CHAPTERS OF ICD-10-CM

Transcription

1 CHAPTERS OF ICD-10-CM Chapter Description Category Chapter 1 Certain Infectious and parasitic diseases A00-B99 Chapter 2 Neoplasms C00-D49 Chapter 3 Diseases of the blood and blood-forming organs and certain D50-D89 disorders involving the immune mechanism Chapter 4 Endocrine, nutritional, and metabolic diseases E00-E89 Chapter 5 Mental, behavioral 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-K99 Chapter 12 Diseases of the skin and subcutaneous tissue L00-L99 Chapter 13 Diseases of the musculoskeletal system and connective M00-M99 tissue Chapter 14 Diseases of the genitourinary system N00-N99 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 Q00-Q99 abnormalities Chapter 18 Symptoms, signs and abnormal clinical and laboratory R00-R99 findings, not elsewhere classified Chapter 19 Injury, poisoning and certain other consequences of external S00-T88 causes Chapter 20 External causes of morbidity V00-Y99 Chapter 21 Factors influencing health status and contact with health services Z00-Z99

2 Chapter 1 Certain Infectious and Parasitic Diseases 1.1 A patient is seen for right lower leg muscle atrophy that is the result of a previous bout of polio. 1.2 An 80-year-old female with fever, malaise and left flank pain. Urinalysis shows bacteria >100,000/ml and culture shows E. coli growth. Provider diagnoses E. coli UTI 1.3 An 87-year-old nursing home patient is being treated with IV antibiotics for E. coli sepsis 1.4 A 75-year-old woman taken to the ER and diagnosed with gram-negative sepsis with acute respiratory failure. Chapter 2 Neoplasms 2.1 Small cell carcinoma of right lower lobe of lung with metastasis to the intrathoracic lymph nodes, brain and right rib. 2.2 Benign carcinoid of the cecum

3 Chapter 3 Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism 3.1 Congenital red cell aplastic anemia Chapter 4 Endocrine, Nutritional and Metabolic Diseases 4.1 A 62-year-old male with mild nonproliferative diabetic retinopathy with macular edema. He has type 2 DM and takes insulin on a daily basis. He also has a diabetic cataract in his right eye. What is the correct code assignment? 4.2 Type 1 diabetic patient with severe chronic diabetic left foot ulcer with diabetic peripheral angiopathy. Also has diabetic stage 2 chronic kidney disease. 4.3 Steroid induced diabetes mellitus due to prolonged use of corticosteroids, which are now discontinued. DM is managed with insulin over last 2 years. Chapter 5 Mental and Behavioral Disorders 5.1 Alcohol dependence with chronic alcoholic gastritis. 5.2 A 52-year-old with dementia and forgetfulness has been wandering from home and getting lost. The diagnosis is dementia due to early-onset of Alzheimer s disease.

4 Chapter 6 Diseases of the Nervous System 6.1 A 72-year-old patient with sudden weakness of the left arm and leg. The patient could speak in the emergency room but was unable to use his left arm and leg. The patient completely recovered and was able to ambulate with no neurological deficits within 24 hours of admission. It was determined that the patient had experienced a TIA. The patient also suffered an intractable classical migraine. 6.2 Left-sided hemiplegia 6.3 Seizure disorder 6.4 Parkinson s disease Chapter 7 Diseases of the Eye and Adnexa 7.1 A patient with moderate primary open-angle glaucoma of the left eye. 7.2 Age-related nuclear cataract, right eye 7.3 Blindness, right eye, low vision, left eye

5 7.4 Nonulcerative bilateral blepharitis of upper eyelids Chapter 8 Diseases of the Ear and Mastoid Process 8.1 Examination of patient reveals left acute serous otitis media and a total perforated tympanic membrane of the right ear due to chronic otitis media. 8.2 Bilateral conductive hearing loss 8.3 Meniere s vertigo of left ear 8.4 Benign paroxysmal vertigo Chapter 9 Diseases of the Circulatory System 9.1 Stage 3 chronic kidney disease with congestive heart failure due to hypertension 9.2 A 72-year-old male with a history of 2-vessel coronary artery bypass last year is seen for unstable angina. Cardiac catheterization shows continued evidence of coronary arteriosclerosis with both bypass grafts patent. He also has a history of CVA with right-sided hemiparesis. 9.3 Acute non-st anterior wall myocardial infarction suffered 5 days ago and atrial fibrillation

6 9.4 Patient from previous case presents to ED two weeks later with acute inferior wall MI. He also has a history of CVA with right-sided hemiparesis. Chapter 10 Diseases of the Respiratory System 10.1 COPD with emphysema 10.2 Moderate persistent asthma with status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease 10.3 MSSA pneumonia 10.4 Upper respiratory tract infection due to novel influenza A virus Chapter 11 Diseases of the Digestive System 11.1 Patient with recurrent right inguinal hernia with gangrene and obstruction 11.2 Acute gastric ulcer with hemorrhage 11.3 Crohn s disease of small intestine with small bowel obstruction

7 Chapter 12 Diseases of the Skin and Subcutaneous Tissue 12.1 Patient with gangrenous pressure ulcer of right hip with cellulitis and pressure ulcer of sacrum documented by physician. Nursing assessment indicated stage 2 sacral ulcer and stage 3 decubitus ulcer of right hip Atherosclerosis of right ankle (native artery), with non-healing ulcer, with breakdown of skin 12.3 A patient with a rash on the trunk and upper extremities over the last 3-4 days due to Ramipril taken for hypertension. Physician discontinues Ramipril and prescribes Captopril and a topical cream for localized dermatitis. Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue 13.1 An 80-year-old female with senile osteoporosis complaining of severe back pain with no history of trauma. Provider documentation reveals pathological compression fractures of several lumbar vertebrae Bacterial Septic Arthritis 13.3 Degenerative disc disease, lumbar region, with myelopathy

8 Chapter 14 Diseases of the Genitourinary System 14.1 An 83-year-old man with complaints of lower abdominal pain and the inability to urinate over the past 24 hours, diagnosed as acute kidney failure due to acute tubular necrosis, caused by a urinary obstruction. The urinary obstruction was a result of the patient s benign prostatic hypertrophy A 78-year-old female with fever, malaise, and left flank pain. A urinalysis shows bacteria of more than 100,000/ml present in the urine and subsequent urine culture shows Proteus growth as the cause of the urinary tract infection. The patient also has a history of repeated UTIs over the past several years. Chapter 17 Congenital Malformations, Deformations and Chromosomal Abnormalities 17.1 Down Syndrome 17.2 Septal Heart Defect Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings 18.1 Patient with fever of 101 degrees with chills. Lab tests and urinalysis are within normal limits. Physician gives final diagnosis as fever with chills, possible viral syndrome Patient complaining of right upper quadrant abdominal pain in addition to nausea and vomiting. Patient also has elevated blood pressure readings, but diagnosis of hypertension is not made. Patient referred for follow up appointment.

9 Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes 19.1 A patient admitted for aftercare following traumatic lateral epicondyle fracture of the right elbow, which is healing normally A patient admitted following surgery for an infected right hip prosthesis A patient taking Digoxin is experiencing nausea, vomiting and profound fatigue. The patient indicates that she has been taking the drug as prescribed. Evaluation and treatment focused on adjustment of medication only. Chapter 21 Factors Influencing Health Status and contact with health services 21.1 A 75-year-old woman was admitted for occupational therapy (OT) following cardiac bypass surgery. She continues to have significant acute post-thoracotomy pain. Assign the correct diagnostic code(s). Code(s):

10 Resident Claim Check Review Pathway Health Services Admit Date Pay Source Days of MC used Name, HIC#, DOB correct in CWF Admission note present Copies of MC/INS Cards Orders to eval & treat Minutes of PT Minutes of OT Minutes of ST Scheduler / RUGs match Restorative Doc. is in place MD Cert Therapy Cert Nsg Doc. In place Dx on UB04 Charges accurate Comments