Download for ICD-10

Anatomy and
Pathophysiology
for
ICD-10
2014
Module 1
Disclaimer
This course was current at the time it was published. This course was prepared as a tool to assist the participant in
understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the
student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of
information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this
course.
AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any
reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s
misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee
claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve
local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable
regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.
This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval
of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be
reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or
mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC
and the sources contained within.
ICD-10 Experts
Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC
VP, ICD-10 Training and Education
Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM
Director, ICD-10 Training
Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD
Director, ICD-10 Development and Training
Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC
Director, ICD-10 Development and Training
Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC
Director, ICD-10 Development and Training
Illustration copyright © OptumInsight. All rights reserved.
©2013 AAPC
2480 South 3850 West, Suite B, Salt Lake City, Utah 84120
800-626-CODE (2633), Fax 801-236-2258, www.aapc.com
Revised 111213. All rights reserved.
CPC®, CPC-H®, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.
ii
Anatomy and Pathophysiology for ICD-10
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Contents
Module 1
Blood and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Blood Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Lymphatic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Diseases and Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Infectious Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
© 2013 AAPC. All rights reserved. 111213
UnitedHealthcare
www.aapc.com
iii
Module
1
Blood and Lymphatic Systems
Terminology
Antibodies—Substances produced by the body in
response to bacteria, viruses, or other foreign substances.
to transport oxygen and nutrients to the cells and to
remove carbon dioxide and other waste products from
the cells for elimination. Blood accounts for approximately 8 percent of the body’s total weight.
Ascites—Accumulation of fluid in the peritoneal cavity
containing large amounts of protein and electrocytes.
Blood Cells
Coagulation—A complex process in which blood forms
clots.
Blood cells are the formed elements of blood and are
generally classified as follows:
• Erythrocytes
• Leukocytes
• Thrombocytes
Erythremia—Abnormal increase in the number of red
blood cells.
Fibrin—Stringy, insoluble protein that is the substance
of a blood clot.
Globulin—A plasma protein made in the liver.
Hemostasis—Termination of bleeding by mechanical or
chemical means.
Immunity—Resistance of an organism to infection or
disease.
Pathogens—Disease-producing microorganisms.
Phagocytosis—The process of a cell engulfing and
destroying bacteria.
Platelet—A clotting cell.
Splenomegaly—An abnormal enlargement of the spleen.
Thrombus—A clot.
Introduction
The hemic (blood) system is the system that passes
nutrients (such as amino acids, electrolytes, and lymph),
gases, hormones, blood cells, etc. to and from cells in
the body to help fight diseases and help stabilize body
temperature and pH to maintain homeostasis. It is
made up of blood containing vessels such as arteries,
capillaries, and veins that carry the blood through
the body. The two main functions of the blood are
© 2013 AAPC. All rights reserved. 111213
UnitedHealthcare
Source: AAPC
www.aapc.com
1
Blood and Lymphatic Systems
Module 1
Erythrocytes
Erythrocytes are red blood cells (RBCs). Erythrocytes
are the most common type of blood cell and an
organism’s principal means of delivering oxygen to
the body tissues via the blood flow through the circulatory system. They take up oxygen in the lungs and
release it while squeezing through the body’s capillaries.
The cells’ cytoplasm is rich in hemoglobin, which is
responsible for the blood’s red color.
Mature erythrocytes are flexible biconcave disks that
lack a cell nucleus and most organelles. The interior of
the cell is composed of cytoplasm, lipids, proteins, and
hemoglobin. Around 2.4 million new erythrocytes are
produced per second through a process called erythropoiesis. Erythropoiesis is the development process in
which new erythrocytes are produced, through which
each cell matures in about seven days. Through this
process erythrocytes are continuously produced in
the red bone marrow of large bones at a rate of about 2
million per second in a healthy adult. (In the embryo,
the liver is the main site of red blood cell production.)
The production can be stimulated by the hormone
erythropoietin (EPO), synthesized by the kidney. Just
before and after leaving the bone marrow, the developing cells are known as reticulocytes; these comprise
about 1 percent of circulating red blood cells.
Before birth, erythrocytes are formed in the bone
marrow, liver, spleen, and lymph glands. After birth,
they develop solely in the bone marrow. They circulate for about 100–120 days in the body before their
components are recycled by macrophages. Each cycle of
circulation takes about 20 seconds to complete. Approximately 25 percent of the cells in the human body are red
blood cells.
Leukocytes
Leukocytes are white blood cells (WBCs). Leukocytes
are cells of the immune system involved in defending
the body against both infectious disease and foreign
materials. Leukocytes are found throughout the body,
including the blood and lymphatic system. Leukocytes
make up approximately 1 percent of blood in adults. An
increase in the normal number of leukocytes is called
leukocytosis, while a decrease in the normal number is
called leukopenia.
2
Anatomy and Pathophysiology for ICD-10
Five different and diverse types of leukocytes exist, but
they are all produced and derived from the hematopoietic stem cell in the bone marrow. They all have many
things in common, but are all distinct in form and function. A major distinguishing feature of some leukocytes
is the presence of granules; white blood cells are often
characterized as granulocytes or agranulocytes:
• Granulocytes (polymorphonuclear leukocytes):
granulocytes are leukocytes characterized by the
presence of differently staining granules in their
cytoplasm when viewed under light microscopy.
These granules are membrane-bound enzymes
which primarily act in the digestion of endocytosed
particles. There are three types of granulocytes:
neutrophils, basophils, and eosinophils, which are
named according to their staining properties.
Neutrophils are filled with neutrally-staining granules
and are the most common type of white blood cell,
comprising about 50–70 percent of all white blood cells.
The mature neutrophil has a segmented nucleus (a seg or
poly) while the immature neutrophil has a band-shaped
nucleus (band). They are phagocytic, are the first to
arrive at the site of infection, and have a short lifespan
(about three days). Before ingesting invasive bacteria,
neutrophils can release a net of fibers called a neutrophil
extracellular trap (NET), which serves to trap and kill
microbes outside of the cell. When neutrophils ingest
microbes, they release a number of proteins in primary,
secondary, and tertiary granules that help kill the
bacteria. They also release superoxide, which becomes
converted into hypochlorous acid, or chlorine bleach.
Basophils got their names because these cells take dyes
and stains very readily, turning a vivid purple when
stained. They are chiefly responsible for allergic and
antigen response, as they secrete a biologically active
chemical, histamine, causing inflammation. Each
basophil has a two-lobed nucleus, surrounded by the
tiny granules it carries. Basophils originate in the bone
marrow where they are created continually by stem cells.
They circulate throughout the body in the blood stream,
with the ability to pass into various tissues as needed.
When an infectious agent is detected by the immune
system, basophils respond, along with numerous other
types of white blood cells.
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Module 1 Blood and Lymphatic Systems
Eosinophils are white blood cells that are one of the
immune system components responsible for combating
multicellular parasites and certain infections. These
cells are eosinophilic or ‘acid-loving’ as shown by their
affinity to coal and tar dyes. Along with mast cells,
they also control mechanisms associated with allergy
and asthma. They are granulocytes that develop during
hematopoiesis in the bone marrow before migrating into
blood. Eosinophils persist in the circulation for 8–12
hours, and can survive in tissue for an additional 8–12
days in the absence of stimulation.
• Agranulocytes (mononuclear leucocytes):
agranulocytes are leukocytes characterized by the
apparent absence of granules in their cytoplasm.
Although the name implies a lack of granules these
cells do contain non-specific azurophilic granules,
which are lysosomes. The cells include lymphocytes
and monocytes.
Lymphocytes are much more common in the lymphatic
system. Lymphocytes are distinguished by having a
deeply staining nucleus which may be eccentric in location, and a relatively small amount of cytoplasm. The
blood has three types of lymphocytes:
Monocytes are made in the bone marrow and can
develop into either dendrites or macrophages. Dendritic
cells are antigen presenting cells; they acquire antigens
and show them to T cells so that the T cells learn to
recognize dangerous antigens. Dendritic cells present
antigens to T cells before they are fully developed, so
that the T cell can respond appropriately after it has
been shown an antigen.
• B cells: B cells make antibodies that bind to
pathogens to enable their destruction. (B cells not
only make antibodies that bind to pathogens, but
after an attack, some B cells will retain the ability to
produce an antibody to serve as a ‘memory’ system.)
• T cells:
ºº CD4+ (helper) T cells co-ordinate the immune
response and are important in the defense against
intracellular bacteria. In acute HIV infection,
these T cells are the main index to identify the
individual’s immune system activity. Research has
shown that CD8+ cells are also another index to
identify human’s immune activity.
ºº CD8+ cytotoxic T cells are able to kill virusinfected and tumor cells.
ºº γδ T cells possess an alternative T cell receptor as
opposed to CD4+ and CD8+ αβ T cells and share
characteristics of helper T cells, cytotoxic T cells
and natural killer cells.
• Natural killer cells (NKC): Natural killer cells are
able to kill cells of the body displaying a signal to
kill them, as they have been infected by a virus or
have become cancerous.
© 2013 AAPC. All rights reserved. 111213
Monocytes share phagocytic function of neutrophils,
but are much longer lived (they spread through the
body in one to three days) as they have an additional
role: they present pieces of pathogens to T cells so that
the pathogens may be recognized again and killed or
so an antibody response may be mounted. Monocytes
eventually leave the bloodstream to become tissue
macrophages which remove dead cell debris as well as
attacking microorganisms. Neither of these can be dealt
with effectively by the neutrophils. They have the kidney
shaped nucleus and are typically agranulated. They also
possess abundant cytoplasm.
Macrophages are cells which ingest foreign material. They attack infectious microorganisms, such as
a bacteria or virus, consuming it so it cannot hurt the
body and preserving an antigen so that the body will
be able to recognize the foreign material in the future.
Macrophages can also eat cells in the body which have
been infected by a pathogen to curb the spread of the
pathogen and keep the body healthy. Blood monocytes
migrate into the tissues of the body and there differentiate into macrophages.
Thrombocytes
Thrombocytes (platelets) are small, regularly-shaped
clear cell fragments originating from fragmentation of
precursor megakaryocytes found in the bone marrow.
The average lifespan of a platelet is normally just five to
nine days. Platelets play a fundamental role in hemostasis, important for normal blood clotting, and are a
natural source of growth factors.
Platelets release a multitude of growth factors, including
platelet-derived growth factor and TGF beta. PGDF is
one of the many growth factors and plays a significant
role in angiogenesis (blood vessel formation), the growth
of blood vessels from already-existing blood vessel
tissue. TGF beta is a protein that controls proliferation,
UnitedHealthcare
www.aapc.com
3
Blood and Lymphatic Systems
Module 1
cellular differentiation, and stimulates the deposition
of extracellular matrix. Both of these growth factors
have been shown to play a significant role in the repair
and regeneration of connective tissues. Other healingassociated growth factors produced by platelets include
basic fibroblast growth factor, insulin-like growth factor
1, platelet-derived epidermal growth factor, and vascular
endothelial growth factor. Local application of these
factors in increased concentrations through platelet-rich
plasma (PRP) has been used as an adjunct to wound
healing for several decades.
Lymphatic System
The lymphatic system is part of the immune system. The
immune system is made up of a network of conduits
that carry a clear fluid called lymph. The conduits, also
known as lymphatic vessels, compose a one-way system
in which lymph flows only toward the heart. Lymphoid
tissue is found in many organs, particularly the lymph
nodes, and in the lymphoid follicles associated with the
digestive system such as the tonsils. The system also
includes all the structures dedicated to the circulation
and production of lymphocytes, which includes the
spleen, thymus, bone marrow, and the lymphoid tissue
associated with the digestive system.
The lymphatic system has three primary functions:
• Defend against invading microorganisms and disease
• Return excess interstitial fluid to the blood
• Absorb fats and fat-soluble vitamins from the
digestive system and transport them as chyle to the
venous circulation
The first and probably most well known function of the
lymphatic system is defense against disease and invading
microorganisms. Lymph nodes and other lymphatic
organs filter the lymph to remove microorganisms
and other foreign particles. Lymphatic organs contain
lymphocytes that destroy invading organisms.
A second function of the lymphatic system is it returns
excess interstitial fluid to the blood. Of the fluid that
leaves the capillary, about 90 percent is returned. The
10 percent that does not return becomes part of the
interstitial fluid that surrounds the tissue cells. Small
protein molecules may “leak” through the capillary
wall and increase the osmotic pressure of the interstitial
fluid. This further inhibits the return of fluid into the
capillaries, and fluid tends to accumulate in the tissue
spaces. If this continues, blood volume and blood pressure decrease significantly and the volume of tissue fluid
increases, which results in edema (swelling). Lymph
capillaries pick up the excess interstitial fluid and
proteins and return them to the venous blood. After the
fluid enters the lymph capillaries, it is called lymph.
The third function of the lymphatic system is the
absorption of fats and fat-soluble vitamins from the
digestive system and the subsequent transport of these
substances to the venous circulation. The mucosa that
lines the small intestine is covered with fingerlike
projections called villi. There are blood capillaries and
special lymph capillaries, called lacteals, in the center of
each villus. The blood capillaries absorb most nutrients,
but the fats and fat-soluble vitamins are absorbed by the
lacteals. The lymph in the lacteals has a milky appearance due to its high fat content and is called chyle.
Source: AAPC
4
Anatomy and Pathophysiology for ICD-10
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Module 1 Blood and Lymphatic Systems
Afferent
vessels (in)
Blood
vessels
Jugulodigastric
Superficial
parotid
Submental
Occipital
Hilum
Efferent
vessel (out)
Schematic
of lymph node
Submandibular
Jugulomyohyoid
Anterior cervical
Lymphatic drainage of the
head, neck, and face
Copyright OptumInsight. All rights reserved
The lymphatic system consists of a fluid (lymph),
lymphatic vessels that transport the lymph, and organs
that contain lymphoid tissue.
Lymph is considered part of the interstitial fluid.
Interstitial fluid lies in the interstices (space that intervenes between things) of all body tissues. Interstitial
fluid becomes lymph when it enters a lymph capillary.
The lymph travels to at least one lymph node before
emptying into either the right or left subclavian vein. It
then mixes back with blood. Lymph returns protein and
excess interstitial fluid for circulation, picks up bacteria
and brings them to lymph nodes to be destroyed, and
transports fats from the digestive system.
Lymphatic vessels are thin walled, valved structures that
carry lymph. They are complementary to the cardiovascular system. Lymph vessels are lined by endothelial
cells, have a thin layer of smooth muscle, and adventitia
that bind the vessel to its surroundings. Lymph vessels
are devoted to propulsion of lymph from the lymph
capillaries. Lymph capillaries are a little bigger than
capillaries of the vascular system. There are two types
of lymphatic vessels: afferent lymph vessels and efferent
lymph vessels. Afferent lymph vessels carry lymph to
a lymph node and efferent lymph vessels carry lymph
from a lymph node.
Lymphatic organs are organs characterized by clusters
of lymphocytes and other cells, such as macrophages,
enmeshed in a framework of short, branching connective tissue fibers. The four types of lymphatic organs are
lymph nodes, tonsils, thymus, and spleen.
© 2013 AAPC. All rights reserved. 111213
• Lymph nodes are small, bean-shaped organs
distributed throughout the body and linked by
lymph vessels. Lymph nodes act as filters for foreign
particles. Lymph nodes are usually less than 2.5
cm in length, are surrounded by a connective
tissue capsule, and divided into compartments
called lymph nodules, which are dense masses of
lymphocytes and macrophages. They are separated
by lymph sinuses. Afferent vessels carry lymph to
move through the lymph sinuses and enters an
efferent vessel that carries the lymph away from
the node. The efferent vessel leaves the node at
an indented region named the hilum. They are
clinically significant as inflammation of the lymph
nodes indicate many conditions.
• Tonsils are clusters of lymphatic tissue just under
the mucous membranes that line the nose, mouth,
and throat. There are three groups of tonsils:
pharyngeal (also called the adenoids), located near
the opening of the nasal cavity into the pharynx;
palatine, located near the opening of the oral
cavity into the pharynx; and lingual, located on the
posterior surface of the tongue near the opening of
the oral cavity into the pharynx.
• The thymus sits in the middle of the pleural
cavity and aids in developing the immune system.
The only known function of the thymus is the
production and “education” of T-lymphocytes
(T cells), which are critical cells of the adaptive
immune system. The thymus is composed of two
identical lobes and is located anatomically in the
anterior superior mediastinum, in front of the
heart and behind the sternum.
The thymus is divided into a central medulla and a
peripheral cortex which is surrounded by an outer
capsule. Cells in the thymus can be divided into
thymic stromal cells and cells of hematopoietic
origin. Developing T-cells are referred to as thymocytes and are of hematopoietic origin. Stromal
cells include thymic cortical epithelial cells, thymic
medullary epithelial cells, and dendritic cells.
The thymus continues to grow between birth and
puberty, as it is largest and most active during the
neonatal and pre-adolescent periods. The thymus
is of a pinkish-gray color, soft, and lobulated on its
surfaces in children. By the early teens, the thymus
UnitedHealthcare
www.aapc.com
5
Blood and Lymphatic Systems
Module 1
begins to atrophy due to high levels of circulating
hormones and because thymic stroma is replaced by
adipose tissue. The thymus of older people is scarcely
distinguishable from surrounding fatty tissue. As
one ages the thymus slowly shrinks and becomes
yellow in color, eventually degenerating into tiny
islands of fatty tissue. Nevertheless, residual T
lymphopoiesis continues throughout adult life.
the numbers may be too high. Pre-hypertension is when
your systolic blood pressure is between 120 and 139 or
your diastolic blood pressure is between 80 and 89 on
multiple readings. If you have pre-hypertension, you are
more likely to develop high blood pressure.
• The spleen is located in the upper left abdominal
cavity, just beneath the diaphragm posterior to the
stomach. It is purple/grey in color and is similar to a
lymph node in shape and structure, but much larger
(11 cm in length, weighing 150–200 grams). In fact,
it is the largest lymphatic organ in the body. The
spleen is surrounded by a connective tissue capsule,
which extends inward to divide the organ into
lobules. There are two types of splenic tissue, white
pulp and red pulp. The white pulp is lymphatic
tissue consisting mainly of lymphocytes around
arteries. The red pulp consists of venous sinuses
filled with blood and cords of lymphatic cells, such
as lymphocytes and macrophages. Blood enters the
spleen through the splenic artery, moves through
the sinuses where it is filtered, then leaves through
the splenic vein.
The spleen filters blood much in the same way that
the lymph node filters lymph. It removes old red
blood cells and the splenic sinuses hold a reserve
of blood in case of hemorrhagic shock. The spleen
also recycles iron. It synthesizes antibodies in its
white pulp and removes antibody-coated bacteria
along with antibody-coated blood cells by way of
blood and lymph node circulation. The spleen only
possesses efferent lymphatic vessels.
• Heart disease. Hypertensive heart disease is coronary
artery disease (CAD), heart failure, and enlargement
of the heart that occurs due to hypertension. The
high blood pressure increases the pressure in the
blood vessels, which makes it work harder over time.
This causes the heart muscle to thicken and the left
ventricle to become enlarged. Then cardiac output
decreases and may develop into congestive heart
failure. Hypertensive heart disease is the leading
cause of illness and death due to hypertension.
• Chronic kidney disease. Hypertension is a major
cause of kidney disease and kidney failure. The high
blood pressure causes damage to the blood vessels
and filters in the kidney. This makes removal of
waste from the body difficult.
Diseases and Disorders
Hypertension
Hypertension is when the systemic arterial blood pressure is elevated. Blood pressure readings are measured
in millimeters of mercury (mm Hg) and usually given
as two numbers. For example, 120 over 80 (written as
120/80 mm Hg). The top number is the systolic pressure which indicates the pressure created when the
heart beats. The bottom number is the diastolic pressure which indicates the pressure inside the blood
vessels when the heart is at rest. Either one or both of
6
Anatomy and Pathophysiology for ICD-10
Persistent hypertension is one of the risk factors for
other conditions, such as:
Moderate elevation of arterial blood pressure leads to
shortened life expectancy. Dietary and lifestyle changes
can improve blood pressure control and decrease the
risk of associated health complications, although drug
treatment may prove necessary in patients for whom
lifestyle changes prove ineffective or insufficient.
Following is a table showing the classifications and
stages for hypertension.
Classification
Systolic Pressure Diastolic Pressure
mm Hg
mm Hg
Normal
90–119
60–79
Prehypertension
120–139
80–89
Stage 1
140–159
90–99
Stage 2
≥160
≥100
Isolated
≥140
Systolic
Hypertension
UnitedHealthcare
<90
Source: American Heart Association (2003).
© 2013 AAPC. All rights reserved.
111213
Module 1 Hypertension has several sub-classifications including,
hypertension stage I, hypertension stage II, and
isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal
diastolic pressure and is common in the elderly. They
are demonstrated in the table above. These classifications are made after averaging a patient’s resting blood
pressure readings taken on two or more office visits.
Hypertension is diagnosed if a patient has a blood
pressure readings consistently of at least 140 mm Hg
systolic or 90 mm Hg diastolic.
Secondary hypertension by definition results from an
identifiable cause. This type is important to recognize
since it’s treated differently to essential hypertension,
by treating the underlying cause of the elevated blood
pressure. Hypertension results in the compromise or
imbalance of the pathophysiological mechanisms, such
as the hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many
conditions cause hypertension, some are common and
well recognized secondary causes, such as Cushing’s
Syndrome, which is a condition where the adrenal
glands overproduce the hormone cortisol. In addition,
hypertension is caused by other conditions that cause
hormone changes such as hyperthyroidism and certain
tumors of the adrenal medulla (eg, pheochromocytoma). Other common causes of secondary hypertension include kidney disease, obesity/metabolic disorder,
pre-eclampsia during pregnancy, the congenital defect
known as coarctation of the aorta, and certain prescription and illegal drugs.
The ICD-10-CM code range for hypertension is I10–I15.9.
To code hypertension in ICD-10-CM the following is
necessary:
• Essential or Secondary
• Causal relationship of other conditions
• Elevated blood pressure versus hypertension
Blood and Lymphatic Systems
Following are the ICD-10-CM codes for hypertension.
Essential hypertension
I10
Hypertensive heart disease with heart failure
I11.0
Hypertensive heart disease without heart
failure
I11.9
Hypertensive chronic kidney disease with
stage 5 chronic kidney disease or end stage
renal disease
I12.0
Hypertensive chronic kidney disease with
stage 1 through stage 4 chronic kidney
disease, or unspecified chronic kidney
disease
I12.9
Hypertensive heart and chronic kidney
I13.0
disease with heart failure and stage 1 through
stage 4 chronic kidney disease, or unspecified
chronic kidney disease
Hypertensive heart and chronic kidney
disease without heart failure, with stage 1
through stage 4 chronic kidney disease, or
unspecified chronic kidney disease
I13.10
Hypertensive heart and chronic kidney
disease without heart failure, with stage 5
chronic kidney disease, or end stage renal
disease
I13.11
Hypertensive heart and chronic kidney
disease with heart failure and with stage 5
chronic kidney disease, or end stage renal
disease
I13.2
Renovascular hypertension
I15.0
Hypertension secondary to other renal
disorders
I15.1
Hypertension secondary to endocrine
disorders
I15.2
Other secondary hypertension
I15.8
Secondary hypertension, unspecified
I15.9
According to the ICD-10-CM guidelines, controlled
hypertension and uncontrolled hypertension are both
© 2013 AAPC. All rights reserved. 111213
UnitedHealthcare
www.aapc.com
7
Blood and Lymphatic Systems
Module 1
coded to I10 Essential hypertension. In some cases a
causal relationship between hypertension and other
diseases is made. For example, with hypertensive heart
disease, a causal relationship must be stated (due to
hypertension) or implied (hypertensive) To use the code
category I11. An additional code from category I50 Heart
failure, should also be used to identify the type of heart
failure. But for hypertensive chronic kidney disease, a
causal relationship is always presumed. An additional
code from category N18 Chronic kidney disease should
also be used to indicate the stage of disease.
Acute lymphadenitis of face, head, and neck L04.0
Acute lymphadenitis of trunk
L04.1
Acute lymphadenitis of upper limb
L04.2
Acute lymphadenitis of lower limb
L04.3
Transient hypertension is an elevated blood pressure
reading without a diagnosis of hypertension. In these
cases, ICD-10-CM code R03.0 Elevated blood pressure
reading without a diagnosis of hypertension should be
assigned.
Acute lympadenitis of other sites
L04.8
Acute lymphadenitis, unspecified
L04.9
Nonspecific mesenteric lymphadenitis
I88.0
Lymphadenitis/Lymphangitis
Tuberculous peripheral lymphadenopathy
A18.2
Acute lymphangitis of right axilla
L03.121
Acute lymphangitis of left axilla
L03.122
Acute lymphangitis of right upper limb
L03.123
Acute lymphangitis of left upper limb
L03.124
Lymphangitis (chronic, NOS)
I89.1
Acute lymphangitis of abdominal wall
L03.321
Acute lymphangitis of chest wall
L03.323
Acute lymphangitis of groin
L03.324
Lymphadenitis is swelling of the lymph nodes. Usually
it occurs in the neck, armpits, or groin. It is relatively
common and most likely indicates the presence of
a bacterial, viral, fungal, or parasitic infection. Less
commonly, it may be a result of cancerous cells invading
the node. The lymph nodes may feel hardened and
painful to the touch. The skin covering the lymph node
may be hot or slightly red.
A more serious form of lymphadenitis is lymphangitis,
which is swelling of the lymph vessels. It almost always
indicates the presence of bacterial infection. Its symptoms include high fever, red streaks around the swollen
lymph node, throbbing pain in the lymph nodes, and
flulike symptoms like lack of appetite, fatigue, and
aching muscles. Lymphangitis is most associated with
strep and staph bacterial infections. Cellulitis, infection
of the blood, is a quite common cause.
The ICD-10-CM codes for lymphadenitis and lymphangitis are spread throughout various chapters. To
code lymphadenitis/lymphangitis in ICD-10-CM the
following is necessary:
•
•
•
•
8
Following are some examples of ICD-10-CM codes for
lymphadenitis and lymphangitis:
Lymphadenitis or lymphangitis
Site of swelling
Acute or chronic
Cause
Anatomy and Pathophysiology for ICD-10
Infectious Disease
Infectious diseases (also called communicable diseases
or transmissible diseases) are usually a clinically evident
illness that results from the transmission and presence
of pathogenic biological agents. Infectious pathogens
include some viruses, bacteria, fungi, protozoa, multicellular parasites, and aberrant proteins known as prions.
These pathogens are the cause of disease epidemics, in the
sense that without the pathogen, no infectious epidemic
occurs. A parasitic disease is an infectious disease caused
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Module 1 Blood and Lymphatic Systems
or transmitted by a parasite. Many parasites do not cause
diseases. Parasitic diseases can affect practically all living
organisms, including plants and mammals.
A parasitic disease is an infectious disease caused or
transmitted by a parasite. Many parasites do not cause
diseases. Parasitic diseases can affect practically all
living organisms, including plants and mammals. Some
parasites like Toxoplasma gondii can cause disease
directly, but other organisms can cause disease by the
toxins that they produce.
Among the almost infinite varieties of microorganisms,
relatively few cause disease in otherwise healthy individuals. Transmission of an infectious disease can occur
in one or multiple ways, including physical contact,
contaminated food, body fluids, objects, airborne
inhalation, or through vector organisms. Transmissible diseases resulting through contact with an ill
person or their secretions or objects touched by them
are especially infective and are sometimes referred to as
contagious diseases. Infectious disease results from the
interplay between those few pathogens and the defenses
of the hosts they infect. The appearance and severity
of disease resulting from any pathogen depends upon
the ability of that pathogen to damage the host as well
as the ability of the host to resist the pathogen. Infectious microorganisms, or microbes, are classified as
either primary pathogens or as opportunistic pathogens
according to the status of host defenses.
Although organisms such as bacteria function as parasites, the usage of the term “parasitic disease” is usually
more restricted. Parasites are classified based on their
interactions with their hosts and their life cycles: ectoparasites and endoparasites. Ectoparasites are parasites
that live on the surface of the host, as seen in mites.
Endoparasites are parasites that live inside the host,
as seen in parasitic worms. Endoparasites are further
broken down into two forms: intercellular, which inhabit
spaces in the host’s body, and intracellular, which
inhabit cells in the host’s body.
Primary pathogens cause disease as a result of their
presence or activity within the normal, healthy host, and
their intrinsic virulence is, in part, a necessary consequence of their need to reproduce and spread. Many
of the most common primary pathogens of humans
only infect humans; however many serious diseases are
caused by organisms acquired from the environment or
which infect non-human hosts.
Opportunistic pathogens are organisms which cause an
infectious disease in a host with depressed resistance.
Opportunistic disease may be caused by microbes
that are ordinarily in contact with the host, such as
pathogenic bacteria or fungi in the gastrointestinal
or the upper respiratory tract, and they may also
result from microbes acquired from other hosts (as in
Clostridium difficile colitis) or from the environment as
a result of traumatic introduction (eg, surgical wound
infections or compound fractures). An opportunistic
disease requires impairment of host defenses, which
may occur as a result of genetic defects, exposure to
antimicrobial drugs or immunosuppressive chemicals,
exposure to ionizing radiation, or as a result of an
infectious disease with immunosuppressive activity.
Primary pathogens may also cause more severe disease
in a host with depressed resistance than would normally
occur in an immunosufficient host.
© 2013 AAPC. All rights reserved. 111213
There are many different infectious and parasitic
diseases. In this portion we will be discussing specific
diseases found in chapter 1, Certain Infectious and
Parasitic Diseases, in the ICD-10-CM manual.
Staphylococcus Aureus
Staphylococcus is a group of bacteria that can cause a
multitude of diseases as a result of infection of various
tissues of the body. Staph-related illness can range
from mild and requiring no treatment to severe and
potentially fatal. Over 30 different types of Staphylococci
can infect humans, but most infections are caused by
Staphylococcus aureus.
Staphylococcus aureus (S. aureus) is an anaerobic,
Gram-positive coccus and is the most common cause
of staph infections. It can be found as part of the skin
flora found in the nose and on skin of 25-30 percent of
healthy adults. It is one of the five most common causes
of nosocomial infections, often causing postsurgical
wound infections.
Methicillin-resistant Staphylococcus aureus, known
as MRSA, is a type of Staphylococcus aureus that is
resistant to the antibiotic methicillin and other drugs
in the same class, including penicillin, amoxicillin,
and oxacillin. MRSA is one example of a so-called
“superbug,” a term used to describe a strain of bacteria
that has become resistant to the antibiotics usually used
UnitedHealthcare
www.aapc.com
9
Blood and Lymphatic Systems
Module 1
to treat it. MRSA first appeared in patients in hospitals
and other health facilities, especially among the elderly,
the very sick, and those with an open wound (such as
a bedsore), or catheter in the body. In these settings,
MRSA is referred to as health-care-associated MRSA
(HA-MRSA). There are also cases of community-associated MRSA (CA-MRSA) when found in the community outside of the hospital. MRSA in the community is
associated with recent antibiotic use, sharing contaminated items, having active skin diseases or injuries, poor
hygiene, and living in crowded settings.
Following are some other ICD-10-CM codes for
staphylococcal conditions that are not first listed codes:
MRSA infections are usually mild superficial infections
of the skin that can be treated successfully with proper
skin care and antibiotics. MRSA, however, can be difficult to treat and can progress to life-threatening blood
or bone infections because there are fewer effective antibiotics available for treatment.
Other Staphylococcus as the cause of diseases
classified elsewhere
B95.7
Another strain of Staphylococcus aureus has been identified that are resistant to the antibiotic vancomycin,
which is normally effective in treating Staph infections.
These bacteria are referred to as vancomycin-intermediate resistance Staphylococcus aureus (VISA) and
vancomycin-resistant Staphylococcus aureus (VRSA).
Most ICD-10-CM codes for Staphylococcus aureus are
found in chapter one. To code Staphylococcus aureus in
ICD-10-CM the following is necessary:
• Type of Staphylococcus
• Condition
Following are the ICD-10-CM codes for Staphylococcus:
10
Foodborne staphylococcal intoxication
A05.0
Sepsis due to Methicillin susceptible
Staphylococcus aureus
A41.01
Sepsis due to Methicillin resistant
Staphylococcus aureus
A41.02
Sepsis due to other specified Staphylococcus
A41.1
Sepsis due to unspecified Staphylococcus
A41.2
Staphylococcal infection, unspecified site
A49.0
Anatomy and Pathophysiology for ICD-10
Methicillin susceptible Staphylococcus
aureus infection as the cause of diseases
classified elsewhere
B95.61
Methicillin resistant Staphylococcus aureus
infection as the cause of diseases classified
elsewhere
B95.62
Unspecified Staphylococcus as the cause of
diseases classified elsewhere
B95.8
These are used for conditions like abscesses, furuncles,
and carbuncles. For example, a cutaneous abscess of the
face caused by Staphylococcus aureus the codes would be
L02.01, B95.6.
Following are some ICD-10-CM codes for staphylococcal conditions that are not located in chapter one:
Staphylococcal scalded skin syndrome
L00
Pneumonia due to Staphylococcus,
unspecified
J15.20
Pneumonia due to Methicillin susceptible
Staphylococcus aureus
J15.211
Pneumonia due to Methicillin resistant
Staphylococcus aureus
J15.212
Pneumonia due to other Staphylococcus
J15.29
Clostridium Difficile
Clostridium difficile (C. diff) is a species of Grampositive bacteria of the genus Clostridium that causes
diarrhea and other intestinal disease when competing
bacteria are wiped out by antibiotics.
Clostridia are anaerobic, spore-forming rods (bacilli). It
is a bacterium that is related to the bacterium that causes
tetanus and botulism. The C. difficile bacterium has two
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Module 1 Blood and Lymphatic Systems
forms, an active, infectious form that cannot survive in
the environment for prolonged periods, and a nonactive
form called a spore, that can survive in the environment
for prolonged periods. Although spores cannot cause
infection directly, when they are ingested they transform
into the active, infectious form.
C. difficile is the most serious cause of antibiotic-associated diarrhea (AAD) and can lead to pseudomembranous
colitis, a severe infection of the colon, often resulting
from eradication of the normal flora by antibiotics. The
C. difficile bacteria, which naturally reside in the body,
become overpopulated: The overpopulation is harmful
because the bacterium releases toxins that can cause
bloating and diarrhea with abdominal pain, which may
become severe. Often, it can be cured by discontinuing
the antibiotics responsible. In more serious cases, oral
administration of medications (metronidazole or vancomycin) is the treatment of choice.
A04.7
Other specified bacterial foodborne
intoxications
A05.8
Sepsis due to anaerobes
A41.4
Gas gangrene
A48.0
Other specified bacterial agents as the cause
of diseases classified elsewhere
B96.89
Human immunodeficiency virus (HIV) is a lentivirus,
a member of the retrovirus family. a condition in which
the immune system begins to fail, leading to life-threatening opportunistic infections. Infection with HIV
occurs by the transfer of blood, semen, vaginal fluid,
pre-ejaculate, or breast milk. Within these bodily fluids,
HIV is present as both free virus particles and virus
within infected immune cells. The four major routes of
transmission are unprotected sex, contaminated needles,
breast milk, and perinatal transmission. Screening of
111213
HIV is most commonly spread in the following
manners:
Contact with infected blood
Accidental exposure
Sexual contact with an infected person
Accidental needle stick from contaminated needles
by health care workers
• Drug users sharing needles or syringes
• Accidental body fluid exposure
Human Immunodeficiency Virus/
Acquired Immune Deficiency Syndrome
© 2013 AAPC. All rights reserved. HIV infects primarily vital cells in the human immune
system such as helper T cells (to be specific, CD4+ T
cells), macrophages, and dendritic cells. HIV infection
leads to low levels of CD4+ T cells through three main
mechanisms: First, direct viral killing of infected cells;
second, increased rates of apoptosis in infected cells; and
third, killing of infected CD4+ T cells by CD8 cytotoxic
lymphocytes that recognize infected cells. When CD4+
T cell numbers decline below a critical level, cell-mediated immunity is lost, and the body becomes progressively more susceptible to opportunistic infections.
•
•
•
•
Most ICD-10-CM codes for clostridium difficile are
found in chapter one.
Enterocolitis due to Clostridium difficile
blood products for HIV has largely eliminated transmission through blood transfusions or infected blood products in the developed world. HIV infection is considered
a pandemic by the World Health Organization (WHO).
HIV progresses to AIDS at a variable rate affected by
viral, host, and environmental factors; many will progress to AIDS within 10 years of HIV infection. Some of
those infected will have progressed much sooner, and
some will take much longer. Treatment with anti-retrovirals increases the life expectancy of people infected
with HIV. Even after HIV has progressed to diagnosable AIDS, the average survival time with antiretroviral
therapy has increased greatly over the years.
The initial infection with HIV generally occurs after
transfer of body fluids from an infected person to an
uninfected one. The first stage of infection, the primary,
or acute infection, is a period of rapid viral replication
that immediately follows the individual’s exposure to
HIV leading to an abundance of virus in the peripheral
blood with levels of HIV commonly approaching several
million viruses per mL.
This response is accompanied by a marked drop in
the numbers of circulating CD4+ T cells. This acute
UnitedHealthcare
www.aapc.com
11
Blood and Lymphatic Systems
Module 1
viremia is associated in virtually all patients with the
activation of CD8+ T cells, which kill HIV-infected cells
and subsequently with antibody production, or seroconversion. The CD8+ T cell response is thought to be
important in controlling virus levels, which peak and
then decline as the CD4+ T cell counts rebound. A good
CD8+ T cell response has been linked to slower disease
progression and a better prognosis, though it does not
eliminate the virus.
transmit the infection to others during this symptomfree period. Meanwhile, if the infection is not detected
and treated, the immune system gradually weakens and
AIDS develops.
During this period (usually 2–4 weeks post-exposure)
most individuals (80 to 90 percent) develop an influenza
or mononucleosis-like illness called acute HIV infection, the most common symptoms of which may include
fever, lymphadenopathy, pharyngitis, rash, myalgia,
malaise,and mouth and esophageal sores; and, symptoms may also include, but less commonly, headache,
nausea and vomiting, enlarged liver/spleen, weight loss,
thrush, and neurological symptoms. Infected individuals may experience all, some, or none of these symptoms. The duration of symptoms varies, averaging 28
days and usually lasting at least a week.
Almost all people infected with HIV, if not treated, will
develop AIDS. There is a small group of patients who
develop AIDS very slowly, or never at all. These patients
are called nonprogressors.
A strong immune defense reduces the number of viral
particles in the blood stream, marking the start of
secondary or chronic HIV infection. The secondary
stage of HIV infection can vary between two weeks and
20 years. During this phase of infection, HIV is active
within lymph nodes, which typically become persistently swollen in response to large amounts of virus that
becomes trapped in the follicular dendritic cells (FDC)
network. The surrounding tissues that are rich in CD4+
T cells may also become infected, and viral particles
accumulate both in infected cells and as free virus. Individuals who are in this phase are still infectious. During
this time, CD4+ CD45RO+ T cells carry most of the
proviral load.
During this stage of infection early initiation of antiretroviral therapy significantly improves survival, as
compared with deferred therapy.
AIDS (acquired immune deficiency syndrome) is the
final and most serious stage of HIV disease, which
causes severe damage to the immune system. Over 25
million people worldwide have died from this infection since the start of the epidemic. AIDS begins with
HIV infection. People infected with HIV may have
no symptoms for 10 years or longer, but they can still
12
Anatomy and Pathophysiology for ICD-10
Acute HIV infection progresses over time to asymptomatic HIV infection and then to early symptomatic HIV
infection. Later, it progresses to AIDS (advanced HIV
infection with CD4 T-cell count below 200 cells/mm3).
The ICD-10-CM codes for HIV are found in multiple
chapters due to the stage and relationship. To code HIV
in ICD-10-CM the following is necessary:
• Symptomatic or asymptomatic
• Reason for encounter
Following are the ICD-10-CM codes for HIV:
Human immunodeficiency virus disease
B20
Inconclusive laboratory evidence of human
immunodeficiency virus
R75
Encounter for screening for human immunodeficiency virus
Z11.4
Asymptomatic human immunodeficiency
virus infection status
Z21
Human immunodeficiency virus counseling
Z71.7
Following are the ICD-10-CM codes for HIV when
complicating pregnancy. These codes always take precedence over all other codes. A code from above would be
used as a secondary code to these listed below.
HIV disease complicating pregnancy, first
trimester
O98.711
HIV disease complicating pregnancy,
second trimester
O98.712
UnitedHealthcare
© 2013 AAPC. All rights reserved.
111213
Module 1 Blood and Lymphatic Systems
HIV disease complicating pregnancy,
third trimester
O98.713
HIV disease complicating pregnancy,
unspecified trimester
O98.719
HIV disease complicating childbirth
O98.72
HIV disease complicating the peurperium
O98.73
According to the ICD-10-CM guidelines, only confirmed
cases of HIV infections should be coded with confirmation meaning the provider has made a diagnostic statement in the patient’s medical record indicating they are
HIV positive or has an HIV-related illness.
Sequencing of these codes is dependent upon the reason
for the encounter. The guidelines state that if a patient
is admitted for an HIV-related condition, then the first
listed code should be B20, followed by additional codes
for all reported HIV-related conditions. If the patient
is admitted for an unrelated condition, the code for the
unrelated condition should be the first listed code, and
other diagnoses would be the HIV appropriate code,
followed by additional diagnosis codes for all reported
HIV-related conditions.
Another important guideline discusses proper use of
B20. Patients with any known prior diagnosis of an HIVrelated illness should be coded to B20. Once a patient
has developed an HIV-related illness, the patient should
always be assigned code B20 on every subsequent admission/encounter. There is an Excludes2 note that indicates
patients previously diagnosed with any HIV illness
should never be assigned to R75 (inconclusive HIV) or
Z21 (asymptomatic HIV).
Sources
Comprehensive Medical Terminology (Fourth Edition) by Betty Davis Jones.
Stedman’s Medical Dictionary, 28th edition
Bates’ Pocket Guide to Physical Examination and History Taking, Third Edition (Lynn S. Bickley-Lippincott)
© 2013 AAPC. All rights reserved. 111213
UnitedHealthcare
www.aapc.com
13