Copyright 2014 AAPC

Rhonda Buckholtz, CPC, CPCI, CPMA, CRC, CDEO, CHPSE..

ICD-10-CM 2017 Coding Updates

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the expressed written permission of AAPC.

2

Agenda

3

Guideline Changes

Coding changes by chapter Neoplasms

Gastrointestinal stromal tumors

Castleman Disease

Endocrine

Mental and Behavioral

Pain

Eye

Ear and Mastoid

Cardiovascular

Musculoskeletal

Genitourinary

Obstetrics

Revisions

Newborns

Congenital

Signs and Symptoms

Additions

Injuries

Additions

Deletions

External Causes

Routine and Administrative

Conclusion

Skyrocketing denials

Volume of codes

MIPS and MACRA

Code changes

Documentation concepts

Overview

4

Guideline Changes

The word with should be interpreted to mean associated with or due to

when it appears in a code title, the Alphabetic Index, or an instructional note

in the Tabular List. The classification presumes a causal relationship

between the two conditions linked by these terms in the Alphabetic Index or

Tabular List. These conditions should be coded as related even in the

absence of provider documentation explicitly linking them, unless the

documentation clearly states the conditions are unrelated. For conditions

not specifically linked by these relational terms in the classification, provider

documentation must link the conditions in order to code them as related.

The word with in the Alphabetic Index is sequenced immediately following

the main term, not in alphabetical order.

With

6

The assignment of a diagnosis code is based on the providers diagnostic

statement that the condition exists. The providers statement that the patient

has a particular condition is sufficient. Code assignment is not based on

clinical criteria used by the provider to establish the diagnosis.

Code assignment and Clinical Criteria

7

A sequela is the residual effect (condition produced) after the acute phase of

an illness or injury has terminated. There is no time limit on when a sequela

code can be used. The residual may be apparent early, such as in cerebral

infarction, or it may occur months or years later, such as that due to a

previous injury. Examples of sequela include: scar formation resulting from a

burn, deviated septum due to a nasal fracture, and infertility due to tubal

occlusion from old tuberculosis. Coding of sequela generally requires two

codes sequenced in the following order: the condition or nature of the

sequela is sequenced first. The sequela code is sequenced second. An

exception to the above guidelines are those instances where the code for

the sequela is followed by a manifestation code identified in the Tabular List

and title, or the sequela code has been expanded (at the fourth, fifth or sixth

character levels) to include the manifestation(s). The code for the acute

phase of an illness or injury that led to the sequela is never used with a

code for the late effect.

Sequela (Late Effects)

8

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. When a

patient has a bilateral condition and each side is treated during separate

encounters, assign the "bilateral" code (as the condition still exists on both

sides), including for the encounter to treat the first side. For the second

encounter for treatment after one side has previously been treated and the

condition no longer exists on that side, assign the appropriate unilateral

code for the side where the condition still exists (e.g., cataract surgery

performed on each eye in separate encounters). The bilateral code would not

be assigned for the subsequent encounter, as the patient no longer has the

condition in the previously-treated site. If the treatment on the first side did

not completely resolve the condition, then the bilateral code would still be

appropriate.

Laterality

9

Neoplasms

Chapter 2 Neoplasms

11

New CodesC49.A0 Gastrointestinal stromal tumor, unspecified site

C49.A1 Gastrointestinal stromal tumor of esophagus

C49.A2 Gastrointestinal stromal tumor of stomach

C49.A3 Gastrointestinal stromal tumor of small intestine

C49.A4 Gastrointestinal stromal tumor of large intestine

C49.A5 Gastrointestinal stromal tumor of rectum

C49.A9 Gastrointestinal stromal tumor of other sites

D47.Z2 Castleman disease

D49.511 Neoplasm of unspecified behavior of right kidney

D49.512 Neoplasm of unspecified behavior of left kidney

D49.519 Neoplasm of unspecified behavior of unspecified kidney

D49.59 Neoplasm unspecified behavior of other genitourinary organ

Gastrointestinal stromal tumors

12

A 57 year-old female presented with vague upper abdominal pain intermittently for two years. There were no other associated general or GI tract symptoms. Examination of the abdomen revealed a well-defined transversely mobile intra-abdominal lump in the right hypochondrium of about 8 6 cm. The abdomen was explored electively and a 10 6 cm tumor was seen arising from the greater curve of the stomach, exophytically, with a sessile base. There was no infiltration of the mass into the surrounding structures, nor any evidence of metastases or lymphadenopathy. The tumor was excised with a 2 cm sleeve of the greater curve of the stomach and the latter repaired classically. The findings favored the diagnosis of epithelioid gastrointestinal stromal tumor.

C49.A2 Gastrointestinal stromal tumor of stomach

Documentation concepts include:

Type

Anatomical location

Case Example

13

It is often associated with HIV and HHV-8 and results in systemic symptoms such as:

Serious infections

Fevers

Weight loss

Fatigue

Night sweats

Nerve damage

Anemia

Hypergammaglobulinemia

Castleman disease

14

A 82-year-old man was seen for a 3 month history of lethargy, decreased appetite and marked weight loss. He had no significant past medical history, but family history showed a brother who had died of lymphoma. Exam revealed mild bilateral cervical and axillary lymphadenopathy with no palpable organomegaly. Labs and testing, including full blood count and biochemical profile as well as hepatic function tests, were within normal range except for raised globulins (55 g/L) with a polyclonal increase in gamma-globulins. Myeloma was excluded due to the fact that protein electrophoresis detected no monoclonal band.

CT showed extensive lymphadenopathy involving the neck, axillae, chest/mediastinum, abdomen and pelvis with mild to moderate splenomegaly. Bone marrow aspiration and trephine biopsy showed small lymphoid follicular aggregates. Excision biopsy of an axillary node was performed and this was showed an increased number of follicles containing amorphous hyaline material and some small blood vessels between simple reactive changes and frank lymphoma, indicative of Castleman's disease.

D47.Z2 Castleman disease

Documentation concepts include:

Type

Case Example

15

Chapter 2 Neoplasms

16

Revisions/Deleted

C81.39

Lymphocyte depleted classical Hodgkin

lymphoma, extranodal and solid organ

sites

C81.39Lymphocyte depleted Hodgkin lymphoma,

extranodal and solid organ sites

C81.40 Lymphocyte-rich classical Hodgkin lymphoma, unspecified site

C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site

C81.70 Other classical Hodgkin lymphoma, unspecified site

C81.70 Other Hodgkin lymphoma, unspecified site

D49.5 Deleted

Neoplasm of unspecified behavior of other

genitourinary organs

Endocrine

Endocrine

18

E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye

E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye

E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye

E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye

E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3319

Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

19

E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye

E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye

E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye

E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye

E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

20

E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye

E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye

E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye

E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye

E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye

E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye

E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral

E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye

E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E08.3529Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

21

E08.3531Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E08.3532Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E08.3533Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E08.3539Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E08.3541Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E08.3542Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E08.3543Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E08.3549Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye

E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye

E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral

E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye

E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye

E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye

E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral

E08.3599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye

E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye

22

E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye

E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral

E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye

E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E09.3299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3319Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E09.3399Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

23

E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E09.3419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E09.3499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E09.3519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E09.3539Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

24

E09.3541Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E09.3542Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, left eye

E09.3543Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, bilateral

E09.3549Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, unspecified eye

E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E09.3559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E09.3599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

25

E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

26

E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E10.3541Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E10.3542Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E10.3543

Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment,

bilateral

E10.3549Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

27

E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

28

E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

29

E11.3532Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, lefteye

E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E11.3541Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E11.3542Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E11.3543Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E11.3549Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

30

E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye

E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye

E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye

E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye

E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye

E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye

E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye

E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye

E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye

E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye

E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral

E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye

E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye

31

E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye

E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral

E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye

E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye

E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye

E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral

E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye

E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye

E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye

E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral

E13.3529Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye

E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye

E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral

E13.3539Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye

E13.3541Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

E13.3542Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye

E13.3543Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral

E13.3549Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye

32

E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye

E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye

E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral

E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye

E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye

E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye

E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral

E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye

E13.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye

E13.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye

E13.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral

E13.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye

E78.00 Pure hypercholesterolemia, unspecified

E78.01 Familial hypercholesterolemia

E89.820 Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure

Endocrine

33

New Combination Codes

E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye

E11.3541

Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye

34

Retinal Detachment

35

Signs and Symptoms

Sudden vision loss without pain

Loss of vision in a visual field

Flashes and floaters

Documentation Concepts

Type

Caused by/due to

Complications/manifestations

Laterality

Body system/area affected

Retinopathy

36

Revisions

E89.810 Revise fromPostprocedural hemorrhage and hematoma of an endocrine system organ or structure following an endocrine system procedure

E89.811 Revise from Postprocedural hemorrhage and hematoma of an endocrine system organ or structure following other procedure

E89.810 Revise to Postprocedural hemorrhage of an endocrine system organ or structure following an endocrine system procedure

E89.811 Revise to Postprocedural hemorrhage of an endocrine system organ or structure following other procedure

E89.820 Add Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure

E89.821 Add Postprocedural hematoma of an endocrine system organ or structure following other procedure

E78.00 Pure hypercholesterolemia, unspecified

E78.01 Familial hypercholesterolemia

Other additions include:

Mental and Behavioral

37

F32.81 Add Premenstrual dysphoric disorder

F32.89 Add Other specified depressive episodes

F34.81 Add Disruptive mood dysregulation disorder

F34.89 Add Other specified persistent mood disorders

F42.2 Add Mixed obsessional thoughts and acts

F42.3 Add Hoarding disorder

F42.4 Add Excoriation (skin-picking) disorder

F42.8 Add Other obsessive compulsive disorder

F42.9 Add Obsessive-compulsive disorder, unspecified

F50.81 Add Binge eating disorder

F50.89 Add Other specified eating disorder

F64.0 Add Transsexualism

F80.82 Add Social pragmatic communication disorder

F32.8 Delete Other depressive episodes

F34.8 Delete Other persistent mood [affective] disorders

F42 Delete Obsessive-compulsive disorder

F50.8 Delete Other eating disorders

F64.1 Revise from Gender identity disorder in adolescence and adulthood

F64.1 Revise to Dual role transvestism

Mental and Behavioral

Case Example

39

Hoarding Disorder

Patient is a 60-year-old female who lives alone. She describes her current hoarding behavior as just difficulty throwing things away. Her difficulties have resulted in a clutter-filled home. As a result, she has been in complete social isolation due to embarrassment of other seeing her home like this. She is urged by her daughter to seek help. Her problem with hoarding began in childhood, where she used to hide things under her bed so her mom wouldnt throw them away. She remembers being fearful and anxious as a child. Her severe hoarding began when she moved into a new home 16 years ago and has progressively gotten worse. She also described having mild symptoms of depression, such as crying spells and painful emotions. She feels like a failure due to her hoarding. She denies other symptoms of OCD. She agrees to participate in an intensive treatment program for her hoarding disorder.

F42.3 Hoarding Disorder

Documentation concepts:

Type

Complications/manifestations

Disruptive Mood Dysregulation Disorder

40

Signs and symptoms:

Severe temper outbursts

occurring at least three times a

week

Sad, irritable or angry mood

almost every day

Bigger reactions than expected

At least six years of age with

symptoms beginning before the

age of 10

Symptoms are present for at

least a year

Difficulty functioning in more than

one place

Documentation

concepts for coding: Type

For templating

considerations:

Frequency of symptoms

Associated

complications/manifestations

Severity of symptoms

Mental and Behavioral

41

Binge Eating Disorder

Signs and symptoms of BED include:

Recurrent episodes of binge eating

Sense of lack of control over eating

Eating more- rapidly

Eating until feeling uncomfortably full

Eating large amounts when not hungry

Eating alone because of feeling embarrassed by how much they eat

Feeling disgusted, depressed or very guilty after

Occurs on average ate least once a week for 3 months

Not associated with purging, bulimia nervosa

Pain

Pain

43

Additions

G56.03 Add Carpal tunnel syndrome, bilateral upper limbs

G56.13 Add Other lesions of median nerve, bilateral upper limbs

G56.23 Add Lesion of ulnar nerve, bilateral upper limbs

G56.33 Add Lesion of radial nerve, bilateral upper limbs

G56.43 Add Causalgia of bilateral upper limbs

G56.83 Add Other specified mononeuropathies of bilateral upper limbs

G56.93 Add Unspecified mononeuropathy of bilateral upper limbs

G57.03 Add Lesion of sciatic nerve, bilateral lower limbs

G57.13 Add Meralgia paresthetica, bilateral lower limbs

G57.23 Add Lesion of femoral nerve, bilateral lower limbs

G57.33 Add Lesion of lateral popliteal nerve, bilateral lower limbs

G57.43 Add Lesion of medial popliteal nerve, bilateral lower limbs

G57.53 Add Tarsal tunnel syndrome, bilateral lower limbs

G57.63 Add Lesion of plantar nerve, bilateral lower limbs

G57.73 Add Causalgia of bilateral lower limbs

G57.83 Add Other specified mononeuropathies of bilateral lower limbs

G57.93 Add Unspecified mononeuropathy of bilateral lower limbs

G61.82 Add Multifocal motor neuropathy

G97.61 Add Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure

G97.62 Add Postprocedural hematoma of a nervous system organ or structure following other procedure

Pain

44

Revisions

G97.51 Revise fromPostprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure

G97.52 Revise fromPostprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure

G97.51 Revise toPostprocedural hemorrhage of a nervous system organ or structure following a nervous system procedure

G97.52 Revise toPostprocedural hemorrhage of a nervous system organ or structure following other procedure

Eye

Retinal Vein Occlusion

Blockage of small veins that carry blood away from the retina

Most often caused by hardening of the arteries

Risk factors include:

Atherosclerosis

Hypertension

Glaucoma, macular edema, vitreous hemorrhage

H34.8110 Centralretinalveinocclusion,righteye,withmacularedema

H34.8111 Centralretinalveinocclusion,righteye,withretinalneovascularization

H34.8112 Centralretinalveinocclusion,righteye,stable

H34.8120 Centralretinalveinocclusion,lefteye,withmacularedema

H34.8121 Centralretinalveinocclusion,lefteye,withretinalneovascularization

H34.8122 Centralretinalveinocclusion,lefteye,stable

H34.8130 Centralretinalveinocclusion,bilateral,withmacularedema

H34.8131 Centralretinalveinocclusion,bilateral,withretinalneovascularization

H34.8132 Centralretinalveinocclusion,bilateral,stable

H34.8190 Centralretinalveinocclusion,unspecifiedeye,withmacularedema

H34.8191 Centralretinalveinocclusion,unspecifiedeye,withretinalneovascularization

H34.8192 Centralretinalveinocclusion,unspecifiedeye,stable

H34.8310 Tributary(branch)retinalveinocclusion,righteye,withmacularedema

H34.8311 Tributary(branch)retinalveinocclusion,righteye,withretinalneovascularization

H34.8312 Tributary(branch)retinalveinocclusion,righteye,stable

H34.8320 Tributary(branch)retinalveinocclusion,lefteye,withmacularedema

H34.8321 Tributary(branch)retinalveinocclusion,lefteye,withretinalneovascularization

H34.8322 Tributary(branch)retinalveinocclusion,lefteye,stable

H34.8330 Tributary(branch)retinalveinocclusion,bilateral,withmacularedema

H34.8331 Tributary(branch)retinalveinocclusion,bilateral,withretinalneovascularization

H34.8332 Tributary(branch)retinalveinocclusion,bilateral,stable

H34.8390 Tributary(branch)retinalveinocclusion,unspecifiedeye,withmacularedema

H34.8391 Tributary(branch)retinalveinocclusion,unspecifiedeye,withretinalneovascularization

H34.8392 Tributary(branch)retinalveinocclusion,unspecifiedeye,stable

Age Related Macular Degeneration

Leading cause of vision loss in patients over age of 50

Stages

Early

Late

Neovascular (wet)

Geographic atrophy (dry)

Age Related Macular Degeneration H35.3110 Nonexudativeage-relatedmaculardegeneration,righteye,stageunspecified

H35.3111 Nonexudativeage-relatedmaculardegeneration,righteye,earlydrystage

H35.3112 Nonexudativeage-relatedmaculardegeneration,righteye,intermediatedrystage

H35.3113 Nonexudativeage-relatedmaculardegeneration,righteye,advancedatrophicwithoutsubfovealinvolvement

H35.3114 Nonexudativeage-relatedmaculardegeneration,righteye,advancedatrophicwithsubfovealinvolvement

H35.3120 Nonexudativeage-relatedmaculardegeneration,lefteye,stageunspecified

H35.3121 Nonexudativeage-relatedmaculardegeneration,lefteye,earlydrystage

H35.3122 Nonexudativeage-relatedmaculardegeneration,lefteye,intermediatedrystage

H35.3123 Nonexudativeage-relatedmaculardegeneration,lefteye,advancedatrophicwithoutsubfovealinvolvement

H35.3124 Nonexudativeage-relatedmaculardegeneration,lefteye,advancedatrophicwithsubfovealinvolvement

H35.3130 Nonexudativeage-relatedmaculardegeneration,bilateral,stageunspecified

H35.3131 Nonexudativeage-relatedmaculardegeneration,bilateral,earlydrystage

H35.3132 Nonexudativeage-relatedmaculardegeneration,bilateral,intermediatedrystage

H35.3133 Nonexudativeage-relatedmaculardegeneration,bilateral,advancedatrophicwithoutsubfovealinvolvement

H35.3134 Nonexudativeage-relatedmaculardegeneration,bilateral,advancedatrophicwithsubfovealinvolvement

H35.3190 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,stageunspecified

H35.3191 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,earlydrystage

H35.3192 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,intermediatedrystage

H35.3193 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,advancedatrophicwithoutsubfovealinvolvement

H35.3194 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,advancedatrophicwithsubfovealinvolvement

H35.3210 Exudativeage-relatedmaculardegeneration,righteye,stageunspecified

H35.3211 Exudativeage-relatedmaculardegeneration,righteye,withactivechoroidalneovascularization

H35.3212 Exudativeage-relatedmaculardegeneration,righteye,withinactivechoroidalneovascularization

H35.3213 Exudativeage-relatedmaculardegeneration,righteye,withinactivescar

H35.3220 Exudativeage-relatedmaculardegeneration,lefteye,stageunspecified

H35.3221 Exudativeage-relatedmaculardegeneration,lefteye,withactivechoroidalneovascularization

Other Additions, Revisions and

DeletionsPrimary Open Angle Glaucoma

Amblyopia suspect

Postprocedural hematoma and hemorrhage

Ear and Mastoid

Ear and Mastoid

52

H90.A11 Add Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side

H90.A12 Add Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side

H90.A21 Add Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side

H90.A22 Add Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side

H90.A31 Add Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side

H90.A32 Add Mixed conductive and sensorineural hearing, unilateral, left ear with restricted hearing on the contralateral side

H93.A1 Add Pulsatile tinnitus, right ear

H93.A2 Add Pulsatile tinnitus, left ear

H93.A3 Add Pulsatile tinnitus, bilateral

H93.A9 Add Pulsatile tinnitus, unspecified ear

H95.41 Revise from Postprocedural hemorrhage and hematoma of ear and mastoid process following a procedure on the ear and mastoid process

H95.41 Revise to Postprocedural hemorrhage of ear and mastoid process following a procedure on the ear and mastoid process

H95.42 Revise from Postprocedural hemorrhage and hematoma of ear and mastoid process following other procedure

H95.42 Revise to Postprocedural hemorrhage of ear and mastoid process following other procedure

H95.51 Add Postprocedural hematoma of ear and mastoid process following a procedure on the ear and mastoid process

H95.52 Add Postprocedural hematoma of ear and mastoid process following other procedure

Pulsatile Tinnitus

53

H93.A1 Pulsatile tinnitus, right ear

H93.A2 Pulsatile tinnitus, left ear

H93.A3 Pulsatile tinnitus, bilateral

H93.A9 Pulsatile tinnitus, unspecified ear Documentation concepts include: Type Laterality

H95.41Revise from

Postprocedural hemorrhage and hematoma of ear and mastoid process following a procedure on the ear and mastoid process

H95.41Revise to

Postprocedural hemorrhage of ear and mastoid process following a procedure on the ear and mastoid process

H95.42Revise from

Postprocedural hemorrhage and hematoma of ear and mastoid process following other procedure

H95.42Revise to

Postprocedural hemorrhage of ear and mastoid process following other procedure

H95.51 AddPostprocedural hematoma of ear and mastoid process following a procedure on the ear and mastoid process

H95.52 AddPostprocedural hematoma of ear and mastoid process following other procedure

Cardiovascular

Cardiovascular

55

Deleted

I60.20 Delete Nontraumatic subarachnoid hemorrhage from unspecified anterior communicating artery

I60.21 Delete Nontraumatic subarachnoid hemorrhage from right anterior communicating artery

I60.22 Delete Nontraumatic subarachnoid hemorrhage from left anterior communicating artery

I69.01 Delete Cognitive deficits following nontraumatic subarachnoid hemorrhage

I69.11 Delete Cognitive deficits following nontraumatic intracerebral hemorrhage

I69.21 Delete Cognitive deficits following other nontraumatic intracranial hemorrhage

I69.31 Delete Cognitive deficits following cerebral infarction

I69.81 Delete Cognitive deficits following other cerebrovascular disease

I69.91 Delete Cognitive deficits following unspecified cerebrovascular disease

I97.62 Delete Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure

Cardiovascular

56

Hypertensive Urgency, Emergency and Crisis

Documentation for these conditions include:

Associated complications/signs/symptoms

Type

I16.0 Hypertensive urgency

I16.1 Hypertensive emergency

I16.9 Hypertensive crisis, unspecified

Cerebral Infarction

57

I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries

I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries

I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries

I63.133 Cerebral infarction due to embolism of bilateral carotid arteries

I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries

I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries

I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries

I63.323 Cerebral infarction due to thrombosis of bilateral anterior arteries

I63.333 Cerebral infarction to thrombosis of bilateral posterior arteries

I63.343 Cerebral infarction to thrombosis of bilateral cerebellar arteries

I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries

I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries

I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries

I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries

I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries

I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries

I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries

I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries

I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries

Documentation concepts include: Type Caused by/due to Laterality Anatomical location

Cardiovascular

58

Other Additions I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage

I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage

I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage

I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage

I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage

I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage

I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage

I69.019 Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage

I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage

I69.111 Memory deficit following nontraumatic intracerebral hemorrhage

I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage

I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage

I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage

I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage

I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage

I69.119 Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage

I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage

I69.211 Memory deficit following other nontraumatic intracranial hemorrhage

I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage

I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage

I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage

I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage

59

I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage

I69.219 Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage

I69.310 Attention and concentration deficit following cerebral infarction

I69.311 Memory deficit following cerebral infarction

I69.312 Visuospatial deficit and spatial neglect following cerebral infarction

I69.313 Psychomotor deficit following cerebral infarction

I69.314 Frontal lobe and executive function deficit following cerebral infarction

I69.315 Cognitive social or emotional deficit following cerebral infarction

I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction

I69.319 Unspecified symptoms and signs involving cognitive functions following cerebral infarction

I69.810 Attention and concentration deficit following other cerebrovascular disease

I69.811 Memory deficit following other cerebrovascular disease

I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease

I69.813 Psychomotor deficit following other cerebrovascular disease

I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease

I69.815 Cognitive social or emotional deficit following other cerebrovascular disease

I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease

I69.819 Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease

I69.910 Attention and concentration deficit following unspecified cerebrovascular disease

I69.911 Memory deficit following unspecified cerebrovascular disease

I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease

I69.913 Psychomotor deficit following unspecified cerebrovascular disease

I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease

I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease

I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease

I69.919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease

I72.5 Aneurysm of other precerebral arteries

Cardiovascular

60

I72.6 Aneurysm of vertebral artery

I77.70 Dissection of unspecified artery

I77.75 Dissection of other precerebral arteries

I77.76 Dissection of artery of upper extremity

I77.77 Dissection of artery of lower extremity

I97.620 Postprocedural hemorrhage of a circulatory system organ or structure following other procedure

I97.621 Postprocedural hematoma of a circulatory system organ or structure following other procedure

I97.630 Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization

I97.631 Postprocedural hematoma of a circulatory system organ or structure following cardiac bypass

I97.638 Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure

Digestive

Digestive

62

Periodontitis

63

K05.211 Add Aggressive periodontitis, localized, slight

K05.212 Add Aggressive periodontitis, localized, moderate

K05.213 Add Aggressive periodontitis, localized, severe

K05.219 Add Aggressive periodontitis, localized, unspecified severity

K05.221 Add Aggressive periodontitis, generalized, slight

K05.222 Add Aggressive periodontitis, generalized, moderate

K05.223 Add Aggressive periodontitis, generalized, severe

K05.229 Add Aggressive periodontitis, generalized, unspecified severity

K05.311 Add Chronic periodontitis, localized, slight

K05.312 Add Chronic periodontitis, localized, moderate

K05.313 Add Chronic periodontitis, localized, severe

K05.319 Add Chronic periodontitis, localized, unspecified severity

K05.321 Add Chronic periodontitis, generalized, slight

K05.322 Add Chronic periodontitis, generalized, moderate

K05.323 Add Chronic periodontitis, generalized, severe

Necrotizing enterocolitis NEC

64

Symptoms include:

Abdominal bloating

Blood in the stool

Diarrhea

Feeding problems

Lack of energy

Unstable body temperature

Unstable breathing, heart rate, or blood pressure

Vomiting

Staging of NEC uses the Bell Stage

classification:

Stage 1

Suspected NEC

Mildest of symptoms

Stage 2

Proven NEC cases

Signs more indicative of NEC (other gastrointestinal disorders have been ruled out)

Abdominal distention is marked

Persistent occult or frank blood in stool may be present

Stage 3

Advanced NEC cases showing stage 1 and 2

Shows a deterioration of vital signs

Evidence of septic shock, marked gastrointestinal bleeding

Documentation concepts include:

Type

Stage

Necrotizing enterocolitis NEC

65

K55.30 Add Necrotizing enterocolitis, unspecified

K55.31 Add Stage 1 necrotizing enterocolitis

K55.32 Add Stage 2 necrotizing enterocolitis

K55.33 Add Stage 3 necrotizing enterocolitis

Necrotizing enterocolitis NEC

66

Other additions

K58.1 Add Irritable bowel syndrome with constipation

K58.2 Add Mixed irritable bowel syndrome

K58.8 Add Other irritable bowel syndrome

K59.03 Add Drug induced constipation

K59.04 Add Chronic idiopathic constipation

K59.31 Add Toxic megacolon

K59.39 Add Other megacolon

K85.00 Add Idiopathic acute pancreatitis without necrosis or infection

K85.01 Add Idiopathic acute pancreatitis with uninfected necrosis

K85.02 Add Idiopathic acute pancreatitis with infected necrosis

K85.10 Add Biliary acute pancreatitis without necrosis or infection

K85.11 Add Biliary acute pancreatitis with uninfected necrosis

Necrotizing enterocolitis NEC

67

Deletions include codes that were expanded with additions:

K04.0 Delete Pulpitis

K05.21 Delete Aggressive periodontitis, localized

K05.22 Delete Aggressive periodontitis, generalized

K05.31 Delete Chronic periodontitis, localized

K05.32 Delete Chronic periodontitis, generalized

K08.8 Delete Other specified disorders of teeth and supporting structures

K52.2 Delete Allergic and dietetic gastroenteritis and colitis

K55.0 Delete Acute vascular disorders of intestine

K59.3 Delete Megacolon, not elsewhere classified

K85.0 Delete Idiopathic acute pancreatitis

K85.1 Delete Biliary acute pancreatitis

K85.2 Delete Alcohol induced acute pancreatitis

K85.3 Delete Drug induced acute pancreatitis

K85.8 Delete Other acute pancreatitis

K85.9 Delete Acute pancreatitis, unspecified

K86.8 Delete Other specified diseases of pancreas

Necrotizing enterocolitis NEC

68

Revised codes include:

K91.61 Revise fromIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure

K91.840 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure

K91.841 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure

K91.61 Revise toIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure

K91.840 Revise toPostprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure

K91.841 Revise toPostprocedural hemorrhage of a digestive system organ or structure following other procedure

Musculoskletal

Musculoskeletal

70

Bunionette

Pathologic lesions include:

Inflamed bursa overlying the lateral aspect of the MT head

Bony enlargement of the head itself

Increased intermetatarsal angle between the fourth and fifth MTs with secondary medial angulation of the phalanx

and abnormal curvature of the fifth MT

M21.611 Add Bunion of right foot

M21.612 Add Bunion of left foot

M21.619 Add Bunion of unspecified foot

M21.621 Add Bunionette of right foot

M21.622 Add Bunionette of left foot

M21.629 Add Bunionette of unspecified foot

Documentation concepts for bunions or bunionettes include:

Type

Anatomical location

Laterality

Incomplete atypical fracture

71

M84.750A Add Atypical femoral fracture, unspecified, initial encounter for fracture

M84.750D Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with routine healing

M84.750G Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with delayed healing

M84.750K Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with nonunion

M84.750P Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with malunion

M84.750S Add Atypical femoral fracture, unspecified, sequela

M84.751A Add Incomplete atypical femoral fracture, right leg, initial encounter for fracture

M84.751D Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing

M84.751G Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing

M84.751K Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion

M84.751P Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with malunion

M84.751S Add Incomplete atypical femoral fracture, right leg, sequela

M84.752A Add Incomplete atypical femoral fracture, left leg, initial encounter for fracture

M84.752D Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing

M84.752G Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing

M84.752K Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion

M84.752P Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with malunion

M84.752S Add Incomplete atypical femoral fracture, left leg, sequela

M84.753A Add Incomplete atypical femoral fracture, unspecified leg, initial encounter for fracture

M84.753D Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing

M84.753G Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing

72

M84.753K Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion

M84.753P Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion

M84.753S Add Incomplete atypical femoral fracture, unspecified leg, sequela

M84.754A Add Complete transverse atypical femoral fracture, right leg, initial encounter for fracture

M84.754D Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing

M84.754G Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing

M84.754K Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion

M84.754P Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with malunion

M84.754S Add Complete transverse atypical femoral fracture, right leg, sequela

M84.755A Add Complete transverse atypical femoral fracture, left leg, initial encounter for fracture

M84.755D Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing

M84.755G Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing

M84.755K Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion

M84.755P Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with malunion

M84.755S Add Complete transverse atypical femoral fracture, left leg, sequela

M84.756A Add Complete transverse atypical femoral fracture, unspecified leg, initial encounter for fracture

M84.756D Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing

M84.756G Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing

M84.756K Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion

M84.756P Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion

M84.756S Add Complete transverse atypical femoral fracture, unspecified leg, sequela

M84.757A Add Complete oblique atypical femoral fracture, right leg, initial encounter for fracture

M84.757D Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing

Musculoskeletal

73

M84.757G Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing

M84.757K Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion

M84.757P Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with malunion

M84.757S Add Complete oblique atypical femoral fracture, right leg, sequela

M84.758A Add Complete oblique atypical femoral fracture, left leg, initial encounter for fracture

M84.758D Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing

M84.758G Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing

M84.758K Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion

M84.758P Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with malunion

M84.758S Add Complete oblique atypical femoral fracture, left leg, sequela

M84.759A Add Complete oblique atypical femoral fracture, unspecified leg, initial encounter for fracture

M84.759D Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing

M84.759G Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing

M84.759K Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion

M84.759P Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion

Documentation

concepts include:

Type

Anatomical location

Laterality

Status

Genitourinary

Genitourinary

75

Incontinence

Documentation concepts include:

Type

N39.491 Add Coital incontinence

N39.492 Add Postural (urinary) incontinence

Other additions

76

Follicular cysts

N83.00 Add Follicular cyst of ovary, unspecified side

N83.01 Add Follicular cyst of right ovary

N83.02 Add Follicular cyst of left ovary

N83.10 Add Corpus luteum cyst of ovary, unspecified side

N83.11 Add Corpus luteum cyst of right ovary

N83.12 Add Corpus luteum cyst of left ovary

N83.201 Add Unspecified ovarian cyst, right side

N83.202 Add Unspecified ovarian cyst, left side

N83.209 Add Unspecified ovarian cyst, unspecified side

N83.291 Add Other ovarian cyst, right side

N83.292 Add Other ovarian cyst, left side

N83.299 Add Other ovarian cyst, unspecified side

N83.311 Add Acquired atrophy of right ovary

N83.312 Add Acquired atrophy of left ovary

N83.319 Add Acquired atrophy of ovary, unspecified side

N83.321 Add Acquired atrophy of right fallopian tube

N83.322 Add Acquired atrophy of left fallopian tube

N83.329 Add Acquired atrophy of fallopian tube, unspecified side

N83.331 Add Acquired atrophy of right ovary and fallopian tube

N83.332 Add Acquired atrophy of left ovary and fallopian tube

N83.339 Add Acquired atrophy of ovary and fallopian tube, unspecified side

Other additions

77

N83.40 Add Prolapse and hernia of ovary and fallopian tube, unspecified side

N83.41 Add Prolapse and hernia of right ovary and fallopian tube

N83.42 Add Prolapse and hernia of left ovary and fallopian tube

N83.511 Add Torsion of right ovary and ovarian pedicle

N83.512 Add Torsion of left ovary and ovarian pedicle

N83.519 Add Torsion of ovary and ovarian pedicle, unspecified side

N83.521 Add Torsion of right fallopian tube

N83.522 Add Torsion of left fallopian tube

N83.529 Add Torsion of fallopian tube, unspecified side

Genitourinary

78

Deletions

N83.0 Delete Follicular cyst of ovary

N83.1 Delete Corpus luteum cyst

N83.20 Delete Unspecified ovarian cysts

N83.29 Delete Other ovarian cysts

N83.31 Delete Acquired atrophy of ovary

N83.32 Delete Acquired atrophy of fallopian tube

N83.33 Delete Acquired atrophy of ovary and fallopian tube

N83.4 Delete Prolapse and hernia of ovary and fallopian tube

N83.51 Delete Torsion of ovary and ovarian pedicle

N83.52 Delete Torsion of fallopian tube

Revisions to existing codes include:

79

N10 Revise from Acute tubulo-interstitial nephritis

N40.0 Revise from Enlarged prostate without lower urinary tract symptoms

N40.1 Revise from Enlarged prostate with lower urinary tract symptoms

N52.39 Revise from Other post-surgical erectile dysfunction

N99.113 Revise from Postprocedural anterior urethral stricture

N99.520 Revise from Hemorrhage of other external stoma of urinary tract

N99.521 Revise from Infection of other external stoma of urinary tract

N99.522 Revise from Malfunction of other external stoma of urinary tract

N99.528 Revise from Other complication of other external stoma of urinary tract

N99.530 Revise from Hemorrhage of other stoma of urinary tract

N99.531 Revise from Infection of other stoma of urinary tract

N99.532 Revise from Malfunction of other stoma of urinary tract

N99.538 Revise from Other complication of other stoma of urinary tract

Documentation concepts

prevalent to these revisions

include:

Type

Anatomical location

Caused by/due to

Complications/manifestations

80

N99.820 Revise fromPostprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure

N99.821 Revise from Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure

N10 Revise to Acute pyelonephritis

N40.0 Revise to Benign prostatic hyperplasia without lower urinary tract symptoms

N40.1 Revise to Benign prostatic hyperplasia with lower urinary tract symptoms

N52.39 Revise to Other and unspecified postprocedural erectile dysfunction

N99.113 Revise to Postprocedural anterior bulbous urethral stricture

N99.520 Revise to Hemorrhage of incontinent stoma of urinary tract

N99.521 Revise to Infection of incontinent stoma of urinary tract

N99.522 Revise to Malfunction of incontinent stoma of urinary tract

N99.528 Revise to Other complication of incontinent stoma of urinary tract

N99.530 Revise to Hemorrhage of continent stoma of urinary tract

N99.531 Revise to Infection of continent stoma of urinary tract

N99.532 Revise to Malfunction of continent stoma of urinary tract

N99.538 Revise to Other complication of continent stoma of urinary tract

N99.820 Revise to Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure

N99.821 Revise to Postprocedural hemorrhage of a genitourinary system organ or structure following other procedure

Documentation concepts

prevalent to these revisions

include:

Type

Anatomical location

Caused by/due to

Complications/manifestations

Obstetrics

Obstetrics

82

Deletions

O00.0 Delete Abdominal pregnancy

O00.1 Delete Tubal pregnancy

O00.2 Delete Ovarian pregnancy

O00.8 Delete Other ectopic pregnancy

O00.9 Delete Ectopic pregnancy, unspecified

O33.7 Delete Maternal care for disproportion due to other fetal deformities

O34.21 Delete Maternal care for scar from previous cesarean delivery

O70.2 Delete Third degree perineal laceration during delivery

Obstetrics

83

Additions

O00.00 Abdominal pregnancy without intrauterine pregnancy

O00.01 Abdominal pregnancy with intrauterine pregnancy

O00.90 Unspecified ectopic pregnancy without intrauterine pregnancy

Obstetrics

84

Remaining Additions

O00.10 Add Tubal pregnancy without intrauterine pregnancy

O00.11 Add Tubal pregnancy with intrauterine pregnancy

O00.20 Add Ovarian pregnancy without intrauterine pregnancy

O00.21 Add Ovarian pregnancy with intrauterine pregnancy

O00.80 Add Other ectopic pregnancy without intrauterine pregnancy

O00.81 Add Other ectopic pregnancy with intrauterine pregnancy

O00.90 Add Unspecified ectopic pregnancy without intrauterine pregnancy

O00.91 Add Unspecified ectopic pregnancy with intrauterine pregnancy

O09.A0 Add Supervision of pregnancy with history of molar pregnancy, unspecified trimester

O09.A1 Add Supervision of pregnancy with history of molar pregnancy, first trimester

O09.A2 Add Supervision of pregnancy with history of molar pregnancy, second trimester

O09.A3 Add Supervision of pregnancy with history of molar pregnancy, third trimester

O11.4 Add Pre-existing hypertension with pre-eclampsia, complicating childbirth

O11.5 Add Pre-existing hypertension with pre-eclampsia, complicating the puerperium