasm

*Use additional code to identify the neoplasm

*If an organ was removed, in total or partial, use a code for acquired absence of the organ

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Aftercare following Surgery on Specified Body Systems V58.7-

NOTE: These codes identify the body system requiring aftercare. They are for use

in conjunction with other aftercare codes to fully explain the aftercare encounter. The condition treated should also be coded if still present.

Excludes Aftercare following organ transplant V58.44

Excludes Aftercare following surgery for neoplasm V58.42

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Aftercare Following Surgery to Specified Body Systems

V58.71 Sense organs

*conditions classifiable to 360-379, 380-389

V58.73 Circulatory system

*conditions classifiable to 390-459

V58.75 Teeth, oral cavity and digestive system

*conditions classifiable to 520-579

V58.78 Musculoskeletal system

*conditions classifiable to 710-739

*Should not need to use V58.49 Other specified aftercare following surgery **get those operative reports!

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Encounter for Care Involving Renal Dialysis and Miscellaneous

V56.1 Encounter for fitting/adjustment of dialysis catheter *includes cleansing of renal dialysis catheter

*Use additional code to identify the associated condition

*Use additional code for current dialysis status V45.11

V66.7 Encounter for palliative care

V66.2 Convalescence following chemotherapy

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Procedure for Updating Codes

At Quarterly Care Conference, look at facesheet and physician orders

Resolve any diagnoses that are NOT current

Make sure that you have MD documentation to support ALL current diagnoses in the record.

Start querying MD’s for any additional documentation needed for ICD-10 (laterality, etc.)

ICD-10 Confidentiality Test

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Tips for Correct Coding

Use code book!

Always count the number of digits and compare with the number of digits required

*use tabular listing in code book

Avoid unspecified codes

*Remember: payers may reject payment based on missing digits

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Questions?

Thanks for coming!!

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