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GUIDE FOR ICD-10’S
AND
AMBULANCE SERVICES
Amanda Jimeson, CPC, CAC
Angela Lehman, RHIA
Rebecca B. Williamson, BA, RN, NRP
TABLE OF CONTENTS
Contents
ICD-10-CM’s ______________________________________________________________________________________________ 1
ICD-10-CM Concepts _____________________________________________________________________________________ 7
General Mapping Equivalence __________________________________________________________________________22
Condition Codes _________________________________________________________________________________________25
Payor Specific ____________________________________________________________________________________________26
Understanding Medical Terminology __________________________________________________________________31
Anatomy and Physiology________________________________________________________________________________32
Vocabulary _______________________________________________________________________________________________33
Abbreviations ____________________________________________________________________________________________42
Understanding Lab Values and Vitals __________________________________________________________________49
Medications ______________________________________________________________________________________________54
Symptoms, Signs and Abnormal Clinical Laboratory Findings ______________________________________56
Great Resource __________________________________________________________________________________________62
Certain Infectious and Parasitic Diseases _____________________________________________________________63
Diseases of Blood, Blood-Forming Organs or Hemorrhage __________________________________________64
Endocrine, Nutritional and Metabolic Diseases _______________________________________________________66
Behavioral Health _______________________________________________________________________________________85
Diseases of the Nervous System ________________________________________________________________________98
Diseases of the Circulatory System __________________________________________________________________ 119
Diseases of the Respiratory System __________________________________________________________________ 143
Diseases of the Digestive System _____________________________________________________________________ 156
Disease of the Skin and Subcutaneous Tissues _____________________________________________________ 160
Diseases of the Musculoskeletal System _____________________________________________________________ 164
Genitourinary __________________________________________________________________________________________ 169
Pregnancy, Childbirth and the Puerperium _________________________________________________________ 174
Injury, Poisoning and Certain Other Consequences of External Causes ___________________________ 178
External Causes of Morbidity _________________________________________________________________________ 189
Factors Influencing Health Status and Contact Health Services ___________________________________ 190
Documentation ________________________________________________________________________________________ 192
TABLE OF CONTENTS
Moving Forward _______________________________________________________________________________________ 195
Resources ______________________________________________________________________________________________ 200
Appendix _______________________________________________________________________________________________ 203
ICD-10-CM’S
ICD-10-CM’s
OVERVIEW
The International Statistical Classification of Disease and Related Health Problems, ICD10, is a medical classification system for coding of:
Diseases
Injuries
Symptoms
Procedures and more
This is the first major change in U.S. coding in more than 30 years.
Some call it healthcare’s version of Y2K.
Expands diagnosis code selections to 68,000+ compared to 14,000 ICD-9-CM selections.
CURRENT REGULATION
Effective January 1, 2012, ICD-9’s were required to be submitted on electronic ambulance
claims to represent a patient’s condition. The determination of what is submitted is based
on the Medicare Administrative Contractors (MAC’s).
•
Option 1: Suppliers may choose codes from the Medical Conditions List provided
by the Centers for Medicare & Medicaid Services (CMS) that corresponds to the
condition of the beneficiary at the time of pickup and report the codes in the
diagnosis field on the claim. The codes in the Medical Conditions List are taken from
the ICD-9-CM diagnosis code set.
Page 1
ICD-10-CM’S
•
Option 2: Suppliers may report an ICD-9-CM (or ICD-10-CM when appropriate)
diagnosis code that is provided to them by the treating physician or other
practitioner.
•
Option 3: Suppliers may report ICD-9-CM diagnosis code 799.9 unspecified illness.
•
Some ambulance services submit ICD-9 codes based on their MAC’s local coverage
determination policy (LCD).
COMPLIANCE DATE
On August 24, 2012, the Department of Health and Human Services (HHS) issued a Final
Rule that delayed the compliance date for the new ICD-10 diagnosis and procedure codes
until October 1, 2014.
The previous compliance deadline of October 1, 2014 was delayed again when President
Barack Obama signed a new law on April 1, 2014. This law ordered HHS to not set an ICD10 deadline any sooner than October 1, 2015. The U.S. Department of Health and Human
Services (HHS) issued in September 2014, a rule finalizing Oct. 1, 2015 as the new
compliance date for health care providers, health plans, and health care clearinghouses to
transition to ICD-10.
Any provider covered by the Health Portability and Accountability Act (HIPAA) must make
the transition to ICD-10’s (MLN Matters Number SE1239).
Claims for services provided on or after the compliance date should be submitted
with ICD-10 diagnosis codes.
Claims for services provided prior to the compliance date should be submitted with
ICD-9 diagnosis codes.
Page 2
ICD-10-CM’S
DEPARTMENT OF HEALTH AND HUMAN SERVICES
MEDLEARN Matters-SE 1409
Effective October 1, 2015
ICD-10 Claims Submission Alternatives
For from dates of services for professional and supplier claims, or discharge dates
on institutional claims on or after October 1, 2015 entities covered under the Health
Insurance Portability Act (HIPAA) are required to use the ICD-10 code sets adopted
under HIPAA.
If a provider or supplier is unable to complete the necessary system changes to
submit claims with ICD-10 codes by October 1, 2015, or find they are unable to
submit claims on or after October 1, 2015, due to issues with their billing software,
vendor, or clearing house, the following claims submission alternatives are
available:
NOTE: claim submission alternatives still REQUIRE the use of ICD-10 code sets for FROM
dates of service (on professional and supplier claims) or date of discharge (on institutional
claims) on or after October 1, 2015.
Free Billing Software
•
Free billing software is offered by CMS via the Electronic Data Interchange
(EDI) via each MAC’s website.
•
This billing software only works for submitting Fee-for-Service claims to
Medicare. It is intended to provide submitters with an ICD-10 compliant
claims submission format; it does not provide coding assistance.
NOTE: Submitting electronic claims to Medicare using the free billing software does not
change the requirement for ICD-10 compliant claims to be submitted for FROM dates of
Page 3
ICD-10-CM’S
service on or after October 1, 2015. Any claims containing ICD-9 codes for FROM dates of
service on or after October 1, 2015, will be rejected by Medicare.
Direct data entry
•
Providers that bill institutional claims are also permitted to submit claims
electronically via direct data entry (DDE) screens. For more information about
DDE, go to http://medicare.fcso.com/Direct_data_entry/.
•
A request to submit claims via DDE must be done by prior to October 1, 2015.
Please note that claims submitted via DDE must contain ICD-10 codes for dates of
discharge/through dates on or after October 1, 2015. Those submitted containing ICD-9
codes for dates of discharge/through dates on or after October 1, 2015, will be returned to
provider (RTP).
Paper claims
•
In limited situations, provider and suppliers may submit paper claims with
ICD-10 codes to Medicare. To find more information on when you may
submit paper claims, visit
http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWai
ver.html
•
A wavier must be submitted before October 1, 2015.
NOTE: Submitting paper claims to Medicare, even if approved for an ASCA waiver, does not
change the requirement for ICD-10 compliant claims to be submitted for FROM dates of
service (on professional and supplier claims) or dates of discharge/through dates (on
institutional claims) on or after October 1, 2015.
Letter from CMS
On July 6, 2015, CMS provided a letter to providers and suppliers detailing that CMS will
be:
Page 4
ICD-10-CM’S
Flexible in claims auditing and quality reporting process.
CMS will set up a communication and collaboration center for monitoring the
implementation of ICD-10’s.
CMS will create an ICD-10 Ombudsman to help triage physician and provider issues.
Further information can be found at www.cms.gov/ICD10.
GEARING UP FOR CHANGE
Change is not easy to embrace, even if the outcome is for the better.
Reasons for change:
o We have to change because the current process is broke; or
o There is a better way to accomplish a task or goal.
WHY THE CHANGE?
Clinical
Better outcomes because of better documentation.
Paints a better picture due to specificity, laterality, and more detailed information
about the disease process.
Improvement of care due to the documentation on higher acuity patients.
Help to design better protocols.
Provides more precise information reporting to the State and other Public Health
entities.
Improved tracking of patient illnesses.
Provides more data for research to develop better patient outcomes; current
system (ICD-9) is archaic compared to other countries.
Operational
Page 5
Improved definitions of patient conditions.
ICD-10-CM’S
For institutional providers, helps with greater specificity to define co-morbidities
and complications.
The ability to share better data based on patient and population.
Financial
Better documentation, which gives ability to understand the patient complexity and
level of care; therefore, supporting reimbursement for the level of care provided.
Allows for better comparison for benchmarking patient conditions.
May aid in lowering audits due to more specific codes supported by greater
documentation.
Page 6
ICD-10-CM CONCEPTS
ICD-10-CM Concepts
ICD-9-CM
Only 17 Chapters
ICD-10-CM
21 Chapters
Page 7
ICD-10-CM CONCEPTS
DOCUMENTATION FOCUS AREAS
Disease type
Disease acuity
Disease stage
Site specific
Laterality
Combination Codes
Changes in timeframes with certain codes
DIFFERENCES
Page 8
ICD-10-CM CONCEPTS
Page 9
ICD-10-CM CONCEPTS
Page 10
ICD-10-CM CONCEPTS
Page 11
ICD-10-CM CONCEPTS
INITIAL VS. SUBSEQUENT VS. SEQUELA
Initial Encounter is While Receiving Active Treatment
o Surgical treatment
o Emergency treatment
o Those who seek a delay in treatment.
Subsequent has completed active care and now in the healing processes.
o Cast change
o Removal of devices
o Follow-up doctor’s visits
Sequela
o Late effect
o A chronic or residual condition that is a complication of an acute condition
that occurs after the acute disease, illness or injury.
Page 12
ICD-10-CM CONCEPTS
Page 13
ICD-10-CM CONCEPTS
Page 14
ICD-10-CM CONCEPTS
ICD-10-CM Official Coding Guidelines
The Centers for Medicare and Medicaid Services (CMS) and the National Center for
Health Statistics (NCHS), two departments within the U.S. Federal Government’s
Department of Health and Human Services (DHHS) provide the following
guidelines for coding and reporting using the International Classification of
Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
These guidelines should be used as a companion document to the official version of
the ICD-10-CM as published on the NCHS website.
These guidelines have been approved by the four organizations that make up the
Cooperating Parties for the ICD-10-CM:
o The American Hospital Association (AHA),
o The American Health Information Management Association (AHIMA),
o CMS, and
o NCHS.
Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is
required under the Health Insurance Portability and Accountability Act (HIPAA).
The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under
HIPAA for all healthcare settings.
Page 15
ICD-10-CM CONCEPTS
Page 16
ICD-10-CM CONCEPTS
Page 17
ICD-10-CM CONCEPTS
Page 18
ICD-10-CM CONCEPTS
Page 19
ICD-10-CM CONCEPTS
Page 20
ICD-10-CM CONCEPTS
Page 21
GENERAL MAPPING EQUIVALENCE
General Mapping Equivalence
Identification of potential corresponding codes between ICD-9 and ICD-10.
Mappings are bi-directional, and goes backwards and forwards.
GEMS are not direct crosswalks; there is not an exact match between more complex
ICD-10-CM codes.
This may limit the likely hood of an exact match.
A single ICD-9 code may map to multiple ICD-10 codes.
o There are new concepts in ICD-10 codes that were not available in ICD-9
codes.
o More than one ICD-9-CM Code may be possible translation of a given ICD10-CM.
Page 22
GENERAL MAPPING EQUIVALENCE
o More than one ICD-9-CM Code may be required to convey the complete
meaning of a given ICD-10-CM.
NATIVE CODING AND UNSPECIFIED CODES
Native coding means to assign an ICD-10 diagnosis code directly based on clinical
documentation.
Providers are encouraged to natively code using ICD-10 code reference sources
instead of using crosswalks, which should be used for general knowledge.
Specific codes reflecting the most appropriate level of certainty known for an
encounter should be evaluated first:
o Specific diagnosis codes should be reported when they are supported by the
available medical record documentation and clinical knowledge of the
patient’s health condition.
o If the end of the encounter has not established a definitive diagnosis, it is
appropriate to report codes for sign(s) and/or symptom(s) in lieu of a
definitive diagnosis.
o When sufficient clinical information is not known or available about a
particular health condition to assign a more specific code, coding should
comply with the payer guidelines for the use of unspecified codes.
Page 23
GENERAL MAPPING EQUIVALENCE
Page 24
CONDITION CODES
Condition Codes
Page 25
PAYOR SPECIFIC
Payor Specific
Workers’ compensation and auto insurance companies are considered non-covered
entities under HIPAA. Will they have to switch to ICD-10-CM?
Answer: Workers' compensation and auto insurance companies are considered noncovered entities and are not covered under HIPAA; however, since the ICD-9-CM codes
will no longer be maintained after the implementation of ICD-10-CM it is recommended
that that they use the new coding system.
Payor Specific Information is based on information available as of July 1, 2015.
Page 26
PAYOR SPECIFIC
Page 27
PAYOR SPECIFIC
Page 28
PAYOR SPECIFIC
Page 29
PAYOR SPECIFIC
Page 30
UNDERSTANDING MEDICAL TERMINOLOGY
Understanding Medical Terminology
Medical billers and medical coders need to be comfortable using and understanding
medical terms in order to apply the correct codes to describe services delivered to
patients.
Very often within the clinical environment, medical terminology is composed of
abbreviations and understanding them makes reading documentation much faster
and easier.
Many of the words used by physicians, surgeons, and other healthcare providers
consist of Greek and Latin root words that are combined to create a multi-syllabic
term that carries a precise meaning.
Most medical terms consist of three basic components:
o root word (the base of the term),
o prefixes (letter groups in front of the root word) and
o suffixes (letter groups at the end of the root word).
For example, the term sub hepatic, “sub” is the prefix meaning “below or under.”
The word root hepat-means “liver” and the suffix –ic means “pertaining to”.
While a medical biller or coder knows what a layperson means when they say that
someone has suffered a heart attack, this term means nothing for coding or billing
purposes.
Medical terminology precisely defines a condition. Professional medical billers are
able to understand the specifics of this terminology in order to communicate it to
third-party payers for accurate reimbursement.
Some of the more commonly used words for EMS documentation are included in
the next few pages.
Page 31
ANATOMY AND PHYSIOLOGY
Anatomy and Physiology
Anatomy
Study of normal body structures.
Physiology
Study of normal, healthy, bodily functions.
Pathophysiology
Study the changes of normal mechanical, physical and biochemical functions.
By understanding the basics of A&P, Billing and Coding can:
•
Gain understanding how diseases affect healthy functions of the organs and
body system.
•
Be better equipped to ask intelligent questions if they need query the
documentation for clarity to ensure appropriate level of billing.
Page 32
VOCABULARY
Vocabulary
aanabad-ad
aden/o
-al
-algia
all/o
amphi-an
andi/o
anteanter/o
anti-ar
arter/o
arteri/o
arthr/o
-ary
-ation
axill/o
bibi/o
bil/i
bradycac/o
carcin/o
cardi/o
-centesis
cephal/o
chem/o
-chezia
chol/e
Page 33
no; not; without
no; not; without
away from
toward
toward
gland
pertaining to
pain
other
around, on both sides, about
pertaining to
vessel (blood)
before; forward
front
against
pertaining to
artery
artery
joint
pertaining to
process; condition
armpit
two
life
bile; gall
slow
bad
cancerous; cancer
heart
surgical puncture to remove fluid
head
drug; chemical
defecation; elimination of wastes
bile; gall
VOCABULARY
chondr/o
chrom/o
-cide
circumcis/o
conconsci/o
contracontus/o
coron/o
corpor/o
cost/o
crani/o
cutane/o
cyan/o
cyst/o
-cyt/o
-cytosis
dederm/o
-derma
-desis
dextr/o
dia-dilation
dilat/o
dipl/o
disdist/o
dolor/o
dors/o
dorsi-dote
duct/o
-dynia
Page 34
cartilage
color
killing
around
to cut
together with
awareness; aware
against; opposite
to bruise
heart
body
rib
skull
skin
blue
urinary bladder; cyst; sac of fluid
cell
condition of cells; slight increase in numbers
lack of; down; less; removal of
skin
skin
to bind; tie together
right
complete; through
widening; stretching; expanding
to enlarge; expand
double
apart; to separate
far; distant
pain
back (of body)
back
to give
to lead; carry
pain
VOCABULARY
dys-eal
ec-ectasia/s
ecto-ectomy
-edema
em-ema
-emesis
-emia
-emic
-en
encephal/o
endendoenter/o
epiepitheli/o
equi-er
erythem/o
erythro
-esis
esoeti/o
euex/oextrafore-form
frig/o
-fusion
gastr/o
-gen
Page 35
bad; painful; difficult; abnormal
pertaining to
out; outside
dilation; dilatation; widening
out; outside
removal; excision; resection
swelling
in
condition
vomiting
blood condition
pertaining to blood condition
in; within
brain
in; within
in; within
intestines (usually small intestine)
above; upon; on
skin; epithelium
equality; equal
one who
flushed; redness
red
action; condition; state of
inward
cause
good; normal
out; away from
outside
before; in front
resembling; in the shape of
cold
to pour; to come together
stomach
substance that produces
VOCABULARY
-genesis
-genic
ger/o
gest/o
gloss/o
gluc/o
glyc/o
-grade
-gram
-graph
graph/o
gravid/o
gynec/o
hapl/o
hem/o
hemat/o
hemihepat/o
hist/o
holohome/o
hydr/o
hyperhypo-ia
-iac
-iasis
-ic
-ical
-icle
in-in/e
-ine
infrainter-
Page 36
producing; forming
produced by or in
old age
pregnancy
tongue
glucose; sugar
glucose; sugar
to go
record
instrument for recording
writing
pregnancy
woman; female
simple; single
blood
blood
half
liver
tissue
entire, complete
sameness; unchanging; constant
water
above; excessive
deficient; below; under; less than normal
condition
pertaining to
abnormal condition
pertaining to
pertaining to
small
in; into; not
a substance; chemical, chemical compound
pertaining to
below; inferior; beneath
between
VOCABULARY
intra-ion
-ior
iris/o
-ism
-itis
labi/o
lal/o
-lalia
lapar/o
-lapse
later/o
-lepsy
levolex/o
lexia
lingu/o
-lipsis
-logist
log/o
-logy
-lysis
-lytic
macromal-malacia
-mania
medi/o
mega
-megaly
mesometa-meter
-metry
Page 37
within; into
process
pertaining to
in
same; equal
process; condition
inflammation
lip
speech
speech
abdominal wall; abdominal
to slide; fall; sag
side
seizure
left
word; phrase
word; phrase
tongue
omit; fail
specialist
study
study (process of)
breakdown; separation; destruction; loosening
to reduce; destroy; separate; breakdown
large
bad
softening
obsessive preoccupation
middle
large
enlargement
middle
change; beyond
measure
process of measuring
VOCABULARY
mi/o
micromon/o
multimy/o
myc/o
mydr/o
necr/o
neonephr/o
neur/o
noct/o
nos/o
ocul/o
-oid
-ole
olig/o
-oma
onc/o
one
-opia
-or
or/o
orth/o
os
-ose
-osis
oste/o
-ous
pale/o
palipalp/o
plapit/o
panpar-
Page 38
smaller; less
small
one; single
many
muscle
fungus
wide
death
new
kidney
nerve
night
disease
eye
resembling; derived from
little; small
scanty
tumor; mass; fluid collection
tumor
mono; uni
vision condition
one who
mouth
straight
opening; mouth
full of; pertaining to
condition (usually abnormal)
bone
pertaining to
old
recurrence; repetition
to touch gently
flutter; throbbing
all
other than; abnormal
VOCABULARY
para-paresis
path/o
-pathy
ped/o
-penia
perperiphag/o
phas/o
-phasia
-phoresis
physi/o
-plasia
-plasty
-plegia
-pnea
pneum/o
polypostpreproproxim/o
pseudopsych/o
-ptosis
py/o
quadriquantquasireretrorhe/o
rhin/o
rot/o
Page 39
near; beside; abnormal; apart from; along the side of
weakness
disease
disease; emotion
child; foot
deficiency
through
surrounding
eat; swallow
speech
speech
carrying; transmission
nature; function
development; formation
surgical repair
paralysis
breathing
lung; air; gas
many; much
after; behind
before; in front of
before; forward
near
false
mind
droop; sag; prolapse; protrude
pus
four; square
how much
to some degree; as if
back; again; backward
behind; back; backward
flow; current; stream
nose
turn; revolve
VOCABULARY
-rrhage
-rrhea
-sclerosis
-scope
sect/o
semi-sepsis
seps/o
sept/o
-sis
somat/o
-spasm
-stasis
-stat
-stenosis
stomat/o
-stomy
subsupersuprasymsyntachy-tension
-therapy
thorac/o
thromb/o
-tic
-tomy
trans-trophy
-ule
ultra-um
uni-
Page 40
bursting forth (of blood)
flow; discharge
hardening
instrument for visual examination
to cut
half
putrefaction
infection
partition
state of; condition
body
sudden contraction of muscles
to stop; control, place
device/instrument for keeping something stationary
tightening; stricture
mouth
new opening
under or below
above; beyond
above; upper
together; with
together; with
fast
pressure
treatment
chest
clot
pertaining to
process of cutting
across; through
nourishment; development (condition of)
little; small
beyond; excess
structure; tissue; thing
one
VOCABULARY
-us
vascul/o
ven/o
ven/i
-verse
-ward
-where
-wise
with-y
Page 41
structure; thing
vessel (blood)
vein
vein
to turn
in the direction of
location
direction
together; united
condition; process
ABBREVIATIONS
Abbreviations
•
Billers and Coders need a list of approved abbreviations used by the Paramedics
and EMT’s in order to understand their documentation.
•
Page 42
As abbreviations are updated they need to be shared with the billing staff.
ABBREVIATIONS
AAA
ABC
abd
AC
a.c.
ACL
ACLS
ad lib
ADL
AEMT
A-fib
AICD
AKA
AKA
AMA
AMI
A/O
A/P
APRN
ASA
B
BBB
b.i.d.
BKA
BLS
BMI
BP or B/P
bpm
BS
BSA
Ca
CABG
CAD
CAT (scan)
CBD
Page 43
abdominal aortic aneurysm
airway, breathing, circulation
abdominal
antecubital (inside of the elbow)
before meals
anterior cruciate ligament
advanced cardiac life support
at liberty (Example: "patient can be up ad lib.")
activities of daily living
advanced level emergency medical technician
atrial fibrillation
automatic implanted cardiac defibrillator
also known as
above the knee amputation
against medical advice
acute myocardial infarction
alert and oriented (as in "A/O x 4)
anterior/posterior
Advanced Practice Registered Nurse
aspirin
Basic (as in: EMT-B)
bundle branch block
twice a day
below the knee amputation
basic life support
body mass index
blood pressure
beats per minute
blood sugar
body surface area
cancer
coronary artery bypass graph
coronary artery disease
computerized axial tomography
complete blood count
ABBREVIATIONS
C/C
CCEMTP
CHF
CNM
c
cm
c-spine
CMS
CNS
C/O
COPD
CP
CPAP
CPR
CSW
CT
CTA
CVA
D5W
D50
DKA
DM
DNR
DOE
DO
DOA
d/t
DVT
dx
ECG
EJ
EKG
EMR
EMT
EMT-P
Page 44
chief complaint
Certified Critical Care Emergency Medical Technician Paramedic
congestive heart failure
Certified Nurse Midwife
with
centimeter
cervical spine
circulation, movement, sensation
central nervous system
complaint of
chronic obstructive pulmonary disease
cerebral palsy
continuous positive airway pressure
cardio pulmonary resuscitation
Clinical Social Worker
computed tomography
clear to auscultation
cerebrovascular accident (stroke)
dextrose 5% in water
dextrose 50%
diabetes ketoacidosis
diabetes mellitus
do not resuscitate
dyspnea on exertion
Doctor of Osteopathy
dead on arrival
due to
deep vein thrombosis
diagnosis
electrocardiograph
external jugular (vein)
electrocardiograph
Emergency Medical Responder
Emergency Medical Technician
Emergency Medical Technician - Paramedic
ABBREVIATIONS
ePCR
ESRD
ESRF
ETA
ETOH
ET / ETT
FBS
FBS
FHT
Fx
G-P
GSW
gtt
Gm
HA
HEENT
H&P
H/O
HPI
h.s.
hx
HTN
ICF
ICP
IDDN
IM
IV
IVP
K
KCl
Kg
L
L&D
LE
LLE
Page 45
electronic patient care report
end stage renal disease
end stage renal failure
estimated time of arrival
alcohol
endotracheal tube
finger stick blood sugar
fasting blood sugar
fetal heart tones
fracture
gravida / Para
gunshot wound
drop / drops
gram
head ache
head, eyes, ears, nose, throat
history and physical
history of
history of present illness
at bedtime
history
hypertension
intermediate care facility
intracranial pressure
insulin dependant diabetes mellitus
intramuscular
intravenous
IV Push
potassium
potassium chloride
kilogram
liter
labor and delivery
law enforcement
left lower extremity
ABBREVIATIONS
LLL
LLQ
LUQ
LMP
LPN
MCL
MD
ME
Mg
MI
Ml
MRI
MRSA
MS
MVA
MVC
NC
NKA
NKDA
NRB
NS
NTG
N/V
N/V/D
Na
NG
NP
npo
NRP
NSR
NSTEMI
O2
OD
O.D
O.S.
Page 46
left lower lobe (of lung)
left lower quadrant (abdominal)
left upper quadrant (abdominal)
last menstrual period
Licensed Practical Nurse
medial collateral ligament
Medical Doctor
Medical Examiner
milligrams
myocardial infarction ("heart attack")
milliliters
magnetic resonance imaging
methicillin resistant staph aureus
morphine sulfate
motor vehicle accident
motor vehicle crash
nasal cannula
no known allergy
no known drug allergy
non-rebreather (oxygen mask)
normal saline
nitroglycerine
nausea and vomiting
nausea, vomiting, and diarrhea
sodium
nasogastric (tube)
Nurse Practioner
nothing by mouth
Nationally Registered Paramedic
normal sinus rhythm
Non-elevated ST segment myocardial infarction
oxygen
overdose
right eye
left eye
ABBREVIATIONS
O.U.
OT
OTC
ORIF
P
P
p
PA
PCR
PD
PE
PE
PEG
PERLA
PERRLA
PICC
PMH
PMS
PPE
prn
pt
PT
PTA
PTAA
q
q.d
q.i.d.
q2h
RLE
RLL
ROM
ROM
RN
R/O
RLQ
Page 47
both eyes
occupational therapy
over the counter
open reduction and internal fixation (such as for a hip fx)
Paramedic
pulse
after
Physician Assistant
patient care report
police department
pulmonary embolus
physical exam
percutaneous endoscopic gastrostomy (PEG tube)
pupils equal, reactive to light and accommodation
pupils equal, round, reactive to light and accommodation
peripherally inserted central catheter (IV line)
past medical history
pulse, movement, sensation
personal protective equipment
as needed
patient
physical therapy
prior to arrival
prior to ambulance arrival
every
each day
four times a day
every two hours
right lower extremity
right lower lobe (of lung)
range of motion
rupture of membranes (pregnancy related)
Registered Nurse
rule out
right lower quadrant (abdomen)
ABBREVIATIONS
RUQ
Rx
s
s/p
SNF
SNT
SOA
SOB
SQ
STEMI
Sx
s/sx
sz
T
t.i.d.
TKO
Tx
UA
US
UTI
V-fib
V-Tach
WNL
wt
right upper quadrant (abdomen)
prescription
without
status post
skilled nursing facility
soft, nontender
shortness of air
shortness of breath
subcutaneous
ST elevation myocardial infarction
symptoms
signs and symptoms
seizure
temperature
three times a day
to keep open (Example: "IV NS TKO")
treatment
urinary analysis
ultrasound
urinary tract infection
ventricular fibrillation
ventricular tachycardia
within normal limits
weight
y/o
year old (Example: "42 y/o female...")
Page 48
UNDERSTANDING LAB VALUES AND VITALS
Understanding Lab Values and Vitals
•
A lab value or vital sign reported as lower or higher than a normal range may not
necessarily indicate a disorder, but:
o It can help support medical necessity; therefore, a biller/coder needs to
understand the normal values.
o It can tell the story of what is going on with the patient and help to define
their disease process.
o Provide information to help a biller/coder to decide the appropriate
diagnosis.
Blood Pressure
•
When measuring blood pressure, your doctor or nurse will use a stethoscope to
listen to the blood moving through an artery.
•
The cuff is inflated to a pressure that’s known to be higher than your systolic blood
pressure. As the cuff deflates, the first sound heard through the stethoscope is the
systolic blood pressure. It sounds like a whooshing noise. When this noise goes
away, that indicates the diastolic blood pressure.
•
The systolic blood pressure number is always said first, and then the diastolic blood
pressure number is given. For example, your blood pressure may be read as "120
over 80" or written as 120/80.
•
Blood pressure is measured in millimeters of mercury (mm Hg).
http://www.webmd.com/hypertension-high-blood-pressure/guide/diastolic-and-systolic-blood-pressure-know-your-numbers
Page 49
UNDERSTANDING LAB VALUES AND VITALS
What can the Blood Pressure tell a biller/coder?
Pulse Ox
A procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is
considered to be a noninvasive, painless, general indicator of oxygen delivery to the
peripheral tissues (such as the finger, earlobe, or nose).
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/oximetry_92,P07754/
What can the Pulse Oximetry tell a biller/coder?
Blood Glucose Test
• Is a way of testing the concentration of glucose in the blood (glycemia).
•
A blood glucose test is performed by piercing the skin (typically, on the finger) to
draw blood, then applying the blood to a chemically active disposable 'test-strip'.
Page 50
UNDERSTANDING LAB VALUES AND VITALS
•
Different manufacturers use different technology, but most systems measure an
electrical characteristic, and use this to determine the glucose level in the blood.
•
The test is usually referred to as capillary blood glucose.
https://en.wikipedia.org/wiki/Blood_glucose_monitoring
What can the Blood Glucose Test tell a biller/coder?
ETCO2(End-Tidal CO2)
•
The level of carbon dioxide released at the end of an exhaled breath (expiration).
•
Carbon dioxide (CO2) reflects cardiac output and pulmonary blood flow as the gas
is transported by the venous system to the heart and then pumped to the lungs.
•
Carbon dioxide concentration reaches a maximum at the end of exhalation.
•
When carbon dioxide diffuses out of the lungs into the exhaled air, the partial
pressure or maximal concentration of the gas at the end of exhalation can be
measured.
What can the ETCO2 Test tell a biller/coder?
•
A high ETCO2 reading in a patient with altered mental status or severe difficulty
breathing may indicate hypoventilation and a possible need for the patient to be
intubated.
•
Page 51
Low ETCO2 readings on patients may indicate hyperventilation.
UNDERSTANDING LAB VALUES AND VITALS
https://en.wikipedia.org/wiki/Capnography
Heart Rate
The heart rate, or pulse, is the number of times your heart beats per minute.
What can the Heart Rate tell a biller/coder?
https://en.wikipedia.org/wiki/Heart_rate
Hemoglobin
•
Protein in red blood cells that carries oxygen
•
Each red blood cell contains several hundred thousand hemoglobin molecules,
which transport oxygen.
Normal values:
Male: 13.8 to 17.2 gm/dL
Female: 12.1 to 15.1 gm/dL
Note: gm/dL = grams per deciliter
What can the Hemoglobin Test tell a biller/coder?
•
Low hemoglobin could indicate anemia.
o Signs and Symptoms: pale skin, weakness, SOB, fainting, palpitations, chest
pain, and restless leg syndrome
Page 52
UNDERSTANDING LAB VALUES AND VITALS
•
High hemoglobin could indicate a lung disease, bone
marrow disorders, overdose or inappropriate use of
the drug epoetin alpha.
Hematocrit (Hct)
Number and size of red blood cells
Performed due to anemia, diet deficiency, and
leukemia.
Normal values:
Male: 40.7-50.3%
Female: 36.1-44.3%
What can the Hematocrit Test tell a biller/coder?
•
•
•
Low hematocrit could indicate anemia, bleeding, leukemia, malnutrition, iron,
folate, B12 & B6 deficiency, or over-hydration.
•
High hematocrit could be a sign of right-sided heart failure, dehydration, hypoxia,
pulmonary fibrosis, bone marrow disease and congenital heart disease.
Page 53
MEDICATIONS
Medications
Medication can help a biller/coder to recognize a patient that has a certain
condition, such insulin for diabetes, or a patient on tamoxifen for breast cancer.
Billing learns important information from medications taken by the patients and
can:
o Help a biller/coder to look for certain conditions and procedures.
o Understand some of the signs and symptoms.
Important Terms
Interosseous-Percutaneous placement of an intravenous catheter into a marrow
cavity provides an alternative route for the administration of fluids and medication
when peripheral blood vessels are collapsed or inaccessible. For EMS purposes, the
proximal tibia or the humerus are the most frequently used sites.
Intramuscular-Within a muscle.
Intranasal-Taken by Nose.
NTG-Used for the prophylaxis and treatment of angina pectoris, the treatment of
congestive heart failure and myocardial infarction
Oral-Taken by mouth.
Subcutaneous-Located, found, or placed just beneath the skin; hypodermic.
Sublingual-Refers to the pharmacological route of administration by which drugs
diffuse into the blood through tissues under the tongue.
Intravenous-Is the infusion of liquid substances directly into a vein
IV Bolus-A large volume of fluid or dose of a drug given intravenously and rapidly
at one time.
IV Drip or Infusion-It is commonly referred to as a drip because many systems of
administration employ a drip chamber, which prevents air from entering the blood
stream (air embolism), and allows an estimation of flow rate.
Page 54
MEDICATIONS
IV Push -Method of quickly injecting medications into a vein.
Number of Dosages-The amount of a therapeutic agent administered.
Routes-Is the path by which a drug, fluid, poison, or other substance is taken into
the body.
Page 55
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
Symptoms, Signs and Abnormal Clinical Laboratory Findings
In medicine a symptom is generally subjective while a sign is objective.
SIGN
Is a disease observed by the doctor, nurse, family members and the patient, such as blood
in the stool, a skin rash.
SYMPTOM
However, stomach, lower-back pain, fatigue, for example, can only be detected or sensed
by the patient - others only know about it if the patient tells them.
Light headache - this can only be a symptom.
• A light headache can only be a symptom because it is only ever detected by
the patient.
High blood sugar - this can only be a sign
• High blood sugar can only be a sign because the patient cannot detect it; it can only
be measured in a medical laboratory.
ICD-10-CM
1. Consist of codes for cases when more specific diagnosis cannot be made even after
all the facts bearing the case have been investigated; and
2. Signs and symptoms existing at the time of the encounter that proved to be the
reason for the encounter.
Many signs and symptoms are grouped by body part or relevant group.
In ambulance transports, code the sign and symptom diagnosis that is the
reason for transport and use any additional codes to support the need for the
transport.
Page 56
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
In ICD-10 coding guidelines, it is acceptable to use signs and symptoms when a
definitive diagnosis cannot be determined, which often times is the case with
emergency transports.
If signs and symptoms are used, it’s a good rule to document in the narrative
box 19 on the CMS claim form.
If a more precise diagnosis is available, refer to your payor guidelines when
coding.
PAIN
Pain is the reason for the transport. Acute onset or bed-confining.
Pain is severity of 7–10 on 10-point severity scale despite pharmacologic
intervention.
Patient needs specialized handling to be moved.
Other emergency conditions are present or reasonably suspected.
Signs of other life- or limb-threatening conditions are present.
Associated cardiopulmonary, neurologic, or peripheral vascular signs and
symptoms are present.
Page 57
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
ICD-10 Code
Code Description
R52
Pain unspecified
FEVER
Significantly high fever unresponsive to pharmacologic intervention.
Adult >102 F after pharmacologic intervention.
Child > 104 F after pharmacologic intervention.
ICD-10 Code
Code Description
R50.81
Fever presenting with other conditions
R50.82
Post procedural fever
R50.83
Post vaccination fever
R50.9
Fever unspecified
HYPOTHERMIA
A disorder characterized by an abnormally low body temperature.
Treatment is required when the body temperature is 35c (95f) or below.
Abnormal low body temperature
Abnormally low body temperature. Treatment is required when the body
temperature is 35c (95f) or below. Symptoms include decreased mental function,
lethargy, and disorientation.
ICD-10 Code
Code Description
R68.0
Hypothermia not associated with weather
Page 58
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
OTHER MALAISE AND FATIGUE
A disorder characterized by a feeling of general discomfort or uneasiness, an out-ofsorts feeling.
A feeling of general discomfort or uneasiness, an out-of-sorts feeling.
A mental disorder characterized by chronic fatigue and concomitant physiologic
symptoms.
Malaise: a vague feeling of physical discomfort or apprehension.
The property of lacking physical or mental strength; liability to failure under pressure
or stress or strain.
ICD-10 Code
Code Description
R53.81
Other malaise
R53.83
Other fatigue
R53.1
Weakness
Page 59
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
OTHER GENERAL SYMPTOMS
ABNORMALITIES OF MOVEMENT
Disorders characterized by lack of coordination of muscle movements resulting in the
impairment or inability to perform voluntary activities. Impairment of the ability to
coordinate the movements required for normal ambulation (walking), which may result
from impairments of motor function or sensory feedback.
ICD-10 Code
Code Description
R26.0
Ataxia gait
Page 60
SYMPTOMS, SIGNS AND ABNORMAL CLINICAL
LABORATORY FINDINGS
R26.1
Paralytic gait
R26.89
Other abnormalities of gait and mobility
R26.9
Unspecified abnormalities of gait and mobility
R27.0
Ataxia, unspecified
R27.8
Other lack of coordination
R27.9
Unspecified lack of coordination
R29.6
Repeated falls
Page 61
GREAT RESOURCE
Great Resource
http://www.roadto10.org/action-plan/phase-2-train/common-codes-other/
Many of the examples were taken from the CMS website.
Page 62
CERTAIN INFECTIOUS AND PARASITIC DISEASES
Certain Infectious and Parasitic Diseases
Infections are grouped by Infections.
o Sexual
o Viral Hepatitis
o Many of the codes have been expanded to reflect manifestations of the
disease; and
o Septicemia is replaced with Sepsis, ALL bloodstream infections are classified
as Sepsis.
WHAT IS SEPSIS?
It is a life threatening system bloodstream infection, originating in the:
Page 63
Urinary Tract
Lungs
GI Tract
Surgical Wound
DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR
HEMORRHAGE
Diseases of Blood, Blood-Forming Organs or Hemorrhage
ANEMIA
Grouped by conditions
•
Nutritional Anemias
•
Hemolytic Anemias
•
Aplastic and Other Anemias and Other Bone Marrow Failure Syndromes.
•
Coagulation Defects, Purpura and Other Hemorrhagic Conditions
•
Other Disorders of Blood Forming Organs.
•
Intraoperative and post procedural complications of the spleen.
•
Certain disorders involving the immune system.
HEMORRHAGE
Potentially life-threatening hemorrhage
Uncontrolled bleeding
Signs of shock and active severe bleeding (quantity identified)
Ongoing or recent bleeding, with potential of immediate re-bleeding
In ICD-9-CM, 459.0-Hemorrhage could be found in the Disease of the Circulatory System
ICD-10 Code
Page 64
Code Description
DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR
HEMORRHAGE
R58
Page 65
Hemorrhage, Not Elsewhere Classified
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Endocrine, Nutritional and Metabolic Diseases
DIABETES MELLITUS
•
Increased level of specificity
•
The diabetes mellitus codes are combination codes that includes:
o The type of body system effected.
o The complications affecting the body system.
Diabetes Mellitus is a disorder in which blood sugar (glucose) levels are abnormally
high because the body does not produce enough insulin.
Insulin, a hormone released from the pancreas, controls the amount of sugar in the
blood. It allows sugar to move from the blood into the cells. Once inside the cells,
sugar is converted to energy.
Types:
Type 1
•
Formerly called insulin-dependent or juvenile-onset diabetes.
•
More than 90% of the insulin-producing cells of the pancreas are permanently
destroyed.
•
The body does not produce enough insulin.
•
Most people with type I diabetes develop the disease before age 30.
Type 2
•
Formerly called non-insulin dependent diabetes or adult-onset diabetes.
•
The pancreas continues to produce insulin, sometimes even at higher than
normal levels.
•
Body develops resistance to the effects of insulin, so there is not enough
insulin to meet the body’s needs.
•
May occur in children and adolescents, but usually begins in people older than
30 and becomes progressively more common with age.
Page 66
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Drug or Chemical Induced
Due to Underlying Condition
Secondary Diabetes
Gestational
No longer classified as controlled/uncontrolled
•
Only classified as diabetes with Hyperglycemia or Hypoglycemia.
•
Defined by out of control, inadequate control, or poorly controlled.
•
If Hypoglycemia it’s coded separately, or
•
Hyperglycemia maybe coded without diabetes.
Complications:
•
What if any other body systems are affected by the diabetes condition? I.e. foot
ulcer.
Treatment:
•
Is the patient on Insulin?
CODING CHANGES
There are five (5) Diabetes Mellitus categories in the ICD-10-CM. They are:
•
E08 Diabetes Mellitus due to an underlying condition
•
E09 Drug or chemical induced diabetes mellitus
•
E10 Type I diabetes mellitus
•
E11 Type 2 diabetes mellitus
•
E13 Other specified diabetes mellitus
Diabetes mellitus codes expanded to include the classification of the diabetes and the
manifestation.
Page 67
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
ICD-10 Code
Code Description
E08.00
Diabetes mellitus due to underlying condition with hyperosmolarity
without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
Diabetes mellitus due to underlying condition with hyperosmolarity
with coma
Diabetes mellitus due to underlying condition with ketoacidosis
without coma
Diabetes mellitus due to underlying condition with ketoacidosis with
coma
Diabetes mellitus due to underlying condition with diabetic
nephropathy
Diabetes mellitus due to underlying condition with diabetic chronic
kidney disease
Diabetes mellitus due to underlying condition with other diabetic
kidney complication
Diabetes mellitus due to underlying condition with unspecified diabetic
retinopathy with macular edema
Diabetes mellitus due to underlying condition with unspecified diabetic
retinopathy without macular edema
Diabetes mellitus due to underlying condition with mild
nonproliferative diabetic retinopathy with macular edema
Diabetes mellitus due to underlying condition with mild
nonproliferative diabetic retinopathy without macular edema
Diabetes mellitus due to underlying condition with moderate
nonproliferative diabetic retinopathy with macular edema
Diabetes mellitus due to underlying condition with moderate
nonproliferative diabetic retinopathy without macular edema
Diabetes mellitus due to underlying condition with severe
nonproliferative diabetic retinopathy with macular edema
Diabetes mellitus due to underlying condition with severe
nonproliferative diabetic retinopathy without macular edema
Diabetes mellitus due to underlying condition with proliferative
diabetic retinopathy with macular edema
Diabetes mellitus due to underlying condition with proliferative
diabetic retinopathy without macular edema
Diabetes mellitus due to underlying condition with diabetic cataract
E08.01
E08.10
E08.11
E08.21
E08.22
E08.29
E08.311
E08.319
E08.321
E08.329
E08.331
E08.339
E08.341
E08.349
E08.351
E08.359
E08.36
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E08.39
E08.620
Diabetes mellitus due to underlying condition with other diabetic
ophthalmic complication
Diabetes mellitus due to underlying condition with diabetic
neuropathy, unspecified
Diabetes mellitus due to underlying condition with diabetic
mononeuropathy
Diabetes mellitus due to underlying condition with diabetic
polyneuropathy
Diabetes mellitus due to underlying condition with diabetic autonomic
(poly)neuropathy
Diabetes mellitus due to underlying condition with diabetic
amyotrophy
Diabetes mellitus due to underlying condition with other diabetic
neurological complication
Diabetes mellitus due to underlying condition with diabetic peripheral
angiopathy without gangrene
Diabetes mellitus due to underlying condition with diabetic peripheral
angiopathy with gangrene
Diabetes mellitus due to underlying condition with other circulatory
complications
Diabetes mellitus due to underlying condition with diabetic
neuropathic arthropathy
Diabetes mellitus due to underlying condition with other diabetic
arthropathy
Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621
Diabetes mellitus due to underlying condition with foot ulcer
E08.622
Diabetes mellitus due to underlying condition with other skin ulcer
E08.628
Diabetes mellitus due to underlying condition with other skin
complications
Diabetes mellitus due to underlying condition with periodontal disease
E08.40
E08.41
E08.42
E08.43
E08.44
E08.49
E08.51
E08.52
E08.59
E08.610
E08.618
E08.630
E08.638
E08.641
Page 69
Diabetes mellitus due to underlying condition with other oral
complications
Diabetes mellitus due to underlying condition with hypoglycemia with
coma
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E08.649
E08.65
E08.69
E08.8
E08.9
E09.00
E09.01
E09.10
E09.11
E09.21
E09.22
E09.29
E09.311
E09.319
E09.321
E09.329
E09.331
E09.339
E09.341
Page 70
Diabetes mellitus due to underlying condition with hypoglycemia
without coma
Diabetes mellitus due to underlying condition with hyperglycemia
Diabetes mellitus due to underlying condition with other specified
complication
Diabetes mellitus due to underlying condition with unspecified
complications
Diabetes mellitus due to underlying condition without complications
Drug or chemical induced diabetes mellitus with hyperosmolarity
without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
Drug or chemical induced diabetes mellitus with hyperosmolarity with
coma
Drug or chemical induced diabetes mellitus with ketoacidosis without
coma
Drug or chemical induced diabetes mellitus with ketoacidosis with
coma
Drug or chemical induced diabetes mellitus with diabetic nephropathy
Drug or chemical induced diabetes mellitus with diabetic chronic
kidney disease
Drug or chemical induced diabetes mellitus with other diabetic kidney
complication
Drug or chemical induced diabetes mellitus with unspecified diabetic
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with unspecified diabetic
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative
diabetic retinopathy with macular edema
Drug or chemical induced diabetes mellitus with mild nonproliferative
diabetic retinopathy without macular edema
Drug or chemical induced diabetes mellitus with moderate
nonproliferative diabetic retinopathy with macular edema
Drug or chemical induced diabetes mellitus with moderate
nonproliferative diabetic retinopathy without macular edema
Drug or chemical induced diabetes mellitus with severe
nonproliferative diabetic retinopathy with macular edema
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E09.349
E09.351
E09.359
E09.36
E09.39
Drug or chemical induced diabetes mellitus with severe
nonproliferative diabetic retinopathy without macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic
retinopathy with macular edema
Drug or chemical induced diabetes mellitus with proliferative diabetic
retinopathy without macular edema
Drug or chemical induced diabetes mellitus with diabetic cataract
E09.620
Drug or chemical induced diabetes mellitus with other diabetic
ophthalmic complication
Drug or chemical induced diabetes mellitus with neurological
complications with diabetic neuropathy, unspecified
Drug or chemical induced diabetes mellitus with neurological
complications with diabetic mononeuropathy
Drug or chemical induced diabetes mellitus with neurological
complications with diabetic polyneuropathy
Drug or chemical induced diabetes mellitus with neurological
complications with diabetic autonomic (poly)neuropathy
Drug or chemical induced diabetes mellitus with neurological
complications with diabetic amyotrophy
Drug or chemical induced diabetes mellitus with neurological
complications with other diabetic neurological complication
Drug or chemical induced diabetes mellitus with diabetic peripheral
angiopathy without gangrene
Drug or chemical induced diabetes mellitus with diabetic peripheral
angiopathy with gangrene
Drug or chemical induced diabetes mellitus with other circulatory
complications
Drug or chemical induced diabetes mellitus with diabetic neuropathic
arthropathy
Drug or chemical induced diabetes mellitus with other diabetic
arthropathy
Drug or chemical induced diabetes mellitus with diabetic dermatitis
E09.621
Drug or chemical induced diabetes mellitus with foot ulcer
E09.622
Drug or chemical induced diabetes mellitus with other skin ulcer
E09.40
E09.41
E09.42
E09.43
E09.44
E09.49
E09.51
E09.52
E09.59
E09.610
E09.618
Page 71
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E09.628
E09.630
E09.638
E09.641
E09.649
E09.65
E09.69
Drug or chemical induced diabetes mellitus with other skin
complications
Drug or chemical induced diabetes mellitus with periodontal disease
Drug or chemical induced diabetes mellitus with other oral
complications
Drug or chemical induced diabetes mellitus with hypoglycemia with
coma
Drug or chemical induced diabetes mellitus with hypoglycemia without
coma
Drug or chemical induced diabetes mellitus with hyperglycemia
E09.9
Drug or chemical induced diabetes mellitus with other specified
complication
Drug or chemical induced diabetes mellitus with unspecified
complications
Drug or chemical induced diabetes mellitus without complications
E10.10
Type 1 diabetes mellitus with ketoacidosis without coma
E10.11
Type 1 diabetes mellitus with ketoacidosis with coma
E10.21
Type 1 diabetes mellitus with diabetic nephropathy
E10.22
Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29
Type 1 diabetes mellitus with other diabetic kidney complication
E10.311
Type 1 diabetes mellitus with unspecified diabetic retinopathy with
macular edema
Type 1 diabetes mellitus with unspecified diabetic retinopathy without
macular edema
Type 1 diabetes mellitus with mild nonproliferative diabetic
retinopathy with macular edema
Type 1 diabetes mellitus with mild nonproliferative diabetic
retinopathy without macular edema
Type 1 diabetes mellitus with moderate nonproliferative diabetic
retinopathy with macular edema
E09.8
E10.319
E10.321
E10.329
E10.331
Page 72
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E10.339
E10.36
Type 1 diabetes mellitus with moderate nonproliferative diabetic
retinopathy without macular edema
Type 1 diabetes mellitus with severe nonproliferative diabetic
retinopathy with macular edema
Type 1 diabetes mellitus with severe nonproliferative diabetic
retinopathy without macular edema
Type 1 diabetes mellitus with proliferative diabetic retinopathy with
macular edema
Type 1 diabetes mellitus with proliferative diabetic retinopathy
without macular edema
Type 1 diabetes mellitus with diabetic cataract
E10.39
Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41
Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42
Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43
Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44
Type 1 diabetes mellitus with diabetic amyotrophy
E10.49
Type 1 diabetes mellitus with other diabetic neurological complication
E10.51
E10.59
Type 1 diabetes mellitus with diabetic peripheral angiopathy without
gangrene
Type 1 diabetes mellitus with diabetic peripheral angiopathy with
gangrene
Type 1 diabetes mellitus with other circulatory complications
E10.610
Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618
Type 1 diabetes mellitus with other diabetic arthropathy
E10.620
Type 1 diabetes mellitus with diabetic dermatitis
E10.341
E10.349
E10.351
E10.359
E10.52
Page 73
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E10.621
Type 1 diabetes mellitus with foot ulcer
E10.622
Type 1 diabetes mellitus with other skin ulcer
E10.628
Type 1 diabetes mellitus with other skin complications
E10.630
Type 1 diabetes mellitus with periodontal disease
E10.638
Type 1 diabetes mellitus with other oral complications
E10.641
Type 1 diabetes mellitus with hypoglycemia with coma
E10.649
Type 1 diabetes mellitus with hypoglycemia without coma
E10.65
Type 1 diabetes mellitus with hyperglycemia
E10.69
Type 1 diabetes mellitus with other specified complication
E10.8
Type 1 diabetes mellitus with unspecified complications
E10.9
Type 1 diabetes mellitus without complications
E11.00
E11.01
Type 2 diabetes mellitus with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC)
Type 2 diabetes mellitus with hyperosmolarity with coma
E11.21
Type 2 diabetes mellitus with diabetic nephropathy
E11.22
Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29
Type 2 diabetes mellitus with other diabetic kidney complication
E11.311
Type 2 diabetes mellitus with unspecified diabetic retinopathy with
macular edema
Type 2 diabetes mellitus with unspecified diabetic retinopathy without
macular edema
Type 2 diabetes mellitus with mild nonproliferative diabetic
retinopathy with macular edema
E11.319
E11.321
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E11.329
E11.36
Type 2 diabetes mellitus with mild nonproliferative diabetic
retinopathy without macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic
retinopathy with macular edema
Type 2 diabetes mellitus with moderate nonproliferative diabetic
retinopathy without macular edema
Type 2 diabetes mellitus with severe nonproliferative diabetic
retinopathy with macular edema
Type 2 diabetes mellitus with severe nonproliferative diabetic
retinopathy without macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy with
macular edema
Type 2 diabetes mellitus with proliferative diabetic retinopathy
without macular edema
Type 2 diabetes mellitus with diabetic cataract
E11.39
Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.40
Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41
Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42
Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43
Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44
Type 2 diabetes mellitus with diabetic amyotrophy
E11.49
Type 2 diabetes mellitus with other diabetic neurological complication
E11.51
E11.59
Type 2 diabetes mellitus with diabetic peripheral angiopathy without
gangrene
Type 2 diabetes mellitus with diabetic peripheral angiopathy with
gangrene
Type 2 diabetes mellitus with other circulatory complications
E11.610
Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.331
E11.339
E11.341
E11.349
E11.351
E11.359
E11.52
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E11.618
Type 2 diabetes mellitus with other diabetic arthropathy
E11.620
Type 2 diabetes mellitus with diabetic dermatitis
E11.621
Type 2 diabetes mellitus with foot ulcer
E11.622
Type 2 diabetes mellitus with other skin ulcer
E11.628
Type 2 diabetes mellitus with other skin complications
E11.630
Type 2 diabetes mellitus with periodontal disease
E11.638
Type 2 diabetes mellitus with other oral complications
E11.641
Type 2 diabetes mellitus with hypoglycemia with coma
E11.649
Type 2 diabetes mellitus with hypoglycemia without coma
E11.65
Type 2 diabetes mellitus with hyperglycemia
E11.69
Type 2 diabetes mellitus with other specified complication
E11.8
Type 2 diabetes mellitus with unspecified complications
E11.9
Type 2 diabetes mellitus without complications
E13.00
E13.01
Other specified diabetes mellitus with hyperosmolarity without
nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
Other specified diabetes mellitus with hyperosmolarity with coma
E13.10
Other specified diabetes mellitus with ketoacidosis without coma
E13.11
Other specified diabetes mellitus with ketoacidosis with coma
E13.21
Other specified diabetes mellitus with diabetic nephropathy
E13.22
Other specified diabetes mellitus with diabetic chronic kidney disease
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E13.29
E13.311
E13.319
E13.321
E13.329
E13.331
E13.339
E13.341
E13.349
E13.351
E13.359
E13.36
E13.39
Other specified diabetes mellitus with other diabetic kidney
complication
Other specified diabetes mellitus with unspecified diabetic retinopathy
with macular edema
Other specified diabetes mellitus with unspecified diabetic retinopathy
without macular edema
Other specified diabetes mellitus with mild nonproliferative diabetic
retinopathy with macular edema
Other specified diabetes mellitus with mild nonproliferative diabetic
retinopathy without macular edema
Other specified diabetes mellitus with moderate nonproliferative
diabetic retinopathy with macular edema
Other specified diabetes mellitus with moderate nonproliferative
diabetic retinopathy without macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic
retinopathy with macular edema
Other specified diabetes mellitus with severe nonproliferative diabetic
retinopathy without macular edema
Other specified diabetes mellitus with proliferative diabetic
retinopathy with macular edema
Other specified diabetes mellitus with proliferative diabetic
retinopathy without macular edema
Other specified diabetes mellitus with diabetic cataract
E13.40
Other specified diabetes mellitus with other diabetic ophthalmic
complication
Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41
Other specified diabetes mellitus with diabetic mononeuropathy
E13.42
Other specified diabetes mellitus with diabetic polyneuropathy
E13.43
Other specified diabetes mellitus with diabetic autonomic
(poly)neuropathy
Other specified diabetes mellitus with diabetic amyotrophy
E13.44
E13.49
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Other specified diabetes mellitus with other diabetic neurological
complication
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E13.51
E13.52
E13.59
E13.610
Other specified diabetes mellitus with diabetic peripheral angiopathy
without gangrene
Other specified diabetes mellitus with diabetic peripheral angiopathy
with gangrene
Other specified diabetes mellitus with other circulatory complications
E13.618
Other specified diabetes mellitus with diabetic neuropathic
arthropathy
Other specified diabetes mellitus with other diabetic arthropathy
E13.620
Other specified diabetes mellitus with diabetic dermatitis
E13.621
Other specified diabetes mellitus with foot ulcer
E13.622
Other specified diabetes mellitus with other skin ulcer
E13.628
Other specified diabetes mellitus with other skin complications
E13.630
Other specified diabetes mellitus with periodontal disease
E13.638
Other specified diabetes mellitus with other oral complications
E13.641
Other specified diabetes mellitus with hypoglycemia with coma
E13.649
Other specified diabetes mellitus with hypoglycemia without coma
E13.65
Other specified diabetes mellitus with hyperglycemia
E13.69
Other specified diabetes mellitus with other specified complication
E13.8
Other specified diabetes mellitus with unspecified complications
E13.9
Other specified diabetes mellitus without complications
E16.1
Other hypoglycemia
E16.2
Hypoglycemia, unspecified
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
O24.011
Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.012
Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
O24.013
Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
O24.019
O24.02
Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified
trimester
Pre-existing diabetes mellitus, type 1, in childbirth
O24.03
Pre-existing diabetes mellitus, type 1, in the puerperium
O24.111
Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
O24.112
Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
O24.113
Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
O24.119
O24.12
Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified
trimester
Pre-existing diabetes mellitus, type 2, in childbirth
O24.13
Pre-existing diabetes mellitus, type 2, in the puerperium
O24.311
Unspecified pre-existing diabetes mellitus in pregnancy, first trimester
O24.312
O24.410
Unspecified pre-existing diabetes mellitus in pregnancy, second
trimester
Unspecified pre-existing diabetes mellitus in pregnancy, third
trimester
Unspecified pre-existing diabetes mellitus in pregnancy, unspecified
trimester
Gestational diabetes mellitus in pregnancy, diet controlled
O24.414
Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419
Gestational diabetes mellitus in pregnancy, unspecified control
O24.313
O24.319
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
O24.420
Gestational diabetes mellitus in childbirth, diet controlled
O24.424
Gestational diabetes mellitus in childbirth, insulin controlled
O24.429
Gestational diabetes mellitus in childbirth, unspecified control
O24.430
Gestational diabetes mellitus in the puerperium, diet controlled
O24.434
Gestational diabetes mellitus in the puerperium, insulin controlled
O24.439
Gestational diabetes mellitus in the puerperium, unspecified control
O24.811
Other pre-existing diabetes mellitus in pregnancy, first trimester
O24.812
Other pre-existing diabetes mellitus in pregnancy, second trimester
O24.813
Other pre-existing diabetes mellitus in pregnancy, third trimester
O24.819
O24.82
Other pre-existing diabetes mellitus in pregnancy, unspecified
trimester
Other pre-existing diabetes mellitus in childbirth
O24.83
Other pre-existing diabetes mellitus in the puerperium
O24.911
Unspecified diabetes mellitus in pregnancy, first trimester
O24.912
Unspecified diabetes mellitus in pregnancy, second trimester
O24.913
Unspecified diabetes mellitus in pregnancy, third trimester
O24.919
Unspecified diabetes mellitus in pregnancy, unspecified trimester
O24.92
Unspecified diabetes mellitus in childbirth
O24.93
Unspecified diabetes mellitus in the puerperium
Z79.4
Long term (current) use of insulin
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Z86.31
Personal history of diabetic foot ulcer
Z86.32
Personal history of gestational diabetes
HYPERGLYCEMIA
•
High blood glucose happens when the body has too little insulin or when the body
can’t use insulin properly.
•
Symptoms :
•
increased thirst
o fatigue
o nausea and vomiting
o dry mouth
o rapid heartbeat
ICD-10 Code
Description
R73.0
Abnormal glucose
R73.09
Other Abnormal glucose
HYPOGLYCEMIA
•
Abnormally low levels of sugar (glucose) in the blood, usually less than 70 mg/dl.
•
Low levels of sugar in the blood interferes with the function of many organ systems.
The brain is particularly sensitive to low sugar levels, because sugar is the brain’s
major energy source.
•
Symptoms:
o shakiness or nervousness
o fatigue
o sweating
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
o hunger
o nausea
o irritability
o irregular or racing heartbeat
o difficulty speaking
o confusion
ICD-10 Code
Description
E16.0
Drug induced hypoglycemia without coma
E16.1
Other hypoglycemia
E16.2
Hypoglycemia unspecified
HYPOGLYCEMIC COMA
•
Life threatening complication that causes unconsciousness.
•
Diabetes, with either dangerously high blood sugar or dangerously low blood sugar,
can lead to a diabetic coma.
ICD-10 Code
Description
E15
Nondiabetic hypoglycemic coma, includes drug-induced insulin coma
in nondiabetic, includes hypoglycemic coma NOS
OBESITY
•
Documentation should give the patient’s height/weight.
•
Any special handling and/or equipment used or the use of extra manpower should
also be documented.
•
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BMI > 80 (Morbid Obesity)
ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
ICD-10 Code
Description
E66.3
Overweight
E66.8
Other obesity
E66.9
Obesity unspecified
VOLUME DEPLETION
Depletion of total body water.
ICD-10 Code
Description
E86
Volume depletion
E86.0
Dehydration
E86.9
Volume depletion unspecified
HYPOVOLEMIA
Depletion of blood volume. Could be caused due to internal bleeding from intestine or
stomach, external bleeding from injury or loss of blood volume and body fluid associated
with diarrhea, vomiting, dehydration or burns.
Signs and symptoms: edema and ascites
ICD-10 Code
Description
E86.1
Hypovolemia (Depletion of volume of plasma
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ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
DEHYDRATION
•
Occurs when the body loses more water than it takes in.
•
Vomiting, diarrhea, the use of diuretics, profuse sweating, and decreased
water intake can all lead to dehydration.
•
Symptoms include
– thirst
– reduced sweating
– reduced skin elasticity
– reduced urine production
– and dry mouth
ICD-10 Code
Description
E86.0
Dehydration
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BEHAVIORAL HEALTH
Behavioral Health
BEHAVIORAL DOCUMENTATION
•
Expressing active signs and/or symptoms of uncontrolled psychiatric condition or
acute substance withdrawal.
•
Is a threat to self or others requiring restraint (chemical or physical).
•
Monitoring and/or intervention of trained medical personnel during transport for
patient and crew safety.
•
Transport required by state law/court order.
•
Disorientation
•
Suicidal Ideations
•
Attempts and gestures
•
Hallucinations
•
Violent or disruptive behavior
•
DT’s
•
Drug withdrawal symptoms
•
Severe anxiety
•
Acute episode or exacerbation of paranoia
ANXIETY
Normal human emotion that everyone experiences at times. The symptoms vary widely
but interfere significantly with normal functioning.
There are several types of anxiety disorders including:
Page 85
BEHAVIORAL HEALTH
•
Mixed Anxiety
•
Panic disorder
•
Social Anxiety Disorder
•
Specific Phobias
•
Generalized Anxiety Disorder
•
Phobias
•
PTSD and Acute Stress Disorder
•
Anxiety caused by physiological or external causes
•
Separation Anxiety
•
Adjustment Disorder
•
Anxiety due to Substance
ICD-10 Code
Code Description
F06.4
Anxiety disorder due to known physiological condition
F40.00
Agoraphobia, unspecified
F40.01
Agoraphobia with panic disorder
F40.02
Agoraphobia without panic disorder
F40.10
Social phobia, unspecified
F40.11
Social phobia, generalized
F40.210
Arachnophobia
F40.218
Other animal type phobia
F40.220
Fear of thunderstorms
F40.228
Other natural environment type phobia
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BEHAVIORAL HEALTH
F40.230
Fear of blood
F40.231
Fear of injections and transfusions
F40.232
Fear of other medical care
F40.233
Fear of injury
F40.240
Claustrophobia
F40.241
Acrophobia
F40.242
Fear of bridges
F40.243
Fear of flying
F40.248
Other situational type phobia
F40.290
Androphobia
F40.291
Gynephobia
F40.298
Other specified phobia
F40.8
Other phobic anxiety disorders
F40.9
Phobic anxiety disorder, unspecified
F41.0
Panic disorder [episodic paroxysmal anxiety] without agoraphobia
F41.1
Generalized anxiety disorder
F41.3
Other mixed anxiety disorders
F41.8
Other specified anxiety disorders
F41.9
Anxiety disorder, unspecified
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BEHAVIORAL HEALTH
F42
Obsessive-compulsive disorder
F43.0
Acute stress reaction
F43.10
Post-traumatic stress disorder, unspecified
F43.11
Post-traumatic stress disorder, acute
F43.12
Post-traumatic stress disorder, chronic
F43.20
Adjustment disorder, unspecified
F43.21
Adjustment disorder with depressed mood
F43.22
Adjustment disorder with anxiety
F43.23
Adjustment disorder with mixed anxiety and depressed mood
F43.24
Adjustment disorder with disturbance of conduct
F43.25
F43.29
Adjustment disorder with mixed disturbance of emotions and
conduct
Adjustment disorder with other symptoms
F51.02
Adjustment insomnia
F93.0
Separation anxiety disorder of childhood
R45.7
State of emotional shock and stress, unspecified
R46.6
Undue concern and preoccupation with stressful events
Z60.0
Problems of adjustment to life-cycle transitions
Z86.51
Personal history of combat and operational stress reaction
Page 88
BEHAVIORAL HEALTH
DELIRIUM
•
Serious disturbance in a person’s mental abilities that results in a decreased
awareness of one’s environment and confused thinking.
•
Delirium can be traced to one or more contributing factors, such as a severe or
chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.
Symptoms:
• Reduced awareness of the environment
– Inability to stay focused on a topic
– Wandering attention
– Being easily distracted by unimportant things
•
Poor thinking skills (cognitive impairment)
– Poor memory, particularly of recent events
– Difficulty speaking or recalling words
– Difficulty understanding speech
•
Behavior changes
– Seeing things that don’t exist (hallucinations)
– Restlessness, agitation, irritability or combative behavior
– Disturbed sleep habits
DEMENTIA
Symptoms
Memory impairment, difficulty with speech, difficulty with motor activity, difficulty
identifying objects, and may have the inability to plan and organize.
Generally in older adults
ICD-10 Code
Page 89
Code Description
BEHAVIORAL HEALTH
F01.50
Vascular dementia without behavioral disturbance
F01.51
Vascular dementia with behavioral disturbance
F02.80
F03.90
Dementia in other diseases classified elsewhere without behavioral
disturbance
Dementia in other diseases classified elsewhere with behavioral
disturbance
Unspecified dementia without behavioral disturbance
F03.91
Unspecified dementia with behavioral disturbance
F10.27
Alcohol dependence with alcohol-induced persisting dementia
F10.97
Alcohol use, unspecified with alcohol-induced persisting dementia
F13.27
F18.17
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or
anxiolytic-induced persisting dementia
Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic
or anxiolytic-induced persisting dementia
Inhalant abuse with inhalant-induced dementia
F18.27
Inhalant dependence with inhalant-induced dementia
F18.97
Inhalant use, unspecified with inhalant-induced persisting dementia
F19.17
G30.0
Other psychoactive substance abuse with psychoactive substanceinduced persisting dementia
Other psychoactive substance dependence with psychoactive substanceinduced persisting dementia
Other psychoactive substance use, unspecified with psychoactive
substance-induced persisting dementia
Alzheimer's disease with early onset
G30.1
Alzheimer's disease with late onset
G30.8
Other Alzheimer's disease
F02.81
F13.97
F19.27
F19.97
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BEHAVIORAL HEALTH
G30.9
Alzheimer's disease, unspecified
R41.81
Age-related cognitive decline
ALCOHOL OR DRUG INTOXICATION
A pattern of abuse of alcohol, drugs, chemicals or external agents.
•
Severe intoxication
•
Unable to care for self
•
Unable to ambulate
•
Altered level of consciousness
ALCOHOL WITHDRAWAL
Symptoms most often occur within 48-96 hours after the last drink. Symptoms can
include:
Page 91
•
Body tremors
•
Changes in mental function
•
Agitation, irritability
•
Confusion, disorientation
•
Decreased attention span
•
Delirium
•
Hallucinations
•
Quick mood changes
•
Restlessness, excitement
•
Sensitivity to light, sound, touch
•
Stupor, sleepiness, fatigue
BEHAVIORAL HEALTH
ALCOHOL WITHDRAWAL DELIRIUM (AWD)
•
Alcohol withdrawal delirium is the most serious form of alcohol withdrawal. It
causes sudden and severe problems in the brain and nervous system.
•
Approximately 5% of hospital patients being treated for alcohol withdrawal also
experience AWD.
•
AWD is also known as delirium tremens or DT’s.
Coding Changes
•
ICD-9-CM subcategory 305.0, alcohol abuse, provides information on whether the
pattern of alcohol use by the patient is continuous, episodic, in remission, or
unspecified.
•
The classification of continuous or episodic alcohol abuse or dependence is not
found in ICD-10-CM.
ICD-10 Code
Description
F10.10
Alcohol abuse, uncomplicated
F10.120
Alcohol abuse with intoxication, uncomplicated
F10.121
Alcohol abuse with intoxication delirium
F10.129
Alcohol abuse with intoxication, unspecified
HALLUCINATIONS
•
Involves seeing things while awake that appear to be real, but instead have been
created by the mind.
•
Common hallucinations include:
o Feeling bodily sensations, such as a crawling feeling on the skin.
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BEHAVIORAL HEALTH
o Hearing sounds, such as music or footsteps.
o Hearing voices when no one has spoken.
o Seeing patterns, lights, beings, or objects that aren’t there.
o Smelling a foul or pleasant odor.
ICD-10 Code
Description
R44.2
Other hallucinations
R44.3
Hallucinations, unspecified
SCHIZOPHRENIA
Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts,
expresses emotions, perceives reality, and relates to others. People with schizophrenia —
the most chronic and disabling of the major mental illnesses — often have problems
functioning in society, at work, at school, and in relationships.
There are nearly 40 ICD-9-CM codes for Schizophrenia, but only 10 in ICD-10-CM.
ICD-10 Code
Description
F20.0
Paranoid schizophrenia
F20.1
Disorganized schizophrenia
F20.2
Catatonic schizophrenia
F20.3
Undifferentiated schizophrenia
F20.5
Residual schizophrenia
F20.8
Other schizophrenia
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BEHAVIORAL HEALTH
F208.1
Schizophreniform disorder
F208.9
Other schizophrenia
F20.9
Schizophrenia, unspecified
F21
Schizotypal disorder
ALTERED LEVEL OF CONSCIOUSNESS
•
Any measure of arousal other than normal.
•
Level of consciousness (LOC) is a measurement of a person’s arousability and
responsiveness to stimuli from the environment.
•
Severe drowsiness in which the patient can be aroused by moderate stimuli and
then drift back to sleep is lethargy.
•
State similar to lethargy in which the patient has a lessened interest in the
environment, slowed responses to stimulation, and tends to sleep more than
normal with drowsiness in between sleep states is obtunded.
•
Stupor means that only vigorous and repeated stimuli will arouse the individual,
and when left undisturbed, the patient will immediately lapse back to the
unresponsive state.
•
Coma is a state of unarousable unresponsiveness.
•
Acute condition with Glasgow Coma Scale < 15.
•
Transient symptoms of dizziness.
•
Associated with neurologic or cardiovascular symptoms and/or signs.
•
Abnormal vital signs
GLASGOW COMA SCALE (GCS)
•
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Neurological scale of recording the conscious state of a person.
BEHAVIORAL HEALTH
Severe, with GCS < 8–9
Moderate, GCS 8 or 9–12
Minor, GCS ≥ 13.
Comma Scale ICD-10-CM-NEW
The scale below will be used by most other health care providers not EMS in an emergency
situation; however, in non-emergency this code may be used if the Coma Scale is going to
be utilized from another healthcare provider.
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BEHAVIORAL HEALTH
When a GCS is taken by the EMS provider the following ICD-10-CM codes can be utilized if
needed or required by the payor.
R40.241 Glasgow Coma Scale score 13-15
R40.242 Glasgow Coma Scale score 9-12
R40.243 Glasgow Coma Scale score 3-8
When a Glasgow Coma Scale score is not documented and the patient is in a coma, or when
only a partial score is reported, assign code:
R40.244, Other coma, without documented Glasgow coma scale score, or with partial score
reported.
Page 96
BEHAVIORAL HEALTH
Primarily used for registries and research use and never should be used as a
primary diagnosis.
When the total score is provided, then per coding guidelines the ICD-10-CM code
R40.241-R40.243 should be used, R40.21, R40.22 and R40.23 is to only be used
when the total GCS is not available.
ICD-10 Code
Description
R40.20
Unspecified coma
R40.0
Somnolence
R40.1
Stupor
R40.3
Persistent vegetative
R41.0
Disorientation, unspecified
R41.81
Age related cognitive decline
R41.82
Altered mental status, unspecified
R41.89
Other symptoms and signs of cognitive functions and awareness
R41.9
Unspecified symptoms involving cognitive functions and awareness
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DISEASES OF THE NERVOUS SYSTEM
Diseases of the Nervous System
SLEEP DISORDERS
Coding Changes
•
Are now in the Disease of the Nervous System instead of Signs and Symptoms.
ALTIZHIMERS
Coding Changes
•
Now reflects onset versus late effects.
EPILEPSY
Epilepsy is a disorder that results from the surges in electrical signals inside the brain,
causing recurring seizures. Seizure symptoms vary. Some people with epilepsy simply
stare blankly for a few seconds during a seizure, while others have convulsions where a
person’s muscles contract and relax repeatedly.
Coding Changes
Terminology
•
Localization-related to idiopathic
•
Generalized idiopathic
•
Special epileptic syndromes
Provide Specificity for:
Page 98
•
Seizures of localized onset
•
Complex partial seizures
•
Intractable
DISEASES OF THE NERVOUS SYSTEM
•
Status epilepticus
– A continuous series of generalized tonic-clonic seizure without return of
consciousness, or any prolonged series of similar seizures without return to
full consciousness between them.
ICD-10
Code
F44.5
Code Description
G40.001
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, not intractable, with status
epilepticus
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, not intractable, without
status epilepticus
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, intractable, with status
epilepticus
Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset, intractable, without status
epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with simple partial seizures, not intractable, with
status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with simple partial seizures, not intractable,
without status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with simple partial seizures, intractable, with
status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with simple partial seizures, intractable, without
status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, not intractable, with
status epilepticus
G40.009
G40.011
G40.019
G40.101
G40.109
G40.111
G40.119
G40.201
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Conversion disorder with seizures or convulsions
DISEASES OF THE NERVOUS SYSTEM
G40.209
G40.801
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, not intractable,
without status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, intractable, with
status epilepticus
Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures, intractable, without
status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, not
intractable, with status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, not
intractable, without status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, intractable,
with status epilepticus
Generalized idiopathic epilepsy and epileptic syndromes, intractable,
without status epilepticus
Other generalized epilepsy and epileptic syndromes, not intractable,
with status epilepticus
Other generalized epilepsy and epileptic syndromes, not intractable,
without status epilepticus
Other generalized epilepsy and epileptic syndromes, intractable, with
status epilepticus
Other generalized epilepsy and epileptic syndromes, intractable,
without status epilepticus
Epileptic seizures related to external causes, not intractable, with status
epilepticus
Epileptic seizures related to external causes, not intractable, without
status epilepticus
Other epilepsy, not intractable, with status epilepticus
G40.802
Other epilepsy, not intractable, without status epilepticus
G40.803
Other epilepsy, intractable, with status epilepticus
G40.804
Other epilepsy, intractable, without status epilepticus
G40.211
G40.219
G40.301
G40.309
G40.311
G40.319
G40.401
G40.409
G40.411
G40.419
G40.501
G40.509
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DISEASES OF THE NERVOUS SYSTEM
G40.811
Lennox-Gastaut syndrome, not intractable, with status epilepticus
G40.812
Lennox-Gastaut syndrome, not intractable, without status epilepticus
G40.813
Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814
Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.821
Epileptic spasms, not intractable, with status epilepticus
G40.822
Epileptic spasms, not intractable, without status epilepticus
G40.823
Epileptic spasms, intractable, with status epilepticus
G40.824
Epileptic spasms, intractable, without status epilepticus
G40.89
Other seizures
G40.901
Epilepsy, unspecified, not intractable, with status epilepticus
G40.909
Epilepsy, unspecified, not intractable, without status epilepticus
G40.911
Epilepsy, unspecified, intractable, with status epilepticus
G40.919
Epilepsy, unspecified, intractable, without status epilepticus
G40.A01
Absence epileptic syndrome, not intractable, with status epilepticus
G40.A09
G40.A11
Absence epilehallptic syndrome, not intractable, without status
epilepticus
Absence epileptic syndrome, intractable, with status epilepticus
G40.A19
Absence epileptic syndrome, intractable, without status epilepticus
G40.B01
Juvenile myoclonic epilepsy, not intractable, with status epilepticus
G40.B09
Juvenile myoclonic epilepsy, not intractable, without status epilepticus
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DISEASES OF THE NERVOUS SYSTEM
G40.B11
Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19
Juvenile myoclonic epilepsy, intractable, without status epilepticus
G83.84
Todd's paralysis (postepileptic)
R56.1
Post traumatic seizures
R56.9
Unspecified convulsions
PARALYSIS
•
Dominant
•
Non-Dominant
•
Unspecified
Hemiplegia Category (G81) – Monoplegia Category (G83.3)
If documentation does not define dominant or non-dominant:
•
Ambidextrous, the default is dominant
•
Left Side, the default is non-dominant
•
Right Side, the default is dominant
SEIZURES
•
Physical findings or changes in behavior that occur after an episode of
abnormal electrical activity in the brain.
•
The term “seizure” is often used interchangeably with “convulsion”.
•
Convulsions occur when a person’s body shakes rapidly and uncontrollably.
•
Some seizures only cause a person to have staring spells. These may go unnoticed.
Symptoms depend on what part of the brain is involved. They may include:
Page 102
DISEASES OF THE NERVOUS SYSTEM
•
Brief blackout followed by a period of confusion
•
Drooling or frothing at the mouth
•
Eye movements
•
Grunting and snorting
•
Loss of bladder or bowel control
•
Shaking of entire body
•
Tasting a bitter or metallic flavor
•
Teeth clenching
•
Uncontrollable muscle spasms with twitching and jerking limbs.
Conditions include:
•
New onset or untreated seizures
•
Significant change in baseline control of seizure activity
•
Ongoing seizure activity
•
Post-ictal neurologic dysfunction
ICD-10 Code Code Description
R56.00
Simple febrile convulsions
R56.01
Complex febrile convulsions
R56.1
Post traumatic seizures
R56.9
Unspecified convulsions
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DISEASES OF THE NERVOUS SYSTEM
TRANSICHEMIC ATTACK (TIA)
•
When blood flow to part of the brain stops for a brief period of time.
•
A person will have stroke like symptoms up to 24 hours, but in most cases for 1-2
hours.
CEREBROVASCULAR ACCIDENT (CVA)
•
A stroke occurs when blood flow to a part of the brain stops.
•
If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients
and oxygen.
•
Brain cells can die, causing lasting damage.
•
This can lead to complete or partial loss of function in the area of the body that is
controlled by the part of the brain that is damaged.
Terms of Cerebrovascular System
•
Frontal lobe-conscious thought; damage can result in mood changes, social
differences, etc. The frontal lobes are the most uniquely human of all the brain
structures.
•
Parietal lobe-plays important roles in integrating sensory information from
various senses, and in the manipulation of objects; portions of the parietal lobe are
involved with visuospatial processing.
•
Page 104
Occipital lobe-sense of sight; lesions can produce hallucinations
DISEASES OF THE NERVOUS SYSTEM
•
Temporal lobe-senses of smell and sound, as well as processing of complex stimuli
like faces and scenes.
•
Limbic lobe-emotion, memory.
•
Insular cortex-pain, some other senses.
Types of stroke:
•
Ischemic stroke
o Occurs when an artery to the brain is
blocked. The brain depends on its arteries to
bring fresh blood from the heart and lungs.
o Is site specific by artery
•
Intracerebral hemorrhage
o Occurs when a diseased blood vessel within the brain bursts, allowing blood
to leak inside the brain. (The name means within the cerebrum or brain)
o
•
Specified by location in the brain.
Subarachnoid hemorrhage
o Bleeding in the space between the brain and the surrounding membrane
(subarachnoid space).
o Specified by specific artery in the brain causing the hemorrhage
Symptoms of a Stroke
Page 105
•
Sudden weakness or paralysis of an arm, a leg, or one side of the body.
•
Sudden dimness or loss of vision, particularly in one eye.
•
Sudden confusion, with difficulty speaking and understanding speech.
•
Loss of balance and coordination, leading to falls.
•
Sudden severe headache with no apparent cause.
DISEASES OF THE NERVOUS SYSTEM
•
Abnormal sensations or loss of sensation in an arm or a leg or on one side of
the body.
CODING CHANGES
Identifies various forms of CVA’s.
Cerebral hemorrhage
Infraction due to thrombosis
Embolism or
Unspecified occlusion or stenosis in the cerebral vessel.
Sequela of Cerebrovascular Disease (Late Effects in ICD-9-CM)
•
Conditions classifiable to categories I60-I67 as the cause of sequelae
(neurologic deficits) which are classified elsewhere.
•
Identified by type of stroke
o Hemorrhage or infarction
•
The symptoms persist after the initial cerebrovascular disease.
•
May arise at any time after the onset of the disease.
ICD-10
Code
Code Description
R42
Dizziness and giddiness
R20.8
Other disturbances of skin sensation
R20.9
Unspecified disturbance of skin sensations
R51
Headache
R29.5
Transient paralysis
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DISEASES OF THE NERVOUS SYSTEM
R29.810
Facial weakness
R29.90
Unspecified signs and symptoms involving the nervous system
R47.01
Aphasia
R47.02
Dysphasia
R47.81
Slurred speech
R47.89
Other speech disturbances
MIGRANES
Must include documentation of:
•
Intractable (pharmacologically or treatment resistant, medically and poorly
controlled)
•
Not Intractable
•
With/Without Status of Migrainosus
•
With Vomiting, etc.
Status of Migrainosus-Is having visions changes, nausea, vomiting, and difficulty
thinking.
ICD-10
Code
G43.601
G43.609
G43.611
G43.619
Page 107
Code Description
Persistent migraine aura with cerebral infarction, not intractable, with
status migrainosus
Persistent migraine aura with cerebral infarction, not intractable, without
status migrainosus
Persistent migraine aura with cerebral infarction, intractable, with status
migrainosus
Persistent migraine aura with cerebral infarction, intractable, without
status migrainosus
DISEASES OF THE NERVOUS SYSTEM
G45.0
Vertebro-basilar artery syndrome
G45.1
Carotid artery syndrome (hemispheric)
G45.2
Multiple and bilateral precerebral artery syndromes
G45.8
Other transient cerebral ischemic attacks and related syndromes
G45.9
Transient cerebral ischemic attack, unspecified
G46.3
Brain stem stroke syndrome
G46.4
Cerebellar stroke syndrome
G97.51
Postprocedural hemorrhage and hematoma of a nervous system organ or
structure following a nervous system procedure
Postprocedural hemorrhage and hematoma of a nervous system organ or
structure following other procedure
Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon
and bifurcation
Nontraumatic subarachnoid hemorrhage from right carotid siphon and
bifurcation
Nontraumatic subarachnoid hemorrhage from left carotid siphon and
bifurcation
Nontraumatic subarachnoid hemorrhage from unspecified middle
cerebral artery
Nontraumatic subarachnoid hemorrhage from right middle cerebral
artery
Nontraumatic subarachnoid hemorrhage from left middle cerebral artery
G97.52
I60.00
I60.01
I60.02
I60.10
I60.11
I60.12
I60.20
I60.21
I60.22
I60.30
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Nontraumatic subarachnoid hemorrhage from unspecified anterior
communicating artery
Nontraumatic subarachnoid hemorrhage from right anterior
communicating artery
Nontraumatic subarachnoid hemorrhage from left anterior
communicating artery
Nontraumatic subarachnoid hemorrhage from unspecified posterior
communicating artery
DISEASES OF THE NERVOUS SYSTEM
I60.31
I60.32
I60.4
I60.50
Nontraumatic subarachnoid hemorrhage from right
communicating artery
Nontraumatic subarachnoid hemorrhage from left
communicating artery
Nontraumatic subarachnoid hemorrhage from basilar artery
posterior
posterior
I60.51
Nontraumatic subarachnoid hemorrhage from unspecified vertebral
artery
Nontraumatic subarachnoid hemorrhage from right vertebral artery
I60.52
Nontraumatic subarachnoid hemorrhage from left vertebral artery
I60.6
Nontraumatic subarachnoid hemorrhage from other intracranial arteries
I60.7
I60.8
Nontraumatic subarachnoid hemorrhage from unspecified intracranial
artery
Other nontraumatic subarachnoid hemorrhage
I60.9
Nontraumatic subarachnoid hemorrhage, unspecified
I61.0
Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I61.1
Nontraumatic intracerebral hemorrhage in hemisphere, cortical
I61.2
Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
I61.3
Nontraumatic intracerebral hemorrhage in brain stem
I61.4
Nontraumatic intracerebral hemorrhage in cerebellum
I61.5
Nontraumatic intracerebral hemorrhage, intraventricular
I61.6
Nontraumatic intracerebral hemorrhage, multiple localized
I61.8
Other nontraumatic intracerebral hemorrhage
I61.9
Nontraumatic intracerebral hemorrhage, unspecified
Page 109
DISEASES OF THE NERVOUS SYSTEM
I62.00
Nontraumatic subdural hemorrhage, unspecified
I62.01
Nontraumatic acute subdural hemorrhage
I62.02
nontraumatic subacute subdural hemorrhage
I62.03
Nontraumatic chronic subdural hemorrhage
I62.1
Nontraumatic extradural hemorrhage
I62.9
Nontraumatic intracranial hemorrhage, unspecified
I63.00
Cerebral infarction due to thrombosis of unspecified precerebral artery
I63.011
Cerebral infarction due to thrombosis of right vertebral artery
I63.012
Cerebral infarction due to thrombosis of left vertebral artery
I63.019
Cerebral infarction due to thrombosis of unspecified vertebral artery
I63.02
Cerebral infarction due to thrombosis of basilar artery
I63.031
Cerebral infarction due to thrombosis of right carotid artery
I63.032
Cerebral infarction due to thrombosis of left carotid artery
I63.039
Cerebral infarction due to thrombosis of unspecified carotid artery
I63.09
Cerebral infarction due to thrombosis of other precerebral artery
I63.10
Cerebral infarction due to embolism of unspecified precerebral artery
I63.111
Cerebral infarction due to embolism of right vertebral artery
I63.112
Cerebral infarction due to embolism of left vertebral artery
I63.119
Cerebral infarction due to embolism of unspecified vertebral artery
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DISEASES OF THE NERVOUS SYSTEM
I63.12
Cerebral infarction due to embolism of basilar artery
I63.131
Cerebral infarction due to embolism of right carotid artery
I63.132
Cerebral infarction due to embolism of left carotid artery
I63.139
Cerebral infarction due to embolism of unspecified carotid artery
I63.19
Cerebral infarction due to embolism of other precerebral artery
I63.20
I63.30
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
precerebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of right
vertebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of left
vertebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
vertebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of basilar
arteries
Cerebral infarction due to unspecified occlusion or stenosis of right
carotid arteries
Cerebral infarction due to unspecified occlusion or stenosis of left carotid
arteries
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
carotid arteries
Cerebral infarction due to unspecified occlusion or stenosis of other
precerebral arteries
Cerebral infarction due to thrombosis of unspecified cerebral artery
I63.311
Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312
Cerebral infarction due to thrombosis of left middle cerebral artery
I63.319
Cerebral infarction due to thrombosis of unspecified middle cerebral
artery
Cerebral infarction due to thrombosis of right anterior cerebral artery
I63.211
I63.212
I63.219
I63.22
I63.231
I63.232
I63.239
I63.29
I63.321
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DISEASES OF THE NERVOUS SYSTEM
I63.322
Cerebral infarction due to thrombosis of left anterior cerebral artery
I63.329
I63.331
Cerebral infarction due to thrombosis of unspecified anterior cerebral
artery
Cerebral infarction due to thrombosis of right posterior cerebral artery
I63.332
Cerebral infarction due to thrombosis of left posterior cerebral artery
I63.339
I63.341
Cerebral infarction due to thrombosis of unspecified posterior cerebral
artery
Cerebral infarction due to thrombosis of right cerebellar artery
I63.342
Cerebral infarction due to thrombosis of left cerebellar artery
I63.349
Cerebral infarction due to thrombosis of unspecified cerebellar artery
I63.39
Cerebral infarction due to thrombosis of other cerebral artery
I63.40
Cerebral infarction due to embolism of unspecified cerebral artery
I63.411
Cerebral infarction due to embolism of right middle cerebral artery
I63.412
Cerebral infarction due to embolism of left middle cerebral artery
I63.419
Cerebral infarction due to embolism of unspecified middle cerebral artery
I63.421
Cerebral infarction due to embolism of right anterior cerebral artery
I63.422
Cerebral infarction due to embolism of left anterior cerebral artery
I63.429
I63.431
Cerebral infarction due to embolism of unspecified anterior cerebral
artery
Cerebral infarction due to embolism of right posterior cerebral artery
I63.432
Cerebral infarction due to embolism of left posterior cerebral artery
I63.439
Cerebral infarction due to embolism of unspecified posterior cerebral
artery
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DISEASES OF THE NERVOUS SYSTEM
I63.441
Cerebral infarction due to embolism of right cerebellar artery
I63.442
Cerebral infarction due to embolism of left cerebellar artery
I63.449
Cerebral infarction due to embolism of unspecified cerebellar artery
I63.49
Cerebral infarction due to embolism of other cerebral artery
I63.50
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of right
middle cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of left middle
cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
middle cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of right
anterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of left
anterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
anterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of right
posterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of left
posterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
posterior cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of right
cerebellar artery
Cerebral infarction due to unspecified occlusion or stenosis of left
cerebellar artery
Cerebral infarction due to unspecified occlusion or stenosis of unspecified
cerebellar artery
Cerebral infarction due to unspecified occlusion or stenosis of other
cerebral artery
Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I63.511
I63.512
I63.519
I63.521
I63.522
I63.529
I63.531
I63.532
I63.539
I63.541
I63.542
I63.549
I63.59
I63.6
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DISEASES OF THE NERVOUS SYSTEM
I63.8
Other cerebral infarction
I63.9
Cerebral infarction, unspecified
I67.81
Acute cerebrovascular insufficiency
I67.82
Cerebral ischemia
I69.30
Unspecified sequela of cerebral infarction
I69.31
Cognitive deficits following cerebral infarction
I69.320
Aphasia following cerebral infarction
I69.321
Dysphasia following cerebral infarction
I69.322
Dysarthria following cerebral infarction
I69.323
Fluency disorder following cerebral infarction
I69.328
Other speech and language deficits following cerebral infarction
I69.331
Monoplegia of upper limb following cerebral infarction affecting right
dominant side
Monoplegia of upper limb following cerebral infarction affecting left
dominant side
Monoplegia of upper limb following cerebral infarction affecting right
non-dominant side
Monoplegia of upper limb following cerebral infarction affecting left nondominant side
Monoplegia of upper limb following cerebral infarction affecting
unspecified side
Monoplegia of lower limb following cerebral infarction affecting right
dominant side
Monoplegia of lower limb following cerebral infarction affecting left
dominant side
Monoplegia of lower limb following cerebral infarction affecting right
non-dominant side
I69.332
I69.333
I69.334
I69.339
I69.341
I69.342
I69.343
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DISEASES OF THE NERVOUS SYSTEM
I69.344
I69.349
I69.351
I69.352
I69.353
I69.354
I69.359
I69.361
I69.362
I69.363
I69.364
I69.365
I69.369
Monoplegia of lower limb following cerebral infarction affecting left nondominant side
Monoplegia of lower limb following cerebral infarction affecting
unspecified side
Hemiplegia and hemiparesis following cerebral infarction affecting right
dominant side
Hemiplegia and hemiparesis following cerebral infarction affecting left
dominant side
Hemiplegia and hemiparesis following cerebral infarction affecting right
non-dominant side
Hemiplegia and hemiparesis following cerebral infarction affecting left
non-dominant side
Hemiplegia and hemiparesis following cerebral infarction affecting
unspecified side
Other paralytic syndrome following cerebral infarction affecting right
dominant side
Other paralytic syndrome following cerebral infarction affecting left
dominant side
Other paralytic syndrome following cerebral infarction affecting right
non-dominant side
Other paralytic syndrome following cerebral infarction affecting left nondominant side
Other paralytic syndrome following cerebral infarction, bilateral
I69.390
Other paralytic syndrome following cerebral infarction affecting
unspecified side
Apraxia following cerebral infarction
I69.391
Dysphagia following cerebral infarction
I69.392
Facial weakness following cerebral infarction
I69.393
Ataxia following cerebral infarction
I69.398
Other sequela of cerebral infarction
I97.810
Intraoperative cerebrovascular infarction during cardiac surgery
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DISEASES OF THE NERVOUS SYSTEM
I97.811
Intraoperative cerebrovascular infarction during other surgery
I97.820
Postprocedural cerebrovascular infarction during cardiac surgery
I97.821
Postprocedural cerebrovascular infarction during other surgery
O87.3
Cerebral venous thrombosis in the puerperium
O99.411
Diseases of the circulatory system complicating pregnancy, first trimester
O99.412
O99.42
Diseases of the circulatory system complicating pregnancy, second
trimester
Diseases of the circulatory system complicating pregnancy, third
trimester
Diseases of the circulatory system complicating pregnancy, unspecified
trimester
Diseases of the circulatory system complicating pregnancy, childbirth
O99.43
Diseases of the circulatory system complicating pregnancy, puerperium
R51
Headache
Z86.73
Personal history of transient ischemic attack (TIA), and cerebral
infarction without residual deficits
O99.413
O99.419
PAIN
When pain is coding from the nervous system chapter, then signs and symptoms from
psychological factors should be included.
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DISEASES OF THE NERVOUS SYSTEM
ICD-10 Code
Code Description
G89
Pain, not elsewhere classified
G89.11
Acute pain, not elsewhere classified-Acute pain due to trauma
G89.12
Acute pain, not elsewhere classified-Acute post-thoracotomy pain
G89.18
Acute pain, not elsewhere classified-Other acute post-procedural
pain
Chronic pain, not elsewhere classified-Chronic pain due to trauma
G89.21
Page 117
DISEASES OF THE NERVOUS SYSTEM
G89.22
G89.28
Page 118
Chronic pain, not elsewhere classified-Chronic post-thoracotomy
pain
Chronic pain, not elsewhere classified-Other chronic postprocedural pain
DISEASES OF THE CIRCULATORY SYSTEM
Diseases of the Circulatory System
The circulatory system is an organ system that permits blood and lymph
circulation to transport nutrients (such as amino acids and electrolytes),
oxygen, carbon dioxide, hormones, blood cells, etc. to and from cells in the
body to nourish it and help to fight diseases, stabilize body temperature
and pH, and to maintain homeostasis.
The circulatory system is made up of the heart and blood vessels.
CARDIAC TERMS
•
Right Atrium
o Receives oxygen-poor blood from the body.
•
Right Ventricle
o Contracts to pump oxygen-poor blood along the pulmonary arteries to the
lungs.
•
Left Atrium
o Receives oxygen rich blood from the pulmonary veins.
•
Left Ventricle
o Contracts to pump oxygen rich blood along the aorta to the body
•
Pulmonary veins
o Return oxygenated blood from each lung to the left atrium of the heart.
•
Superior Vena Cava
o The second largest vein in the human body. Moves blood from the upper half
of the body to the heart.
•
Page 119
Tricuspid Valve
DISEASES OF THE CIRCULATORY SYSTEM
o Separates the right atrium and right ventricle, allowing blood to enter the
ventricle but not flow back to the atrium.
•
Inferior Vena Cava
o Largest vein in the human body. It collects blood from the lower body and
carries it to the heart.
•
Pulmonary Valve
o Blood flows from the right ventricle through the pulmonic valve into the
lungs.
•
Mitral Valve
o Separates the left atrium and left ventricle.
•
Aortic Valve
o Blood flows from the left ventricle to the aorta through the aortic valve.
•
Right Coronary Artery
o Supplies blood to the right atrium, right ventricle, and bottom portion of the
left ventricle and back of the septum.
•
Left Anterior Descending Coronary Artery
o Supplies blood to the front and bottom of the left ventricle and the front of
the septum.
•
Circumflex Coronary Artery
o Supplies blood to the left atrium and the side and back of the left ventricle.
•
Left Main Coronary Artery
o Divides into two branches: the circumflex artery and the left anterior
descending artery.
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DISEASES OF THE CIRCULATORY SYSTEM
HYPERTENSION
An abnormal evaluation of systolic and/or diastolic blood pressure.
Conditions:
Essential, Benign, Malignant
Hypertensive Heart and Chronic Kidney Disease
Secondary Hypertension
Relationship:
Renal
Pulmonary, etc.
Coding Changes
•
Deletion of the codes: benign, malignant and unspecified.
•
Hypertension table is no longer necessary.
Essential (primary) hypertension I10
Includes: High blood pressure
Hypertension (arterial) (benign) (essential) (malignant)
(primary) (systemic)
I
1
0
Overview
Systolic-The top number, higher of the two numbers, measures the pressure in the arteries
when the heart beats. (when the heart muscle contracts)
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DISEASES OF THE CIRCULATORY SYSTEM
Diastolic-The bottom number, lower of the two numbers, measures the pressure in the
arteries between heartbeats (when the heart muscle is resting between beats and refilling
with blood)
•
Prehypertension: Systolic (120-139) or Diastolic (80-89)
•
High Blood Pressure (Stage 1): Systolic (140-159) or Diastolic (90-99)
•
High Blood Pressure (Stage 2): Systolic (160 or higher) or Diastolic (100 or
higher)
•
Hypertensive Crisis: Systolic (Higher than 180) or Diastolic (Higher than 110)
Uncontrolled-May be untreated hypertension or hypertension not responding to current
therapeutic regimen.
Controlled-This diagnostic statement usually refers to an existing state of hypertension
under control by therapy.
Standard commonly applied is that a sustained diastolic pressure above 90 mm Hg
and a sustained systolic pressure above 140 mm Hg constitutes hypertension.
ICD-10 Code
Code Description
H35.031
Hypertensive retinopathy, right eye
H35.032
Hypertensive retinopathy, left eye
H35.033
Hypertensive retinopathy, bilateral
H35.039
Hypertensive retinopathy, unspecified eye
I10
Essential (primary) hypertension
I11.0
Hypertensive heart disease with heart failure
I11.9
Hypertensive heart disease without heart failure
Page 122
DISEASES OF THE CIRCULATORY SYSTEM
I12.0
I15.0
Hypertensive chronic kidney disease with stage 5 chronic kidney
disease or end stage renal disease
Hypertensive chronic kidney disease with stage 1 through stage 4
chronic kidney disease, or unspecified chronic kidney disease
Hypertensive heart and chronic kidney disease with heart failure
and stage 1 through stage 4 chronic kidney disease, or unspecified
chronic kidneyheart
disease
Hypertensive
and chronic kidney disease without heart
failure, with stage 1 through stage 4 chronic kidney disease, or
unspecified chronic
disease kidney disease without heart
Hypertensive
heartkidney
and chronic
failure, with stage 5 chronic kidney disease, or end stage renal
disease
Hypertensive
heart and chronic kidney disease with heart failure
and with stage 5 chronic kidney disease, or end stage renal disease
Renovascular hypertension
I15.1
Hypertension secondary to other renal disorders
I15.2
Hypertension secondary to endocrine disorders
I15.8
Other secondary hypertension
I15.9
Secondary hypertension, unspecified
I67.4
Hypertensive encephalopathy
O10.011
O10.02
Pre-existing essential hypertension complicating pregnancy, first
trimester
Pre-existing essential hypertension complicating pregnancy,
second trimester
Pre-existing essential hypertension complicating pregnancy, third
trimester
Pre-existing essential hypertension complicating pregnancy,
unspecified trimester
Pre-existing essential hypertension complicating childbirth
O10.03
Pre-existing essential hypertension complicating the puerperium
O10.111
Pre-existing hypertensive heart disease complicating pregnancy,
first trimester
I12.9
I13.0
I13.10
I13.11
I13.2
O10.012
O10.013
O10.019
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DISEASES OF THE CIRCULATORY SYSTEM
O10.112
O10.113
O10.119
O10.12
O10.13
O10.211
O10.212
O10.213
O10.219
O10.22
O10.23
O10.311
O10.312
O10.313
O10.319
O10.32
O10.33
O10.411
O10.412
Page 124
Pre-existing hypertensive heart disease complicating pregnancy,
second trimester
Pre-existing hypertensive heart disease complicating pregnancy,
third trimester
Pre-existing hypertensive heart disease complicating pregnancy,
unspecified trimester
Pre-existing hypertensive heart disease complicating childbirth
Pre-existing hypertensive heart disease complicating the
puerperium
Pre-existing hypertensive chronic kidney disease complicating
pregnancy, first trimester
Pre-existing hypertensive chronic kidney disease complicating
pregnancy, second trimester
Pre-existing hypertensive chronic kidney disease complicating
pregnancy, third trimester
Pre-existing hypertensive chronic kidney disease complicating
pregnancy, unspecified trimester
Pre-existing hypertensive chronic kidney disease complicating
childbirth
Pre-existing hypertensive chronic kidney disease complicating the
puerperium
Pre-existing hypertensive heart and chronic kidney disease
complicating pregnancy, first trimester
Pre-existing hypertensive heart and chronic kidney disease
complicating pregnancy, second trimester
Pre-existing hypertensive heart and chronic kidney disease
complicating pregnancy, third trimester
Pre-existing hypertensive heart and chronic kidney disease
complicating pregnancy, unspecified trimester
Pre-existing hypertensive heart and chronic kidney disease
complicating childbirth
Pre-existing hypertensive heart and chronic kidney disease
complicating the puerperium
Pre-existing secondary hypertension complicating pregnancy, first
trimester
Pre-existing secondary hypertension complicating pregnancy,
second trimester
DISEASES OF THE CIRCULATORY SYSTEM
O10.413
O10.42
Pre-existing secondary hypertension complicating pregnancy, third
trimester
Pre-existing secondary hypertension complicating pregnancy,
unspecified trimester
Pre-existing secondary hypertension complicating childbirth
O10.43
Pre-existing secondary hypertension complicating the puerperium
O10.911
Unspecified pre-existing hypertension complicating pregnancy,
first trimester
Unspecified pre-existing hypertension complicating pregnancy,
second trimester
Unspecified pre-existing hypertension complicating pregnancy,
third trimester
Unspecified pre-existing hypertension complicating pregnancy,
unspecified trimester
Unspecified pre-existing hypertension complicating childbirth
O10.419
O10.912
O10.913
O10.919
O10.92
O10.93
O11.1
Unspecified pre-existing hypertension complicating
puerperium
Pre-existing hypertension with pre-eclampsia, first trimester
O11.2
Pre-existing hypertension with pre-eclampsia, second trimester
O11.3
Pre-existing hypertension with pre-eclampsia, third trimester
O11.9
Pre-existing
trimester
hypertension
with
pre-eclampsia,
the
unspecified
HYPOTENTION
When blood pressure is too low, not enough blood reaches all parts of the body; as a result,
cells do not receive enough oxygen and nutrients, and waste products are not adequately
removed.
Systolic: 90 or less Diastolic: 60 or less
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DISEASES OF THE CIRCULATORY SYSTEM
Symptoms
•
Dizziness or lightheadedness
•
Fainting (syncope)
•
Lack of concentration
•
Blurred vision
•
Nausea
•
Cold, clammy, pale skin
•
Rapid, shallow breathing
•
Fatigue
•
Depression
•
Thirst
ICD-10
Code
I95.9
Page 126
Code Description
Hypotension
DISEASES OF THE CIRCULATORY SYSTEM
ELEVATED BLOOD PRESSURE
Elevated blood pressure reading
Elevated blood pressure reading without diagnosis of hypertension (situation)
Elevated blood-pressure reading without diagnosis of hypertension
Elevated BP reading without HTN diagnosis
Finding of increased blood pressure
This category is to be used to record an episode of elevated blood pressure in a
patient in whom no formal diagnosis of hypertension has been made, or as an
isolated incidental finding.
ICD-10
Code
R03.0
Code Description
Elevated Blood Pressure
ACUTE MYOCARDIAL INFARCTION (AMI)
Coding Changes
Timeframe:
An AMI is now “acute” for 4 weeks from the time of incident versus 8
weeks with ICD-9.
Episode of Care:
ICD-10 does not capture episode of care. (E.g. initial, subsequent
sequelae.
Subsequent:
Use a subsequent code if patient had an MI during the 4 weeks “acute
period” of the original AMI.
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DISEASES OF THE CIRCULATORY SYSTEM
STEMI:
ST Segment Elevation Myocardial Infarction
Non-STEMI: NON-ST Segment Elevation Myocardial Infarction
Coding Note
If NSTEMI evolves to STEMI, then a STEMI Code is used, if a STEMI converts to NSTEMI due
to thrombolytic therapy, it is still coded to STEMI.
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DISEASES OF THE CIRCULATORY SYSTEM
And LATERALY is USED
MI’s are now specified by artery causing MI
Right Coronary
Left Circumflex
Left Main Artery
Other Sights
Left Anterior Descending
Unspecified Sites
ICD-10 Code
Code Description
I21.01
I21.29
ST elevation (STEMI) myocardial infarction involving left main
coronary artery
ST elevation (STEMI) myocardial infarction involving left anterior
descending coronary artery
ST elevation (STEMI) myocardial infarction involving other coronary
artery of anterior wall
ST elevation (STEMI) myocardial infarction involving right coronary
artery
ST elevation (STEMI) myocardial infarction involving other coronary
artery of inferior wall
ST elevation (STEMI) myocardial infarction involving left circumflex
coronary artery
ST elevation (STEMI) myocardial infarction involving other sites
I21.3
ST elevation (STEMI) myocardial infarction of unspecified site
I21.4
Non-ST elevation (NSTEMI) myocardial infarction
I22.0
I22.1
Subsequent ST elevation (STEMI) myocardial infarction of anterior
wall
Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2
Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8
Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9
Subsequent ST elevation (STEMI) myocardial infarction of unspecified
site
I21.02
I21.09
I21.11
I21.19
I21.21
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DISEASES OF THE CIRCULATORY SYSTEM
I23.0
I23.7
Hemopericardium as current complication following acute myocardial
infarction
Atrial septal defect as current complication following acute myocardial
infarction
Ventricular septal defect as current complication following acute
myocardial infarction
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Rupture of chordae tendineae as current complication following acute
myocardial infarction
Rupture of papillary muscle as current complication following acute
myocardial infarction
Thrombosis of atrium, auricular appendage, and ventricle as current
complications following acute myocardial infarction
Post infarction angina
I23.8
Other current complications following acute myocardial infarction
I25.2
Old myocardial infarction
I23.1
I23.2
I23.3
I23.4
I23.5
I23.6
ATHEROCLEROTIC HEART DISEASE
•
Occurs when the blood vessels that carry oxygen and nutrients from the heart to
the rest of the body and arteries become thick and stiff-sometimes restricting blood
flow to the organs and tissues.
•
Healthy arteries are flexible and elastic, but over time, the walls in the arteries can
harden.
•
Atherosclerosis is a specific type of arteriosclerosis but the terms are sometimes
used interchangeably.
•
Refers to the buildup of fats, cholesterol and other substances in and on the artery
walls (plaques), which can restrict blood flow.
•
Page 130
Symptoms (atherosclerosis in heart arteries)
DISEASES OF THE CIRCULATORY SYSTEM
o Chest pain or pressure (angina)
Coding Changes
Atherosclerotic Heart Disease with Angina Pectoris
Cause:
Assumed to be atherosclerosis
Stability
Stable Angina Pectoris or Unstable Angina Pectoris
Vessel:
If known, which artery is involved and whether the artery is native or
autologous.
Graft
Involvement:
If appropriate, whether a bypass graft was involved in the angina
pectoris diagnosis; also note the original location of the graft and
whether it is autologous or biologic.
ICD-10 Code
Code Description
I25.110
Atherosclerotic hearth disease of a native coronary artery with unstable
angina
Atherosclerosis of autologous vein coronary artery bypass graft(s) with
unstable angina
I21.02
ATRIAL FIBRILLATION AND FLUTTER
The two small upper chambers (atria) of the heart do not beat the way they should. Instead
of beating in a normal pattern, the atria beat irregularly and too fast, quivering like a bowl
of gelatin.
Symptoms
Page 131
•
General fatigue
•
Rapid and irregular heartbeat
•
Fluttering or thumping in the chest
DISEASES OF THE CIRCULATORY SYSTEM
•
Dizziness
•
Shortness of breath and anxiety
•
Faintness or confusion
•
Fatigue when exercising
•
Sweating
Location:
Atrial, ventricular, supraventricular, etc.
Rhythm Name:
Flutter, fibrillation, sick sinus syndrome.
Acuity:
Acute, chronic, etc.
Cause:
Hyperkalemia, hypertension, alcohol consumption, digoxin, etc.
ICD-10 Code
Code Description
I48.0
Paroxysmal atrial fibrillations
I48.1
Persistent atrial fibrillation
I48.2
Chronic atrial fibrillation
I48.3
Typical atrial flutter
I48.4
Atypical atrial flutter
I48.91
Unspecified atrial fibrillation
I48.92
Unspecified atrial flutter
CARDIAC ARRHYTHMIAS
•
Symptomatic or potentially life-threatening arrhythmia.
Necessary symptoms include:
•
Syncope or near syncope.
•
Chest pain and dyspnea.
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DISEASES OF THE CIRCULATORY SYSTEM
•
Includes severe bradycardia or tachycardia.
•
Patients are expected to have conditions that require monitoring during and after
transportation.
ICD-10 Code
Code Description
I49.01
Ventricular fibrillation
I49.02
Ventricular flutter
I49.1
Atrial premature depolarization
I49.2
Junctional premature depolarization
I49.3
Ventricular premature depolarization
I49.40
Unspecified premature depolarization
I49.49
Other premature depolarization
I49.5
Sick sinus syndrome
I49.8
Other specified cardiac arrhythmias
I49.9
Cardiac arrhythmia
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DISEASES OF THE CIRCULATORY SYSTEM
When to use I49.8
A prime example when an ICD-10-CM Codebook will be useful.
PALPITATIONS
Clinical Information A disorder characterized by an unpleasant sensation of
irregular and/or forceful beating of the heart.
A rapid or irregular heartbeat that a person can feel.
An unpleasant sensation of irregular and/or forceful beating of the heart.
Signs required include severe bradycardia or tachycardia (rate < 60 or > 120).
Page 134
DISEASES OF THE CIRCULATORY SYSTEM
When to use Bradycardia
When to use Tachycardia
When to Use Palpitations and Abnormal Heart Rate
Page 135
DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code
Code Description
R00.0
Tachycardia unspecified
R00.1
Bradycardia unspecified
R00.2
Palpitations
R00.8
Other abnormalities of the heart beat
R00.9
Unspecified abnormalities of heart beat
HEART FAILURE
Congestive Heart Failure when fluids build up in various parts of the body in which the
heart cannot pump enough blood to the rest of the body.
Type of Heart Failure
•
Systolic Heart Failure: Heart muscle contracts with too little force, causing less
oxygen-rich blood to be pumped (pumping problem).
•
Diastolic Heart Failure: Heart contracts normally, but ventricle walls don’t relax
enough to let the chamber fill (filling problem).
Symptoms
•
Shortness of breath
•
Persistent coughing or wheezing
•
Buildup of excess fluid in body tissues (edema)
Page 136
DISEASES OF THE CIRCULATORY SYSTEM
•
Fatigue
•
Lack of appetite or nausea
•
Impaired thinking
•
Increased heart rate
Conditions:
Congestive heart failure
Left/right heart failure
Systolic/diastolic heart failure
Cardiac arrest
Failure related to hypertensive disease
Acute and chronic heart failure
Heart failure in pregnancy due to anesthesia
Rheumatic heart failure
Coding Changes
Acuity:
Acute or Chronic
Decompensation=Chronic
Exacerbation=Acute
Type:
Page 137
Systolic or Diastolic
DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code
Description
I50.1
Left ventricular failure
I50.20
Unspecified systolic (congestive) heart failure
I50.21
Acute systolic (congestive) heart failure
I50.22
Chronic systolic (congestive) heart failure
I50.23
Acute on chronic systolic (congestive) heart failure
I50.30
Unspecified diastolic (congestive) heart failure
I50.31
Acute diastolic (congestive) heart failure
I50.32
Chronic diastolic (congestive) heart failure
I50.33
Acute on chronic diastolic (congestive) heart failure
I50.40
Unspecified
I50.41
(congestive) heart failure
Acute combined systolic (congestive) and diastolic (congestive) heart
I50.42
failure
Chronic combined systolic (congestive) and diastolic (congestive)
I50.43
heart failure
Acute on chronic combined systolic (congestive) and diastolic
I50.9
(congestive) heart failure
Heart failure, unspecified
combined
systolic
(congestive)
and
diastolic
CARDIOMYOPATHY
Type:
Dilated/congestive, obstructive or non-obstructive hypertrophic, etc.
Location:
Endocarditis, right ventricle, etc.
Cause:
Congenital, alcohol, etc.
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DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code
Description
I42.0
Dilated cardiomyopathy
I42.1
Obstructive hypertrophic cardiomyopathy
I42.3
Endomyocardial disease
CHEST PAIN
•
Pain usually characterized as severe, tight, dull, crushing, substernal, epigastric, or
left sided.
•
Associated pain of the jaw, left arm, neck, back
•
GI symptoms (such as nausea or vomiting)
•
Arrhythmias
•
Palpitations
•
Difficulty breathing
•
Pallor
•
Diaphoresis
•
Alteration of consciousness
ICD-10 Code
Description
R07.1
Chest pain on breathing
R07.2
Percordial pain
R07.81
Pleurodynia
R07.82
Intercostal pain
R07.89
Other chest pain
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DISEASES OF THE CIRCULATORY SYSTEM
R07.9
Chest pain unspecified
SYNCOPE AND COLLAPSE
•
A disorder characterized by spontaneous loss of consciousness caused by
insufficient blood supply to the brain.
•
A spontaneous loss of consciousness caused by insufficient blood supply to the
brain.
•
A spontaneous loss of consciousness caused by insufficient blood to the brain.
•
A transient loss of consciousness and postural tone caused by diminished blood
flow to the brain (i.e., brain ischemia). Presyncope refers to the sensation of
lightheadedness and loss of strength that precedes a syncopal event or
accompanies an incomplete syncope.
•
Extremely weak; threatened with syncope.
•
Fainting due to a sudden fall of blood pressure below the level required to maintain
oxygenation of brain tissue.
•
Fainting usually happens when the blood pressure drops suddenly, causing a
decrease in blood flow to the brain. Some causes of fainting include:
o heat or dehydration
o emotional distress
o standing up too quickly
o certain medicines
o drop in blood sugar
o heart problems
•
Loss of consciousness due to a reduction in blood pressure that is associated
with an increase in vagal tone and peripheral vasodilation.
ICD-10 Code
Page 140
Description
DISEASES OF THE CIRCULATORY SYSTEM
R55
Syncope and collapse
PULMONARY EMBOLISM
•
One or more pulmonary arteries in the lungs become blocked.
•
In most cases, pulmonary embolism is caused by blood clots that travel to the lungs
from the legs or rarely other parts of the body. (DVT)
Common signs and symptoms
•
Shortness of breath
•
Chest Pain
•
Cough
Other signs and symptoms that can occur with PE
•
Leg pain or swelling, or both, usually in calf
•
Clammy or discolored skin
•
Excessive Sweating
•
Rapid or irregular heartbeat
•
Lightheadedness or dizziness
CARDIAC ARREST
•
Abrupt loss of heart function in a person who may or may not have diagnosed heart
disease.
•
The term “heart attack” is often mistakenly used to describe cardiac arrest. While
a heart attack may cause cardiac arrest and sudden death, the terms don’t mean the
same thing.
Coding Changes
Cardiac Arrest (427.5) Goes from 1 Code to 1 of 7 Codes.
Page 141
DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code
Description
I46.2
Cardiac arrest due to underlying cardiac condition
I46.8
Cardiac arrest due to other underlying cardiac condition
I46.9
Cardiac arrest, cause unspecified
I97.120
Postprocedural cardiac arrest following cardiac surgery
I97.121
Postprocedural cardiac arrest following other surgery
I97.710
Intraoperative cardiac arrest during cardiac surgery
I97.711
Intraoperative cardiac arrest during other surgery
Page 142
DISEASES OF THE RESPIRATORY SYSTEM
Diseases of the Respiratory System
•
The respiratory system draws oxygen into the body and removes carbon dioxide.
•
The body cells use oxygen to release the energy they need to live. Energy is released
by a process called cell respiration.
•
This process also releases waste carbon dioxide, which has to be removed before it
poisons the body.
•
The respiratory system consists of the lungs and the air passages that carry air to
and from the lungs.
•
It works by drawing “fresh” air containing oxygen into the body and pushing out
“stale” air containing carbon dioxide.
•
A person can never take a break from breathing. People breathe around 20,000
times a day because their cells need a constant supply of oxygen.
Upper respiratory tract:
Nose or nostrils, nasal cavity, mouth, throat (pharynx), and voice box (larynx).
Lower respiratory tract:
Windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.
RESPIRATORY TERMS
•
Mechanical Ventilation
Clinically indicated for patient with apnea, acute respiratory failure and impending
acute respiratory failure. Invasive mechanical ventilation pumps air into the
patient’s lungs even where there is no attempt by the patient to breath on their own.
•
Nasopharyngeal Airway
o Also known as an NPA, nasal trumpet (because of its flared end), or nose
hose, a type of airway adjunct, is a tube that is designed to be inserted into
the nasal passageway to secure an open airway.
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DISEASES OF THE RESPIRATORY SYSTEM
•
Oral Airway
o Is a medical device called an airway adjunct used to maintain or open a
patient's airway. It does this by preventing the tongue from covering the
epiglottis, which could prevent the person from breathing.
•
Endotracheal Intubation
o Is the placement of a flexible plastic tube into the trachea (windpipe) to
maintain an open airway or to serve as a conduit through which to
administer certain drugs.
•
Kings Airway
o Is an airway device is a disposable supraglottic airway and is reported to be
the safest and most reliable disposable supraglottic airway tool alternative
for emergency ventilation when direct laryngoscopy is not feasible or mask
ventilation is deemed insufficient.
•
Continuous Positive Airway Pressure (CPAP’s)
o A machine that increases air pressure in the throat so airway doesn't
collapse when a person breathes in.
RESPIRATORY DOCUMENTATION
Page 144
•
Tachypnea
•
Labored respiration
•
Hypoxemia
•
Requiring oxygen administration
•
Require advanced airway management such as ventilator management
•
Apnea monitoring for possible intubation
•
Deep airway suctioning
DISEASES OF THE RESPIRATORY SYSTEM
CODING CHANGES
ICD-10-CM codes are grouped by:
Upper and lower respiratory tract infections
Diseases of the pleura and intraoperative
Post-procedural complications; and
Disorders of the respiratory system
ICD-9-CM
Acute
Other
Pneumonia
Chronic
ICD-10-CM
Anatomic site of infection
Severity
Cause
Acute, other, then chronic
Mechanical Ventilation Complications
This was in the Complication Chapter of ICD-9-CM, it is now in the Disease of the
Respiratory.
ICD-10 Code
Description
J95.00
Tracheostomy complications
J95.09
Other tracheostomy complications
J95.850
Mechanical complication of respirator
I95.851
Ventilator associated pneumonia
J95.859
Other complication of respirator ventilator
J95.89
Other post procedure complications and disorders of respiratory
system, NEC
Page 145
DISEASES OF THE RESPIRATORY SYSTEM
ASTHMA
•
Asthma is a chronic lung disease that inflames and narrows the airways.
•
Asthma causes recurring periods of wheezing (a whistling sound when you
breathe), chest tightness, shortness of breath, and coughing.
o The coughing often occurs at night or early in the morning.
•
Airways are tubes that carry air into and out of lungs.
•
People who have asthma have inflamed airways.
o The inflammation makes the airways swollen and very sensitive.
o The airways tends to react strongly to certain inhaled substances.
o When the airways react, the muscles around them tighten.
o This narrows the airways, causing less air to flow into the lungs.
o The swelling also can worsen, making the airways even narrower.
o Cells in the airways might make more mucus than usual.
o Mucus is a sticky thick liquid that can further narrow the airways.
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DISEASES OF THE RESPIRATORY SYSTEM
Coding Changes
Stages of Asthma
Defined by the World Allergy Organization
Page 147
DISEASES OF THE RESPIRATORY SYSTEM
ICD-10 Code
Code Description
J45.20
Mild intermittent asthma, uncomplicated
J45.21
Mild intermittent asthma with (acute) exacerbation
J45.22
Mild intermittent asthma with status asthmaticus
J45.30
Mild persistent asthma, uncomplicated
J45.31
Mild persistent asthma with (acute) exacerbation
J45.32
Mild persistent asthma with status asthmaticus
J45.40
Moderate persistent asthma, uncomplicated
J45.41
Moderate persistent asthma with (acute) exacerbation
J45.42
Moderate persistent asthma with status asthmaticus
J45.50
Severe persistent asthma, uncomplicated
J45.51
Severe persistent asthma with (acute) exacerbation
J45.52
Severe persistent asthma with status asthmaticus
J45.901
Unspecified asthma with (acute) exacerbation
J45.902
Unspecified asthma with status asthmaticus
J45.909
Unspecified asthma, uncomplicated
J45.990
Exercise induced bronchospasm
J45.991
Cough variant asthma
J45.998
Other asthma
Page 148
DISEASES OF THE RESPIRATORY SYSTEM
COPD
•
Chronic obstructive pulmonary disease refers to a group of lung diseases that block
airflow and make breathing difficult.
•
Emphysema and chronic bronchitis are the two most common conditions that make
up COPD.
•
Chronic bronchitis is an inflammation of the lining of the bronchial tubes, which
carry air to and from the lungs.
•
Emphysema occurs when the air sacs (alveoli) at the end of the smallest air
passages (bronchioles) in the lungs are gradually destroyed.
•
The main cause of COPD is tobacco smoking. However, in the developing world,
COPD often occurs in women exposed to fumes from burning fuel for cooking and
heating in poorly ventilated homes.
Symptoms
•
Shortness of breath
•
Wheezing
•
Chest tightness
•
Having to clear the throat first thing in the morning due to excess mucus in the
lungs.
•
A chronic cough that produces sputum that may be clear, white, yellow or greenish.
•
Blueness of the lips or fingernail beds (cyanosis).
•
Frequent respiratory infections.
•
Lack of energy.
•
Unintended weight loss (in later stages).
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DISEASES OF THE RESPIRATORY SYSTEM
COPD Exacerbation
•
Acute exacerbation of chronic obstructive bronchitis and asthma
•
Uncomplicated cases
•
With acute lower respiratory tract infection
•
Acute exacerbation.
An acute exacerbation is not equivalent to an infection superimposed on a chronic
condition.
An exacerbation may be triggered by an infection.
ICD-10 Code
Code Description
J41.0
Simple chronic bronchitis
J41.1
Mucopurulent chronic bronchitis
J41.8
Mixed simple and mucopurulent chronic bronchitis
J42
Unspecified chronic bronchitis
J43.0
Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1
Panlobular emphysema
J43.2
Centrilobular emphysema
J43.8
Other emphysema
J43.9
Emphysema, unspecified
J44.0
J44.1
Chronic obstructive pulmonary disease with acute lower respiratory
infection
Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9
Chronic obstructive pulmonary disease, unspecified
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DISEASES OF THE RESPIRATORY SYSTEM
J98.3
Compensatory emphysema
PULMONARY EDEMA
Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in
the numerous air sacs in the lungs, making it difficult to breathe.
Symptoms include:
Extreme shortness of breath.
A feeling of suffocating or drowning.
Wheezing or gasping for breath.
Anxiety, restlessness or sense of apprehension.
Cough that produces frothy sputum and may be tinged with blood.
Chest pain if pulmonary edema is caused by heart disease.
A rapid, irregular heartbeat (palpitations).
Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues
around them.
The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and
difficulty breathing.
ICD-10 Code
Code Description
J81.0
Acute pulmonary edema
J81.1
Chronic pulmonary edema
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DISEASES OF THE RESPIRATORY SYSTEM
PNEUMONIA
Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around
them. The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and
difficulty breathing.
Symptoms
•
Cough that produces sputum
•
Chest pain
•
Chills
•
Fever
•
Shortness of breath
ICD-10 Code
Code Description
J18.8
Other pneumonia, unspecified organism
J18.9
Pneumonia, unspecified organism
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
(Acute Pulmonary Insufficiency)
Type of lung failure resulting from many different disorders that cause fluid to accumulate
in the lungs and oxygen levels in the blood to be too low.
•
This deprives the organs of the oxygen they need to function.
•
Typically occurs in people who are already critically ill or who have significant
injuries.
Symptoms
•
Severe shortness of breath
•
Labored and unusually rapid breathing
•
Low blood pressure
Page 152
DISEASES OF THE RESPIRATORY SYSTEM
•
Confusion and extreme tiredness
ICD-10 Code
Code Description
J80.0
Acute respiratory distress syndrome
HYPOXIA AND HYPERCAPNIA
Hypoxia
A condition in which the body or a region of the body is deprived of adequate oxygen
supply.
Hypercapnia
A condition of abnormally elevated carbon dioxide (CO2) levels in the blood.
ICD-10 Code
Code Description
R09.02
Hypoxemia
RESPIRATORY FAILURE
Respiratory Failure is a condition in which the level of oxygen in the blood becomes
dangerously low or the level of carbon dioxide becomes dangerously high.
Symptoms
•
Page 153
Cyanosis
DISEASES OF THE RESPIRATORY SYSTEM
•
Confusion
•
Sleepiness
•
Deep, rapid breathing
•
Deteriorating consciousness or unconsciousness
•
Arrhythmias
ICD-10 Code
Code Description
J96.00
Acute respiratory failure, unspecified with hypoxia or hypercapnia
J96.01
Acute respiratory failure with hypoxia
J96.02
Acute respiratory failure with hypercapnia
J96.10
Chronic respiratory failure, unspecified with hypoxia and hypercapnia
J96.11
Chronic respiratory failure with hypoxia
J96.12
Chronic respiratory failure with hypercapnia
J96.20
J96.21
Acute and chronic respiratory failure, unspecified with hypoxia or
hypercapnia
Acute and chronic respiratory failure with hypoxia
J96.22
Acute and chronic respiratory failure with hypercapnia
J96.90
J96.91
Unspecified respiratory failure, unspecified
hypercapnia
Unspecified respiratory failure with hypoxia
J96.92
Unspecified respiratory failure with hypercapnia
with
hypoxia
or
RESPIRATORY ABNORMALITY
When the body is short of breath, it's hard or uncomfortable to take in the oxygen
the body needs. A person may feel as if they are not getting enough air.
Page 154
DISEASES OF THE RESPIRATORY SYSTEM
Sometimes mild breathing problems are from a stuffy nose or hard exercise. But
shortness of breath can also be a sign of a serious disease.
If someone has trouble breathing, it is important to find out the cause.
ICD-10 Code
Code Description
R06.00
Dyspnea, unspecified
R06.02
Shortness of breath
R06.09
Other forms of dyspnea
R06.3
Periodic breathing
R06.4
Hyperventilation
R06.82
Tachypnea, not elsewhere classified
R06.83
Snoring
R06.89
Other abnormalities of breathing
Page 155
DISEASES OF THE DIGESTIVE SYSTEM
Diseases of the Digestive System
Coding Changes
•
Hemorrhage is used for ulcers.
•
Bleeding is used for gastritis, duodenitis, diverticulosis and
diverticulitis.
•
“Obstruction” is no longer an axis of classification.
o ICD-9-CM
Acute Gastric Ulcer with hemorrhage and
Obstruction.
o ICD-10-CM
•
Acute Gastric Ulcer with Hemorrhage.
Complications of artificial openings, including colostomy, enterostomy and
gastrostomy infections and malfunctions are all included in the digestive disease
chapter.
ICD-10 Code
Code Description
K29.00
Acute gastritis without bleeding
K29.01
Acute gastritis with bleeding
K29.70
Gastritis, unspecified without bleeding
K56.69
Other intestinal obstruction
K92.2
Gastrointestinal hemorrhage, unspecified
J92.0
Hematemesis
J92.1
Melena
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DISEASES OF THE DIGESTIVE SYSTEM
J92.2
Gastrointestinal hemorrhage, unspecified
K92.81
Gastrointestinal muscositis
K92.89
Other specified diseases of the digestive system
K92.9
Disease of digestive system unspecified
ABDOMINAL PAIN
Location:
Generalized, right upper quadrant, periumbilical, etc.
Pain or Tenderness type:
Colic, tenderness, rebound, etc.
Documentation:
Accompanied by other signs or symptoms
Associated symptoms include nausea, vomiting, fainting.
Associated signs include tender or pulsatile mass, distention, rigidity, rebound
tenderness on exam, guarding.
ICD-10 Code
Code Description
R10.0
Acute abdominal pain
R10.9
Unspecified abdominal pain
R10.11
Abdominal right upper quadrant pain
R10.12
Abdominal left upper quadrant pain
R10.31
Abdominal right lower quadrant pain
R10.32
Abdominal left lower quadrant pain
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DISEASES OF THE DIGESTIVE SYSTEM
R10.33
Periumbilical pain
R10.13
Epigastric pain
R10.84
Generalized abdominal pain
R10.10
Upper abdominal pain, unspecified
R10.2
Pelvic and perineal pain
R10.30
Lower abdominal pain, unspecified
R19.07
Generalized intra-abdominal pelvic swelling, mass, and lump
R19.09
Other intra-abdominal pelvic swelling, mass and lump
R19.30
Abdominal rigidity, unspecified site
R10.819
Abdominal tenderness, unspecified site
R10.829
Rebound abdominal tenderness, unspecified sit
R10.817
Generalized abdominal tenderness
R10.827
Generalized rebound abdominal tenderness
R10.819
Abdominal tenderness, unspecified site
R10.829
Rebound abdominal tenderness, unspecified site
NAUSEA/VOMITING
Expelling the contents of the stomach and the sensations associated with it. They are
symptoms of an underlying disease or condition and not a specific illness.
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DISEASES OF THE DIGESTIVE SYSTEM
Nausea and Vomiting in an emergency situation should have other contraindications,
such as:
vomited for longer than 24 hours
blood in the vomit
severe abdominal pain
headache and stiff neck
signs of dehydration, such as dry mouth, infrequent urination or dark urine
ICD-10 Code
Code Description
R11.0
Nausea
R11.10
Vomiting unspecified
R11.11
Vomiting without nausea
R11.12
Projectile vomiting
R11.13
Vomiting of fecal mater
R11.14
Billous vomiting
R11.2
Nausea with vomiting, unspecified
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DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
Disease of the Skin and Subcutaneous Tissues
CELLULITIS
An acute inflammation of a localized area of tissue.
DERMATITIS
Is the inflammation of the skin.
ERYTHEMATOUS CONDITIONS
Is a redness of the skin due to capillary dilation.
PRESSURE ULCER OR DECUBITUS ULCER
Caused by hypoxia secondary to pressure-induced vascular insufficiency.
Documentation
Location
Size
Stage of the ulcer
Other information that would explain why a wheelchair or other means of moving
the patient other than an ambulance could not be used.
Decubitus Ulcer Staging
Stage I: A reddened area on the skin that, when pressed, does not turn white.
Stage II: The skin blisters or forms an open sore. The area around the sore may be
red and irritated.
Stage III: The skin now develops an open, sunken hole called a crater. There is
damage to the tissue below the skin.
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DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
Stage IV: The pressure ulcer has become so deep that there is damage to the muscle
and bone, and sometimes to tendons and joints.
CODING CHANGES
Combination codes identify the site of a pressure ulcer as well as the stage of the
ulcer.
If the pressure ulcer is documented as completely healed than it is not coded.
If the pressure ulcer is healing it should be coded to the highest stage that is healing.
Laterality is included with many diagnoses.
Dermatitis and Eczema are used synonymously.
Non-pressure chronic ulcers are also specified by site, laterality, and severity.
Chronic or non-pressure ulcers are usually caused by other conditions and should
be coded first, if known.
The 6th Character level in L89 denotes the “depth of the Ulcer” i.e. L89.503, “stage
3”, pressure ulcer of the ankle, unspecified.
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DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
ABNORMAL SKIN SIGNS
Includes:
Diaphoresis-Sweating, especially to an unusual degree as a symptom of disease or
side effect of a disease.
Cyanosis-Bluish discoloration of the skin resulting from poor circulation or
inadequate oxygenation of the blood.
Delayed capillary refill-How long it takes color to return to an external capillary
bed after pressure is applied.
Diminish skin turgor-The skin’s ability to change shape and return to normal
elasticity.
Mottled skin-Patch skin color areas where the skin color is irregular.
ICD-10 Code
Code Description
R23.0
Cyanosis
R23.1
Pallor
R23.2
Flushing
R23.4
Changes in skin texture
R23.8
Other skin changes
R23.9
Unspecified skin changes
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DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
R60.0
Localized edema
R60.1
Generalized edema
R60.9
Edema unspecified
R61
Generalized hyperhidrosis
Page 163
DISEASES OF THE MUSCULOSKELETAL SYSTEM
Diseases of the Musculoskeletal System
CODING CHANGES
Almost all the ICD-10 codes have been expanded.
Most codes provide for laterality and site.
LATERALITY
ARTHRITIS
In ICD-10-CM, there are specific codes for primary and secondary arthritis.
Within the secondary arthritis codes there are specific codes for post-traumatic
osteoarthritis and other secondary osteoarthritis.
For secondary osteoarthritis of the hip there is also a code for dysplastic
osteoarthritis.
Arthritis codes in ICD-10-CM is both similar and different than ICD-9-CM.
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DISEASES OF THE MUSCULOSKELETAL SYSTEM
In ICD-9, osteoarthritis can be described as degenerative, hypertrophic, or
secondary to other factors, and the type as generalized or localized.
In ICD-10 provides more options for the coding osteoarthritis related encounters,
including:
o Generalized forms of osteoarthritis or arthritis where multiple joints are
involved.
o Localized forms of osteoarthritis with more specificity that includes primary
versus secondary types, subtypes, laterality, and joint involvement.
o Indicate the type, location, and specific bones and joints (multiple sites if
applicable) involved in the disease. In addition, describe any related
underlying diseases or conditions.
BACK PAIN
Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or
requiring special positioning only available by ambulance.
7–10 on 10-point severity scale.
Neurologic symptoms and/or signs.
Absent leg pulses.
Pulsatile abdominal mass, concurrent chest or abdominal pain.
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DISEASES OF THE MUSCULOSKELETAL SYSTEM
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DISEASES OF THE MUSCULOSKELETAL SYSTEM
CONTRACTURES
Abnormal shortening of muscle tissue, rendering the muscle highly resistant to passive
stretching.
There should be a description about whether the patient has upper or lower limb
contracture(s).
The location and severity/degree of the contracture should be documented.
Lower extremity contractures must be of sufficient degree as to prohibit sitting in
a wheelchair (severe fixed contractures at or proximal to the knee).
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DISEASES OF THE MUSCULOSKELETAL SYSTEM
Page 168
GENITOURINARY
Genitourinary
HEMATURIA
Hematuria
Is the presence of blood in the urine.
Gross Hematuria
Is presence of blood in the urine in sufficient quantity to be visible to the naked eye.
Cause
UTI’s
Benign Prostatic Hypertrophy
Ureteral Calculi
Cardinal Sign of bladder cancer.
KIDNEY FAILURE
A clinical syndrome associated with the retention of renal waste products or uremic toxins
in the blood. It is usually the result of renal insufficiency. Most uremic toxins are end
products of protein or nitrogen catabolism, such as urea or creatinine. Severe uremia can
lead to multiple organ dysfunctions with a constellation of symptoms.
A condition in which the kidneys stop working and are not able to remove waste and extra
water from the blood or keep body chemicals in balance.
Chronic Kidney Disease
Has five stages based on the patients glomerular filtration rate (GFR).
Care of a patient with stage IV and V is very intense and complicated.
Chronic renal insufficiency is a form of chronic kidney disease.
A neoplastic or non-neoplastic condition affecting the kidney.
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GENITOURINARY
Conditions in which the function of kidneys deteriorates suddenly in a matter of
days or even hours.
It is characterized by the sudden drop in glomerular filtration rate.
Impairment of health or a condition of abnormal functioning of the kidney.
Pathological processes of the kidney or its component tissues.
Chronic Renal Failure maybe due to:
High Blood Pressure
Diabetes
Chronic renal failure is irreversible and requires hemodialysis.
Signs and Symptoms
Excess in the blood of urea,
creatinine and other nitrogenous end products of protein and
amino acid metabolism.
End Stage Renal Disease (ESRD)
Is the final stage of the loss of kidney function (also referred to as “Stage V”). This stage
will require transplant of renal dialysis for survival.
Renal Insufficiency
Poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys
caused by renal artery disease. Normally, the kidneys regulate body fluid and blood
pressure, as well as regulate blood chemistry and remove organic waste.
Acute Renal Failure
Occurs suddenly, and usually due to trauma, infection, inflammation or toxicity. It develops
quickly and usually reversible as the underlying condition is treated.
Page 170
GENITOURINARY
CODING CHANGES
Many diagnoses are based on gender.
Prostatic hypertrophy is now “enlarged prostrate”.
There are several notes throughout the chapter identifying to use additional codes.
ICD-10 Code
Code Description
I12.0
N13.8
Hypertensive chronic kidney disease with stage 5 chronic kidney
disease or end stage renal disease
Hypertensive heart and chronic kidney disease without heart failure,
with stage 5 chronic kidney disease, or end stage renal disease
Hypertensive heart and chronic kidney disease with heart failure and
with stage 5 chronic kidney disease, or end stage renal disease
Urinary obstruction
N17.8
Other acute kidney failure
N17.9
Acute kidney failure, unspecified
N18.1
Chronic kidney disease, stage 1
N18.2
Chronic kidney disease, stage 2
N18.3
Chronic kidney disease, stage 3
N18.4
Chronic kidney disease, stage 4
N18.5
Chronic kidney disease, stage 5
N18.6
End stage renal disease
N19
Unspecified kidney failure
N39.41
Urinary incontinence-urge incontinence
I13.11
I13.2
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GENITOURINARY
N39.42
Urinary incontinence-without sensory awareness
N39.43
Urinary incontinence-post-void dribbling
N39.44
Urinary incontinence-nocturnal enuresis
N39.45
Urinary incontinence-continuous leakage
N39.46
Urinary incontinence-mixed incontinence (urge and stress)
N39.490
Other specified urinary incontinence-overflow incontinence
N39.498
Other specified urinary incontinence (reflex or total incontinence)
N39.8
Other specified disorder of urinary system
N39.9
Disorder of urinary system, unspecified
N99.510
Cystostomy hemorrhage
N99.511
Cystostomy infection
N99.512
Cystostomy malfunction
N99.518
Other cystostomy complication
N99.520
Hemorrhage of other external stoma of urinary tract
N99.521
Infection of other external stoma of urinary tract
N99.522
Malfunction of other external stoma of urinary tract
N99.528
Other external stoma of urinary tract
N99.530
Hemorrhage of other stoma of urinary tract
N99.531
Infection of other stoma of urinary tract
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GENITOURINARY
N99.532
Malfunction of other stoma of urinary tract
N99.538
Other stoma of urinary tract complications
R30
Hematuria
R33.8
Urinary retention
R35.1
Nocturia
R39.11
Urinary hesitancy
R39.12
Weak urinary system
R39.14
Incomplete bladder emptying
R39.15
Urinary urgency
R39.16
Straining on urination
R39.81
Functional urinary incontinence
R39.89
Other symptoms and signs involving the genitourinary system
R39.9
Unspecified symptoms and signs involving the genitourinary system
Z99.2
Dependence on renal dialysis
Page 173
PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
Pregnancy, Childbirth and the Puerperium
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PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
POSTPARTUM
The period begins immediately after delivery and continues for six weeks following
delivery.
A postpartum complication is any complication occurring within the six-week period.
CODING GUIDELINES
If an OB patient with diabetes it’s coded to the Diabetes code in the pregnancy,
childbirth and puerperium chapter followed by an E Code from Chapter 4.
If Gestational Diabetes only a code from the pregnancy, childbirth and puerperium
chapter is coded.
If pregnancy complications occur because of alcohol and tobacco use during
pregnancy code from the pregnancy, childbirth and puerperium chapter first,
followed by a code from chapter 5.
If there is a poisoning, toxic effects, adverse effects and underdosing in an OB
Patient, code first O9A.2 Injury, poisoning and certain other consequences of
external causes should be sequenced first, followed by a code to identify the
substance and the condition that is being treated.
If a baby is born, then the gestation needs to be coded from the Z34 codes.
ICD-10 Code
Code Description
O24.011
Pre-existing diabetes mellitus, type 1, 1st trimester
O24.012
Pre-existing diabetes mellitus, type 1, 2nd trimester
O24.013
Pre-existing diabetes mellitus, type 1, 3rd trimester
O24.019
Pre-existing diabetes mellitus, type 1, unspecified
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PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
O24.111
Pre-existing diabetes mellitus, type 2, 1st trimester
O24.112
Pre-existing diabetes mellitus, type 2, 1st trimester
O24.113
Pre-existing diabetes mellitus, type 2, 1st trimester
O24.119
Pre-existing diabetes mellitus, type 2, 1st trimester
O24.311
Unspecified pre-existing diabetes mellitus in pregnancy, 1st trimester
O24.312
Unspecified pre-existing diabetes mellitus in pregnancy, 2nd trimester
O24.313
Unspecified pre-existing diabetes mellitus in pregnancy, 3rd trimester
O24.319
O24.410
Unspecified pre-existing diabetes mellitus in pregnancy, unspecified
trimester
Gestational diabetes mellitus in pregnancy, diet controlled
O24.414
Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419
Gestational diabetes mellitus in pregnancy, unspecified controlled
O24.811
Other pre-existing diabetes mellitus, 1st trimester
O24.812
Other pre-existing diabetes mellitus, 2nd trimester
O24.813
Other pre-existing diabetes mellitus, 3rd trimester
O24.819
Other pre-existing diabetes mellitus, unspecified trimester
O24.911
Unspecified diabetes mellitus, 1st trimester
O24.912
Unspecified diabetes mellitus, 2nd trimester
O24.913
Unspecified diabetes mellitus, 3rd trimester
O24.919
Unspecified diabetes mellitus, unspecified trimester
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PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
075.9
Complication of labor and delivery, unspecified
O80
Encounter for full-term uncomplicated delivery
O9A.211
Injury, poisoning, and certain external causes complicating pregnancy,
1st trimester
Injury, poisoning, and certain external causes complicating pregnancy,
2nd trimester
Injury, poisoning, and certain external causes complicating pregnancy,
3rd trimester
Injury, poisoning, and certain external causes complicating pregnancy,
unspecified trimester
O9A.212
O9A.213
O9A.219
BIRTH
If a baby is born while in transport, then an ICD-10 code from the Z38 is coded for live born
infant.
ICD-10 Code
Code Description
Z38.1
Single live born outside of hospital
Z38.4
Twins live born outside of hospital
Z38.7
Multiple live born outside of hospital
R68.13
Apparent life threatening event of an infant
Page 177
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Injury, Poisoning and Certain Other Consequences of External
Causes
INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL
CAUSES
INJURIES
Episode of Care:
Initial, subsequent, sequelae
Injury site:
Be as specific as possible
Etiology:
How was the injury sustained (e.g. sports, motor
vehicle crash, pedestrian, slip and fall, environmental
exposure, etc.)?
Place of Occurrence:
School, work, etc.
Initial encounters may also require, where appropriate:
Intent:
Unintentional or accidental, self-harm, etc.
Status :
Civilian, military, etc.
FRACTURES
Type:
o Open, closed, pathological, neoplastic disease, stress
Pattern:
o Comminuted, oblique, segmental, spiral, transverse
Encounter of care:
o Initial, subsequent, sequelae
Healing status, if subsequent encounter:
o Normal healing, delayed healing, nonunion, malunion
Page 178
Localization:
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
o Shaft, head, neck, distal, proximal, styloid
Displacement:
o Displaced, non-displaced
Classification:
o Gustilo-Anderson, Salter-Harris
Any complications, whether acute or delayed:
o Direct result of trauma sustained
Terminology
Pathological Fracture
Occurs in existing diseases, which weekends the bones.
Malunion Fracture
Fracture is reduced, but the bone ends did not align properly during the healing
process.
Nonunion Fracture
Is the failure of the bone ends to align or heal.
Stress Fracture
May be cause by repetitive forces applied to the bone and its supporting structures.
Comminuted
A break/splinter of the bone into more than two fragments.
Oblique
Slanted fractures that occur when a force is applied at any angle.
Segmental
A fracture in two parts of the same bone.
Spiral
Is a fracture occurring when a rotating force is applied along the axis of the bone.
Page 179
Transverse
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Is a perpendicular break along the axis of the bone from a result of a force applied
at an angle.
Displaced
The bone moves in two or more parts and moves so the two ends do not line up.
Non-displaced
Then bone cracks either in part or all the way through, but maintains alignment.
Gustilo-Anderson
System is the most commonly used classification system for Open fractures.
Salter Harris
Are epiphyseal plate fractures and are common and important as they can result in
premature closure and therefore limb shortening and abnormal growth.
o Typically occurs in 10-15 years old
Page 180
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
CODING CHANGES
The “S” Codes are for injuries related to a single body region.
The “T” Codes cover injuries to unspecified body regions, as well as poisons.
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INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Injuries
Features an expanded category for injuries. Injuries are grouped by anatomical site rather
than by injury. Most are seven digits.
A seventh character extension identifies the encounter type, with:
A- Initial encounter for closed fracture
B- Initial encounter for open fracture
D- Subsequent encounter for fracture with routine healing
G- Subsequent encounter for fracture with delayed healing
K- Subsequent encounter for fracture with nonunion
P- Subsequent encounter for fracture with malunion
S- Sequela
WHEN A FRACTURE IS NOT DESCRIBED AS OPEN OR CLOSED IT SHOULD BE CODED TO A CLOSED
FRACTURE.
FRACTURES ARE CODED INDIVIDUALLY TO EACH SPECIFIC SITE.
WHEN THERE IS AFTERCARE OF AN INJURY YOU CODE THE ACUTE INJURY CODE WITH THE
“SUBSEQUENT ENCOUNTER” 7th digit.
PATHOLOGICAL FRACTURES
ICD-10 identifies for 3 different causes to pathological fractures.
o Neoplastic disease
o Osteoporosis
o Other specified disease
M80 Category should be used when it is known the patient has Osteoporosis with
a fracture.
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INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
http://www.roadto10.org/whats-different
Burns
A new term of Corrosion, which are burns due to chemicals.
Drugs
Are divided up by:
Poisoning
Adverse Effect
Underdoing
Is taking less medication than prescribed by a provider, resulting in a negative health
consequences.
WHEN CODING BURNS, THE BURN TO THE HIGHEST DEGREE IS CODED FIRST.
Open Wounds
ICD-10 provides a laterality distinction to be made and the type of open wound including:
Page 183
Laceration, with or without foreign body
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Puncture wound with or without foreign body
Open bite
Unspecified open wound
GOOD DOCUMENTATION PRACTICE
Accident
o Where did it occur?
Assault
o What was the assault and what part of the body?
Asphyxiation
o Where and how did it occur?
Bites
o What was the bite from and where did it occur?
Burns
st
nd
rd
o Was it 1 , 2 , or 3 degree, and what part of the body?
Trauma with one or more of the following:
o Glasgow < 14;
o systolic BP < 90;
o RR < 10 or > 29
o All penetrating injuries to head, neck, torso, extremities proximal to elbow
or knee
o Flail chest
o Combination of trauma and burns
o Pelvic fracture
o Two or more long-bone fractures
o Open or depressed skull fracture
o Paralysis
Page 184
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Suspected Fracture/Dislocation Documentation
Suspected fracture or dislocation requires splinting/immobilization and renders
patient unable to be transported by another vehicle.
Includes suspected fractures or dislocations of spine and long bones and joints
proximal to knee and elbow.
The record will demonstrate history of significant trauma and/or findings to
support such suspicions.
BURNS
First-degree burns are red, moist, swollen, and painful.
Second-degree burns are red, swollen, and painful, and they develop blisters that
may ooze a clear fluid.
Third-degree burns usually are not painful because the nerves have been
destroyed. The skin becomes leathery and may be white, black, or bright red. No
blisters develop.
Heat burns (thermal burns) are caused by fire, steam, hot objects, or hot liquids.
Scald burns from hot liquids are the most common burns to children and older
adults.
Electrical burns are caused by contact with electrical sources or by lightning.
Chemical burns are caused by contact with household or industrial chemicals in
liquid, solid, or gas form. Natural foods such as chili peppers, which contain a
substance irritating to the skin, can cause a burning sensation.
Radiation burns are caused by the sun, tanning booths, sunlamps, x-rays, or
radiation therapy for cancer treatment.
Friction burns are cause by contact with any hard surface such as roads, carpets,
or gym floor surfaces.
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INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Burn Documentation
Partial thickness burns > 10% Total Body Surface Area (TBSA).
Involvement of face, hands, feet, genitalia, perineum or major joints.
Third degree burns
Electrical, chemical, inhalation burns with pre-existing medical disorders.
POISONING
Requires cardiopulmonary and/or neurologic monitoring and/or urgent
pharmacologic intervention.
When quantity and identity of agent know to be life threatening.
When quantity and identity of agent are not known but there are signs/symptoms
of neurologic dysfunction.
Page 186
INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Poisoning is an overdose of a substance if the wrong substance is given or taken in
error.
Coding Changes
Types:
Poisoning, accidental
Poisoning, intentional self-harm
Poisoning, undetermined
Adverse effect
Underdosing
Underdosing
Refers to taking less medication than prescribed. Codes for under dosing should never be
assigned as a principal diagnosis. The medical condition should be coded first.
Proper administration of drug
When a medication has been taken properly, code the condition first followed by the
adverse effect of the drug “T” code.
Improper use of drug
First assign the overdose or wrong administration of drug “T” code first, followed by
manifestations that occurred, including if abuse, or dependence of the drug.
Intent
If the intent is not documented or not known than the “accidental intent” ICD-10 code is
used. The Undetermined intent is only used when there is not documentation that shows
it is undetermined.
HEAT EXHAUSTION
Excessive loss of salts (electrolytes) and fluids due to heat, leading to decreased blood
volume that causes many symptoms, sometimes including fainting or collapse.
Symptoms:
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INJURY, POISONING AND CERTAIN OTHER
CONSEQUENCES OF EXTERNAL CAUSES
Dizziness
Light-headedness
Weakness
Fatigue
Headache
Blurred Vision
Muscle Aches
Nausea/Vomiting
HYPOTHERMIA
Results when the body loses more heat than can be replaced by increasing
metabolism or by increasing warming from external sources, such as a fire or the
sun.
Initial symptoms include intense shivering and teeth
chattering.
As body temp falls further, shivering stops and
movements become slow and clumsy, reaction time is
longer, thinking is blurred, and judgment is impaired.
MEDICAL DEVICE FALIURE
Life- or limb-threatening malfunction, failure or complication.
Malfunction of internal pacemaker, internal defibrillator, implanted drug delivery
device, O2 supply malfunction, and orthopedic device failure.
Page 188
EXTERNAL CAUSES OF MORBIDITY
External Causes of Morbidity
Captures the Cause of the Injury or Health Condition.
The Intent
o Unintentional or accidental;
o Suicide or assault.
The Place the Even Occurred.
The Activity of the Patient at the Time of the Event.
The Person’s Status
o Civilian
o Military
o Most codes require a 7th character.
PER CMS Website
If you have not been reporting ICD-9-CM external cause codes, you will not be
required to report ICD-10-CM codes found in Chapter 20 unless a new State or
payer-based requirement about the reporting of these codes is instituted. If
such a requirement is instituted, it would be independent of ICD-10-CM
implementation.
In the absence of a mandatory reporting requirement, you are encouraged to
voluntarily report external cause codes, as they provide valuable data for
injury research and evaluation of injury prevention strategies.
Page 189
FACTORS INFLUENCING HEALTH STATUS AND CONTACT
HEALTH SERVICES
Factors Influencing Health Status and Contact Health Services
o Z Codes Represent Reasons for the encounters.
o These codes are provided for occasions when circumstances other than a disease.
o Injury, or external cause classifiable to the other categories.
o This occurs two ways:
o When a person who may or may not be sick encounters healthcare for
some specific purpose; or
o When circumstances or problem is present which influences the person’s
health status but is not in itself a current illness or injury.
Complete Injury Coding
BED CONFINED
The patient must meet all of the following three criteria:
Unable to get up from bed without assistance.
Unable to ambulate
Unable to sit in a chair (including wheelchair)
Non-emergency ambulance transportation is not covered for patients who are
restricted to bed rest by a physician’s instructions but who do not meet the above
three criteria.
There should be a narrative description that describes the reason the term “bed
confined” is being used.
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FACTORS INFLUENCING HEALTH STATUS AND CONTACT
HEALTH SERVICES
Page 191
DOCUMENTATION
Documentation
The patient’s condition should be coded based on the documentation from the
personnel on scene.
Non-Emergency clearly has to already be specific to the patient’s condition and
need for the ambulance.
The Diagnosis Code is to support the reason for transport.
Medical Necessity
Medicare Benefit Policy-Chapter 10-Ambulance
When the patient’s condition requires the vehicle itself and/or the specialized
services of the ambulance personnel were provided and clear clinical
documentation in the patient’s ePCR validates their medical need and their
provision.
The patient’s condition, as well as changes in that condition and the treatment
provided, must be recorded.
These are conditions which may establish medical necessity:
o Patient had to be transported due to an emergency (as the result of an
accident or injury).
o Patient needs to be restrained.
o Patient is unconscious or in shock.
o Patient requires oxygen or other emergency treatment.
o Exhibits signs and symptoms of acute respiratory distress or cardiac
distress.
o Patient needs to be immobile because of fracture or the possibility of
fracture.
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DOCUMENTATION
o Patient sustains an active stroke or MI.
o Patients experiences severe hemorrhaging.
o Patient was bed confined or
o Needed to be moved by stretcher.
Emergency Documentation
Chief Complaint
History of Present Illness (HPI) has always been critical to obtain
Past Medical History (PMH)
Any pertinent documentation from family or facility
ALS Assessment if performed, documented
Vital signs
Assessment of head to toe
Pain Assessment
Treatment and interventions
Successful or Unsuccessful Attempts
How was the patient moved
Patient status while transported
Non-Emergency
For nonemergency transports, the crew should generally focus more on the patient’s
deficits that prevents transportation by another means, rather than what may appear
to be the main diagnosis.
WHY DO YOU HAVE TO BE THERE?
Pain:
What was the scale, where is the pain?
Paralysis:
Where? Left? Or Right?
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DOCUMENTATION
Fall Risk:
Is the patient a danger to their self or to others and why?
Pressure
Ulcers:
Where? Left or Right? Upper or Lower? And What is the stage?
Oxygen:
Is the patient unable to administer oxygen and why?
Bed
Confined:
Are they able to sit, stand or ambulate?
Most
Important:
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Does the patient need to be transported by Ambulance?
MOVING FORWARD
Moving Forward
Pull your top 25-50 ICD-9-CM Diagnosis Codes
Crosswalk them with available resources
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Identify in your organization where ICD-9-CM’s are currently utilized and will need
to be updated, i.e. NEMSIS.
MOVING FORWARD
•
Evaluate the CMS and your MAC’s website.
•
Order ICD-10 Code Books and various other resources to help educate your
team.
•
Watch for various webinars available for team training.
•
Have billing, IT and Operations collaborate in implementing of ICD-10’s.
•
When new procedures, protocols, medicines or equipment is being used,
provide in-services for billing staff.
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MOVING FORWARD
•
Determine if there are weaknesses in your documentation and begin correcting
immediately.
•
Update Compliance Plans and policies and procedures to reflect ICD-10-CM.
•
Consider implementing a query processes for your medics when billing staff
needs clarification. This could make a difference in medical necessity and
ensuring proper billing.
•
Have a clear understanding how your software vendor is implementing ICD10-CM’s.
•
If you have contracts with Commercial Carriers, verify their language and
ensure the level of specificity they will require.
•
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Monitor your MAC’s websites for updates and changes.
MOVING FORWARD
•
Update you billing system with ICD-10-CM’s, test running reports, claims and
files.
•
Once ICD-10-CM’s are implemented continue to monitor system to ensure
claims are going out the door appropriately.
•
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Watch for denials due to ICD-10-CM’s and monitor closely.
MOVING FORWARD
If the payors receive non-compliant codes OR incorrectly associate ICD-10-CM codes in
their systems…then major disruption…and if there’s disruption…
Provider has to call the Payor
Payor answers questions, request more information.
Claims are delayed.
Disruptions in cash flows.
No one is happy.
It is everyone’s best interest to work toward a seamless transition.
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RESOURCES
Resources
Page 200
RESOURCES
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RESOURCES
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APPENDIX
Appendix
American Ambulance Association Top Ambulance ICD-10-CM Diagnosis Codes
American Ambulance Association Condition Code List ICD-10 Updated
CMS/AMA Announces Efforts to Help Providers Get Ready for ICD-10
CMS Letter to Providers Regarding ICD-10’s
CMS Clarifying Q&A’s Related to CMS/AMA Announcement Regarding ICD-10’s
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