1. science
2. medicine
3. surgery

Good Morning! Welcome to Day 2 of ICD‐10‐CM Training.
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Now we will continue on to Chapter 7 Diseases of the Eye and Adnexa. This is a new chapter in ICD‐10. The codes in this chapter existed mainly in the I‐9 Nervous System and Sense Organ chapter. Now, please turn to page 528 in your code books – Chapter 7 Diseases of the Eye and Adnexa. 2
Please turn to page 528 in your code book
There is a note that appears immediately beneath the chapter title directing us to use an external cause code following the eye condition code to identify the cause of the eye condition, when applicable. Then, following the excludes 2 conditions, you will see the blocks that are contained within this new Chapter. 3
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Some significant changes to this chapter are the availability of laterality‐specific codes –
right, left, bilateral, unspecified. If bilateral is not available we assign a code for right and left. In addition, We no longer classify cataracts as senile, but rather age‐related.
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There are a couple of instructional notes I would like to call to your attention in Chapter 7. Turn to page 554 in your code books and go to subcategory H47.5 Disorders of other visual pathways. Here you will find an instructional note to code also the underlying condition. This differs from ICD‐9 in that a single code was used to identify the visual pathway disorder and the associated condition. Also, under category H54 Blindness and low vision on page 557 there is an instructional note to code first any associated underlying cause of the blindness if documented. This instructional note includes sequencing direction. No such note appears in ICD‐9. 5
We have five new guidelines in Chapter 7. The first guideline, 7a1, located on page 39 of your OCG handout, addresses the coding of glaucoma. We are directed to assign as many code as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage. Please turn to pages 549. Here we see numerous glaucoma codes contained in categories H40‐H42. This guideline allows assignment of as many codes as we need from category H40 to describe the patient’s glaucoma. This guideline goes on to state when the patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma we should report only the code for the type of glaucoma, bilateral with the seventh character for the stage. 6
The next glaucoma guideline, 7a2, continues that when a patient has bilateral glaucoma and both eyes are documented as being the same type and stage and the classification does not provide a code for bilateral glaucoma we report only one code for the type of glaucoma with the appropriate seventh character for the stage. In the second column on page 549 look at codes H40.10, H40.11 and H40.20. These are the only glaucoma codes that do not provide a bilateral option. 7
The third glaucoma guideline, 7a3 addresses how to code when there are different types or stages regarding laterality. When we have a patient with bilateral glaucoma and each eye is documented as having a different type or stage and the classification distinguishes lateral, we assign the appropriate code for each eye rather than the code for bilateral glaucoma. If you look on page 549 at subcategories H40.12 and H40.13 lets say the patient has low‐
tension glaucoma in both eyes but the left eye is mild stage and the right eye is moderate stage we would assign H40.122 and add the 7th character 1 for the left eye with mild stage and then assign H40.121 with 7th character of 2 for the right eye with moderate stage rather than assigning H40.123 for the bilateral low tension glaucoma. 8
The guideline goes on to state that when we have a patient with bilateral glaucoma and each eye is documented as having a different type and the classification does not distinguish laterality – again the three codes we previously discussed H40.10, H40.11, and H40.20, we assign one code for each type of glaucoma with the appropriate seventh character for the stage. An example would be bilateral open‐angle glaucoma, primary open‐angle in the left eye, moderate stage and
Unspecified open‐angle in the right eye, mild stage We would code H40.11x2 for Primary open‐angle glaucoma, moderate stage for the left eye and H40.10x1 for the unspecified open‐angle glaucoma mild stage for the right eye
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The guideline goes on to state that when we have a patient with bilateral glaucoma and each eye is documented as having a different stage and the classification does not distinguish laterality – again the three codes we previously discussed H40.10, H40.11, and H40.20, we assign each type of glaucoma with the appropriate seventh character for the stage for each eye. An example would be bilateral primary open‐angle glaucoma,the left eye identified as moderate stage and mild stage in the right eye. We code
H40.11x2 Primary open‐angle glaucoma , moderate (left eye)
H40.11x1 Primary open‐angle glaucoma, mild (right eye)
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The fourth glaucoma guideline, 7a4, directs that we code the highest stage of glaucoma documented if the stage of the patient’s glaucoma progresses during admission.
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And the last glaucoma guideline, 7a5, addresses those instances when the stage of the glaucoma cannot be clinically determined. We are to assign the seventh character “4” when the stage cannot be clinically determined. In those instances where the physician did not document a stage we suggest querying the physician. If the physician cannot determine the stage then you should assign a 7th character of “4”; however, if you get no response from your query you should then assign 7th character of “0” for unspecified since there is no documentation regarding the stage of the glaucoma.
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So lets practice coding a case in Chapter 7. Please turn to pg 109 in your CTM & code case 1.51 This is a visit for patient with moderate primary open‐angle glaucoma of the left eye. The diagnosis code H25.11X2 is for primary open‐angle glaucoma
When we index Glaucoma – open angle – primary we get H40.11 with a dash which means that more characters are needed.
In the Tabular there is a check X 7th box in front of H40.11 so we add an x as a place holder and choose moderate stage, value 2 as a 7th character.
13
Primary open‐angle glaucoma is characterized by visual field abnormalities and intraocular pressure that is too high for the continued health of the eye. In this case, ICD‐10‐CM does not have separate codes to identify specific eyes. 14
Before we leave Chapter 7 do you have any questions? (or is there anything you would like to go over again? 15
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Next we will cover Chapter 8 Diseases of the Ear and Mastoid Process. Now, please turn to Next
we will cover Chapter 8 Diseases of the Ear and Mastoid Process. Now, please turn to
page 559 in your code books – Chapter 8 Diseases of the Ear and Mastoid. 16
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As with Chapter 7 eye and adnexa, Chapter 8 begins with an instructional note on page 559 As
with Chapter 7 eye and adnexa, Chapter 8 begins with an instructional note on page 559
in the first column directing us to use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition.
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Next I would like you to turn to page 561 to the block for Diseases of middle ear and Next
I would like you to turn to page 561 to the block for Diseases of middle ear and
mastoid which begins with category H65 Nonsuppurative otitis media. Categories H65 and H67 include an instructional note to use an additional code for any associated perforated tympanic membrane using category H72 Perforation of tympanic membrane. Categories H65 and H66 also include instructional notes to use additional codes to identify a number of tobacco related exposures and diagnoses including exposure to environmental tobacco smoke, and history of tobacco use, tobacco dependence or use.
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At this time, there are no chapter‐specific guidelines for Chapter 8. Space has been reserved, should they need to be added at a later date.
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Now lets code exercise 1.56. (allow 5 minutes to code) Does anyone need more time? For this case you will code 2 diagnoses codes and one complication code. For this case, no place of occurrence code is necessary.
(A place of occurrence code can also be reported for this case; however, since this information is not covered until Chapter 20, you will not be expected to assign the associated classification code. Only assign it if you have extra time after entering the first 3 codes in the question box) q
)
This patient has undergone an stapedectomy for bilateral conductive hearing loss due to nonobliterative otosclerosis of the stapes at the oval window. During the surgery an inadvertent laceration was made to the tympanic meatal flap which and was repaired.
So the first code is going to be for the Otosclerosis, code H80.03. Indexed on page 236 So
the first code is going to be for the Otosclerosis, code H80.03. Indexed on page 236
under the main term otosclerosis, and subterms involving oval window., nonobliterative
directs us to see subcategory H80.0 which is located in the tabular on page 565 where we are reminded to add a 5th character for laterality. We select the option for bilateral, value 3. The 2nd code we report for this case is H90.0 for the bilateral conductive hearing loss. If you access the main term Loss – subterm hearing, directs you to deafness ‐ conductive, and then bilateral on page 80.
then bilateral on page 80.
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We also have H95.31 for the accidental puncture and laceration of the ear and mastoid process during the procedure. You can go under main term complication then ear procedure laceration page 59 or complication, intraoperative puncture or laceration ear during procedure on ear and mastoid process on page 62. The index entry on pg 59 for complication, ear procedure, intraoperative, laceration directs us to see the index entry for complications, intraoperative puncture or laceration, ear, during procedure on ear and mastoid process which is located on pg 62. Our last code is Y92.234 for the place of occurrence in the hospital operating room. You can locate this code in the Index to external causes, place of occurrence, hospital, operating room on page 415.
Similar to ICD‐9, we locate our index entry in the index to external causes. Indexing then differs from ICD‐9 in that rather than being referred to see Accident, occurring in or at, under the main term for place of occurrence for accident, ICD‐10 has subterms for specific locations under the main term titled place of occurrence. 21
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The rationale supports the selection of the otosclerosis as first listed since it is the The
rationale supports the selection of the otosclerosis as first listed since it is the
underlying condition causing the hearing loss and there is no sequencing instruction in the classification system. In I‐10 some complications are actually included in the body system chapters. Subcategory H95.3 includes codes for accidental puncture and laceration of the ear and mastoid process when a procedure on the ear and mastoid process is being performed as well as during other procedures. The cause of the complication is included in the complication code. We can however, add a place of occurrence code to identify that the complication occurred in the hospital operating room. Once again, Instructional guidance for assigning place of occurrence codes is covered in the lesson for Chapter 20.
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Before we leave Chapter 8 do you have any questions? (or is there anything you would like to go over again?) 23
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So now we will cover Chapter 9 Diseases of the Circulatory System. Now, please turn to So
now we will cover Chapter 9 Diseases of the Circulatory System. Now, please turn to
page 569 in your code books – Chapter 9 Diseases of the Circulatory System. 24
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First, if you turn to the hypertension block I10
First,
if you turn to the hypertension block I10‐I15,
I15, p 570, you will see that the type of p 570, you will see that the type of
hypertension – benign, malignant, unspecified is no longer an axis. If you turn to page 169 in the alphabetic index, the second column at the bottom, you will see that benign and malignant are nonessential modifiers under hypertension. I also wanted to mention there is no hypertension table in the Alphabetic Index in I‐10.
The time frame for Acute Myocardial Infarction has changed to 4 weeks or less from 8 weeks or less. 25
Please turn to category I21 ST elevation (STEMI) and non‐ST elevation (NSTEMI) myocardial infarction, page 570.
You will see that we no longer have a last digit assignment to designate initial, subsequent or unspecified episode for AMIs. ‐Instead, we have category I21 which includes an instructional note for the initial AMIs up to 4 weeks (28 days) since onset. This will be a significant change for us to keep in mind because we are so used to considering anything within 8 weeks of onset as an acute MI. This applies to transfers from another acute setting or postacute setting. This means that we could be coding an initial MI on a patient who actually experienced an MI 3 weeks ago if he is continuing to receive care for the MI. ‐I22 for subsequent MI’s occurring within 4 (28 days) weeks or less of a previous acute MI. 26
So what’s new with Subsequent episode of care for designation of Acute myocardial infarction? ‐‐Subsequent Episode of Care is used in I‐10 to identify a New AMI within a 4 weeks healing period of an initial AMI rather than the ICD‐9 designation of a patient who is admitted for further observation, evaluation or treatment for a myocardial infarction that has received initial treatment, but is still less than 8 weeks old.
(Leave slide up for class to process)
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Key points in assigning subsequent acute MI codes:
‐Guideline 9.e.4 directs us to assign a code from both category I22 and I21 for subsequent AMIs occurring within 4 weeks of a previous AMI. Category I22 is never used alone.
‐The sequencing of the I21 and I22 codes would depend upon the circumstances of the encounter. For example, if the patient was admitted due to a subsequent AMI we would code the subsequent from category I22 as the principal and the initial from I21 as the secondary. However, if a patient was admitted within the 4 week window of the initial for another condition and during the stay had a subsequent AMI, neither AMI would be sequenced as pdx. The other condition for which the patient was admitted would be the principal diagnosis.
If a second AMI occurs longer than 4 weeks following the initial, we would assign an initial code. ‐For encounters after the 4 week time frame, if the patient is still receiving care related to the MI we code an appropriate aftercare code rather than a code from I21. ‐I25.2 Old myocardial infarction is used to report the healed infarction older than 28 days.
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Next lets go to category I23, Certain current complications following STEMI and NSTEMI within the 28 day period. +Some of the conditions included in this category are hemopericardium resulting from a current acute MI, postinfarction angina and other complications listed on this slide.
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Before we practice assigning acute vs subsequent MI’s, let’s take a closer look at the MI types of STEMI vs NSTEMI. You’ll notice that in I‐10 the types are included within the code fS
S
’ll
i h i 10 h
i l d d i hi h
d
titles. A STEMI, or ST elevation MI is the more severe type of myocardial infarction that is caused by a complete obstruction of the coronary artery which causes damage to the full thickness of the heart muscle. Because of the large amount of damage, an ECG will show an ST segment elevation. Similar terms of a STEMI are transmural and Q wave. In ICD‐10, we can g
Q
,
also code to the site of the STEMI if the location of a specific wall is documented. Myocardial infarction not otherwise specified is also included in the STEMI codes.
An NSTEMI, or non‐st elevation MI is a form of myocardial infarction that is caused by a partial obstruction of the coronary artery and does not cause damage to the full thickness of the heart muscle. Similar terms of an NSTEMI are nontransmural, non‐Q wave, and subendocardial Subendocardial only involves the layer of the muscle below the
subendocardial. Subendocardial only involves the layer of the muscle below the endocardium. You’ll notice on the slide the arrows are pointing to the differences in depth of damage to the heart muscle with a Non‐q wave or subendocardial MI versus the Q‐wave or transmural mi. 30
To help us better understand how to determine which AMI codes to assign I’ve created a couple of flow charts. Lets start with a patient admitted due to an AMI. ‐A question to ask yourself is did the patient have a previous AMI? ‐If No, the patient did not have a previous AMI ‐then we just assign a code from I21.
‐If yes, ‐was
was it older than 28 days? it older than 28 days?
‐If no meaning the patient had a previous MI and it is equal to or less than 28 days old ‐then we would assign a code from I22 for the subsequent (current) AMI and a code from I21 for the recent MI within 28 days. ‐If yes, ‐then we assign a code from I21 for the current AMI and I25.2 for the old MI. 31
Now lets walk through coding a case where the patient is admitted due to another condition and has an AMI during this admission. ‐The next question is was there a previous AMI? ‐If No, the patient did not have a previous AMI ‐then we would just code the current AMI I21 as an additional diagnosis following the condition the patient was admitted for. condition
the patient was admitted for
‐If yes, ‐the other condition is principal diagnosis. ‐Then we ask whether the previous AMI is older than 28 days. ‐If no, the patient
If no the patient’ss AMI is equal to or less than 28 days AMI is equal to or less than 28 days
‐then we would code a code from I22 for the current (subsequent) AMI and a code from I21 for the previous AMI within 28 days. ‐If yes, ‐then we would assign a code from I21 for the current AMI that occurred during this g
g
admission and I25.2 for the old MI. 32
Now I would like to review the changes to the Circulatory System Chapter‐specific guidelines. Please turn to page 41 in your Official Coding Guidelines. I think its important to mention that there is no change to the guideline directing that a causal relationship must be stated or implied when coding hypertension with heart disease. The physician must still document that the heart disease is due to or caused by hypertension. And the guidelines have also not changed in regard to coding hypertension with chronic kidney disease. In this scenario we will continue to presume a cause‐and‐effect relationship in ICD‐10
ICD
10 when both hypertension and chronic kidney disease are documented. when both hypertension and chronic kidney disease are documented
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Moving to guideline 9.a.3 Hypertensive Heart and Chronic Kidney Disease, we will continue to code these combination diagnoses the same as we did in I‐9; however, there is a new paragraph to the guideline that directs that the codes in category I13 Hypertensive heart and chronic kidney disease are combination codes that include hypertension, heart disease and chronic kidney disease and that we should not assign codes from categories I11 or I12 when assigning a code from I13. This was true in I‐9 with category 404; however, there was not a guideline that addressed the combination code category.
34
Next, we have a new guideline, 9.b. Atherosclerotic Coronary Artery Disease and Angina. We now have combination codes for atherosclerotic heart disease with angina pectoris. The subcategories are I25.11 and I25.7. Lets take a quick look at these in the code books. Turn to page 572 in your code book. Here we see the choices of atherosclerotic heart disease of native coronary artery with unstable angina, with angina with documented spasm, with other forms of angina and with unspecified angina. Continuing on we see the same combinations of angina codes with atherosclerosis of coronary artery bypass grafts, autologous vein coronary artery bypass grafts autologous artery coronary artery bypass
autologous vein coronary artery bypass grafts, autologous artery coronary artery bypass grafts, nonautologous biological coronary artery bypass grafts, native coronary artery of transplanted heart, bypass graft of coronary artery of transplanted heart and other coronary artery bypass grafts. 35
This guideline continues by directing that we not code angina as a separate diagnosis and that a causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris unless the documentation indicates the angina is due to something other than the atherosclerosis.
The guideline ends by stating that we should sequence an AMI before the coronary artery disease when both diagnoses are documented and the patient is admitted due to the AMI. 36
Our next guideline 9.c Intraoperative and Postprocedural cerebrovascular accident. The first part of this guideline is no different than how we have coded in I‐9. The record must clearly specify the cause and effect relationship between the medical intervention procedure and the CVA in order to code it as an intraoperative or postprocedural CVA. The guideline goes on to state that the code assignment depends on whether it was an infarct versus a hemorrhage and whether it occurred intraoperatively or postoperative. Lets turn to category I97 on page 599 – Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified. If you go to subcategory d di d
f i l t
t
t l
h
l ifi d If
t
b t
I97.41 you will see the codes for intraoperative hemorrhage complicating a cardiac cath, complicating a cardiac bypass, other circulatory system procedure and then complicating all other procedures. If you go to subcategory I97.61 you see the same codes repeated for postprocedure hemorrhage. Looking further to subcategory I97.8 you will see both intraoperative and postprocedural CVA during cardiac surgery and other surgery. This is another good example of the complications now listed within the body system categories.
g
p
p
y y
g
37
Our next guideline 9 d Sequela of cerebrovascular disease
Category I69 is used to indicate sequela/late effects/ neurological deficits of conditions in category I60 through I67 that persist after the initial onset of the causal condition.
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This guideline continues to state
This new guideline provides direction for determining the dominant or nondominant
affected side. For ambidextrous patients, 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. However, if documentation states “left handed” then if the left side is affected dominant side would be coded. If right side is affected non‐dominant side would be coded.
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Guideline Chapter 9.d.2 states
Codes from category I69 may be assigned on a health care record with codes from I60‐I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease. Guideline 9.d.3 states that Codes from category I69 should not be assigned if the patient does not have neurologic deficits.
does not have neurologic deficits. 40
Now please turn to guideline 9.e.1 beginning on page 45 of your guidelines. The first paragraph of this guideline is comparable to the first paragraph in the I‐9 guidelines. The directions in the second paragraph beginning with “If NSTEMI” is not new to us; however, the first sentence is new to the AMI guidelines, being if an NSTEMI evolves to STEMI we are to assign a STEMI code. And if a STEMI converts to a NSTEMI due to thrombolytic therapy, it is still coded as STEMI – which is in our current I‐9 guidelines.
The guideline goes on to state that when the MI is equal to, or less than, four weeks old, i l di t
including transfers to another acute setting or a postacute setting and the patient requires f t
th
t
tti
t t
tti
d th
ti t
i
continued care for the MI, codes from category I21 may continue to be reported. This means that we could be coding an initial MI on a patient who actually experienced it 3 weeks ago if he has continued to receive care for the MI. .
41
This guideline goes on to state for encounters after 4 weeks and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned rather than a code from category I21. For old or healed MI's not requiring further care, code I25.2 old myocardial infarction may be assigned.
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So lets code some scenarios from Chapter 9. Please code exercise 1.59. ( (allow 2 minutes) Does anyone need more time? )
The patient suffered an acute non‐ST anterior wall MI 5 days ago and she also has atrial fibrillation.
Our first code is I21.4 Non Stemi myocardial infarction that’s within 4 weeks or less. This can be indexed on page 175 under Infarct myocardium –
can be indexed on page 175 under Infarct –
myocardium non‐ST elevation.
non ST elevation
Another code is I48.91, unspecified atrial fibrillation can be indexed on page 137 under Fibrillation – atrial or auricular. 43
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As you recall, we just reviewed the coding guideline that states nontransmural or subendocardial infarctions with site provided are still coded as a subendocardial
infarctions with site provided are still coded as a subendocardial AMI. The AMI The
NonStemi is caused by a partial obstruction and the damage does not involve the full thickness of the heart wall as contrasted with the STEMI which is caused by complete obstruction of the coronary artery and causes damage that involves the full thickness of the heart muscle.
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Now lets code case 1.60. ((allow 3 minutes to code) Does anyone need more time?) This same patient returned 2 weeks later to the ER and was diagnosed with an acute inferior wall MI. She is still being monitored following her initial heart attack 3 weeks earlier and continues to have the atrial fibrillation.
The first listed code is I22.1 Subsequent STEMI myocardial infarction of inferior wall, indexed on pages 175‐176 Infarct – Myocardium ‐ subsequent ‐ Inferior
Also I21.4 Non‐STEMI myocardial infarction she had 3 weeks earlier, also indexed on page 175 under Infarct – Myocardial – Non‐ST elevation.
And the last code is I48.91 Unspecified Atrial fibrillation, indexed on page 137 under Fibrillation – Atrial or auricular. 45
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Let’s talk a bit about the sequencing of this case. We previously reviewed the new coding guideline that directs we should sequence the I21 and I22 codes depending on the circumstances of the encounter. The patient in this case is admitted for treatment of a subsequent MI which has occurred within the 4 week time‐frame, so the I22 code is sequenced first, followed by the I21 code for the intial MI. Had the patient still been in the hospital from case 1.59, and suffered a second AMI, the sequencing would be reversed.
46
Before we leave Chapter 9 do you have any questions? (or is there anything you would like to go over again? )
47
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Now we will continue to Chapter 10 Diseases of the respiratory system on page 601 in Now
we will continue to Chapter 10 Diseases of the respiratory system on page 601 in
your code books.
48
There are several changes in the respiratory system classification I’d like to point out where we may see more opportunities for physician clarification. On page 601, category J01 acute sinusitis. You will see that in I‐10 we can identify whether it is acute recurrent for the specific sinus affected. Under category J03 Acute recurrent tonsillitis is now an option as well
Under category J03, Acute recurrent tonsillitis is now an option as well. Now turn to page 604 and let’s look at category J20 Acute bronchitis. For I‐10 we can specify the organism if known within the bronchitis code itself. Turning to page 606 to category J43 Emphysema, notice that we now can classify the emphysema as panlobular or centrilobular, where in I‐9 these were nonessential modifiers.
Over on page 607, category J45 Asthma. Here we see asthma classified as mild intermittent, mild persistent, moderate persistent, and severe persistent. 49
This table provides a comparison of the stages of asthma in children. It may be of help to you in determining the severity of asthma in cases you code. Of course, the physician will still need to document the severity level, the coder cannot make that clinical determination. 50
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We have already discussed the new asthma terminology but I did want to comment on the We
have already discussed the new asthma terminology but I did want to comment on the
second and third bullets on this slide. If you turn back to page 601 in your code books you will see the note just beneath the chapter title that directs when a respiratory condition occurs in more than one site and is not specifically indexed, it should be classified to the lower anatomic site. The example is tracheobronchitis which is coded to bronchitis If you look in the alphabetic index on page
tracheobronchitis which is coded to bronchitis. If you look in the alphabetic index on page 303 under main term tracheobronchitis you will be referred to bronchitis. Also, with the respiratory conditions we are directed to use an additional code to identify external causes of the respiratory condition such as exposure to tobacco smoke in the perinatal period, tobacco dependence, history of tobacco use and tobacco use.
51
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Now turn to pg 606 in the tabular. This slide reiterate the code also note under category J44 We are to code also the type of asthma in category J45 if applicable
J44. We are to code also the type of asthma in category, J45, if applicable.
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Then under category, J45, is an excludes 2 note for asthma with COPD. This excludes 2 note means that it is acceptable to report J44 9 and a code from category J45 when the
note means that it is acceptable to report J44.9 and a code from category J45 when the patient has both conditions documented.
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Before we discuss new guidelines for Chapter 10, let’s quickly review one respiratory guideline that is still in effect, but is not currently listed in the draft version of the I‐10‐CM guidelines. For I‐9, we are directed under guideline 8.a.4 “Acute exacerbation of asthma and status asthmaticus” that it is incorrect to assign an asthma code with acute exacerbation together with an asthma code with status asthmaticus. According to the 2014 I‐10 AHA coding handbook on page 230, we are instructed to only assign one diagnosis code, the code assignment indicating status asthmaticus, since that term is used for life threatening respiratory emergency and is more severe than an acute exacerbation.
Hence, the correct code assignment for a patient who presents with moderate persistent asthma with acute exacerbation with status asthmaticus is J45.42 Moderate persistent asthma with status asthmaticus
asthma with status asthmaticus.
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The first coding guideline change in Chapter 10 begins on page 47 of your OCD handout. Here we are instructed to code only confirmed cases of influenza due to certain and other identified influenza viruses. Please turn to page 602 in your code books. The codes in categories J09 & J10 should only be assigned when the physician has confirmed the diagnosis. We do not code possible, probable, rule out diagnoses for these codes, even for inpatients.
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Guideline 10.c goes on to state that if a physician documents the influenza as possible, probable, or suspected we are to assigned a code from category J11 on pages 602 and 603 rather than a code from category J09 or J10.
56
There is a guideline regarding the coding of ventilator associated pneumonia that has been relocated to the respiratory system guidelines from the complications of care section. The first part of guideline 10.d.1 directs that we should only assign the J95.851 Ventilator associated pneumonia code when the provider has documented ventilator associated pneumonia. We are directed not to assign additional codes from categories J12‐J18 to identify the type of pneumonia, but instead to assign an additional code to identify the type of organism.
57
The third paragraph of the guideline directs that we not assign J95.851 when the patient has pneumonia and is on mechanical ventilation but the physician has not specifically stated the pneumonia is a ventilator associated pneumonia. If the documentation does not specify this, then we should query for clarification. 58
And the last paragraph addresses those instances when a patient is admitted with one type of pneumonia and then subsequently develops ventilator associated pneumonia. In this case you would code the pneumonia diagnosed at the time of admission and then add J95.851 to report the presence of ventilator associated pneumonia.
59
Now that we’ve completed our overview of chapter 10 for diseases of the respiratory system, let’s practice coding a case in the coder training manual.
Please code exercise 1.78. Please assign the codes. ( (Allow 4 minutes to code) Anyone need more time? ) HINT: And just a reminder to review the instructional coding notes in the boxes above the HINT:
And just a reminder to review the instructional coding notes in the boxes above the
summary for this case.
The discharge diagnosis for this case is moderate persistent asthma with status asthmaticus and acute exacerbation of COPD.
Our first code is J45.42 Moderate persistent asthma with status asthmaticus. This can be accessed in the index under main term asthma, then subterm
d i th i d
d
i t
th
th
bt
asthmatic, moderate th ti
d t
persistent with status asthmaticus on page 31
And our second code is J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation. This is accessed under the main term disease, then lung, obstructive with acute exacerbation on page 101.
60
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The rationale supports that we code the type of asthma based on the instructional note The
rationale supports that we code the type of asthma based on the instructional note
under category J44 to code the type of asthma if known. The excludes 2 note under category J45 for asthma with chronic obstructive pulmonary disease means “not included here”, meaning that the condition excluded is not part of the condition represented by the code, but if a patient has both conditions then both codes should be assigned.
61
Before we leave Chapter 10 do you have any questions (or is there anything you would like to go over again?) 62
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So now we will cover Chapter 11 Diseases of the Digestive System on page 612. Currently, So
now we will cover Chapter 11 Diseases of the Digestive System on page 612. Currently,
there are no chapter‐specific guidelines in the I‐10 official coding guidelines.
63
Please turn to page 612 in your code books. At the top of the first column you will find the blocks in the Digestive System chapter. While it is organized similar to I‐9 there is one new block – Diseases of liver. 64
There are a few things I would like to call to your attention. First, turn to category K25 Gastric ulcer on page 617. In ICD‐10, Ulcers are classified based on presence or absence of hemorrhage and perforation. Obstruction is no longer a part of the ulcer classification. Let’s compare K25.0 to K29.01. Note the term “hemorrhage” with acute gastric ulcer K25.0 Let’s
compare K25 0 to K29 01 Note the term “hemorrhage” with acute gastric ulcer K25 0
versus the term “bleeding with acute gastritis K29.01 and diverticulosis K57.31. Bleeding is also included in code titles for duodenitis K29.8 located on page 618 and category K57 for diverticulosis and diverticulitis which is again located on page 622.
While there is not a specific definition for these terms (hemorrhage & bleeding) in the training manual or the Official Coding Guidelines, indexing seems to suggest that the terms are interchangeable from a coding perspective. Turn to page 38 in your index. Under the main term for bleeding, note that a coder is directed to “see also hemorrhage.”
65
Now please turn to page 618 K40 Inguinal hernia. I want to call to your attention that in ICD‐9 the term “and obstruction” is a nonessential modifier under the hernia with gangrene codes. So if we have a hernia with both gangrene and obstruction we code it to hernia with gangrene. We do the same in ICD‐10 except that there is no reference in the tabular to the obstruction although the Alphabetic Index does list “obstruction” as a nonessential modifier under the hernia main terms. Now turn to category K50 Crohn’s disease on page 620. Note that Crohn’s disease codes specify the site at the 4th digit level and the 5th and 6th digits are reserved for further classification of the specific complications such as intestinal obstruction and abscess.
66
This is a photo of an inguinal hernia that became obstructed resulting in significant gangrene.
67
Now that we’ve completed our overview of chapter 11 for diseases of the digestive system, let’s practice coding a case in the coder training manual.
Next we will work on exercise 1.87 on page 120. ((allow 4 minutes to code) Anyone need more time? Ok – what is our first listed code?) This patient has extensive cellulitis of the abdominal wall. His existing gastrostomy site is infected. He had a feeding tube inserted four months ago because of carcinoma of the infected.
He had a feeding tube inserted four months ago because of carcinoma of the
middle esophagus. The responsible organism is confirmed MRSA.
Yes K94.22 Gastrostomy infection and you access this in the index under the main term complication on page 61 Complications ‐ Gastrostomy
Yes L03.311 Cellulitis of abdominal wall and this is accessed using Cellulitis as the main term on page 51 Cellulitis – Abdominal Wall
YYes C15.4 Malignant neoplasm of middle third of esophagus and you access this in the C15 4 M li
t
l
f iddl thi d f
h
d
thi i th
neoplasm table on page 326 Neoplasm table – esophagus – middle (third) in a malignant primary column.
68
And the last code is B95.62 Staphylococcus aureus as the cause of diseases classified elsewhere methicillin resistant. This can be accessed under main term infection – then subterm staphylococcal – as cause of disease classified elsewhere – aureus – methicilin resistant (MRSA) on page 179.
69
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The key to coding and sequencing this exercise correctly is to follow the The
key to coding and sequencing this exercise correctly is to follow the “use
use additional
additional” note under K94.22 Gastrostomy infection which directs us to use an additional code to specify type of infection. We code the organism per the instructional note under the section “Infections of the skin and subcutaneous tissue. 70
Before we leave Chapter 11 do you have any questions (or is there anything you would like to go over) again? 71
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Okay. Now we will continue on to Chapter 12 Diseases of the skin and subcutaneous Okay.
Now we will continue on to Chapter 12 Diseases of the skin and subcutaneous
tissue. Before we begin our code book review, I want to mention that currently there are no changes to the chapter 12 guidelines in I‐10.Please turn to page 629 in your code books. The blocks are similar to those in I‐9. 72
Just added this slide because so many errors
Pleas turn to page 629. Look at block L00‐L08 Infections of the skin and subcutaneous tissue.
Beneath the block heading in red, we are instructed to use additional code (B95‐B97) to identify infectious agents in these diseases classified elsewhere.
Turn back to pg 439 in your code book. In the lower portion of the 2nd column, we see the block for bacterial & viral infectious agents (B95‐B97)
block for bacterial & viral infectious agents (B95
B97). The note which follows reminds us The note which follows reminds us
that this category range is assigned as a supplementary or additional code to identify the infectious agent or agents in diseases that are classified elsewhere. Indexing for this range of supplemental codes is located under the main term infection or the main term for the specific type of infection, such as streptococcus, and then we would select the subterm for “as cause of disease classified elsewhere.”
This information was covered in Chapter 1.
73
Pleas turn to pg 632. Look at block L20‐L30 Dermatitis and eczema.
There is a note immediately following the heading that states the terms dermatitis and eczema are used synonymously and interchangeably in this block. Also, take a look at codes L23.3 and L24.4. Here we are instructed to use an additional code for adverse effect, from categories T36‐T65 to identify the drug, if applicable. There is the same instruction for codes L27.0 and L27.1 on page 633
74
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f hi
bli i
b
d d
di
i l
transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.
Next, turn to page 636 in your code book, category L89 Pressure Ulcer. As you look through the pressure ulcer codes beginning with L89 000 you will see that the stage and
through the pressure ulcer codes beginning with L89.000 you will see that the stage and even the laterality is now included in the pressure ulcer code, so you only have to assign one code to fully describe a pressure ulcer. Now go to page 642 in your code book, category L97 non‐pressure chronic ulcer of lower limb. Let’s look at the note directly under this category that gives us some sequencing direction. As you see in red font, we are given direction to code first any associated underlying condition. This includes atherosclerosis of the lower extremities, diabetic ulcers and other conditions
ulcers, and other conditions. L97 may be used as a principal or first listed code if no underlying condition is documented as the cause of the ulcer and meets the definition of PDX.
There is also a note to code first any associated gangrene. As you see in this section, the non pressure chronic ulcer codes also include the site laterality and even the severity
non pressure chronic ulcer codes also include the site, laterality, and even the severity. 75
Now let’s practice coding a few practice cases for Chapter 12 in the coder training manual.
Now lets code exercise 1 88 on page 122 Hint coding note above case ((allow 4 minutes to code)
Now lets code exercise 1.88 on page 122. Hint‐coding note above case. ((allow 4 minutes to code)
HINT: Remember to review the coding guidelines & the coding note located above the case. ((allow 4 minutes to code) We will be reporting 2 codes for this case, one for the dermatitis & one for the adverse effect of the antibiotic that was taken correctly as prescribed. There will be a use additional note in the tabular under the code assignment for the dermatitis instructing you to report a code from category T36‐T50 for the adverse effect of the drug. While coding of adverse effects will be covered in Chapter 19, the logic for indexing is similar to ICD‐9‐CM. You will need to reference the index for the Table of Drugs & Chemicals. This index follows the Neoplasm table and can be located on pg 339 in your ,y
g
g
,
code book. Once in the index, you will select the related substance or drug and using the column for adverse effect, identify the classification code to verify in the tabular.
For this case, we have dermatitis covering the entire body from penicillin taken correctly.
Yes, the first code is L27 Generalized skin eruption due to drugs and medicament taken internally. In case you are not familiar with the term medicament it is an agent that promotes recovery from injury or ailment; a medicine, according to the Free Dictionary on the web. You access this under the main term dermatitis due to drugs and medicaments on page 93. The instructional note at L27.0 and L27.1 on page 633 of your coding book directs us to “use additional code” for adverse effect of the drug using a code from category T36‐T50 using a 5th or 6th character of 5 if applicable. The adverse effect code T36.0x5A Adverse effect of penicillins, initial encounter is sequenced following the dermatitis code. This is accessed under the drug & chemical table in the index, adverse effect column on page 372 and then choose A in the Tabular for Initial. 76
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The rationale reminds us there is a use additional code note under L27.0, to use additional The
rationale reminds us there is a use additional code note under L27.0, to use additional
code for the adverse effect if applicable. In this case this was the initial encounter, so we also add A as the 7th character.
77
Now lets turn to exercise 1.92 on page 123. (allow 6 minutes to code) Does anyone need more time? ) HINT: Gluteal is not an indexable subterm. Based on anatomy gluteal refers to the buttock region.
This elderly patient has cellulitis in the right lower extremity caused by Streptococcus B. He has stage 1 decub ulcer of the left buttock and stage 2 in the right gluteal region.
Our first listed code is L03.115 cellulitis of right lower limb accessed under the main term cellulitis. The index entry for the cellulitis be found on P51, Cellulitis – lower limb where we are directed to see L03.11. Then, referring to the Tabular on P630 to choose 5 for right lower limb.
The use additional note back on pg 629 in the Tabular under the section Infections of the Skin and Subcutaneous Tissue (L00‐L08) instructs us to use an additional code (B95‐B97) to identify the infectious agent. Hence, we additionally report
B95.1 Streptococcus, group B as the cause of diseases classified elsewhere and this is access under main term infection. Or, you could have indexed this under the main term for the infectious agent, Streptococcus and then selected the subterms for “as cause of disease classified elsewhere, group, B.
78
Now this patient also had a stage 1 decubitus ulcer of the left buttock and a stage 2 decubitus ulcer in the right gluteal region.
The gluteal region based on anatomy equates to the buttock so our code would be L89.312 for the stage 2 decubitus ulcer in the right gluteal region indexed on page 311 Ulcer –
Pressure – Stage 2 – Buttock. we are referred to L89.3 which is located on p639 in the Tabular. Here we choose the 5th character of 1 for the right buttock and a 6th character of 2 for stage 2
And L89.321 Pressure ulcer of left buttock, stage 1 for the pressure ulcer of the left buttock. This is also Indexed again under ulcer – pressure – stage 1 – buttock on page 311. Tabular page 639 choose 5th and 6th characters 2 and 1 for left buttock and stage 1.
79
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The key to correctly coding this case is to list the cellulitis as the first listed diagnosis.
The
key to correctly coding this case is to list the cellulitis as the first listed diagnosis. This This
is a good example of coding laterality as well. We also are required to add an additional code to identify the infectious agent, Streptococcus Group B. And the decubitus ulcers are classified both by stage and laterality.
80
Before we leave Chapter 12 do you have any questions? (or is there anything you would like to go over again?) 81
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Now we will study Chapter 13 Diseases of the Musculoskeletal System and Connective Now
we will study Chapter 13 Diseases of the Musculoskeletal System and Connective
Tissue.
82
Please turn to page 645 in your code books. At the top of the first column you will find the blocks in Chapter 13. The first block is new to us – infectious arthropathies. In a moment we will take a look at new guidelines developed to assist us in defining and coding direct and indirect infections. 83
The remainder of the chapter is similar to I‐9.
84
There is one other new block of codes M99 Biomechanical lesions, not elsewhere classified. If you turn to page 719 in the code book you will see the numerous new codes in this category.
85
There are also some instructional notes I want to call to your attention. Please go to M21.7 on page 667 Unequal limb length (acquired). Immediately below the subcategory title we see the note that the site used should correspond to the shorter limb.
Moving on to M50 Cervical disc disorder on page 682 we see a note to code to the most superior level of disorder. Per Stedman’s medical dictionary, Superior is defined as: in human anatomy, situated nearer the vertex of the head in relation to a specific reference point. So in this case, we would code to the level nearest the head.
86
Next, I would like for you to return to page 645. I want to call your attention to two new definitions under the Infectious arthropathies block M00‐M02. First, we have a definition for direct infection of joint – where the organisms invade the synovial tissue and microbial antigen is present in the joint. Those direct infections are listed in category M00 Pyogenic arthritis and M01 Direct infections of joint in infectious and parasitic diseases classified elsewhere. Then we have a definition of indirect infection meaning that either a microbial infection of the body is established but neither organisms nor antigens can be identified in the joint or a post‐infective
the joint or a post
infective arthropathy where the microbial antigen is present but arthropathy where the microbial antigen is present but
recovery of an organism is inconstant and evidence of local multiplication is lacking. These definitions of indirect infection apply to category M02 Postinfective and reactive arthropathies. 87
Next, please go to page 692, category M66 spontaneous rupture of synovium and tendon. Here we find an instructional note that a spontaneous rupture is one that occurs when a normal force is applied to tissues. And M80 Osteoporosis with current pathological fracture. We now have a definition for pathological fracture, one that is sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone. Of course, the physician still needs to document this link and they are the ones that must make this interpretation.
88
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Also, I want to call your attention to the definitions for the 7th character in category M80 and M84 Disorder of continuity of bone – stress fractures. We will assign A as the 7th character for the initial encounter, and D for a subsequent admission during the routine healing period. The next 3‐ G, K, and P, fall under the subsequent category and are delayed healing, nonunion, and malunion. Then our last 7th character option for these categories is sequela. I’ve included definitions for the last four 7th character options that we see on the slide. 89
The first of these is delayed healing. Delayed healing or union is present when an adequate period of time has elapsed since the initial injury without achieving bone union, taking into account the patient’s age, bone involved, level of the fracture and the associated soft tissue injury. 90
Nonunion is when the healing completely stops without a bony union. This is the more severe form of delayed healing and is usually determined by radiographic criteria and time.
91
Malunion is defined as a healing of bones in an abnormal position. 92
And sequela is a pathological condition resulting from a disease, injury or other trauma. An example would be a patient admitted due to chronic pain following the complete healing of a pathological fracture. 93
Let’s turn to the Official Coding Guidelines, Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00‐M99) on page 50. Our first guideline, 13.a addresses instances where more than one bone, joint or muscle is involved. In some instances there will be a “multiple sites” code available such as for osteoarthritis. In those instances where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.
94
The next part of the site and laterality guideline 14.a.1 addresses bone versus joint. The guideline directs that when the bone is affected at the upper or lower end, the site designation will be the bone, not the joint. This graphic shows the osteoporotic fracture at the femoral head and the diseased portion of the femur. In this case we would code the osteoporosis with pathological fracture of the femur. 95
Moving to 13 b Acute traumatic versus chronic or recurrent musculoskeletal conditions. This guideline states that Chapter 13 includes bone, joint or muscle conditions that are the result of a healed injury. Chapter 13 also includes bone joint or muscle conditions that are recurrent. Also any current, acute injury is to be coded to the appropriate injury code from Chapter 19 Injury and Poisoning and Certain other consequences of external causes.
96
The guideline goes on to state that chronic or recurrent conditions should generally be coded with a code from Chapter 13 and if we are unable to determine whether it is chronic or recurrent versus acute we should query the provider.
97
Our next new guideline 15 c. Coding of Pathologic Fractures explains that the 7th character A is for use as long as the patient is receiving active treatment for the fracture. It also gives examples of active treatment including surgery, treatment in the ER, and evaluation and treatment by a new physician. In contrast, the 7th character D is used for encounters after the patient has completed active treatment.
98
The guidelines goes on to state that the other 7th characters listed under each subcategory in the Tabular List are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae. Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication code. 99
We also have a set of guidelines for coding osteoporosis. The first part of the guideline explains that osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. If you turn in your code book to page 700 category M80 and category M81 on page 701 you will see that site of osteoporosis is not mentioned in the codes; instead, the fracture site is listed. 100
Guideline 13.d.1) addresses the coding of osteoporosis without a pathological fracture. You see the codes on page 701 in category M81. These codes should be used only for patients with osteoporosis who do not currently have a pathologic fracture due to osteoporosis, even if they have had a fracture in the past. If they have had a fracture in the past then Z87.310 Personal history of healed osteoporosis fracture should be assigned following the code from M81. 101
The last osteoporosis guideline addresses the coding of a current pathological fracture with osteoporosis. Here we are directed to use a code from category M80 Osteoporosis with current pathological fracture for any patient with known osteoporosis who suffers a fracture even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal healthy bone. Again, it is not appropriate for the coder to interpret if the patient had a minor fall or trauma that would not usually break a normal, healthy bone. The physician must provide a connection between the fall and fracture due to osteoporosis. osteoporosis
Let’s take a look in the tabular at category M80 on page 700. I want to point out that category M80.0 Age‐related osteoporosis with current pathological fracture also includes Osteoporosis NOS with current pathological fracture. 102
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Before we go to our exercises I just want to point out that ICD
Before
we go to our exercises I just want to point out that ICD‐10
10 has 3 different categories has 3 different categories
for pathologic fractures – one due to neoplastic disease, another due to other specified disease, in addition to those due to osteoporosis.
103
The indexing of fractures has changed in ICD‐10‐CM. Let’s take a minute to look at the i d
index under Fracture on pages 143‐149. d
1 31 9
Fractures are indexed by ‐fractures, pathological or +factures, traumatic.
Fracture, pathological starts in the middle of the second column. Fracture, traumatic, starts on page 144 then continues on to page 149. h
A fracture of the right ankle due to neoplastic disease would be indexed under ‐Fracture, pathological – due to ‐neoplastic
neoplastic disease NEC disease NEC
– and then ankle
Note the Pathological fractures start with the letter M and are coded in chapter 13 Diseases of the Musculoskeletal System and Connective Tissue and traumatic fractures are coded in chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes (S00‐T88)
104
Now lets try an exercise. Please turn to page 126 in your coder training manual and do exercise 1.98. ((allow 7 minutes to code) Does anyone need more time? ) A hint for this case – we will code 2 diagnoses codes and 2 history codes so a total of 4 codes. So for this case, we had a 76 year old man who was originally diagnosed with left upper lobe carcinoma 5 years ago and he’s seen for a fracture of the shaft of the right femur, now 8 months ago he was also diagnosed with metastatic bone cancer which was from the lung. It is documented that this fracture is a result of the metastatic disease. So the patients lung cancer was treated with radiation and there is no longer evidence of an existing primary malignancy
primary malignancy. Our 1st code would be M84.551A, the7th character of A for the initial encounter, for the Pathological fracture you would access under fracture – pathological – then due to neoplastic disease – femur. And then your 2nd code C79.51 is to identify the mets to the bone. This is accessed either by first going to carcinoma metastatic in the alphabetic index which directs you to the neoplasm table – by site, bone neoplasm table by site bone ‐ secondary.
secondary
105
Then let’s look at our last two codes. These will both be personal history codes. The 1st one is Z85.118 Personal history of the lung malignancy. The main term to access this is history – personal – malignant neoplasm ‐ lung. And then Z92.3 Personal history of irradiation and again accessed under history – personal – radiation therapy.
106
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We assigned the 7th character A because the patient is still receiving active treatment for the fracture. This would include surgical treatment, an ER visit or evaluation and treatment by a new physician. An optional code is the Z92.3 depending on whether the facility codes to this level of detail.
107
Now lets code exercise 1.99. (allow 4 minutes to code) Does anyone need more time? ) In this scenario, a patient with senile osteoporosis is seen with complaints of severe back pain not stemming from any kind of trauma. X‐ray revealed pathological compression fractures of several lumbar vertebrae.
M80.08 can be found in the index under osteoporosis, age‐related with current pathologic fracture, vertebra. There is a check x 7th by this code in the tabular on page 701 indicating th
the need for an x placeholder and 7th character. 7th character A is selected for initial df
l h ld
d 7th h
t 7th h
t Ai
l t d f i iti l
encounter. The complete code is M80.08xA age‐related osteoporosis with current pathological fracture, vertebra. 108
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This is a good example of the combination codes in ICD‐10, combining osteoporosis with an associated pathological fracture. 109
Before we leave Chapter 13 does anyone have any questions? ( – or is there anything you would like to go over a second time?) 110
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Now we will cover Chapter 14 Diseases of the Genitourinary system. Please turn to page 721 in your code books. The blocks in ICD‐10 are organized similar to the categories in ICD‐9. And I just wanted to mention there are no changes to the chapter‐specific guidelines for Chapter 14.
111
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of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.
For this chapter, there are several categories that require additional codes. Please turn to category N17 Acute kidney failure, page 724. You will see the note to code also any associated underlying condition. underlying
condition
Next under category N18 Chronic kidney disease there are two instructional notes. We are instructed to code first any associated diabetic chronic kidney disease or hypertensive chronic kidney disease and to use an additional code to identify kidney transplant status if applicable. Turning to N30 Cystitis on page 725. Here we have an instructional note to code also the infectious agent. And at category N31 Neuromuscular dysfunction of bladder, not elsewhere classified, we are instructed to use additional code to identify any associated urinary incontinence. At category N33 Bladder disorders in diseases classified elsewhere, o page 726 we find an instructional note to code first the underlying disease. This note also gives us sequencing directions. And at subcategory N40.1 Enlarged prostate with lower urinary tract symptoms, on page 727, we find a note And
at subcategory N40 1 Enlarged prostate with lower urinary tract symptoms on page 727 we find a note
to use additional code for associated symptoms, when specified. 112
Next, lets code case 1.104. (allow 5 minutes to code) Does anyone need more time?) Remember to review the coding guideline in the instructional box that is located just above this case in your CTM. In addition, be sure to review the instructional notes in the tabular portion of your code book for reporting of any additional code assignments. We have a 45 year old female currently being treated for chronic kidney disease, stage 3. We
have a 45 year old female currently being treated for chronic kidney disease, stage 3.
She has previously undergone a kidney transplant but still continues to suffer from chronic kidney disease. She is also treated for hypothyroidism following removal of the thyroid carcinoma and they clarified that at this time, there is no longer evidence of an existing thyroid malignancy.
So our 1st code is N18 3 for the stage 3 chronic kidney disease
So our 1st code is N18.3 for the stage 3 chronic kidney disease. Our next code is Z94.0 Kidney transplant status, based on the use additional code note under subcategory N18.3. This is indexed under transplant – kidney.
113
Also, E89.0 postprocedural endocrine and metabolic complications and disorders, not elsewhere classified and this is indexed under hypothyroidism, postsurgical and
And the last code for this case is, Z85.850, History of thyroid cancer. Indexing under the main terms for history, personal, cancer, we are directed to see history, personal‐malignant neoplasm‐ and then we select the subterm for the site which is thyroid.
114
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The choice of codes is based on the coding guideline that states the presence of CKD alone does not constitute a transplant complication. The note at category N18 advises us to use an additional code to identify kidney transplant status if applicable.
115
Before we leave Chapter 14 does anyone have any questions or is there anything you would like me to review again?
116
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Next we will take a look at Chapter 15 Pregnancy, Childbirth and the Puerperium.
117
Please turn to page 734 in your code books. At the top of the first column you will see the blocks in this chapter. As you look through the first block O00‐O88 Pregnancy with abortive outcome you will see that there are no codes for elective (legal or therapeutic) abortion in this block. These are reported using code Z33.2 Encounter for elective termination of pregnancy in Chapter 21. However, complications following termination of pregnancy, including induced termination are found beginning with category O04 Complications following (induced) termination of pregnancy. Note that the term induced is a nonessential modifier in the category title and code titles following
modifier in the category title and code titles following. Otherwise, the pregnancy chapter is organized similar to ICD‐9.
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Encounters for delivery are classified to O80 and O82 categories followed by complications related to the puerperium and then the catch‐all categories O94‐O9A
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While the blocks are similar to ICD‐9 there are a number of changes in code titles. For example, in ICD‐9 we have 654 Abnormality of organs and soft tissues of pelvis. In 10 the title is revised to Maternal care for abnormality of pelvic organs. And in I‐9, 664 Trauma to perineum and vulva during delivery has been revised to O70 Perineal laceration during delivery. 120
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reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, photocopying, recording or otherwise without prior permission from the publisher.
There is a significant change in the pregnancy codes. We no longer code episode of care as we did in ICD‐9 using the fifth digit. If you turn to page 734 at the top of the page you will see that the codes are now classified by trimester. The first trimester being less than 14 weeks, the 2nd being 14
14 weeks to less than 28 weeks and the 3rd being 28 weeks until delivery. The days are counted k t l th 28
k
d th 3 d b i 28
k
til d li
Th d
t d
from the first day of the last menstrual period. As we all know, this is not always well documented in the prenatal record so we will probably be needing to query physicians when the documentation is missing or not specific. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters but may occur in more than just one. When a patient is admitted to the hospital for complication of pregnancy during one trimester and remains in the hospital into a subsequent trimester we should code the trimester character for the antepartum complication based on the trimester when the complication developed not the
antepartum complication based on the trimester when the complication developed, not the trimester of the discharge. If trimester is not a component of a code it is because the condition always occurs in a specific trimester or the concept of trimester of pregnancy is not applicable. We should seldom if ever use the codes for the unspecified trimester. In those rare instances where it is not well documented, we should query the physician before completing the coding.
q y
p y
p
g
g
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As with ICD‐9, codes from Chapter 15 are to be used only on maternal records, never on newborn records. Also, codes from this chapter are to be used for conditions related to or aggravated by the pregnancy, childbirth, or by the puerperium. As with I‐9 any condition that occurs during pregnancy, childbirth, or the puerperium is considered to be a complication unless the attending physician specifically documents that it neither affects the pregnancy nor is affected by the pregnancy.
Additional codes are to be added to identify weeks of gestation, category Z3A. These codes can be indexed under Pregnancy, weeks of gestation on page 254 and found in the tabular on page 1064.
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There are a few other changes you should be aware of. First, abortion has been changed to 20 weeks or less and fetal death begins at 20 weeks, 1 day. Early versus late vomiting is also changed in the same way. Preterm labor is defined as before 37 completed weeks of gestation. 123
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Next I would like for you to turn to page 747 in the code book. Beginning with category O31 Complications specific to multiple gestation. We now have a 7th character assignment to these codes that identifies which fetus for which the code applies. These 7th character characters apply to categories O31 through O69.
We will assign the 7th character 0 for single gestations, or for multiple gestations when the documentation in the record is insufficient to determine the fetus affected and we are unable to obtain clarification, or when it is simply not possible to clinically determine which fetus is affected.
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Also, I would like for you to turn to categories O64 through O66 on page 755. Here you will see that the obstructed labor codes are now combination codes that include the reason for the obstruction with the obstructed labor in one code. 125
I would like to go over the changes in the Official Coding Guidelines for chapter 15. Guidelines 15.a.4 and 15.a.5 have been discussed previously so we won’t repeat them here.
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The next guideline 15.a.6 discusses fetal extensions which we already reviewed previously.
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The next new guideline, 15.c addresses the need for us to distinguish between conditions of the mother that existed prior to the pregnancy versus those that are a direct result of the pregnancy
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The guideline goes on to say that we may use codes from categories that do not distinguish between pre‐existing and pregnancy related conditions for either. We also may use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter. For example, turn to category O90, page 758 Complications of the puerperium, NEC. Lets say a patient has distress during labor and delivery and then prior to discharge develops a hematoma of an obstetric wound. We would assign O75.0 on page 757 for the maternal distress during labor and delivery and O90 2 for the hematoma of the obstetric wound
delivery and O90.2 for the hematoma of the obstetric wound 129
The next new guideline 15.d addresses the coding of pre‐existing hypertension in pregnancy. If you turn in your code books to category O10 on page 739 you will see codes to report this condition. However, you also need to add a secondary code from the appropriate hypertension category to specify the type of heart failure or chronic kidney disease.
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The next guideline, 15.i has some new directions so we will review the entire guideline. Gestational diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. If you turn to your code books to page 742, subcategory O24.4 Gestational diabetes mellitus you will find the codes we are to use when this condition occurs. Note that this subcategory is included in category O24 Diabetes mellitus in pregnancy etc. No other code from category O24 is to be used with a code from subcategory O24.4 Gestational diabetes mellitus.
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The guideline also points out that if a patient is treated with both diet and insulin only, the code for insulin controlled is assigned. O24.414, Gestational diabetes mellitus in pregnancy, insulin controlled, is an example. In this category, there is also a diet controlled code, O24.410 and then the unspecified code, O24.419.
We are also directed not to assign Z79.4 Long term (current) use of insulin with codes from subcategory O24.4 Gestational diabetes mellitus. An abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy etc.
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Continuing on, to guideline 15L which addresses alcohol and tobacco use during pregnancy etc. If you turn to page 761 in your code books, subcategory O99.31 Alcohol use complicating pregnancy, these codes should be assigned for any pregnancy case when a mother uses alcohol during pregnancy, childbirth, or the puerperium. These codes can be used for an admission subsequent to the delivery encounter if alcohol causes complications during the puerperium. We are also directed to assign a code from category F10 alcohol related disorders to identify manifestations of the alcohol use. 133
There is a similar guideline for tobacco use during pregnancy. We apply the same principals; however, we need to code either a secondary code from category F17 Nicotine dependence or Z72.0 if the physician only documents tobacco use, not dependence.
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The next guideline is 15.m. Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient. It directs us to assign a code from subcategory O9a.2 Injury, poisoning and certain other consequences of external causes complicating pregnancy first, followed by the appropriate poisoning, toxic effect, adverse effect or underdosing code, and then coding the condition caused by the poisoning, toxic effect, adverse effect or underdosing. 135
The next guideline is 15.n. Normal Delivery. Guideline n.1 instructs us that code O80 would be the principal diagnosis if a woman has a normal delivery without any documented antepartum, delivery and/or postpartum complications. 136
Guideline 15n also clarifies that the only outcome of delivery code appropriate for use with O80 is Z37.0 for a single live birth. 137
The next new guideline 15.o.5 Pregnancy associated cardiomyopathy directs that we assign O90.3 when a patient who did not have pre‐existing heart disease develops cardiomyopathy in the third trimester of pregnancy. This condition may also continue to progress months after delivery. 138
The next guideline 15.p. addresses the coding of sequelae of complication of pregnancy, childbirth, and the puerperium. If you turn to page 759 in your code books, to code O94 this code is to be used for those cases when an initial complication of pregnancy develops a sequela requiring care or treatment at a future date. We may assign this code any time after the initial postpartum period.
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We sequence O94 following the code describing the sequelae of the complication. 140
And the next guideline is 15.r Abuse in a pregnant patient. If you turn to subcategories beginning with O9a.3 on page 763 in your code book you will see the physical, sexual, and psychological abuse codes complicating pregnancy etc. These should be sequenced first followed by the appropriate codes if applicable to identify any associated current injury due to physical abuse, sexual abuse and the perpetrator of abuse. The perpetrator of abuse codes are in the Index to External Cause of Injury under main term Perpetrator.
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There is one addition to the guidelines for Chapter 21 that I want to call to your attention because it pertains to coding deliveries. Please turn to page 1064 in your code book. Here you will find new codes that describe weeks of gestation. Our guideline advises that we may assign these codes to provide additional information about the pregnancy. They would never be used as a principal or first listed diagnosis. The guideline has been revised for 2014 to state that we use the date of admission to determine the weeks of gestation for admissions that are longer than one gestational week. Note the red instructional note immediately following the category name – we code first complications of pregnancy, immediately following the category name we code first complications of pregnancy
childbirth and the puerperium. We use these codes only on the maternal record to indicate the weeks of gestation of the pregnancy. 142
Case 1.113 on page 132.
This patient, with pre‐existing type 2 diabetes was admitted in active labor at 38 weeks. A second degree perineal laceration occurred during the delivery and was repaired. A female infant was delivered.
The first code is O70.1 Second degree perineal laceration during delivery. This is indexed under Delivery under
Delivery ‐ complicated by complicated by – laceration laceration ‐ perineum perineum ‐ second degree. second degree.
The second code is 024.12 Pre‐existing diabetes mellitus, type 2 in childbirth. Indexed under delivery – complicated by – diabetes mellitus – type 2. There is a note in red under subcategory O24.1 to use additional code from category E11 to further identify any manifestations which leads us to the next code for type 2 diabetes.
The next code E11.9 for the type 2 diabetes is indexed under Diabetes, diabetic ‐ Type 2
The next code is Z3A.38 which is 38 weeks gestation of pregnancy. This is found under pregnancy ‐ weeks of gestation ‐ 38 weeks. And our last code is Z37.0 Single live birth indexed under Outcome of delivery – single ‐
liveborn. 143
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The rationale for this case is that the patient had a second degree perineal laceration during delivery. The patient’s preexisting type 2 diabetes is identified with O24.12. The ‘in childbirth’ option is included due to coding guideline 15.a.3 which states “whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.
We also add the single liveborn code Z37.0. We also code the Z3A.38 to report the 38 weeks of gestation.
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Does anyone have any questions? (or is there anything you would like to review again before we close for the day? If so, please enter your question in the question box.) Since there are no more questions we will close for the day. See you tomorrow! 145