ICD-10-AM/ACHI/ACS Eighth Edition. HIMAA/NCCH Conference Renal workshop October 2014
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1 ICD-10-AM/ACHI/ACS Eighth Edition HIMAA/NCCH Conference Renal workshop October 2014
2 Record 1 N18.5 Chronic kidney disease, stage 5 E11.22 Type 2 diabetes mellitus with established diabetic nephropathy E11.31 Type 2 diabetes mellitus with background retinopathy E11.40 Type 2 diabetes mellitus with unspecified neuropathy 2
3 Record 1 (cont.) E11.71 Type 2 diabetes mellitus with multiple microvascular and other specified nonvascular complications E87.7 Fluid overload Z89.5 Acquired absence of leg at or below knee B18.1 Chronic viral hepatitis B without delta-agent 3
4 Record 1 (cont.) T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts Y84.1 Kidney dialysis as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Y92.22 Place of occurrence, health service area 4
5 Record 1 (cont.) [1060] Haemodialysis 5
6 Record 1 (cont.)?e11.65?e87.5?z91.1 Type 2 diabetes mellitus with poor control Hyperkalaemia Personal history of noncompliance with medical treatment and regimen?i95.9 Hypotension, unspecified 6
7 Underlying principles: ACS 1438 Chronic kidney disease Kidney replacement therapy - Classification 1. Cases of chronic kidney disease with ongoing kidney replacement therapy, whether by dialysis or by transplant, which comply with ACS 0002 Additional diagnoses, require a code from N18.- Chronic kidney disease to describe the current stage of disease, except in routine dialysis only admissions. 2. For routine dialysis only admissions it can be assumed from the assignment of Z49.1 Extracorporeal dialysis or Z49.2 Other dialysis that the patient has CKD stage 5 (see also ACS 1404 Admission for kidney dialysis). 7
8 Underlying principles: ACS 0104 Viral hepatitis Classification Viral hepatitis should always be coded when documented except when hepatitis C is documented with terms such as 'cured', 'cleared' or 'with SVR', see 4. Cured/cleared hepatitis C below. When documentation is unclear or ambiguous terms such as 'hepatitis B', 'hepatitis C', 'hepatitis D', 'hepatitis B positive', 'hepatitis C positive' or 'hepatitis D positive' are documented, verify with the clinician if the disease is at the acute or chronic stage. Where consultation is not possible, assign the following code for: hepatitis B: B18.1 Chronic viral hepatitis B without delta-agent hepatitis C: B18.2 Chronic viral hepatitis C hepatitis D: B18.0 Chronic viral hepatitis B with delta-agent 8
9 Record 2 I95.1 Orthostatic hypotension E11.43 Type 2 diabetes mellitus with diabetic autonomic neuropathy E11.22 Type 2 diabetes mellitus with established diabetic nephropathy N18.5 Chronic kidney disease, stage 5 I10 Essential (primary) hypertension 9
10 Record 2 (cont.) E11.35 Type 2 diabetes mellitus with advanced ophthalmic disease E11.71 Type 2 diabetes mellitus with multiple microvascular and other specified nonvascular complications 10
11 Record 2 (cont.) [1060] Haemodialysis 11
12 Underlying principles: ICD-10-AM Alphabetic Index: Diabetes, diabetic - with - - hypotension orthostatic E postural E1-.43 Pre-existing Type 2 diabetes mellitus links to postural hypotension 12
13 Underlying principles: ICD-10-AM Alphabetic Index: Diabetes, diabetic - with - - rubeosis E iris (rubeosis iridis) E1-.35 Pre-existing Type 2 diabetes mellitus links to rubeosis iridis 13
14 Underlying principles: ACS 0401 Diabetes mellitus and intermediate hyperglycaemia 2. SPECIFIC CLASSIFICATION PRINCIPLES FOR DM AND IH Retinopathy and DM When retinopathy complications classifiable to more than one code from E1-.31 E1-.33 and/or E1-.35 are documented, only the most advanced stage should be coded. Patient has documented both: iridis rubeosis (E11.35) and proliferative retinopathy (E11.33) 14
15 Record 3 Z49.1 Extracorporeal dialysis N18.5 Chronic kidney disease, stage [1060] Haemodialysis 15
16 Record 3 (cont.)?z91.1 Personal history of noncompliance with medical treatment and regimen 16
17 Underlying principles: ACS 1404 Admission for kidney dialysis Same-day and overnight episodes of care for dialysis For episodes of care where the patient is discharged on the same day as the admission or on the next day after admission, code as principal diagnosis either Z49.1 Extracorporeal dialysis or Z49.2 Other dialysis as appropriate. Note: ACS criteria is length of stay, not admission circumstances of planned or unplanned 17
18 Underlying principles: ACS 1438 Chronic kidney disease Kidney replacement therapy - Classification 1. Cases of chronic kidney disease with ongoing kidney replacement therapy, whether by dialysis or by transplant, which comply with ACS 0002 Additional diagnoses, require a code from N18.- Chronic kidney disease to describe the current stage of disease, except in routine dialysis only admissions. 2. For routine dialysis only admissions it can be assumed from the assignment of Z49.1 Extracorporeal dialysis or Z49.2 Other dialysis that the patient has CKD stage 5 (see also ACS 1404 Admission for kidney dialysis). This patient is not routine as they came in as late presentation via ED 18
19 Underlying principles: ICD-10-AM Tabular List: 19
20 Record 4 T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts I74.2 Embolism and thrombosis of arteries of upper extremities AV fistula I82.8 Embolism and thrombosis of other both parts specified veins Y84.1 Kidney dialysis as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure Y92.22 Place of occurrence, health service area 20
21 Record 4 (cont.) E11.22 Type 2 diabetes mellitus with established diabetic nephropathy N18.5 Chronic kidney disease, stage 5 I10 Essential (primary) hypertension 21
22 Record 4 (cont.) E11.31 Type 2 diabetes mellitus with background retinopathy E11.71 Type 2 diabetes mellitus with multiple microvascular and other specified nonvascular complications 22
23 Record 4 (cont.)?z91.1 Personal history of noncompliance with medical treatment and regimen 23
24 Record 4 (cont.) [1060] Haemodialysis 24
25 Underlying principles: ICD-10-AM Alphabetic Index: Thrombosis, thrombotic... (vein) (vessel) I artery, arteries - - limb upper I specified site NEC I82.8 Difficult to represent both the arterial and venous nature of the AV Fistula Selected as best fit for venous 25
26 Underlying principles: ACS 1904 Procedural complications READMISSION FOR TREATMENT OF PROCEDURAL/POSTPROCEDURAL COMPLICATIONS The following guidelines apply: Renal Workshop If documentation does not state that the condition arose as a complication of the initial surgery, only the condition is coded Where documentation clearly states that the condition arose as a complication of the initial surgery the condition should be coded as a procedural/post procedural complication 26
27 Record 5 E87.7 Fluid overload E11.22 Type 2 diabetes mellitus with established diabetic nephropathy N18.5 Chronic kidney disease, stage 5 I10 J90 Essential (primary) hypertension Pleural effusion, NEC 27
28 Record 5 (cont.) E11.72 Type 2 diabetes mellitus with features of insulin resistance E11.31 Type 2 diabetes mellitus with background retinopathy E11.71 Type 2 diabetes mellitus with multiple microvascular and other specified nonvascular complications Z92.22 Personal history of long-term (current) use of other medicaments, insulin 28
29 Record 5 (cont.) Z91.1 Personal history of noncompliance with medical treatment and regimen F41.9 Anxiety disorder, unspecified 29
30 Record 5 (cont.) [1060] Haemodialysis 30
31 Record 5 (cont.)?r18 Ascites?E11.65 Type 2 diabetes mellitus with poor control?f03 Unspecified dementia 31
32 Underlying principles: ICD-10-AM Tabular List: 32
33 Questions
34 ICD-10-AM/ACHI/ACS Eighth Edition HIMAA/NCCH Conference Renal workshop October 2014 Thank you
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