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20 October 2013 Today’s Wound Clinic® www.todayswoundclinic.com
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ICD-10-CM
As the implementation deadline for ICD-10-CM nears, TWC offers readers an exclusive collection of tip sheets to assist in identifying pertinent documentation improvement topics in wound care. Readers should refer to the tools provided to better understand the terminologies associated with the new coding system. The first installment covers topics related
to infectious disease. For additional information on how to utilize these documentation guidelines, refer to the introductory article “Preparing Your Documentation for ICD-10-CM” available in the October 2013 issue of TWC and online in the “Supplements and Special Projects” section at www.todayswoundclinic.com. n
ICD-10-CM DIAgnosIs CoDIng DoCuMentAtIon tIps for WounD CAre
InfeCtIous DIseAses (A00-B99)
TABLE. ICD-10-CM Diagnosis Coding Documentation Tips for Wound Care Infectious Diseases (A00-B99)
Topic ICD-10-CM Code Ranges Documentation Tips/Guidelines
HIV
HIV Asymptomatic
AIDS
Z21-HIV currently asymptomatic
B20-AIDS
Code only confirmed cases.
Confirmation does not require positive serology or culture for HIV-only; requires physician statement.
NOTE: Inpatient hospital guidelines are different.
Known HIV or HIV-positive should be clearly documented.
If patient admitted for HIV-related disease or AIDS, first-listed diagnosis is B20, then the additional codes for the related conditions.
Bacterial/Viral Infections B95.0-B96.89 May be used as an additional code to specify infectious organism if not already included in the disease code, ie, Acute Bronchitis due to Strep. Used for infections for diseases classified elsewhere.
Document specific organism in the medical record if known.
Examples: Streptococcus, Staphylococcus, Enterococcus.
Infections Resistant to Antibiotics Z16-Resistance to antimicrobial drug Specify which antibiotic the organism is resistant to in the medical record.
MRSA Conditions
MRSA Carrier/Colonization
MRSA Susceptible/Colonization
Usually appears as a combination code that has the disease and causal organism together.
Z22.322 Carrier or suspected carrier of MRSA
Z22.321 Carrier or suspected carrier of methicillin susceptible
Z22.321 MRSA susceptible with colonization
Example: Pneumonia due to MRSA is code J15.212.Do not use additional code for resistance to Penicillin, Z16.11.If a current infection does not have a combination code for MRSA, use a code to identify the condition and use B95.62 for MRSA organism.
Document carrier or susceptibility to MRSA.
Osteomyelitis, Acute
Osteomyelitis, Chronic
M86.00-M86.29
M86.30-M86.9
Document whether acute hematogenous, other acute osteomyelitis, or sub-acute. Document left or right and specific site as applicable.
Document whether chronic multifocal, chronic with draining sinus, other chronic hematogenous, or other chronic. Document left, right, and specific site as applicable.
Asceptic Necrosis M87.00-M90.59 Specify in documentation whether due to drugs, trauma, idiopathic, asceptic necrosis, or secondary osteonecrosis. Specify exact anatomic site as well as laterality (left or right).
Cellulitis
Carbuncle/Furuncle
Cellulitis/Abscess/Onchyia/Paronychia
L02.02-L02.93
L02.02-L03.91
Specify carbuncle/furuncle and provide exact site location.
Document specific body part, cellulitis, abscess, lymphangitis as appropriate. Document right or left as appropriate.
RESOURCE: 2014 ICD-10-CM Official Guidelines for Coding and Reporting 2014 - National Center for Health Statistics. Accessed online at www.cdc.gov/nchs/icd/icd10cm.htm.
