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2019

ICD-10-CM Expert for SNF, IRF, and LTCH The complete official code set

Codes valid from October 1, 2018 through September 30, 2019

EXPERT

ITSN_ITSN19_CVR.indd 1 12/4/17 2:54 PM

ICD-10-CM 2019

ContentsPreface ................................................................................ iii

ICD-10-CM Official Preface ........................................................................ iiiCharacteristics of ICD-10-CM .................................................................... iii

What’s New for 2019 .......................................................... ivOfficial Updates ............................................................................................ ivProprietary Updates ...................................................................................vii

Introduction ....................................................................... ixHistory of ICD-10-CM ................................................................................. ix

How to Use ICD-10-CM Expert for Skilled Nursing Facilities, Inpatient Rehabilitation Services, and Inpatient Hospice 2019 ....................................................... x

Use of Official Sources ................................................................................. xSteps to Correct Coding ............................................................................. xOrganization .................................................................................................. x

Introduction ........................................................................................... xOfficial ICD-10-CM Conventions and Guidelines........................... xAlphabetic Index to Diseases ............................................................. xNeoplasm Table..................................................................................... xTable of Drugs and Chemicals ........................................................... xIndex to External Causes .................................................................... xiTabular List of Diseases ...................................................................... xiAppendixes............................................................................................ xiIllustrations ............................................................................................ xi

Overview of ICD-10-CM Official Conventions ................... xiiFormat ................................................................................................ xiiPunctuation ................................................................................................. xiiAbbreviations .............................................................................................. xii

NEC ........................................................................................................ xiiNOS ........................................................................................................ xii

Typeface ................................................................................................. xiiGeneral Notes ............................................................................................. xii

Includes Notes ..................................................................................... xiiInclusion Terms.................................................................................... xiiExcludes Notes..................................................................................... xiiNote .......................................................................................................xiiiDefault Codes......................................................................................xiiiSyndromes...........................................................................................xiiiAnd .......................................................................................................xiiiWith .......................................................................................................xiiiSee and See Also ................................................................................xiiiInstructional Notes Used in the Tabular List ...............................xiiiCode Assignment and Clinical Criteria .........................................xiii

Additional Annotations .................................................... xivCode-Level Notations ...............................................................................xiv

Italics .....................................................................................................xivColor Coding/Symbols ......................................................................xivFootnotes .............................................................................................xvi

Chapter-Level Notations ..........................................................................xviChapter-Specific Guidelines with Coding Examples .................xviMuscle Tendon Table .......................................................................xvi

Index Notations ..........................................................................................xviFollowing References.........................................................................xvi

ICD-10-CM Official Guidelines for Coding and Reporting 2017 ............................. Coding Guidelines–1

ICD-10-CM Index to Diseases and Injuries .......................... 1

ICD-10-CM Neoplasm Table ............................................ 331

ICD-10-CM Table of Drugs and Chemicals ...................... 349

ICD-10-CM Index to External Causes ............................... 397

ICD-10-CM Tabular List of Diseases and Injuries ............ 433Chapter 1. Certain Infectious and Parasitic Diseases

(A00-B99) .........................................................................433

Chapter 2. Neoplasms (C00-D49) ...................................................457

Chapter 3. Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) .................................495

Chapter 4. Endocrine, Nutritional and Metabolic Diseases(E00-E89) ..........................................................................505

Chapter 5. Mental, Behavioral, and Neurodevelopmental Disorders (F01-F99) .......................................................525

Chapter 6. Diseases of the Nervous System (G00-G99) ............549

Chapter 7. Diseases of the Eye and Adnexa (H00-H59) ............569

Chapter 8. Diseases of the Ear and Mastoid Process(H60-H95) ........................................................................605

Chapter 9. Diseases of the Circulatory System (I00-I99) ...........617

Chapter 10. Diseases of the Respiratory System (J00-J99) .........657

Chapter 11. Diseases of the Digestive System (K00-K95) ...........673

Chapter 12. Diseases of the Skin and Subcutaneous Tissue(L00-L99) ..........................................................................695

Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) ....................................715

Chapter 14. Diseases of the Genitourinary System(N00-N99) ........................................................................803

Chapter 15. Pregnancy, Childbirth and the Puerperium(O00-O9A) ........................................................................821

Chapter 16. Certain Conditions Originating in the Perinatal Period (P00-P96) ............................................................857

Chapter 17. Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) .................869

Chapter 18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) .......................................................887

Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) .......................................907

Chapter 20. External Causes of Morbidity (V00-Y99)................. 1115

Chapter 21. Factors Influencing Health Status and Contact With Health Services (Z00-Z99) ............................... 1177

Appendixes .....................................................Appendixes–1Appendix A: 10 Steps to Correct Coding ......................Appendixes–1Appendix B: Valid 3-character ICD-10-CM

Codes ............................................................Appendixes–3Appendix C: Pharmacology List 2018............................Appendixes–5Appendix D: Z Codes for Long-Term Drug Use

with Associated Drugs............................ Appendixes–21Appendix E: Z Codes Only as Principal/First-Listed

Diagnosis ................................................... Appendixes–24Appendix F: Hospice Criteria for Medicare Coverage

of Noncancer Hospice Care .................. Appendixes–25

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Lymphangitis — continuedacute — continued

hip — see Lymphangitis, acute, lower limbjaw (region) L03.212knee — see Lymphangitis, acute, lower limbleg — see Lymphangitis, acute, lower limblower limb L03.12- S

toe — see Lymphangitis, acute, toenavel L03.326neck (region) L03.222orbit, orbital — see Cellulitis, orbitpectoral (region) L03.323perineal, perineum L03.325scalp (any part) L03.891shoulder — see Lymphangitis, acute, upper limbspecified site NEC L03.898thigh — see Lymphangitis, acute, lower limbthumb (intrathecal) (periosteal) (subcutaneous)

(subcuticular) — see Lymphangitis, acute,finger

toe (intrathecal) (periosteal) (subcutaneous) (sub-cuticular) L03.04- S

trunk L03.329abdominal wall L03.321back (any part) L03.322buttock L03.327chest wall L03.323groin L03.324perineal, perineum L03.325umbilicus L03.326

umbilicus L03.326upper limb L03.12- S

axilla — see Lymphangitis, acute, axillafinger — see Lymphangitis, acute, fingerthumb — see Lymphangitis, acute, finger

wrist — see Lymphangitis, acute, upper limbbreast

gestational — see Mastitis, obstetricchancroidal A57chronic (any site) I89.1due to

Brugia (malayi) B74.1timori B74.2

Wuchereria bancrofti B74.0following ectopic or molar pregnancy O08.89penis

acute N48.29gonococcal (acute) (chronic) A54.09

puerperal, postpartum, childbirth O86.89strumous, tuberculous A18.2subacute (any site) I89.1tuberculous — see Tuberculosis, lymph gland

Lymphatic (vessel) — see conditionLymphatism E32.8Lymphectasia I89.0Lymphedema (acquired) (see also Elephantiasis)

congenital Q82.0hereditary (chronic) (idiopathic) Q82.0postmastectomy I97.2praecox I89.0secondary I89.0surgical NEC I97.89

postmastectomy (syndrome) I97.2Lymphoblastic — see conditionLymphoblastoma (diffuse) — see Lymphoma, lym-

phoblastic (diffuse)giant follicular — see Lymphoma, lymphoblastic (dif-

fuse)macrofollicular — see Lymphoma, lymphoblastic

(diffuse)Lymphocele I89.8Lymphocytic

chorioencephalitis (acute) (serous) A87.2choriomeningitis (acute) (serous) A87.2meningoencephalitis A87.2

Lymphocytoma, benign cutis L98.8Lymphocytopenia D72.810Lymphocytosis (symptomatic) D72.820

infectious (acute) B33.8Lymphoepithelioma — see Neoplasm, malignant, by

siteLymphogranuloma (malignant) (see also Lymphoma,

Hodgkin)chlamydial A55inguinale A55venereum (any site) (chlamydial) (with stricture of

rectum) A55

Lymphogranulomatosis (malignant) (see also Lym-phoma, Hodgkin)

benign (Boeck's sarcoid) (Schaumann's) D86.1Lymphohistiocytosis, hemophagocytic (familial) D76.1Lymphoid — see conditionLymphoma (of) (malignant) C85.90

adult T-cell (HTLV-1-associated) (acute variant)(chronic variant) (lymphomatoid variant)(smouldering variant) C91.5- S

anaplastic large cellALK-negative C84.7- SALK-positive C84.6- SCD30-positive C84.6- Sprimary cutaneous C86.6

angioimmunoblastic T-cell C86.5BALT C88.4B-cell C85.1- Sblastic NK-cell C86.4blastic plasmacytoid dendritic cell neoplasm (BPDCN)

C86.4B-precursor C83.5- Sbronchial-associated lymphoid tissue [BALT-lym-

phoma] C88.4Burkitt (atypical) C83.7- SBurkitt-like C83.7- Scentrocytic C83.1- Scutaneous follicle center C82.6- Scutaneous T-cell C84.A- S (following C84.7)diffuse follicle center C82.5- Sdiffuse large cell C83.3- S

anaplastic C83.3- SB-cell C83.3- SCD30-positive C83.3- Scentroblastic C83.3- Simmunoblastic C83.3- Splasmablastic C83.3- Ssubtype not specified C83.3- ST-cell rich C83.3- S

enteropathy-type (associated) (intestinal) T-cell C86.2extranodal marginal zone B-cell lymphoma of mucosa-

associated lymphoid tissue [MALT-lymphoma]C88.4

extranodal NK/T-cell, nasal type C86.0follicular C82.9- S

gradeI C82.0- SII C82.1- SIII C82.2- SIIIa C82.3- SIIIb C82.4- S

specified NEC C82.8- Shepatosplenic T-cell (alpha-beta) (gamma-delta) C86.1histiocytic C85.9- S

true C96.A (following C96.6)Hodgkin C81.9 S

lymphocyte depleted (classical) C81.3- Slymphocyte-rich (classical) C81.4- Smixed cellularity (classical) C81.2- Snodular

lymphocyte predominant C81.0- Ssclerosis (classical) C81.1- S

nodular sclerosis (classical) C81.1- Sspecified NEC (classical) C81.7- S

intravascular large B-cell C83.8- SLennert's C84.4- Slymphoblastic (diffuse) C83.5- Slymphoblastic B-cell C83.5- Slymphoblastic T-cell C83.5- Slymphoepithelioid C84.4- Slymphoplasmacytic C83.0- S

with IgM-production C88.0MALT C88.4mantle cell C83.1- Smature T-cell NEC C84.4- Smature T/NK-cell C84.9- S

specified NEC C84.Z- S (following C84.7)mediastinal (thymic) large B-cell C85.2- SMediterranean C88.3mucosa-associated lymphoid tissue [MALT-lymphoma]

C88.4NK/T cell C84.9- Snodal marginal zone C83.0- Snon-follicular (diffuse) C83.9- S

specified NEC C83.8- Snon-Hodgkin (see also Lymphoma, by type) C85.9- S

specified NEC C85.8- S

Lymphoma — continuednon-leukemic variant of B-CLL C83.0- Speripheral T-cell, not classified C84.4- Sprimary cutaneous

anaplastic large cell C86.6CD30-positive large T-cell C86.6

primary effusion B-cell C83.8- SSALT C88.4skin-associated lymphoid tissue [SALT-lymphoma]

C88.4small cell B-cell C83.0- Ssplenic marginal zone C83.0- Ssubcutaneous panniculitis-like T-cell C86.3T-precursor C83.5- Strue histiocytic C96.A (following C96.6)

Lymphomatosis — see LymphomaLymphopathia venereum, veneris A55Lymphopenia D72.810Lymphoplasmacytic leukemia — see Leukemia,

chronic lymphocytic, B-cell typeLymphoproliferation, X-linked disease D82.3Lymphoreticulosis, benign (of inoculation) A28.1Lymphorrhea I89.8Lymphosarcoma (diffuse) (see also Lymphoma)

C85.9- SLymphostasis I89.8Lypemania — see MelancholiaLysine and hydroxylysine metabolism disorder E72.3Lyssa — see Rabies

MMacacus ear Q17.3Maceration, wet feet, tropical (syndrome) T69.02- SMacLeod's syndrome J43.0Macrocephalia, macrocephaly Q75.3Macrocheilia, macrochilia (congenital) Q18.6Macrocolon (see also Megacolon) Q43.1Macrocornea Q15.8

with glaucoma Q15.0Macrocytic — see conditionMacrocytosis D75.89Macrodactylia, macrodactylism (fingers) (thumbs)

Q74.0toes Q74.2

Macrodontia K00.2Macrogenia M26.05Macrogenitosomia (adrenal) (male) (praecox) E25.9

congenital E25.0Macroglobulinemia (idiopathic) (primary) C88.0

monoclonal (essential) D47.2Waldenström C88.0

Macroglossia (congenital) Q38.2acquired K14.8

Macrognathia, macrognathism (congenital)(mandibular) (maxillary) M26.09

Macrogyria (congenital) Q04.8Macrohydrocephalus — see HydrocephalusMacromastia — see Hypertrophy, breastMacrophthalmos Q11.3

in congenital glaucoma Q15.0Macropsia H53.15Macrosigmoid K59.39

congenital Q43.2Macrospondylitis , acromegalic E22.0Macrostomia (congenital) Q18.4Macrotia (external ear) (congenital) Q17.1Macula

cornea, corneal — see Opacity, corneadegeneration (atrophic) (exudative) (senile) (see also

Degeneration, macula)hereditary — see Dystrophy, retina

Maculae ceruleae B85.1Maculopathy, toxic — see Degeneration, macula, toxicMadarosis (eyelid) H02.729

left H02.726lower H02.725upper H02.724

right H02.723lower H02.722upper H02.721

Madelung'sdeformity (radius) Q74.0disease

radial deformity Q74.0symmetrical lipomas, neck E88.89

Madness — see Psychosis

Lymphangitis—

Madness

Index

215S Additional Character Required — Refer to the Tabular List for Character Selection2 Subterms under main terms may continue to next column or page

MadnessICD-10-CM 2019

Sample

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Chapter 3. Diseases of the Blood and Blood-form

ing Organs

D63–D

68.311ICD-10-CM 2019 Chapter 3. Diseases of the Blood and Blood-forming Organs D63–D68.311

g Placeholder Alert RUG IV Special Care High Dx RUG IV Clinically Complex Dx RUG IV Special Care Low Dx Manifestation Code BUnspecified CodeS Additional Character Required ICD-10-CM 2019 499

b D63 Anemia in chronic diseases classified elsewhereD63.0 Anemia in neoplastic disease

Code first neoplasm (C00-D49)1 anemia due to antineoplastic chemotherapy (D64.81)

aplastic anemia due to antineoplastic chemotherapy (D61.1)

2wanemia due to antineoplastic chemotherapy (D64.81)x

D63.1 Anemia in chronic kidney diseaseErythropoietin resistant anemia (EPO resistant anemia)Code first underlying chronic kidney disease (CKD) (N18.-)

D63.8 Anemia in other chronic diseases classified elsewhereCode first underlying disease, such as:

diphyllobothriasis (B70.0)hookworm disease (B76.0-B76.9)hypothyroidism (E00.0-E03.9)malaria (B50.0-B54)symptomatic late syphilis (A52.79)tuberculosis (A18.89)

b D64 Other anemias1 refractory anemia (D46.-)

refractory anemia with excess blasts in transformation [RAEB T] (C92.0-)

D64.0 Hereditary sideroblastic anemia Sex-linked hypochromic sideroblastic anemia

D64.1 Secondary sideroblastic anemia due to diseaseCode first underlying disease

D64.2 Secondary sideroblastic anemia due to drugs and toxinsCode first poisoning due to drug or toxin, if applicable (T36-T65

with fifth or sixth character 1-4 or 6)Use additional code for adverse effect, if applicable, to identify

drug (T36-T50 with fifth or sixth character 5)D64.3 Other sideroblastic anemias

Sideroblastic anemia NOSPyridoxine-responsive sideroblastic anemia NEC

D64.4 Congenital dyserythropoietic anemiaDyshematopoietic anemia (congenital)1 Blackfan-Diamond syndrome (D61.01)

Di Guglielmo's disease (C94.0)

c D64.8 Other specified anemiasD64.81 Anemia due to antineoplastic chemotherapy A

Antineoplastic chemotherapy induced anemia1 aplastic anemia due to antineoplastic

chemotherapy (D61.1)2 anemia in neoplastic disease (D63.0)AHA: 2014, 4Q, 22DEF: Reversible adverse effect of chemotherapy, causing inhibition of bone marrow production; decrease in red blood cell production prevents adequate oxygenation of the tissues and organs causing fatigue, SOB, and exacerbation of other medical conditions.

D64.89 Other specified anemiasInfantile pseudoleukemia

D64.9 Anemia, unspecified BAHA: 2017, 1Q, 7

Coagulation defects, purpura and other hemorrhagic conditions (D65-D69)

D65 Disseminated intravascular coagulation [defibrination A syndrome]

Afibrinogenemia, acquiredConsumption coagulopathyDiffuse or disseminated intravascular coagulation [DIC]Fibrinolytic hemorrhage, acquiredFibrinolytic purpuraPurpura fulminans1 disseminated intravascular coagulation (complicating):

abortion or ectopic or molar pregnancy (O00-O07, O08.1)in newborn (P60)pregnancy, childbirth and the puerperium (O45.0, O46.0,

O67.0, O72.3)

D66 Hereditary factor VIII deficiency A Classical hemophiliaDeficiency factor VIII (with functional defect)Hemophilia AHemophilia NOS1 factor VIII deficiency with vascular defect (D68.0)DEF: Hereditary, sex-linked lack of antihemophilic globulin (AHG) (factor VIII); causes abnormal coagulation characterized by increased bleeding, large bruises of skin, bleeding in mouth, nose, gastrointestinal tract; hemorrhages into joints, resulting in swelling and impaired function.

D67 Hereditary factor IX deficiency A Christmas diseaseFactor IX deficiency (with functional defect)Hemophilia BPlasma thromboplastin component [PTC] deficiency

b D68 Other coagulation defects1 abnormal coagulation profile (R79.1)

coagulation defects complicating abortion or ectopic or molar pregnancy (O00-O07, O08.1)

coagulation defects complicating pregnancy, childbirth and the puerperium (O45.0, O46.0, O67.0, O72.3)

AHA: 2016, 1Q, 14TIP: Do not assign to identify routine therapeutic anticoagulation effects; assign only for documented adverse effects.

D68.0 Von Willebrand's diseaseAngiohemophiliaFactor VIII deficiency with vascular defectVascular hemophilia1 capillary fragility (hereditary) (D69.8)

factor VIII deficiency NOS (D66)factor VIII deficiency with functional defect (D66)

DEF: Abnormal blood coagulation caused by deficient blood factor VII; congenital; symptoms include excess or prolonged bleeding.

D68.1 Hereditary factor XI deficiencyHemophilia CPlasma thromboplastin antecedent [PTA] deficiencyRosenthal’s disease

D68.2 Hereditary deficiency of other clotting factorsAC globulin deficiencyCongenital afibrinogenemiaDeficiency of factor I [fibrinogen]Deficiency of factor II [prothrombin]Deficiency of factor V [labile]Deficiency of factor VII [stable]Deficiency of factor X [Stuart-Prower]Deficiency of factor XII [Hageman]Deficiency of factor XIII [fibrin stabilizing]Dysfibrinogenemia (congenital)HypoproconvertinemiaOwren's diseaseProaccelerin deficiency

c D68.3 Hemorrhagic disorder due to circulating anticoagulantsd D68.31 Hemorrhagic disorder due to intrinsic circulating

anticoagulants, antibodies, or inhibitorsD68.311 Acquired hemophilia

Autoimmune hemophiliaAutoimmune inhibitors to clotting factorsSecondary hemophilia

Red blood cells

White blood cell

Platelets

Fibrin

Injury site

Coagulation

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8 Newborn 9 Pediatric x Maternity y Adult % RIC Dx 7 Noncancer Dx u Primary Dx A RIC CC Condition wx Revised Text l New Code s Revised Code Title564 ICD-10-CM 2019

G71.12–G81.14 Chapter 6. Diseases of the Nervous System ICD-10-CM 2019G7

1.12

–G81

.14

Chap

ter 6

. Dis

ease

s of t

he N

ervo

us S

yste

m G71.12 Myotonia congenita %Acetazolamide responsive myotonia congenitaDominant myotonia congenita [Thomsen disease]Myotonia leviorRecessive myotonia congenita [Becker disease]

G71.13 Myotonic chondrodystrophy %Chondrodystrophic myotoniaCongenital myotonic chondrodystrophySchwartz-Jampel disease

G71.14 Drug induced myotonia %Use additional code for adverse effect, if applicable,

to identify drug (T36-T50 with fifth or sixth character 5)

G71.19 Other specified myotonic disorders %Myotonia fluctuansMyotonia permanensNeuromyotonia [Isaacs]Paramyotonia congenita (of von Eulenburg)PseudomyotoniaSymptomatic myotonia

G71.2 Congenital myopathies %Central core diseaseFiber-type disproportionMinicore diseaseMulticore diseaseMyotubular (centronuclear) myopathyNemaline myopathy1 arthrogryposis multiplex congenita (Q74.3)

G71.3 Mitochondrial myopathy, not elsewhere classified1 Kearns-Sayre syndrome (H49.81)

Leber's disease (H47.21)Leigh's encephalopathy (G31.82)mitochondrial metabolism disorders (E88.4-)Reye's syndrome (G93.7)

G71.8 Other primary disorders of musclesG71.9 Primary disorder of muscle, unspecified B

Hereditary myopathy NOS

b G72 Other and unspecified myopathies1 arthrogryposis multiplex congenita (Q74.3)

dermatopolymyositis (M33.-)ischemic infarction of muscle (M62.2-)myositis (M60.-)polymyositis (M33.2-)

G72.0 Drug-induced myopathy %

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

G72.1 Alcoholic myopathy %

Use additional code to identify alcoholism (F10.-)G72.2 Myopathy due to other toxic agents %

Code first (T51-T65) to identify toxic agentG72.3 Periodic paralysis %

Familial periodic paralysisHyperkalemic periodic paralysis (familial)Hypokalemic periodic paralysis (familial)Myotonic periodic paralysis (familial)Normokalemic paralysis (familial)Potassium sensitive periodic paralysis1 paramyotonia congenita (of von Eulenburg) (G71.19)

c G72.4 Inflammatory and immune myopathies, not elsewhere classifiedG72.41 Inclusion body myositis [IBM]G72.49 Other inflammatory and immune myopathies, not

elsewhere classifiedInflammatory myopathy NOS

c G72.8 Other specified myopathiesG72.81 Critical illness myopathy

Acute necrotizing myopathyAcute quadriplegic myopathyIntensive care (ICU) myopathyMyopathy of critical illness

G72.89 Other specified myopathiesG72.9 Myopathy, unspecified B

b G73 Disorders of myoneural junction and muscle in diseases classified elsewhereG73.1 Lambert-Eaton syndrome in neoplastic disease

Code first underlying neoplasm (C00-D49)1 Lambert-Eaton syndrome not associated with

neoplasm (G70.80-G70.81)

G73.3 Myasthenic syndromes in other diseases classified elsewhereCode first underlying disease, such as:

neoplasm (C00-D49)thyrotoxicosis (E05.-)

G73.7 Myopathy in diseases classified elsewhereCode first underlying disease, such as:

hyperparathyroidism (E21.0, E21.3)hypoparathyroidism (E20.-)glycogen storage disease (E74.0)lipid storage disorders (E75.-)

1 myopathy in:rheumatoid arthritis (M05.4-)sarcoidosis (D86.87)scleroderma (M34.82)sicca syndrome [Sjögren] (M35.03)systemic lupus erythematosus (M32.19)

Cerebral palsy and other paralytic syndromes (G80-G83)

b G80 Cerebral palsy1 hereditary spastic paraplegia (G11.4)

G80.0 Spastic quadriplegic cerebral palsy %Congenital spastic paralysis (cerebral)

G80.1 Spastic diplegic cerebral palsy %Spastic cerebral palsy NOS

G80.2 Spastic hemiplegic cerebral palsy %

G80.3 Athetoid cerebral palsy %Double athetosis (syndrome)Dyskinetic cerebral palsyDystonic cerebral palsyVogt disease

G80.4 Ataxic cerebral palsy %

G80.8 Other cerebral palsy %Mixed cerebral palsy syndromes

G80.9 Cerebral palsy, unspecified BCerebral palsy NOS

b G81 Hemiplegia and hemiparesis0 This category is to be used only when hemiplegia

(complete)(incomplete) is reported without further specification, or is stated to be old or longstanding but of unspecified cause. The category is also for use in multiple coding to identify these types of hemiplegia resulting from any cause.

1 congenital cerebral palsy (G80.-)hemiplegia and hemiparesis due to sequela of cerebrovascular

disease (I69.05-, I69.15-, I69.25-, I69.35-, I69.85-, I69.95-)AHA: 2015, 1Q, 25

c G81.0 Flaccid hemiplegiaG81.00 Flaccid hemiplegia affecting unspecified side AB

RIC Excl: 01 StrokeG81.01 Flaccid hemiplegia affecting right A

dominant sideRIC Excl: 01 Stroke

G81.02 Flaccid hemiplegia affecting left Adominant side

RIC Excl: 01 StrokeG81.03 Flaccid hemiplegia affecting right A

nondominant sideRIC Excl: 01 Stroke

G81.04 Flaccid hemiplegia affecting left Anondominant side

RIC Excl: 01 Strokec G81.1 Spastic hemiplegia

G81.10 Spastic hemiplegia affecting unspecified side ABRIC Excl: 01 Stroke

G81.11 Spastic hemiplegia affecting right Adominant side

RIC Excl: 01 StrokeG81.12 Spastic hemiplegia affecting left A

dominant sideRIC Excl: 01 Stroke

G81.13 Spastic hemiplegia affecting right Anondominant side

RIC Excl: 01 StrokeG81.14 Spastic hemiplegia affecting left A

nondominant sideRIC Excl: 01 Stroke

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Chapter 10. Diseases of the Respiratory System

ICD-10-CM 2019 Chapter 10. Diseases of the Respiratory System Guidelines and Examples

ICD-10-CM 2019 657

Chapter 10. Diseases of the Respiratory System (J00–J99)

Chapter Specific Guidelines with Coding ExamplesThe chapter specific guidelines from the ICD-10-CM Official Guidelines for Coding and Reporting have been provided below. Along with these guidelines are coding examples, contained in the shaded boxes, that have been developed to help illustrate the coding and/or sequencing guidance found in these guidelines.

a. Chronic obstructive pulmonary disease [COPD] and asthma1) Acute exacerbation of chronic obstructive bronchitis and asthma

The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

b. Acute respiratory failure1) Acute respiratory failure as principal diagnosis

A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

2) Acute respiratory failure as secondary diagnosisRespiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

3) Sequencing of acute respiratory failure and another acute conditionWhen a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

c. Influenza due to certain identified influenza virusesCode only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider’sdiagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.If the provider records “suspected” or “possible” or “probable” avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.

d. Ventilator associated pneumonia1) Documentation of ventilator associated pneumonia

As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between thecondition and the procedure.Code J95.851, Ventilator associated pneumonia, should be assigned only when the provider has documented ventilator associated pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories J12-J18 to identify the type of pneumonia.Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

Patient admitted for continued IV antibiotic administration and physical therapy with diagnoses of MRSA pneumonia with acute exacerbation of COPD. Provider documentation indicates comorbid moderate persistent asthma.

J15.212 Pneumonia due to methicillin resistant Staphylococcus aureus

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

J45.40 Moderate persistent asthma, uncomplicated

Z45.2 Encounter for adjustment and management of vascular access catheter

Explanation: ICD-10-CM uses combination codes to create organism-specific classifications for many types of pneumonia. Category J44 distinguishes between COPD that is exacerbated, COPD with acute lower respiratory infection, and COPD without mention of a complication (unspecified). When a lower respiratory infection is present and COPD is diagnosed, two codes would be required, J44.0 and the code for the infection. Sequencing will be dependent on the condition that is the focus of treatment upon admission to the post-acute setting, which in this case is the MRSA pneumonia.

An acute exacerbation is a worsening or decompensation of a chronic condition and must be specified by the provider as such. When both COPD and asthma are diagnosed and the provider reports an acute exacerbation of COPD, an acute exacerbation of asthma cannot be assumed unless specifically stated by the provider.

Exacerbation of moderate persistent asthma with status asthmaticus

J45.42 Moderate persistent asthma with status asthmaticus

Explanation: Category J45 Asthma includes severity-specific subcategories and fifth-character codes to distinguish between uncomplicated cases, those in acute exacerbation, and those with status asthmaticus.

Acute pneumococcal pneumonia with subsequent development of acute respiratory failure

J13 Pneumonia due to Streptococcus pneumoniae

J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

Explanation: Acute respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission but does not meet the definition of principal diagnosis.

Influenza due to avian influenza virus with pneumonia

J09.X1 Influenza due to identified novel influenza A virus with pneumonia

Explanation: Codes in category J09 Influenza due to certain identified influenza viruses should be assigned only for confirmed cases. “Confirmation” does not require positive laboratory testing of a specific influenza virus but does need to be based on the provider’s diagnostic statement, which should not include terms such as “possible,” “probable,” or “suspected.”Sam

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Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes

S05.4–S06.2X8ICD-10-CM 2019 Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes S05.4–S06.2X8

g Placeholder Alert RUG IV Special Care High Dx RUG IV Clinically Complex Dx RUG IV Special Care Low Dx Manifestation Code BUnspecified CodeS Additional Character Required ICD-10-CM 2019 921

c S05.4 Penetrating wound of orbit with or without foreign body2 retained (old) foreign body following penetrating

wound in orbit (H05.5-)

g S05.40 Penetrating wound of orbit with or without %Bforeign body, unspecified eye

g S05.41 Penetrating wound of orbit with or without %foreign body, right eye

g S05.42 Penetrating wound of orbit with or without %foreign body, left eye

c S05.5 Penetrating wound with foreign body of eyeball2 retained (old) intraocular foreign body (H44.6-, H44.7)

g S05.50 Penetrating wound with foreign body of %Bunspecified eyeball

g S05.51 Penetrating wound with foreign body of right % eyeball

g S05.52 Penetrating wound with foreign body of left %eyeball

c S05.6 Penetrating wound without foreign body of eyeballOcular penetration NOS

g S05.60 Penetrating wound without foreign body of %B unspecified eyeball

g S05.61 Penetrating wound without foreign body of %right eyeball

g S05.62 Penetrating wound without foreign body of %left eyeball

c S05.7 Avulsion of eyeTraumatic enucleation

g S05.70 Avulsion of unspecified eye %Bg S05.71 Avulsion of right eye %

g S05.72 Avulsion of left eye %

c S05.8 Other injuries of eye and orbitLacrimal duct injury

d S05.8X Other injuries of eye and orbite S05.8X1 Other injuries of right eye and orbit %

e S05.8X2 Other injuries of left eye and orbit %

e S05.8X9 Other injuries of unspecified eye % Band orbit

c S05.9 Unspecified injury of eye and orbitInjury of eye NOS

g S05.90 Unspecified injury of unspecified eye and %Borbit

g S05.91 Unspecified injury of right eye and orbit %Bg S05.92 Unspecified injury of left eye and orbit %B

b S06 Intracranial injury0 w7th characters D and S do not apply to codes in category S06

with 6th character 7 – death due to brain injury prior to regaining consciousness, or 8 – death due to other cause prior to regaining consciousnessx

1 traumatic brain injuryCode also any associated:

open wound of head (S01.-)skull fracture (S02.-)

1 head injury NOS (S09.90)AHA: 2017, 1Q, 42; 2015, 3Q, 37TIP: When residual conditions persist as a result of intracranial injury, assign codes to identify the residual deficits, followed by the appropriate S06 code to identify the intracranial injury using 7th character S to identify sequelae. Do not assign Z87.820 Personal history of traumatic brain injury, when residual conditions are present.

c S06.0 ConcussionCommotio cerebri1 concussion with intracranial injuries classified in

subcategories S06.1- to S06.6-, S06.81-, S06.82-code to specified intracranial injury

d S06.0X Concussione S06.0X0 Concussion without loss of %

consciousness

e S06.0X1 Concussion with loss of %consciousness of 30 minutes or less

e S06.0X9 Concussion with loss of % Bconsciousness of unspecified duration

Concussion NOSc S06.1 Traumatic cerebral edema

Diffuse traumatic cerebral edemaFocal traumatic cerebral edema

d S06.1X Traumatic cerebral edemae S06.1X0 Traumatic cerebral edema without %

loss of consciousnesse S06.1X1 Traumatic cerebral edema with %

loss of consciousness of 30 minutes or less

e S06.1X2 Traumatic cerebral edema with %loss of consciousness of 31 minutes to 59 minutes

e S06.1X3 Traumatic cerebral edema with %loss of consciousness of 1 hour to 5 hours 59 minutes

e S06.1X4 Traumatic cerebral edema with %loss of consciousness of 6 hours to 24 hours

e S06.1X5 Traumatic cerebral edema with %loss of consciousness greater than 24 hours with return to pre-existing conscious level

4,9 e S06.1X6 Traumatic cerebral edema with % 7loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving

e S06.1X7 Traumatic cerebral edema with loss %of consciousness of any duration with death due to brain injury prior to regaining consciousness

e S06.1X8 Traumatic cerebral edema with loss % of consciousness of any duration with death due to other cause prior to regaining consciousness

e S06.1X9 Traumatic cerebral edema with %B loss of consciousness of unspecified duration

Traumatic cerebral edema NOSc S06.2 Diffuse traumatic brain injury

Diffuse axonal brain injury1 traumatic diffuse cerebral edema (S06.1X-)

d S06.2X Diffuse traumatic brain injurye S06.2X0 Diffuse traumatic brain injury %

without loss of consciousnesse S06.2X1 Diffuse traumatic brain injury with %

loss of consciousness of 30 minutes or less

e S06.2X2 Diffuse traumatic brain injury with %loss of consciousness of 31 minutes to 59minutes

e S06.2X3 Diffuse traumatic brain injury with %loss of consciousness of 1 hour to 5 hours 59 minutes

e S06.2X4 Diffuse traumatic brain injury with %loss of consciousness of 6 hours to 24 hours

e S06.2X5 Diffuse traumatic brain injury with %loss of consciousness greater than 24 hours with return to pre-existing conscious levels

4,9 e S06.2X6 Diffuse traumatic brain injury %7with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving

e S06.2X7 Diffuse traumatic brain injury with %loss of consciousness of any duration with death due to brain injury prior to regaining consciousness

e S06.2X8 Diffuse traumatic brain injury with % loss of consciousness of any duration with death due to other cause prior to regaining consciousness

The appropriate 7th character is to be added to each code from category S06.A initial encounterD subsequent encounterS sequela

4 Special Care High = With 7th character indicating subsequent encounter9 Hospice noncancer diagnosis with 7th character indicating subsequent encounter.

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ICD-10-CM 2019 Illustrations

ICD-10-CM 2019 Illustrations–27

Chapter 10. Diseases of the Respiratory System (J00–J99)

Respiratory System

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