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Applying ICD-10-CM Guidelines Illustrated guide and practical examples of ICD-10-CM coding guidelines and conventions

Applying IC

D-10-C

M

Guidelines

ICD-10 ESSENTIALS

ITEC_ITEC20_CVR.indd 1 12/4/18 10:29 AM

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Contents

Case Studies ............................................................................................................................................vii

Case Studies (Alphabetical Listing) ..........................................................................................................xv

Figures .................................................................................................................................................xxiii

Tables .................................................................................................................................................... xxv

Introduction ............................................................................................................................................. 1How to Use ICD-10 Essentials: Applying ICD-10-CM Guidelines ............................................................................................ 1

ICD-10-CM Guideline ................................................................................................................................................................ 2Illustrations ................................................................................................................................................................................. 2AHA Coding Clinic ..................................................................................................................................................................... 3Practical Application for Guidelines ..................................................................................................................................... 4Beyond the Guidelines............................................................................................................................................................. 5Official ICD-10-CM Resources ................................................................................................................................................. 5

10 Steps to Correct Coding ....................................................................................................................... 7Follow the 10 steps below to correctly code encounters for health care services. ........................................................... 7

Official Coding and Reporting Guidelines: Section I.A. Conventions for the ICD-10-CM .......................... 13A. Conventions for the ICD-10-CM ..............................................................................................................................................13

Official Coding and Reporting Guidelines: Section I.B. General Coding Guidelines ................................. 19B. General Coding Guidelines .......................................................................................................................................................19

Chapter 1: Certain Infectious and Parasitic Diseases (A00–B99) ............................................................. 25Human Immunodeficiency Virus (HIV) Infections (I.C.1.a) .....................................................................................................26Infectious Agents As the Cause of Diseases Classified to Other Chapters (I.C.1.b) ..........................................................39Infections Resistant to Antibiotics (I.C.1.c) ................................................................................................................................. 40Sepsis, Severe Sepsis, and Septic Shock (I.C.1.d) ...................................................................................................................... 42Methicillin Resistant Staphylococcus aureus (MRSA) Conditions (I.C.1.e) .........................................................................66Zika Virus Infections (I.C.1.f) ..........................................................................................................................................................70

Chapter 2: Neoplasms (C00–D49) ........................................................................................................... 73General Guidelines .......................................................................................................................................................................... 75Treatment Directed At the Malignancy (I.C.2.a) ....................................................................................................................... 82Treatment of Secondary Site (I.C.2.b) .......................................................................................................................................... 83Coding and Sequencing of Complications (I.C.2.c) .................................................................................................................85Primary Malignancy Previously Excised (I.C.2.d) ..................................................................................................................... 91Admissions/Encounters Involving Chemotherapy, Immunotherapy and Radiation Therapy (I.C.2.e) .......................94Admission/Encounter to Determine Extent of Malignancy (I.C.2.f) ..................................................................................100Symptoms, Signs, and Abnormal Findings Listed in Chapter 18 Associated with Neoplasms (I.C.2.g) ...................102Admission/Encounter for Pain Control/Management (I.C.2.h) ...........................................................................................103Malignancy in Two or More Noncontiguous Sites (I.C.2.i) ...................................................................................................104Disseminated Malignant Neoplasm, Unspecified (I.C.2.j) ....................................................................................................106Malignant Neoplasm Without Specification of Site (I.C.2.k) ................................................................................................107Sequencing of Neoplasm Codes (I.C.2.l) ...................................................................................................................................108Current Malignancy Versus Personal History of Malignancy (I.C.2.m) ..............................................................................115Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in Remission Versus Personal

History (I.C.2.n) ..............................................................................................................................................................117Aftercare Following Surgery for Neoplasm (I.C.2.o) ..............................................................................................................119Follow-up Care for Completed Treatment of a Malignancy (I.C.2.p) .................................................................................120

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Prophylactic Organ Removal for Prevention of Malignancy (I.C.2.q) ............................................................................... 122Malignant Neoplasm Associated with Transplanted Organ (I.C.2.r) ................................................................................. 124

Chapter 3: Disease of the Blood and Blood-forming Organs and Certain Disorders Involvingthe Immune Mechanism (D50–D89) .......................................................................................................127

Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00–E89) ..................................................129Diabetes Mellitus (I.C.4.a) ............................................................................................................................................................ 131

Chapter 5: Mental, Behavioral, and Neurodevelopmental Disorders (F01–F99) .....................................155Pain Disorders Related to Psychological Factors (I.C.5.a) .................................................................................................... 156Mental and Behavioral Disorders Due to Psychoactive Substance Use (I.C.5.b) ............................................................ 158Factitious Disorder (I.C.5.c) .......................................................................................................................................................... 167

Chapter 6: Diseases of the Nervous System (G00–G99) .........................................................................173Dominant/Nondominant Side (I.C.6.a) .................................................................................................................................... 174Pain—Category G89 (I.C.6.b) ...................................................................................................................................................... 178

Chapter 7: Diseases of the Eye and Adnexa (H00–H59) .........................................................................195Glaucoma (I.C.7.a) .......................................................................................................................................................................... 196Blindness (I.C.7.b) .......................................................................................................................................................................... 205

Chapter 8: Diseases of the Ear and Mastoid Process (H60–H95) .............................................................215

Chapter 9: Diseases of the Circulatory System (I00–I99) ........................................................................217Hypertension (I.C.9.a) ................................................................................................................................................................... 220Atherosclerotic Coronary Artery Disease and Angina (I.C.9.b) ........................................................................................... 243Intraoperative and Postprocedural Cerebrovascular Accident (I.C.9.c) ........................................................................... 246Sequelae of Cerebrovascular Disease (I.C.9.d) ....................................................................................................................... 250Acute Myocardial Infarction (AMI) (I.C.9.e) ............................................................................................................................. 256

Chapter 10: Diseases of the Respiratory System (J00–J99) ....................................................................273Chronic Obstructive Pulmonary Disease [COPD] and Asthma (I.C.10.a) .......................................................................... 274Acute Respiratory Failure (I.C.10.b) ........................................................................................................................................... 280Influenza Due to Certain Identified Influenza Viruses (I.C.10.c) ......................................................................................... 285Ventilator Associated Pneumonia (I.C.10.d) ........................................................................................................................... 287

Chapter 11: Diseases of the Digestive System (K00–K95) .......................................................................291

Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00–L99) ..................................................293Pressure Ulcer Stage Codes (I.C.12.a) ....................................................................................................................................... 295Non-Pressure Chronic Ulcers (I.C.12.b) ..................................................................................................................................... 305

Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00–M99) ......................315Site and Laterality (I.C.13.a) ........................................................................................................................................................ 317Acute Traumatic Versus Chronic or Recurrent Musculoskeletal Conditions (I.C.13.b) ................................................. 323Coding of Pathologic Fractures (I.C.13.c) ................................................................................................................................. 326Osteoporosis (I.C.13.d) ................................................................................................................................................................. 328

Chapter 14: Diseases of Genitourinary System (N00–N99) ....................................................................339Chronic Kidney Disease (I.C.14.a) ............................................................................................................................................... 343

Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00–O9A) .....................................................353General Rules for Obstetric Cases (I.C.15.a) ............................................................................................................................. 356Selection of OB Principal or First-listed Diagnosis (I.C.15.b) ............................................................................................... 368Pre-existing Conditions versus Conditions Due to the Pregnancy (I.C.15.c) .................................................................. 383Pre-existing Hypertension in Pregnancy (I.C.15.d) ............................................................................................................... 386Fetal Conditions Affecting the Management of the Mother (I.C.15.e) ............................................................................. 388HIV Infection in Pregnancy, Childbirth and the Puerperium (I.C.15.f) .............................................................................. 391

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ICD-10 Essentials: Applying ICD-10-CM Guidelines Contents

Diabetes Mellitus in Pregnancy (I.C.15.g) .................................................................................................................................393Long-Term Use of Insulin and Oral Hypoglycemics (I.C.15.h) .............................................................................................394Gestational (Pregnancy Induced) Diabetes (I.C.15.i) .............................................................................................................395Sepsis and Septic Shock Complicating Abortion, Pregnancy, Childbirth and the Puerperium (I.C.15.j) ..................399Puerperal Sepsis (I.C.15.k) ............................................................................................................................................................401Alcohol, Tobacco and Drug Use During Pregnancy, Childbirth and the Puerperium (I.C.15.l) ..................................403Poisoning, Toxic Effects, Adverse Effects and Underdosing in a Pregnant Patient (I.C.15.m) ....................................405Normal Delivery, Code O80 (I.C.15.n) ........................................................................................................................................407The Peripartum and Postpartum Periods (I.C.15.o) ...............................................................................................................409Code O94, Sequelae of Complication of Pregnancy, Childbirth, and the Puerperium (I.C.15.p) ...............................413Termination of Pregnancy and Spontaneous Abortions (I.C.15.q) ....................................................................................414Abuse in a Pregnant Patient (I.C.15.r) .......................................................................................................................................420

Chapter 16: Certain Conditions Originating in the Perinatal Period (P00–P96) .....................................421General Perinatal Rules (I.C.16.a) ................................................................................................................................................422Observation and Evaluation of Newborns for Suspected Conditions Not Found (I.C.16.b) ........................................436Coding Additional Perinatal Diagnoses (I.C.16.c) ...................................................................................................................439Prematurity and Fetal Growth Retardation (I.C.16.d) ...........................................................................................................442Low Birth Weight and Immaturity Status (I.C.16.e) ...............................................................................................................445Bacterial Sepsis of Newborn (I.C.16.f) ........................................................................................................................................447Stillbirth (I.C.16.g) ...........................................................................................................................................................................450

Chapter 17: Congenital Malformations, Deformations, and ChromosomalAbnormalities (Q00–Q99) .....................................................................................................................451

Congenital Malformations, Deformations, and Chromosomal Abnormalities (I.C.17) .................................................452

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings,Not Elsewhere Classified (R00–R99) ......................................................................................................465

Use of Symptom Codes (I.C.18.a) ...............................................................................................................................................470Use of a Symptom Code with a Definitive Diagnosis Code (I.C.18.b) ................................................................................473Combination Codes That Include Symptoms (I.C.18.c) ........................................................................................................477Repeated Falls (I.C.18.d) ...............................................................................................................................................................479Coma Scale (I.C.18.e) .....................................................................................................................................................................480SIRS due to Non-Infectious Process (I.C.18.g) .........................................................................................................................484Death NOS (I.C.18.h) ......................................................................................................................................................................486NIHSS Stroke Scale (I.C.18.i) .........................................................................................................................................................487

Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00–T88) .............489

Chapter 20: External Causes of Morbidity (V00–Y99) ............................................................................501

Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00–Z99) .................509

Official Coding and Reporting Guidelines: Section II. Selection of Principal Diagnosis ..........................529

Official Coding and Reporting Guidelines: Section III. Reporting Additional Diagnoses ........................533

Official Coding and Reporting Guidelines: Section IV. Diagnostic Coding and ReportingGuidelines for Outpatient Services ........................................................................................................535

Official Coding and Reporting Guidelines: Appendix I. Present on Admission Reporting Guidelines .....539Sample page

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Case Studies

Case Study 1.1. HIV, Possible Infection .............................................................................................................27Case Study 1.2. Pneumocystis Jiroveci with History of AIDS .......................................................................30Case Study 1.3. AIDS Patient Admitted with Cholelithiasis .........................................................................30Case Study 1.4. HIV-Positive Patient with Herpesviral Keratitis ..................................................................31Case Study 1.5. HIV, Inconclusive Test ..............................................................................................................33Case Study 1.6. HIV Positive with History of HIV-Related Candidal Esophagitis ....................................34Case Study 1.7. HIV-Positive Patient Admitted for Delivery ........................................................................35Case Study 1.8. HIV-Positive Patient Admitted in Obstructed Labor Due to Breech Position ............35Case Study 1.9. HIV, Follow-up Appointment to Discuss Negative HIV Test Results ............................38Case Study 1.10. Coxsackie Pharyngitis ............................................................................................................39Case Study 1.11. Croup Due to Adenovirus .....................................................................................................40Case Study 1.12. Antimycobacterial-Resistant Primary Pulmonary Tuberculosis ..................................41Case Study 1.13. Sepsis Due to Pseudomonas UTI .........................................................................................43Case Study 1.14. Sepsis Due to Pneumonia .....................................................................................................44Case Study 1.15. Negative Blood Culture in Patient with Leukocytosis ...................................................45Case Study 1.16. Urosepsis ...................................................................................................................................46Case Study 1.17. Sepsis in Patient with Acute Respiratory Failure and COPD Exacerbation ...............48Case Study 1.18. Septicemia, Severe with Acute Kidney Failure ................................................................50Case Study 1.19. Septic Shock Secondary to Pneumonia ............................................................................51Case Study 1.20. Sepsis, Severe Secondary to Cellulitis ................................................................................53Case Study 1.21. Septic Shock, Acute Respiratory Failure Due to Sepsis .................................................55Case Study 1.22. Pelvic Cellulitis Progressing to Sepsis Following Admission .......................................56Case Study 1.23. Sepsis, Severe with Septic Shock Secondary to Intra-abdominal Abscess ...............61Case Study 1.24. Severe Sepsis Due to PICC Line ...........................................................................................61Case Study 1.25. Sepsis Secondary to Third-Degree Burns ..........................................................................63Case Study 1.26. Sepsis Due to Papillomavirus ...............................................................................................65Case Study 1.27. Postoperative MRSA Cellulitis ..............................................................................................67Case Study 1.28. Sepsis, MRSA ............................................................................................................................68Case Study 1.29. Alveolar Abscess with MSSA Positive Swab .....................................................................69Case Study 1.30. Zika Virus, Confirmed .............................................................................................................71Case Study 1.31. Zika Virus Infection, Possible in Pregnant Female ..........................................................71Case Study 1.32. Congenital Zika Infection in 6-Month-Old .......................................................................72Case Study 2.1. Adenoma, Pituitary ...................................................................................................................79Case Study 2.2. Neoplasm, Overlapping Sites .................................................................................................79Case Study 2.3. Adenocarcinoma .......................................................................................................................80Case Study 2.4. Neoplasm, Recurrence .............................................................................................................80Case Study 2.5. Neoplasm, Malignant Thyroid Cancer and Hypothyroidism ..........................................82Case Study 2.6. Neoplasm, Metastatic to Lung ...............................................................................................83Case Study 2.7. Neoplasm, Metastatic from Breast ........................................................................................84Case Study 2.8. Neoplasm with Treatment of Anemia .................................................................................87Case Study 2.9. Neoplasm with Treatment of Chemo-Induced Anemia ..................................................87Case Study 2.10. Neoplasm with Radiation Treatment and IDA ................................................................88Case Study 2.11. Neoplasm with Dehydration ................................................................................................89Case Study 2.12. Neoplasm with Surgical Wound Complication ...............................................................90Case Study 2.13. Neoplasm History on Tamoxifen .......................................................................................92Case Study 2.14. Neoplasm, Carcinoid History ...............................................................................................93Case Study 2.15. Neoplasm, Transplanted Organ, Chemotherapy Initiation ..........................................96Case Study 2.16. Neoplasm, Encounter for Immunotherapy and Chemotherapy .................................97Case Study 2.17. Neoplasm, Radiation to Secondary Site ............................................................................97Case Study 2.18. Neoplasm Treatment with Nausea/Vomiting ..................................................................99Case Study 2.19. Neoplasm Treatment with Urinary Retention ................................................................99Case Study 2.20. Neoplasm Evaluation and Chemotherapy ................................................................... 101

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Case Studies (Alphabetical Listing)

Abortion with Liveborn Fetus .......................................................................................................................... 416Abortion, Elective with Complications Leading to and Following Termination ................................. 419Abortion, Failed Attempt with Retained Products of Conception with Complications .................... 418Abortion, Spontaneous with Retained Products of Conception ............................................................. 418Abortion, Threatened ......................................................................................................................................... 361Abuse and Dependence, Alcohol .................................................................................................................... 163Abuse, Alcohol ..................................................................................................................................................... 164Abuse, Alcohol with Use, Cannabis ................................................................................................................. 163Acute Respiratory Failure and Acute Idiopathic Pulmonary Hemorrhage in Infants ......................... 476Adenocarcinoma ....................................................................................................................................................80Adenoma, Pituitary ................................................................................................................................................79AIDS Patient Admitted with Cholelithiasis .......................................................................................................30Altered Mental Status ......................................................................................................................................... 471Alveolar Abscess with MSSA Positive Swab .....................................................................................................69Amblyopia ............................................................................................................................................................. 213Amblyopia Suspect ............................................................................................................................................. 213Antimycobacterial-Resistant Primary Pulmonary Tuberculosis .................................................................41Atherosclerosis, Native and Bypass Graft with Angina .............................................................................. 245Bipolar Disorder, Manic, Moderate ................................................................................................................. 170Bipolar Type 1, Manic with Psychosis ............................................................................................................. 171Blindness ............................................................................................................................................................... 207Blindness, Bilateral .............................................................................................................................................. 207Blindness, Right Eye ............................................................................................................................................ 207Bone vs Joint Right Humerus ........................................................................................................................... 322Bone vs Joint Right Shoulder ............................................................................................................................ 322Cataract with Neovascularization ................................................................................................................... 210Cataract, Drug-Induced ..................................................................................................................................... 211Cataract, Senile Cortical ..................................................................................................................................... 210Cerebral Infarction and Ruptured Aneurysm Sequela ............................................................................... 253Cerebral Infarction, Acute, and History with Residual Conditions .......................................................... 254Cerebral Infarction, History ............................................................................................................................... 255Cerebrovascular Accident (CVA), Postprocedural ....................................................................................... 248Chronic Obstructive Asthma Exacerbation ................................................................................................... 278Chronic Renal Impairment ................................................................................................................................ 344CKD Following Kidney Transplant ................................................................................................................... 346CKD, Stage 4 with ESRD ..................................................................................................................................... 344CKD, Stage 5 ......................................................................................................................................................... 344Compartment Syndrome, Nontraumatic ...................................................................................................... 325Congenital Auditory Stricture .......................................................................................................................... 457Congenital Cleft Palate and Lip ....................................................................................................................... 459Congenital Condition, Marfan’s Syndrome ................................................................................................... 461Congenital Condition, Noonan Syndrome .................................................................................................... 460Congenital Cytomegalovirus ............................................................................................................................ 429Congenital Hypothyroidism and Down Syndrome .................................................................................... 463Congenital Mycoplasma Pneumonia ............................................................................................................. 430Congenital Patent Foramen Ovale or Atrial Septal Defect ........................................................................ 458Congenital Rieger’s Anomaly ........................................................................................................................... 456Congenital Spina Bifida ...................................................................................................................................... 455Congenital Testicular Torsion and Cryptorchism ........................................................................................ 460Congenital Zika Infection in 6-Month-Old .......................................................................................................72Contact-Induced Edema .................................................................................................................................... 208COPD and Emphysema ...................................................................................................................................... 279

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Figures

Figure 1.1. Encounter for Review of HIV Test Results ....................................................................................38Figure 1.2. Sepsis Coding Decision Tree ...........................................................................................................55Figure 1.3. Development of Sepsis from Noninfectious Process ................................................................63Figure 2.1. Colon .....................................................................................................................................................77Figure 2.2. Pancreas ...............................................................................................................................................80Figure 2.3. Female Breast .....................................................................................................................................84Figure 2.4. Neoplasm Principal Diagnosis Flow Chart ..................................................................................96Figure 2.5. Pleural Effusion ................................................................................................................................ 101Figure 2.6. Lung Lobes ....................................................................................................................................... 105Figure 4.1. Endocrine System ........................................................................................................................... 129Figure 4.2. Hierarchy of Oral Hypoglycemic and Insulin Use .................................................................... 139Figure 4.3. Excerpt from Table of Drugs and Chemicals—Insulin .......................................................... 142Figure 4.4. Excerpt from Table of Drugs and Chemicals—Beta Blocker ................................................ 146Figure 4.5. Thyroid .............................................................................................................................................. 149Figure 5.1. Progression of Severity .................................................................................................................. 162Figure 6.1. Sagittal Plane ................................................................................................................................... 174Figure 7.1. Anatomy of the Eye ........................................................................................................................ 196Figure 7.2. Glaucoma—Open and Closed Angle ........................................................................................ 197Figure 7.3. Blindness/Low Vision Decision Tree .......................................................................................... 206Figure 7.4. Cataracts ........................................................................................................................................... 209Figure 9.1. Arterial System ................................................................................................................................ 218Figure 9.2. Venous System ................................................................................................................................ 219Figure 9.3. Atherosclerosis ................................................................................................................................ 243Figure 9.4. Coronary Arteries ............................................................................................................................ 258Figure 9.5. STEMI or NSTEMI ............................................................................................................................. 259Figure 9.6. Anatomy of Heart ........................................................................................................................... 270Figure 10.1. Respiratory System ...................................................................................................................... 273Figure 12.1. Skin and Subcutaneous Tissue .................................................................................................. 293Figure 12.2. Pressure Ulcer Stages .................................................................................................................. 296Figure 13.1. Skeletal System ............................................................................................................................. 316Figure 13.2. Displacement Intervertebral Disc ............................................................................................. 335Figure 14.1. Anatomy of Urinary System ....................................................................................................... 339Figure 14.2. Male Genitourinary System ....................................................................................................... 340Figure 14.3. Female Internal Genitalia ........................................................................................................... 340Figure 14.4. Female Genitourinary Tract Lateral View ............................................................................... 341Figure 14.5. Female Breast ................................................................................................................................ 341Figure 15.1. Term Pregnancy—Single Gestation ........................................................................................ 355Figure 15.2. Placenta Previa .............................................................................................................................. 364Figure 15.3. Twin Gestation—Monochorionic/Diamniotic (MO-DI) ...................................................... 367Figure 15.4. Fetal Malposition .......................................................................................................................... 373Figure 15.5. Twin Gestation—Dichorionic/Diamniotic (DI-DI) ................................................................ 377Figure 15.6. Twin Gestation—Monochorionic/Monoamniotic (MO-MO) ............................................. 382Figure 15.7. Hierarchy of Gestational Diabetes Control ............................................................................ 396Figure 15.8. Retained Products of Conception Following an Abortion ................................................ 418Figure 16.1. Maternal Versus Newborn Codes ............................................................................................. 422Figure 16.2. Newborn Suspected Diseases and Conditions Ruled Out .................................................. 437Figure 16.3. Vacuum Assisted Birth ................................................................................................................ 441Figure 17.1. Spinal Bifida ................................................................................................................................... 455Figure 17.2. External Auditory Canal .............................................................................................................. 456Figure 17.3. Atrial Septal Defect ...................................................................................................................... 457Figure 17.4. Congenital Cleft Lip ..................................................................................................................... 458Figure 17.5. Congenital Cleft Palate ............................................................................................................... 459

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Introduction

ICD-10 Essentials: Applying ICD-10-CM Guidelines is a new coding reference for ICD-10-CM focusing on how to apply the coding guidelines. This book provides a comprehensive look at ICD-10-CM guidelines along with supporting examples, case studies, and in-depth coding rationales designed to ensure accurate application of the guideline in real-life coding situations. New and veteran coding professionals will find this book to be a valuable resource that explains and clarifies key coding concepts related to ICD-10-CM.

The coding guidance found in ICD-10 Essentials: Applying ICD-10-CM Guidelines is based on the official version of the ICD-10-CM Official Guidelines for Coding and Reporting (ICD-10-CM), effective October 1, 2019.

Changes reflecting the dynamic world of coding are ongoing, and Optum360 would welcome readers’ input on what should be included in future editions of the book.

How to Use ICD-10 Essentials: Applying ICD-10-CM Guidelines

The organization of ICD-10 Essentials: Applying ICD-10-CM Guidelines follows the format of ICD-10-CM Official Guidelines for Coding and Reporting. There is a chapter devoted to each of the topics covered in the guidelines, as follows:

• Certain infectious and parasitic diseases

• Neoplasms

• Endocrine, nutritional, and metabolic diseases

• Mental, behavioral, and neurodevelopmental disorders

• Diseases of the nervous system

• Diseases of the eye and adnexa

• Diseases of the circulatory system

• Diseases of the respiratory system

• Diseases of the skin and subcutaneous tissue

• Diseases of the musculoskeletal system and connective tissue

• Diseases of the genitourinary system

• Pregnancy, childbirth, and the puerperium

• Certain conditions originating in the perinatal period

• Congenital malformations, deformations, and chromosomal abnormalities

• Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified

Additionally, placeholders for the following chapters are included for future development:

• Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

• Diseases of the ear and mastoid process

• Diseases of the digestive system

• Injury, poisoning, and certain other consequences of external causes

• External causes of morbidity

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Introduction ICD-10 Essentials: Applying ICD-10-CM Guidelines

• Factors influencing health status and contact with health services

Shaded boxes in different colors allow the user to quickly differentiate the various components of each chapter. Blue boxes enclose the focus guideline in each section. Spotlights in yellow boxes alert the user to key facts, important information, and coding advice, while pink boxes highlight definitions.

Valuable information has been provided in case studies, tables, and figures that include illustrations and decision trees, all of which are listed in the front of the book and are easily searchable. Located in the back of the book are Official ICD-10-CM resources to supplement the material contained in the chapters, as well as an alphabetical index to search pertinent information.

ICD-10-CM GuidelineAs an ICD-10-CM guideline is examined, the full, official text is presented in a blue box followed by an overview of the guideline, helpful illustrations, as well as practical applications of the guideline.

Example:

Guideline I.C.13.d.1—Osteoporosis without pathological fracture

IllustrationsIllustrations are included to provide visual support to text.

Example:The primary endocrine organs represented by the codes in chapter 4 of the ICD-10-CM official code set are depicted in the illustration on the following page and include:

• Adrenal gland

• Ovaries

• Pancreas

• Parathyroid gland

• Pineal gland

• Pituitary gland

• Testes

Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.

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ICD-10 Essentials: Applying ICD-10-CM Guidelines Introduction

Figure 4.1. Endocrine System

AHA Coding ClinicOfficial citations from AHA’s Coding Clinic for ICD-10-CM have been provided for conventions and guidelines, as applicable. The citations appear in red type with the year, quarter, and page of the reference, as well as the title of the question as it appears in that AHA Coding Clinic table of contents. AHA Coding Clinic citations included in this edition have been updated through the second quarter of 2018.

Example: AHA Coding Clinic2016, 4Q, 50 Gestational Diabetes Mellitus2016, 1Q, 3 Selection of Principal Diagnosis for Vaginal Delivery2015, 4Q, 34 Gestational Diabetes and Oral Medication

Pineal gland

Hypothalamus

Parathyroid gland

Adrenal gland

Testicle

Ovaries

Pituitary gland

Thyroid

Pancreas

Thymus gland

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Official Coding and Reporting Guidelines: Section I.B. General Coding Guidelines

B. General Coding Guidelines 1. Locating a code in the ICD-10-CM

To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.

It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.

2. Level of Detail in Coding

Diagnosis codes are to be used and reported at their highest number of characters available.

ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail.

A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.

3. Code or codes from A00.0 through T88.9, Z00-Z99.8

The appropriate code or codes from A00.0 through T88.9, Z00-Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit.

4. Signs and symptoms

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for symptoms.

See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

5. Conditions that are an integral part of a disease process

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

6. Conditions that are not an integral part of a disease process

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

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ICD-10 Essentials: Determining the Diagnosis Official Coding and Reporting Guidelines: Section I.B.

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.

See Section I.C.9. Sequelae of cerebrovascular disease

See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium

See Section I.C.19. Application of 7th characters for Chapter 19

11. Impending or Threatened Condition

Code any condition described at the time of discharge as “impending” or “threatened” as follows:

If it did occur, code as confirmed diagnosis.

If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for “impending” or “threatened” and also reference main term entries for “Impending” and for “Threatened.”

If the subterms are listed, assign the given code.

If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.

12. Reporting Same Diagnosis Code More than Once

Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code.

13. Laterality

Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

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.

14. Documentation by Clinicians Other than the Patient's Provider

Code assignment is based on the documentation by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis). There are a few exceptions, such as codes for the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer)

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Chapter 1: Certain Infectious and Parasitic Diseases (A00–B99)

This chapter covers diseases caused by infectious and parasitic organisms, which include diseases generally recognized as communicable or transmissible. Only a small percentage of organisms in the environment cause disease. Most bacteria, viruses, fungi, and other microorganisms found in the external environment (e.g., air, water, and soil) or the internal environment (e.g., on or within our bodies) are harmless or even beneficial. Disease is caused almost exclusively by microorganisms that are human pathogens, also referred to as pathogenic microorganisms, except in persons or hosts whose weakened immune systems allow normally harmless microorganisms to cause opportunistic infections.

This chapter is organized primarily by the type of infectious organism or parasite, such as infections caused by bacteria, viruses, and mycoses, and parasitic diseases caused by protozoa and helminthes. Some code blocks are organized by site of infection, such as intestinal infectious diseases, and other code blocks are organized by mode of transmission, such as infections with a predominantly sexual mode of transmission, arthropod-borne viral fevers, and viral hemorrhagic fevers.

Chapter 1 of the ICD-10-CM official code set is broken down into the following code blocks:

A00–A09 Intestinal infection diseases

A15–A19 Tuberculosis

A20–A28 Certain zoonotic bacterial diseases

A30–A39 Other bacterial diseases

A50–A64 Infections with a predominantly sexual mode of transmission

A65–A69 Other spirochetal diseases

A70–A74 Other diseases caused by chlamydiae

A75–A79 Rickettsioses

A80–A89 Viral and prion infections of the central nervous system

A90–A99 Arthropod–borne viral fevers and viral hemorrhagic fevers

B00–B09 Viral infections characterized by skin and mucous membrane lesions

B10 Other human herpesviruses

B15–B19 Viral hepatitis

B20 Human immunodeficiency virus [HIV] disease

B25–B34 Other viral diseases

B35–B49 Mycoses

B50–B64 Protozoal diseases

B65–B83 Helminthiases

B85–B89 Pediculosis, acariasis and other infestations

B90–B94 Sequelae of infectious and parasitic diseases

B95–B97 Bacterial and viral infectious agents

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Chapter 2: Neoplasms (C00–D49)

Neoplasms are abnormal tissue growths resulting from rapid division of cells. They can be either solid or fluid-filled and are classified primarily by site, with subclassifications for morphology or behavior such as malignant, benign, in situ, uncertain behavior, and unspecified. The neoplasm table should be used to identify the correct site (topography) code. In some cases, such as malignant melanoma and certain neuroendocrine tumors, the morphology is included in the category and codes. The tabular section should always be consulted for the specific code.

In addition to classifications for solid tissue malignant neoplasms, there are additional classifications for histological types of cancers such as of lymphoid, hematopoietic, malignant, and benign neuroendocrine tumors; and some specific types of skin cancers, such as melanoma, basal cell carcinoma, and squamous cell carcinoma.

All neoplasms are classified to this chapter, whether or not they are functionally active. A functionally active neoplasm is a growth that performs functions ascribed to surrounding tissue, as in a thyroid tumor that secretes thyroxine and causes hyperthyroidism in the patient. An additional code from chapter 4, “Endocrine, Nutritional and Metabolic Diseases,” may be used to identify functional activity associated with any neoplasm.

Chapter 2 of the ICD-10-CM official code set is broken down into the following code blocks:

C00–C14 Malignant neoplasms of lip, oral cavity and pharynx

C15–C26 Malignant neoplasms of digestive organs

C30–C39 Malignant neoplasms of respiratory and intrathoracic organs

C40–C41 Malignant neoplasms of bone and articular cartilage

C43–C44 Melanoma and other malignant neoplasms of skin

C45–C49 Malignant neoplasms of mesothelial and soft tissue

C50 Malignant neoplasms of breast

C51–C58 Malignant neoplasms of female genital organs

C60–C63 Malignant neoplasms of male genital organs

C64–C68 Malignant neoplasms of urinary tract

C69–C72 Malignant neoplasms of eye, brain and other parts of central nervous system

C73–C75 Malignant neoplasms of thyroid and other endocrine glands

C7A Malignant neuroendocrine tumors

C7B Secondary neuroendocrine tumors

C76–C80 Malignant neoplasms of ill–defined, other secondary and unspecified sites

Definitions

histological. Referring to the microscopic tissues, which consist of four basic types:

• Epithelial (epi, upon or over) is found throughout the body and makes up the covering ofexternal and internal surfaces.

• Connective tissue is the most widespread in the human body. It forms bones, cartilage, tendons, and ligaments and performs the duties of protection, support and binding together. Blood is also included here as it is found in connective tissue.

• Muscle which produces movement and includes either striated or smooth • Nerves which receive stimuli and conduct impulses and includes both central and peripheral

tissues.morphology. Study of cells to determine tissue of origin combining histology and behavior development of the neoplasm such as malignant, benign, uncertain, in situ. Morphology also considers the grade or stage which is not currently specified in ICD-10-CM.

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Chapter 2: Neoplasms (C00–D49) ICD-10 Essentials: Applying ICD-10-CM Guidelines

C81–C96 Malignant neoplasms of lymphoid, hematopoietic and related tissue

D00–D09 In situ neoplasms

D10–D36 Benign neoplasms, except benign neuroendocrine tumors

D3A Benign neuroendocrine tumors

D37–D48 Neoplasms of uncertain behavior, polycythemia vera and myelodysplastic syndromes

D49 Neoplasms of unspecified behavior

The guidelines for this chapter address coding and sequencing of neoplasms, complications associated with neoplasms, and complications with therapy for the neoplasms. Users must take into account the morphology (histologic type) of neoplasms and any associated manifestations or complications when assigning codes.

Guidelines for chapter 2 cover the following conditions:

• General guidelines

• Treatment directed at the malignancy (I.C.2.a)

• Treatment of secondary site (I.C.2.b)

• Coding and sequencing of complications (I.C.2.c)

• Primary malignancy previously excised (I.C.2.d)

• Admissions/encounters involving chemotherapy, immunotherapy, and radiation therapy (I.C.2.e)

• Admission/encounter to determine extent of malignancy (I.C.2.f )

• Symptoms, signs, and abnormal findings listed in chapter 18 associated with neoplasms (I.C.2.g)

• Admission/encounter for pain control/management (I.C.2.h)

• Malignancy in two or more noncontiguous sites (I.C.2.i)

• Disseminated malignant neoplasm, unspecified (I.C.2.j)

• Malignant neoplasm without specification of site (I.C.2.k)

• Sequencing of neoplasm codes (I.C.2.l)

• Current malignancy versus personal history of malignancy (I.C.2.m)

• Leukemia, multiple myeloma, and malignant plasma cell neoplasms in remission versus personal history (I.C.2.n)

• Aftercare following surgery for neoplasm (I.C.2.o)

• Follow-up care for completed treatment of a malignancy (I.C.2.p)

• Prophylactic organ removal for prevention of malignancy (I.C.2.q)

• Malignant neoplasm associated with transplanted organ (I.C.2.r)Sample page