Copyright © 2014 AAPC
Rhonda Buckholtz, CPC, CPCI, CPMA, CRC, CDEO, CHPSE…..
ICD-10-CM 2017 Coding Updates
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the expressed written permission of AAPC.
2
Agenda
3
• Guideline Changes
• Coding changes by chapter• Neoplasms
• Gastrointestinal stromal tumors
• Castleman Disease
• Endocrine
• Mental and Behavioral
• Pain
• Eye
• Ear and Mastoid
• Cardiovascular
• Musculoskeletal
• Genitourinary
• Obstetrics
• Revisions
• Newborns
• Congenital
• Signs and Symptoms
• Additions
• Injuries
• Additions
• Deletions
• External Causes
• Routine and Administrative
• Conclusion
• Skyrocketing denials
• Volume of codes
• MIPS and MACRA
• Code changes
• Documentation concepts
Overview
4
• The word “with” should be interpreted to mean “associated with” or “due to”
when it appears in a code title, the Alphabetic Index, or an instructional note
in the Tabular List. The classification presumes a causal relationship
between the two conditions linked by these terms in the Alphabetic Index or
Tabular List. These conditions should be coded as related even in the
absence of provider documentation explicitly linking them, unless the
documentation clearly states the conditions are unrelated. For conditions
not specifically linked by these relational terms in the classification, provider
documentation must link the conditions in order to code them as related.
• The word “with” in the Alphabetic Index is sequenced immediately following
the main term, not in alphabetical order.
With
6
• The assignment of a diagnosis code is based on the provider’s diagnostic
statement that the condition exists. The provider’s statement that the patient
has a particular condition is sufficient. Code assignment is not based on
clinical criteria used by the provider to establish the diagnosis.
Code assignment and Clinical Criteria
7
• A sequela is the residual effect (condition produced) after the acute phase of
an illness or injury has terminated. There is no time limit on when a sequela
code can be used. The residual may be apparent early, such as in cerebral
infarction, or it may occur months or years later, such as that due to a
previous injury. Examples of sequela include: scar formation resulting from a
burn, deviated septum due to a nasal fracture, and infertility due to tubal
occlusion from old tuberculosis. Coding of sequela generally requires two
codes sequenced in the following order: the condition or nature of the
sequela is sequenced first. The sequela code is sequenced second. An
exception to the above guidelines are those instances where the code for
the sequela is followed by a manifestation code identified in the Tabular List
and title, or the sequela code has been expanded (at the fourth, fifth or sixth
character levels) to include the manifestation(s). The code for the acute
phase of an illness or injury that led to the sequela is never used with a
code for the late effect.
Sequela (Late Effects)
8
• Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs
on the left, right or is bilateral. If no bilateral code is provided and the condition is
bilateral, assign separate codes for both the left and right side. If the side is not
identified in the medical record, assign the code for the unspecified side. When a
patient has a bilateral condition and each side is treated during separate
encounters, assign the "bilateral" code (as the condition still exists on both
sides), including for the encounter to treat the first side. For the second
encounter for treatment after one side has previously been treated and the
condition no longer exists on that side, assign the appropriate unilateral
code for the side where the condition still exists (e.g., cataract surgery
performed on each eye in separate encounters). The bilateral code would not
be assigned for the subsequent encounter, as the patient no longer has the
condition in the previously-treated site. If the treatment on the first side did
not completely resolve the condition, then the bilateral code would still be
appropriate.
Laterality
9
Chapter 2 Neoplasms
11
New CodesC49.A0 Gastrointestinal stromal tumor, unspecified site
C49.A1 Gastrointestinal stromal tumor of esophagus
C49.A2 Gastrointestinal stromal tumor of stomach
C49.A3 Gastrointestinal stromal tumor of small intestine
C49.A4 Gastrointestinal stromal tumor of large intestine
C49.A5 Gastrointestinal stromal tumor of rectum
C49.A9 Gastrointestinal stromal tumor of other sites
D47.Z2 Castleman disease
D49.511 Neoplasm of unspecified behavior of right kidney
D49.512 Neoplasm of unspecified behavior of left kidney
D49.519 Neoplasm of unspecified behavior of unspecified kidney
D49.59 Neoplasm unspecified behavior of other genitourinary organ
A 57 year-old female presented with vague upper abdominal pain intermittently for two years. There were no other associated general or GI tract symptoms. Examination of the abdomen revealed a well-defined transversely mobile intra-abdominal lump in the right hypochondrium of about 8 × 6 cm. The abdomen was explored electively and a 10 × 6 cm tumor was seen arising from the greater curve of the stomach, exophytically, with a sessile base. There was no infiltration of the mass into the surrounding structures, nor any evidence of metastases or lymphadenopathy. The tumor was excised with a 2 cm sleeve of the greater curve of the stomach and the latter repaired classically. The findings favored the diagnosis of epithelioid gastrointestinal stromal tumor.
C49.A2 Gastrointestinal stromal tumor of stomach
Documentation concepts include:
Type
Anatomical location
Case Example
13
It is often associated with HIV and HHV-8 and results in systemic symptoms such as:
Serious infections
Fevers
Weight loss
Fatigue
Night sweats
Nerve damage
Anemia
Hypergammaglobulinemia
Castleman disease
14
A 82-year-old man was seen for a 3 month history of lethargy, decreased appetite and marked weight loss. He had no significant past medical history, but family history showed a brother who had died of lymphoma. Exam revealed mild bilateral cervical and axillary lymphadenopathy with no palpable organomegaly. Labs and testing, including full blood count and biochemical profile as well as hepatic function tests, were within normal range except for raised globulins (55 g/L) with a polyclonal increase in gamma-globulins. Myeloma was excluded due to the fact that protein electrophoresis detected no monoclonal band.
CT showed extensive lymphadenopathy involving the neck, axillae, chest/mediastinum, abdomen and pelvis with mild to moderate splenomegaly. Bone marrow aspiration and trephine biopsy showed small lymphoid follicular aggregates. Excision biopsy of an axillary node was performed and this was showed an increased number of follicles containing amorphous hyaline material and some small blood vessels between simple reactive changes and frank lymphoma, indicative of Castleman's disease.
D47.Z2 Castleman disease
Documentation concepts include:
Type
Case Example
15
Chapter 2 Neoplasms
16
Revisions/Deleted
C81.39
Lymphocyte depleted classical Hodgkin
lymphoma, extranodal and solid organ
sites
C81.39Lymphocyte depleted Hodgkin lymphoma,
extranodal and solid organ sites
C81.40 Lymphocyte-rich classical Hodgkin lymphoma, unspecified site
C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site
C81.70 Other classical Hodgkin lymphoma, unspecified site
C81.70 Other Hodgkin lymphoma, unspecified site
D49.5 Deleted
Neoplasm of unspecified behavior of other
genitourinary organs
Endocrine
18
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3319
Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
19
E08.3211 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, right eye
E08.3212 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, left eye
E08.3213 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3219 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3291 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, right eye
E08.3292 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, left eye
E08.3293 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3299 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3311 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E08.3312 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E08.3313 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3319 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
20
E08.3391 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E08.3392 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E08.3393 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3399 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3411 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, right eye
E08.3412 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, left eye
E08.3413 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E08.3419 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E08.3491 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, right eye
E08.3492 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, left eye
E08.3493 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E08.3499 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E08.3511 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, right eye
E08.3512 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, left eye
E08.3513 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, bilateral
E08.3519 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema, unspecified eye
E08.3521 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E08.3522 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E08.3523 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E08.3529Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
21
E08.3531Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E08.3532Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E08.3533Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E08.3539Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E08.3541Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E08.3542Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E08.3543Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E08.3549Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E08.3551 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, right eye
E08.3552 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, left eye
E08.3553 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, bilateral
E08.3559 Diabetes mellitus due to underlying condition with stable proliferative diabetic retinopathy, unspecified eye
E08.3591 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, right eye
E08.3592 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, left eye
E08.3593 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, bilateral
E08.3599 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema, unspecified eye
E08.37X1 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, right eye
22
E08.37X2 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, left eye
E08.37X3 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, bilateral
E08.37X9 Diabetes mellitus due to underlying condition with diabetic macular edema, resolved following treatment, unspecified eye
E09.3211 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E09.3212 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E09.3213 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3219 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3291 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E09.3292 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E09.3293 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3299 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3311 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E09.3312 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E09.3313 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3319Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3391 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E09.3392 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E09.3393 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3399Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3411 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E09.3412 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
23
E09.3413 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E09.3419 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E09.3491 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E09.3492 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E09.3493 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E09.3499 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E09.3511 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E09.3512 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E09.3513 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E09.3519 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E09.3521 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E09.3522 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E09.3523 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E09.3529 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E09.3531 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E09.3532 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E09.3533 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E09.3539Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
24
E09.3541Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E09.3542Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, left eye
E09.3543Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, bilateral
E09.3549Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment andrhegmatogenous retinal detachment, unspecified eye
E09.3551 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E09.3552 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E09.3553 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E09.3559 Drug or chemical induced diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E09.3591 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E09.3592 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E09.3593 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E09.3599 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E09.37X1 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E09.37X2 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E09.37X3 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E09.37X9 Drug or chemical induced diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
25
E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3311 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E10.3312 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E10.3313 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3391 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E10.3392 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E10.3393 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E10.3411 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E10.3412 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E10.3413 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3491 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E10.3492 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E10.3493 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
26
E10.3511 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E10.3512 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E10.3513 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E10.3521 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E10.3522 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E10.3523 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E10.3531 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E10.3532 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E10.3533 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E10.3541Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E10.3542Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E10.3543
Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment,
bilateral
E10.3549Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E10.3551 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E10.3552 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E10.3553 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
27
E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E10.3591 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E10.3592 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E10.3593 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E10.37X1 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E10.37X2 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E10.37X3 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E10.37X9 Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3311 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E11.3312 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E11.3313 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
28
E11.3391 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E11.3392 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E11.3393 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3411 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E11.3412 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E11.3413 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E11.3491 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
E11.3492 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E11.3493 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E11.3511 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E11.3512 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E11.3513 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E11.3521 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E11.3522 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E11.3523 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E11.3531 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
29
E11.3532Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, lefteye
E11.3533 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E11.3541Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E11.3542Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E11.3543Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E11.3549Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
E11.3551 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E11.3552 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E11.3553 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E11.3591 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E11.3592 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E11.3593 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E11.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E11.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E11.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E11.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
30
E13.3211 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E13.3212 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E13.3213 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3291 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E13.3292 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E13.3293 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3311 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye
E13.3312 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye
E13.3313 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3391 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye
E13.3392 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye
E13.3393 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3411 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye
E13.3412 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye
E13.3413 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral
E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eye
E13.3491 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye
31
E13.3492 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye
E13.3493 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral
E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eye
E13.3511 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye
E13.3512 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye
E13.3513 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral
E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye
E13.3521 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye
E13.3522 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye
E13.3523 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral
E13.3529Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E13.3531 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye
E13.3532 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye
E13.3533 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral
E13.3539Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eye
E13.3541Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
E13.3542Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye
E13.3543Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral
E13.3549Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eye
32
E13.3551 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, right eye
E13.3552 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, left eye
E13.3553 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, bilateral
E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eye
E13.3591 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye
E13.3592 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye
E13.3593 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral
E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye
E13.37X1 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye
E13.37X2 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye
E13.37X3 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral
E13.37X9 Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eye
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
E89.820 Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure
Endocrine
33
New Combination Codes
E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eye
E11.3541
Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye
Retinal Detachment
35
Signs and Symptoms
Sudden vision loss without pain
Loss of vision in a visual field
Flashes and floaters
Documentation Concepts
Type
Caused by/due to
Complications/manifestations
Laterality
Body system/area affected
Retinopathy
36
Revisions
E89.810 Revise fromPostprocedural hemorrhage and hematoma of an endocrine system organ or structure following an endocrine system procedure
E89.811 Revise from Postprocedural hemorrhage and hematoma of an endocrine system organ or structure following other procedure
E89.810 Revise to Postprocedural hemorrhage of an endocrine system organ or structure following an endocrine system procedure
E89.811 Revise to Postprocedural hemorrhage of an endocrine system organ or structure following other procedure
E89.820 Add Postprocedural hematoma of an endocrine system organ or structure following an endocrine system procedure
E89.821 Add Postprocedural hematoma of an endocrine system organ or structure following other procedure
E78.00 Pure hypercholesterolemia, unspecified
E78.01 Familial hypercholesterolemia
Other additions include:
Mental and Behavioral
37
F32.81 Add Premenstrual dysphoric disorder
F32.89 Add Other specified depressive episodes
F34.81 Add Disruptive mood dysregulation disorder
F34.89 Add Other specified persistent mood disorders
F42.2 Add Mixed obsessional thoughts and acts
F42.3 Add Hoarding disorder
F42.4 Add Excoriation (skin-picking) disorder
F42.8 Add Other obsessive compulsive disorder
F42.9 Add Obsessive-compulsive disorder, unspecified
F50.81 Add Binge eating disorder
F50.89 Add Other specified eating disorder
F64.0 Add Transsexualism
F80.82 Add Social pragmatic communication disorder
F32.8 Delete Other depressive episodes
F34.8 Delete Other persistent mood [affective] disorders
F42 Delete Obsessive-compulsive disorder
F50.8 Delete Other eating disorders
F64.1 Revise from Gender identity disorder in adolescence and adulthood
F64.1 Revise to Dual role transvestism
Case Example
39
Hoarding Disorder
Patient is a 60-year-old female who lives alone. She describes her current hoarding behavior as just difficulty throwing things away. Her difficulties have resulted in a clutter-filled home. As a result, she has been in complete social isolation due to embarrassment of other seeing her home like this. She is urged by her daughter to seek help. Her problem with hoarding began in childhood, where she used to hide things under her bed so her mom wouldn’t throw them away. She remembers being fearful and anxious as a child. Her severe hoarding began when she moved into a new home 16 years ago and has progressively gotten worse. She also described having mild symptoms of depression, such as crying spells and painful emotions. She feels like a failure due to her hoarding. She denies other symptoms of OCD. She agrees to participate in an intensive treatment program for her hoarding disorder.
F42.3 Hoarding Disorder
Documentation concepts:
Type
Complications/manifestations
Disruptive Mood Dysregulation Disorder
40
Signs and symptoms:
Severe temper outbursts
occurring at least three times a
week
Sad, irritable or angry mood
almost every day
Bigger reactions than expected
At least six years of age with
symptoms beginning before the
age of 10
Symptoms are present for at
least a year
Difficulty functioning in more than
one place
Documentation
concepts for coding: Type
For templating
considerations:
Frequency of symptoms
Associated
complications/manifestations
Severity of symptoms
Mental and Behavioral
41
Binge Eating Disorder
Signs and symptoms of BED include:
Recurrent episodes of binge eating
Sense of lack of control over eating
Eating more- rapidly
Eating until feeling uncomfortably full
Eating large amounts when not hungry
Eating alone because of feeling embarrassed by how much they eat
Feeling disgusted, depressed or very guilty after
Occurs on average ate least once a week for 3 months
Not associated with purging, bulimia nervosa
Pain
43
Additions
G56.03 Add Carpal tunnel syndrome, bilateral upper limbs
G56.13 Add Other lesions of median nerve, bilateral upper limbs
G56.23 Add Lesion of ulnar nerve, bilateral upper limbs
G56.33 Add Lesion of radial nerve, bilateral upper limbs
G56.43 Add Causalgia of bilateral upper limbs
G56.83 Add Other specified mononeuropathies of bilateral upper limbs
G56.93 Add Unspecified mononeuropathy of bilateral upper limbs
G57.03 Add Lesion of sciatic nerve, bilateral lower limbs
G57.13 Add Meralgia paresthetica, bilateral lower limbs
G57.23 Add Lesion of femoral nerve, bilateral lower limbs
G57.33 Add Lesion of lateral popliteal nerve, bilateral lower limbs
G57.43 Add Lesion of medial popliteal nerve, bilateral lower limbs
G57.53 Add Tarsal tunnel syndrome, bilateral lower limbs
G57.63 Add Lesion of plantar nerve, bilateral lower limbs
G57.73 Add Causalgia of bilateral lower limbs
G57.83 Add Other specified mononeuropathies of bilateral lower limbs
G57.93 Add Unspecified mononeuropathy of bilateral lower limbs
G61.82 Add Multifocal motor neuropathy
G97.61 Add Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure
G97.62 Add Postprocedural hematoma of a nervous system organ or structure following other procedure
Pain
44
Revisions
G97.51 Revise fromPostprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure
G97.52 Revise fromPostprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure
G97.51 Revise toPostprocedural hemorrhage of a nervous system organ or structure following a nervous system procedure
G97.52 Revise toPostprocedural hemorrhage of a nervous system organ or structure following other procedure
Retinal Vein Occlusion
Blockage of small veins that carry blood away from the retina
Most often caused by hardening of the arteries
Risk factors include:
Atherosclerosis
Hypertension
Glaucoma, macular edema, vitreous hemorrhage
H34.8110 Centralretinalveinocclusion,righteye,withmacularedema
H34.8111 Centralretinalveinocclusion,righteye,withretinalneovascularization
H34.8112 Centralretinalveinocclusion,righteye,stable
H34.8120 Centralretinalveinocclusion,lefteye,withmacularedema
H34.8121 Centralretinalveinocclusion,lefteye,withretinalneovascularization
H34.8122 Centralretinalveinocclusion,lefteye,stable
H34.8130 Centralretinalveinocclusion,bilateral,withmacularedema
H34.8131 Centralretinalveinocclusion,bilateral,withretinalneovascularization
H34.8132 Centralretinalveinocclusion,bilateral,stable
H34.8190 Centralretinalveinocclusion,unspecifiedeye,withmacularedema
H34.8191 Centralretinalveinocclusion,unspecifiedeye,withretinalneovascularization
H34.8192 Centralretinalveinocclusion,unspecifiedeye,stable
H34.8310 Tributary(branch)retinalveinocclusion,righteye,withmacularedema
H34.8311 Tributary(branch)retinalveinocclusion,righteye,withretinalneovascularization
H34.8312 Tributary(branch)retinalveinocclusion,righteye,stable
H34.8320 Tributary(branch)retinalveinocclusion,lefteye,withmacularedema
H34.8321 Tributary(branch)retinalveinocclusion,lefteye,withretinalneovascularization
H34.8322 Tributary(branch)retinalveinocclusion,lefteye,stable
H34.8330 Tributary(branch)retinalveinocclusion,bilateral,withmacularedema
H34.8331 Tributary(branch)retinalveinocclusion,bilateral,withretinalneovascularization
H34.8332 Tributary(branch)retinalveinocclusion,bilateral,stable
H34.8390 Tributary(branch)retinalveinocclusion,unspecifiedeye,withmacularedema
H34.8391 Tributary(branch)retinalveinocclusion,unspecifiedeye,withretinalneovascularization
H34.8392 Tributary(branch)retinalveinocclusion,unspecifiedeye,stable
Age Related Macular Degeneration
Leading cause of vision loss in patients over age of 50
Stages
Early
Late
Neovascular (wet)
Geographic atrophy (dry)
Age Related Macular Degeneration H35.3110 Nonexudativeage-relatedmaculardegeneration,righteye,stageunspecified
H35.3111 Nonexudativeage-relatedmaculardegeneration,righteye,earlydrystage
H35.3112 Nonexudativeage-relatedmaculardegeneration,righteye,intermediatedrystage
H35.3113 Nonexudativeage-relatedmaculardegeneration,righteye,advancedatrophicwithoutsubfovealinvolvement
H35.3114 Nonexudativeage-relatedmaculardegeneration,righteye,advancedatrophicwithsubfovealinvolvement
H35.3120 Nonexudativeage-relatedmaculardegeneration,lefteye,stageunspecified
H35.3121 Nonexudativeage-relatedmaculardegeneration,lefteye,earlydrystage
H35.3122 Nonexudativeage-relatedmaculardegeneration,lefteye,intermediatedrystage
H35.3123 Nonexudativeage-relatedmaculardegeneration,lefteye,advancedatrophicwithoutsubfovealinvolvement
H35.3124 Nonexudativeage-relatedmaculardegeneration,lefteye,advancedatrophicwithsubfovealinvolvement
H35.3130 Nonexudativeage-relatedmaculardegeneration,bilateral,stageunspecified
H35.3131 Nonexudativeage-relatedmaculardegeneration,bilateral,earlydrystage
H35.3132 Nonexudativeage-relatedmaculardegeneration,bilateral,intermediatedrystage
H35.3133 Nonexudativeage-relatedmaculardegeneration,bilateral,advancedatrophicwithoutsubfovealinvolvement
H35.3134 Nonexudativeage-relatedmaculardegeneration,bilateral,advancedatrophicwithsubfovealinvolvement
H35.3190 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,stageunspecified
H35.3191 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,earlydrystage
H35.3192 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,intermediatedrystage
H35.3193 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,advancedatrophicwithoutsubfovealinvolvement
H35.3194 Nonexudativeage-relatedmaculardegeneration,unspecifiedeye,advancedatrophicwithsubfovealinvolvement
H35.3210 Exudativeage-relatedmaculardegeneration,righteye,stageunspecified
H35.3211 Exudativeage-relatedmaculardegeneration,righteye,withactivechoroidalneovascularization
H35.3212 Exudativeage-relatedmaculardegeneration,righteye,withinactivechoroidalneovascularization
H35.3213 Exudativeage-relatedmaculardegeneration,righteye,withinactivescar
H35.3220 Exudativeage-relatedmaculardegeneration,lefteye,stageunspecified
H35.3221 Exudativeage-relatedmaculardegeneration,lefteye,withactivechoroidalneovascularization
Other Additions, Revisions and
DeletionsPrimary Open Angle Glaucoma
Amblyopia suspect
Postprocedural hematoma and hemorrhage
Ear and Mastoid
52
H90.A11 Add Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A12 Add Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side
H90.A21 Add Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side
H90.A22 Add Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side
H90.A31 Add Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A32 Add Mixed conductive and sensorineural hearing, unilateral, left ear with restricted hearing on the contralateral side
H93.A1 Add Pulsatile tinnitus, right ear
H93.A2 Add Pulsatile tinnitus, left ear
H93.A3 Add Pulsatile tinnitus, bilateral
H93.A9 Add Pulsatile tinnitus, unspecified ear
H95.41 Revise from Postprocedural hemorrhage and hematoma of ear and mastoid process following a procedure on the ear and mastoid process
H95.41 Revise to Postprocedural hemorrhage of ear and mastoid process following a procedure on the ear and mastoid process
H95.42 Revise from Postprocedural hemorrhage and hematoma of ear and mastoid process following other procedure
H95.42 Revise to Postprocedural hemorrhage of ear and mastoid process following other procedure
H95.51 Add Postprocedural hematoma of ear and mastoid process following a procedure on the ear and mastoid process
H95.52 Add Postprocedural hematoma of ear and mastoid process following other procedure
Pulsatile Tinnitus
53
H93.A1 Pulsatile tinnitus, right ear
H93.A2 Pulsatile tinnitus, left ear
H93.A3 Pulsatile tinnitus, bilateral
H93.A9 Pulsatile tinnitus, unspecified ear Documentation concepts include: Type Laterality
H95.41Revise from
Postprocedural hemorrhage and hematoma of ear and mastoid process following a procedure on the ear and mastoid process
H95.41Revise to
Postprocedural hemorrhage of ear and mastoid process following a procedure on the ear and mastoid process
H95.42Revise from
Postprocedural hemorrhage and hematoma of ear and mastoid process following other procedure
H95.42Revise to
Postprocedural hemorrhage of ear and mastoid process following other procedure
H95.51 AddPostprocedural hematoma of ear and mastoid process following a procedure on the ear and mastoid process
H95.52 AddPostprocedural hematoma of ear and mastoid process following other procedure
Cardiovascular
55
Deleted
I60.20 Delete Nontraumatic subarachnoid hemorrhage from unspecified anterior communicating artery
I60.21 Delete Nontraumatic subarachnoid hemorrhage from right anterior communicating artery
I60.22 Delete Nontraumatic subarachnoid hemorrhage from left anterior communicating artery
I69.01 Delete Cognitive deficits following nontraumatic subarachnoid hemorrhage
I69.11 Delete Cognitive deficits following nontraumatic intracerebral hemorrhage
I69.21 Delete Cognitive deficits following other nontraumatic intracranial hemorrhage
I69.31 Delete Cognitive deficits following cerebral infarction
I69.81 Delete Cognitive deficits following other cerebrovascular disease
I69.91 Delete Cognitive deficits following unspecified cerebrovascular disease
I97.62 Delete Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure
Cardiovascular
56
Hypertensive Urgency, Emergency and Crisis
Documentation for these conditions include:
Associated complications/signs/symptoms
Type
I16.0 Hypertensive urgency
I16.1 Hypertensive emergency
I16.9 Hypertensive crisis, unspecified
Cerebral Infarction
57
I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries
I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries
I63.133 Cerebral infarction due to embolism of bilateral carotid arteries
I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries
I63.323 Cerebral infarction due to thrombosis of bilateral anterior arteries
I63.333 Cerebral infarction to thrombosis of bilateral posterior arteries
I63.343 Cerebral infarction to thrombosis of bilateral cerebellar arteries
I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries
I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries
I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries
I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries
I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries
I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries
I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries
I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries
Documentation concepts include: Type Caused by/due to Laterality Anatomical location
Cardiovascular
58
Other Additions I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage
I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage
I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage
I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage
I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid hemorrhage
I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage
I69.018 Other symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage
I69.019 Unspecified symptoms and signs involving cognitive functions following nontraumatic subarachnoid hemorrhage
I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage
I69.111 Memory deficit following nontraumatic intracerebral hemorrhage
I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage
I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage
I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral hemorrhage
I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage
I69.118 Other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage
I69.119 Unspecified symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage
I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage
I69.211 Memory deficit following other nontraumatic intracranial hemorrhage
I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial hemorrhage
I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage
I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial hemorrhage
I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage
59
I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage
I69.219 Unspecified symptoms and signs involving cognitive functions following other nontraumatic intracranial hemorrhage
I69.310 Attention and concentration deficit following cerebral infarction
I69.311 Memory deficit following cerebral infarction
I69.312 Visuospatial deficit and spatial neglect following cerebral infarction
I69.313 Psychomotor deficit following cerebral infarction
I69.314 Frontal lobe and executive function deficit following cerebral infarction
I69.315 Cognitive social or emotional deficit following cerebral infarction
I69.318 Other symptoms and signs involving cognitive functions following cerebral infarction
I69.319 Unspecified symptoms and signs involving cognitive functions following cerebral infarction
I69.810 Attention and concentration deficit following other cerebrovascular disease
I69.811 Memory deficit following other cerebrovascular disease
I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease
I69.813 Psychomotor deficit following other cerebrovascular disease
I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease
I69.815 Cognitive social or emotional deficit following other cerebrovascular disease
I69.818 Other symptoms and signs involving cognitive functions following other cerebrovascular disease
I69.819 Unspecified symptoms and signs involving cognitive functions following other cerebrovascular disease
I69.910 Attention and concentration deficit following unspecified cerebrovascular disease
I69.911 Memory deficit following unspecified cerebrovascular disease
I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease
I69.913 Psychomotor deficit following unspecified cerebrovascular disease
I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease
I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease
I69.918 Other symptoms and signs involving cognitive functions following unspecified cerebrovascular disease
I69.919 Unspecified symptoms and signs involving cognitive functions following unspecified cerebrovascular disease
I72.5 Aneurysm of other precerebral arteries
Cardiovascular
60
I72.6 Aneurysm of vertebral artery
I77.70 Dissection of unspecified artery
I77.75 Dissection of other precerebral arteries
I77.76 Dissection of artery of upper extremity
I77.77 Dissection of artery of lower extremity
I97.620 Postprocedural hemorrhage of a circulatory system organ or structure following other procedure
I97.621 Postprocedural hematoma of a circulatory system organ or structure following other procedure
I97.630 Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization
I97.631 Postprocedural hematoma of a circulatory system organ or structure following cardiac bypass
I97.638 Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure
63
K05.211 Add Aggressive periodontitis, localized, slight
K05.212 Add Aggressive periodontitis, localized, moderate
K05.213 Add Aggressive periodontitis, localized, severe
K05.219 Add Aggressive periodontitis, localized, unspecified severity
K05.221 Add Aggressive periodontitis, generalized, slight
K05.222 Add Aggressive periodontitis, generalized, moderate
K05.223 Add Aggressive periodontitis, generalized, severe
K05.229 Add Aggressive periodontitis, generalized, unspecified severity
K05.311 Add Chronic periodontitis, localized, slight
K05.312 Add Chronic periodontitis, localized, moderate
K05.313 Add Chronic periodontitis, localized, severe
K05.319 Add Chronic periodontitis, localized, unspecified severity
K05.321 Add Chronic periodontitis, generalized, slight
K05.322 Add Chronic periodontitis, generalized, moderate
K05.323 Add Chronic periodontitis, generalized, severe
Necrotizing enterocolitis NEC
64
Symptoms include:
Abdominal bloating
Blood in the stool
Diarrhea
Feeding problems
Lack of energy
Unstable body temperature
Unstable breathing, heart rate, or blood pressure
Vomiting
Staging of NEC uses the Bell Stage
classification:
Stage 1
Suspected NEC
Mildest of symptoms
Stage 2
Proven NEC cases
Signs more indicative of NEC (other gastrointestinal disorders have been ruled out)
Abdominal distention is marked
Persistent occult or frank blood in stool may be present
Stage 3
Advanced NEC cases showing stage 1 and 2
Shows a deterioration of vital signs
Evidence of septic shock, marked gastrointestinal bleeding
Documentation concepts include:
Type
Stage
Necrotizing enterocolitis NEC
65
K55.30 Add Necrotizing enterocolitis, unspecified
K55.31 Add Stage 1 necrotizing enterocolitis
K55.32 Add Stage 2 necrotizing enterocolitis
K55.33 Add Stage 3 necrotizing enterocolitis
Necrotizing enterocolitis NEC
66
Other additions
K58.1 Add Irritable bowel syndrome with constipation
K58.2 Add Mixed irritable bowel syndrome
K58.8 Add Other irritable bowel syndrome
K59.03 Add Drug induced constipation
K59.04 Add Chronic idiopathic constipation
K59.31 Add Toxic megacolon
K59.39 Add Other megacolon
K85.00 Add Idiopathic acute pancreatitis without necrosis or infection
K85.01 Add Idiopathic acute pancreatitis with uninfected necrosis
K85.02 Add Idiopathic acute pancreatitis with infected necrosis
K85.10 Add Biliary acute pancreatitis without necrosis or infection
K85.11 Add Biliary acute pancreatitis with uninfected necrosis
Necrotizing enterocolitis NEC
67
Deletions include codes that were expanded with additions:
K04.0 Delete Pulpitis
K05.21 Delete Aggressive periodontitis, localized
K05.22 Delete Aggressive periodontitis, generalized
K05.31 Delete Chronic periodontitis, localized
K05.32 Delete Chronic periodontitis, generalized
K08.8 Delete Other specified disorders of teeth and supporting structures
K52.2 Delete Allergic and dietetic gastroenteritis and colitis
K55.0 Delete Acute vascular disorders of intestine
K59.3 Delete Megacolon, not elsewhere classified
K85.0 Delete Idiopathic acute pancreatitis
K85.1 Delete Biliary acute pancreatitis
K85.2 Delete Alcohol induced acute pancreatitis
K85.3 Delete Drug induced acute pancreatitis
K85.8 Delete Other acute pancreatitis
K85.9 Delete Acute pancreatitis, unspecified
K86.8 Delete Other specified diseases of pancreas
Necrotizing enterocolitis NEC
68
Revised codes include:
K91.61 Revise fromIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure
K91.840 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure
K91.841 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure
K91.61 Revise toIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure
K91.840 Revise toPostprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure
K91.841 Revise toPostprocedural hemorrhage of a digestive system organ or structure following other procedure
Musculoskeletal
70
Bunionette
Pathologic lesions include:
Inflamed bursa overlying the lateral aspect of the MT head
Bony enlargement of the head itself
Increased intermetatarsal angle between the fourth and fifth MTs with secondary medial angulation of the phalanx
and abnormal curvature of the fifth MT
M21.611 Add Bunion of right foot
M21.612 Add Bunion of left foot
M21.619 Add Bunion of unspecified foot
M21.621 Add Bunionette of right foot
M21.622 Add Bunionette of left foot
M21.629 Add Bunionette of unspecified foot
Documentation concepts for bunions or bunionettes include:
Type
Anatomical location
Laterality
Incomplete atypical fracture
71
M84.750A Add Atypical femoral fracture, unspecified, initial encounter for fracture
M84.750D Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with routine healing
M84.750G Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with delayed healing
M84.750K Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with nonunion
M84.750P Add Atypical femoral fracture, unspecified, subsequent encounter for fracture with malunion
M84.750S Add Atypical femoral fracture, unspecified, sequela
M84.751A Add Incomplete atypical femoral fracture, right leg, initial encounter for fracture
M84.751D Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing
M84.751G Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing
M84.751K Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion
M84.751P Add Incomplete atypical femoral fracture, right leg, subsequent encounter for fracture with malunion
M84.751S Add Incomplete atypical femoral fracture, right leg, sequela
M84.752A Add Incomplete atypical femoral fracture, left leg, initial encounter for fracture
M84.752D Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing
M84.752G Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing
M84.752K Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion
M84.752P Add Incomplete atypical femoral fracture, left leg, subsequent encounter for fracture with malunion
M84.752S Add Incomplete atypical femoral fracture, left leg, sequela
M84.753A Add Incomplete atypical femoral fracture, unspecified leg, initial encounter for fracture
M84.753D Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing
M84.753G Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing
72
M84.753K Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion
M84.753P Add Incomplete atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion
M84.753S Add Incomplete atypical femoral fracture, unspecified leg, sequela
M84.754A Add Complete transverse atypical femoral fracture, right leg, initial encounter for fracture
M84.754D Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing
M84.754G Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing
M84.754K Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion
M84.754P Add Complete transverse atypical femoral fracture, right leg, subsequent encounter for fracture with malunion
M84.754S Add Complete transverse atypical femoral fracture, right leg, sequela
M84.755A Add Complete transverse atypical femoral fracture, left leg, initial encounter for fracture
M84.755D Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing
M84.755G Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing
M84.755K Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion
M84.755P Add Complete transverse atypical femoral fracture, left leg, subsequent encounter for fracture with malunion
M84.755S Add Complete transverse atypical femoral fracture, left leg, sequela
M84.756A Add Complete transverse atypical femoral fracture, unspecified leg, initial encounter for fracture
M84.756D Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing
M84.756G Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing
M84.756K Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion
M84.756P Add Complete transverse atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion
M84.756S Add Complete transverse atypical femoral fracture, unspecified leg, sequela
M84.757A Add Complete oblique atypical femoral fracture, right leg, initial encounter for fracture
M84.757D Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with routine healing
Musculoskeletal
73
M84.757G Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with delayed healing
M84.757K Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with nonunion
M84.757P Add Complete oblique atypical femoral fracture, right leg, subsequent encounter for fracture with malunion
M84.757S Add Complete oblique atypical femoral fracture, right leg, sequela
M84.758A Add Complete oblique atypical femoral fracture, left leg, initial encounter for fracture
M84.758D Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with routine healing
M84.758G Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with delayed healing
M84.758K Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with nonunion
M84.758P Add Complete oblique atypical femoral fracture, left leg, subsequent encounter for fracture with malunion
M84.758S Add Complete oblique atypical femoral fracture, left leg, sequela
M84.759A Add Complete oblique atypical femoral fracture, unspecified leg, initial encounter for fracture
M84.759D Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with routine healing
M84.759G Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with delayed healing
M84.759K Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with nonunion
M84.759P Add Complete oblique atypical femoral fracture, unspecified leg, subsequent encounter for fracture with malunion
Documentation
concepts include:
Type
Anatomical location
Laterality
Status
Genitourinary
75
Incontinence
Documentation concepts include:
Type
N39.491 Add Coital incontinence
N39.492 Add Postural (urinary) incontinence
Other additions
76
Follicular cysts
N83.00 Add Follicular cyst of ovary, unspecified side
N83.01 Add Follicular cyst of right ovary
N83.02 Add Follicular cyst of left ovary
N83.10 Add Corpus luteum cyst of ovary, unspecified side
N83.11 Add Corpus luteum cyst of right ovary
N83.12 Add Corpus luteum cyst of left ovary
N83.201 Add Unspecified ovarian cyst, right side
N83.202 Add Unspecified ovarian cyst, left side
N83.209 Add Unspecified ovarian cyst, unspecified side
N83.291 Add Other ovarian cyst, right side
N83.292 Add Other ovarian cyst, left side
N83.299 Add Other ovarian cyst, unspecified side
N83.311 Add Acquired atrophy of right ovary
N83.312 Add Acquired atrophy of left ovary
N83.319 Add Acquired atrophy of ovary, unspecified side
N83.321 Add Acquired atrophy of right fallopian tube
N83.322 Add Acquired atrophy of left fallopian tube
N83.329 Add Acquired atrophy of fallopian tube, unspecified side
N83.331 Add Acquired atrophy of right ovary and fallopian tube
N83.332 Add Acquired atrophy of left ovary and fallopian tube
N83.339 Add Acquired atrophy of ovary and fallopian tube, unspecified side
Other additions
77
N83.40 Add Prolapse and hernia of ovary and fallopian tube, unspecified side
N83.41 Add Prolapse and hernia of right ovary and fallopian tube
N83.42 Add Prolapse and hernia of left ovary and fallopian tube
N83.511 Add Torsion of right ovary and ovarian pedicle
N83.512 Add Torsion of left ovary and ovarian pedicle
N83.519 Add Torsion of ovary and ovarian pedicle, unspecified side
N83.521 Add Torsion of right fallopian tube
N83.522 Add Torsion of left fallopian tube
N83.529 Add Torsion of fallopian tube, unspecified side
Genitourinary
78
Deletions
N83.0 Delete Follicular cyst of ovary
N83.1 Delete Corpus luteum cyst
N83.20 Delete Unspecified ovarian cysts
N83.29 Delete Other ovarian cysts
N83.31 Delete Acquired atrophy of ovary
N83.32 Delete Acquired atrophy of fallopian tube
N83.33 Delete Acquired atrophy of ovary and fallopian tube
N83.4 Delete Prolapse and hernia of ovary and fallopian tube
N83.51 Delete Torsion of ovary and ovarian pedicle
N83.52 Delete Torsion of fallopian tube
Revisions to existing codes include:
79
N10 Revise from Acute tubulo-interstitial nephritis
N40.0 Revise from Enlarged prostate without lower urinary tract symptoms
N40.1 Revise from Enlarged prostate with lower urinary tract symptoms
N52.39 Revise from Other post-surgical erectile dysfunction
N99.113 Revise from Postprocedural anterior urethral stricture
N99.520 Revise from Hemorrhage of other external stoma of urinary tract
N99.521 Revise from Infection of other external stoma of urinary tract
N99.522 Revise from Malfunction of other external stoma of urinary tract
N99.528 Revise from Other complication of other external stoma of urinary tract
N99.530 Revise from Hemorrhage of other stoma of urinary tract
N99.531 Revise from Infection of other stoma of urinary tract
N99.532 Revise from Malfunction of other stoma of urinary tract
N99.538 Revise from Other complication of other stoma of urinary tract
Documentation concepts
prevalent to these revisions
include:
Type
Anatomical location
Caused by/due to
Complications/manifestations
80
N99.820 Revise fromPostprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure
N99.821 Revise from Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure
N10 Revise to Acute pyelonephritis
N40.0 Revise to Benign prostatic hyperplasia without lower urinary tract symptoms
N40.1 Revise to Benign prostatic hyperplasia with lower urinary tract symptoms
N52.39 Revise to Other and unspecified postprocedural erectile dysfunction
N99.113 Revise to Postprocedural anterior bulbous urethral stricture
N99.520 Revise to Hemorrhage of incontinent stoma of urinary tract
N99.521 Revise to Infection of incontinent stoma of urinary tract
N99.522 Revise to Malfunction of incontinent stoma of urinary tract
N99.528 Revise to Other complication of incontinent stoma of urinary tract
N99.530 Revise to Hemorrhage of continent stoma of urinary tract
N99.531 Revise to Infection of continent stoma of urinary tract
N99.532 Revise to Malfunction of continent stoma of urinary tract
N99.538 Revise to Other complication of continent stoma of urinary tract
N99.820 Revise to Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure
N99.821 Revise to Postprocedural hemorrhage of a genitourinary system organ or structure following other procedure
Documentation concepts
prevalent to these revisions
include:
Type
Anatomical location
Caused by/due to
Complications/manifestations
Obstetrics
82
Deletions
O00.0 Delete Abdominal pregnancy
O00.1 Delete Tubal pregnancy
O00.2 Delete Ovarian pregnancy
O00.8 Delete Other ectopic pregnancy
O00.9 Delete Ectopic pregnancy, unspecified
O33.7 Delete Maternal care for disproportion due to other fetal deformities
O34.21 Delete Maternal care for scar from previous cesarean delivery
O70.2 Delete Third degree perineal laceration during delivery
Obstetrics
83
Additions
O00.00 Abdominal pregnancy without intrauterine pregnancy
O00.01 Abdominal pregnancy with intrauterine pregnancy
O00.90 Unspecified ectopic pregnancy without intrauterine pregnancy
Obstetrics
84
Remaining Additions
O00.10 Add Tubal pregnancy without intrauterine pregnancy
O00.11 Add Tubal pregnancy with intrauterine pregnancy
O00.20 Add Ovarian pregnancy without intrauterine pregnancy
O00.21 Add Ovarian pregnancy with intrauterine pregnancy
O00.80 Add Other ectopic pregnancy without intrauterine pregnancy
O00.81 Add Other ectopic pregnancy with intrauterine pregnancy
O00.90 Add Unspecified ectopic pregnancy without intrauterine pregnancy
O00.91 Add Unspecified ectopic pregnancy with intrauterine pregnancy
O09.A0 Add Supervision of pregnancy with history of molar pregnancy, unspecified trimester
O09.A1 Add Supervision of pregnancy with history of molar pregnancy, first trimester
O09.A2 Add Supervision of pregnancy with history of molar pregnancy, second trimester
O09.A3 Add Supervision of pregnancy with history of molar pregnancy, third trimester
O11.4 Add Pre-existing hypertension with pre-eclampsia, complicating childbirth
O11.5 Add Pre-existing hypertension with pre-eclampsia, complicating the puerperium
85
O12.04 Add Gestational edema, complicating childbirth
O12.05 Add Gestational edema, complicating the puerperium
O12.14 Add Gestational proteinuria, complicating childbirth
O12.15 Add Gestational proteinuria, complicating the puerperium
O12.24 Add Gestational edema with proteinuria, complicating childbirth
O12.25 Add Gestational edema with proteinuria, complicating the puerperium
O13.4 Add Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth
O13.5 Add Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium
O14.04 Add Mild to moderate pre-eclampsia, complicating childbirth
O14.05 Add Mild to moderate pre-eclampsia, complicating the puerperium
O14.14 Add Severe pre-eclampsia complicating childbirth
O14.15 Add Severe pre-eclampsia, complicating the puerperium
O14.24 Add HELLP syndrome, complicating childbirth
O14.25 Add HELLP syndrome, complicating the puerperium
O14.94 Add Unspecified pre-eclampsia, complicating childbirth
O14.95 Add Unspecified pre-eclampsia, complicating the puerperium
O16.4 Add Unspecified maternal hypertension, complicating childbirth
O16.5 Add Unspecified maternal hypertension, complicating the puerperium
O24.415 Add Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs
O24.425 Add Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs
O24.435 Add Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs
O33.7XX0 Add Maternal care for disproportion due to other fetal deformities, not applicable or unspecified
O33.7XX1 Add Maternal care for disproportion due to other fetal deformities, fetus 1
O33.7XX2 Add Maternal care for disproportion due to other fetal deformities, fetus 2
O33.7XX3 Add Maternal care for disproportion due to other fetal deformities, fetus 3
O33.7XX4 Add Maternal care for disproportion due to other fetal deformities, fetus 4
O33.7XX5 Add Maternal care for disproportion due to other fetal deformities, fetus 5
O33.7XX9 Add Maternal care for disproportion due to other fetal deformities, other fetus
O34.211 Add Maternal care for low transverse scar from previous cesarean delivery
O34.212 Add Maternal care for vertical scar from previous cesarean delivery
O34.219 Add Maternal care for unspecified type scar from previous cesarean delivery
O44.20 Add Partial placenta previa NOS or without hemorrhage, unspecified trimester
O44.21 Add Partial placenta previa NOS or without hemorrhage, first trimester
O44.22 Add Partial placenta previa NOS or without hemorrhage, second trimester
O44.23 Add Partial placenta previa NOS or without hemorrhage, third trimester
Obstetrics
86
O44.30 Add Partial placenta previa with hemorrhage, unspecified trimester
O44.31 Add Partial placenta previa with hemorrhage, first trimester
O44.32 Add Partial placenta previa with hemorrhage, second trimester
O44.33 Add Partial placenta previa with hemorrhage, third trimester
O44.40 Add Low lying placenta NOS or without hemorrhage, unspecified trimester
O44.41 Add Low lying placenta NOS or without hemorrhage, first trimester
O44.42 Add Low lying placenta NOS or without hemorrhage, second trimester
O44.43 Add Low lying placenta NOS or without hemorrhage, third trimester
O44.50 Add Low lying placenta with hemorrhage, unspecified trimester
O44.51 Add Low lying placenta with hemorrhage, first trimester
O44.52 Add Low lying placenta with hemorrhage, second trimester
O44.53 Add Low lying placenta with hemorrhage, third trimester
O70.20 Add Third degree perineal laceration during delivery, unspecified
O70.21 Add Third degree perineal laceration during delivery, IIIa
O70.22 Add Third degree perineal laceration during delivery, IIIb
O70.23 Add Third degree perineal laceration during delivery, IIIc
Obstetrics
87
Revisions
O24.011 Revise from Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.011 Revise to Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester
O09.10 Revise from
Supervision of pregnancy with history of ectopic or molar pregnancy,
unspecified trimester
O09.11 Revise from
Supervision of pregnancy with history of ectopic or molar pregnancy, first
trimester
O09.12 Revise fromSupervision of pregnancy with history of ectopic or molar pregnancy, second
trimester
O09.13 Revise from
Supervision of pregnancy with history of ectopic or molar pregnancy, third
trimester
O15.00 Revise from Eclampsia in pregnancy, unspecified trimester
O15.02 Revise from Eclampsia in pregnancy, second trimester
O15.03 Revise from Eclampsia in pregnancy, third trimester
O15.1 Revise from Eclampsia in labor
O15.2 Revise from Eclampsia in the puerperium
88
O24.011 Revise from Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.012 Revise from Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
O24.013 Revise from Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
O24.019 Revise from Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
O24.02 Revise from Pre-existing diabetes mellitus, type 1, in childbirth
O2403 Revise from Pre-existing diabetes mellitus, type 1, in the puerperium
O24.111 Revise from Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
O24.112 Revise from Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
O24.113 Revise from Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
O24.119 Revise from Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
O24.12 Revise from Pre-existing diabetes mellitus, type 2, in childbirth
O24.13 Revise from Pre-existing diabetes mellitus, type 2, in the puerperium
O44.00 Revise from Placenta previa specified as without hemorrhage, unspecified trimester
O44.01 Revise from Placenta previa specified as without hemorrhage, first trimester
O44.02 Revise from Placenta previa specified as without hemorrhage, second trimester
O44.03 Revise from Placenta previa specified as without hemorrhage, third trimester
O44.10 Revise from Placenta previa with hemorrhage, unspecified trimester
O44.11 Revise from Placenta previa with hemorrhage, first trimester
O44.12 Revise from Placenta previa with hemorrhage, second trimester
O44.13 Revise from Placenta previa with hemorrhage, third trimester
89
O09.10 Revise to Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester
O09.11 Revise to Supervision of pregnancy with history of ectopic pregnancy, first trimester
O09.12 Revise to Supervision of pregnancy with history of ectopic pregnancy, second trimester
O09.13 Revise to Supervision of pregnancy with history of ectopic pregnancy, third trimester
O15.00 Revise to Eclampsia complicating pregnancy, unspecified trimester
O15.02 Revise to Eclampsia complicating pregnancy, second trimester
O15.03 Revise to Eclampsia complicating pregnancy, third trimester
O15.1 Revise to Eclampsia complicating childbirth
O15.2 Revise to Eclampsia complicating the puerperium
O24.011 Revise to Pre-existing type 1 diabetes mellitus, in pregnancy, first trimester
O24.012 Revise to Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester
O24.013 Revise to Pre-existing type 1 diabetes mellitus, in pregnancy, third trimester
O24.019 Revise to Pre-existing type 1 diabetes mellitus, in pregnancy, unspecified trimester
O24.02 Revise to Pre-existing type 1 diabetes mellitus, in childbirth
O24.03 Revise to Pre-existing type 1 diabetes mellitus, in the puerperium
O24.111 Revise to Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester
O24.112 Revise to Pre-existing type 2 diabetes mellitus, in pregnancy, second trimester
O24.113 Revise to Pre-existing type 2 diabetes mellitus, in pregnancy, third trimester
O24.119 Revise to Pre-existing type 2 diabetes mellitus, type 2, in pregnancy, unspecified trimester
O24.12 Revise to Pre-existing type 2 diabetes mellitus, in childbirth
O24.13 Revise to Pre-existing type 2 diabetes mellitus, in the puerperium
Obstetrics
90
O44.00 Revise to Complete placenta previa NOS or without hemorrhage, unspecified trimester
O44.01 Revise to Complete placenta previa NOS or without hemorrhage, first trimester
O44.02 Revise to Complete placenta previa NOS or without hemorrhage, second trimester
O44.03 Revise to Complete placenta previa NOS or without hemorrhage, third trimester
O44.10 Revise to Complete placenta previa with hemorrhage, unspecified trimester
O44.11 Revise to Complete placenta previa with hemorrhage, first trimester
O44.12 Revise to Complete placenta previa with hemorrhage, second trimester
O44.13 Revise to Complete placenta previa with hemorrhage, third trimester
Newborns
92
Additions
P05.09 Add Newborn light for gestational age, 2500 grams and over
P05.19 Add Newborn small for gestational age, other
Newborns
93
Revisions
P00.0 Revise from Newborn (suspected to be) affected by maternal hypertensive disorders
P00.0 Revise to Newborn affected by maternal hypertensive disorders
P00.2 Revise from Newborn (suspected to be) affected by maternal infectious and parasitic diseases
P00.2 Revise to Newborn affected by maternal infectious and parasitic diseases
P00.3 Revise from Newborn (suspected to be) affected by other maternal circulatory and respiratory diseases
P00.3 Revise to Newborn affected by other maternal circulatory and respiratory diseases
P00.4 Revise from Newborn (suspected to be) affected by maternal nutritional disorders
P00.4 Revise to Newborn affected by maternal nutritional disorders
P00.5 Revise from Newborn (suspected to be) affected by maternal injury
P00.5 Revise to Newborn affected by maternal injury
P00.6 Revise from Newborn (suspected to be) affected by surgical procedure on mother
P00.6 Revise to Newborn affected by surgical procedure on mother
P00.7 Revise from Newborn (suspected to be) affected by other medical procedures on mother, not elsewhere classified
P00.7 Revise to Newborn affected by other medical procedures on mother, not elsewhere classified
P00.81 Revise from Newborn (suspected to be) affected by periodontal disease in mother
P00.81 Revise to Newborn affected by periodontal disease in mother
P00.89 Revise from Newborn (suspected to be) affected by other maternal conditions
P00.89 Revise to Newborn affected by other maternal conditions
The information in the
parenthesis was
removed
94
P00.9 Revise from Newborn (suspected to be) affected by unspecified maternal condition
P00.9 Revise to Newborn affected by unspecified maternal condition
P01.0 Revise from Newborn (suspected to be) affected by incompetent cervix
P01.0 Revise to Newborn affected by incompetent cervix
P01.1 Revise from Newborn (suspected to be) affected by premature rupture of membranes
P01.1 Revise to Newborn affected by premature rupture of membranes
P01.3 Revise from Newborn (suspected to be) affected by polyhydramnios
P01.3 Revise to Newborn affected by polyhydramnios
P01.4 Revise from Newborn (suspected to be) affected by ectopic pregnancy
P01.4 Revise to Newborn affected by ectopic pregnancy
P01.5 Revise from Newborn (suspected to be) affected by multiple pregnancy
P01.5 Revise to Newborn affected by multiple pregnancy
P01.6 Revise from Newborn (suspected to be) affected by maternal death
P01.6 Revise to Newborn affected by maternal death
P01.7 Revise from Newborn (suspected to be) affected by malpresentation before labor
P01.7 Revise to Newborn affected by malpresentation before labor
P01.8 Revise from Newborn (suspected to be) affected by other maternal complications of pregnancy
P01.8 Revise to Newborn affected by other maternal complications of pregnancy
P01.9 Revise from Newborn (suspected to be) affected by maternal complication of pregnancy, unspecified
P01.9 Revise to Newborn affected by maternal complication of pregnancy, unspecified
P02.0 Revise from Newborn (suspected to be) affected by placenta previa
P02.0 Revise to Newborn affected by placenta previa
P02.1 Revise from Newborn (suspected to be) affected by other forms of placental separation and hemorrhage
P02.1 Revise to Newborn affected by other forms of placental separation and hemorrhage
P02.20 Revise from Newborn (suspected to be) affected by unspecified morphological and functional abnormalities of placenta
P02.20 Revise to Newborn affected by unspecified morphological and functional abnormalities of placenta
P02.29 Revise from Newborn (suspected to be) affected by other morphological and functional abnormalities of placenta
P02.29 Revise to Newborn affected by other morphological and functional abnormalities of placenta
95
P02.3 Revise from Newborn (suspected to be) affected by placental transfusion syndromes
P02.3 Revise to Newborn affected by placental transfusion syndromes
P02.4 Revise from Newborn (suspected to be) affected by prolapsed cord
P02.4 Revise to Newborn affected by prolapsed cord
P02.5 Revise from Newborn (suspected to be) affected by other compression of umbilical cord
P02.5 Revise to Newborn affected by other compression of umbilical cord
P02.60 Revise from Newborn (suspected to be) affected by unspecified conditions of umbilical cord
P02.60 Revise to Newborn affected by unspecified conditions of umbilical cord
P02.69 Revise from Newborn (suspected to be) affected by other conditions of umbilical cord
P02.69 Revise to Newborn affected by other conditions of umbilical cord
P02.7 Revise from Newborn (suspected to be) affected by chorioamnionitis
P02.7 Revise to Newborn affected by chorioamnionitis
P02.8 Revise from Newborn (suspected to be) affected by other abnormalities of membranes
P02.8 Revise to Newborn affected by other abnormalities of membranes
P02.9 Revise from Newborn (suspected to be) affected by abnormality of membranes, unspecified
P02.9 Revise to Newborn affected by abnormality of membranes, unspecified
P03.0 Revise from Newborn (suspected to be) affected by breech delivery and extraction
P03.0 Revise to Newborn affected by breech delivery and extraction
P03.1 Revise from Newborn (suspected to be) affected by other malpresentation, malposition and disproportion during labor and delivery
P03.1 Revise to Newborn affected by other malpresentation, malposition and disproportion during labor and delivery
P03.2 Revise from Newborn (suspected to be) affected by forceps delivery
P03.2 Revise to Newborn affected by forceps delivery
P03.3 Revise from Newborn (suspected to be) affected by delivery by vacuum extractor [ventouse]
P03.3 Revise to Newborn affected by delivery by vacuum extractor [ventouse]
P03.4 Revise from Newborn (suspected to be) affected by Cesarean delivery
P03.4 Revise to Newborn affected by Cesarean delivery
P03.5 Revise from Newborn (suspected to be) affected by precipitate delivery
P03.5 Revise to Newborn affected by precipitate delivery
96
P03.6 Revise from Newborn (suspected to be) affected by abnormal uterine contractions
P03.6 Revise to Newborn affected by abnormal uterine contractions
P03.810 Revise from Newborn (suspected to be) affected by abnormality in fetal (intrauterine) heart rate or rhythm before the onset of labor
P03.810 Revise to Newborn affected by abnormality in fetal (intrauterine) heart rate or rhythm before the onset of labor
P03.811 Revise from Newborn (suspected to be) affected by abnormality in fetal (intrauterine) heart rate or rhythm during labor
P03.811 Revise to Newborn affected by abnormality in fetal (intrauterine) heart rate or rhythm during labor
P03.819 Revise from Newborn (suspected to be) affected by abnormality in fetal (intrauterine) heart rate or rhythm, unspecified as to time of onset
P03.819 Revise to Newborn affected by abnormality in fetal (intrauterine) heart rate or rhythm, unspecified as to time of onset
P03.89 Revise from Newborn (suspected to be) affected by other specified complications of labor and delivery
P03.89 Revise to Newborn affected by other specified complications of labor and delivery
P03.9 Revise from Newborn (suspected to be) affected by complication of labor and delivery, unspecified
P03.9 Revise to Newborn affected by complication of labor and delivery, unspecified
P04.0 Revise from Newborn (suspected to be) affected by maternal anesthesia and analgesia in pregnancy, labor and delivery
P04.0 Revise to Newborn affected by maternal anesthesia and analgesia in pregnancy, labor and delivery
P04.1 Revise from Newborn (suspected to be) affected by other maternal medication
P04.1 Revise to Newborn affected by other maternal medication
P04.2 Revise from Newborn (suspected to be) affected by maternal use of tobacco
P04.2 Revise to Newborn affected by maternal use of tobacco
P04.3 Revise from Newborn (suspected to be) affected by maternal use of alcohol
P04.3 Revise to Newborn affected by maternal use of alcohol
P04.41 Revise from Newborn (suspected to be) affected by maternal use of cocaine
P04.41 Revise to Newborn affected by maternal use of cocaine
Newborns
97
P04.49 Revise from Newborn (suspected to be) affected by maternal use of other drugs of addiction
P04.49 Revise to Newborn affected by maternal use of other drugs of addiction
P04.5 Revise from Newborn (suspected to be) affected by maternal use of nutritional chemical substances
P04.5 Revise to Newborn affected by maternal use of nutritional chemical substances
P04.6 Revise from Newborn (suspected to be) affected by maternal exposure to environmental chemical substances
P04.6 Revise to Newborn affected by maternal exposure to environmental chemical substances
P04.8 Revise from Newborn (suspected to be) affected by other maternal noxious substances
P04.8 Revise to Newborn affected by other maternal noxious substances
P04.9 Revise from Newborn (suspected to be) affected by maternal noxious substance, unspecified
P04.9 Revise to Newborn affected by maternal noxious substance, unspecified
Congenital
99
Deletions
Q25.2 Delete Atresia of aorta
Q25.4 Delete Other congenital malformations of aorta
Q52.12 Delete Longitudinal vaginal septum
Q66.2 Delete Congenital metatarsus (primus) varus
Congenital
100
Additions
Q25.21 Add Interruption of aortic arch
Q25.29 Add Other atresia of aorta
Q25.40 Add Congenital malformation of aorta unspecified
Q25.41 Add Absence and aplasia of aorta
Q25.42 Add Hypoplasia of aorta
Q25.43 Add Congenital aneurysm of aorta
Q25.44 Add Congenital dilation of aorta
Q25.45 Add Double aortic arch
Q25.46 Add Tortuous aortic arch
Q25.47 Add Right aortic arch
Q25.48 Add Anomalous origin of subclavian artery
Q25.49 Add Other congenital malformations of aorta
Q52.120 Add Longitudinal vaginal septum, nonobstructing
Q52.121 Add Longitudinal vaginal septum, obstructing, right side
Q52.122 Add Longitudinal vaginal septum, obstructing, left side
Q52.123 Add Longitudinal vaginal septum, microperforate, right side
Q52.124 Add Longitudinal vaginal septum, microperforate, left side
Q52.129 Add Other and unspecified longitudinal vaginal septum
Q66.21 Add Congenital metatarsus primus varus
Q66.22 Add Congenital metatarsus adductus
Q87.82 Add Arterial tortuosity syndrome
Documentation concepts for this chapter include: Type Anatomical location Laterality
Signs and Symptoms
102
Deletions
R31.2 Delete Other microscopic hematuria
R39.19 Delete Other difficulties with micturition
R40.241 Delete Glasgow coma scale score 13-15
R40.242 Delete Glasgow coma scale score 9-12
R40.243 Delete Glasgow coma scale score 3-8
R40.244 Delete Other coma, without documented Glasgow coma scale score, or with partial score reported
R82.7 Delete Abnormal findings on microbiological examination of urine
R93.4 Delete Abnormal findings on diagnostic imaging of urinary organs
R97.2 Delete Elevated prostate specific antigen [PSA]
Signs and Symptoms
103
Additions
Example:
R93.421 Add Abnormal radiologic findings on diagnostic imaging of right kidney
R29.700 Add NIHSS score 0
R29.701 Add NIHSS score 1
R29.702 Add NIHSS score 2
R29.703 Add NIHSS score 3
R29.704 Add NIHSS score 4
R29.705 Add NIHSS score 5
R29.706 Add NIHSS score 6
R29.707 Add NIHSS score 7
R29.708 Add NIHSS score 8
R29.709 Add NIHSS score 9
R29.710 Add NIHSS score 10
104
R29.711 Add NIHSS score 11
R29.712 Add NIHSS score 12
R29.713 Add NIHSS score 13
R29.714 Add NIHSS score 14
R29.715 Add NIHSS score 15
R29.716 Add NIHSS score 16
R29.717 Add NIHSS score 17
R29.718 Add NIHSS score 18
R29.719 Add NIHSS score 19
R29.720 Add NIHSS score 20
R29.721 Add NIHSS score 21
R29.722 Add NIHSS score 22
R29.723 Add NIHSS score 23
R29.724 Add NIHSS score 24
R29.725 Add NIHSS score 25
R29.726 Add NIHSS score 26
R29.727 Add NIHSS score 27
R29.728 Add NIHSS score 28
R29.729 Add NIHSS score 29
R29.730 Add NIHSS score 30
R29.731 Add NIHSS score 31
R29.732 Add NIHSS score 32
R29.733 Add NIHSS score 33
R29.734 Add NIHSS score 34
R29.735 Add NIHSS score 35
R29.736 Add NIHSS score 36
R29.737 Add NIHSS score 37
R29.738 Add NIHSS score 38
R29.739 Add NIHSS score 39
R29.740 Add NIHSS score 40
R29.741 Add NIHSS score 41
R29.742 Add NIHSS score 42
R31.21 Add Asymptomatic microscopic hematuria
R31.29 Add Other microscopic hematuria
R39.191 Add Need to immediately re-void
R39.192 Add Position dependent micturition
R39.198 Add Other difficulties with micturition
105
R39.82 Add Chronic bladder pain
R40.2410 Add Glasgow coma scale score 13-15, unspecified time
R40.2411 Add Glasgow coma scale score 13-15, in the field [EMT or ambulance]
R40.2412 Add Glasgow coma scale score 13-15, at arrival to emergency department
R40.2413 Add Glasgow coma scale score 13-15, at hospital admission
R40.2414 Add Glasgow coma scale score 13-15, 24 hours or more after hospital admission
R40.2420 Add Glasgow coma scale score 9-12, unspecified time
R40.2421 Add Glasgow coma scale score 9-12, in the field [EMT or ambulance]
R40.2422 Add Glasgow coma scale score 9-12, at arrival to emergency department
R40.2423 Add Glasgow coma scale score 9-12, at hospital admission
R40.2424 Add Glasgow coma scale score 9-12, 24 hours or more after hospital admission
R40.2430 Add Glasgow coma scale score 3-8, unspecified time
R40.2431 Add Glasgow coma scale score 3-8, in the field [EMT or ambulance]
R40.2432 Add Glasgow coma scale score 3-8, at arrival to emergency department
R40.2433 Add Glasgow coma scale score 3-8, at hospital admission
R40.2434 Add Glasgow coma scale score 3-8, 24 hours or more after hospital admission
R40.2440 Add Other coma, without documented Glasgow coma scale score, or with partial score reported, unspecified time
R40.2441 Add Other coma, without documented Glasgow coma scale score, or with partial score reported, in the field [EMT or ambulance]
R40.2442 Add Other coma, without documented Glasgow coma scale score, or with partial score reported, at arrival to emergency department
R40.2443 Add Other coma, without documented Glasgow coma scale score, or with partial score reported, at hospital admission
R40.2444 Add Other coma, without documented Glasgow coma scale score, or with partial score reported, 24 hours or more after hospital admission
R73.03 Add Prediabetes
R82.71 Add Bacteriuria
R82.79 Add Other abnormal findings on microbiological examination of urine
R93.41 Add Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder
R93.421 Add Abnormal radiologic findings on diagnostic imaging of right kidney
R93.422 Add Abnormal radiologic findings on diagnostic imaging of left kidney
R93.429 Add Abnormal radiologic findings on diagnostic imaging of unspecified kidney
R93.49 Add Abnormal radiologic findings on diagnostic imaging of other urinary organs
R97.20 Add Elevated prostate specific antigen [PSA]
R97.21 Add Rising PSA following treatment for malignant neoplasm of prostate
Documentation
concepts in this chapter
include:
Type
Patient status
Anatomical location
Injuries
107
Additions
S02.101A Add Fracture of base of skull, right side, initial encounter for closed fracture
S02.101B Add Fracture of base of skull, right side, initial encounter for open fracture
S02.101D Add Fracture of base of skull, right side, subsequent encounter for fracture with routine healing
S02.101G Add Fracture of base of skull, right side, subsequent encounter for fracture with delayed healing
S02.101K Add Fracture of base of skull, right side, subsequent encounter for fracture with nonunion
S02.101S Add Fracture of base of skull, right side, sequela
S02.102A Add Fracture of base of skull, left side, initial encounter for closed fracture
S02.102B Add Fracture of base of skull, left side, initial encounter for open fracture
S02.102D Add Fracture of base of skull, left side, subsequent encounter for fracture with routine healing
S02.102G Add Fracture of base of skull, left side, subsequent encounter for fracture with delayed healing
S02.102K Add Fracture of base of skull, left side, subsequent encounter for fracture with nonunion
S02.102S Add Fracture of base of skull, left side, sequela
S02.109A Add Fracture of base of skull, unspecified side, initial encounter for closed fracture
S02.109B Add Fracture of base of skull, unspecified side, initial encounter for open fracture
S02.109D Add Fracture of base of skull, unspecified side, subsequent encounter for fracture with routine healing
S02.109G Add Fracture of base of skull, unspecified side, subsequent encounter for fracture with delayed healing
S02.109K Add Fracture of base of skull, unspecified side, subsequent encounter for fracture with nonunion
S02.109S Add Fracture of base of skull, unspecified side, sequela
Documentation concepts for coding of skull base fractures includes: Type Anatomical location Status Laterality
Occipital Condyle Fracture
108
The fractures are subdivided into three types:
Type I fracture
• impaction fracture of the occipital condyle
• due to axial compression
• stable injury
Type II fracture
• basilar skull fracture that extends to involve the occipital condyle
• due to direct blow to the skull
• stable injury
Type III fracture
• avulsion injury of condyle in region of alar ligament attachment
• due to forced contralateral bending and rotation
• potentially unstable injury
Occipital Condyle Fracture
109
Additions
S02.11AA Add Type I occipital condyle fracture, right side, initial encounter for closed fracture
S02.11AB Add Type I occipital condyle fracture, right side, initial encounter for open fracture
S02.11AD Add Type I occipital condyle fracture, right side, subsequent encounter for fracture with routine healing
S02.11AG Add Type I occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing
S02.11AK Add Type I occipital condyle fracture, right side, subsequent encounter for fracture with nonunion
S02.11AS Add Type I occipital condyle fracture, right side, sequela
S02.11BA Add Type I occipital condyle fracture, left side, initial encounter for closed fracture
S02.11BB Add Type I occipital condyle fracture, left side, initial encounter for open fracture
S02.11BD Add Type I occipital condyle fracture, left side, subsequent encounter for fracture with routine healing
S02.11BG Add Type I occipital condyle fracture, left side, subsequent encounter for fracture with delayed healing
S02.11BK Add Type I occipital condyle fracture, left side, subsequent encounter for fracture with nonunion
S02.11BS Add Type I occipital condyle fracture, left side, sequela
S02.11CA Add Type II occipital condyle fracture, right side, initial encounter for closed fracture
S02.11CB Add Type II occipital condyle fracture, right side, initial encounter for open fracture
S02.11CD Add Type II occipital condyle fracture, right side, subsequent encounter for fracture with routine healing
S02.11CG Add Type II occipital condyle fracture, right side, subsequent encounter for fracture with delayed healing
S02.11CK Add Type II occipital condyle fracture, right side, subsequent encounter for fracture with nonunion
S02.11CS Add Type II occipital condyle fracture, right side, sequela
S02.11DA Add Type II occipital condyle fracture, left side, initial encounter for closed fracture
Documentation concepts include: Type Anatomical
location Status Laterality
Other Additions
110
S02.40DB Add Maxillary fracture, left side, initial encounter for open fracture
S02.650A Add Fracture of angle of mandible, unspecified side, initial encounter for closed fracture
S99.111B AddSalter-Harris Type I physeal fracture of right metatarsal, initial encounter for open fracture
S99.131B AddSalter-Harris Type III physeal fracture of right metatarsal, initial encounter for open fracture
S99.149B AddSalter-Harris Type IV physeal fracture of unspecified metatarsal, initial encounter for open fracture
Documentation concepts for these type of changes for fractures remain consistent to what we have previously learned. Type Status Anatomical location Laterality Complications
Additions
111
For example:
Documentation concepts for this type of clinical conditions includes:
Type
Caused by/due to
Complications/manifestations
Anatomical location
Status
T83.011A Add Breakdown (mechanical) of indwelling urethral catheter, initial encounter
T83.031A Add Leakage of indwelling urethral catheter, initial encounter
T83.123D Add Displacement of other urinary stents, subsequent encounter
T83.510D Add Infection and inflammatory reaction due to cystostomy catheter, subsequent encounter
Deletions
112
T85.81XD Delete Embolism due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent encounter
T85.85XA Delete Stenosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, initial encounter
S06.0X4A Delete Concussion with loss of consciousness of 6 hours to 24 hours, initial encounter
S02.64XS Delete Fracture of ramus of mandible, sequela
S02.61XB Delete Fracture of condylar process of mandible, initial encounter for open fracture
External Causes
114
Additions
Examples:
X50.0XXA Add Overexertion from strenuous movement or load, initial encounter
X50.1XXD Add Overexertion from prolonged static or awkward postures, subsequent encounter
X50.1XXS Add Overexertion from prolonged static or awkward postures, sequela
X50.3XXA Add Overexertion from repetitive movements, initial encounter
115
V47.0XXA Add Car driver injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.0XXD Add Car driver injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.0XXS Add Car driver injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.1XXA Add Car passenger injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.1XXD Add Car passenger injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.1XXS Add Car passenger injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.3XXA Add Unspecified car occupant injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.3XXD Add Unspecified car occupant injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.3XXS Add Unspecified car occupant injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.5XXA Add Car driver injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.5XXD Add Car driver injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.5XXS Add Car driver injured in collision with fixed or stationary object in traffic accident, sequela
V47.6XXA Add Car passenger injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.6XXD Add Car passenger injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.6XXS Add Car passenger injured in collision with fixed or stationary object in traffic accident, sequela
V47.9XXA Add Unspecified car occupant injured in collision with fixed or stationary object in traffic accident, initial encounter
116
V47.9XXD Add Unspecified car occupant injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.9XXS Add Unspecified car occupant injured in collision with fixed or stationary object in traffic accident, sequela
W26.2XXA Add Contact with edge of stiff paper, initial encounter
W26.2XXD Add Contact with edge of stiff paper, subsequent encounter
W26.2XXS Add Contact with edge of stiff paper, sequela
W26.8XXA Add Contact with other sharp object(s), not elsewhere classified, initial encounter
W26.8XXD Add Contact with other sharp object(s), not elsewhere classified, subsequent encounter
W26.8XXS Add Contact with other sharp object(s), not elsewhere classified, sequela
W26.9XXA Add Contact with unspecified sharp object(s), initial encounter
W2.69XXD Add Contact with unspecified sharp object(s), subsequent encounter
W26.9XXS Add Contact with unspecified sharp object(s), sequela
X50.0XXA Add Overexertion from strenuous movement or load, initial encounter
X50.0XXD Add Overexertion from strenuous movement or load, subsequent encounter
X50.0XXS Add Overexertion from strenuous movement or load, sequela
X50.1XXA Add Overexertion from prolonged static or awkward postures, initial encounter
X50.1XXD Add Overexertion from prolonged static or awkward postures, subsequent encounter
X50.1XXS Add Overexertion from prolonged static or awkward postures, sequela
X50.3XXA Add Overexertion from repetitive movements, initial encounter
X50.3XXD Add Overexertion from repetitive movements, subsequent encounter
X50.3XXS Add Overexertion from repetitive movements, sequela
X50.9XXA Add Other and unspecified overexertion or strenuous movements or postures, initial encounter
X50.9XXD Add Other and unspecified overexertion or strenuous movements or postures, subsequent encounter
X50.9XXS Add Other and unspecified overexertion or strenuous movements or postures, sequela
Y93.85 Add Activity, choking game
External Causes
117
Deletions
V47.01XA Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.01XD Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.01XS Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.02XA Delete Driver of other type car injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.02XD Delete Driver of other type car injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.02XS Delete Driver of other type car injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.11XA Delete Passenger of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.11XD Delete Passenger of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.11XS Delete Passenger of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.12XA Delete Passenger of other type car injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.12XD Delete Passenger of other type car injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.12XS Delete Passenger of other type car injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.31XA Delete Unspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.31XD Delete
Unspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, subsequent
encounter
V47.31XS Delete Unspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.32XA Delete Unspecified occupant of other type car injured in collision with fixed or stationary object in nontraffic accident, initial encounter
V47.32XD Delete Unspecified occupant of other type car injured in collision with fixed or stationary object in nontraffic accident, subsequent encounter
V47.32XS Delete Unspecified occupant of other type car injured in collision with fixed or stationary object in nontraffic accident, sequela
V47.51XA Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.51XD Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.51XS Delete Driver of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, sequela
V47.52XA Delete Driver of other type car injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.52XD Delete Driver of other type car injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.52XS Delete Driver of other type car injured in collision with fixed or stationary object in traffic accident, sequela
118
V47.61XA DeletePassenger of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.61XD Delete Passenger of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.61XS Delete Passenger of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, sequela
V47.62XA Delete Passenger of other type car injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.62XD Delete Passenger of other type car injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.62XS Delete Passenger of other type car injured in collision with fixed or stationary object in traffic accident, sequela
V47.91XA DeleteUnspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, initial encounter
V479.1XD DeleteUnspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.91XS Delete Unspecified occupant of sport utility vehicle injured in collision with fixed or stationary object in traffic accident, sequela
V47.92XA Delete Unspecified occupant of other type car injured in collision with fixed or stationary object in traffic accident, initial encounter
V47.92XD DeleteUnspecified occupant of other type car injured in collision with fixed or stationary object in traffic accident, subsequent encounter
V47.92XS Delete Unspecified occupant of other type car injured in collision with fixed or stationary object in traffic accident, sequela
W4.51XXA Delete Paper entering through skin, initial encounter
W4.51XXD Delete Paper entering through skin, subsequent encounter
W4.51XXS Delete Paper entering through skin, sequela
W4.52XXA Delete Lid of can entering through skin, initial encounter
W45.2XXD Delete Lid of can entering through skin, subsequent encounter
Routine and Administrative
120
Deletions
Z22.50 Delete Carrier of unspecified viral hepatitis
Z22.51 Delete Carrier of viral hepatitis B
Z22.52 Delete Carrier of viral hepatitis C
Z22.59 Delete Carrier of other viral hepatitis
Z98.89 Delete Other specified postprocedural states
Routine and Administrative
121
AdditionsZ05.0 Add Observation and evaluation of newborn for suspected cardiac condition ruled out
Z05.1 Add Observation and evaluation of newborn for suspected infectious condition ruled out
Z05.2 Add Observation and evaluation of newborn for suspected neurological condition ruled out
Z05.3 Add Observation and evaluation of newborn for suspected respiratory condition ruled out
Z05.41 Add Observation and evaluation of newborn for suspected genetic condition ruled out
Z05.42 Add Observation and evaluation of newborn for suspected metabolic condition ruled out
Z05.43 Add Observation and evaluation of newborn for suspected immunologic condition ruled out
Z05.5 Add Observation and evaluation of newborn for suspected gastrointestinal condition ruled out
Z05.6 Add Observation and evaluation of newborn for suspected genitourinary condition ruled out
Z05.71 Add Observation and evaluation of newborn for suspected skin and subcutaneous tissue condition ruled out
Z05.72 Add Observation and evaluation of newborn for suspected musculoskeletal condition ruled out
Z05.73 Add Observation and evaluation of newborn for suspected connective tissue condition ruled out
Z05.8 Add Observation and evaluation of newborn for other specified suspected condition ruled out
Z05.9 Add Observation and evaluation of newborn for unspecified suspected condition ruled out
Z19.1 Add Hormone sensitive malignancy status
Z19.2 Add Hormone resistant malignancy status
Z22.5 Add Carrier of viral hepatitis
Z29.11 Add Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV)
Z29.12 Add Encounter for prophylactic antivenin
Z29.13 Add Encounter for prophylactic Rho(D) immune globulin
Z29.14 Add Encounter for prophylactic rabies immune globin
Z29.3 Add Encounter for prophylactic fluoride administration
122
Z29.8 Add Encounter for other specified prophylactic measures
Z29.9 Add Encounter for prophylactic measures, unspecified
Z30.015 Add Encounter for initial prescription of vaginal ring hormonal contraceptive
Z30.016 Add Encounter for initial prescription of transdermal patch hormonal contraceptive device
Z30.017 Add Encounter for initial prescription of implantable subdermal contraceptive
Z30.44 Add Encounter for surveillance of vaginal ring hormonal contraceptive device
Z30.45 Add Encounter for surveillance of transdermal patch hormonal contraceptive device
Z30.46 Add Encounter for surveillance of implantable subdermal contraceptive
Z31.7 Add Encounter for procreative management and counseling for gestational carrier
Z33.3 Add Pregnant state, gestational carrier
Z51.6 Add Encounter for desensitization to allergens
Z53.31 Add Laparoscopic surgical procedure converted to open procedure
Z53.32 Add Thoracoscopic surgical procedure converted to open procedure
Z53.33 Add Arthroscopic surgical procedure converted to open procedure
Z53.39 Add Other specified procedure converted to open procedure
Documentation concepts for
this chapter include:
Type
Patient status
Complications/manifestations