ICD-10-CM Cding Basics Chapter Specifics Chapter 10 Diseases f the Respiratry System Vilma Smith, LVN, CPC, CCS AHIMA Apprved ICD-10-CM/PCS Trainer Debra Bales, LVN, CPC 1 Rev. May 2015
ICD-10-CM Cnventins General rules fr use f the classificatin independent f the guidelines. Cnventins and instructins f the classificatin takes precedence ver guidelines. Incrprated within the Alphabetic Index and Tabular list as instructinal ntes. 2
Chapter 10: Diseases f the Respiratry System (J00-J99) Organized by the general type f disease r cnditin and by the affected site Upper respiratry system Lwer respiratry system Nte: Per guidelines, fr respiratry cnditins ccurring in mre than ne site and the dcumented cnditin is nt specifically indexed, reprt nly the lwer anatmic site (i.e. trachebrnchitis, cde nly brnchitis J40.-) Cmmn instructinal terms Use additinal cde(s) when applicable t identify Expsure t envirnmental tbacc smke (Z77.22) Expsure t tbacc smke in the perinatal perid (P96.81) Histry f tbacc use (Z87.891) Occupatinal expsure t envirnmental tbacc smke (Z57.31) Tbacc dependence (F17.-) Tbacc use (Z72.0) Cding cnventins and instructinal ntes (i.e. Excludes 1 & 2, cde first, and cde additinal ntes) are ntable and help with cding and sequencing f respiratry cnditins including asthma, COPD, brnchitis, pneumnia and influenza 3
Chapter 10: (cnt.) Asthma (J45.-) Dcument Acuity Acute exacerbatin Uncmplicated Asthma An acute exacerbatin is a wrsening r a decmpensatin f a chrnic cnditin Nt equivalent t an infectin superimpsed n a chrnic cnditin, thugh an exacerbatin may be triggered by an infectin Verbiage such as wrsening r decmpensatin f a chrnic cnditin shuld always be dcumented t shw status Type f asthma and the severity must be dcumented clearly in the prgress nte (i.e. Intermittent, persistent, mild, mderate etc. fr extrinsic and intrinsic) Please refer t the table n the fllwing slide 4
Type f Asthma Acuity ICD-10-CM Mild intermittent Asthma With (acute) exacerbatin J45.21 with status asthmaticus J45.22 uncmplicated J45.20 Mild persistent Asthma With (acute) exacerbatin J45.31 with status asthmaticus J45.32 uncmplicated J45.30 Mderate persistent Asthma With (acute) exacerbatin J45.41 with status asthmaticus J45.42 uncmplicated J45.40 Severe persistent Asthma With (acute) exacerbatin J45.51 with status asthmaticus J45.52 uncmplicated J45.50 5
Type f Asthma Acuity ICD-10-CM Unspecified Asthma With (acute) exacerbatin J45.901 Other Asthma : with status asthmaticus J45.902 uncmplicated J45.909 (Exercised induced brnchspasm) J45.990 (cugh variant asthma) J45.991 (ther asthma) J45.998 6
Chapter 10: (cnt.) COPD with Brnchitis Dcumentatin tips Include the infectin cde (if knwn) fr highest specificity (B95.- ; B96.-; B97.-) Classificatins fr chrnic brnchitis nw include a cde specific fr COPD with acute lwer respiratry infectin (J44.0) COPD with (acute) exacerbatin (J44.1) has an Excludes 2 ntatin fr COPD with acute brnchitis which is reprted with J44.0 (this means yu may use bth cdes if apprpriate) *Use additinal cde t identify: tbacc use Z72.0, dependence F17.- r expsure t envirnmental tbacc smke J45.- 7
Chrnic Lwer Respiratry disease Acuity ICD-10-CM Brnchitis Nt specified as acute r chrnic J40 Acute, unspecified J20.9 Simple Chrnic J41.0 Mucpurulent Chrnic J41.1 Mixed simple and mucpurulent Chrnic Chrnic, NOS J41.8 J42 8
Chrnic Lwer Respiratry disease Acuity ICD-10-CM COPD With acute lwer respiratry infectin J44.0 With (acute) exacerbatin J44.1 Uncmplicated, NOS J44.9 Emphysema Type ICD-10-CM Unilateral pulmnary (MacLed s syndrme) J43.0 Panlbar (Panacinar) J43.1 Centrilbular J43.2 9
ICD-10-CM Chapter Specific Chapter 10 (cnt.) Influenza and Pneumnia Influenza (J09.- thru J11.-) Identify the presence f a virus ICD-10-CM guidelines require cnfirmatin f Avian influenza r nvel H1N1 flu (J09.X-) Dcument als the manifestatin (i.e. respiratry, gastrintestinal) Fr Influenza, NOS (J11.1), Influenza due t unidentified influenza virus with ther respiratry manifestatins Viral Pneumnia (J12.-) Identify type (ie. Adenviral, RSV, Parainfluenza, Human metapneumvirus r ther viral pneumnia due t SARS-assciated crnavirus) Fr Pneumnia due t Hemphilus influenzae, reprt J14 10
ICD-10-CM Chapter Specific Chapter 10 (cnt.) Influenza and Pneumnia Bacterial Pneumnia (J13 thru J18.-) Identify type (i.e. due t Streptcccus pneumniae, Klebsiella pneumniae, Pseudmnas, MSSA, MRSA, E. Cli, Mycplasma pneumniae, etc.) Dcument assciated lung abscess (J85.1), when applicable Similar guidelines fr respiratry failure cding Acute Respiratry Failure, J96.0- (with hypxia, with hypercapnia) Chrnic Respiratry Failure, unspecified whether with hypxia r hypercapnia, J96.10 Chrnic Respiratry Failure with hypxia, J96.11 Chrnic Respiratry Failure with hypercapnia, J96.12 Acute and Chrnic respiratry failure, J96.2-11