SCCA REFERENCE MANUAL ICD-10

Transcription

1 SCCA REFERENCE MANUAL ICD-10 NORTHWEST HOSPITAL 1

2 BREAST CANCER BREAST (INC. PAGET S DISEASE) 0 - Nipple and areola 1 - Central portion 2 - Upper-inner quadrant 3 - Lower-inner quadrant 4 - Upper-outer quadrant 5 - Lower-outer quadrant 6 - Axillary tail site 1 - Female 2 - Male C50. Use additional code to identify estrogen receptor status Cancer In Situ of BREAST 0 - Lobular (LCIS) 1 - Intraductal (DCIS) 8 - Other specified type of type of ESTROGEN RECEPTOR STATUS 0 - Positive status [ER+] 1 - Negative status [ER-] D Unspecified 2 - Right 3 - Left Z17. GU/PROSTATE KIDNEY, EXCEPT RENAL PELVIS kidney kidney RENAL PELVIS C64. C65. BLADDER 0 - Trigone 1 - Dome 2 - Lateral wall 3 - Anterior wall 4 - Posterior wall 5 - Bladder neck 6 - Ureteric orifice 7 - Urachus 8 - Overlapping C67. renal pelvis renal pelvis URETER ureter ureter C66. Other & UNSPECIFIED URINARY ORGANS 0 - Urethra 1 - Paraurethral glands C68. PENIS C60. PROSTATE C Prepuce 1 - Glans 2 - Body 8 - Overlapping OTHER & UNSPECIFIED MALE GENITAL ORGANS C63. TESTIS C Epididymis 1 - Spermatic cord 0 - Undescended 1 - Descended 2 - Scrotum 7 -Other specified 2

3 GI: MALIGNANT NEOPLASMS OF DIGESTIVE ORGANS ESOPHAGUS 3 - Upper third of esophagus 4 - Middle third of esophagus 5 - Lower third of esophagus of esophagus STOMACH 0 - Cardia 1 - Fundus of stomach 2 - Body of stomach 3 - Pyloric antrum 4 - Pylorus 5 - Lesser curvature of stomach, unspecified 6 - Greater curvature of stomach, unspecified of stomach SMALL INTESTINE 0 - Duodenum 1 - Jejunum 2 - Ileum 3 - Meckel's diverticulum, malignant of small intestine Excludes Carcinoid C15. C16. C17. RECTUM Excludes Carcinoid ANUS & ANAL CANAL 0 - Anus, unspecified 1 - Anal canal 2 -Cloacogenic zone of rectum, anus and anal canal LIVER & INTRAHEPATIC BILE DUCTS 0 - Liver cell 1 - Intrahepatic bile duct 2 - Hepatoblastoma 3 - Angiosarcoma of liver 4 - Other sarcomas of liver 7 - Other specified s of liver 8 - Malignant neoplasm of liver, primary, unspecified as to type 9 - Malignant neoplasm of liver, not specified as primary or secondary GALL BLADDER C20 C21. C22. Use additional code to identify alcohol abuse / dependence and Hepatitis C or B. C23 COLON 0 - Cecum 1 - Appendix 2 - Ascending colon 3 - Hepatic flexure 4 - Transverse colon 5 - Splenic flexure 6 - Descending colon 7 - Sigmoid colon of colon C18. RECTOSIGMOID JUNCTION Excludes Carcinoid OTHER & ILL-DEFINED DIGESTIVE ORGANS 0 - Intestinal tract, part unspecified 1 - Spleen 9 - Ill-defined sites within the digestive system Excludes Carcinoid C26. C19 OTHER & UNSPECIFIED PARTS OF BILIARY 0 - Extrahepatic bile duct 1 - Ampulla of Vater of biliary tract 9 - Biliary tract, unspecified C24. CARCINOID SYNDROME E34.0 PANCREAS C Head of pancreas 1 - Body of pancreas 2 - Tail of pancreas 3 - Pancreatic duct 4 - Endocrine pancreas (Use additional code to identify any functional activity) 7 - Other parts of pancreas of pancreas Use additional code to identify alcohol abuse and dependence 3

4 HNL: MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use additional code to identify - alcohol abuse and dependence - Exposure to environmental tobacco smoke - Exposure to tobacco smoke in perinatal period - History of tobacco - Occupational exposure to environmental tobacco smoke - Tobacco dependence - Tobacco use LIP 0 - External upper lip 1 - External lower lip 2 - External lip, unspecified 3 - Upper lip, inner aspect 4 - Lower lip, inner aspect 5 - Lip, unspecified, inner aspect 6 - Commissure of lip, unspecified of lip BASE OF TONGUE * Document alcohol/ tobacco use OTHER & UNSPECIFIED PARTS OF TONGUE 0 - Dorsal surface 1 - Border 2 - Ventral surface 3 - Anterior two-thirds of tongue, part unspecified 4 - Lingual tonsil of tongue GUM 0 - Upper gum 1 - Lower gum FLOOR OF MOUTH 0 - Anterior 1 - Lateral * Document alcohol/ tobacco use C00. C01 C02. C03. C04. PALATE 0 - Hard palate 1 - Soft palate 2 - Uvula PAROTID GLAND C05. OTHER & UNSPECIFIED MAJOR SALIVARY GLANDS 0 - Submandibular gland 1 - Sublingual gland TONSIL 0 - Fossa 1 - Pillar (anterior & posterior) OROPHARYNX 0 - Vallecula 1 - Anterior surface of epiglottis 2 - Lateral wall of oropharynx 3 - Posterior wall of oropharynx 4 - Branchial cleft C07 C08. C09. C10. 4

5 HNL: MALIGNANT NEOPLASMS OF LUNG - RESPIRATORY & INTRATHORACIC ORGANS DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use additional code to identify - alcohol abuse and dependence - Exposure to environmental tobacco smoke - Exposure to tobacco smoke in perinatal period - History of tobacco - Occupational exposure to environmental tobacco smoke - Tobacco dependence - Tobacco use NASOPHARYNX 0 - Superior wall 1 - Posterior wall 2 - Lateral wall 3 - Anterior wall C11. * Document tobacco use LARYNX 0 - Glottis 1 - Supraglottis 2 - Subglottis 3 - Laryngeal cartilage C32. PYRIFORM SINUS * Document tobacco use C12 TRACHEA C33 HYPOPHARYNX 0 - Postcricoid region 1 - Aryepiglottic fold, hypopharyngeal aspect 2 - Posterior wall NASAL CAVITY & MIDDLE EAR 0 - Nasal cavity 1 - Middle ear C13. * Document tobacco use C30. BRONCHUS & LUNG 0 - Main bronchus 1 Upper lobe, bronchus or lung 3 Lower lobe, bronchus or lung of bronchus & lung 9 Unspecified part of bronchus or lung 2 - Middle lobe, bronchus or lung Excludes Carcinoid & Kaposi s * Document tobacco use THYMUS C34. C37 ACCESSORY SINUSES 0 - Maxillary sinus 1 - Ethmoidal sinus 2 - Frontal sinus 3 - Sphenoid sinus C31. HEART, MEDIASTINUM & PLEURA 0 - Heart 1 - Anterior mediastinum 2 - Posterior mediastinum 3 - Mediastinum, part unspecified 4 - Pleura of heart, mediastinum and pleura C38. 5

6 MELANOMA & OTHER MALIGNANT NEOPLASM OF SKIN Malignant Melanoma of SKIN 1- Eyelid including canthus 2 - Ear and external auricular canal 6 - Upper limb, including shoulder 7 - Lower limb, including hip 3 - Other and unspecified parts of face 5 - Trunk 0 - Lip 4 - Scalp & neck of skin MERKEL CELL CARCINOMA 1- Eyelid including canthus 2 - Ear and external auricular canal 6 - Upper limb, including shoulder 7 - Lower limb, including hip 3 - Other and unspecified parts of face C Nose 9 Other parts of face 1 - Anal skin 2 - Skin of breast 9 Other part of trunk C4A. 1 - Nose 9 Other parts of face Other & Unspecified Malignant Neoplasm of SKIN 0 - Lip 4 - Skin of scalp & neck of skin 1- Eyelid including canthus 6 - Upper limb, Including shoulder 7 - Lower limb, including hip 2 - Ear and external auricular canal 3 - Other and unspecified parts of face 1 - Basal cell 2 - Squamous cell 9 Other 1 - Basal cell 2 - Squamous cell 9 Other 1 - Basal cell 2 - Squamous cell 9 Other C Basal cell 2 - Squamous cell 9 Other specified 1 - Unspecified 2 - Right 9 - Left 1 - Unspecified 2 - Right 9 - Left 1 - Unspecified 1 - Nose 9 - Other parts of face 5 - Trunk 0 - Lip 4- Scalp & neck of skin 1 - Anal skin 2 - Skin of breast 9 Other part of trunk 5 - Trunk 1 - Basal cell 2 - Squamous cell 9 Other 0 - Anal skin 1 - Skin of breast 9 - Other part of trunk SECONDARY NEUROENDOCRINE TUMORS 0 - Secondary carcinoid tumors 1- Secondary Merkel cell 8- Other secondary neuroendocrine tumors 1 - Distant lymph nodes 2 - Liver 3 - Bone 4 - Peritoneum 9 - Other sites C7B. 6

7 SECONDARY & UNSPECIFIED SITES Secondary OTHER & UNSPECIFIED SITES 0 - Kidney & Renal Pelvis 6 - Ovary 7 - Adrenal gland 1- Bladder and other and unspecified urinary organs 2 - Skin 3 Brain and cerebral meninges 4 Other & unspecified parts of nervous system urinary organs 1 - Bladder 9 - Other urinary organs 9 - Other 5 Bone and bone marrow 1 - Bone 2 -Bone marrow 8 Other specified sites C79. 1 Brain 2 Cerebral meninges 1 - Breast 2 - Genital organs 9 - Other Malignant NEUROENDOCRINE TUMORS 0- Malignant Carcinoid Tumors 0- Unspecified site 1- Small intestine 2- Appendix, large intestine, and rectum 9- Other sites 1 - Malignant poorly differentiated neuroendocrine tumors 8 - Other malignant neuroendocrine tumors C7A. 0 Duodenum 1- Jejunum 2- Ileum 9 Unspecified 0- Appendix 1- Cecum 2- Ascending colon 3- Transverse colon 0- Bronchus/Lung 1- Thymus 2- Stomach 3- Kidney 4- Descending colon 5- Sigmoid colon 6- Rectum 9- Large intestine, unspecified 4- Foregut NOS 5- Midgut NOS 6- Hindgut NOS 8- Other sites OTHER & ILL-DEFINED SITES 0 - Head, face & neck 1- Thorax 2 - Abdomen 3 - Pelvis 8 -Other specified ill-defined sites 4 - Upper limb 5- Lower limb C76. SECONDARY NEUROENDOCRINE TUMORS 0 - Secondary carcinoid tumors 1- Secondary Merkel cell 8- Other secondary neuroendocrine tumors 1 - Distant lymph nodes 2 - Liver 3 - Bone 4 - Peritoneum 9 - Other sites C7B. Neoplasm of Uncertain Behavior of OTHER & UNSPECIFIED SITES 0 - Bone and articular cartilage 1 - Connective and other soft tissue 2 - Peripheral nerves and autonomic nervous system 3 - Retroperitoneum 4 - Peritoneum 5 - Skin 7 - Other specified sites 6 - Breast D48. Neoplasm of UNSPECIFIED BEHAVIOR 8 - Other specified sites 1 - Retina and choroid 9 - Other specified sites D Digestive system 1 - Respiratory system 2 - Bone, soft tissue and skin 3 - Breast 4 - Bladder 5 - Genitourinary organs 6 - Brain 7 - Endocrine glands and other parts of nervous system site 7

8 ANEMIAS Anemia due to ENZYME DISORDERS D Due to glucose-6-phosphate dehydrogenase [G6PD] deficiency 1 - Other disorders of glutathione metabolism 2 - Disorders of glycolytic enzymes 3 - Disorders of nucleotide metabolism 8 - Other anemias THALASSEMIA D56. 0 Alpha 1 - Beta 2 - Delta-beta 3 - Minor 4 - HPFH (Hereditary persistence of fetal hemoglobin) 5 - Hemoglobin E-beta 8 - Other SICKLE CELL DISORDERS 0 - Hb-SS with crisis 1 - Sickle cell without crisis 3 - Sickle-cell trait 2 - Hb-C disease 4 - Thalassemia 8 - Other Sickle-Cell 0 - Without crisis 1 - With crisis Use additional code for any associated fever OTHER ANEMIAS D Acute chest syndrome 2 - Splenic sequestration 0 - Hereditary sideroblastic anemia 1 - Secondary sideroblastic anemia due to disease 2 - Secondary sideroblastic anemia due to drugs and toxins 3 - Other sideroblastic anemias 4 - Congenital dyserythropoietic anemia 8 Other specified anemias 1 - Acute chest syndrome 2 - Splenic sequestration D Anemia due to anti-neoplastic chemotherapy 9 -Other specified anemias Hemolytic Anemia, ACQUIRED D Drug-induced autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 1 - Other autoimmune 2 - Drug-induced non-autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 3 - Hemolytic-uremic syndrome (Use additional code to identify associated: E. coli, Pneumoncoccal pneumonia, or Shigella dysenteriae) 4 - Other non-autoimmune 5 - Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) 6 - Hemoglobinuria due to hemolysis from other external causes 8 - Other acquired hemolytic anemias Other Aplastic Anemias & Other BONE MARROW FAILURE SYNDROMES 0 Constitutional aplastic anemia 8 - Other specified aplastic anemias & other bone marrow failure syndromes 1 - Constitutional (pure) red blood cell aplasia 9 - Other constitutional aplastic anemia 1- Pancytopenia 2 - Myelophthisis 9- Other specified aplastic anemias & other bone marrow failure syndrome D Antineoplastic chemotherapy induced pancytopenia 1 - Other drug-induced pancytopenia 8 - Other pancytopenia 1 - Drug-induced aplastic anemia (If applicable, use additional code for adverse effects to identify drug) 2 - Aplastic anemia due to other external agents (If applicable, code first toxic effects of substance chiefly non-medicinal as to source (T51-T65) 3 - Idiopathic aplastic anemia Anemia in CHRONIC DISEASES CLASSIFIED ELSEWHERE 0 - Anemia in neoplastic disease (Code first neoplasm) 1 - Anemia in chronic kidney disease (Code first underlying CKD) 8 - Anemia in other chronic diseases classified elsewhere (Code first underlying disease such as: - Hypothyroidism - Tuberculosis) D63. 8

9 DRUG-INDUCED PHENOMENON AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY D70.1 TOXIC LIVER DISEASE 0 - With cholestasis 2 - With acute hepatitis K71. AGRANULOCYTOSIS D70.2 DUE TO NON-CHEMOTHERAPY DRUG ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY OTHER SECONDARY THROMBOCYTOPENIA D69.59 * Due to drugs, EtOH, alloimmunization; NOT ITP DRUG (OPIATE) INDUCED CONSTIPATION DRUG (OPIATE) INDUCED CONSTIPATION D64.81 K59.09 K With hepatic necrosis This is for toxic effects due to drug; Does Not include ETOH 0 - Without coma 1 -With coma Other & Unspecified POLYNEUROPATHIES 0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents (as used for AIDS) 8 - Other specified 1 -Critical illness 2 - Radiation-induced 9 - Other G62. POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE (Includes myeloma induced neuropathy) ORAL MUCOSITIS, ULCERATIVE 0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other G63 K12.3 DRUG-INDUCED ADRENOCORTICAL INSUFFICIENCY E27.3 DRUG-INDUCED CUSHING'S SYNDROME E24.2 Copyright 2015; Revised 5/15/15 6