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CHAPTER 5

CHAPTER 5. CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10). Certain Infectious and Parasitic Diseases, Chapter 1. A00-B99 Classified according to etiology (cause) of disease Combination coding = 1 code to fully describe DX B37.0 Candidiasis infection of mouth

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CHAPTER 5

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  1. CHAPTER 5 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)

  2. Certain Infectious and Parasitic Diseases, Chapter 1 A00-B99 Classified according to etiology (cause) of disease Combination coding = 1 code to fully describe DX B37.0 Candidiasis infection of mouth Multiple coding = 2 or more to fully describe DX N39.0 (UTI), B96.2 (E. coli)

  3. Resistant Infections & Sepsis Resistant to antibiotics Examples: Methicillin-resistant Staphylococcus aureus (MRSA) Multi-drug-resistant Mycobacterium tuberculosis (MDR-TB) First-listed DX = Infection Followed by Z16, Infection with drug resistant microorganism

  4. Sepsis, Severe Sepsis, and Septic Shock Sepsis = systemic inflammatory response syndrome (SIRS) Report infection first If unknown organism, report A41.9, Sepsis, unspecified Severe sepsis = multiple organ dysfunction (MOD), hypotension or collection of fluid in tissues (hypoperfusion)—must be documented Report infection, followed by an R65.2 code Septic shock = circulatory failure associated with severe sepsis Report infection first, followed by R65.21

  5. Human Immunodeficiency B20 reports HIV and includes AIDS Positive serology or culture, but no symptoms, report: Z21, Asymptomatic HIV status HIV exposure, but no symptoms, report: Z20.6, contact/exposure to HIV Inconclusive serology, R75 (Cont’d…)

  6. Human Immunodeficiency (…Cont’d) HIV testing, report Z11.4, Encounter for screening for HIV Assign additional codes for known high-risk behavior: Z72.51, High risk heterosexual behavior Z72.52, High risk homosexual behavior Z72.53, High risk bisexual behavior

  7. Neoplasms, Chapter 2 C00-D49 C00-C96, Malignant neoplasms Primary and secondary D00-D09, Ca in situ (CIS) Not invasive D10-D36, Benign D37-D48, Uncertain Not clearly benign or malignant D49, Unspecified behavior Not stated as to behavior

  8. Stages of Neoplams Staging for renal cancer staged Stage I tumor of kidney capsule only Stage II tumor invading renal capsule/vein but within fascia Stage III tumor extending to regional lymph node/vena cava Stage IV other organ metastasis Pathology report & staging information will be documented in medical record

  9. Sequencing and Complications Treatment directed at primary site, sequence primary first secondary site, sequence secondary first Types : Chemotherapy, Z51.11 Immunotherapy, Z51.12 Radiation therapy, Z51.0 Complications, sequence complication first

  10. History of Neoplasm Codes History of neoplasm codes are only reported when neoplasm eradicated and is no longer present with no active treatment Example: Z85 personal history of malignant neoplasm If active treatment, such as chemo, no history code can be reported

  11. Chapter 3, ICD-10-CM Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) Frequently reported codes: Anemia, D50-D64 Coagulation Defects, D65-D69 Other Disorders of Blood and Blood-Forming Organs, D70-D77

  12. Endocrine, Nutritional, and Metabolic Diseases, Chapter 4 E00-E90 Diabetes codes E08-E13 Due to conditions classified elsewhere, E08 Drug or chemical induced DM, E09 Type 1 DM, E10 Type 2 DM, E11 Other specified DM, E13

  13. Diabetes Mellitus DM codes are combination codes that include type of DM, body system affected, and complications Example: E10.21 Type 1 diabetes mellitus with diabetic nephropathy If type of DM not stated, query physician

  14. Mental and Behavioral Disorders, Chapter 5 F01-F99 Alcohol dependence and use, F10 Opioid, cannabis, sedatives, cocaine, stimulants, hallucinogens, nicotine, F11-F19 Psychological disorders, F20-F29 Mood disorders, F30-F39 Such as, bipolar disorder (Cont’d…)

  15. Mental and Behavioral Disorders Codes (…Cont’d) Anxiety, stress-related, etc., F40-F48 Behavior syndromes, F50-F59 Such as eating and sleep disorders Adult personality and behavior, F60-F69 Mental retardation, F70-F79 Developmental disorders, F80-F89 Child or adolescent behavioral and emotional disorders, F90-F98 Unspecified mental disorder, F99

  16. Pain Pain disorders related to psychological factors, report G89 for pain and F45.41 for pain related to psychological factors Dementia F01 (vascular dementia) F02 (dementia in diseases classified elsewhere F03 (unspecified dementia)

  17. Diseases of the Nervous System, Chapter 6 G00-G99 Many combination codes Example G06.0 Intracranial abscess and granuloma Manifestation codes Example G21.11 Neuroleptic induced parkinsonism Code first (T43.3-T43.5) to identify drug

  18. Non-Psychological Pain Localized pain is reported with codes throughout the I-10 Example, eye pain (H92.0-) or limb pain (M79.6-) Category G89 is NEC pain Example, G89.11 NEC acute pain due to trauma or G89.21 NEC chronic pain due to trauma R52 reports unspecified pain that is: Acute, chronic, generalized, or NOS

  19. Dominant and Nondominant Sides Dominant side: right or left handed Paralysis (plegia) is reported based on dominant or nondominant side Example G81.10 Spastic hemiplegia affecting unspecified side G81.11 Spastic hemiplegia affecting right dominant side G81.12 Spastic hemiplegia affecting left dominant side G81.13 Spastic hemiplegia affecting right nondominant side G81.14 Spastic hemiplegia affecting left nondominant side If dominant unknown, report dominant

  20. Diseases of the Eye and Adnexa, Chapter 7 H00-H59 Does not contain all the eye and adnexa codes Chapter Excludes2 directs to other categories, such as: injury (trauma) of eye and orbit (S05.-) injury, poisoning and certain other consequences of external causes (S00-T98) neoplasms (C00-D48)

  21. Structure of Eye and Ocular Adnexa Figure: 5.15 Eye and Ocular Adnexa

  22. Hordeolum and Chalazion Hordeolum = infection of sebaceous glands (stye) reported on location and type Right or left upper/lower, or unspecified External, report H00.01- Internal, report H00.02- Chalazion = infection of eyelid that forms mass reported on location H00.1

  23. Entropion/Ectropion Entropion = turning inward of eyelid, H02.0- From Frazier MS, Drzymkowski JW: Essentials of Human Diseases and Conditions, ed 4, St. Louis, 2009, Saunders. Figure: 5.18A • Ectropion = turning outward of eyelid, H02.1- From Frazier MS, Drzymkowski JW: Essentials of Human Diseases and Conditions, ed 4, St. Louis, 2009, Saunders. Figure: 5.19A

  24. Lacrimal System Category H04 Codes reported on right, left, bilateral, unspecified, such as: H04.131 Lacrimal cyst right lacrimal gland H04.132 Lacrimal cyst left lacrimal gland H04.133 Lacrimal cyst bilateral lacrimal glands H04.139 Lacrimal cyst unspecified lacrimal gland Figure: 5.17 Lacrimal apparatus

  25. Diseases of the Ear and Mastoid Process, Chapter 8 H60-H95 Excludes2 indicates other categories for reporting other ear conditions, such as: endocrine, nutritional and metabolic diseases (E00-E90) injury, poisoning and certain other consequences of external causes (S00-T98) neoplasms (C00-D48) H60-H95 codes report diseases of external, middle, and inner ear, as well as mastoid, other, and surgical complications NEC

  26. Diseases of the Circulatory System, Chapter 9 I00-I99 Excludes2 note indicates other categories for other circulatory conditions, such as: neoplasms (C00-D48) symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) systemic connective tissue disorders (M30-M36) I00-I99 reports conditions such as rheumatic fever, hypertension, ischemic heart disease, cerebrovascular diseases, etc.

  27. Hypertension Report I10; includes arterial, benign, essential, malignant, primary, and systemic Arterial: Increased arterial blood pressure, hypertension Systemic: Arterial BP exceeds norm for several months Primary: Essential, cause unknown Secondary: Due to underlying condition Malignant: Severe form Benign: Mild form (Cont’d…)

  28. Hypertension (…Cont’d) Transient: Temporary, R03.0, elevated BP without DX of hypertension During or due to pregnancy, O13.- or O14.-

  29. Hypertension with Heart Disease I11, Hypertensive heart disease Includes conditions reported with I50.- or I51.4-I51.9 (myocarditis, cardiomegaly, ill-defined or unspecified heart disease) when condition due to hypertension I11.0 Hypertensive heart disease with heart failure Hypertensive heart failure Use additional code to identify type of heart failure (I50.-) I11.9 Hypertensive heart disease without heart failure Hypertensive heart disease NOS (Cont’d…)

  30. Hypertension with Heart Disease (…Cont’d) Same heart condition not stated to be “due to hypertension” or “hypertensive,” report the heart disease and hypertension separately

  31. Kidney Disease and Hypertension Assume a relationship between the kidney disease and the hypertension I13, combination code for hypertensive heart and chronic kidney disease If heart disease is present, assign a category I50 code (Cont’d…)

  32. Kidney Disease and Hypertension (…Cont’d) CRF/CKD/CRI + hypertension I12.9 + N18.9 CKD stage 1 + hypertension I12.9 + N18.1 CKD stage 2 + hypertension I12.9 + N18.2 CKD stage 3 + hypertension I12.9 + N18.3 CKD stage 4 + hypertension I12.9 + N18.4 CKD stage 5 + hypertension I12.9 + N18.5 CKD stage 6 or ESRD or on dialysis + I12.9 + N18.6 Patient with CKD on any type of dialysis I12.9 + N18.6 + Z99.2

  33. Myocardial Infarction Acute heart attack with occlusion of coronary artery STEMI, ST elevation MI, most severe, total occlusion Example: I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery NSTEMI, non-ST elevation MI, less severe, partial occlusion Example, I21.4 Non-ST elevation (NSTEMI) myocardial infarction (Cont’d...)

  34. Myocardial Infarction (…Cont’d) Subsequent STEMI or NSTEMI are reported with I22.- Example, I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall Complications within 28 days of initial MI, I23 Example, I23.1 Atrial septal defect as current complication following acute myocardial infarction

  35. Diseases of the Respiratory System, Chapter 10 J00-J99 Some codes are combination codes that identify condition and causative organism Example: J03.01 Acute recurrent streptococcal tonsillitis Other codes require separate reporting of organism Example: J01.01 Acute recurrent maxillary sinusitis (Use additional code (B95-B97) to identify infectious agent )

  36. ConclusionCHAPTER 5 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)

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