Similarities and Differences between ICD9CM & ICD10 CM

Transcription

1 Similarities and Differences between ICD9CM & ICD10 CM Subject ICD9 CM ICD10 CM Minimum number of digits/characters Maximum number of digits/characters Number of chapters Supplemental Classification V Codes and E Codes No, incorporated into classification Laterality (right & left) No Yes Alphanumeric vs. numeric Numeric, except for V codes and E codes Excludes notes Yes Excludes 1 Excludes 2 Placeholder characters No Yes: X Number of Codes 14,000 Nearly 70,000 Alphanumeric, with all codes starting with an alpha character and some codes with alpha seventh-character value

2 Example of code ICD9CM and ICD10 CM Code structure 5 digits vs. 7 digits Basal cell carcinoma of skin upper limb C Basal cell carcinoma of skin of right upper limb, including shoulder

3 Tabular List has 21 Chapters Chapter Listing Code Range One Certain Infectious diseases (A00 B99) Two Neoplasms (C00 D49) Three Three Character listings Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50 D89) Four Endocrine, Nutritional and Metabolic Diseases (E00 E90) Five Mental Behavioral and Neurodevelopmental Disorders (F01 F99) Six Diseases of the Nervous System (G00 G99) Seven Disorder of the Eye and Adnexa (H00 H59) Eight Diseases of the Ear and Mastoid Process (H60 H95) Nine Disease of the Circulatory System (I00 I99) Ten Disease of the Respiratory System (J00 J99)

4 Tabular List has 21 Chapters Continued Chapter Listing Code Range Eleven Diseases of the Digestive System (K00 K95) Twelve Diseases of the Skin and Subcutaneous Tissue (L00 L99) Thirteen Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) Fourteen Disease of the Genitourinary System (N00 N99) Fifteen Pregnancy, Childbirth and the Puerperium (O00 O9A) Sixteen Certain Conditions Origination in the Perinatal Period (P00- P96) Seventeen Eighteen Nineteen Congenital Malformations, Deformations and Chromosomal Abnormalities Symptoms, Signs and Abnormal Clinical and Laboratory Findings, NEC Injury, Poisoning and Certain Other Consequences of External Causes (Q00 Q99) (R00 R99) (S00 T88) Twenty External Causes of Morbidity (V00 Y99) Twenty One Three Character listings Factors influencing Health Status and Contact with Health Services (Z00 Z99)

5 Tabular List 1.Categories 3 Characters 2.Subcategories 4 or 5 Characters 3.Codes 7 Characters Categories Subcategories Codes 3 Characters long 4 or 5 Characters long 7 Characters long Has no further subdivision. i.e. Can not be broken down any further A code that has an applicable 7 th character is invalid without the 7 th character For reporting purposes only use codes Provides further specificity about a condition

6 Conventions: Abbreviations NEC Not Elsewhere Classifiable Used in both the Index and Tabular list to indicate that there is no separate code for the condition even though the provider s diagnosis may be very specific Means the book simply didn t have enough room for it NOS Not Otherwise Specified Equivalent of unspecified and is used in both the Index and Tabular list to indicated that the documentation was not specific enough to assign a more specified code Means the doctor wasn t specific

7 Conventions: Punctuation Punctuation Definition Example ( ) Parenthesis (tabular & index) Supplementary words/nonessential modifiers [ ] Square Brackets (tabular) Enclose synonyms, alternative wordings, or explanatory phrases : Colon (tabular) After an incomplete term which needs 1 or more modifiers following the colon to make it assignable to a given category Used with includes and excludes notes - Dashes (tabular & index) Used at the end of a code number to indicate that the code is complete Used to determined additional character(s).

8 Conventions: Instructional Notes (Includes and Excludes1&2) Note Definition Example Includes (tabular) Used to clarify conditions included within a particular chapter, section, category, subcategory or code At the code level does not precede the codes Excludes1 (tabular) Means NOT CODED HERE. Do not code the condition below with the code above Excludes2 (tabular) Means NOT CODED HERE. Indicates condition excluded is not a part of the condition represented by the code, but a patient MAY have both conditions at the same time When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if patient has both

9 Cross Reference Notes: (See, See Also, See Condition, See Category) Term See (index) See Also (index) See Condition (index) See Category (index) Definition Indicates that the coder must refer to an alternative term in the tabular section. This instruction is MANDATORY; coding cannot be completed without adhering to this instruction. Advises the coder that there is another place in the index that should be referenced when there is no specific code for the diagnosis Advices the coder to refer to the main term of a condition. A variation of see. Yet the coder is to reference the tabular section and select from the options provided

10 Relational Terms: (And,With, Due To) Term And (index & tabular) With (index & tabular) Due To (index & tabular) Definition Should be interpreted as meaning and or when it appears in a code title Should be interpreted to mean associated with or due to when it appears in a code title in the Index, or in an instructional note I the Tabular List. The With in the Index is sequenced immediately following the main term, not in alphabetical order Indicates that a causal relationship between 2 conditions is present. Follow the index entry for sequencing guidance, however whatever the disease is due to is typically the etiology and should be sequenced first

11 Additional Conventions: (Age, Sex Edits) Term Newborn Definition Newborn Pediatric Age Age: 0 to 17 Maternity Age Age: Adult Age Age: Male Female Diagnosis that can only be assigned to males Diagnosis that can only be assigned to females

12 Additional Conventions: New code, Revised Text, Revise Title Code Term New Code Revised Text Revised Text Code Definition Indicates that the code is new. Text has been revised since the previous edition Means a pall or part of the code title has been revised

13 Definitions: Laterality Character at the end of code Definition 1 Right side 2 Left side 3 Bilateral 0 or 9 Unspecified depending upon whether it is a fifth or sixth character Example of laterality Laterality was added to ICDCM to increase specificity. Laterality describes which side of the body/part that the illness or disease is present.

14 Definitions: Granularity & Combination code Term Definition Example Granularity Refers to the level of hierarchy and the amount of information provided in the code description. More specific and definitive language within a code Combination Code Two diagnosis, either a diagnosis with an associated sign or symptom or a diagnosis with an associated complication.

15 Definition: Principal Diagnosis & First Listed Diagnosis Term Definition Principal Diagnosis The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care First Listed/Primary The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

16 Definitions: Term Definition Example Conditions (Signs and Symptoms) that ARE an integral part of a confirmed disease Do not code Abdominal pain, high fever, the doctor diagnoses the patient with appendicitis, do not code the abdominal pain & high fever only the appendicitis Conditions (Signs and symptoms) that are NOT an integral part of a confirmed disease or diagnosis Code them Abdominal pain, high fever the doctor diagnoses the patient with foot pain, code all three: abdominal pain, high fever, and foot pain. Multiple coding for a single condition When 2 codes are required for a single condition. Reference the notes for sequencing order and for combination codes. Seek first the combination code, then seek the individual codes Signs and Symptoms Codes the describe symptoms and signs as opposed to diagnosis and are acceptable to report in the absence of a diagnosis. Abdominal pain, high fever, the doctor diagnoses the patient with r/o appendicitis, do not code r/o appendicitis. Only code the abdominal pain & high fever. Acute and Chronic Conditions in the same setting Sequence the Acute/subacute condition first then the Chronic Acute Pharyngitis and Chronic Pharyngitis. Sequence Acute Pharyngitis first. Sequela (late effects) Is the residual effect after the acute phase of an illness or injury has terminated. CVA (Cerebral Vascular Accident) can cause Dysphasia, or an Acute Fracture can be the cause of a pathological fracture. Its 7th character encounter is S. There is no time limit for when a sequela S code can be used.

17 Term Definitions: Definition Complications of Surgery and Other Medical Care When the admission is for treatment of a complication resulting from surgery or other medical care. Sequence the complication first. Reporting Same Diagnosis Code More than Once Only one ICD-10-CM may be report per encounter Syndromes Documentation of Complications of Care Following instructions in the Alphabetic Index. If not in the index assign codes for the documented manifestations. There must be a stated cause and effect relationship between the care provided and the condition Selection of Secondary Diagnosis Is coded if the diagnosis impacts the patient s care or treatment (refer to ICD9 part II) Previous Conditions Abnormal Test Findings Are coded only if required by the hospital or physician office policy Are not coded or reported unless the physician indicates their clinical significance.

18 Other facts about ICD 10 CM ICD-10-CM codes are alphanumeric and include all letters except "U," thus providing a greater pool of code numbers. ICD-9-CM s V and E codes are incorporated into the main classification in ICD-10-CM. The length of codes in ICD-10-CM can be a maximum of seven characters (digits and letters) as opposed to ICD-9-CM s five digits. ICD-10-CM offers the addition of information relative to ambulatory and managed care encounters. Conditions that are new or that were not uniquely identified in ICD-9-CM have been assigned code numbers in ICD-10-CM. In ICD-10-CM, some three-character categories are not used in order to allow for revisions and future expansion. Instead of grouping by categories of injury or type of wound, ICD-10-CM groups injuries by site of the injury and then the type. Excludes notes were expanded in order to provide guidance on the hierarchy of the chapters and to clarify priority of code assignment. Some conditions with a new treatment protocol or perhaps a recently discovered or new etiology have been listed in a more appropriate chapter. Combination codes are used for both symptom and diagnosis, and etiology and manifestations for example K50.03 Crohn s disease of small intestine with fistula. Codes for postoperative complications have been expanded. Also a distinction has been made between intraoperative complications and post-procedural disorders for example, K91 Intraoperative and postprocedural complications and disorders of digestive system, NEC. Implementation of ICD-10 in other Countries

19 HIV Code Definition Example B20 HIV/AIDS once assigned, the coder MAY NEVER USE ANY OTHER HIV related code for this patient Code only confirmed cases, and for patients with symptoms R75 Inconclusive Laboratory evidence of HIV Is used when a patient has an inconclusive test or serology result. Z20.6 Contact with and exposure to HIV Is reported when a patient believes he/she has been exposed to HIV Z11.4 Encounter for screening for HIV HIV test or serology is being administered Z71.7 HIV counseling (Negative Result) Patient returns to the Dr. to find out the result, Dr. Counsels the patient Z21 Asymptomatic HIV and (Positive test result with no symptoms) O98.7 HIV disease complicating pregnancy, childbirth and the puerperium Sequencing HIV/AIDS If the reason for the encounter is an HIV/AIDS related conditions, then HIV/AIDS is sequenced first. If the Reason for the encounter is not related to HIV/AIDS, then sequence the reason for the encounter first. Patient must be without symptoms Use additional code to identify the type of HIV disease

20 Sepsis Code/Disease Definition Example Sepsis Underlying organism /Septicemia NOS (requires a minimum of 1 code) Severe Sepsis (requires a minimum of 2 codes) Septic Shock (requires a minimum of 2 codes) An infection due to an organism that triggers a systemic inflammatory response. If the type of sepsis is not documented (sepsis or severe sepsis), code as sepsis. Must be documented as severe sepsis or an associated acute organ dysfunction Septic shock represents a type of acute organ dysfunction and the presence of severe sepsis. A41.9 (if organism is unknown), A41.X (if known) Code first the Underlying systemic infection A41.9 (if unknown), next a code from R65.2, assign the organ dysfunction, then code the organ dysfunction For all cases of septic shock, code first the Underlying organism (A41.9), followed by R65.21: Severe sepsis with septic shock. This code is assigned even if the term severe sepsis is not documented. If other acute organ dysfunctions are document it will be coded individually. Sepsis due to Post Procedural Infection PPI should be sequenced first, then sepsis, must have a documented causal relationship Ie. T81.4, followed by the code for the specific infection, R65.2 (severe sepsis) Never assign R65.2X codes first

21 MRSA Code/Disease Definition Example MRSA Methicillin resistant Staphylococcus aureus Use B95.62 if no specific combination code is available B95.62 Methicillin resistant staphylococcus aureus infection DO NOT use if there is an appropriate combination code that includes the causal organism. Z16.11 Resistance to penicillin When a person has MRSA, do not use this code MSSA Methicillin Susceptible Staphylococcus Aureus B95.61 MSSA and MRSA Colonization Means the MSSA or MRSA is present on the body; however not necessarily causing an illness Z Carrier or suspected carrier of Methicillin resistant Staphylococcus Aureus (MRSA) Use for Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus for patients with MRSA colonization Z Carrier or suspected carrier of Methicillin susceptible Staphylococcus Aureus (MSSA) Use for Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus for patient documented as having MSSA colonization

22 Neoplasms Code/Disease Definition Example Primary Is the first cancer diagnosed If treatment is directed at the primary site. It should be coded as the primary diagnosis, the only exception to this guideline is if the patient admission/encounter is solely for the admission of chemotherapy/immunotherapy/radiatio n therapy assign the appropriate Z51 code Secondary (Metastasized) Personal History of Cancer Family History of Cancer Is cancer that has spread from one site to another or the second cancer diagnosed Code whenever pertinent to the encounter Code whenever pertinent to the encounter When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary is still present Use a code from category Z85 Read the Code first notes Use a code from category Z80

23 Diabetes Code/Disease Definition Coding Instructions E08 E09 Diabetes mellitus due to an underlying condition. Secondary DM Drug or chemical induced diabetes mellitus. Although this is secondary diabetes, we need to follow the rules for reporting poisoning or adverse effects. E10 (Type 1) Diabetes mellitus type 1 (Juvenile diabetes) age is not the determining factor of the type of diabetes. i.e. a child can have type 2 diabetes and an adult can have type 1 diabetes (this code can be used for diabetes with ) E11 (Type 2) Diabetes mellitus type 2 (this code can be used for diabetes with ) See the code first notes for coding instructions The notes instruct coders to: Code first poisoning due to drug or toxin, if applicable (T36-T65 with fifth or sixth character 1-4 or 6) 2 nd use additional code for adverse effect, if applicable, identify drug (T36-T50 with fifth or sixth character 5) 3 rd use E09 4th Use additional code to identify any insulin use (Z79.4) Juvenile diabetes/insulin dependent **When the diabetes type is undocumented code from the E11 category

24 Diabetes Code/Disease Definition Coding Instructions E13 Other specified diabetes mellitus Identify complications/manifestation associated with the Other specified diabetes.. Z79.4 Long-term (current) use of insulin Use this code to identify ANY insulin use for any type of insulin except E10 (insulin dependent) O24 Always Use Diabetes complication code when diabetes preexisted prior to pregnancy. The 4 th characters indicates if the diabetes is type 1 or 2, The 5 th indicates if the diabetes is treated in pregnancy, 6 th indicates if the diabetes is diet, insulin or not specified controlled T85.6 Complications due to an insulin pump failure: Overdose T85.6 Complications due to an insulin pump failure: Underdose Code the Pregnancy complication first (O, then the pregnancy trimester using a Z3A code). See section (I.C.15 Diabetes mellitus in pregnancy) Code first: T85.6, followed by T38.3X6-, then type of diabetes, then any associated complications Code first: T85.6, followed by T38.3X1-, the type of dm then, any associated complications

25 Obesity & BMI Code/Disease Obesity Morbid Obesity Overweight BMI Coding Instruction E66.0 and if the cause of obesity is stated use the appropriate code. Use secondary code for BMI Dr. Must specify use code E Use secondary code for BMI Use secondary code for BMI Use code Z68

26 Psych Code/Disease Definition Example/ Instruction Pain disorders related to psychological factors Mental and behavior disorders due to psychoactive substance use Use only for pain that is exclusively related to psych disorders. Otherwise use code from G89 note Refers to behavioral disorders due to psychoactive substance use The appropriate codes for remission are assigned only on the basis of provider documentation Use code F45.41 Use code F10-F19 Psychoactive Substance Use, Abuse and Dependence If all are present in the same setting: Only one code should be used based on hierarchy DEPENDENCE 1 st ABUSE 2 nd USE 3 rd If both USE and ABUSE are documented, assign only the code for ABUSE If both abuse and dependence are documented, assign only the code for DEPENDENCE If Use, abuse and dependence are all documented assign only the code for DEPENDENCE If both use and dependence are documented assign only the code for DEPENDENCE

27 Pain Code/Disease Definition Example/Coding Instruction Pain Chronic Pain Chronic Pain Syndrome Persists over time and is often resistant to medical treatments. Dr. Must assign diagnosis Chronic pain syndrome (CPS) is a common problem that presents a major challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy Dr. must assign diagnosis Use category G89.2 May be used with site of pain code Use code G89.4 Central Pain Syndrome Central pain syndrome is a neurological condition caused by damage to or dysfunction of the central nervous system (CNS), which includes the brain, brainstem, and spinal cord Dr. must assign diagnosis Use code G89.0 Postoperative Pain associated with a specific postoperative complication Postoperative Pain not associated with a specific postoperative complication Dr. must assign diagnosis Dr. must assign diagnosis Use appropriate complication code chapter 19 Use code G89

28 Pain Code/Disease Definition Example/Coding Instruction Site specific codes Identify the site of the pain, if the code does not fully describe the site of the pain use an additional code Use Category G89 along with an additional code. If the reason for the encounter is due to pain, sequence the pain code first. Pain due to cancer Use Subcategory G89.3 First Listed Diagnosis Circumstances when pain can be listed first: Sequence first when: When pain control or pain management is the reason for the admission/encounter When a patient is admitted for the insertion of a neurostimulator for pain control Acute and Chronic Pain Undocumented pain (acute or chronic) If the underlying cause of the pain is known When both are diagnosed in the same setting and Sequence Acute first R52 Do not use pain codes Do not use pain codes

29 Eyes Code/Disease Glaucoma Open-angle glaucoma Angle-closure glaucoma Bilateral Glaucoma with same type and stage Bilateral Glaucoma with different type and stage Definition A condition of increased pressure within the eyeball, causing gradual loss of sight A disease of the eye in which the pressure of fluid inside the eyeball is abnormally high, caused by obstructed outflow of the fluid. The increased pressure can damage the optic nerve and lead to partial or complete loss of vision. Is least common, but can cause a sudden buildup of pressure in the eye. The angle between the iris and corneas may be too narrow. i.e. chronic or acute glaucoma Use one code and identify the stage at the 7 th character Use two codes for each eye, and assign the appropriate stage at the 7 th character

30 Hypertension Code/Disease Definition Example/Coding Instructions Hypertension Hypertension w/heart Disease Hypertensive Chronic Kidney Disease Hypertensive Heart and Chronic Kidney Disease Includes: Essential, Malignant, Benign, HTNs use the same code: Hypertension in the setting of heart disease. The Dr. must specify a causal relationship i.e. due to Hypertension in the setting of Kidney disease. The Dr. does not have to specify a causal relationship Hypertension in the setting of heart and kidney disease, dr. must specify a causal relationship between the hypertension and the heart disease, but the HTN and CKD relationship is implied by nature of the fact that they are in the same setting I10 Use code I11 and an additional code to specify the heart failure. I50.- or I I51.9 Use code I12.0 and N18 to identify the stage of the Kidney disease Use code I13.0 and N18 to indicate the stage of the kidney disease Hypertension table is not in ICD-10-CM no longer necessary

31 Hypertension Code/Disease Definition Example/Coding Instructions Hypertension Cerebrovascular disease Hypertensive Retinopathy Hypertension secondary Hypertension, Transient Hypertension in the setting of Cerebrovascular disease. The doctor must specify the causal relationship Hypertension in the setting of Retinopathy Secondary HTN is due to an underlying condition. Elevated Blood pressure..i.e. White Coat Syndrome I60-I69 Use code I10 for the HTN and H35.0 sequence in accordance with the reason for the encounter 2 codes are required: Code I15 to Identify the HTN. Then due to is sequenced first Use code R03.0 Hypertension Controlled HTN controlled by therapy Use Code I10 Hypertension Uncontrolled HTN not responding to therapy Use Code I20 Pregnancy Complications During pregnancy Use code O13 of gestational HTN and O14 for pre-eclampsia

32 ASHD Code/Disease Definition Example/Coding Instructions Atherosclerotic Coronary Artery Disease AHSD and Angina AMI (Acute Myocardial Infarction in ASHD Have combination codes Patient is admitted due to an AMI I25.11 combines both AHSD and Angina, do not code them separately in the same encounter. The doctor does not have to specify a causal relationship. Sequence the AMI first

33 AMI Codes/Disease Definition Example/Coding Instructions AMI Acute Myocardial Infarction I21.3 Old MI ST elevation myocardial infarction (STEMI) *Old Myocardial infarction is defined as having occurred 4 weeks or longer The ST segment is the flat, isoelectric section of the ECG appears typically it is elevated I25.2 I21.0-I21.2 and I21.3- be sure to specify the site of the infarction Non ST elevation myocardial infarction (NSTEMI) Subsequent AMI The Non ST segment is when the isoelectric section is depressed or below the lead Another AMI occurs within the acute phase of treatment (4 weeks or less since the last AMI) I21.4 I22 is coded with I21 codes, and sequencing depends on the reason for the encounter

34 How to code AMI s Patient is admitted for an acute AMI. Code in the following manner Patient is admitted due to other conditions and has an AMI during the encounter Had a Previous AMI No Previous AMI Had a previous AMI No previous AMI If older than 28 days use code first I25 then I25.2 Use code I21 If older than 28 days the other condition is the principal DX, then I21, I25.2 Other condition is the principal Dx, then I21 If not older than 28 days code first I22 then I21 If not older than 28 days I22, I21

35 CVA Code/Disease Definition Example/Coding Instructions Cerebrovascular accident CVA or stroke I60-I67 Sequelae of Cerebrovascular disease Personal history of Transient ischemic attack (TIA) and Cerebral infarction without residual deficits Late effects or residual effects of a stroke I69 following coding notes Use code Z86.73

36 Respiratory Code/Disease Definition Example/coding Instructions Chronic Obstructive Pulmonary Disease (COPD) Acute Exacerbation of COPD and Asthma Category Includes: Asthma with COPD Chronic asthmatic (obstructive bronchitis Chronic bronchitis with airways obstruction Chronic emphysematous bronchitis Chronic obstructive asthma Chronic obstructive bronchitis Chronic obstructive tracheobronchitis An acute exacerbation is a worsening or decompensation of a chronic condition J44 and J45 J44 and J45

37 Respiratory Failure Code/Disease Definition Example/Coding instructions Acute Respiratory Failure as a Primary Diagnosis Respiratory failure and another acute condition Acute respiratory failure is a condition that occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs cannot release oxygen (air) into your blood. In turn, your organs can't get enough oxygenrich blood to function. COPD is an example of chronic respiratory failure J96.0 (Acute), J96.1 (Chronic) and J96.2 Acute and Chronic Depends on the circumstance surrounding the admission.

38 Diseases of Skin and Subcutaneous Tissue Code/Disease Definition Example/Guidelines Pressure Ulcers Also known as decubitus ulcers Are combination codes that identify the site of the pressure ulcer as well as the stage (no longer requires 2 codes) L89 Pressure Ulcers are classified based upon stages (1-4) Unstageable Pressure Ulcers Unspecified Pressure Ulcers Admitted with Evolving Ulcers Pressure Ulcers and BMI(Body Mass Index) Non Chronic Pressure Ulcers Gangrene Review clinical documentation to determine the stage Use for ulcers whose stage can not be clinically determined (e.g. the ulcer is treated with eschar or has been treated with a skin or muscle graft) Use this code if the stage is not specified even if the ulcer is documented as healing Graduating (evolving) from one stage to another Code BMI if documented Non-Chronic Pressure Ulcers can be coded for lower limbs. When pressure ulcers have gangrene involvement L Use code L Assign the highest stage Assign codes from category Z68- for BMI and sequence after the pressure ulcer and stage Coded according to depth of skin down to the bone I96 Gangrene NEC

39 Disease of the Musculoskeletal System and Connective Tissue Code/Disease Definition Example/Guidelines Laterality and Designations Bone Verses Joint Most codes have site and laterality designations For certain conditions, the bone may be affected at the upper or lower end e.g. vascular necrosis of bone, M87, Osteoporosis M80, M81 Acute Traumatic Vs. Chronic or Recurrent Musculoskeletal conditions Pathological Fractures Osteoporosis A Fracture that results after the acute phase of an illness Code by Placing the 7 th character on the acute fracture code. Defined as all of the bones of the musculoskeletal system is affected Code conditions that result from a healed injury from chapter 13. Code acute injuries from chapter 19 7 th character A is for use as long as the patient is receiving active treatment for the fracture. i.e. surgical treatment, ED, evaluation and continuing treatment by the same or different physician. Use D After patient has completed active treatment use G,K,P subsequent encounters for treatment of problems associated with healing i.e. malunions (bad or poorly healed), non-unions, and sequelae M81, Osteoporosis without current pathological fracture use Z if applicable M80 Osteoporosis with current pathological fracture History of Osteoporosis Use for personal history Z sequence after M81 Never Code pathological fx and acute fx in the same setting

40 CKD Code Disease Definition Example/Guidelines Chronic Kidney Disease CKD Stages Stage 2 Stage 3 Stage 4 ESRD If both a stage of CKD and ESRD are documented, assign code for ESRD CKD and transplant status CKD complications or rejections CKD in other conditions i.e. Hypertensive CKD and Chronic Kidney disease and Kidney transplanted CKD is coded based upon severity. The severity of CKD is designated by stages 1-5 Mild CKD Moderate CKD Severe CKD End Stage Renal Disease After a transplant the patient may still have some form of CKD Patient may also suffer from other serious conditions most commonly diabetes mellitus and hypertension. Relationship is assumed in HTN. Dr. must state a causal relationship between the DM & Heart Dz. N18.1 N Mild N Moderate N Severe N18.5 N ESRD Assign N18.6 ESRD Assign appropriate code N18 for the stage and Z94.0 kidney transplant status See Chapter 19 (i.c.19g.)for complications of a kidney transplant See I.C.9 Hypertensive CKD Complications See I. C. 19. CKD and Chapter I.C. 21 Kidney Transplant.

41 Pregnancy, childbirth, and the puerperium Code/Disease Definition Example/Guidelines Obstetric Cases require codes from chapter 15, THESE CODES HAVE SEQUENCING PRIORITY OVER OTHER CHAPTERS. Pregnancy incidental to the encounter Use Chapter 15 (O codes ) only on the maternity record Trimesters as a final character **Every O code requires a Z Pregnancy, Childbirth, and the Puerperium. No complications The majority of codes in chapter 15 have a final character indicating the trimester of pregnancy i.e O23.91 (Unspecified genitourinary tract infection in pregnancy, first trimester) Every Maternity record requires the week of gestation to be documented in addition to the Maternity code. Code Range O00-O9A. Additional codes are required to further specify conditions Use code Z33.1 (pregnant state) do not use codes from chapter 15 (O codes) Assignment of the final character for trimester should be based on the provider's documentation of the trimester for the current encounter. Use Unspecified Trimester category codes when the document is insufficient. Sequence O00-O9A first, then Z3A 7 th Character for Fetus identification When you want to identify a specific fetus Where applicable, a seventh character is to be assigned for certain categories (O31,O32,) O33.3-O33.6, 035, O36, O40, O41, O60.1, O60.2, O64 and O69). Assign 7 th character 0 for single gestations and when the documentation in the record is insufficient to determine the fetus.

42 Pregnancy, childbirth, and the puerperium Code/Disease Definition Example/Guidelines Trimesters Are counted from the first day of the last menstrual cycle. They are defined as: 1 st Trimester Less than 14 weeks 0 Days 2 nd Trimester 14 weeks 0 days to less than 28 weeks 0 days 3 rd Trimester 28 weeks 0 days until delivery Use Additional Code Z3A, Weeks of gestation to identify the specific week of the pregnancy

43 Pregnancy, childbirth, and the puerperium Code/Disease Definition Example/Guidelines Selection of OB first listed/principal diagnosis - Routine Prenatal visits (No complications) - Prenatal outpatient visits for highrisk pregnancies - Episodes when no delivery occurs - When a delivery occurs - **Outcome of delivery- must be included on every maternal record** Z34 (should not be used with chapter 15 codes) O09 (high risk pregnancy code) first list diagnosis The principal dx should correspond to the principal complication of the pregnancy which necessitated the encounter The principal dx should correspond to the main circumstances or complication of the delivery. In cases of Cesarean delivery the selection the principal diagnosis should be the reason for the encounter or principal dx definition i.e reason for the C- section Z37 should be included on every maternal record when a delivery has occurred. Do not use on subsequent records or on the newborn record

44 Pregnancy, childbirth, and the puerperium Code/Disease Definition Example/Guidelines Pre-existing conditions vs. conditions due to the pregnancy Pre-existing HTN in Pregnancy Fetal Conditions Affecting the Management of the Mother Did the illness/condition exist prior to pregnancy? If yes it is preexisting. If not, it was developed during pregnancy Hypertensive heart and Hypertensive Chronic Kidney Disease When known or suspected fetal anomalies and damage Distinguish if preexisting or not assign the appropriate code. **Categories that do not distinguish between pre-existing conditions and pregnancy related conditions are ok to use for both conditions Use O10 (If dx includes a heart dz, it is necessary to add a secondary code from chapter 9 to specify the type of hypertensive heart disease O35 and O36 Utero Surgery Surgery on the fetus O35 for the mother only! HIV infection in Pregnancy HIV and Asymptomatic HIV in Pregnancy i.e. 22 weeks HIV pregnant woman, goes to the ER with chest pain. She is dx d with pneumonia , , B20, Z3A.22 First O98.7 followed by the code(s) for the HIV-related illnesses), followed by the weeks pregnant Z3A O98.7 followed by B20 or Z21 followed by weeks pregnant

45 Pregnancy, childbirth, and the puerperium Code/Disease Definition Example/Guidelines Diabetes Mellitus in pregnancy Long Term Use of Insulin Gestational Diabetes Diabetes pre-existed prior to the pregnancy. Assign if the diabetes mellitus is being treated with insulin Pregnancy induced (brought on by pregnancy). Codes include how the insulin is being controlled. If the patient is being controlled by both diet and insulin, use the insulin code and do not code an additional insuliun code. 024 then E08-E13, then insulin if the patient uses it Z79.4 with Z3A Z if patient uses insulin use one of the following: , O24.424, O24.434, (gestational diabetes code) Do not use Z79.4 with Z3A Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium Alcohol and tobacco use during pregnancy, child birth and the Puerperium Assign appropriate code O85 Alcohol use complicating pregnancy and childbirth, and the puerperium. Should be assigned for any pregnancy case when a mother uses alcohol during the pregnancy or postpartum. Tobacco use During Pregnancy Should be assign for any pregnancy case when a mother uses any type of tobacco product during the pregnancy or post-partum If severe sepsis or organ failure is present use code R65.2 Alcohol: First O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium, then F10 (Alcohol related disorders) with Z3A Tobacco: First O99.33 (smoking complicating pregnancy), then F17 (nicotine dependence) or Z72.0 (tobacco use) with Z3A

46 Pregnancy, childbirth, and the puerperium Code Disease Definition Example/Guidelines Poisoning, Toxic Effects, Adverse Effects, and Underdosing in a Pregnant Patient Normal Delivery O80 Single Live Birth Pregnancy associated with Cardiomyopathy Sequelae of Complication of Pregnancy, Childbirth, and the Puerperium Use when the patient is admitted for a full-term normal delivery and delivers a single, healthy infant without complications antepartum, during the delivery or postpartum during the delivery episode. Is the only outcome of delivery code appropriate for use with O80 Use when an initial complication of a pregnancy develops a sequelae that requires treatment at a future date First O99A- followed by the appropriate toxic effect, adverse effect or underdosing code, and then the additional code(s) that specifies the condition caused by the poisoning, Toxic effect, adverse effect or underdosing. Z3A First O80 (single live birth), second code the delivery outcome Z37.0 Requires minimal or no assistance with or without episiotomy, without fetal manipulation O90.3 O94

47 Perinatal Codes/Disease Definition Example/Guidelines Perinatal Codes may never be used on the maternal record, and may be used throughout the life of the patient if the condition is still present Perinatal is the period before birth through the 28 th day after birth. Codes in this section address diagnosis obtained during the perinatal period Perinatal conditions can be found under the main term Birth or as a subterm/secondary under the condition s main term Principal Diagnosis for Birth Record Use of Codes from Other Chapters with Codes from Chapter 16 Use of Chapter 16 codes after the Perinatal Period This identifies the place of birth and type of delivery when used as a principal diagnosis Condition originates in the perinatal period and continues throughout life. Code Z38 (Liveborn code) only once (at the time of delivery). For infants transferred after birth to another facility, the facility the infant transferred to may not use code Z38 Codes may be used to provide more specific detail including codes for signs and symptoms in the absence of a more definitive diagnosis May use the code throughout the patient s life if the condition still exists i.e. birth injuries that cause permanent damage or disfigurement. Birth process or community acquired conditions When the condition occurred during the process of birth or acquired When the documentation does not specify if the condition was acquired during birth or acquired, the default is due to the birth process

48 Perinatal Code/Disease Definition Example/Guidelines Code all clinically significant conditions noted on routine newborn exam Observation and Evaluation of Newborns for Suspected Conditions Not Found Prematurity and Fetal Growth Retardation Low Birth Weight and Gestational age When a health newborn is evaluated for a suspected condition that is determined after study not to be present Must be documented that the infant has prematurity When both the low birth weight and gestational age is available use 2 codes The following are considered clinically significant: Clinical evaluation; or Therapeutic treatment; or Diagnostic procedures; or Extended length of hospital stay; or Increased nursing care and/or monitoring or Has implications for future health care needs Use codes P00-P04 (Do not use these codes when a patient has identified signs or symptoms of a suspected problem. Code the signs and symptoms. Use P05 (Disorders of newborn related to slow fetal growth and fetal malnutrition), and P07 (Disorders of newborn related to short gestation and low birth weight, not elsewhere classified) Use 2 codes from P07

49 Perinatal Code/Disease Definition Example/Guidelines Low Birth Weight and Immaturity Status Bacterial Sepsis of Newborn Stillbirth Are used for a child or adult who was premature or had a low birth weight as a newborn and this is affecting the patient s current health status (see sectioni.c.2 factors influencing health status and contact with health services Determine if congenital or community acquired. If unknown congenital is the default Used only on the infant record and for institutions that maintain separate records for stillbirths. Use P07 (Disorders of newborn related to short gestation and low birth weight) Use P36 (Bacterial sepsis of newborn, includes congenital sepis) if P36 includes the causal organism assign an additional code from category B95. If P36 does not include the causal organism assign code B96 Use R65.2 (severe sepsis) if applicable for severe sepsis or organ dysfunction Use P95

50 Congenital Malformations, Deformations, and Chromosomal Abnormalities Code/Disease Definition Example/Guidelines Congenital Malformations, Deformations, and Chromosomal abnormalities First-listed/Principal Dx Codes from chapter 17 may be used throughout the life of the patient Live born Infants Are present at birth and may be genetic e.g. (down syndrome, spina bifida, hypospadias) When documented, a condition from chapter 17 may be a first or secondary diagnosis Upon delivery. Code according to the place of birth and type of delivery first, then the congenital defect. Use Q00-Q99 Use Q00-Q99 Upon delivery sequence the live born code first Z38, then the congenital defect Q00-Q99

51 Signs and Symptoms Code/Disease Definition Example/Guidelines Use signs and symptom Codes Use of a signs symptom code with a definitive diagnosis code Combination codes that include symptoms Repeated Falls Use codes from chapter 18 when a definitive diagnosis has not been established Code only when the sign or symptom is not routinely associated with the diagnosis Code Second after the diagnosis An additional code to describe the symptom is not necessary Use R29.6 (repeated falls) code Z91.81 (history of falling). When appropriate use both R29.6 and Z91.81 Coma Scale Typically used in trauma registries Sequence Second R40.2- (coma scale) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae or cerebrovascular disease codes if applicable. Use R40.24 when only the total score is documented in the medical record.

52 Signs and Symptoms Code/Disease Definition Example/Guidelines Functional Quadriplegia SIRS due to Non-infectious process Death NOS Is the lack of ability to use one s limbs or to ambulate due to extreme debility not associated with any neurologic deficit or injury. When SIRS occurs due to a noninfectious disease process such as trauma, malignant neoplasms or pancreatitis Ill-defined and unknown cause of mortality Use code R53.2 (do not use for neurologic deficits or injuries) Code first the Underlying condition, then use code R65.10 (systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction. when SIRS is documented and no infectious disease or condition is documented Use code R65.11 with organ dysfunction if appropriate Use R99 use when the patient has already died and brought into the ED to be pronounced Dead upon arrival

53 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Code injury according to anatomical site first, then the type of injury Locate the anatomical site, then the type of injury Fractures not specified as open or closed Fracture not indicated whether displaced or not displaced If a dislocation accompanies the fracture Amputations not identified as partial or complete Code as closed Code as displaced Dislocations are bundled into the fracture if present at the time of the fracture Code as complete

54 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Most categories in chapter 19 have a 7 th character requirement for each applicable code The 7 th character extenders are: A = initial encounter (active treatment) D = subsequent encounter (after the patient has received active treatment of the condition and is receiving routine care for the condition for the healing during the recovery phase) S = sequela is used for complications or conditions such as scar formation after a burn Do not use Z codes (aftercare codes) on injuries, poisonings, where 7 th characters are provided to identify subsequent care use 7 th character D Examples of when to use 7 th character A initial encounter: - Surgical treatment - Emergency department - Evaluation and continuing treatment by the same or different physician Examples of when to use 7 th character D subsequent encounter: - Cast change or removal X-ray to check healing status of a Fx - Removal of an internal/external fixation device - Medication adjustment - Other aftercare and follow up visits How to use 7 th character S sequela encounter: - Code the injury code that precipitated the sequela and the sequela itself - Add S only to the injury responsible for the sequela

55 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Complication Codes (Describe the current condition that results or is related to something previous) Coding of Injuries Unspecified Injury Active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier problem that precipitated the illness or condition Example T84.50XA, infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter. Code each injury separately unless there is a combination code. Use code T07 Sequencing of multiple injuries Superficial Injuries are defined as cuts, abrasions or contusions are not coded when associated with more sever injuries of the same site. Primary injury with damage to nerve/blood vessels Do not code superficial injuries! Sequence the primary injury first, with additional codes for injuries to nerve and spinal cord next.

56 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Traumatic Fractures Resulting from traumatic incident Coded individually by site S02, S12, S22, S32, S42, S52, S62,S72,S82, S92 and the level of detail furnished by medical record content. Non Specified Fractures Initial Vs. Subsequent encounter for fractures Care for complications of surgical treatment for fracture repairs during healing or recovery phase Care of complications of fx such as malunion and nonunion, should be reported with the appropriate 7 th character for subsequent care with nonunion Osteoporosis Multiple Fractures Sequencing If the documentation does not specify the type of fracture See definitions of ADS 7 th digit extenders If patient with known osteoporosis suffers a fracture regardless of the type of fracture Code the fracture as a closed fracture Use appropriate complications code (K,M,N), or subsequent care with malunion (P,Q,R) Use code M80 See I.C. 13 Sequence the most severe first

57 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Coding of Burns and Corrosions Sunburn codes are not found in chapter 19 Current Burns Sequencing Burns and related conditions Difference between burns and corrosions. Burns include thermal burns from a heat source, fire, electricity, radiation (not the sun)..corrosions are acquired through chemicals Sunburn and other ultraviolet radiation burns are classified in Chapter 12 (L55) Are classified by the depth (denoted by the 4 th character: First degree erythema (redness) Second degree - blistering Third degree - full-thickness through the dermis Burns of the eye and internal organs DO NOT CODE SUNBURNS from the injury chapter Use T20-T25 Use T26-T28 1 Code the highest degree of burn when more than one burn is present Principal Diagnosis and Burns The reason for the encounter according to the physician

58 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Burn Classifications Multiple Burns of the same local site Non-healing burns Infected Burn Assign separate codes for each burn site Burns and corrosions Classified According to Extent of Body Surface Involved According to general anatomical site When burns are of the same local site but of different degrees to the subcategory Rule of 9 s apply: 9% - each arm 18% - each leg (9 upper and lower and 9 front and back0 Posterior trunk - 18% (9 upper and 9 lower ) Anterior trunk - 18% (9 upper And 9 lower) Genitalia - 1% Locate codes in the index under Burns then search for the anatomical site Code the highest degreet20-t28 Code the most severe burn Code as acute burns (active treatment phase) Use an additional code for the infection Use T30 (Burn and corrosion, body region unspecified) Use T31 (Burns classified according to extent of body surface involved) or T32 Corrosions classified according to extent of the body surface involved.. Use T31 when the site is not specified and additional information is needed and when the % of 3 rd degree burns exceed 20% of the body surface

59 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Encounters for treatment of sequela of burns i.e. scars and joint contractures Use a burn or corrosion code with a 7 th character S for sequela. Sequelae with a late effect code and current burn When appropriate use both a code for a current burn or corrosion with 7 th character A or D, and a burn or corrosion code with 7 th character S when both a current and a sequela burn exists Coding General Burns: 1. Code the most severe 1 st (T20 T28) 2. Code the next severe next (T20 T28) 3. Code the least severe next (T20 T28) 4. Code extent of the percentage of 3 rd degree burns over 20% (T31 or T32) 5. If a related illness/infection code it 6. Assign Encounter codes (who, what, when how codes) When the degree of burn is not specified Use T31 Use Encounter Codes Use as many as you need to tell the story Who, what, when or how

60 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Examples/Guidelines Adverse Effects, Poisoning, Underdosing and Toxic Effects Do not code directly from the Table of Drugs Use as many codes as necessary to describe the drugs, medicinal or biological substances. Adverse Effect **If the same code would describe the causative agent for more than one adverse reaction, poisoning, toxic effect or underdosing, assign the code only once. ** If two or more drugs medicinal or biological substances are reported code each individually unless a combo code exists. When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect of drug, then code the adverse of drug.examples of adverse effects: Vomiting, tachycardia, delirium, gastrointestinal hemorrhaging, hypokalemia, hepatitis, renal or respiratory failure. Key word (PROPER administration drug) Use Codes T36-T65 Underdosing means taking or receiving less medicine than prescribed. (never assign as the principal dx) Code first the Nature (Illness), then the drug T36-T50 (the code for the drug should a 5 th or 6 th character 5 ) i.e. a patient took tetracycline as prescribed by his physician immediately after ingestion the patient developed severe abdominal pains diagnosed as gastrointestinal bleed : K92.2, T36.4x5A

61 Injury, poisoning, and Certain other Consequences of External Causes Code/Disease Definition Example/Guidelines Poisoning or reaction Is defined as an improper use of a medication (overdose, wrong, substance given or taken in error, wrong route of administration) Key words: accidental, intentional selfharm, assault, and undetermined. (i.e. error made in prescription, overdose of the drug intentionally taken, non-prescribed drug taken with correctly prescribed and properly administered drug, interaction of drug(s) and alcohol.. Key word is (IMPROPER administration and/or interaction of substances ) Code first T36-T50, sequence next additional codes for all manifestations of poisonings. i.e. Taking medication prescribed to someone else when no intent of poisoning is indicated, the code for accidental poisoning should be assigned. Because categories include the responsible substances well as the external cause, no additional external cause code is required. Underdosing When the patient takes or receives less medication than prescribed by a physician or manufacturer. Use T36-T50 (5 or 6 character 5 ) always sequence after the primary diagnosis, as codes for underdosing can never be listed first. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then code only the medical condition

62 External Causes of Morbidity Code/Disease Definition Example/Guidelines Never Sequence these codes first General External Cause Coding Guidelines: These codes were created for the collection of data for injury research. These codes capture the why, how, and who of the illness or injury - Use with any code in the range of A00.00-T88.9, Z00-Z99 - External cause code used for length of treatment External Cause codes can never be a principal diagnosis.and can not stand alone Assign the external cause code with appropriate 7 th character for each encounter documented at the initial encounter - Use the full range of external cause codes Use the full range of external cause codes to completely describe the cause, the intent, the place of occurrence, if applicable, and the activity of the patient a the time of the event, for all injuries, and other health conditions due to an external cause. - Assign as Many External Cause codes as Necessary - The Selection of the Appropriate External Cause Code Reference the Index to External Causes and search alphabetical order and exclusion notes in the tabular list

63 External Causes of Morbidity Code/Disease Definition Example/Guidelines Never Sequence these codes first General External Cause Coding Guidelines: These codes were created for the collection of data for injury research. These codes capture the why, how, and who of the illness or injury - Use with any code in the range of A00.00-T88.9, Z00-Z99 - External cause code used for length of treatment External Cause codes can never be a principal diagnosis.and can not stand alone Assign the external cause code with appropriate 7 th character for each encounter documented at the initial encounter - Use the full range of external cause codes Use the full range of external cause codes to completely describe the cause, the intent, the place of occurrence, if applicable, and the activity of the patient a the time of the event, for all injuries, and other health conditions due to an external cause. - Assign as Many External Cause codes as Necessary - The Selection of the Appropriate External Cause Code Reference the Index to External Causes and search alphabetical order and exclusion notes in the tabular list

64 External Causes of Morbidity Code/Disease Definition Example/Guidelines Place of Occurrence Activity Code Multiple External Cause Coding Guidelines I.e. Apartment, home, military base, mobile home, car, etc. Identifies the activity of the patient at the time of the encounter. Work-Related Activity use when patient is receiving payment or income for the activity. When 2 or more events cause separate injuries, an external cause should be assigned for each cause: Priority Hierarchy (sequencing) - External cause codes for child and adult abuse take priority over all external cause codes - External cause codes for terrorism takes priority except child and adult abuse - External cause codes for cataclysmic events except child and adult abuse - External cause codes for transport accidents take priority except child and adult abuse. Use Code Y92 document once and only at the initial encounter. (secondary code) Use code Y93 document once at the initial encounter (secondary code) Y93.9 Child and adult abuse are considered assault: Use the assault codes. If assailant is known use code Y09 (perpetrator of maltreatment and neglect) to describe them

65 External Causes of Morbidity Code/Disease Definition Example/Guidelines Late Effects of External Cause Guidelines Terrorism Guidelines External Status Codes Codes are reported with the seventh character extension S for sequela, these code should be used with any report of a late effect or sequela resulting from a previous illness or injury: Late Effect External Cause Code with a Related Current Injury Use of Late Effect External Cause Codes for Subsequent Visits When cause of injury has been identified by the FBI as terrorism Cause of Injury is suspected to be the result of terrorism Code Y38, Terrorism and Secondary effects Assign whenever any other external cause code is assigned for an encounter including an activity code A late effect external cause code should never be used with a related current nature of injury code Use a late effect external cause code when a late effect of an initial injury is being treated. Not to be used for follow-up treatment when no late effect of the injury has been documented. Code first (after the illness) Y38, next Y92.2- (place of service) if known DO NOT USE code Y38 Use code Y38.9 may use with Y38 Use Y99 DO NOT assign a code from category Y99 for: Poisonings, adverse effects, Misadventure or Late Effects! And if the status is not documented in the medical record

66 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Use of Z codes in Any Healthcare Setting Z codes are not procedure or diagnosis codes Z code Categories Specified Z codes can be firstlisted, but more commonly used as secondary codes Contact/Exposure use for contact or exposure to communicable diseases See list for Z-codes that can be sequenced first. Before chapter 21. Use Z20 can be first listed, but more commonly used as a secondary code. Inoculations and Vaccines prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection (Push Code) Use Z23 Status Codes These codes serve as information to indicate that the status may affect the course of treatment Do not use status codes where the diagnosis code of the information is provided in the diagnosis code. i.e. heart transplant status and complication of heart transplant

67 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Additional Z Status codes applicable to the patient s family or personal history Z16 Resistance to antimicrobial drugs Z17 Estrogen receptor status Z18 Retained foreign body fragments Z21 Asymptomatic HIV infection status Z22 Carrier of infectious disease Z28.3 Underimmunization Z33.1 Pregnant state, incidental (secondary code) use when the pregnancy is in no way complicating the reason for the visit. If so, then use a code from chapter 15 pregnancy complications Z66 Do Not Resuscitate Z67 Blood Type Z68 Body mass index (BMI) Z74.01 Bed confinement status Z76.82 Awaiting organ transplant status Physical Constraint Long term Drug therapy When doctor documents that the patient has been put in restraints during the current encounter. (Not temporary restraint) When continuous use of a prescribed drug (including therapeutic aspirin) for the longterm treatment of a condition or for prophylactic use. Z78 Other specified health status Z78.1 Z79 Use for medicines administered for extended periods not acute illnesses (Do not use for patients with drug addictions)

68 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Status codes Z88 Allergy status to drugs Except Z88.9 Allergy status to unspecified drugs Z89 Acquired absence of limb Z90 Acquired absence of organs, NEC Z91.0 Allergy status, other an to drugs Z91.82 Status post admin of tpa(rtpa in a different fac. w/in the last 24 hours prior to admit Z93 Artificial opening status Z94 Transplanted organ and tissue status Z95 presence of cardiac and vascular implants and grafts Z96 presence of other functional implants Z97 Presence of other devices Z98 Other post procedural states Z98.85 Transplanted organ removal status Z99 Dependence on enabling machines and devices NEC

69 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines History codes Screening There are 2 types of history of codes: Personal and family Personal a past medical condition that no longer exists, but there is potential for recurrence. Can be used in conjunction with follow up codes Family - when a family member has had a particular disease that can cause the patient to be at higher risk of contracting the disease Is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (if signs and symptoms are present, it is a diagnostic exam not a screening code the signs and symptoms) Common Personal History of codes: Z85 primary and secondary malignant neoplasm Z86 certain other diseases Z87 other disease and conditions Z91.4 psychological trauma, NEC Z91.5 Self-harm Z91.6 other physical trauma Z91.8 Other specified personal risk factors, NEC Z92 medical treatment except; Z92.0 personal history of contraception Z92.82 Status post administration of tpa (rtpa) in a diff fac. w/in the last 24 hours prior to admit Common Family History of codes: Z80 primary malignat neoplasm Z81 mental and behavioral disorders Z82 certain disabilities and chronic diseases Z83 other specific disorders Z84 other conditions Common screening codes (can be first-listed) Z11 Encounter for screening for infectious and parasitic diseases Z12 Encounter for screening for malignant neoplasms Z13 Encounter for screening for other disease and disorders except: Z13.9 encounter for screening, unspecified Z36 Encounter for antenatal screening for mother

70 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Aftercare generally a first listed code Status Codes and Aftercare codes When the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequence of the disease DO NOT use if treatment is directed at he current, acute disease. Use the current acute care diagnosis code Don Not use for aftercare for injuries assign he acute injury code with the 7 th character D (subsequent encounter).. Status codes may be used with aftercare codes to indicated the Nature of the aftercare. i.e. Z95.1 presence of aortocoronary bypass graft with Z Encounter for surgical aftercare following surgery on the circulatory system to indicate the surgery for which the aftercare is being performed. Status code should not be used when the after care code indicates the type of status, such as using Z43.0 Encounter for attention to tracheostomy with Z93.0 tracheostomy status. Exceptions to the Aftercare rule: These are first listed when the patient s encounter is soley for the purpose of receiving radiation or chemo treatment for Neoplasms: Z51.0 (encounter for antineoplastic radiation therapy) is the only exception Z51.1 (Encounter for antineoplastic chemotherapy and immunotherapy) * Both can be assigned together, and in this case one will have to be the secondary diagnosis. Common Aftercare Z category/codes: Z42 Encounter for plastic and reconstructive surgery. Z43 Encounter for attention to artificial openings Z44 Encounter for fitting and adjustment of external prosthetic device Z45 Encounter for adjustment and management of implanted device Z46 Encounter for fitting and adjustment of other devices Z47 Orthopedic aftercare Z48 Encounter for other post procedural aftercare Z49 Encounter for care involving renal dialysis Z51 Encounter for other aftercare

71 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Follow up Donor When you need to explain the continuing surveillance following completed treatment of a disease, condition or injury. They imply that the condition has been fully treated and no longer exists. Should not be confused with Aftercare codes or injury codes with the 7 th character D Key word: no treatment These codes are only used when donating to others. The donor can t be the recipient. These codes are not used to identify cadaveric (nonliving) donations. Common follow-up codes: Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up exam after completed treatment for conditions other than malignant neoplasm Z39 Encounter for maternal postpartum care and exam Z52

72 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Counseling When a patient or family receives assistance after an illness or injury or when support is required in coping with family or social problems Do not use with diagnosis codes with integral counseling. Common counseling codes: Z30.0- Encounter for general counseling and advice on contraception Z31.5 Encounter for genetic counseling Z31.6 Encounter for general counseling and advice on procreation Z32.2 Encounter for childbirth instruction Z32.3 Encounter for childcare instruction Z69 Encounter for mental health services for victim and perp of abuse Z70 Counseling related to sexual attitude, behavior and orientation Z71 Persons encountering health services for other counseling and medical advice, NEC Z76.81 Expectant parent(s) pre-birth pediatrician visit

73 Factors Influencing Health Status and Contact with Health Services Code/Disease Definition Example/Guidelines Z codes for family planning (Contraceptive) or procreative management and counseling should be included on an obstetric record. *Outcome of delivery Z codes for pregnancy are for use in those circumstances when none of the problems or complications included in the codes from the obstetrics chapter exists (a routine prenatal visit or postpartum care> **Should be included on all maternal delivery records. It is always a secondary code** Z34, Encounter for supervision of normal pregnancy, are always first-listed ad are not to be used with any other code from the OB chapter, codes in category Z3A, weeks of gestation may be assigned to provide additional information Z37

74 References ICD 10 CM and ICD10 PCS Handbook, 2016 Nelly Leon-Chisen, RHIA AHA Coding Clinic Guidelines for ICD 10 CM and ICD 10 PCS, May 2015 ICD 10CM Manual AAPC public, supplemental manuals and publications 2015