ICD-10-CM Professional for Physicians The complete official code set Codes valid October 1, 2016 through September 30, 2017

Transcription

1 ICD-10-CM Professional for Physicians The complete official code set Codes valid October 1, 2016 through September 30, 2017 ICD-10 IS NOW. For more resources and training visit Optum360Coding.com.

2 Contents Preface... iii ICD-10-CM Official Preface... iii Characteristics of ICD-10-CM... iii What s New for iv Introduction... v History of ICD-10-CM... v ICD-10-CM: The Complete Official Code Set... v How to Use ICD-10-CM for Physicians vi Use of Official Sources... vi Steps to Correct Coding... vi Organization... vi Introduction... vi Official ICD-10-CM Conventions and Guidelines... vi Alphabetic Index to Diseases... vi Neoplasm Table... vi Table of Drugs and Chemicals... vi Index to External Causes... vi Tabular List of Diseases... vi Illustrations... vi Overview of ICD-10-CM Official Conventions... vii Format... vii Punctuation...vii Abbreviations...vii NEC... vii NOS... vii Typeface...vii General Notes...vii Includes Notes...vii Inclusion Terms...vii Excludes Notes...vii Note...viii Default Codes...viii Syndromes...viii And...viii With...viii Instruction Notes Used in the Tabular...viii Additional Annotations... ix Code-Level Notations... ix Italics... ix Color Coding/Symbols... ix Chapter-Level Notations... xi Chapter-Specific Guidelines with Coding Examples... xi Muscle/Tendon Table... xi Index Notations... xi Following References... xi ICD-10-CM Official Guidelines for Coding and Reporting Coding Guidelines 1 ICD-10-CM Index to Diseases and Injuries... 1 ICD-10-CM Neoplasm Table ICD-10-CM Table of Drugs and Chemicals ICD-10-CM Index to External Causes ICD-10-CM Tabular List of Diseases and Injuries Chapter 1. Certain Infectious and Parasitic Diseases (A00-99) Chapter 2. Neoplasms (C00-D49) Chapter 3. Diseases of the lood and lood-forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) Chapter 4. Endocrine, Nutritional and Metabolic Diseases (E00-E89) Chapter 5. Mental, ehavioral, and Neurodevelopmental Disorders (F01-F99) Chapter 6. Diseases of the Nervous System (G00-G99) Chapter 7. Diseases of the Eye and Adnexa (H00-H59) Chapter 8. Diseases of the Ear and Mastoid Process (H60-H95) Chapter 9. Diseases of the Circulatory System (I00-I99) Chapter 10. Diseases of the Respiratory System (J00-J99) Chapter 11. Diseases of the Digestive System (K00-K95) Chapter 12. Diseases of the Skin and Subcutaneous Tissue (L00-L99) Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) Chapter 14. Diseases of the Genitourinary System (N00-N99).781 Chapter 15. Pregnancy, Childbirth and the Puerperium (O00-O9A) Chapter 16. Certain Conditions Originating in the Perinatal Period (P00-P96) Chapter 17. Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99) Chapter 18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88) Chapter 20. External Causes of Morbidity (V00-Y99) Chapter 21. Factors Influencing Health Status and Contact With Health Services (Z00-Z99) Illustrations... Illustrations 1 Chapter 3. Diseases of the lood and lood-forming Organs and Certain Disorders Involving the Immune Mechanism (D50 D89)...Illustrations 1 Red lood Cells...Illustrations 1 White lood Cell...Illustrations 1 Platelet...Illustrations 2 Coagulation...Illustrations 2 Spleen Anatomical Location and External Structures...Illustrations 3 Spleen Interior Structures...Illustrations 3 i

3 Contents Chapter 4. Chapter 6. Chapter 7. Chapter 8. Chapter 9. Endocrine, Nutritional and Metabolic Diseases (E00 E89)... Illustrations 4 Endocrine System... Illustrations 4 Thyroid... Illustrations 5 Thyroid and Parathyroid Glands... Illustrations 5 Pancreas... Illustrations 6 Anatomy of the Adrenal Gland... Illustrations 6 Structure of an Ovary... Illustrations 7 Testis and Associated Structures... Illustrations 7 Thymus... Illustrations 8 Diseases of the Nervous System (G00 G99)... Illustrations 9 rain... Illustrations 9 Cranial Nerves... Illustrations 9 Peripheral Nervous System... Illustrations 10 Spinal Cord and Spinal Nerves... Illustrations 11 Nerve Cell... Illustrations 12 Diseases of the Eye and Adnexa (H00 H59)... Illustrations 13 Eye... Illustrations 13 Posterior Pole of Globe/Flow of Aqueous Humor... Illustrations 13 Lacrimal System... Illustrations 14 Eye Musculature... Illustrations 14 Eyelid Structures... Illustrations 15 Diseases of the Ear and Mastoid Process (H60 H95)... Illustrations 16 Ear Anatomy... Illustrations 16 Diseases of the Circulatory System (I00 I99)... Illustrations 17 Anatomy of the Heart... Illustrations 17 Heart Cross Section... Illustrations 17 Heart Valves... Illustrations 18 Heart Conduction System... Illustrations 18 Coronary Arteries... Illustrations 19 Arteries... Illustrations 20 Veins... Illustrations 21 Internal Carotid and Vertebral Arteries and ranches... Illustrations 22 External Carotid Artery and ranches... Illustrations 22 ranches of Abdominal Aorta... Illustrations 23 Portal Venous Circulation... Illustrations 23 Lymphatic System... Illustrations 24 Axillary Lymph Nodes... Illustrations 25 Lymphatic System of Head and Neck... Illustrations 25 Lymphatic Capillaries... Illustrations 26 Lymphatic Drainage... Illustrations 26 Chapter 10. Diseases of the Respiratory System (J00 J99)...Illustrations 27 Respiratory System...Illustrations 27 Upper Respiratory System...Illustrations 28 Lower Respiratory System...Illustrations 28 Paranasal Sinuses...Illustrations 28 Lung Segments...Illustrations 29 Alveoli...Illustrations 29 Chapter 11. Diseases of the Digestive System (K00 K95)...Illustrations 30 Digestive System...Illustrations 30 Omentum and Mesentery...Illustrations 31 Peritoneum and Retroperitoneum..Illustrations 31 Chapter 12. Diseases of the Skin and Subcutaneous Tissue (L00 L99)...Illustrations 32 Nail Anatomy...Illustrations 32 Skin and Subcutaneous Tissue...Illustrations 32 Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue (M00 M99)...Illustrations 33 ones and Joints...Illustrations 33 Shoulder Anterior View...Illustrations 34 Shoulder Posterior View...Illustrations 34 Elbow Anterior View...Illustrations 34 Elbow Posterior View...Illustrations 35 Hand...Illustrations 35 Hip Anterior View...Illustrations 36 Hip Posterior View...Illustrations 36 Knee Anterior View...Illustrations 36 Knee Posterior View...Illustrations 37 Foot...Illustrations 37 Muscles...Illustrations 38 Chapter 14. Diseases of the Genitourinary System (N00 N99)...Illustrations 39 Urinary System...Illustrations 39 Male Genitourinary System...Illustrations 40 Female Internal Genitalia...Illustrations 40 Female Genitourinary Tract Lateral View...Illustrations 41 Chapter 15. Pregnancy, Childbirth and the Puerperium (O00 O9A)...Illustrations 42 Term Pregnancy Single Gestation Illustrations 42 Twin Gestation Dichorionic Diamniotic (DI-DI)...Illustrations 42 Twin Gestation Monochorionic Diamniotic (MO-DI)...Illustrations 43 Twin Gestation Monochorionic Monoamniotic (MO-MO)...Illustrations 43 ii

4 Index Glaucoma Glucose-galactose malabsorption Glaucoma Glaucoma continued corticosteroid-induced see Glaucoma, secondary, drugs hypersecretion H S in (due to) amyloidosis E85.4 [H42] aniridia Q13.1 [H42] concussion of globe see Glaucoma, secondary, trauma dislocation of lens see Glaucoma, secondary disorder of lens NEC see Glaucoma, secondary drugs see Glaucoma, secondary, drugs endocrine disease NOS E34.9 [H42] eye inflammation see Glaucoma, secondary, inflammation trauma see Glaucoma, secondary, trauma hypermature cataract see Glaucoma, secondary iridocyclitis see Glaucoma, secondary, inflammation lens disorder see Glaucoma, secondary Lowe's syndrome E72.03 [H42] metabolic disease NOS E88.9 [H42] ocular disorders NEC see Glaucoma, secondary onchocerciasis pupillary block see Glaucoma, secondary retinal vein occlusion see Glaucoma, secondary Rieger's anomaly Q13.81 [H42] rubeosis of iris see Glaucoma, secondary tumor of globe see Glaucoma, secondary infantile Q15.0 low tension see Glaucoma, open angle, primary, low-tension malignant H S narrow angle see Glaucoma, angle-closure newborn Q15.0 noncongestive (chronic) see Glaucoma, open angle nonobstructive see Glaucoma, open angle obstructive (see also Glaucoma, angle-closure) due to lens changes see Glaucoma, secondary open angle H S primary H S capsular (with pseudoexfoliation of lens) H S low-tension H S pigmentary H S residual stage H S phacolytic see Glaucoma, secondary pigmentary see Glaucoma, open angle, primary, pigmentary postinfectious see Glaucoma, secondary, inflammation secondary (to) H40.5- S drugs H40.6- S inflammation H40.4- S trauma H40.3- S simple (chronic) H S simplex H S specified type NEC H40.89 suspect H S syphilitic A52.71 traumatic (see also Glaucoma, secondary, trauma) newborn (birth injury) P15.3 tuberculous A18.59 Glaucomatous flecks (subcapsular) see Cataract, complicated Glazed tongue K14.4 Gleet (gonococcal) A54.01 Glénard's disease K63.4 Glioblastoma (multiforme) with sarcomatous component specified site see Neoplasm, malignant, by site giant cell specified site see Neoplasm, malignant, by site specified site see Neoplasm, malignant, by site Glioma (malignant) astrocytic specified site see Neoplasm, malignant, by site mixed specified site see Neoplasm, malignant, by site nose Q30.8 specified site NEC see Neoplasm, malignant, by site Glioma continued subependymal D43.2 specified site see Neoplasm, uncertain behavior, by site unspecified site D43.2 Gliomatosis cerebri C71.0 Glioneuroma see Neoplasm, uncertain behavior, by site Gliosarcoma specified site see Neoplasm, malignant, by site Gliosis (cerebral) G93.89 spinal G95.89 Glisson's disease see Rickets Globinuria R82.3 Globus (hystericus) F45.8 Glomangioma D18.00 intra-abdominal D18.03 intracranial D18.02 skin D18.01 specified site NEC D18.09 Glomangiomyoma D18.00 intra-abdominal D18.03 intracranial D18.02 skin D18.01 specified site NEC D18.09 Glomangiosarcoma see Neoplasm, connective tissue, malignant Glomerular disease in syphilis A52.75 nephritis see Glomerulonephritis Glomerulitis see Glomerulonephritis Glomerulonephritis (see also Nephritis) N05.9 with edema see Nephrosis minimal change N05.0 minor glomerular abnormality N05.0 acute N00.9 chronic N03.9 crescentic (diffuse) NEC (see also N00-N07 with fourth character.7) N05.7 dense deposit (see also N00-N07 with fourth character.6) N05.6 diffuse crescentic (see also N00-N07 with fourth character.7) N05.7 endocapillary proliferative (see also N00-N07 with fourth character.4) N05.4 membranous (see also N00-N07 with fourth character.2) N05.2 mesangial proliferative (see also N00-N07 with fourth character.3) N05.3 mesangiocapillary (see also N00-N07 with fourth character.5) N05.5 sclerosing N05.8 endocapillary proliferative (diffuse) NEC (see also N00- N07 with fourth character.4) N05.4 extracapillary NEC (see also N00-N07 with fourth character.7) N05.7 focal (and segmental) (see also N00-N07 with fourth character.1) N05.1 hypocomplementemic see Glomerulonephritis, membranoproliferative IgA see Nephropathy, IgA immune complex (circulating) NEC N05.8 in (due to) amyloidosis E85.4 [N08] bilharziasis 65.9 [N08] cryoglobulinemia D89.1 [N08] defibrination syndrome D65 [N08] diabetes mellitus see Diabetes, glomerulosclerosis disseminated intravascular coagulation D65 [N08] Fabry (-Anderson) disease E75.21 [N08] Goodpasture's syndrome M31.0 hemolytic-uremic syndrome D59.3 Henoch (-Schönlein) purpura D69.0 [N08] lecithin cholesterol acyltransferase deficiency E78.6 [N08] microscopic polyangiitis M31.7 [N08] multiple myeloma C90.0- S [N08] Plasmodium malariae 52.0 schistosomiasis 65.9 [N08] sepsis A41.9 [N08] streptococcal A40- S [N08] sickle-cell disorders D57.- S [N08] strongyloidiasis 78.9 [N08] Glomerulonephritis continued in continued subacute bacterial endocarditis I33.0 [N08] syphilis (late) congenital A50.59 [N08] systemic lupus erythematosus M32.14 thrombotic thrombocytopenic purpura M31.1 [N08] typhoid fever A01.09 Waldenström macroglobulinemia C88.0 [N08] Wegener's granulomatosis M31.31 latent or quiescent N03.9 lobular, lobulonodular see Glomerulonephritis, membranoproliferative membranoproliferative (diffuse)(type 1 or 3) (see also N00-N07 with fourth character.5) N05.5 dense deposit (type 2) NEC (see also N00-N07 with fourth character.6) N05.6 membranous (diffuse) NEC (see also N00-N07 with fourth character.2) N05.2 mesangial IgA/IgG see Nephropathy, IgA proliferative (diffuse) NEC (see also N00-N07 with fourth character.3) N05.3 mesangiocapillary (diffuse) NEC (see also N00-N07 with fourth character.5) N05.5 necrotic, necrotizing NEC (see also N00- N07 with fourth character.8) N05.8 nodular see Glomerulonephritis, membranoproliferative poststreptococcal NEC N05.9 acute N00.9 chronic N03.9 rapidly progressive N01.9 proliferative NEC (see also N00-N07 with fourth character.8) N05.8 diffuse (lupus) M32.14 rapidly progressive N01.9 sclerosing, diffuse N05.8 specified pathology NEC (see also N00- N07 with fourth character.8) N05.8 subacute N01.9 Glomerulopathy see Glomerulonephritis Glomerulosclerosis (see also Sclerosis, renal) intercapillary (nodular) (with diabetes) see Diabetes, glomerulosclerosis intracapillary see Diabetes, glomerulosclerosis Glossagra K14.6 Glossalgia K14.6 Glossitis (chronic superficial) (gangrenous) (Moeller's) K14.0 areata exfoliativa K14.1 atrophic K14.4 benign migratory K14.1 cortical superficial, sclerotic K14.0 Hunter's D51.0 interstitial, sclerous K14.0 median rhomboid K14.2 pellagrous E52 superficial, chronic K14.0 Glossocele K14.8 Glossodynia K14.6 exfoliativa K14.4 Glossoncus K14.8 Glossopathy K14.9 Glossophytia K14.3 Glossoplegia K14.8 Glossoptosis K14.8 Glossopyrosis K14.6 Glossotrichia K14.3 Glossy skin L90.8 Glottis see condition Glottitis (see also Laryngitis) J04.0 Glucagonoma pancreas benign D13.7 malignant C25.4 uncertain behavior D37.8 specified site NEC benign see Neoplasm, benign, by site malignant see Neoplasm, malignant, by site uncertain behavior see Neoplasm, uncertain behavior, by site unspecified site benign D13.7 malignant C25.4 uncertain behavior D37.8 Glucoglycinuria E72.51 Glucose-galactose malabsorption E S Additional Character Required Refer to the Tabular List for Character Selection 2 Subterms under main terms may continue to next column or page

5 Glue ear see Otitis, media, nonsuppurative, chronic, mucoid sniffing (airplane) see Abuse, drug, inhalant dependence see Dependence, drug, inhalant Glutaric aciduria E72.3 Glycinemia E72.51 Glycinuria (renal) (with ketosis) E72.09 Glycogen infiltration see Disease, glycogen storage storage disease see Disease, glycogen storage Glycogenosis (diffuse) (generalized) (see also Disease, glycogen storage) cardiac E74.02 [I43] diabetic, secondary see Diabetes, glycogenosis, secondary pulmonary interstitial J Glycopenia E16.2 Glycosuria R81 renal E74.8 Gnathostoma spinigerum (infection) (infestation), gnathostomiasis (wandering swelling) 83.1 Goiter (plunging) (substernal) E04.9 with hyperthyroidism (recurrent) see Hyperthyroidism, with, goiter thyrotoxicosis see Hyperthyroidism, with, goiter adenomatous see Goiter, nodular cancerous C73 congenital (nontoxic) E03.0 diffuse E03.0 parenchymatous E03.0 transitory, with normal functioning P72.0 cystic E04.2 due to iodine-deficiency E01.1 due to enzyme defect in synthesis of thyroid hormone E07.1 iodine-deficiency (endemic) E01.2 dyshormonogenetic (familial) E07.1 endemic (iodine-deficiency) E01.2 diffuse E01.0 multinodular E01.1 exophthalmic see Hyperthyroidism, with, goiter iodine-deficiency (endemic) E01.2 diffuse E01.0 multinodular E01.1 nodular E01.1 lingual Q89.2 lymphadenoid E06.3 malignant C73 multinodular (cystic) (nontoxic) E04.2 toxic or with hyperthyroidism E05.20 with thyroid storm E05.21 neonatal NEC P72.0 nodular (nontoxic) (due to) E04.9 with hyperthyroidism E05.20 with thyroid storm E05.21 thyrotoxicosis E05.20 with thyroid storm E05.21 endemic E01.1 iodine-deficiency E01.1 sporadic E04.9 toxic E05.20 with thyroid storm E05.21 nontoxic E04.9 diffuse (colloid) E04.0 multinodular E04.2 simple E04.0 specified NEC E04.8 uninodular E04.1 simple E04.0 toxic see Hyperthyroidism, with, goiter uninodular (nontoxic) E04.1 toxic or with hyperthyroidism E05.10 with thyroid storm E05.11 Goiter-deafness syndrome E07.1 Goldberg syndrome Q89.8 Goldberg-Maxwell syndrome E34.51 Goldblatt's hypertension or kidney I70.1 Goldenhar (-Gorlin) syndrome Q87.0 Goldflam-Erb disease or syndrome G70.00 with exacerbation (acute) G70.01 in crisis G70.01 Goldscheider's disease Q81.8 Goldstein's disease (familial hemorrhagic telangiectasia) I78.0 Golfer's elbow see Epicondylitis, medial Gonadoblastoma specified site see Neoplasm, uncertain behavior, by site unspecified site female D39.10 male D40.10 Gonecystitis see Vesiculitis Gongylonemiasis 83.8 Goniosynechiae see Adhesions, iris, goniosynechiae Gonococcemia A54.86 Gonococcus, gonococcal (disease) (infection) (see also condition) A54.9 anus A54.6 bursa, bursitis A54.49 conjunctiva, conjunctivitis (neonatorum) A54.31 endocardium A54.83 eye A54.30 conjunctivitis A54.31 iridocyclitis A54.32 keratitis A54.33 newborn A54.31 other specified A54.39 fallopian tubes (acute) (chronic) A54.24 genitourinary (organ) (system) (tract) (acute) lower A54.00 with abscess (accessory gland) (periurethral) A54.1 upper (see also condition) A54.29 heart A54.83 iridocyclitis A54.32 joint A54.42 lymphatic (gland) (node) A54.89 meninges, meningitis A54.81 musculoskeletal A54.40 arthritis A54.42 osteomyelitis A54.43 other specified A54.49 spondylopathy A54.41 pelviperitonitis A54.24 pelvis (acute) (chronic) A54.24 pharynx A54.5 proctitis A54.6 pyosalpinx (acute) (chronic) A54.24 rectum A54.6 skin A54.89 specified site NEC A54.89 tendon sheath A54.49 throat A54.5 urethra (acute) (chronic) A54.01 with abscess (accessory gland) (periurethral) A54.1 vulva (acute) (chronic) A54.02 Gonocytoma specified site see Neoplasm, uncertain behavior, by site unspecified site female D39.10 male D40.10 Gonorrhea (acute) (chronic) A54.9 artholin's gland (acute) (chronic) (purulent) A54.02 with abscess (accessory gland) (periurethral) A54.1 bladder A54.01 cervix A54.03 conjunctiva, conjunctivitis (neonatorum) A54.31 contact Z20.2 Cowper's gland (with abscess) A54.1 exposure to Z20.2 fallopian tube (acute) (chronic) A54.24 kidney (acute) (chronic) A54.21 lower genitourinary tract A54.00 with abscess (accessory gland) (periurethral) A54.1 ovary (acute) (chronic) A54.24 pelvis (acute) (chronic) A54.24 female pelvic inflammatory disease A54.24 penis A54.09 prostate (acute) (chronic) A54.22 seminal vesicle (acute) (chronic) A54.23 specified site not listed (see also Gonococcus) A54.89 spermatic cord (acute) (chronic) A54.23 urethra A54.01 with abscess (accessory gland) (periurethral) A54.1 vagina A54.02 vas deferens (acute) (chronic) A54.23 vulva A54.02 Goodall's disease A08.19 Goodpasture's syndrome M31.0 Gopalan's syndrome (burning feet) E53.0 Gorlin-Chaudry-Moss syndrome Q87.0 Gout, gouty Gottron's papules L94.4 Gougerot-lum syndrome (pigmented purpuric lichenoid dermatitis) L81.7 Gougerot-Carteaud disease or syndrome (confluent reticulate papillomatosis) L83 Gougerot's syndrome (trisymptomatic) L81.7 Gouley's syndrome (constrictive pericarditis) I31.1 Goundou A66.6 Gout, chronic (see also Gout, gouty) M1A.9 S (following M08) drug-induced M1A.20 S (following M08) ankle M1A.27- S (following M08) elbow M1A.22- S (following M08) foot joint M1A.27- S (following M08) hand joint M1A.24- S (following M08) hip M1A.25- S (following M08) knee M1A.26- S (following M08) multiple site M1A.29- S (following M08) shoulder M1A.21- S (following M08) vertebrae M1A.28 S (following M08) wrist M1A.23- S (following M08) idiopathic M1A.00 S (following M08) ankle M1A.07- S (following M08) elbow M1A.02- S (following M08) foot joint M1A.07- S (following M08) hand joint M1A.04- S (following M08) hip M1A.05- S (following M08) knee M1A.06- S (following M08) multiple site M1A.09 S (following M08) shoulder M1A.01- S (following M08) vertebrae M1A.08 S (following M08) wrist M1A.03- S (following M08) in (due to) renal impairment M1A.30 S (following M08) ankle M1A.37- S (following M08) elbow M1A.32- S (following M08) foot joint M1A.37- S (following M08) hand joint M1A.34- S (following M08) hip M1A.35- S (following M08) knee M1A.36- S (following M08) multiple site M1A.39 S (following M08) shoulder M1A.31- S (following M08) vertebrae M1A.38 S (following M08) wrist M1A.33- S (following M08) lead-induced M1A.10 S (following M08) ankle M1A.17- S (following M08) elbow M1A.12- S (following M08) foot joint M1A.17- S (following M08) hand joint M1A.14- S (following M08) hip M1A.15- S (following M08) knee M1A.16- S (following M08) multiple site M1A.19 S (following M08) shoulder M1A.11- S (following M08) vertebrae M1A.18 S (following M08) wrist M1A.13- S (following M08) primary see Gout, chronic, idiopathic saturnine see Gout, chronic, lead-induced secondary NEC M1A.40 S (following M08) ankle M1A.47- S (following M08) elbow M1A.42- S (following M08) foot joint M1A.47- S (following M08) hand joint M1A.44- S (following M08) hip M1A.45- S (following M08) knee M1A.46- S (following M08) multiple site M1A.49 S (following M08) shoulder M1A.41- S (following M08) vertebrae M1A.48 S (following M08) wrist M1A.43- S (following M08) syphilitic (see also subcategory M14.8-) A52.77 tophi M1A.9 S (following M08) Gout, gouty (acute) (attack) (flare) (see also Gout, chronic) M10.9 drug-induced M10.20 ankle M S elbow M S foot joint M S hand joint M S hip M S knee M S multiple site M10.29 shoulder M S vertebrae M10.28 wrist M S idiopathic M10.00 ankle M S elbow M S Index Glue Gout, gouty 2 Subterms under main terms may continue to next column or page S Additional Character Required Refer to the Tabular List for Character Selection 159

6 Chapter 10. Diseases of the Respiratory System Guidelines and Examples Chapter 10. Diseases of the Respiratory System Chapter 10. Diseases of the Respiratory System (J00 J99) Chapter Specific Guidelines with Coding Examples The chapter specific guidelines from the ICD-10-CM Official Guidelines for Coding and Reporting have been provided below. Along with these guidelines are coding examples, contained in the shaded boxes, that have been developed to help illustrate the coding and/or sequencing guidance found in these guidelines. a. Chronic obstructive pulmonary disease [COPD] and asthma 1) Acute exacerbation of chronic obstructive bronchitis and asthma The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection. Acute streptococcal bronchitis with acute exacerbation of COPD J20.2 Acute bronchitis due to streptococcus J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation Explanation: ICD-10-CM uses combination codes to create organism-specific classifications for acute bronchitis. Category J44 codes include combination codes with severity components, which differentiate between COPD with acute lower respiratory infection (acute bronchitis), COPD with acute exacerbation, and COPD without mention of a complication (unspecified). An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection, as in this example. Exacerbation of moderate persistent asthma with status asthmaticus J45.42 Moderate persistent asthma with status asthmaticus Explanation: Category J45 Asthma includes severity-specific subcategories and fifth-character codes to distinguish between uncomplicated cases, those in acute exacerbation, and those with status asthmaticus. b. Acute respiratory failure 1) Acute respiratory failure as principal diagnosis A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence. Acute hypoxic respiratory failure due to COPD exacerbation J96.01 Acute respiratory failure with hypoxia J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation Explanation: Category J96 classifies respiratory failure with combination codes that designate the severity and the presence of hypoxia and hypercapnia. Code J96.01 is sequenced as the first-listed diagnosis, as the reason for the admission. Respiratory failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital and the selection is supported by the Alphabetic Index and Tabular List. 2) Acute respiratory failure as secondary diagnosis Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis. Acute respiratory failure due to accidental oxycodone overdose T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Explanation: Respiratory failure may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines, such as poisoning, that provide sequencing direction take precedence. When coding a poisoning or reaction to the improper use of a medication (e.g. overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36 T50. Use additional code(s) for all manifestations of the poisoning. In this instance, the respiratory failure is a manifestation of the poisoning and is sequenced as a secondary diagnosis. Acute pneumococcal pneumonia with subsequent development of acute respiratory failure J13 Pneumonia due to Streptococcus pneumoniae J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Explanation: Acute respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission but does not meet the definition of principal diagnosis. 3) Sequencing of acute respiratory failure and another acute condition When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations. If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification. Acute pneumococcal pneumonia and acute respiratory failure, both present on admission J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J13 Pneumonia due to Streptococcus pneumoniae Explanation: When a patient is admitted with respiratory failure and another acute condition, such as a bacterial pneumonia, the principal diagnosis is not the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. The principal diagnosis depends on the circumstances of admission. c. Influenza due to certain identified influenza viruses Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis). In this context, confirmation does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider s diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J

7 Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue Muscle/Tendon Table Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue Muscle/Tendon Table ICD-10-CM categorizes certain muscles and tendons in the upper and lower extremities by their action (e.g., extension, flexion), their anatomical location (e.g., posterior, anterior), and/or whether they are intrinsic or extrinsic to a certain anatomical area. The Muscle/Tendon Table is provided at the beginning of chapters 13 and 19 as a resource to help users when code selection depends on one or more of these characteristics. Please note that this table is not all-inclusive, and proper code assignment should be based on the provider s documentation. Shoulder Upper arm Forearm ody Region Muscle Extensor Tendon Flexor Tendon Other Tendon Deltoid Posterior deltoid Anterior deltoid Rotator cuff Infraspinatus Subscapularis Supraspinatus Teres minor Teres major Anterior muscles iceps brachii long head iceps brachii short head rachialis Coracobrachialis Posterior muscles Triceps brachii Teres major Triceps brachii Anterior muscles Flexors Deep Flexor digitorum profundus Flexor pollicis longus Intermediate Flexor digitorum superficialis Superficial Flexor carpi radialis Flexor carpi ulnaris Palmaris longus Pronators Pronator quadratus Pronator teres Posterior muscles Extensors Deep Abductor pollicis longus Extensor indicis Extensor indicis Extensor pollicis brevis Extensor pollicis brevis Extensor pollicis longus Extensor pollicis longus Superficial rachioradialis Extensor carpi radialis brevis Extensor carpi radialis brevis Extensor carpi radialis longus Extensor carpi radialis longus Extensor carpi ulnaris Extensor carpi ulnaris Extensor digiti minimi Extensor digiti minimi Extensor digitorum Extensor digitorum Anconeus Anconeus Supinator iceps brachii long head iceps brachii short head rachialis Coracobrachialis Flexor digitorum profundus Flexor pollicis longus Flexor digitorum superficialis Flexor carpi radialis Flexor carpi ulnaris Palmaris longus Infraspinatus Subscapularis Supraspinatus Teres minor Pronator quadratus Pronator teres Abductor pollicis longus rachioradialis Supinator 698

8 Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue M M70.88 M M70.88 M67.98 M67.99 M Unspecified disorder of synovium and tendon, unspecified ankle and foot Unspecified disorder of synovium and tendon, other site Unspecified disorder of synovium and tendon, multiple sites Other soft tissue disorders (M70-M79) b M70 Soft tissue disorders related to use, overuse and pressure 1 soft tissue disorders of occupational origin Use additional external cause code to identify activity causing disorder (Y93.-) 1 bursitis NOS (M71.9-) 2 bursitis of shoulder (M75.5) enthesopathies (M76-M77) pressure ulcer (pressure area) (L89.-) c M70.0 Crepitant synovitis (acute) (chronic) of hand and wrist d M70.03 Crepitant synovitis (acute) (chronic), wrist M Crepitant synovitis (acute) (chronic), right wrist M Crepitant synovitis (acute) (chronic), left wrist M Crepitant synovitis (acute) (chronic), unspecified wrist d M70.04 Crepitant synovitis (acute) (chronic), hand M Crepitant synovitis (acute) (chronic), right hand M Crepitant synovitis (acute) (chronic), left hand M Crepitant synovitis (acute) (chronic), unspecified hand c M70.1 ursitis of hand M70.10 ursitis, unspecified hand M70.11 ursitis, right hand M70.12 ursitis, left hand c M70.2 Olecranon bursitis M70.20 Olecranon bursitis, unspecified elbow M70.21 Olecranon bursitis, right elbow M70.22 Olecranon bursitis, left elbow c M70.3 Other bursitis of elbow M70.30 Other bursitis of elbow, unspecified elbow M70.31 Other bursitis of elbow, right elbow M70.32 Other bursitis of elbow, left elbow c M70.4 Prepatellar bursitis M70.40 Prepatellar bursitis, unspecified knee M70.41 Prepatellar bursitis, right knee M70.42 Prepatellar bursitis, left knee c M70.5 Other bursitis of knee M70.50 Other bursitis of knee, unspecified knee Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue M70.51 Other bursitis of knee, right knee M70.52 Other bursitis of knee, left knee c M70.6 Trochanteric bursitis Trochanteric tendinitis M70.60 Trochanteric bursitis, unspecified hip M70.61 Trochanteric bursitis, right hip M70.62 Trochanteric bursitis, left hip c M70.7 Other bursitis of hip Ischial bursitis M70.70 Other bursitis of hip, unspecified hip M70.71 Other bursitis of hip, right hip M70.72 Other bursitis of hip, left hip c M70.8 Other soft tissue disorders related to use, overuse and pressure M70.80 Other soft tissue disorders related to use, overuse and pressure of unspecified site d M70.81 Other soft tissue disorders related to use, overuse and pressure of shoulder M Other soft tissue disorders related to use, overuse and pressure, right shoulder M Other soft tissue disorders related to use, overuse and pressure, left shoulder M Other soft tissue disorders related unspecified shoulder d M70.82 Other soft tissue disorders related to use, overuse and pressure of upper arm M Other soft tissue disorders related to use, overuse and pressure, right upper arm M Other soft tissue disorders related to use, overuse and pressure, left upper arm M Other soft tissue disorders related unspecified upper arms d M70.83 Other soft tissue disorders related to use, overuse and pressure of forearm M Other soft tissue disorders related to use, overuse and pressure, right forearm M Other soft tissue disorders related to use, overuse and pressure, left forearm M Other soft tissue disorders related unspecified forearm d M70.84 Other soft tissue disorders related to use, overuse and pressure of hand M Other soft tissue disorders related to use, overuse and pressure, right hand M Other soft tissue disorders related to use, overuse and pressure, left hand M Other soft tissue disorders related unspecified hand d M70.85 Other soft tissue disorders related to use, overuse and pressure of thigh M Other soft tissue disorders related to use, overuse and pressure, right thigh M Other soft tissue disorders related to use, overuse and pressure, left thigh M Other soft tissue disorders related unspecified thigh d M70.86 Other soft tissue disorders related to use, overuse and pressure lower leg M Other soft tissue disorders related to use, overuse and pressure, right lower leg M Other soft tissue disorders related to use, overuse and pressure, left lower leg M Other soft tissue disorders related unspecified leg d M70.87 Other soft tissue disorders related to use, overuse and pressure of ankle and foot M Other soft tissue disorders related to use, overuse and pressure, right ankle and foot M Other soft tissue disorders related to use, overuse and pressure, left ankle and foot M Other soft tissue disorders related unspecified ankle and foot M70.88 Other soft tissue disorders related to use, overuse and pressure other site 1 Not coded here Not included here 8 Newborn Age : 0 9 Pediatric Age : 0-17 x Maternity Age : y Adult Age :

9 Other diseases of the urinary system (N30-N39) 1 urinary infection (complicating): abortion or ectopic or molar pregnancy (O00-O07, O08.8) pregnancy, childbirth and the puerperium (O23.-, O75.3, O86.2-) b N30 Cystitis Use additional code to identify infectious agent (95-97) 1 prostatocystitis (N41.3) c N30.0 Acute cystitis 1 irradiation cystitis (N30.4-) trigonitis (N30.3-) N30.00 Acute cystitis without hematuria N30.01 Acute cystitis with hematuria c N30.1 Interstitial cystitis (chronic) N30.10 Interstitial cystitis (chronic) without hematuria N30.11 Interstitial cystitis (chronic) with hematuria c N30.2 Other chronic cystitis N30.20 Other chronic cystitis without hematuria N30.21 Other chronic cystitis with hematuria c N30.3 Trigonitis Urethrotrigonitis N30.30 Trigonitis without hematuria N30.31 Trigonitis with hematuria c N30.4 Irradiation cystitis N30.40 Irradiation cystitis without hematuria N30.41 Irradiation cystitis with hematuria c N30.8 Other cystitis Abscess of bladder N30.80 Other cystitis without hematuria N30.81 Other cystitis with hematuria c N30.9 Cystitis, unspecified N30.90 Cystitis, unspecified without hematuria N30.91 Cystitis, unspecified with hematuria b N31 Neuromuscular dysfunction of bladder, not elsewhere classified Use additional code to identify any associated urinary incontinence (N39.3-N39.4-) 1 cord bladder NOS (G95.89) neurogenic bladder due to cauda equina syndrome (G83.4) neuromuscular dysfunction due to spinal cord lesion (G95.89) N31.0 Uninhibited neuropathic bladder, not elsewhere classified N31.1 Reflex neuropathic bladder, not elsewhere classified N31.2 Flaccid neuropathic bladder, not elsewhere classified Atonic (motor) (sensory) neuropathic bladder Autonomous neuropathic bladder Nonreflex neuropathic bladder N31.8 Other neuromuscular dysfunction of bladder N31.9 Neuromuscular dysfunction of bladder, unspecified Neurogenic bladder dysfunction NOS b N32 Other disorders of bladder 2 calculus of bladder (N21.0) cystocele (N81.1-) hernia or prolapse of bladder, female (N81.1-) N32.0 ladder-neck obstruction ladder-neck stenosis (acquired) 1 congenital bladder-neck obstruction (Q64.3-) DEF: ladder outlet and vesicourethral obstruction; occurs as a consequence of benign prostatic hypertrophy or prostatic cancer; may also occur in either sex due to strictures, radiation, cystoscopy, catheterization, injury, infection, blood clots, bladder cancer, impaction, or other disease that compresses the bladder neck. N32.1 Vesicointestinal fistula Vesicorectal fistula N32.2 Vesical fistula, not elsewhere classified 1 fistula between bladder and female genital tract (N82.0-N82.1) N32.3 Diverticulum of bladder c N congenital diverticulum of bladder (Q64.6) diverticulitis of bladder (N30.8-) Other specified disorders of bladder N32.81 Overactive bladder Detrusor muscle hyperactivity 1 frequent urination due to specified bladder condition - code to condition SAdditional Character Required g Placeholder Alert Chapter 14. Diseases of the Genitourinary System Manifestation Dx N32.89 Other specified disorders of bladder ladder hemorrhage ladder hypertrophy Calcified bladder Contracted bladder N32.9 ladder disorder, unspecified N33 ladder disorders in diseases classified elsewhere Code first underlying disease, such as: schistosomiasis ( ) 1 bladder disorder in syphilis (A52.76) bladder disorder in tuberculosis (A18.12) candidal cystitis (37.41) chlamydial cystitis (A56.01) cystitis in gonorrhea (A54.01) cystitis in neurogenic bladder (N31.-) diphtheritic cystitis (A36.85) syphilitic cystitis (A52.76) trichomonal cystitis (A59.03) b N34 Urethritis and urethral syndrome Use additional code (95-97), to identify infectious agent 2 Reiter's disease (M02.3-) urethritis in diseases with a predominantly sexual mode of transmission (A50-A64) urethrotrigonitis (N30.3-) N34.0 Urethral abscess Abscess (of) Cowper's gland Abscess (of) Littré's gland Abscess (of) urethral (gland) Periurethral abscess 1 urethral caruncle (N36.2) N34.1 Nonspecific urethritis Nongonococcal urethritis Nonvenereal urethritis N34.2 Other urethritis Meatitis, urethral Postmenopausal urethritis Ulcer of urethra (meatus) Urethritis NOS N34.3 Urethral syndrome, unspecified b N35 Urethral stricture 1 congenital urethral stricture (Q64.3-) postprocedural urethral stricture (N99.1-) c N35.0 Post-traumatic urethral stricture Urethral stricture due to injury 1 postprocedural urethral stricture (N99.1-) d N35.01 Post-traumatic urethral stricture, male N Post-traumatic urethral stricture, male, meatal : N Post-traumatic bulbous urethral stricture N Post-traumatic membranous urethral stricture N Post-traumatic anterior urethral stricture N Post-traumatic urethral stricture, male, unspecified : d N35.02 Post-traumatic urethral stricture, female N Urethral stricture due to childbirth ; N Other post-traumatic urethral stricture, female ; c N35.1 Postinfective urethral stricture, not elsewhere classified 1 gonococcal urethral stricture (A54.01) syphilitic urethral stricture (A52.76) urethral stricture associated with schistosomiasis (65.-, N29) d N35.11 Postinfective urethral stricture, not elsewhere Unspecified Dx classified, male N Postinfective urethral stricture, not elsewhere classified, male, meatal N Postinfective bulbous urethral stricture, not elsewhere classified N Postinfective membranous urethral stricture, not elsewhere classified N Postinfective anterior urethral stricture, not elsewhere classified N Postinfective urethral stricture, : not elsewhere classified, male, unspecified wx Revised Text l New Code N30 N : s Revised Code Title 787 Chapter 14. Diseases of the Genitourinary System N30 N35.119

10 c O34.7 Maternal care for abnormality of vulva and perineum 2 maternal care for perineal and vulval varices in pregnancy (O22.1-) Chapter 15. Pregnancy, Childbirth and the Puerperium O34.70 Maternal care for abnormality of vulva and perineum, unspecified trimester O34.71 Maternal care for abnormality of vulva and perineum, first trimester O34.72 Maternal care for abnormality of vulva and perineum, second trimester O34.73 Maternal care for abnormality of vulva and perineum, third trimester c O34.8 Maternal care for other abnormalities of pelvic organs O34.80 Maternal care for other abnormalities of pelvic organs, unspecified trimester O34.81 Maternal care for other abnormalities of pelvic organs, first trimester O34.82 Maternal care for other abnormalities of pelvic organs, second trimester O34.83 Maternal care for other abnormalities of pelvic organs, third trimester c O34.9 Maternal care for abnormality of pelvic organ, unspecified O34.90 Maternal care for abnormality of pelvic organ, unspecified, unspecified trimester O34.91 Maternal care for abnormality of pelvic organ, unspecified, first trimester O34.92 Maternal care for abnormality of pelvic organ, unspecified, second trimester O34.93 Maternal care for abnormality of pelvic organ, unspecified, third trimester b O35 Maternal care for known or suspected fetal abnormality and damage 1 the listed conditions in the fetus as a reason for hospitalization or other obstetric care to the mother, or for termination of pregnancy Code also any associated maternal condition 1 encounter for suspected maternal and fetal conditions ruled out (Z03.7-) One of the following 7th characters is to be assigned to each code under category O35. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O35 that has a 7th character of 1 through 9. 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus g O35.0 Maternal care for (suspected) central nervous system malformation in fetus Maternal care for fetal anencephaly Maternal care for fetal hydrocephalus Maternal care for fetal spina bifida 2 chromosomal abnormality in fetus (O35.1) g O35.1 Maternal care for (suspected) chromosomal abnormality in fetus g O35.2 Maternal care for (suspected) hereditary disease in fetus 2 chromosomal abnormality in fetus (O35.1) g O35.3 Maternal care for (suspected) damage to fetus from viral disease in mother Maternal care for damage to fetus from maternal cytomegalovirus infection Maternal care for damage to fetus from maternal rubella g O35.4 Maternal care for (suspected) damage to fetus from alcohol g O35.5 Maternal care for (suspected) damage to fetus by drugs Maternal care for damage to fetus from drug addiction g O35.6 Maternal care for (suspected) damage to fetus by radiation O34.7 O g O35.7 Maternal care for (suspected) damage to fetus by other medical procedures Maternal care for damage to fetus by amniocentesis Maternal care for damage to fetus by biopsy procedures Maternal care for damage to fetus by hematological investigation Maternal care for damage to fetus by intrauterine contraceptive device Maternal care for damage to fetus by intrauterine surgery g O35.8 Maternal care for other (suspected) fetal abnormality and damage Maternal care for damage to fetus from maternal listeriosis Maternal care for damage to fetus from maternal toxoplasmosis g O35.9 Maternal care for (suspected) fetal abnormality and damage, unspecified b O36 Maternal care for other fetal problems 1 the listed conditions in the fetus as a reason for hospitalization or other obstetric care of the mother, or for termination of pregnancy 1 encounter for suspected maternal and fetal conditions ruled out (Z03.7-) placental transfusion syndromes (O43.0-) 2 labor and delivery complicated by fetal stress (O77.-) AHA: 2015,3Q,40 One of the following 7th characters is to be assigned to each code under category O36. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category O30, Multiple gestation, must also be assigned when assigning a code from category O36 that has a 7th character of 1 through 9. 0 not applicable or unspecified 1 fetus 1 2 fetus 2 3 fetus 3 4 fetus 4 5 fetus 5 9 other fetus c O36.0 Maternal care for rhesus isoimmunization Maternal care for Rh incompatibility (with hydrops fetalis) d O36.01 Maternal care for anti-d [Rh] antibodies AHA: 2014,4Q,17 e O Maternal care for anti-d [Rh] antibodies, first trimester e O Maternal care for anti-d [Rh] antibodies, second trimester e O Maternal care for anti-d [Rh] antibodies, third trimester e O Maternal care for anti-d [Rh] antibodies, unspecified trimester d O36.09 Maternal care for other rhesus isoimmunization e O Maternal care for other rhesus isoimmunization, first trimester e O Maternal care for other rhesus isoimmunization, second trimester e O Maternal care for other rhesus isoimmunization, third trimester e O Maternal care for other rhesus isoimmunization, unspecified trimester c O36.1 Maternal care for other isoimmunization Maternal care for AO isoimmunization d O36.11 Maternal care for Anti-A sensitization Maternal care for isoimmunization NOS (with hydrops fetalis) e O Maternal care for Anti-A sensitization, first trimester e O Maternal care for Anti-A sensitization, second trimester e O Maternal care for Anti-A sensitization, third trimester e O Maternal care for Anti-A sensitization, unspecified trimester d O36.19 Maternal care for other isoimmunization Maternal care for Anti- sensitization e O Maternal care for other isoimmunization, first trimester Chapter 15. Pregnancy, Childbirth and the Puerperium O34.7 O SAdditional Character Required g Placeholder Alert Manifestation Dx Unspecified Dx wx Revised Text l New Code s Revised Code Title 819

11 Chapter 21. Factors Influencing Health Status and Contact With Health Services c Z03.7 Encounter for suspected maternal and fetal conditions ruled Z04.72 Encounter for examination and out observation following alleged child u 9 found 1 known or suspected fetal anomalies affecting management of mother, not ruled out (O26.-, O35.-, O36.-, O40.-, O41.-) Encounter for suspected maternal and fetal conditions not Suspected child physical abuse, ruled out 1 confirmed case of child physical abuse (T74.-) encounter for examination and observation physical abuse Z03.71 Encounter for suspected problem with u following alleged child sexual abuse amniotic cavity and membrane ruled out (Z04.42) Encounter for suspected oligohydramnios ruled out Encounter for suspected polyhydramnios ruled out suspected case of child physical abuse, not ruled out (T76.-) Z03.72 Encounter for suspected placental u Z04.8 Encounter for examination and observation for problem ruled out other specified reasons u Z03.73 Encounter for suspected fetal anomaly u Encounter for examination and observation for request for ruled out expert evidence Z03.74 Encounter for suspected problem with u Z04.9 Encounter for examination and observation for fetal growth ruled out unspecified reason u Z03.75 Encounter for suspected cervical u Encounter for observation NOS shortening ruled out l b Z05 Encounter for observation and evaluation of newborn for Z03.79 Encounter for other suspected maternal u suspected diseases and conditions ruled out and fetal conditions ruled out This category is to be used for newborns, within the neonatal c Z03.8 Encounter for observation for other suspected diseases and period (the first 28 days of life), who are suspected of having conditions ruled out an abnormal condition unrelated to exposure from the d Z03.81 Encounter for observation for suspected exposure to biological agents ruled out mother or the birth process, but without signs or symptoms, Z Encounter for observation for and which, after examination and observation, is ruled out. u suspected exposure to anthrax 2 newborn observation for suspected condition, related to ruled out exposure from the mother or birth process (P00-P04) Z Encounter for observation for l u Z05.0 Observation and evaluation of newborn for suspected cardiac suspected exposure to other condition ruled out biological agents ruled out l Z05.1 Observation and evaluation of newborn for suspected Z03.89 Encounter for observation for other u infectious condition ruled out suspected diseases and conditions ruled l Z05.2 Observation and evaluation of newborn for suspected out neurological condition ruled out b Z04 Encounter for examination and observation for other reasons l Z05.3 Observation and evaluation of newborn for suspected respiratory condition ruled out 1 encounter for examination for medicolegal reasons l c Z05.4 Observation and evaluation of newborn for suspected NOTE This category is to be used when a person without a genetic, metabolic or immunologic condition ruled out diagnosis is suspected of having an abnormal condition, l Z05.41 Observation and evaluation of newborn for without signs or symptoms, which requires study, but after suspected genetic condition ruled out examination and observation, is ruled-out. This category is also for use for administrative and legal observation status. l Z05.42 Observation and evaluation of newborn for suspected metabolic condition ruled out Z04.1 Encounter for examination and observation l u Z05.43 Observation and evaluation of newborn for following transport accident suspected immunologic condition ruled out 1 encounter for examination and observation following l Z05.5 Observation and evaluation of newborn for suspected work accident (Z04.2) gastrointestinal condition ruled out Z04.2 Encounter for examination and observation l u Z05.6 Observation and evaluation of newborn for suspected following work accident genitourinary condition ruled out Z04.3 Encounter for examination and observation l u c Z05.7 Observation and evaluation of newborn for suspected skin, following other accident subcutaneous, musculoskeletal and connective tissue c Z04.4 Encounter for examination and observation following alleged condition ruled out rape l Z05.71 Observation and evaluation of newborn for Encounter for examination and observation of victim following suspected skin and subcutaneous tissue condition alleged rape ruled out l Encounter for examination and observation of victim following Z05.72 Observation and evaluation of newborn for suspected musculoskeletal condition ruled out alleged sexual abuse l Z05.73 Observation and evaluation of newborn for Z04.41 Encounter for examination and u y suspected connective tissue condition ruled out observation following alleged adult rape l Z05.8 Observation and evaluation of newborn for other specified Suspected adult rape, ruled out suspected condition ruled out Suspected adult sexual abuse, ruled out l Z05.9 Observation and evaluation of newborn for Z04.42 Encounter for examination and u 9 unspecified suspected condition ruled out observation following alleged child rape Suspected child rape, ruled out Z08 Encounter for follow-up examination after completed treatment Suspected child sexual abuse, ruled out Z04.6 Encounter for general psychiatric examination, requested by authority u c Z04.7 Encounter for examination and observation following alleged physical abuse Z04.71 Encounter for examination and observation following alleged adult u y physical abuse Suspected adult physical abuse, ruled out 1 confirmed case of adult physical abuse (T74.-) encounter for examination and observation following alleged adult sexual abuse (Z04.41) suspected case of adult physical abuse, not ruled out (T76.-) Z09 Z03.7 Z09 for malignant neoplasm Medical surveillance following completed treatment Use additional code to identify any acquired absence of organs (Z90.-) Use additional code to identify the personal history of malignant neoplasm (Z85.-) 1 aftercare following medical care (Z43-Z49, Z51) Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Medical surveillance following completed treatment Use additional code to identify any applicable history of disease code (Z86.-. Z87.-) 1 aftercare following medical care (Z43-Z49, Z51) surveillance of contraception (Z30.4-) surveillance of prosthetic and other medical devices (Z44-Z46) AHA: 2015,1Q,8 Chapter 21. Factors Influencing Health Status and Contact With Health Services Z03.7 Z09 SAdditional Character Required g Placeholder Alert Manifestation Dx Unspecified Dx wx Revised Text l New Code s Revised Code Title 1147

12 Illustrations Chapter 10. Diseases of the Respiratory System (J00 J99) Respiratory System Illustrations 27