Guidelines for Chapters Three through Eight

Transcription

1 Guidelines for Chapters Three through Eight Blood Conditions Chapter 3, Diseases of Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism, contains codes D50 D89. The codes you will probably report most often are the anemia codes. Anemia is the most common blood disease: a deficiency of red blood cells. It is important not to confuse chronic simple anemia with anemia of chronic disease. Anemia of chronic disease is caused by chronic disease, like the anemia caused by cancer in the neoplasms chapter. To find the correct code, look in the index first. Chronic simple anemia is found under Anemia, chronic simple D53.9. Check the subterm in the tabular to make sure that it matches the notes. Anemia of chronic disease is in the index as Anemia due to (in) (with) the chronic disease. There are three anemia of chronic disease codes; D63.0 Anemia in neoplastic disease, D63.1 Anemia in chronic kidney disease, and D63.8 Anemia in other chronic diseases.

2 Endocrine Diseases Chapter 4, Endocrine, Nutritional and Metabolic Diseases, is the chapter that contains the codes for all metabolic disorders. This includes malnutrition, obesity and nutritional deficiencies, disorders of the thyroid, and diabetes mellitus. The diabetes codes are used most often because diabetes has become increasingly widespread in the U.S. The diabetes codes are combination codes that include the type of diabetes and any complications caused by it. To find the appropriate code for a diabetes condition, use the index and check through the subterms and then check the code that seems the closest in the tabular. If the type of diabetes is not specified in the physician's notes, ask the physician or assign a default code for Type 2 diabetes. One tricky situation to code for diabetics is the malfunction of an insulin pump. Code this with three codes: one to report the mechancical problem with the pump, one to report the underdose or overdose, and one to report the diabetes. Coding Mental and Behavioral Health The codes for mental and behavioral health and neuro-developmental disorders are in Chapter 5. It is sometimes difficult to code mental disorders because physicians are not always as specific as you need them to be to find the codes. Mental disorders are groups based on etiology: physciological conditions, substance abuse, and mental disorders. There are many types of dementia, for example, and how you code them depends on their origin. If you are coding vascular dementia (F01) or dementia classified elsewhere (F02), you are instructed to "code first the underlying physiological condition." For instance, if a patient has dementia because of Alzheimer's disease, the first code is for Alzheimer's disease, the second for the dementia. Some codes can contain dementia in the description. For a patient with Parkinson's who has dementia, code G31.83, dementia with Parkinsonism. Look for "Excludes 1" and "Excludes 2" instructions to make sure you do not code dementia twice accidentally.

3 Substance Abuse Issues The codes for alcohol and drug abuse are F10 F19. Each substance has its own series, with codes selected based on whether the condition is documented to be abuse, dependence, dependence with withdrawal, or unspecified use. Psychological Disorders Codes F20 F29 report non-mood psychological disorders. Codes F30 F39 cover mood and non-mood psychological disorders. Mood disorders include anxiety, depression and bipolar disorders. Codes F40 F99 report phobias, OCD, adjustment disorders and hypochondrias. Intellectual disabilities are coded using F70 F79. Psychological Pain Code F45.41 Pain disorder with related phychological factors is the code for physiological pain. This code may also be assigned with a code from category G89 Pain, not elsewhere classified which includes codes for many other types of pain. Nervous System Disorders Category codes for disorders of the nervous system are listed below: G00 G09 G10 G14 Inflammatory diseases of the central nervous system Systemic atrophies primarily affecting the central nervous system G20 G26 Extrapyramidal and movement disorders G30 G32 G35 G37 G40 G47 G50 G59 Other degenerative diseases of the nervous system Demyelinating diseases of the central nervous system Episodic and paroxysmal disorders Nerve, nerve root and plexus disorders

4 G60 G65 Polyneuropathies and other disorders of the peripheral nervous system G70 G73 Diseases of myoneural junction and muscle G80 G83 Cerebral palsy and other paralytic syndromes G89 G99 Other disorders of the nervous system Guidelines for coding dominant and nondominant sides The codes from the categories given below identify whether the dominant or nondominant side is affected: G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb G83.2, Monoplegia of upper limb G83.3, Monoplegia, unspecified When the affected site has to be documented and the provider has not specified it and the classification system does not indicate a default, report codes based on the following: For ambidextrous patients, the default should be dominant. If the left side is affected, the default is non-dominant. If the right side is affected, the default is dominant. Disease of the Eye and Adnexa Category codes for disorders of the eye and adnexa (codes H00 H59) are listed below. Remember that the term adnexa refers to associated structures. H00 H05 Disorders of eyelid, lacrimal system and orbit H10 H11 Disorders of conjuctiva

5 H15 H22 Disorders of sclera, cornea, iris and ciliary body H25 H28 Disorders of lens H30 H36 Disorders of choroid and retina H40 H442 Glaucoma H43 H44 Disorders of vireous body and globe H46 H47 Disorders of optic nerve and visual pathways H49 H52 Disorders of ocular muscles, binocular movement, accommodation and refraction H53 H54 Visual disturbances and blindness H55 H57 H59 Other disorders of eye and adnexa Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified Guidelines of Coding some of the Diseases of the Eye and Adnexa Hordeolum: It is an inflammatory infection of the sebaceous glands at the base of the eyelashes (Stye). Report codes: Hordeolum and Chalazion H if external H if internal Chalazion: It is an infection of the eyelid, which forms a mass on the eyelid. Report the codes based on the location of mass. Entropion and Ectropion Entropion: It is the inversion of the margin of the eyelid. Entropian can be: Unspecified (H02.00-)

6 A result of a scar or tightening (cicatricial, H02.01-) Mechanical (lack of muscle support, H02.02-) Senile (due to aginig, H02.03-) Spastic (spasm of muscel, H02.04-) Ectropion: It is the eversion of the eyelid. Ectropion can be: Unspecified (H02.10-) cicatricial (H02.11-) Mechanical (H02.12-) Senile (H02.13-) Spastic (H02.14-) Lacrimal System Report disorders associated with lacrimal system, with codes from category H04. Diseases of the Ear and Mastoid Process Category codes for diseases of the ear and mastoid process are H60 H95. They are divided based on the structure of the ear. H60 H62 Diseases of external ear H65 H75 Diseases of middle ear and mastoid H80 H83 Diseases of inner ear H90 H94 Other disorders of ear H95 Intraperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified.