Endocrinology ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1,

Endocrinology

ICD-10 CM Training

• ICD-10-CM will be valid for dates of service on or after October 1, 2015– Outpatient dates of service of October 1, 2015 and

beyond. – Inpatient hospital service claims, is effective for dates of

discharge after September 30, 2015

ICD-10-CM Compliance Dates

• Covered Entities– Everyone covered by the Health Insurance Portability

Accountability Act (HIPAA)

• Non-Covered Entities– Worker’s Compensation– Auto Insurance– Non covered HIPAA entities are exempt but are

encouraged to adapt the new code set

Covered and Non-Covered Entities

• 21 Chapters• Alpha-numeric codes; not case-sensitive

– Codes begin with Alpha letter, A-Z, excluding U– Common errors

• I verses 1• O verses 0

• “x” Placeholder• 3 to 7 characters

– Decimal following 3rd character

ICD-10 Code Structure

• Placeholder “x”– Used for future expansion of a code– Fills in empty characters when a 6th and/or 7th character

apply– The placeholder may be used in different scenarios but

should never serve as the final character.

Example: W19.XXXA Unspecified fall, Initial Encounter


• 7th Character– Provides specified information regarding the clinical visit– Is required for certain categories and must be reported in

the seventh position– May be alpha or numeric– Has different meanings depending on the coding category


7th Character DescriptionA Initial encounter for closed fracture

B Initial encounter for open fracture type I or II, or NOS

C Initial encounter for open fracture type IIIA, IIIB, or IIIC

D Subsequent encounter for closed fracture with routine healing

E Subsequent encounter for open fracture of type I or II with routine healing

F Subsequent encounter for open fracture of type IIIA, IIIB, or IIIC with routine healing

G Subsequent encounter for closed fracture with delayed healing

H Subsequent encounter for open fracture of type I or II with delayed healing

J Subsequent encounter for open fracture of type IIIA, IIIB, or IIIC with delayed healing

K Subsequent encounter for closed fracture with nonunion

M Subsequent encounter for open fracture of type I or II with nonunion

N Subsequent encounter for open fracture of type IIIA, IIIB, or IIIC with nonunion

P Subsequent encounter for closed fracture with malunion

Q Subsequent encounter for open fracture of type I or II with malunion

R Subsequent encounter for open fracture of type IIIA, IIIB, or IIIC with malunion

S Sequela


• Laterality– Some ICD-10-CM codes indicate laterality, specifying

whether the condition occurs on the left, right or is bilateral.

– If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

– If the side is not identified in the medical record, assign the code for the unspecified side.

OGCR section 1.B.13


• “Other” Codes– Codes titled “other” or “other specified” are for use when

the information in the medical record provides detail for which a specific code does not exist.

• “Unspecified” Codes– Codes titled “unspecified” are for use when the

information in the medical record is insufficient to assign a more specific code.

OGCR section 1.A.9.a.b


• Excludes Notes– Excludes1

• A type 1 Excludes note is a pure excludes note• It means “NOT CODED HERE”• The code excluded should never be used at the same time• When two conditions cannot occur together

– Excludes2• Represents “Not included here”• The condition excluded is not part of the condition represented

by the code• It is acceptable to use both the code and the excluded code

together, when appropriateOGCR section 1.A.12.a.b

ICD-10 Structure

• “Code First” and “Use Additional Code”– ICD-10 has a coding convention that requires the

underlying condition be sequenced first followed by the manifestation.

– These instructional notes indicate the proper sequencing order of the codes.

OGCR section 1.A.13

• The “-” indicates there are additional reporting options


Most Common Diagnosis Codes

Vitamin D deficiency, unspecifiedICD-9 Code ICD-10 Code Description Excludes1 Excludes2

268.9 E55.9 Vitamin D deficiency, unspecified

Applicable To:Avitaminosis D

• Adult osteomalacia (M83.-)

• Osteoporosis (M80.-)

• Sequelae of rickets (E64.3)

• Nutritional anemias (D50-D53)

Mixed hyperlipidemiaICD-9 Code ICD-10 Code Description Excludes1 Excludes2

272.2 E78.2 Mixed hyperlipidemia

Applicable To:• Broad- or floating-

betalipoproteinemia• Combined hyperlipidemia

NOS• Elevated cholesterol with

elevated triglycerides NEC• Fredrickson's

hyperlipoproteinemia, type IIb or III

• Hyperbetalipoproteinemia with prebetalipoproteinemia

• Hypercholesteremia with endogenous hyperglyceridemia

• Hyperlipidemia, group C• Tubo-eruptive xanthoma• Xanthoma tuberosum

• Sphingolipidosis (E75.0-E75.3)

• cerebrotendinous cholesterosis [van Bogaert-Scherer- Epstein] (E75.5)

• familial combined hyperlipidemia (E78.4)

N/A

• Type– Mixed– Other– Unspecified

Hyperlipidemia Documentation Tips

Elevated C-reactive protein (CRP)ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

790.95 R79.82 Elevated C-reactive protein (CRP)

• abnormality of fluid, electrolyte or acid-base balance (E86-E87)

• asymptomatic hyperuricemia (E79.0)

• hyperglycemia NOS (R73.9)• hypoglycemia NOS (E16.2)• neonatal hypoglycemia (P70.3-

P70.4)• specific findings indicating

disorder of amino-acid metabolism (E70-E72)

• specific findings indicating disorder of carbohydrate metabolism (E73-E74)

• specific findings indicating disorder of lipid metabolism (E75.-)

N/A

There are more specific code choice selections below:

R79.81 Abnormal blood-gas level

R79.89 Other specified abnormal findings of blood chemistry

Use additional code to identify any retained foreign body, if applicable (Z18.-)

Documentation Tips

• ICD-10-CM R00-R99• Acceptable to code when a related definitive diagnosis has

not been established (confirmed) by the provider.• Signs and symptoms that are associated routinely with a

disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

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

Signs and symptoms

• Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code

Use of symptom codes

ObesityICD-9 Code ICD-10 Code Description Excludes1 Excludes2

278.00 E66.9 Obesity, unspecified• Obesity NOS• Code first obesity

complicating pregnancy, childbirth and the puerperium, if applicable (O99.21-)

Use additional code to identify body mass index (BMI), if known (Z68.-)

• Adiposogenital dystrophy (E23.6)

• Lipomatosis NOS (E882.)

• Lipomatosis dolorosa [Dercum] (E88.2)

• Prader-Willi Syndrome (Q87.1)

N/A


278.01 E66.01 Morbid (severe) obesity due to excess calories

278.00 E66.09 Other obesity due to excess calories

278.00 E66.1 Drug-induced obesity

278.03 E66.2 Morbid (severe) obesity with alveolar hypoventilation

278.02 E66.3 Overweight

278.00 E66.8 Other obesity

Overweight and Obesity

Weight Status Category Body Mass Index Range

Overweight 25.0-29.9

Obese 30.0-49.9

Morbid Obese 50.0-59.9

Adult, 21 years and older

Pediatric, 2-20 years

Weight Status Category Percentile Range

Underweight Less than the 5th percentile

Normal or Healthy Weight 5th percentile to less than the 85th percentile

Overweight 85th to less than the 95th percentile

Obese Equal to or greater than the 95th percentile

• Identify condition:– Obesity

• Drug-induced– Use additional code for adverse effect, if applicable to identify drug (T36-T50) with fifth or sixth

character 5)

• Due to excess calories– Morbid– Other

• Morbid/severe with alveolar hypoventilation (Body Mass Index 50-59.9, )• Other

– Overweight (Body Mass Index 25-29.9)• Use additional code to identify body mass index (BMI), if

known (Z68

Obesity Documentation Tips

Body Mass Index (BMI) 21 years of ageand older

Z68.1 Body mass index (BMI) 19 or less, adultZ68.20 Body mass index (BMI) 20.0-20.9, adultZ68.21 Body mass index (BMI) 21.0-21.9, adultZ68.22 Body mass index (BMI) 22.0-22.9, adultZ68.23 Body mass index (BMI) 23.0-23.9, adultZ68.24 Body mass index (BMI) 24.0-24.9, adultZ68.25 Body mass index (BMI) 25.0-25.9, adultZ68.26 Body mass index (BMI) 26.0-26.9, adultZ68.27 Body mass index (BMI) 27.0-27.9, adultZ68.28 Body mass index (BMI) 28.0-28.9, adultZ68.29 Body mass index (BMI) 29.0-29.9, adult

Overweight


Z68.30 Body mass index (BMI) 30.0-30.9, adultZ68.31 Body mass index (BMI) 31.0-31.9, adultZ68.32 Body mass index (BMI) 32.0-32.9, adultZ68.33 Body mass index (BMI) 33.0-33.9, adultZ68.34 Body mass index (BMI) 34.0-34.9, adultZ68.35 Body mass index (BMI) 35.0-35.9, adultZ68.36 Body mass index (BMI) 36.0-36.9, adultZ68.37 Body mass index (BMI) 37.0-37.9, adultZ68.38 Body mass index (BMI) 38.0-38.9, adultZ68.39 Body mass index (BMI) 39.0-39.9, adult

Obese


Z68.41 Body mass index (BMI) 40.0-44.9, adultZ68.42 Body mass index (BMI) 45.0-49.9, adultZ68.43 Body mass index (BMI) 50-59.9 , adultZ68.44 Body mass index (BMI) 60.0-69.9, adultZ68.45 Body mass index (BMI) 70 or greater, adult

Morbid Obese

Body Mass Index (BMI) 2-20 years of age

Z68.51 Body mass index (BMI) pediatric, less than 5th percentile for ageZ68.52 Body mass index (BMI) pediatric, 5th percentile to less than 85th

percentile for ageZ68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th

percentile for ageZ68.54 Body mass index (BMI) pediatric, greater than or equal to 95th

percentile for age

Pediatric BMI

Abnormal GlucoseICD-9 Code ICD-10 Code Description Excludes1 Excludes2

790.21 R73.01 Impaired Fasting glucose• Elevated fasting

glucose

• Abnormal glucose in pregnancy (O99.81-)

• Diabetes mellitus (E08-E13)

• Dysmetabolic syndrome X (E88.81)

• Gestational diabetes (O24.4-)

• Glycosurai (R81)• Hypoglycemia

(E16.2)

N/A


790.22 R73.02 Impaired glucose tolerance (oral)

790.29 R73.09 Other abnormal glucose

Type• Elevated fasting glucose R73.01• Elevated glucose tolerance R73.02• Abnormal glucose NOS R73.09

– Abnormal non-fasting glucose tolerance– Latent diabetes– Pre-diabetes

Abnormal Glucose Documentation Tips

Menopausal and female climacteric statesICD-9 Code ICD-10 Code Description Excludes1 Excludes2

627.2 N95.1 Menopausal and female climacteric states

• excessive bleeding in the premenopausal period (N92.4)

• menopausal and perimenopausal disorders due to artificial or premature menopause (E89.4-, E28.31-)

• premature menopause (E28.31-)

• asymptomatic menopausal state (Z78.0)

• symptoms associated with artificial menopause (E89.41)

• symptoms associated with premature menopause (E28.310)

• postmenopausal osteoporosis (M81.0-)

• postmenopausal osteoporosis with current pathological fracture (M80.0-)

• postmenopausal urethritis (N34.2)

Use additional code for associated symptoms

• Symptoms such as flushing, sleeplessness, headache, lack of concentration, associated with natural (age-related) menopause

Menopausal Documentation Tips

HypothyroidismICD-9 Code ICD-10 Code Description Excludes1 Excludes2

244.9 E03.9 Hypothyroidism, unspecified

• Iodine-deficiency related hypothyroidism (E00-E02)

• Postprocedural hypothyroidism (E89.0)

N/A


243 E03.0 Congenital hypothyroidism with diffuse goiter

243 E03.1 Congenital hypothyroidism without goiter

244.2244.3

E03.2 Hypothyroidism due to medicaments and other exogenous substances

244.8 E03.3 Postinfectious hypothyroidism

246.8 E03.4 Atrophy of thyroid (acquired)

780.01 E03.5 Myxedema coma

244.8 E03.8 Other specified hypothyroidism

• Identify Congenital Hypothyroidism– With goiter– Without goiter

• Identify Acquired Hypothyroidism– Due to acquired atrophy of the thyroid– Due to medication– Postinfectious– Postprocedural– Subclinical iodine-deficiency– Other– Unspecified type

Hypothyroidism Documentation Tips

Vitamin B DeficiencyICD-9 Code ICD-10 Code Description Excludes1 Excludes2

266.2 E53.8 Deficiency of other specified B group vitamins

Applicable to:• Biotin deficiency• Cyanocobalamin deficiency• Folate deficiency• Folic acid deficiency• Pantothenic acid deficiency• Vitamin B12 deficiency

• Sequelae of vitamin B deficiency (E64.8)

• Folate deficiency anemia (D52.1-)

• Vitamin B12 deficiency anemia

• nutritional anemias (D50-D53)

266.0 E53.0 Riboflavin deficiency Ariboflavinosis Vitamin B2 deficiency

N/A N/A

266.1 E53.1 Pyridoxine deficiency Vitamin B6 deficiency

266.9 E53.9 Vitamin B deficiency, unspecified N/A N/A

Disorder of adrenal gland, unspecifiedICD-9 Code ICD-10 Code Description Excludes1 Excludes2

255.9 E27.9 Disorder of adrenal gland, unspecified

• galactorrhea (N64.3)

• gynecomastia (N62)

N/A


E27.0 Other adrenocortical overactivity

E27.1 Primary adrenocortical insufficiency

E27.2 Addisonian crisis

E27.3 Drug-induced adrenocortical insufficiency

E27.40 Unspecified adrenocortical insufficiency

E27.41 Other adrenocortical insufficiency

E27.5 Adrenomedullary hyperfunction

E27.8 Other specified disorders of adrenal gland

Other abnormal blood chemistryICD-9 Code ICD-10 Code Description Excludes1 Excludes2

790.6 R79.89 Finding of other specified substances, not normally found in blood

• abnormalities (of)(on):• abnormal findings on antenatal

screening of mother (O28.-)• coagulation hemorrhagic disorders

(D65-D68)• lipids (E78.-)• platelets and thrombocytes (D69.-)• white blood cells classified elsewhere

(D70-D72)• diagnostic abnormal findings classified

elsewhere - see Alphabetical Index• hemorrhagic and hematological

disorders of newborn (P50-P61)abnormality of fluid, electrolyte or acid-base balance (E86-E87)

• asymptomatic hyperuricemia (E79.0)• hyperglycemia NOS (R73.9)• hypoglycemia NOS (E16.2)• neonatal hypoglycemia (P70.3-P70.4)• specific findings indicating disorder of

amino-acid metabolism (E70-E72)• specific findings indicating disorder of

carbohydrate metabolism (E73-E74)• specific findings indicating disorder of

lipid metabolism (E75.-)

N/A

R79.0 Abnormal level of blood mineral

Use additional code to identify any retained foreign body, if applicable (Z18.-)

Testicular hypofunctionICD-9 Code ICD-10 Code Description Excludes1 Excludes2

257.2 E29.1 Testicular hypofunction

Applicable To:• Defective

biosynthesis of testicular androgen NOS

• 5-delta-Reductase deficiency (with male pseudohermaphroditism)

• Testicular hypogonadism NOS

• galactorrhea (N64.3)• gynecomastia (N62)• androgen insensitivity

syndrome (E34.5-)• azoospermia or

oligospermia NOS (N46.0-N46.1)

• isolated gonadotropin deficiency (E23.0)

• Klinefelter's syndrome (Q98.0-Q98.2, Q98.4)

• postprocedural testicular hypofunction (E89.5)

N/A

Use Additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

• All neoplasms, whether functionally active or not, are classified in Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.-) may be used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere.

Testicular hypofunction Documentation Tips

DiabetesICD-9 Code ICD-10 Code Description Excludes1 Excludes2

250.00 E11.9 Type 2 Diabetes mellitus without complications• Diabetes (mellitus)

due to insulin secretory defect

• Diabetes (NOS)• Insulin resistant

diabetes (mellitus)

Use additional code to identify any insulin use (Z79.4)

• Diabetes mellitus due to underlying condition (E08.-)

• Drug or chemical induced diabetes mellitus (E09.1-)

• Gestational diabetes (O24.4-)

• Neonatal diabetes mellitus (P70.2)

• Postpancreatectomy diabetes mellitus (E13.-)

• Postprocedural diabetes mellitus (E13.-)

• Secondary diabetes mellitus NEC (E13.-)

• Type 1 diabetes mellitus (E10.-)

N/A

Diabetes is a chronic condition that requires multi-specialty management. • The documentation should indicate relevant details regarding the

management of each case as it relates to the services rendered or actions taken to coordinate the patients care.

• The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen.

• The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration, sensitivity to touch)

Diabetes Documentation Tips

• Indicate Type• Indicate additional conditions, manifestations, or

complications• Cataract• Circulatory complication• Foot ulcer• Gastroparesis

• Notate causal relationships (due to, with, secondary)• State due to drugs or chemicals

Diabetes Documentation Tips

HypertensionICD-9 Code ICD-10 Code Description Excludes1 Excludes2

401.1401.9401.0

I10 Essential (Primary) HypertensionIncludes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic)

• Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16)

• Neonatal hypertension (P29.2)

• Primary pulmonary hypertension (I127.0)

• Essential (primary) hypertension involving vessels of brain (I60-I69)

• Essential (primary) hypertension involving vessels of eye (H35.0-)

Hypertensive Diseases Categories (I10-I15)

The use additional codes and Excludes1 codes apply for all categories.

(I10-I15) Use additional code to identify:• Exposure to

environmental tobacco smoke (Z77.22)

• History of tobacco use (Z87.891)

• Occupational exposure to environmental tobacco smoke (Z57.31)

• Tobacco dependence (F17.-)

• Tobacco use (Z72.0)

• Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16)

• Neonatal hypertension (P29.2)

• Primary Pulmonary hypertension (I27.0)

Hypertension cont.

ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

402.01402.11402.91

I11.0 Hypertensive Heart Disease with heart failure• Use additional code to

identify type of heart failure (I50.-)

N/A N/A

402.00402.10402.90

I11.9 Hypertensive Heart Disease without heart failure

N/A N/A

403.01403.11403.91

I12.0 Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease.• Use additional code to

identify the stage of chronic kidney disease (N185.5, N18.6)

• Hypertension due to Kidney Disease (I15.0, I15.1)

• Renovascular Hypertension (I15.0)

• Secondary Hypertension (I115.-)

Acute Kidney Failure (N17.-)

403.00403.10403.90

I12.9 Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease.• Use additional code to

identify the stage of chronic kidney disease (N18.1-N18.9)

• Hypertension due to Kidney Disease (I15.0, I15.1)

• Renovascular Hypertension (I15.0)

• Secondary Hypertension (I115.-)

Acute Kidney Failure (N17.-)

Hypertension cont.ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

404.01404.11404.91

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney disease• Use additional code to identify

type of heart failure (I50.-)• Use additional code to identify

stage of chronic kidney disease (N18.1-NN18.4, N18.9)

N/A N/A

404.00404.10404.90

I13.10 Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease.• Use additional code to identify

the stage of chronic kidney disease (N18.1-N18.4, N18.9)

N/A N/A

404.02404.12404.92

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease.• Use additional code to identify

the stage of chronic kidney disease (N18.5, N18.6)

N/A N/A

404.03404.13404.93

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease.• Use additional code to identify

type of heart failure (I50.-)• Use additional code to identify

the stage of chronic kidney disease (N18.5. N18.6)

N/A N/A

Hypertension cont.ICD-9 Code ICD-10 Code Description Excludes1 Excludes2

405.01405.11405.91

I15.0 Renovascular Hypertension• Code also underlying

condition

Postprocedural hypertension (I97.3)

• Secondary hypertension involving vessels of brain (I60-I69)

• Secondary hypertension involving vessels of eye (H35.0-)

405.91 I15.1 Hypertension secondary to other renal disorders• Code also underlying

condition




405.99 I15.2 Hypertension secondary to endocrine disorders• Code also underlying

condition




405.09405.19405.99

I15.8 Other secondary hypertension• Code also underlying

condition




405.99 I15.9 Secondary hypertension, unspecified• Code also underlying

condition




• Hypertension is no longer classified as benign, malignant or unspecified.• ICD-10 Codes have been grouped according to disease progression:

– I10 Essential Hypertension– I11.- Hypertensive Heart Disease– I12.- Hypertensive CKD

» Further subdivided by stage of kidney disease

– I13.- Hypertensive Heart and CKD» Further subdivided by stage of kidney disease

– I15.- Secondary Hypertension

• Transient Hypertension– A code for hypertension is NOT assigned unless the patient has a

documented, established diagnosis of hypertension.• R03.0 Elevated blood pressure reading without diagnosis of hypertension

• Document requirements– Type– Current Status– Associated relationships

Hypertension Documentation Tips

Other Malaise and FatigueICD-9 Code ICD-10 Code Description Excludes1 Excludes2

780.79 R53.1 Weakness Asthenia NOS

• age-related weakness (R54)

• muscle weakness (M62.8-)

• senile asthenia (R54)

N/A

780.79 R53.81 Other malaise• Chronic debility• Debility NOS• General physical deterioration• Malaise NOS• Nervous debility

• age-related physical debility (R54)

N/A

780.79 R53.82 Chronic fatigue, unspecified

• Postviral fatigue syndrome NOS

N/A

780.79 R53.83 Other fatigue• Fatigue NOS• Lack of energy• Lethargy• Tiredness

N/A N/A

• Identify type of malaise and fatigue– Neoplastic related fatigue– Weakness– Functional quadriplegia– Other malaise– Chronic fatigue, unspecified– Other fatigue

Other Malaise and Fatigue Documentation Tips

Mineral deficiency not elsewhere classifiedICD-9 Code ICD-10 Code Description Excludes1 Excludes2

269.3 E58 Mineral deficiency not elsewhere classified

• disorders of calcium metabolism (E83.5-)

• sequelae of calcium deficiency (E64.8)

• nutritional anemias (D50-D53)

E59 Dietary selenium deficiency

E60 Dietary zinc deficiency

E61.4 Chromium deficiency

E61.5 Molybdenum deficiency

All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.

• Site specificity• Document notation of qualifiers

– Exacerbation– Manifestations– Relapse– Status– Stages

• Indicate acute or chronic• Indicate underlying or external cause factors

– Medication– Smoke– Accidents– Mechanical failure

• Laterality– Bilateral– Right – Left

Documentation – Start Now

• Episode of Care for injuries, poisoning, external causes and other conditions– Initial Encounter

• Use while the patient is receiving active treatment of the condition– Active treatment includes surgical treatment, an emergency encounter, and

evaluation and treatment by a new physician

– Subsequent Encounter• Used on encounter after the patient has received active treatment of

the condition and is receiving routine care for the condition during the healing or recovery phase.

– Medication adjustments, aftercare, device adjustments, cast change

– Sequela• Used for complications or conditions that arise as a direct result of a

condition, late effect


• Combination codes that capture– Etiology and manifestation– Related conditions– Disease, injury or other medical condition and

complications– Disease or other medical conditions and common signs or

symptoms


UnderdosingUnderdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).

Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.

Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.

OGCR Section 1.C.19.e.5.c

Official Guidelines for Coding and Reporting

[email protected]

Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm

Questions

mailto:[email protected]

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.cdc.gov/nchs/icd/icd10cm.htm

Documents

Endocrinology ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1,