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ICD-10-CM FY2017 CHANGES Sally Phillips, RHIA NIHIMA Fall Seminar October 2016 2017 FY ICD-10-CM CODING UPDATE • • • • 1,974 NEW codes 311 Deleted codes 425 Revised codes Most Impact by Chapter: • Chapter 4 – Endocrine, nutritional and metabolic diseases • Chapter 13 – Diseases of the musculoskeletal system and connective tissue • Chapter 19 – Injury, poisoning and certain other consequences of external causes • Numerous Tabular Instruction Changes (Excludes 1 Corrections!) 2 Coding Guideline Updates FY 2017 MAJOR Changes ONLY Presented 3 2017 FY ICD-10-CM Coding Guidelines Changes Continuation of the interim advice from NCHS posted 10/19/2015 and updated 10/26/2015 regarding the Excludes 1 note application 4 Section I.A.12. Excludes Notes a. Excludes 1 An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes 1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes 1 note for “sleep related teeth grinding (G47.63),” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together. 2017 FY ICD-10-CM Coding Guidelines Changes Section 1.A.15. “With” 5 NEW! NEW! NEW! Change in interpretation of Hypertension and Heart Disease due to re-interpreting “with” 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 Alphabetical Index is sequenced immediately following the main term, not in alphabetical order. WATCH FOR ANY “WITH” STATEMENTS! 2017 FY ICD-10-CM Coding Guidelines Changes 6 Section I.A.19. Code assignment and Clinical Criteria The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The providers’ statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. NEW! NEW! NEW! Potential conflict with CDI and also auditors who expect validation of codes (clinical criteria/indicators) be documented! VERY CONTROVERSIAL CHANGE! 2017 FY ICD-10-CM Coding Guidelines Changes Section I.B.13. Laterality 7 CLARIFICATION! Helpful guidance on use of “bilateral” vs specific laterality when sites are previously treated 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. 2017 FY ICD-10-CM Coding Guidelines Changes 8 Coma scale (GCS) and NIHSS added to list that doesn’t require provider to document Section I.B.14. Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stages, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale). However, the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification. The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses. 2017 FY ICD-10-CM Coding Guidelines Changes 9 I.C.1.f. Zika virus infections Comparable to guideline on HIV infection/illness 1) Code only confirmed cases Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II.H. In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission. If the provider documents “suspected,” “possible” or “probable” Zika, do not assign coded A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases. New Z79.84 Long-term (current) use of oral hypoglycemic drugs code 2017 FY ICD-10-CM Coding Guidelines Changes 10 I.C.4.a.(3) Diabetes mellitus and the use of insulin and oral hypoglycemics If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4, Long-term (current) use of insulin, or Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be assigned to indicate that the patient uses insulin or hypoglycemic drugs. Code Z79.4 should not be assigned if insulin is given temporarily to bring a type 2 patient’s blood sugar under control during an encounter. I.C.4.a.(6)(a) Secondary diabetes mellitus and the use of insulin or hypoglycemic drugs For patient who routinely use insulin or hypoglycemic drugs, code Z79.4, Longterm (current) use of insulin, or Z79.84, Long-term (current) use of oral hypoglycemic drugs should also be assigned. . . . 2017 FY ICD-10-CM Coding Guidelines Changes NEW! NEW! NEW! Change in interpretation of Hypertension and Heart Disease due to re-interpreting “with” 11 I.C.9.a. Hypertension The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. 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 hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the classification, provider documentation must link the conditions in order to code them as related. 1) Hypertension with Heart Disease Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure. 2017 FY ICD-10-CM Coding Guidelines Changes 12 I.C.9.a.(10) Hypertensive Crisis Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter. More information with chapter-specific review 2017 FY ICD-10-CM Coding Guidelines Changes 13 I.C.12.a(5) Patients admitted with pressure ulcers documented as healing ... Coding/Guideline Clarification! For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission. I.C.12.a(6) Patient admitted with pressure ulcer evolving into another stage during the admission If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the highest stage reported for that site. two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. Coding/Guideline Change! 2017 FY ICD-10-CM Coding Guidelines Changes 14 I.C.15.b.(2) Supervision of High-Risk Pregnancy Codes from category O09, Supervision of high-risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from Chapter 15. If there are no complications during the labor or delivery episode, assign code O80, Encounter for full-term uncomplicated delivery. ... Coding/Guideline Clarification! 2017 FY ICD-10-CM Coding Guidelines Changes Sequencing Clarification! 15 I.C.15.b.(4) When a delivery occurs When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery. When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient’s admission. if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis. 2017 FY ICD-10-CM Coding Guidelines Changes 16 I.C.15.h. Long term use of insulin and oral hyopglycemics Code Z79.4, Long-term (current) use of insulin, or code Z79.84, Long-term (current) use of oral hypoglycemic drugs, should also be assigned if the diabetes mellitus is being treated with insulin or oral medications. If the patient is treated with both oral medications and insulin, only the code for insulincontrolled should be assigned. New Z79.84 Long-term (current) use of oral hypoglycemic drugs code 2017 FY ICD-10-CM Coding Guidelines Changes 17 I.C.15.i. Gestational (pregnancy induced) diabetes ... The codes under subcategory O24.4 include diet controlled, and insulin controlled, and controlled by oral hypoglycemic drugs. If a patient with gestational diabetes is treated with both diet and insulin, only the code for insulin-controlled is required. If a patient with gestational diabetes is treated with both diet and oral hypoglycemic medications, only the code for “controlled by oral hypoglycemic drugs” is required. Code Z79.4, Long-term (current) use of insulin or code Z79.84, Long-term (current) use of oral hypoglycemic drugs, should not be assigned with subcategory O24.4. ... New Z79.84 Long-term (current) use of oral hypoglycemic drugs code New Z05 Observation and evaluation of newborns and infants for suspected conditions ruled out 2017 FY ICD-10-CM Coding Guidelines Changes 18 I.16.b. Observation and Evaluation of Newborns for Suspected Conditions not Found 1) Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom. 2) A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present. 3) Z05 on a birth record A code from category Z05 is to be used as a secondary code after the code from category Z38, Liveborn infants according to place of birth and type of delivery. 2017 FY ICD-10-CM Coding Guidelines Changes 19 New R29.7- NIH Stroke Scale codes I.C.18.i. NIHSS Stroke Scale The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in conjunction with acute stroke codes (I63) to identify the patient’s neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). At a minimum, report the initial score documented. If desired, a facility may choose to capture multiple stroke scale scores. See Section I.B.14. for information concerning the medical record documentation that may be used for assignment of NIHSS codes. 2017 FY ICD-10-CM Coding Guidelines Changes 20 I.C.19.a. Application of 7th Characters in Chapter 19 Attempt to clarify use of 7th Character initial, subsequent encounter; REMOVED EXAMPLES! ... 7th character “A,” initial encounter is used for each encounter where while the patient is receiveding active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. 7th character “D” subsequent encounter is used for encounters after the patient has completed received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. 2017 FY ICD-10-CM Coding Guidelines Changes 21 I.C.19.c(1) Initial vs. Subsequent Encounters for Fractures ... Malunion/nonunion: The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q). ... Attempt to clarify use of 7th Character for open fractures 2017 FY ICD-10-CM Coding Guidelines Changes 22 I.C.19.e. Adverse Effects, Poisoning, Underdosing and Toxic Effects 5) (b) Poisoning When coding a poisoning or reaction to the improper use of a medication (e.g. overdose, wrong route of administration), first assign the appropriate code from categories T36-T50. The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined. If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined. Use additional code(s) for all manifestations of poisonings. POISONING default defined: accidental 2017 FY ICD-10-CM Coding Guidelines Changes 23 New Z05 Observation and evaluation of newborns and infants for suspected conditions ruled out I.C.21.b.(6) Observation There are two three observation Z code categories. . . . The observation codes are to be used as principal diagnosis only. The only exception to this is when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery. Then a code from category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in addition to the observation code but only if they are unrelated to the suspected condition being observed. ... Z03 Z04 Z05 Encounter for medical observation for suspected diseases and conditions ruled out Encounter for examination and observation for other reasons Except: Z04.9, Encounter for examination and observation for unspecified reason Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out 2017 FY ICD-10-CM Coding Guidelines Changes 24 I.C.21.b.(7) Aftercare ... Z51 Encounter for other aftercare and medical care I.C.21.b.(11) Encounters for Obstetrical and Reproductive Services ... Coding/Guideline CHANGE for Z3A Codes in category Z3A, Weeks of gestation, may be assigned to provide additional information about the pregnancy. Category Z3A codes should not be assigned for pregnancies with abortive outcomes (categories O00-O08), elective termination of pregnancy (code Z33.32), nor for postpartum conditions, as category Z3A is not applicable to these conditions. The date of the admission should be used to determine weeks of gestation for inpatient admissions that encompass more than one gestational week. 2017 FY ICD-10-CM Coding Guidelines Changes 25 Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services These guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits. Guidelines in Section I, Conventions, general coding guidelines, and chapter-specific guidelines, should also be applied for outpatient services and office visits. Guideline clarified ... The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals.does not apply to hospital-based outpatient services and provider-based office visits. 2017 FY ICD-10-CM Coding Guidelines Changes 26 IV.P. Encounters for general medical examinations with abnormal findings The subcategories for encounters for general medical examinations, Z00.0-, provide codes for with and without abnormal findings. Should a general medical examination result in an abnormal finding, the code for general medical examination with abnormal finding should be assigned as the firstlisted diagnosis. An examination with abnormal findings refers to a condition/ diagnosis that is newly identified or a change in severity of a chronic condition (such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease) during a routine physical examination. A secondary code for the abnormal finding should also be coded. Guideline clarification Changed “combination codes” to “codes that contain multiple clinical concepts” 2017 FY ICD-10-CM Coding Guidelines Changes 27 Appendix I. Present on Admission Chronic condition with acute exacerbation during the admission If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to combination codes codes that contain multiple clinical concepts. Combination Codes That Contain Multiple Clinical Concepts Assign “N” if at least one of the clinical concepts included in the any part of the combination code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission). Assign “Y” if all parts of the combination clinical concepts included in the code were present on admission (e.g., patient with acute prostatitis admitted with hematuria duodenal ulcer that perforates prior to admission). Chapter Specific Changes FY 2017 MAJOR/SIGNIFICANT Changes ONLY Presented 28 Multiple Chapters: 29 • Title REVISIONS: Postprocedural hemorrhage and hematoma of [system/organ/structure] following a/an [system] procedure Postprocedural hemorrhage and hematoma of [system/organ/structure] following other procedure • NEW CODES: Postprocedural Postprocedural Postprocedural Postprocedural hematoma of a/an [system/organ/structure] following a/an [system] procedure hematoma of a/an [system/organ/structure] following other procedure seroma of a/an [system/organ/structure] following a/an [system procedure seroma of a/an [system/organ/structure] following other procedure • Carved out hematoma and added seroma (a pocket of clear, serous fluid that sometimes develops after surgery) for postprocedural complications in the following chapters: • Chapter 3 – Diseases of the blood and blood-forming organs . . . (D50-D89) • Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) • Chapter 6 – Diseases of the nervous system (G00-G99) Multiple Chapters: • Carve out continued in the following chapters: • • • • • • • • Chapter 7 – Diseases of the eye and adnexa (H00-H59) Chapter 8 – Diseases of the ear and mastoid process (H60-H95) Chapter 9 – Diseases of the circulatory system (I00-I99) Chapter 10 – Diseases of the respiratory system (J00-J99) Chapter 11 – Diseases of the digestive system (K00-K95) Chapter 12 – Diseases of the skin and subcutaneous tissue (L00-L99) Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) Chapter 14 – Diseases of the genitourinary system (N00-N99) 30 Chapter 1 – Certain infectious and parasitic diseases (A00-B99) 31 NEW code: Zika Virus Disease A92.5 • Spreads primarily through the bite of an infected Aedes species mosquito. Can be passed from a pregnant woman to her fetus. • Symptoms: fever, rash, joint pain, conjunctivitis • Mild symptoms, short duration (several days to a week), low mortality • Serious/Severe birth defects: microcephaly, fetal brain defects • Treat symptoms: rest, hydration, fever reduction and analgesic medications (acetaminophen) • Human testing of Zika vaccine approved in mid-June 2016 Chapter 2 – Neoplasms (C00-D49) • Excludes 1 corrected to Excludes 2: C78 Secondary malignant neoplasm of respiratory and digestive organs • Lymph node metastases (C77.0) C79 Secondary malignant neoplasm of other and unspecified sites • Lymph node metastases (C77.0) D16.4 Benign neoplasm of bones of skull and face • Benign neoplasm of lower jaw bone (D16.5) • Code title revisions: C81- Classical Hodgkin lymphoma 32 Chapter 2 – Neoplasms (00-D49) 33 New codes: • C49.A- Gastrointestinal stromal tumor GIST: uncommon tumors of the GI tract, most originate in the stomach, some are benign, start from different cells than other GI cancers so need different types of treatment and have a different prognosis • D47.Z2 Castleman disease A rare disease of lymph nodes and related tissues. AKA Giant lymph node hyperplasia or angiofollicular lymph node hyperplasia (AFH). It’s a lymphoproliferative disorder that results in an abnormal overgrowth of lymph cells • D49.51- Neoplasm of unspecified behavior of kidney • D49.59 Neoplasm of unspecified behavior of other genitourinary organ Chapter 3 – Diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism (D50-D89) 34 • Instructional note code title revisions • Excludes 1 corrected to Excludes 2: D61.81 Pancytopenia • Pancytopenia (due to) (with) myelodysplastic syndromes (D46.-) D64.81 Anemia due to antineoplastic chemotherapy • Anemia in neoplastic disease (D63.0) • NEW CODES: D89.4- Mast cell activation syndrome and related disorders • AKA Mast cell activation disorder (MCAD) is an immunological condition in which mast cells inappropriately and excessively release chemical mediators resulting in a range of chronic symptoms such as dermatological, gastrointestinal, neurological, cardiovascular, and respiratory Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 35 • New Diabetes Mellitus category codes (E08-, E09-, E10-, E11-, E13-) “use additional” instructional notes related to new Z79.84 Long term (current) use of oral hypoglycemic drugs: Use additional code to identify control using: Insulin (Z79.4) Oral antidiabetic drugs (Z79.84) Oral hypoglycemic drugs (Z79.84) Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 36 • New Diabetes Mellitus category codes’ (E08-, E09-, E10-, E11-, E13-) 7th characters for laterality of ophthalmic complications: -.32 -.33 -.34 -.35 -.37 Diabetes Diabetes Diabetes Diabetes Diabetes mellitus mellitus mellitus mellitus mellitus . . . . . . . . . . . . . . . with with with with with mild nonproliferative diabetic retinopathy moderate nonproliferative diabetic retinopathy severe nonproliferative diabetic retinopathy proliferative retinopathy diabetic macular edema, resolved following treatment One of the following 7th characters is to be assigned to codes in subcategory _____ to designate laterality of the disease: 1 right eye 2 left eye 3 bilateral 9 unspecified eye Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 37 New codes: Diabetes mellitus category codes (E08-, E09-, E10-, E11-, E13-) -.352 Diabetes mellitus . . .with proliferative diabetic retinopathy with traction retinal detachment involving the macula -.353 Diabetes mellitus . . . with proliferative diabetic retinopathy with traction retinal detachment not involving the macula -.354 Diabetes mellitus . . . with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment -.355 Diabetes mellitus . . . with stable proliferative diabetic retinopathy -.37X Diabetes mellitus . . . with diabetic macular edema, resolved following treatment • (all of the above with the new 7th character for eye laterality) Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) • Proliferative retinopathy: new growth of small blood vessels from the retina that bleed easily causing scar tissue that shrinks and pulls off (detaches) the retina causing blindness. Treated with laser. Common diabetic complication. • Traction retinal detachment: scar tissue or other abnormal tissue grows on the retina causing the retina to pull away from the layer below (detachment); proliferative retinopathy is the most common cause of this detachment • Rhegmatogenous retinal detachment: most common type of detachment; caused by holes or tears in the retina that allow fluid to build up under the retina, pushing it away (detachment) from the layer below 38 Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 39 • New instructional notes E16.0 Drug-induced hypoglycemia without coma • Excludes 1: diabetes with hypoglycemia without coma (E09.692) E16.1 Other hypoglycemia • Excludes 1: diabetes with hypoglycemia (E08.649, E10.649, E11.649, E13.649 E16.2 Hypoglycemia, unspecified • Excludes 1: diabetes with hypoglycemia (E08.649, E10.649, E11.649, E13.649 E66.2 Morbid (severe) obesity with alveolar hypoventilation • Obesity hypoventilation syndrome (OHS) E86 Volume depletion • Use Additional code(s) for any associated disorders of electrolyte and acid-base balance (E87.-) • Revised instructional notes Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 40 New codes: E78.00 Pure hypercholesterolemia, unspecified E78.01 Familial hypercholesterolemia • An autosomal dominant disorder that causes severe elevations in total cholesterol and low-density lipoprotein cholesterol Chapter 4 – Endocrine, nutritional and metabolic diseases (E00-E89) 41 • Diabetes index addition: uncontrolled meaning hyperglycemia – see Diabetes, by type, with, hyperglycemia hypoglycemia – see Diabetes, by type, with hypoglycemia NOT THE SAME AS: “inadequately controlled,” or “out of control” or “poorly controlled”: code to Diabetes, by type, with hyperglycemia • NOT ADDED: Diabetes Mellitus, type 2, with ketoacidosis • Continue to assign E13.10 Other specified diabetes mellitus with ketoacidosis without coma • Above coding advice from Coding Clinic, 1Q2013, pp 26-27, and re-cited in Coding Clinic 2Q2016, p. 10 Chapter 5 – Mental, behavioral and neurodevelopmental disorders (F01-F99) • Added instructional notes • For example: F02 Dementia in other diseases classified elsewhere Includes: Major neurocognitive disorder in other diseases classified elsewhere Code first dementia with Parkinsonism (G31.83) Huntington’s disease (G10) Prion disease (A81.9) Traumatic brain injury (S06.-) F10.10 Alcohol abuse, uncomplicated Alcohol use disorder, mild F10.20 Alcohol dependence, uncomplicated Alcohol use disorder, moderate Alcohol use disorder, severe 42 Chapter 5 – Mental, behavioral and neurodevelopmental disorders (F01-F99) 43 • Excludes 1 corrected to Excludes 2: F10.22 Alcohol dependence with intoxication • Alcohol dependence with withdrawal (F10.23-) F10.23 Alcohol dependence with withdrawal • Alcohol dependence with intoxication (F10.22-) • Excludes 1 notes added: F32.81 Premenstrual dysphoric disorder • Excludes 1: premenstrual tension syndrome (N94.3) F42.4 Excoriation (skin-picking) disorder • Excludes 1: factitial dermatitis (L98.1) • Other specified behavioral and emotional disorders with onset usually occurring in early childhood and adolescence (F98.8) F44.0 Dissociative amnesia • Excludes 1: dissociative amnesia with dissociative fugue (F44.1) Chapter 6 – Diseases of the nervous system (G00-G99) 44 • Excludes 1 corrected to Excludes 2: G40 Epilepsy and recurrent seizures • • • • Hippocampal sclerosis (G93.81) Mesial temporal sclerosis (G93.81) Temporal sclerosis (G93.81) Todd’s paralysis (G83.84) New codes: G61.82 Multifocal motor neuropathy • MNN is a progressively worsening condition wherein muscles in the extremities gradually weaken Chapter 6 – Diseases of the nervous system (G00-G99) New codes for BILATERAL: G56.03 G56.13 G56.23 G56.43 G56.83 G56.93 G57.03 G57.13 G57.23 G57.33 G57.43 G57.53 G57.63 G57.73 G57.83 G57.93 Carpal tunnel syndrome, bilateral upper limbs Other lesions of median nerve, bilateral upper limbs Lesion of ulnar nerve, bilateral upper limbs Causalgia of bilateral upper limbs Other specified mononeouropathies of bilateral upper limbs Unspecified mononeuropathy of bilateral upper limbs Lesion of sciatic nerve, bilateral lower limbs Meralgia paresthetica, bilateral lower limbs Lesion of femoral nerve, bilateral lower limbs Lesion of lateral popliteal nerve, bilateral lower limbs Lesion of medial popliteal nerve, bilateral lower limbs Tarsal tunnel syndrome, bilateral lower limbs Lesion of plantar nerve, bilateral lower limbs Causalgia of bilateral lower limbs Other specified mononeuropathies of bilateral lower limbs Unspecified mononeuropathy of bilateral lower limbs 45 Chapter 7 – Diseases of the eye and adnexa (H00-H59) • Excludes 1 revised to Excludes 2: H42 Glaucoma in diseases classified elsewhere • Glaucoma (in) diabetes mellitus (E08.39, E09.39, E10.39, E11.39, E13.39) 46 Chapter 7 – Diseases of the eye and adnexa (H00-H59) 47 • 7th characters added to codes: H34.81 Central retinal vein occlusion H34.83 Tributary (branch) retinal vein occlusion • 0 with macular edema • 1 with retinal neovascularization • 2 stable H35.31 Nonexudative age-related macular degeneration H35.32 Exudative age-related macular degeneration • • • • 0 stage unspecified 1 with active choroidal neovascularization 2 with inactive choroidal neovascularization with involuted or regressed neovascularization 3 with inactive scar Chapter 7 – Diseases of the eye and adnexa (H00-H59) 48 New codes: H35.311 Nonexudative age-related macular degeneration, right eye H35.312 Nonexudative age-related macular degeneration, left eye H35.313 Nonexudative age-related macular degeneration, bilateral H35.319 Nonexudative age-related macular degeneration, unspecified eye • Or “dry,” is associated with the presence of drusen [yellow deposits under the retina made up of lipids] and is generally much slower to progress to visual loss compared to exudative age-related macular degeneration • Age-related macular degeneration (ARMD) signs and symptoms: • • • • Difficulty with night vision and changing light conditions Visual fluctuation Difficulty with reading and making out faces Distortion of visual images Chapter 7 – Diseases of the eye and adnexa (H00-H59) 49 New codes: H35.321 Exudative age-related macular degeneration, right eye H35.322 Exudative age-related macular degeneration, left eye H35.323 Exudative age-related macular degeneration, bilateral H35.329 Exudative age-related macular degeneration, unspecified eye • In “wet,” (exudative) form, pathologic choroidal neovascular membranes (CNVM) develop under the retina causing fluid and blood leakage. Faster progression to visual loss than the “dry” form. • Signs and symptoms: • Subretinal fluid • Retinal pigment epithelial (RPE) detachments • Subretinal hemorrhage • Subretinal lipid deposits (occasionally) • Painless, progressive blurring of central visual acuity Chapter 7 – Diseases of the eye and adnexa (H00-H59) 50 New codes: H40.111 Primary open-angle glaucoma, right eye H40.112 Primary open-angle glaucoma, left eye H40.113 Primary open-angle glaucoma, bilateral H40.119 Primary open-angle glaucoma, unspecified eye • A multifactorial optic neuropathy that is chronic and progressive; includes an acquired loss of optic nerve fibers that develops in the presence of open anterior chamber angles. Chapter 7 – Diseases of the eye and adnexa (H00-H59) 51 New codes: H53.041 Amblyopia suspect, right eye H53.042 Amblyopia suspect, left eye H53.043 Amblyopia suspect, bilateral H53.049 Amblyopia suspect, unspecified eye • Vision in one of the eyes is reduced because the eye and brain are not working together properly; also called “lazy eye.” Occurs in any condition that prevents the eye from focusing clearly such as with misalignment of the two eyes in strabismus or with the clouding caused by cataracts. Chapter 8 – Diseases of the ear and mastoid process (H60-H95) 52 • Instructional note revisions • NEW codes: H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side H90.A21 Sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A22 Sensorineural hearing loss, unilateral, left ear with restricted hearing on the contralateral side H90.A31 Mixed conductive hearing loss, unilateral, right ear with restricted hearing on the contralateral side H90.A32 Mixed conductive hearing loss, unilateral, left ear with restricted hearing on the contralateral side Chapter 8 – Diseases of the ear and mastoid process (H60-H95) 53 New Codes: H93.A1 Pulsatile tinnitus, right ear H93.A2 Pulsatile tinnitus, left ear H93.A3 Pulsatile tinnitus, bilateral H93.A9 Pulsatile tinnitus, unspecified ear • Pulsatile tinnitus: ear noise perceived as a rhythmic pulsing, often in time with the heartbeat. Can be a thumping or whooshing sound. Also called vascular tinnitus as it originates within the blood vessels in the head or neck region when blood flow is disturbed either as an increase in flow or due to narrowing of the blood vessel. It is unrelated to continuous tinnitus which results from damage to the cochlea and/or hearing nerve. Chapter 9 – Diseases of the circulatory system (I00-I99) 54 • Corrections to instructional notes: • Excludes 1 to Excludes 2: Hypertensive diseases (I10-I16) • Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16) I42 Cardiomyopathy • Ischemic cardiomyopathy (I25.5) • Peripartum cardiomyopathy (O90.3) I50 Heart failure • Cardiac arrest (I46.-) I50.9 Heart failure, unspecified • Fluid overload (E87.10) I60 Nontraumatic subarachnoid hemorrhage • Sequelae of subarachnoid hemorrhage (I69.0-) I61 Nontraumatic intracerebral hemorrhage • Sequelae of intracerebral hemorrhage (I69.1-) Chapter 9 – Diseases of the circulatory system (I00-I99) • Corrections to instructional notes: • Excludes 1 to Excludes 2: I62 Other and unspecified nontraumatic intracranial hemorrhage • Sequelae of intracranial hemorrhage (I69.2) I63 Cerebral infarction • Sequelae of cerebral infarction (I69.3-) I67 Other cerebrovascular diseases • Sequelae of the listed conditions (I69.8) • Correction: I96 Gangrene, not elsewhere classified • Now: gangrene in diabetes mellitus (E08-E13 with .52) 55 Chapter 9 – Diseases of the circulatory system (I00-I99) 56 • New instructional notes: • I20.8 Other forms of angina pectoris Stable angina • I63 Cerebral infarction Use Additional code, if known, to indicate National Institutes of Health Stroke Scale (NIHSS) score (R29.7-) • I72- Other aneurysm Excludes 2: dissection of precerebral artery, congenital (nonruptured) Q28.1) • I72.5 Aneurysm of other precerebral arteries Aneurysm of basilar artery (trunk) Excludes 2: aneurysm of carotid artery (I72.0) aneurysm of vertebral artery (I72.6) dissection of carotid artery (I77.71) dissection of other precerebral arteries (I77.75) dissection of vertebral artery (I77.74) Chapter 9 – Diseases of the circulatory system (I00-I99) • New instructional notes: I72.6 Aneurysm of vertebral artery • Excludes 2: dissection of vertebral artery (I77.74) I87.2 Venous insufficiency (chronic)(peripheral) • Excludes 1: stasis dermatitis with varicose veins of lower extremities (I83.1-, I83.2-) • Deleted instructional notes: I83.1 Varicose veins of lower extremities with inflammation I87.2 Venous insufficiency (chronic)(peripheral) Stasis dermatitis 57 Chapter 9 – Diseases of the circulatory system (I00-I99) 58 NEW Codes: I16 Hypertensive crisis Code also any identified hypertensive disease (I10-I15) I16.0 Hypertensive urgency I16.1 Hypertensive emergency I16.9 Hypertensive crisis, unspecified • Hypertensive crisis: severe increase in blood pressure (BP); urgency or emergency • Hypertensive urgency: severely elevated blood pressure (≥ 180 systolic (top) or ≥ 110 diastolic (bottom) but no associated organ damage. Potential symptoms: severe headache, shortness of breath, nosebleed, severe anxiety. Treatment: immediate evaluation and readjustment and/or additional dosing of oral medications. • Hypertensive emergency: blood pressure levels resulting in damage to organs. BP > 180 systolic OR > 120 diastolic but may be less in patients whose blood pressure had not been previously high. Complications include: stroke, loss of consciousness, memory loss, heart attack, damage to eyes and kidneys, loss of kidney function, aortic dissection, angina (unstable chest pain), pulmonary edema (fluid backup in the lungs), eclampsia Chapter 9 – Diseases of the circulatory system (I00-I99) 59 NEW Codes: • Bilateral Cerebral Infarction Sites: 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 due to thrombosis of bilateral posterior arteries I63.343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries Chapter 9 – Diseases of the circulatory system (I00-I99) 60 NEW Codes: • Bilateral Cerebral Infarction Sites (continued): 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 anterior arteries I63.523 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 Chapter 9 – Diseases of the circulatory system (I00-I99) 61 NEW Codes: different types of cognitive deficits Attention and concentration deficit Memory deficit Visuospatial deficit and spatial neglect Psychomotor deficit Frontal lobe and executive function deficit Cognitive social or emotional deficit Sequelae following: Other symptoms and signs involving cognitive functions Unspecified symptoms and signs involving cognitive functions Subarachnoid hemorrhage I69.010 I69.011 I69.012 I69.013 I69.014 I69.015 I69.018 I69.019 Intracerebral hemorrhage I69.110 I69.111 I69.112 I69.113 I69.114 I69.115 I69.118 I69.119 Other nontraumatic intracranial hemorrhage I69.210 I69.211 I69.212 I69.213 I69.214 I69.215 I69.218 I69.219 Cerebral infarction I69.310 I69.311 I69.312 I69.313 I69.314 I69.315 I69.318 I69.319 Other cerebrovascular disease I69.810 I69.811 I69.812 I69.813 I69.814 I69.815 I69.818 I69.819 Unspecified cerebrovascular disease I69.910 I69.911 I69.912 I69.913 I69.914 I69.915 I69.918 I69.919 Chapter 9 – Diseases of the circulatory system (I00-I99) 62 NEW Codes: I77.70 Dissection of unspecified artery I77.75 Dissection of other precerebral artery I77.76 Dissection of artery of upper extremity I77.77 Dissection of artery of lower extremity • Dissection: separation of the layers of the artery wall resulting from a tear or daage to the inner wall or lining of the artery Chapter 10 – Diseases of the respiratory system (J00-J99) • Excludes 1 corrected to Excludes 2: J44 Other chronic obstructive pulmonary disease Lung diseases due to external agents (J60-J70) • New instructional notes: J47.0 Bronchiectasis with acute lower respiratory infection Use additional code to identify the infection • Deleted instructional notes: J84.89 Other specified interstitial pulmonary diseases Organizing pneumonia due to known underlying cause • MAPPING (Index) CHANGE: Distress acute respiratory J80 J80 Acute Respiratory distress syndrome Distress acute respiratory R06.00 syndrome J80 R06.00 Dyspnea, unspecified 63 Chapter 10 – Diseases of the respiratory system (J00-J99) 64 NEW codes: J98.51 Mediastinitis Code first underlying condition, if applicable, such as postoperative mediastinitis (T81.1-) A life-threatening infection with a high mortality most often associated with cardiac surgery. Symptoms include chest pain, shortness of breath and fever. Diagnosis made from CXR or CT. Treated with antibiotics J98.59 Other diseases of mediastinum, not elsewhere classified Fibrosis of mediastinum: a rare, late complication of histoplasmosis Hernia of mediastinum: congenital or due to aspiration of the mediastinum into the left hemithorax caused by lack of re-expansion of the left lung in patients with bilateral pneumothorax Retraction of mediastinum Chapter 11 – Diseases of the digestive system (K00-K95) • New instructional notes: K02 Dental caries Includes: caries of dentine Early childhood caries Pre-eruptive caries Recurrent caries (dentino enamel junction) (enamel) (to the pulp) K02.52 Dental caries on pit and fissure surface penetrating into dentin Primary dental caries, cervical origin K52.2 Allergic and dietetic gastroenteritis and colitis Excludes 2: allergic eosinophilic colitis (K52.82), Allergic eosinophilic esophagitis (K20.0), Allergic eosinophilic gastritis (K52.81), Allergic eosinophilic gastroenteritis (K52.81), Food protein-induced proctocolitis (K52.82) 65 Chapter 11 – Diseases of the digestive system (K00-K95) • New instructional notes: K52.82 Eosinophilic colitis Allergic proctocolitis Food-induced eosinophilic proctocolitis Food protein-induced proctocolitis Milk protein-induced proctocolitis • Excludes 1 corrected to Excludes 2: K52.81 Eosinophilic gastritis or gastroenteritis Eosinophilic esophagitis (K20.0) 66 Chapter 11 – Diseases of the digestive system (K00-K95) 67 NEW codes: K04.01 Reversible pulpitis • pulp is inflamed and is responding to an irritant, such as dental caries. Symptoms include transient pain or sensitivity to hot/cold/sweet. Removal of the irritant restores pulp to a healthy state K04.02 Irreversible pulpitis • pulp is irreversibly damaged and results in necrosis of the tissue. Symptoms include dull aching, pain fro hot/cold K05.211 Aggressive periodontitis, localized, slight K05.212 Aggressive periodontitis, localized, moderate K05.213 Aggressive periodontitis, localized, severe K05.219 Aggressive periodontitis, localized, unspecified severity • Rapid loss of attachment and bone destruction Chapter 11 – Diseases of the digestive system (K00-K95) 68 NEW codes: K05.221 Aggressive periodontitis, generalized, slight K05.222 Aggressive periodontitis, generalized, moderate K05.223 Aggressive periodontitis, generalized, severe K05.229 Aggressive periodontitis, generalized, unspecified severity This is a form of periodontal disease. Aggressive periodontitis is less common than chronic periodontitis, generally affects younger patients. Results in the rapid loss of attachment of the teeth and bone destruction. Includes depressed neutrophil function. Localized and generalized are distinct forms of this disease. Chapter 11 – Diseases of the digestive system (K00-K95) 69 NEW codes: K05.311 Chronic periodontitis, localized, slight. K05.312 Chronic periodontitis, localized, moderate K05.313 Chronic periodontitis, localized, severe K05.319 Chronic periodontitis, localized, unspecified severity K05.321 Chronic periodontitis, generalized, slight K05.322 Chronic periodontitis, generalized, moderate K05.323 Chronic periodontitis, generalized, severe K05.329 Chronic periodontitis, generalized, unspecified severity A common disease of the oral cavity, involves chronic inflammation of the periodontal tissues caused by accumulation of profuse amounts of dental plaque. Symptoms may included redness or bleeding gums while brushing teeth, using dental floss or biting into hard food, recurrent gum swelling, halitosis (bad breath) and persistent metallic taste in the mouth, gingival recession, loose teeth; however, it may be painless. Chapter 11 – Diseases of the digestive system (K00-K95) 70 NEW codes: K08.81 Primary occlusal trauma K08.82 Secondary occlusal trauma Occlusal trauma results when the occlusal (biting) surface of any of the teeth is altered to the detriment of the teeth. Primary occlusal trauma occurs when greater than normal occlusal forces are placed on the teeth such as with bruxism or other chewing/biting habits involving fingernails, pencils and pens. Secondary occlusal trauma occurs when normal occlusal forces are placed on teeth with compromised periodontal attachment. Chapter 11 – Diseases of the digestive system (K00-K95) 71 NEW codes: K52.21 Food protein-induced enterocolitis syndrome • FPIES is a type of food allergy which involves a non-IgE mediated immune reaction in the GI system to one or more specific foods. Most common foods are cow’s milk and soy. Symptoms include profuse vomiting and diarrhea. Prolonged exposure to these foods results in poor growth. K52.22 Food protein-induced enteropathy • an uncommon malabsorption syndrome of chronic diarrhea, weight loss, and failure to thrive. Most commonly due to cow’s milk protein intolerance. K52.29 Other allergic and dietetic gastroenteritis and colitis • food-related hypersensitivity GI disorders. Symptoms include vomiting, diarrhea, blood in stools, weight loss, abdominal pain, failure to thrive. Chapter 11 – Diseases of the digestive system (K00-K95) 72 NEW codes: K52.831 Collagenous colitis K52.832 Lymphocytic colitis K52.838 Other microscopic colitis K52.839 Microscopic colitis, unspecified Relatively rare conditions that are diagnosed when a patient with chronic watery nonbloody diarrhea with normal radiographic or endoscopic colon but mucosal biopsies show inflammatory changes. Lymphocytic colitis is characterized by an infiltration of lymphocytes in the colonic epithelium. Collagenous colitis has the same lymphocytic infiltration but also has a distinctive thickening of the subepithelial collagen table. Chapter 11 – Diseases of the digestive system (K00-K95) 73 NEW codes: K55.011 Focal (segmental) acute (reversible) ischemia of small intestine K55.012 Diffuse acute (reversible) ischemia of small intestine K55.019 Acute (reversible) ischemia of small intestine, extent unspecified K55.031 Focal (segmental) acute (reversible) ischemia of large intestine K55.032 Diffuse acute (reversible) ischemia of large intestine K55.039 Acute (reversible) ischemia of large intestine, extent unspecified K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified K55.052 diffuse acute (reversible) ischemia of intestine, part unspecified K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified Reduced blood flow to the small or large intestine. More common in the elderly. Causes can include circulation disorders such as low blood pressure or blood vessel stricture or blood clot. Mild to moderate ischemia is treated with IV fluids, analgesia and bowel rest (no food or water by mouth). Chapter 11 – Diseases of the digestive system (K00-K95) 74 NEW codes: K55.021 Focal (segmental) acute infarction of small intestine K55.022 Diffuse acute infarction of small intestine K55.029 Acute infarction of small intestine, extent unspecified K55.041 Focal (segmental) acute infarction of large intestine K55.042 Diffuse acute infarction of large intestine K55.049 Acute infarction of large intestine, extent unspecified K55.061 Focal (segmental) acute infarction of intestine, part unspecified K55.062 Diffuse acute infarction of intestine, part unspecified K55.069 Acute infarction of intestine, part and extent unspecified Severe ischemia can progress to infarction of the small or large intestine resulting in sepsis, intestinal gangrene or bowel perforation. Surgery and intensive care are often required. Chapter 11 – Diseases of the digestive system (K00-K95) 75 NEW codes: K55.30 Necrotizing enterocolitis, unspecified K55.31 Stage 1 necrotizing enterocolitis K55.32 Stage 2 necrotizing enterocolitis K55.33 Stage 3 necrotizing enterocolitis NEC typically occurs in the 2nd-3rd week of life in premature, formula-fed infants. It’s characterized by variable damage to the intestinal tract ranging from mucosal injury to fullthickness necrosis and perforation. Symptoms include abdominal distention and tenderness, feeding residuals, gross or occult blood in stool, absent bowel sounds, temperature instability, glucose instability, lethargy, apnea, bradycardia. Stage 1= suspected NEC, Stage 2 = definite NEC. Stage 3 = Advanced NEC. Chapter 11 – Diseases of the digestive system (K00-K95) 76 NEW codes: K58.1 Irritable bowel syndrome with constipation K58.2 Mixed irritable bowel syndrome K58.8 Other irritable bowel syndrome Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. Commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation. It is a chronic condition. It doesn’t cause changes in bowel tissue or increase colorectal cancer risk. Symptoms range from mild to severe and it’s managed by diet, lifestyle changes, stress reduction. Medication and counseling are also used to managed the disorder. Can be IBS-D (with Diarrhea) or IBS-C (with constipation) or mixed. IBS-D specific codes already defined. Chapter 11 – Diseases of the digestive system (K00-K95) 77 NEW codes: K59.03 Drug induced constipation Use Additional code for adverse effect, if applicable, to identify drug K59.04 Chronic idiopathic constipation (CIC) AKA functional constipation Constipation can be a side effect (adverse effect) of many drugs, including antacids, antihistamines, antipsychotic drugs, aspirin, beta blockers, blood pressure medications, calcium channel blockers, iron or calcium supplements, narcotics (especially opioids), NSAIDS, and tricyclic antidepressants. Stimulant (e.g. Senna, bisacodyl) and Osmotic (e.g. Lactulose, glycerin, polyethylene glycol) are more effective than emollient (e.g. docusate or mineral oil) laxatives for treating drug induced constipation. CIC is simply defined as the chronic presence of constipation without a defined underlying cause. Chapter 11 – Diseases of the digestive system (K00-K95) NEW codes: K85.00 Idiopathic acute pancreatitis without necrosis or infection K85.01 Idiopathic acute pancreatitis with uninfected necrosis K85.02 Idiopathic acute pancreatitis with infected necrosis K85.10 Biliary acute pancreatitis without necrosis or infection K85.11 Biliary acute pancreatitis with uninfected necrosis K85.12 Biliary acute pancreatitis with infected necrosis K85.20 Alcohol induced acute pancreatitis without necrosis or infection K85.21 Alcohol induced acute pancreatitis with uninfected necrosis K85.22 Alcohol induced acute pancreatitis with infected necrosis 78 Chapter 11 – Diseases of the digestive system (K00-K95) NEW codes (continued): K85.30 Drug induced acute pancreatitis without necrosis or infection K85.31 Drug induced acute pancreatitis with uninfected necrosis K85.32 Drug induced acute pancreatitis with infected necrosis K85.80 Other acute pancreatitis without necrosis or infection K85.81 Other acute pancreatitis with uninfected necrosis K85.82 Other acute pancreatitis with infected necrosis K85.90 Acute pancreatitis without necrosis or infection, unspecified K85.91 Acute pancreatitis with uninfected necrosis, unspecified K85.92 Acute pancreatitis with infected necrosis, unspecified 79 Chapter 11 – Diseases of the digestive system (K00-K95) 80 NEW codes (continued): Idiopathic pancreatitis: no cause is identified for the pancreatitis Acute Biliary pancreatitis: a serious complication of biliary calculous disease Alcohol induced pancreatitis: pancreatitis related to heavy alcohol consumption Drug-induced pancreatitis: there is a long list of drugs associated with or found to be contributing factors to acute pancreatitis AKA acute necrotizing pancreatitis, acute pancreatitis with necrosis is a serious related condition. Pancreatic cells die or necrotize during recurring attacks of pancreatitis. Pancreas can then become invaded with bacteria (infection). Pancreatic abscess is a late complication of acute necrotizing pancreatitis. Chapter 11 – Diseases of the digestive system (K00-K95) 81 NEW codes: K86.81 Exocrine pancreatitic insufficiency K86.89 Other specified diseases of pancreas Exocrine pancreatic insufficiency (EPI) is characterized by the deficiency of the exocrine pancreatitic enzymes and results in the inability to digest food properly. Signs and symptoms of this condition are not always evident or similar to those of other GI diseases or are due to dietary restrictions K90.41 Non-celiac gluten sensitivity Gluten sensitivity NOS Gluten sensitivity describes individuals who can’t tolerate gluten and experience symptoms similar to that of celiac disease but lack the same antibodies and intestinal damage that’s present in celiac disease. K90.49 Malabsorption due to intolerance, not elsewhere classified Malabsorption (prevention of absorption of nutrients and fluids in the bowel) due to other types of intolerance such as lactose or fructose intolerance. Chapter 12 – Diseases of the skin and subcutaneous tissue (L00-L99) 82 REVISIONS to and Additions to instructional and excludes notes Mostly technical corrections (e.g., stasis dermatitis (I83.1-.2) to (I87.2) NEW CODES: L98.7 Excessive and redundant skin and subcutaneous tissue Loose or sagging skin following bariatric surgery weight loss Loose or sagging skin following dietary weight loss Loose or sagging skin, NOS • Typically excessive and redundant skin and subcutaneous tissue occurs after massive weight loss • Might also be used with cosmetic procedures Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) • Excludes 1 corrected to Excludes 2: M1A Chronic Gout: acute gout (M10.-) M10 Gout: chronic gout (M1A.-) • Instructional Note Added: M62.84 Sarcopenia (Code first underlying disease, if applicable) • Includes note added: M48.5 Collapsed vertebra, not elsewhere classified Compression fracture of vertebra NOS • Excludes 1 note added: M62.5 Muscle wasting and atrophy, not elsewhere classified Excludes 1: muscle weakness in sarcopenia (M62.84) 83 Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) 84 • Excludes 2 note added: M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified Excludes 2: periprosthethic fracture around internal prosthetic joint (M97.-) M97 Periprosthetic fracture around internal prosthetic joint Excludes 2: fracture of bone following insertion of orthopedic implant, joint prosthesis or bone plate (M96.6-); breakage (fracture of prosthetic joint (T84.01-) • REVISIONS to and ADDITIONS to instructional and excludes notes Technical corrections Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) 85 NEW codes: M04.1 Periodic fever syndromes Includes Familial Mediterranean fever, Hyperimmunoglobulin D syndrome, Mevalonate kinase deficiency, and Tumor necrosis factor receptor associated periodic syndrome (TRAPS) M04.2 Cryoprin-associated periodic syndromes Includes Chronic infantile neurological, cutaneous and articular syndrome (CINCA), Familial cold autoinflammatory syndrome, Familial cold urticaria, Muckle-Wells syndrome, and Neonatal onset multisystemic inflammatory disorder (NOMID) M04.8 Other autoinflammatory sydnromes Includes Blau syndrome, Deficiency of interleukin 1 receptor antagonist (DIRA), Majeed syndrome, Periodic fever, apthous stomatitis, pharyngitis, and adenopathy syndrome (PFAPA), Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (PAPA) M04.9 Autoinflammatory syndrome, unspecified Autoinflammatory syndromes have frequent recurring, often cyclic, fevers with affects on a number of organs and tissues; rash, headache, vomiting, diarrhea, mouth ulcers, swollen lymph nodes, abdominal and joint pains and fatigue are common Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) 86 NEW codes: M21.61 Bunion with laterality (right/left/unspecified), M21.611, M21.612, M21.619 M21.62 Bunionette • • • • • with laterality (right/left/unspecified), M21.621, M21.622, M21.629 “Bunion” removed as an includes term from Hallux valgus (M20.1) “Bunion” is a bump on the side of the foot with the big toe “Bunion” is the deformity known as a hallux abducto valgus that is characterized by a medial deviation of the first metatarsal bone and lateral deviation of the hallux (ie, big toe) “Bunionette” or Tailor’s bunion is found on the little toe on the outside (contralateral from the bunion) of the foot “Bunionette” is a prominence on the lateral aspect of the fifth metatarsal head Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) 87 NEW Codes: M25.54 Pain in joints of hand with laterality (right, left, unspecified) (M25.541, M25.542, M25.549) • Hand joint pain not present; currently just assigned to hand pain (not specific to joint) M26.60 Temporomandibular joint disorder, unspecified M26.61 Adhesions and ankyloses of temporomandibular joint M26.62 Arthralgia of temporomandibular joint M26.63 Articular disc disorder of temporomandibular joint added laterality to all of the above (right, left, bilateral, unspecified) M26.601, M26.602, M26.603, M26.609, M26.611, M26.612, M26.613, M26.619, M26.621, M26.622, M26.623, M26.629, M26.631, M26.632, M26.633, M26.639 Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) NEW codes: • Increased specificity for levels: M50.020 Cervical disc disorder with myelopathy, mid-cervical region, unspecified level M50.021 Cervical disc disorder at C4-C5 level with myelopathy M50.022 Cervical disc disorder at C5-C6 level with myelopathy M50.023 Cervical disc disorder at C6-C7 level with myelopathy M50.120 Mid-cervical disc disorder, unspecified M50.121 Cervical disc disorder at C4-C5 level with radiculopathy M50.122 Cervical disc disorder at C5-C6 level with radiculopathy M50.123 Cervical disc disorder at C6-C7 level with radiculopathy 88 Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) NEW codes: • Increased specificity for levels: M50.220 Other cervical disc displacement, mid-cervical region, unspecified level M50.221 Other cervical disc displacement at C4-C5 level M50.222 Other cervical disc displacement at C5-C6 level M50.223 Other cervical disc displacement at C6-C7 level M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level M50.321 Other cervical disc degeneration at C4-C5 level M50.322 Other cervical disc degeneration at C5-C6 level M50.323 Other cervical disc degeneration at C6-C7 level 89 Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) NEW codes: • Increased specificity for levels: M50.820 Other cervical disc disorders, mid-cervical region, unspecified level M50.821 Other cervical disc disorders at C4-C5 level M50.822 Other cervical disc disorders at C5-C6 level M50.823 Other cervical disc disorders at C6-C7 level M50.920 Unspecified cervical disc disorder, mid-cervical region, unspecified level M50.921 Unspecified cervical disc disorder at C4-C5 level M50.922 Unspecified cervical disc disorder at C5-C6 level M50.923 Unspecified cervical disc disorder at C6-C7 level 90 Chapter 13 – Diseases of the musculoskeletal system and connective tissue (M00-M99) 91 NEW codes: M84.75 Atypical femoral fracture with laterality (right, left, unspecified) and specificity (incomplete, complete transverse, complete oblique) and 7th characters for fractures (A, D, G, K, P, S) M84.750, M84.751, M84.752, M84.753, M84.754, M84.755, M84.756, M84.757, M84.758, M84.759 M97.- Periprosthetic fracture around internal prosthetic joint with laterality (right, left) and specificity (hip, knee, ankle, shoulder, elbow, other and unspecified) and 7th characters for fractures (A, D, S) M97.01, M97.02, M97.11, M97.12, M97.21, M97.22, M97.31, M97.32, M97.41, M97.42, M97.8, M97.9 Chapter 14: Diseases of the genitourinary system (N00-N99) 92 • Revised code titles: N10 Acute tubulo-interstitial nephritis pyelonephritis N40.0 Enlarged prostate Benign prostatic hyperplasia without lower urinary tract symptoms N40.1 Enlarged prostate Benign prostatic hyperplasia with lower urinary tract symptoms N52.39 Other post-surgical and unspecified postprocedural erectile dysfunction N99.113 Postprocedural anterior bulbous urethral stricture N99.520 Hemorrhage of other incontinent external stoma of urinary tract N99.521 Infection of other incontinent external stoma of urinary tract N99.522 Malfunction of other incontinent external stoma of urinary tract N99.528 Other complication of other incontinent external stoma of urinary tract N99.530 Hemorrhage of other continent stoma of urinary tract N99.531 Infection of other continent stoma of urinary tract N99.532 Malfunction of other continent stoma of urinary tract N99.538 Other complication of other continent stoma of urinary tract Chapter 14: Diseases of the genitourinary system (N00-N99) • REVISIONS to and ADDITIONS to instructional and excludes notes Technical corrections (e.g. urethroscrotal fistula (N50.8) to (N50.89) • Instructional Note Added: N39.42 Incontinence without sensory awareness Insensible (urinary) incontinence • Excludes 1 note Added: M36.8 Other specified disorders of urethra Excludes 1: congenital urethrocele (Q64.7); female urethrocele (N81.0) 93 Chapter 14: Diseases of the genitourinary system (N00-N99) 94 NEW codes: N13.0 Hydronephrosis with ureteropelvic junction obstruction Hydronephrosis due to acquired occlusion of ureteropelvic junction Excludes 2: Hydronephrosis with ureteropevlic junction obstruction due to calculus (N13.2) N39.491 Coital incontinence N39.492 Postural (urinary) incontinence • Coital incontinence: involuntary loss of urine with sexual intercourse • Postural incontinence: involuntary loss of urine with change of body position (eg. Rising from a seated or lying position) N42.30 Unspecified dysplasia of prostate N42.31 Prostatic intraepithelial neoplasia N42.32 Atypical small acinar proliferation of prostate N42.39 Other dysplasia of prostate • Precancerous forms of prostate tissue Chapter 14: Diseases of the genitourinary system (N00-N99) NEW codes: N50.81 Testicular pain with laterality (right, left, unspecified) N50.811, N50.812, N50.819 N50.82 Scrotal pain N50.89 Other specified disorders of the male genital organs • Increased specificity for sites of male genital organ pain 95 Chapter 14: Diseases of the genitourinary system (N00-N99) NEW codes: N52.35 Erectile dysfunction following radiation therapy N52.36 Erectile dysfunction following interstitial seed therapy N52.37 Erectile dysfunction following prostate ablative therapy • Increased specificity for types of postprocedural erectile dysfunction N61.0 Mastitis without abscess N61.1 Abscess of the breast and nipple • Increased specificity for abscess of breast/nipple 96 Chapter 14: Diseases of the genitourinary system (N00-N99) 97 NEW codes: N83.0- Follicular cyst of ovary N83.1- Corpus luteum cyst of ovary N83.20- Unspecified ovarian cyst N83.29- Other ovarian cysts N83.31- Acquired atrophy of ovary N83.32- Acquired atrophy of fallopian tube N83.33- Acquired atrophy of ovary and fallopian tube N83.4- Proplase and hernia of ovary and fallopian tube N83.51- Torsion of ovary and ovarian pedicle N83.52- Torsion of fallopian tube laterality added (right, left, unspecified) N83.00, N83.01, N83.02, N83.10, N83.11, N83.12, N83.201, N83.202, N83.209, N83.291, N83.292, N83.299, N83.311, N83.312, N83.319, N83.321, N83.322, N83.329, N83.331, N83.332, N83.339, N83.40, N83.41, N83.42, N83.511, N83.512, N83.519, N83.521, N83.522, N83.529 Chapter 14: Diseases of the genitourinary system (N00-N99) 98 NEW codes: N90.60 Unspecified hypertrophy of vulva N90.61 Childhood asymmetric labium majus enlargement N90.69 Other specified hypertrophy of vulva • Enlargement of the labia • Usually affects the inner labia (labia minora) but can also affect the outer labia (labia majora) • Can be asymetrical, affecting only one side • Symptoms range from none to irritation Chapter 14: Diseases of the genitourinary system (N00-N99) 99 NEW codes: N93.1 Pre-pubertal vaginal bleeding • Can be associated with genital redness, itching, discharge, and pain • Must be distinguished from injury due to sexual abuse N94.10 Unspecified dyspareunia N94.11 Superficial (introtial) dyspareunia N94.12 Deep dyspareunia N94.19 Other specified dyspareunia • Increased specificity • “Painful intercourse” – persistent or recurrent genital pain before/during/after intercourse • Causes range from structural to psychological Chapter 14: Diseases of the genitourinary system (N00-N99) NEW codes: N99.115 Postprocedural fossa navicularis urethral stricture N99.523 Herniation of incontinent stoma of urinary tract N99.524 Stenosis of incontinent stoma of urinary tract N99.533 Herniation of continent stoma of urinary tract N99.534 Stenosis of continent stoma of urinary tract • Increased specificity 100 Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) 101 • Instructional note revisions: Use addition code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy, if known. O24.0- Premature rupture of membranes, onset of labor within 24 hours of rupture Premature rupture of membranes at or after 37 completed weeks of gestation, onset of labor within 24 hours of rupture • Excludes 2 note additions/revisions: O09.81 Supervision of pregnancy resulting from assisted reproductive technology Excludes 2: gestational carrier status (Z33.3) • Excludes 1 note additions/revisions: O99.82 Streptococcus B carrier state complicating pregnancy, childbirth and the puerperium Excludes 1: Carrier of streptococcus group B (GBS) in a nonpregnant woman (Z22.330) Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) 102 • Code title revisions: O09.1- Supervision of pregnancy with history of ectopic or molar pregnancy O15.0- Eclampsia in complicating pregnancy O15.1 Eclampsia in complicating labor O15.2 Eclampsia in complicating the puerperium O24.0- Pre-existing type 1 diabetes mellitus, type 1, in pregnancy, childbirth and the puerperium O24.1- Pre-existing type 2 diabetes mellitus, type 2, in pregnancy, childbirth and the puerperium O44.0- Complete Placenta previa specified as NOS or without hemorrhage O44.1- Complete Placenta previa with hemorrhage O99.33- Tobacco use disorder Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) • 7th characters Added: O33.7 Maternal care for disproportion due to other fetal deformities 0-5, 9 for single gestation and multiple gestations where the fetus is specified • Includes notes added: O34.0 Maternal care for congenital malformation of uterus Maternal care for double uterus, Maternal care for uterus bicornis O34.29 Maternal care due to uterine scar from other previous surgery Maternal care due to uterine scar from other transmural uterine incision 103 Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) NEW codes: O00.00 Abdominal pregnancy without intrauterine pregnancy O00.01 Abdominal pregnancy with intrauterine pregnancy O00.10 Tubal pregnancy without intrauterine pregnancy O00.11 Tubal pregnancy with intrauterine pregnancy O00.20 Ovarian pregnancy without intrauterine pregnancy O00.21 Ovarian pregnancy with intrauterine pregnancy O00.80 Other ectopic pregnancy without intrauterine pregnancy O00.81 Other ectopic pregnancy with intrauterine pregnancy O00.90 Unspecified ectopic pregnancy without intrauterine pregnancy O00.91 Unspecified ectopic pregnancy with intrauterine pregnancy • Codes added to distinguish ectopic pregnancies with or without intrauterine pregnancy 104 Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) NEW codes: 105 O09.A- Supervision of pregnancy with history of molar pregnancy with specificity for trimester (first, second, third, unspecified) Code O09.1- Revised to remove “molar” from code description O11.4 Pre-existing hypertension with pre-eclampsia, complicating childbirth O11.5 Pre-existing hypertension with pre-eclampsia, complicating the puerperium O12.04 Gestational edema, complicating childbirth O12.05 Gestational edema, complicating the puerperium O12.14 Gestational proteinuria, complicating childbirth O12.15 Gestational proteinuria, complicating the puerperium O12.24 Gestational edema with proteinuria, complicating childbirth O12.25 Gestational edema with proteinuria, complicating the puerperium O13.4 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth O13.5 Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating the puerperium • Added time periods for childbirth and puerperium complications Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) NEW codes: O14.04 Mild to moderate pre-eclampsia, complicating childbirth O14.05 Mild to moderate pre-eclampsia, complicating the puerperium O14.14 Severe pre-eclampsia complicating childbirth O14.15 Severe pre-eclampsia complicating the puerperium O14.24 HELLP syndrome, complicating childbirth O14.25 HELLP syndrome, complicating the puerperium O14.94 Unspecified pre-eclampsia, complicating childbirth O14.95 Unspecified pre-eclampsia, complicating the puerperium O16.4 Unspecified maternal hypertension, complicating childbirth O16.5 Unspecified maternal hypertension, complicating the puerperium • Added time periods for childbirth and puerperal complications 106 Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) NEW codes: 107 O24.415 Gestational diabetes mellitus in pregnancy, controlled by oral hypoglycemic drugs O24.425 Gestational diabetes mellitus in childbirth, controlled by oral hypoglycemic drugs O24.435 Gestational diabetes mellitus in puerperium, controlled by oral hypoglycemic drugs • See Coding Guideline I.C.15.i. Gestational (pregnancy induced) diabetes O33.7xx- Maternal care for disproportion due to other fetal deformities added 7th character for single and multiple gestations where the fetus is specified O44.2- Partial placenta previa without hemorrhage O44.3- Partial placenta previa with hemorrhage O44.4- Low lying placenta NOS or without hemorrhage O44.5- Low lying placenta with hemorrhage • Placenta previa is distinguished between partial and total coverage of the cervix, either can be accompanied or not by hemorrhage. Low lying placenta is a placenta attached to the lower part of the uterus near to but not covering the cervix, also may/may not be associated with hemorrhage Chapter 15 – Pregnancy, childbirth and the puerperium (O00-O9A) NEW codes: O70.20 Third degree perineal laceration during delivery, unspecified O70.21 Third degree perineal laceration during delivery, IIIa O70.22 Third degree perineal laceration during delivery IIIb O70.23 Third degree perineal laceration during delivery III • Three subcategories of third-degree tear or laceration are now specified: • 3a: partial tear of the external anal sphincter involving less than 50% thickness • 3b: greater than 50% tear of the external anal sphincter • 3c: internal sphincter is torn 108 Chapter 16 – Certain conditions originating in the perinatal period (P00-P96) 109 Code REVISIONS: P00- Newborn (suspected to be) affected by maternal conditions that may be unrelated to present pregnancy P01- Newborn (suspected to be) affected by maternal complications of pregnancy P02- Newborn (suspected to be) affected by complications of placenta, cord and membranes P03- newborn (suspected to be) affected by other complications of labor and delivery P04- newborn (suspected to be) affected by noxious substances transmitted via placenta or breast milk Explanation: new code created to capture the newborns with suspected conditions ruled out: Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions rule out Chapter 16 – Certain conditions originating in the perinatal period (P00-P96) 110 • Excludes 1 additions: P07.0 Extremely low birth weight newborn P07.1 Other low birth weight newborn Excludes 1: low birth weight due to slow fetal growth and fetal malnutrition (P05.-) NEW codes: P05.09 Newborn light for gestational age, 2500 grams and over P05.19 Newborn small for gestation age, other • Returned the 2,500 gram and over code option to this category Chapter 17 – Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 111 • Includes note additions/revisions: Q25.1 Coarctation of aorta Stenosis of aorta Q82.6 Congenital sacral dimple Parasacral dimple • Excludes 2 note additions/revisions: Q82.6 Congenital sacral dimple Excludes 2: pilonidal cyst with abscess (L05.01); pilonidal cyst without abscess (L05.91) Chapter 17 – Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) NEW codes: Q25.21 Interruption of aortic arch Q25.29 Other atresia of aorta Q25.40 Congenital malformation of aorta unspecified Q25.41 Absence and aplasia of aorta Q25.42 Hypoplasia of aorta Q25.43 Congenital aneurysm of aorta Q25.44 Congenital dilation of aorta Q25.45 double aortic arch Q25.46 Tortuous aortic arch Q25.47 Right aortic arch Q25.48 Anomalous origin of subclavian artery Q25.49 Other congenital malformations of artery • Specific abnormalities (congenital) of the aorta 112 Chapter 17 – Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 113 NEW codes: Q52.120 Longitudinal vaginal septum, nonobstructing Q52.121 Longitudinal vaginal septum, obstructing, right side Q52.122 Longitudinal vaginal septum, obstructing, left side Q52.123 Longitudinal vaginal septum, microperforate, right side Q52.124 Longitudinal vaginal septum, microperforate, left side Q52.129 Other and unspecified longitudinal vaginal septum • A vaginal septum occurs when the female reproductive tract does not develop and merge correctly, creating a dividing wall of tissue inside the vagina • The condition may block normal menstrual flow, may cause pain during intercourse, or be asymptomatic Chapter 17 – Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) 114 NEW codes: Q66.21 Congenital metatarsus primus varus • A congenital deformity of the foot in which the forepart rotates inward toward the midline of the body and the heel remains straight Q66.22 Congenital metatarsus adductus Congenital metatarsus varus • A congenital deformity with adduction of the forefoot at the tarsometatarsal joint Q87.82 Arterial tortuosity syndrome • A disorder that affects connective tissue; it is characterized by blood vessel abnormalities that carry blood from the heart to the rest of the body; tortuosity arises from abnormal elongation of the arteries; the extra length twists and curves and may result in constriction (stenosis) and bulging (aneurysms) of the vessels, as well as small clusters of enlarged blood vessels just under the skin (telangiectasia). Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) 115 • Excludes 1 corrected to Excludes 2: R00 Abnormalities of heart beat: I47-I49 R01 Cardiac murmur, unspecified: Q40.0, K92.0-K92.2, K56.-, P54.0-P54.3, K31.3, R30-R39, N94.-, N48-N50 Symptoms and signs involving the digestive system and abdomen (R10-R19) Q40.0, K92.0-K92.2, K56.-, P54.0-P54.3, P76.-, K31.3, R30-R39, N94.-, N48-N50 Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46) Symptoms and signs constituting part of a pattern of mental disorder F01-F99 Abnormal findings on examination of blood, without diagnosis (R70-R79): O28.-, D69.-, D70-D72, D65-D68, P50-P61 R93.4 Abnormal findings on diagnostic imaging of urinary organs: N28.81 Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) 116 • Includes terms additions/revisions: R01.1 Cardiac murmur, unspecified Systolic murmur NOS • Instructional note change to “Note” R40.24 Glasgow coma scale, total score NOTE: Assign a code from subcategory R40.24 when only the total coma score is documented • Excludes 1 note additions/revisions: R41.84 Other specified cognitive deficit Excludes 1: cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-, I69.21-, I69.31-, I69.81-, I69.91-) Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) 117 NEW codes: R29.70 NIHSS score 0-9 R29.71 NIHSS score 10-19 R29.72 NIHSS score 20-29 R29.73 NIHSS score 30-39 R29.74 NIHSS score 40-42 with specificity to assign exact NIHSS score R29.700, R29.701, R29.702, R29.703, R29.704, R29.705, R29.706, R29.707, R29.708, R29.709, R29.710, R29.711, R29.712, R29.713, R29.714, R29.715, R29.716, R29.717, R29.718, R29.719, R29.720, R29.721, R29.722, R29.723, R29.724, R29.725, R29.726, R29.727, R29.728, R29.729, R29.730, R29.731, R29.732, R29.733, R29.734, R29.735, R29.736, R29.737, R29.738, R29.739, R29.740, R29.741, R29.742 Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) 118 NEW codes: R31.21 Asymptomatic microscopic hematuria • Presence of three or more red blood cells per HPF visible in a urine specimen • No symptoms: common causes include urinary tract infection, benign prostatic hyperplasia, urinary calculi; 5% found to have urologic malignancy R31.29 Other microscopic hematuria R39.191 Need to immediately re-void R39.192 Position dependent micturition R39.198 Other difficulties with micturition • Increased specificity for urination/micturition difficulties Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) NEW codes: R39.82 Chronic bladder pain R40.24-Glasgow coma scale, total score Added 7th character: 0 1 2 3 4 unspecified in the field [EMT or ambulance] at arrival to emergency department at hospital admission 24 hours or more after hospital admission R73.03 Prediabetes • Higher than normal blood sugar but not high enough to be classified as diabetes • A1c 5.7%-6.4%; fasting plasma glucose (FPG) 100-125 mg/dl; GTT 140-199 mg/dl • AKA impaired glucose tolerance or impaired fasting glucose 119 Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) NEW codes: R82.71 Bacteriuria R82.79 Other abnormal findings on microbiological examination of urine • Bacteriuria: presence of bacteria in urine R93.41 Abnormal radiologic findings on imaging of renal pelvis, ureter or bladder R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney R93.422 Abnormal radiologic findings on diagnostic imaging of left kidney R93.429 Abnormal radiologic findings on diagnostic imaging of unspecified kidney R93.49 Abnormal radiologic findings on diagnostic imaging of other urinary organs 120 Chapter 18 – Symptoms, signs and abnormal clinical findings, not elsewhere classified (R00-R99) NEW codes: R97.20 Elevated prostate specific antigen [PSA] R97.21 Rising PSA following treatment for malignant neoplasm of prostate 121 Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) • Excludes 1 changed to Excludes 2: T78.05 Anaphylactic reaction due to tree nuts and seeds: T78.01 • NEW includes note: T82.855 Stenosis of coronary artery stent In-stent stenosis (restenosis) of coronary artery stent Restenosis of coronary artery stent T82.856 Stenosis of peripheral vascular stent In-stent stenosis (restenosis) of peripheral vascular stent Restenosis of peripheral vascular stent 122 Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) 123 LATERALITY ADDED: S02.10- Unspecified fracture of base of skull S02.3- Fracture of orbital floor S02.40- Fracture of malar, maxillary, and zygoma bones S02.6- Fracture of mandible S03.0- Dislocation of jaw S03.4- Sprain of jaw LATERALITY AND SPECIFICITY ADDED: S02.11- Fracture of occiput • Type I, II, and III occipital condyle fractures (Anderson and Montesano classification Type I = impaction, Type II = basilar skull, Type III = occipital condyle avulsion) S99.0- Physeal fracture of calcaneus S99.1- Physeal fracture of metatarsal S99.2- Physeal fracture of phalanx of toe • Salter-Harris Types I, II, III, and IV, and other and unspecified physeal fractures Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) CODES DELETED: 124 S06.0x2 to S06.0x8 Concussion with loss of consciousness of 31 minutes to 59 minutes to Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness T84.04- Periprosthetic fracture around internal prosthetic joint CODE TITLES REVISED: T82.81- Embolism due to of cardiac and vascular prosthetic devices, implants and grafts T82.82- Fibrosis due to of cardiac and vascular prosthetic devices, implants and grafts T82.83- Hemorrhage due to of cardiac and vascular prosthetic devices, implants and grafts T82.84- Pain due to from cardiac and vascular prosthetic devices, implants and grafts T82.85- Stenosis due to of cardiac and vascular prosthetic devices, implants and grafts T82.857 Stenosis of other vascular prosthetic devices, implants and grafts T82.858 Stenosis of other vascular prosthetic devices, implants and grafts T82.867 Thrombosis due to of cardiac prosthetic devices, implants and grafts T82.868 Thrombosis due to of vascular prosthetic devices, implants and grafts Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) 125 CODE TITLES REVISED: T83.711 Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue T83.718 Erosion of other implanted mesh and other prosthetic materials to surrounding organ or tissue T83.721 Exposure of implanted vaginal mesh and other prosthetic materials into vagina T83.728 Exposure of other implanted mesh and other prosthetic materials to surrounding organ or tissue T83.81 Embolism due to of genitourinary prosthetic devices, implants and grafts T83.82 Fibrosis due to of genitourinary prosthetic devices, implants and grafts T83.83 Hemorrhage due to of genitourinary prosthetic devices, implants and grafts T83.84 Pain due to from genitourinary prosthetic devices, implants and grafts T83.85 Stenosis due to of genitourinary prosthetic devices, implants and grafts T83.86 Thrombosis due to of genitourinary prosthetic devices, implants and grafts Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) 126 CODE TITLES REVISED: T85.110 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of brain electrode (lead) T85.111 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of peripheral nerve electrode (lead) T85.112 Breakdown (mechanical) of implanted electronic neurostimulator (electrode) of spinal cord electrode (lead) T85.120 Displacement of implanted electronic neurostimulator (electrode) of brain electrode (lead) T85.121 Displacement of implanted electronic neurostimulator (electrode) of peripheral nerve electrode (lead) T85.122 Displacement of implanted electronic neurostimulator (electrode) of spinal cord electrode (lead) Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) 127 CODE TITLES REVISED: T85.190 Other mechanical complication of implanted electronic neurostimulator (electrode) of brain electrode (lead) T85.191 Other mechanical complication of implanted electronic neurostimulator (electrode) of peripheral nerve electrode (lead) T85.192 Other mechanical complication of implanted electronic neurostimulator (electrode) of spinal cord electrode (lead) T85.610 Breakdown (mechanical) of epidural and subdural cranial or spinal infusion catheter T85.620 Displacement of epidural and subdural cranial or spinal infusion catheter T85.630 Leakage of epidural and subdural cranial or spinal infusion catheter T85.690 Other mechanical complication of epidural and subdural cranial or spinal infusion catheter Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) NEW codes: S92.81- Other fracture of foot with laterality (right, left, unspecified) T83.011 Breakdown (mechanical) of indwelling urethral catheter T83.012 Breakdown (mechanical) of nephrostomy catheter T83.021 Displacement of indwelling urethral catheter T83.022 Displacement of nephrostomy catheter T83.031 Leakage of indwelling urethral catheter T83.032 Leakage of nephrostomy catheter T83.091 Other mechanical complication of indwelling urethral catheter T83.092 Other mechanical complication of nephrostomy catheter T83.24 Erosion of graft of urinary organ T83.25 Exposure of graft of urinary organ • Added specificity for catheter and graft complications 128 Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) NEW codes: 129 T83.510 Infection and inflammatory reaction due to cystostomy catheter T83.511 Infection and inflammatory reaction due to indwelling urethral catheter T83.512 Infection and inflammatory reaction due to nephrostomy catheter T83.518 Infection and inflammatory reaction due to other urinary catheter T83.590 Infection and inflammatory reaction due to implanted urinary neurostimulation device T83.591 Infection and inflammatory reaction due to implanted urinary sphincter T83.592 Infection and inflammatory reaction due to indwelling ureteral stent T83.593 Infection and inflammatory reaction due to other urinary stents T83.598 Infection and inflammatory reaction due to other prosthetic device, implant and graft in urinary system T83.61 Infection and inflammatory reaction due to implanted penile prosthesis T83.62 Infection and inflammatory reaction due to implanted testicular prosthesis T83.69 Infection and inflammatory reaction due to other prosthetic device, implant and graft in genital tract • Added specificity for catheters, stents, prostheses, implants, devices complications Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) 130 NEW codes: T83.712 Erosion of implanted urethral mesh to surrounding organ or tissue T83.713 Erosion of implanted urethral bulking agent to surrounding organ or tissue T83.719 Erosion of other prosthetic materials to surrounding organ or tissue T83.722 Exposure of implanted urethral mesh into urethra T83.723 Exposure of implanted urethral bulking agent into urethra T83.724 Exposure of implanted ureteral bulking agent into ureter T83.729 Exposure of other prosthetic materials into organ or tissue T83.79 Other specified complication due to other genitourinary prosthetic materials T85.123 Displacement of implanted electronic neurostimulator, generator T85.193 Other mechanical complication of implanted electronic neurostimulator, generator • Added specificity implant complications Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) NEW codes: 131 T85.615 Breakdown (mechanical) of other nervous system device, implant or graft T85.625 Displacement of other nervous system device, implant or graft T85.635 Leakage of other nervous system device, implant or graft T85.695 Other mechanical complication of other nervous system device, implant or graft T85.730 Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt T85.731 Infection and inflammatory reaction due to implanted electronic neurostimulator of brain, electrode (lead) T85.732 Infection and inflammatory reaction due to implanted electronic neurostimulator of peripheral nerve, electrode (lead) T85.733 Infection and inflammatory reaction due to implanted electronic neurostimulator of spinal cord, electrode (lead) T85.734 Infection and inflammatory reaction due to implanted electronic neurostimulator, generator T85.735 Infection and inflammatory reaction due to cranial or spinal infusion catheter T85.738 Infection and inflammatory reaction due to other nervous system device, implant or graft • Added specificity for complications Chapter 19 – Injury, poisoning and certain other consequences of external causes (S00-T88) NEW codes: 132 T85.810 Embolism due to nervous system prosthetic devices, implants and grafts T85.818 Embolism due to other internal prosthetic devices, implants and grafts T85.820 Fibrosis due to nervous system prosthetic devices, implants and grafts T85.828 Fibrosis due to other internal prosthetic devices, implants and grafts T85.830 Hemorrhage due to nervous system prosthetic devices, implants and grafts T85.838 Hemorrhage due to other internal prosthetic devices, implants and grafts T85.840 Pain due to nervous system prosthetic devices, implants and grafts T85.848 Pain due to other internal prosthetic devices, implants and grafts T85.850 Stenosis due to nervous system prosthetic devices, implants and grafts T85.858 Stenosis due to other internal prosthetic devices, implants and grafts T85.860 Thrombosis due to nervous system prosthetic devices, implants and grafts T85.868 Thrombosis due to other internal prosthetic devices, implants and grafts T85.890 Other specified complication of nervous system prosthetic devices, implants and grafts T85.898 Other specified complication of other internal prosthetic devices, implants and grafts T85.53 Unintended awareness under general anesthesia during procedure • Added specificity for complications Chapter 20 – External causes of morbidity (V00-Y99): HIGHLIGHTS ONLY 133 NEW CODES W26.2 Contact with edge of stiff paper Paper cut W26.8 Contact with other sharp object(s), not elsewhere classified Contact with tin can lid W26.9 Contact with unspecified sharp object(s) • DELETED: W45.1 Paper entering through skin (Paper cut) and W45.2 Lid of can entering through skin X50.0 Overexertion from strenuous movement or load X50.1 Overexertion from prolonged static or awkward postures X50.3 Overexertion from repetitive movements X50.9 Other and unspecified overexertion or strenuous movements or postures • Added missing overexertion code(s) Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 134 • Excludes 1 corrected to Excludes 2: Z12.4 Encounter for screening for malignant neoplasm of cervix: Z11.51 Z99.2 Dependence on renal dialysis: Z91.15 • Includes note added: Z45.01 Encounter for adjustment and management of cardiac pacemaker Encounter for adjustment and management of cardiac resynchronization therapy pacemaker (CRT-P) Z45.02 encounter for adjustment and management of automatic implantable cardiac defibrillator Encounter for adjustment and management of cardiac resynchronization therapy defibrillator (CRT-D) Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 135 NEW codes: Z05.0 Observation and evaluation of newborn for suspected cardiac condition ruled out Z05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z05.2 Observation and evaluation of newborn for suspected neurological condition ruled out Z05.3 Observation and evaluation of newborn for suspected respiratory condition ruled out Z05.41 Observation and evaluation of newborn for suspected genetic condition ruled out Z05.42 Observation and evaluation of newborn for suspected metabolic condition ruled out Z05.43 Observation and evaluation of newborn for suspected immunologic condition ruled out Z05.5 Observation and evaluation of newborn for suspected gastrointestinal condition ruled out Z05.6 Observation and evaluation of newborn for suspected genitourinary condition ruled out Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 136 NEW codes: Z05.71 Observation and evaluation of newborn for suspected skin and subcutaneous tissue condition ruled out Z05.72 Observation and evaluation of newborn for suspected musculoskeletal condition ruled out Z05.73 Observation and evaluation of newborn for suspected connective tissue condition ruled out Z05.8 Observation and evaluation of newborn for other specified suspected condition ruled out Z05.9 Observation and evaluation of newborn for unspecified condition ruled out • See Coding Guidelines I.C.16.b. Observation and Evaluation of Newborns for Suspected Conditions not Found and I.C.21.c(6) Observation for specific usage and sequencing guidance. Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 137 NEW codes: Z19.1 Hormone sensitivity malignancy status Z19.2 Hormone resistant malignancy status • Certain cancers are hormone sensitive or dependent, ie, they need hormones to grow or develop. Hormone therapies can slow or stop the growth of these cancers Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV) Z29.12 Encounter for prophylactic antivenim Z29.13 Encounter for prophylactic Rho(D) immune globulin Z29.14 Encounter for prophylactic rabies immune globin Z29.3 Encounter for prophylactic fluoride administration Z29.8 Encounter for other specified prophylactic measures Z29.9 Encounter for prophylactic measures, unspecified Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 138 NEW codes: Z30.015 Encounter for initial prescription of vaginal ring hormonal contraceptive Z30.016 Encounter for initial prescription of transferal patch hormonal contraceptive device Z30.017 encounter for initial prescription of implantable subdermal contraceptive Z30.018 Encounter for initial prescription of other contraceptives Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Z30.45 Encounter for surveillance of transdermal patch hormonal contraceptive device Z30.46 Encounter for surveillance of implantable subdermal contraceptive Z30.49 Encounter for surveillance of other contraceptives Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 139 NEW codes: Z31.7 Encounter for procreative management and counseling for gestational carrier Z33.3 Pregnant state, gestational carrier • Codes for gestational surrogate added Z53.31 Laparoscopic surgical procedure converted to open procedure Z53.32 Thoracoscopic surgical procedure converted to open procedure Z53.33 Arthroscopic surgical procedure converted to open procedure Z53.39 Other specified procedure converted to open procedure • Added codes to explain two PCS codes with endoscopic procedure converted to open procedure Chapter 21 – Factors influencing health status and contact with health services (Z00-Z99) 140 New codes: Z79.84 Long term (current) use of oral hypoglycemic drugs • See Coding Guideline I.C.4.a(3) Diabetes mellitus and the use of insulin and oral hypoglycemic and I.C.4.a(6)(a) Secondary diabetes mellitus and the use of insulin or hypoglycemic drugs and I.C.15.h. Long term use of insulin and oral hypoglycemic and I.C.15.i. Gestational (pregnancy induced) diabetes Z83.42 Family history of familial hypercholesterolemia Z84.82 Family history of sudden infant death syndrome Z98.890 Other specified postpocedural states Z98.891 History of uterine scar from previous surgery Excludes 1: Maternal care due to uterine scar from previous surgery (O34.2-) 141