Download chapter 5 chapter-specific guidelines (icd-10-cm chapters 1

CHAPTER 5
CHAPTER-SPECIFIC GUIDELINES
(ICD-10-CM CHAPTERS 1-10)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 1
Certain Infectious and Parasitic
Diseases, Chapter 1
• A00-B99
• Classified according to etiology (cause) of
disease
– Combination coding = 1 code to fully describe
DX
• B37.0 Candidiasis infection of mouth
– Multiple coding = 2 or more to fully describe
DX
• N39.0 (UTI), B96.2 (E. coli)
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Slide 2
Resistant Infections & Sepsis
• Resistant to antibiotics
– Examples:
• Methicillin-resistant Staphylococcus aureus
(MRSA)
• Multi-drug-resistant Mycobacterium tuberculosis
(MDR-TB)
• First-listed DX = Infection
• Followed by Z16, Infection with drug
resistant microorganism
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Slide 3
Sepsis, Severe Sepsis, and
Septic Shock
• Sepsis = systemic inflammatory response syndrome
(SIRS)
– Report infection first
– If unknown organism, report A41.9, Sepsis, unspecified
• Severe sepsis = multiple organ dysfunction (MOD),
hypotension or collection of fluid in tissues
(hypoperfusion)—must be documented
– Report infection, followed by an R65.2 code
• Septic shock = circulatory failure associated with severe
sepsis
– Report infection first, followed by R65.21
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Slide 4
Human Immunodeficiency
• B20 reports HIV and includes AIDS
• Positive serology or culture, but no symptoms,
report:
– Z21, Asymptomatic HIV status
• HIV exposure, but no symptoms, report:
– Z20.6, contact/exposure to HIV
• Inconclusive serology, R75
(Cont’d…)
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Slide 5
Human Immunodeficiency
(…Cont’d)
• HIV testing, report Z11.4, Encounter for
screening for HIV
• Assign additional codes for known highrisk behavior:
– Z72.51, High risk heterosexual behavior
– Z72.52, High risk homosexual behavior
– Z72.53, High risk bisexual behavior
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Slide 6
Neoplasms, Chapter 2
• C00-D49
• C00-C96, Malignant neoplasms
– Primary and secondary
• D00-D09, Ca in situ (CIS)
– Not invasive
• D10-D36, Benign
• D37-D48, Uncertain
– Not clearly benign or malignant
• D49, Unspecified behavior
– Not stated as to behavior
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Slide 7
Stages of Neoplams
• Staging for renal cancer staged
– Stage I tumor of kidney capsule only
– Stage II tumor invading renal capsule/vein but within
fascia
– Stage III tumor extending to regional lymph
node/vena cava
– Stage IV other organ metastasis
• Pathology report & staging information will
be documented in medical record
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Slide 8
Sequencing and Complications
• Treatment directed at
– primary site, sequence primary first
– secondary site, sequence secondary first
• Types :
– Chemotherapy, Z51.11
– Immunotherapy, Z51.12
– Radiation therapy, Z51.0
• Complications, sequence complication first
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Slide 9
History of Neoplasm Codes
• History of neoplasm codes are only
reported when neoplasm eradicated and is
no longer present with no active treatment
– Example:
• Z85 personal history of malignant neoplasm
• If active treatment, such as chemo, no
history code can be reported
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Slide 10
Chapter 3, ICD-10-CM
• Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving
the Immune Mechanism
(D50-D89)
• Frequently reported codes:
– Anemia, D50-D64
– Coagulation Defects, D65-D69
– Other Disorders of Blood and Blood-Forming
Organs, D70-D77
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Slide 11
Endocrine, Nutritional, and
Metabolic Diseases, Chapter 4
• E00-E90
• Diabetes codes E08-E13
– Due to conditions classified elsewhere, E08
– Drug or chemical induced DM, E09
– Type 1 DM, E10
– Type 2 DM, E11
– Other specified DM, E13
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Slide 12
Diabetes Mellitus
• DM codes are combination codes that include
type of DM, body system affected, and
complications
• Example: E10.21 Type 1 diabetes mellitus with
diabetic nephropathy
– If type of DM not stated, query physician
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 13
Mental and Behavioral
Disorders, Chapter 5
• F01-F99
• Alcohol dependence and use, F10
• Opioid, cannabis, sedatives, cocaine, stimulants,
hallucinogens, nicotine, F11-F19
• Psychological disorders, F20-F29
• Mood disorders, F30-F39
– Such as, bipolar disorder
(Cont’d…)
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Slide 14
Mental and Behavioral
Disorders Codes
(…Cont’d)
• Anxiety, stress-related, etc., F40-F48
• Behavior syndromes, F50-F59
– Such as eating and sleep disorders
•
•
•
•
Adult personality and behavior, F60-F69
Mental retardation, F70-F79
Developmental disorders, F80-F89
Child or adolescent behavioral and emotional
disorders, F90-F98
• Unspecified mental disorder, F99
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Slide 15
Pain
• Pain disorders related to psychological factors,
report
– G89 for pain and
– F45.41 for pain related to psychological factors
• Dementia
– F01 (vascular dementia)
– F02 (dementia in diseases classified elsewhere
– F03 (unspecified dementia)
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Slide 16
Diseases of the Nervous
System, Chapter 6
• G00-G99
• Many combination codes
– Example
• G06.0 Intracranial abscess and granuloma
• Manifestation codes
– Example
• G21.11 Neuroleptic induced parkinsonism
– Code first (T43.3-T43.5) to identify drug
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Slide 17
Non-Psychological Pain
• Localized pain is reported with codes
throughout the I-10
– Example, eye pain (H92.0-) or limb pain (M79.6-)
• Category G89 is NEC pain
– Example, G89.11 NEC acute pain due to trauma or
G89.21 NEC chronic pain due to trauma
• R52 reports unspecified pain that is:
– Acute, chronic, generalized, or NOS
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Slide 18
Dominant and Nondominant
Sides
• Dominant side: right or left handed
• Paralysis (plegia) is reported based on dominant
or nondominant side
– Example
• G81.10 Spastic hemiplegia affecting unspecified side
• G81.11 Spastic hemiplegia affecting right dominant side
• G81.12 Spastic hemiplegia affecting left dominant side
• G81.13 Spastic hemiplegia affecting right nondominant side
• G81.14 Spastic hemiplegia affecting left nondominant side
• If dominant unknown, report dominant
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Slide 19
Diseases of the Eye and
Adnexa, Chapter 7
• H00-H59
• Does not contain all the eye and adnexa
codes
• Chapter Excludes2 directs to other
categories, such as:
– injury (trauma) of eye and orbit (S05.-)
– injury, poisoning and certain other consequences of
external causes (S00-T98)
– neoplasms (C00-D48)
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Slide 20
Structure of Eye and Ocular
Adnexa
Figure: 5.15
Eye and Ocular Adnexa
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Slide 21
Hordeolum and Chalazion
• Hordeolum = infection of sebaceous
glands (stye) reported on location and type
– Right or left upper/lower, or unspecified
• External, report H00.01• Internal, report H00.02-
• Chalazion = infection of eyelid that forms
mass reported on location
– H00.1
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Slide 22
Entropion/Ectropion
• Entropion = turning inward of eyelid,
H02.0Figure: 5.18A
From Frazier MS, Drzymkowski JW: Essentials
of Human Diseases and Conditions, ed 4, St.
Louis, 2009, Saunders.
• Ectropion = turning outward of eyelid,
H02.1Figure: 5.19A
From Frazier MS, Drzymkowski JW: Essentials
of Human Diseases and Conditions, ed 4, St.
Louis, 2009, Saunders.
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Slide 23
Lacrimal System
• Category H04
• Codes reported on right, left, bilateral,
unspecified, such as:
– H04.131 Lacrimal cyst right lacrimal gland
– H04.132 Lacrimal cyst left lacrimal gland
– H04.133 Lacrimal cyst bilateral lacrimal glands
– H04.139 Lacrimal cyst unspecified lacrimal gland
Figure: 5.17
Lacrimal apparatus
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Slide 24
Diseases of the Ear and
Mastoid Process, Chapter 8
• H60-H95
• Excludes2 indicates other categories for
reporting other ear conditions, such as:
– endocrine, nutritional and metabolic diseases (E00-E90)
– injury, poisoning and certain other consequences of external
causes (S00-T98)
– neoplasms (C00-D48)
• H60-H95 codes report diseases of external, middle, and
inner ear, as well as mastoid, other, and surgical
complications NEC
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Slide 25
Diseases of the Circulatory
System, Chapter 9
• I00-I99
• Excludes2 note indicates other categories for
other circulatory conditions, such as:
– neoplasms (C00-D48)
– symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified
(R00-R94)
– systemic connective tissue disorders (M30-M36)
• I00-I99 reports conditions such as rheumatic
fever, hypertension, ischemic heart disease,
cerebrovascular diseases, etc.
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Slide 26
Hypertension
• Report I10; includes arterial, benign,
essential, malignant, primary, and
systemic
– Arterial: Increased arterial blood pressure, hypertension
– Systemic: Arterial BP exceeds norm for several months
– Primary: Essential, cause unknown
– Secondary: Due to underlying condition
– Malignant: Severe form
– Benign: Mild form
(Cont’d…)
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Slide 27
Hypertension
(…Cont’d)
• Transient: Temporary, R03.0, elevated BP
without DX of hypertension
• During or due to pregnancy, O13.- or
O14.-
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Slide 28
Hypertension with Heart
Disease
• I11, Hypertensive heart disease
– Includes conditions reported with I50.- or I51.4-I51.9
(myocarditis, cardiomegaly, ill-defined or unspecified
heart disease) when condition due to hypertension
• I11.0 Hypertensive heart disease with heart failure
Hypertensive heart failure
Use additional code to identify type of heart failure (I50.-)
• I11.9 Hypertensive heart disease without heart failure
Hypertensive heart disease NOS
(Cont’d…)
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Slide 29
Hypertension with Heart
Disease
(…Cont’d)
• Same heart condition not stated to be “due
to hypertension” or “hypertensive,” report
the heart disease and hypertension
separately
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Slide 30
Kidney Disease and
Hypertension
• Assume a relationship between the kidney
disease and the hypertension
• I13, combination code for hypertensive
heart and chronic kidney disease
• If heart disease is present, assign a
category I50 code
(Cont’d…)
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Slide 31
Kidney Disease and
Hypertension
(…Cont’d)
• CRF/CKD/CRI + hypertension I12.9 + N18.9
• CKD stage 1 + hypertension
I12.9 + N18.1
• CKD stage 2 + hypertension
I12.9 + N18.2
• CKD stage 3 + hypertension
I12.9 + N18.3
• CKD stage 4 + hypertension
I12.9 + N18.4
• CKD stage 5 + hypertension
I12.9 + N18.5
• CKD stage 6 or ESRD or on dialysis + I12.9 + N18.6
• Patient with CKD on any type of dialysis I12.9 + N18.6 +
Z99.2
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Slide 32
Myocardial Infarction
• Acute heart attack with occlusion of coronary
artery
• STEMI, ST elevation MI, most severe, total
occlusion
– Example: I21.01 ST elevation (STEMI) myocardial
infarction involving left main coronary artery
• NSTEMI, non-ST elevation MI, less severe,
partial occlusion
– Example, I21.4 Non-ST elevation (NSTEMI)
myocardial infarction
(Cont’d...)
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Slide 33
Myocardial Infarction
(…Cont’d)
• Subsequent STEMI or NSTEMI are
reported with I22.– Example, I22.1 Subsequent ST elevation (STEMI)
myocardial infarction of inferior wall
• Complications within 28 days of initial MI,
I23
– Example, I23.1 Atrial septal defect as current
complication following acute myocardial infarction
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Slide 34
Diseases of the Respiratory
System, Chapter 10
• J00-J99
• Some codes are combination codes that
identify condition and causative organism
– Example: J03.01 Acute recurrent streptococcal tonsillitis
• Other codes require separate reporting of
organism
– Example: J01.01 Acute recurrent maxillary sinusitis (Use
additional code (B95-B97) to identify infectious agent )
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Slide 35
Conclusion
CHAPTER 5
CHAPTER-SPECIFIC GUIDELINES
(ICD-10-CM CHAPTERS 1-10)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 36