ICD-10-CM Coding Guidelines for Specific Conditions, Exams of Advanced Education

Download ICD-10-CM Coding Guidelines for Specific Conditions and more Exams Advanced Education in PDF only on Docsity!

ICD-10-CM Guidelines Chapters 1-

Exam (Verified 2024)

What letter is used as a placeholder in ICD-10-CM? - ANS-X What is found inside parentheses in the Alphabetic Index and Tabular List? - ANS-An Essential Modifier What is an instruction following a main term in the Alphabetic Index indicating another term must be referenced? - ANS-See What is the code found in brackets in the Alphabetic Index and must always be sequenced second after the Etiology Code? - ANS-Manifestation What is used when two conditions cannot occur together e.g. congenital vs acquired of the same condition? - ANS-Excludes 1 Note It is essential to use both the Alphabetic Index and this when locating and assigning a code. - ANS-The Tabular Index Which is sequenced first if the same condition is described as both acute and chronic? - ANS-Acute What is one of the two conditions where codes can be assigned based on medical record documentation from ancillary staff e.g. nurses? - ANS-BMI or Pressure Ulcer Stages What is the minimum number of characters that can be used in ICD-10-CM coding? - ANS- What is the residual effect after the acute phase of an illness or injury has terminated? Sequela or Late Effect - ANS-Sequela or Late Effect What is the diagnosis code(s) for an elevated blood pressure reading? - ANS-R03. What is the diagnosis code(s) for Meningoencephalitis? - ANS-G04. What is the diagnosis code(s) for Hives resulting from penicillin taken as prescribed (initial encounter)? - ANS-T36.0X5A, L50. What is the diagnosis code(s) for Lipoma, skin of abdomen? - ANS-D17. What is the diagnosis code(s) for Alzheimer's disease? - ANS-G30.9, F02.

What is the diagnosis code(s) assigned for Proteinuria complicating pregnancy? - ANS- O12.10, Z3A. What is found in the first black section of the ICD-10-CM book? - ANS-The Neoplasm Table What is found in the 2nd light blue section of the ICD-10-CM book? - ANS-Symptoms, Signs, and Abnormal Clinical and Laboratory Findings What page can The Table of Drugs and Chemicals be found on? - ANS-Page 339 What category of codes can you find the newborn codes in? - ANS-P00-P What page are the chapter specific guidelines for adverse effects, poisoning, under- dosing and toxic effects found on? - ANS-Page 20 of the Coding Guidelines What color is used to show what documentation differentiates the codes? - ANS-Green What color is a 7th character extension alert shown in? - ANS-Aqua What color is an unspecified code highlighted in? - ANS-Yellow What color is a manifestation code highlighted in? - ANS-Blue What color in the Tabular List is the Code also and Use additional code shown in? - ANS-Red [ ] Brackets in Tabular list - ANS-Synonyms, alternative wording, explanations. Disease manifestations. Mandatory dual coding, e.g.G30.9 [F02.80] in Index = Code both ( ) Parentheses - ANS-Supplementary words AKA Nonessential modifiers Use of "and" - ANS-Means "and/or" Excludes notes (1 and 2) - ANS-Excludes 1 = Not coded here. The excluded code should never be used at the same time as the code above the Excludes 1 note. Excludes 2 = Not included here. Code if patient has it along with main code "In diseases classified elsewhere" - ANS-Manifestation codes. May not be primary diagnosis. Underlying disease is primary diagnosis. Codes in brackets on secondary diagnosis. "See" - ANS-Go to the code directed and use it "See Also" - ANS-There is another term that may be useful. No need to follow if original term describes the condition

"Code Also" - ANS-Helps fully describe the condition, but no sequencing direction. You decide what the primary diagnosis is Signs and symptoms routinely associated with a disease/not associated with the disease - ANS-Not assigned, unless instructed by classification/additionally assigned Signs and symptoms as diagnoses - ANS-Ok to use as diagnosis if no definitive diagnosis is given by the physician Combo Codes - ANS-Use only one combo code if it describes all conditions. If it lacks specificity, use additional codes Sequela - ANS-Late Effect. Condition sequenced first, sequela second unless sequela code describes condition with 4th, 5th, 6th digit Impending or threatened condition - ANS-1. If it occurred, code as confirmed;

2. If it didn't occur, see if Impending or Threatened is in index;
3. If nothing in index, code underlying conditions and omit coding Impending or Threatened condition Borderline diagnosis - ANS-Code as confirmed unless borderline in index in all settings. Borderline is NOT the same as likely, possible, etc Chapter 1: Infectious and parasitic diseases: HIV testing - ANS-1. Z11.4, Encounter for screening for HIV + codes for high risk behavior;
4. If patient comes back for results and results are negative - Z71.7, HIV counseling Chapter 1: Infectious and parasitic diseases: Rx resistance - ANS-Z16 category as secondary diagnosis for infection code UNLESS infection code says RX resistant Chapter 1: Infectious and parasitic diseases: Sepsis - ANS-1. Code underlying systemic infection;
5. If no causal infection mentioned, A41.9, Sepsis
6. R65.2, Severe sepsis (if present and organ dysfunction DUE to sepsis). No R65.2 if dysfunction is NOT due to sepsis;
7. Urosepsis has no code = Query the physician Chapter 1: Infectious and parasitic diseases: Severe sepsis - ANS-Minimum of 2 codes:
8. Code for underlying systemic infection (A49 or A41.9 if no infection specified);
9. Code from R65.2 category (NEVER a primary diagnosis) Chapter 1: Infectious and parasitic diseases: Septic shock - ANS-Can't be primary diagnosis. 2 Codes:
10. Underlying infection or A41.9;
11. R65.21, Severe sepsis with septic shock;

or T81.12, Postprocedural septic shock;

3. Organ failure (if present) Chapter 1: Infectious and parasitic diseases: Sepsis see localized infection, e.g. Pneumonia, Cellulitis - ANS-1. Underlying infection- primary diagnosis;
4. Localized infection- secondary diagnosis;
5. R65.2, severe sepsis (if present) localized infection may be primary diagnosis if sepsis developed after admission for localized infection Chapter 1: Infectious and parasitic diseases: Sepsis due to postprocedural infection - ANS-1. Postprocedural infection- primary diagnosis (T80.2, T81.4, T88.0, O86.0)
6. R65.2, severe sepsis (if present)-secondary diagnosis Chapter 1: Infectious and parasitic diseases: Sepsis associated with noninfectious process - ANS-e.g. Trauma, burn, etc. If treatment is for injury = primary diagnosis, if treatment is for infection = sepsis primary diagnosis. If treatment is for both = either primary diagnosis. Only one code from R65 may be used Chapter 1: Infectious and parasitic diseases: Combo code for MRSA - ANS-If condition code describes "due to MRSA",
7. OMIT B95.62, MRSA as the cause of disease
8. OMIT Z16.11, resistance to Penicillin Chapter 1: Infectious and parasitic diseases: MRSA - ANS-If no combo codes exists, code B95.62, MRSA OMIT Z16.11, Resistance to Penicillin Chapter 1: Infectious and parasitic diseases: MRSA colonization of MSSA - ANS- Diagnosis, MRSA screen positive or MRSA nasal swab positive, Code Z22.322, carrier or MRSA for MRSA colonized patients Code Z22.321, carrier of MSSA for MSSA colonized patients Both codes may be assined if patient is MRSA colonized and MSSA colonized Chapter 2: Neoplasms: Overlapping boundaries - ANS-Classify to subcategory .8, overlapping lesions unless there is another code covering each site affected e.g. quadrants of the same breast should be coded together if several quadrants affected Chapter 2: Neoplasms: Treatment directed at malignancy - ANS-Malignancy- primary diagnosis UNLESS encounter is only for chemo, immuno or radiation = Z51.- as primary diagnosis and cancer site - secondary diagnosis Chapter 2: Neoplams: Anemia in cancer - ANS-If cancer patient is treated for anemia associated with cancer - cancer primary diagnosis and anemia secondary diagnosis e.g. D63.0, anemia in cancer

Chapter 2: Neoplasms: Anemia due to chemo, immunotherapy, or radiation therapy - ANS-If patient is treated as adverse event of chemo, immunotherapy or radiation, anemia primary diagnosis, cancer secondary diagnosis and adverse event of medication - secondary diagnosis Chapter 2: Neoplasms: Anemia due to radiation - ANS-Anemia primary diagnosis; cancer - secondary diagnosis; Adverse event of radiation Y84.2 - secondary diagnosis Chapter 2: Neoplasms: Dehydration due to malignancy - ANS-If only dehydration is treated = primary diagnosis, cancer - secondary diagnosis Chapter 2: Neoplasms: Primary site previously excised - ANS-1. If no evidence of primary cancer = Z85, personal history;

2. If extension, invasion, metastasis to another site = secondary cancer of that site - primary diagnosis and Z85 - secondary diagnosis Chapter 2: Neoplasms: Encounter for administration of of chemo, immuno, and radiation therapy - ANS-1. If only chemo, immuno, or radiation therapy given = Z51.0, Z51.11, or Z51.12 + cancer as secondary diagnosis
3. If patient receives >1 Rx, all related Z51.- may be used Chapter 2: Neoplasms: Complication of chemo, immuno, and radiation therapy administration - ANS-If patient has adverse events to medication e.g. Nausea/vomiting, dehydration = Z51.- as primary diagnosis and complication would be the secondary diagnosis Chapter 2: Neoplasms: Admission to determine extent of malignancy - ANS-Primary malignancy is the primary diagnosis, metastasis - secondary diagnosis. Any chemo, immuno, or radiation is also a secondary diagnosis Chapter 2: Neoplasms: Symptoms, signs and abnormal findings associated with neoplams - ANS-Cancer is always primary diagnosis, followed by signs, symptoms related to cancer Chapter 2: Neoplasms: Disseminated neoplasm - ANS-C80.0, disseminated malignant neoplasm, unspecified. Use only in patients with advanced metastatic disease and there are no known primary or secondary sites Chapter 2: Neoplasms: Cancer in pregnancy - ANS-O9A.1-, malignancy complicating pregnancy - primary diagnosis; Cancer site - secondary diagnosis Chapter 2: Neoplasms: Complications of malignancy - ANS-e.g. Dehydration related to cancer = Dehydration primary diagnosis, cancer - secondary diagnosis, except for Anemia (CA - Primary and anemia - secondary)

Chapter 2: Neoplasms: Pathologic fracture due to neoplasm - ANS-1. If treatment for fracture - M84.5, Pathologic fracture in neoplastic disease - primary diagnosis;

2. If treatment is for cancer - cancer primary diagnosis and fracture would be the secondary diagnosis Chapter 2: Neoplasms: Site excised but still under treatment - ANS-As long as the patient receives treatment for cancer, code active cancer. Personal history only if nothing more is done for cancer after excision and completion of Rx Chapter 2: Neoplasms: Cancer of transplanted organ - ANS-1. Transplant complication = T86.-, complications of transplant - as primary diagnosis;
3. C80.2, malignancy associated with transplanted organ - secondary diagnosis;
4. Specific malignancy site Chapter 3: Blood and immune disorders - ANS-Reserved for future expansion Chapter 4: Endocrine, Nutritional and Metabolic Diseases- Diabetes Mellitus - ANS-Use as many codes from E08 - E13 as needed to describe all conditions that the patient has Chapter 4: Endocrine. Diabetes Mellitus type not documented - ANS-Diabetes Mellitus E11.- is default Chapter 4: Endocrine. Diabetes Mellitus, long term insulin use - ANS-Z79.4 used when patient is on insulin NOT used if insulin is temporarily used to bring down blood sugar during visit Chapter 4: Endocrine. Insulin pump malfunction, underdosing - ANS-1. Underdose - T85.6, Mechanical complication - primary diagnosis
5. T38.3X6-, underdosing of insulin - secondary diagnosis
6. Diabetes Mellitus - secondary diagnosis
7. Complications - secondary diagnosis Chapter 4: Endocrine. Insulin pump malfunction, overdosing - ANS-1. T85.6-, mechanical complication
8. T38.3X1-, poisoning by insulin, accidental Chapter 4: Endocrine. Diabetes Mellitus due to pancreatectomy - ANS-1. E89.1, postprocedural hypoinsulinemia
9. E
10. Z91.41-, acquired absence of pancreas Chapter 5: Mental and behavioral disorders. Substance use, abuse, dependence - ANS- If use, abuse recorded = code abuse If use, dependence recorded = code dependence

Chapter 6: Diseases of Nervous System. Dominant/Nondominant side - ANS-If the medical record is not clear about domination: Ambidextrous patients = dominant (any side is dominant) If left side is affected = Nondominant. If right side is affected = dominant Chapter 6: Diseases of Nervous System. Pain - ANS-1. Expected postop pain = no code

2. If treatment directed at pain = G89.- as primary diagnosis and site is secondary diagnosis Chapter 6: Diseases of Nervous System. Neoplasm related pain - ANS-1. G89.3 as primary diagnosis no matter if acute or chronic (if visit for pain control/management) + cancer as secondary diagnosis
3. If cancer is treated and pain is documented = G89.3 as secondary (OMIT site of pain) Chapter 7: Diseases of Eye. Glaucoma - ANS-Use as many glaucoma codes as needed to describe glaucoma, affected eye and stage (H40 category) Chapter 7: Diseases of Eye. Bilateral glaucoma same type and stage - ANS-1. If there's a code for bilateral - use it
4. If there's NO code for bilateral - code once (not twice to cover both eyes unlike pain in right hand and left hand) Chapter 7: Disease of Eye. Bilateral glaucoma different types/stages - ANS-1. If same stage - code for each eye, NOT bilateral
5. If different stages - same code twice, but different 7th character for stage Chapter 7: Diseases of Eye. Glaucoma stage progressed while in hospital - ANS-Code the highest stage documented Chapter 7: Diseases of Eye. Indeterminate stage VS unspecified - ANS-Not the same. If no stage is documented - 0, unspecified Chapter 8: Diseases of Ear and Mastoid Process (H60 - H95) - ANS-Reserved for expansion Chapter 9: Diseases of Circulatory system. Hypertensive - ANS-Use hypertensive category ONLY when the physician indicates due to HTN or hypertensive. Otherwise code conditions separately Chapter 9: Diseases of Circulatory system. Transient Hypertension - ANS-1. Non- pregnant: R03.0, elevated BP without diagnosis of HTN
6. O13.-, gestational HTN without significant proteinuria
7. O14.-, pre-eclampsia Chapter 9: Disease of Circulatory system. CAD with angina - ANS-Combo codes.

1. I25.11, CAD of native artery with angina and I25.7, CAD of graft and artery of transplanted heart with angina
2. No angina secondary diagnosis code needed
3. Angina is assumed to be due to CAD, unless the physician says that it is not Chapter 9: Diseases of Circulatory system. CVA current and Late Effect - ANS- Sequelae of CVA with deficits (category I69) may be used in patients with current CVA deficits (I60 - I67 categories) Chapter 9: Diseases of Circulatory system. STEMI, NSTEMI - ANS-1. I21.0-I21.3 - STEMI
4. I21.4, NSTEMI and nontransmural MIs
5. If NSTEMI evolves to STEMI = code STEMI, if STEMI turns STEMI after treatment = still code STEMI Chapter 9: Diseases of Circulatory system. Current VS old MI - ANS-1. MI 4 weeks - I21, current subsequent encounter
6. MI treated, but >4 weeks - code aftercare
7. No treatment for MI = I25.2, old MI Chapter 9: Diseases of Circulatory system. Diagnosis acute MI unspecified or STEMI or Transmural MI - ANS-I21.3, STEMI of unspecified site Chapter 9: Diseases of Circulatory system. MI dianosis subendocardial or transmural and site is given - ANS-Code as subendocardial AMI Chapter 9: Diseases of Circulatory system. Subsequent AMI - ANS-1. I22, subsequent STEMI or NSTEMI. Use on patients who had another AMI within 4 weeks of initial MI + code from I
8. Sequencing depends on circumstances of encounter Chapter 10: Respiratory System: COPD and Asthma - ANS-J44 and J45. Acute exacerbation is NOT = to infection superimposed on a chronic condition, but may be triggered by infection Chapter 10: Respiratory System. Acute respiratory failure - ANS-May be secondary diagnosis if occurs after admission, or if it is present on admission, but doesn't meet definition of primary diagnosis Chapter 10: Respiratory System. Flu due to identified flu virus - ANS-Code only confirmed cases (J09, J10 categories) this is an exception to hospital IP guideline Chapter 10: Respiratory System. Flu due to suspected flu virus - ANS-J11, flu due to unidentified flu virus

Chapter 10: Respiratory System. VAP develops after admit for PNA - ANS-If patient is admitted for PNA, e.g. J13, PNA due to strep and develops VAP in hospital - PNA is primary diagnosis and VAP is secondary diagnosis Chapter 11: Diseases of the Digestive System - ANS-Reserved for future expansion Chapter 12: Diseases of Skin and Subcutaneous Tissue. Pressure ulcers - ANS- Category L89 - combo codes identifying site of ulcer and stage. Use as many L89 codes as needed to code all ulcers Chapter 12: Diseases of Skin and Subcutaneous Tissue. Healing pressure ulcers - ANS-Code as current. If not clear if new or healing - query the physician Chapter 12: Diseases of Skin and Subcutaneous Tissue. Pressure ulcer evolved to higher stage - ANS-If patient is admitted with one stage ulcer and evolves to higher stage = code both, stage on admin and highest stage developed Chapter 13: Diseases of Musculoskeletal System. Multiple sites - ANS-1. If multiple sites code available, e.g. osteoarthritis, use that code

2. If no code for multiple sites exists, code each site separately Chapter 13: Diseases of Musculoskeletal System. Bone VS Joint - ANS-Bone affected at upper or lower end near joint or involving a joint = code the site bone NOT joint Chapter 13: Diseases of Musculoskeletal System. Acute VS chronic or recurrent conditions - ANS-Acute - ch 19 (S00-T88) Chronic or recurrent - ch 13 (M00-M99) Chapter 13: Diseases of Musculoskeletal System. Osteoporosis - ANS-Affects all bones. M80 category (Osteoporosis with current pathological fracture) identify site of fracture, NOT osteoporosis Chapter 13: Diseases of Musculoskeletal System. Osteoporosis without significant pathological fracture - ANS-1. Category M81 for patients who have osteoporosis, but no current pathological fracture
3. If patient had a history of pathological fracture = M81 + Z87.210, history of osteoporosis fracture Chapter 13: Diseases of Musculoskeletal System. Osteoporosis with current pathological fracture - ANS-M80 for site of fracture. Use for any patient with osteoporosis with fracture if trauma wouldn't usually break a healthy bone Chapter 15: Pregnancy. Condition encompass > one trimester - ANS-1. Code on basis of trimester when complication developed, not trimester of D/C
4. If condition developed prior to admission, code trimester at time of encounter

Chapter 15: Pregnancy. 7th character for fetus ID - ANS-Assign 0 for single gestations; when unclear which fetus is affected Chapter 15: Pregnancy. Routine prenatal visits - ANS-1. Z34, encounter for supervision of normal pregnancy

2. Can't use any ch 15 codes with Z Chapter 15: Pregnancy. Supervision of high-risk pregnancy - ANS-O09 as primary diagnosis + any ch 15 codes applicable Chapter 15: Pregnancy. Delivery occurs - ANS-1. C-section done = primary diagnosis is condition responsible for visit
3. Condition is NOT due to C-section = primary diagnosis for condition responsible for admission Chapter 15: Pregnancy. Delivery outcome - ANS-Z37 category has to be on every maternal medical record Chapter 15: Pregnancy. Puerperium and admit for delivery - ANS-May use specific puerperium codes complicating pregnancy if condition arises postpartum during delivery encounter Chapter 15: Pregnancy. Pre-existing HTN in pregnancy - ANS-Category O10 + secondary diagnosis from HTN category to specify type of heart failure or CKD (chronic kidney disease) Chapter 15: Pregnancy. Fetal conditions affecting management of the Mother - ANS- Categories O35-O36. Use only if management of mother is affected by fetal condition. Presence of fetal condition alone does not justify the use of codes from range O35-O Chapter 15: Pregnancy. HIV in pregnancy - ANS-O98.7- + B20 + AIDS related condition (if it applies) + Z3A for weeks of gestation Chapter 15: Pregnancy. Gestational Diabetes Mellitus - ANS-O24.4 category. If insulin controlled use insulin controlled, but OMIT Z79.4, long term insulin use