ICD-10 Coding Guidelines and Conventions, Exams of Medicine

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ICD 10 (MEDA 115)Exam 2024/2025 fully

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"Code first underlying disease" - ANSWER-• Mandatory instruction!

• Code for underlying disease is sequenced first, followed by code for the manifestation "Code, if applicable, any causal condition first" - ANSWER-•Discretionary instruction •Follow instruction if information available "Use additional code" - ANSWER-One or more codes necessary to fully identify specific condition •Implies "cause and effect" Slanted Brackets - ANSWER- ➡️ Indicate mandatory multiple coding. Both codes must be assigned in order to fully describe the condition ➡️ List codes sequentially in the order they appear •The code in slanted brackets is also italicized: italicized codes are never to be listed as the primary or principal diagnosis Italicized: - ANSWER-Italicized codes are never to be listed as the primary or principal diagnosis First-listed condition - ANSWER-• first-listed diagnosis is used in lieu of principal diagnosis
• coding conventions of ICD-10-CM as well as the general and disease specific guidelines take precedence over the outpatient guidelines

Uncertain Diagnosis - ANSWER-* do not code uncertain DX. ➡️ Code the condition to the highest degree of certainty such as signs, symptoms, abnormal test results Diabetes mellitus codes - ANSWER- ➡️ Combination codes that include the diabetes mellitus type, body system affected & complications ➡️ Use as many codes (E08-E13) as needed to accurately identify associated conditions ➡️ Sequenced based on reason of encounter Type 1 Diabetes (juvenile diabetes) - ANSWER- ➡️ Most (but not all) Type 1's develop condition before puberty Type 2 Diabetes - ANSWER- ➡️ If type of diabetes mellitus is not documented in medical record default is Type 2 (E11) Diabetes mellitus and the use of insulin - ANSWER-If medical records do not indicate type of diabetes but does indicate pt uses insulin ➡️ CODE E11 (type 2) ➡️ CODE Z79-4 (long term/current insulin usage) DON'T CODE Z79-4 if insulin is temporary! Diabetes Mellitus in Pregnancy and gestational diabetes - ANSWER- ➡️ See Section I.C. 15 Diabetes Mellitus in Pregnancy ➡️ See Section I.C. 15 Gestational (pregnancy induced) diabetes Complications due to insulin pump malfunction - UNDERDOSE of Insulin - ANSWER- ➡️ 1st CODE T85.6 Insulin pump malfunction ➡️ 2nd CODE T38.3X6- underdosing ➡️ 3rd CODE E11.- Additional codes for type of diabetes and associated complications due to underdosing... Complications due to insulin pump malfunction - OVERDOSE of Insulin - ANSWER- ➡️ 1st CODE T85.6- Insulin pump malfunction ➡️ 2nd CODE T38.3X1- Poisoning by insulin and oral...accidental

➡️ 3rd CODE E11.- Additional codes for type of diabetes and associated Receiving Insulin does not always mean: - ANSWER-type 1 diabetic because type 2 can receive insulin too. Thyroiditis Acute and chronic - ANSWER- ➡️ same indention level ➡️ 1st CODE Acute, followed by Chronic when both conditions reported Partial thyroid lobectomy - ANSWER- ➡️ rarely done ➡️ CODE (60210 or 60212) ➡️ lesion must be located in upper or lower portion of only one lobe Total thyroid lobectomy - ANSWER- ➡️ least complex ➡️ (60220 or 60225) ➡️ with or without isthmusectomy Subtotal Thyroidectomy - ANSWER- ➡️ 60210, 60212, 60252, 60254 ➡️ excise all questionable tissue on side of gland as well as isthmus and majority of opposite lobe. Non aggressive thyroid neoplasms as well as goiters in neck or extend into chest (substernal goiters) Total Thyroidectomy - ANSWER- ➡️ 60240, 60252 Cyst formed on Thyroid - ANSWER- ➡️ aspiration or injection (60300) ➡️ aspiration and injection (60300) Code 1st underlying PHYSIOLOGICAL condition - ANSWER-Underlying condition (etiology) is listed first followed by the dementia code. signs and symptoms - ANSWER- should not be coded separately

• are not to be used as the principal diagnosis when a related definitive diagnosis has been established ➡️ are acceptable for reporting when a diagnosis has not been established by provider

➡️ Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis ➡️ Symptoms are not coded when the underlying disease is established First-listed condition - ANSWER- First-listed condition-Outpatient surgery - ANSWER-code the reason for the surgery even if the surgery is not performed Chronic diseaes - ANSWER-treated on an ongoing basis may be coded and reported as many times as the patient receives treatment If there is no combination code for an infection due to MRSA/MSSA-Dx- seuqencing - ANSWER-Principal- Infection Secondary-Organism Status asthmaticus - ANSWER-Acute asthmatic attack in which the degree of bronchial obstruction that is not relieved by usual treatments Asthma severity terms - ANSWER-intermittent, mild, moderate, or severe persistent Provider documents use, abuse, and dependence of the same substance, how many codes should be assigned? - ANSWER-Only one code should be assigned to identify the pattern of use based on hierarchy Which pattern would be assigned? Use and abuse are documented, - ANSWER-assign only the abuse code Abuse and dependence are documented, - ANSWER-assign only the dependence Use, Abuse, and dependence are documented - ANSWER-assign only dependence Use and dependence are documented - ANSWER-assign only dependence

How do we report a history of drug or alcohol dependence? - ANSWER-Is coded as in remission, but the diagnosis of history or in remission requires the provider's clinical judgment and must be specifically documented in the patient's record. Sequelae of infectious and parasitic diseases - ANSWER- ➡️ Code first the condition resulting from the infectious or parasitic disease ➡️ Next code the sequela (condition that remains or develops later after the acute phase of the illness of infection is over.) B20 - Human immunodeficiency Virus (HIV) - ANSWER- ➡️ once in category always will be ➡️ Code only confirmed cases of AIDS/HIV illness ➡️ Once a patient has been diagnosed with an HIV-related condition or disease, that patient should always be assigned B20 on every subsequent healthcare encounter ➡️ Human immunodeficiency virus (HIV) status -Patients with HIV related illness also include acquired immunodeficiency syndrome (AIDS), Aids related complex (ARC), and HIV infection symptomatic Z11.4 - ANSWER-If pt is being seen for HIV status determination R75 - ANSWER- ➡️ Inconclusive laboratory evidence of HIV. Code is used for patients incuding infants with non-conclusive HIV test finding ➡️ "Patients previously diagnosed with any HIV illness should never be assigned to Z21 or R75" Z71.7 - ANSWER-• Seen for testing

• Discussion of negative results of HIV testing with patient (ie. patient is not HIV+) Z21 - ANSWER-Asymptomatic human immunodeficiency virus (HIV) infection status. Patients with physician documented a symptomatic HIV infection who have never had an HIV related illness "Patients previously diagnosed with any HIV illness should never be assigned to Z21 or R75"

Sequencing for AIDS/HIV illness - ANSWER- ➡️ If a patient is admitted for an AIDS/HIV-related condition, the principal diagnosis is B20, followed by additional code(s) for all HIV-related conditions If a patient with AIDS is admitted for a non-HIV related condition, - ANSWER- ➡️ Code for the non-HIV related condition first, ➡️ followed by B20 to identify the AIDS (comorbid condition) Pregnancy and AIDS - ANSWER-Pregnancy/childbirth coding takes priority over all other code assignments ➡️ First Code Childbirth & the Puerperium ➡️ Second Code for Aids Admitted for HIV related illness ➡️ Asymptomatic - o98.7, Z ➡️ Symptomatic - o98.7, B HIV and AIDS (Z21 or R75) Coding in CA - ANSWER-It is illegal to assign codes that identify a patient with the following diagnoses without the written permission of the patient:

• California coders should make it a rule to avoid use of these codes (Z21 or R75) altogether. ➡️ Code instead:

• Z20.828 Contact with or exposure to other viral disease
• Z22.8 Carrier or suspected carrier of other specified infectious organism
• Z71.7 Encounter for HIV counseling (education, advice, instruction)
• Z11.59 Screening for viral disease, NEC Pain Codes in conjunction with Nervous System - ANSWER-Pain Codes (G89) may be used with other codes unless ➡️ pain is not specified as acute chronic, post-thoracotoy, postprocedural or neoplasm related ➡️ if underlying dx is known unless the encounter is pain control mgmt (G89) pain codes as principal - ANSWER- ➡️ pain control is reason for encounter ➡️ insertion of neurostimulator for pain control (G89) pain codes in conjunction with site specific pain codes - ANSWER-

Coding unrelated conditions with HIV - ANSWER-"Conditions are HIV related only if so documented by the provider."

1. Code the unrelated condition first 2. Then 042, then any HIV related conditions. Cause & Effect - ANSWER-Code Cause first always! Out patient setting coding - ANSWER-Code first listed diagnosis as principal diagnosis If no diagnosis confirmed - ANSWER-CODE Signs and Symptoms : What is the Colon used for - ANSWER-1. The words that precede the colon are not considered complete terms 2. Must be appended by one of the modifiers indented under the statement before the condition can be assigned the correct code. Excludes 1 - ANSWER--"Not coded here!" -Mutually exclusive conditions; both codes cannot be used together Excludes2 - ANSWER--"Not included here!" -Serves as a warning that the condition excluded is not a part of the code description. -The two conditions may occur in same patient. (Verify documentation) Codes for signs and symptoms may be reported in addition to a related definitive diagnosis - ANSWER-when the sign or symptom is not routinely associated with that diagnosis Use patient's documented symptoms or signs - ANSWER-When a diagnosis has not yet been established to justify testing or observation services Abnormal blood lab finding - ANSWER-1. Must be interpreted in context by physician
2. May be primary or principal diagnosis

Only use a code from Abnormal Findings when the physician has - ANSWER- documented the clinical significance of the abnormal finding in the medical record Death, NOS R99, Ill-defined and unknown cause of mortality - ANSWER-1. Only used to for patient who has expired, brought to a health care facility, and pronounced dead on arrival. No underlying cause is identified for the death

2. R99 does not represent the discharge disposition of "death" Residual condition (sequela): the condition that remains or develops later after the acute phase of the illness of infection is over. No time frame - ANSWER-Code first the condition resulting from the infectious or parasitic disease Looking up terms in Alpha Index - ANSWER-Pregnancy is first term

• Pregnancy (condition)
• Pregnancy, complicated by
• Delivery, (condition)
• Delivery complicated by ... Final character in pregnancy code refers to trimester of pregnancy (first, second, third) - ANSWER-Trimester represented by either the 5th or 6th character level Pregnancy Conditions: pre-existing, during or after - ANSWER-• Antepartum: during pregnancy, before delivery •Postpartum: immediately, and up to 6 wks post delivery •Peripartum: last month of pregnancy to 5 months postpartum Perinatal Conditions - ANSWER-•P09 Abnormal findings on neonatal screening •Use additional code to identify signs, symptoms and conditions associated with the screening Weeks of gestation Z3A- - ANSWER-Look up Pregnancy Weeks Trimester Definitions - ANSWER-• First Trimester:

0 - 14 weeks

• Second Trimester: 14 weeks - less than 28 weeks
• Third Trimester: 28 weeks - delivery Postpartum - ANSWER-Index - puerperal, puerperium -up to 6wks after birth. Liver Test - ANSWER-look up elevation MRSA - ANSWER-Infection Severe Sepis - ANSWER-(2 codes)
• Underlying systemic infection
• R65. Septic shcok - ANSWER-• systemic infection
• R65. Burns - ANSWER-• Coding 2 burns, code highest degree burn 1st, assign separate codes for each burn site.
• Burns of same local site 1st˚and 2nd˚ burns - only code 2nd˚
• Burn codes are for thermal burns, heat source, except sunburns classified by depth and degree˚
• Corrosions are burns due to chemicals and classified by depth and degree˚ and agent.
• Eyes and internal organs are classified by site NOT ˚
• Current Burns are classified by depth, extent and agent
• Non healing burns coded as acute burns
• Necrosis of burned skin coded as a non-healed burn
• Use T31 Burns & T32 Corrosions when site of burn is not specified
• Use T31 when reporting evaluating burn mortality, 3rd˚ burn involving 20% or more of BSA
• Treatment of late effects of burns or corrosions is 7th character S(sequela)
• Use external cause codes to specify source, intent and place burn happened.

RULE OF NINES: Extent of body area burned - ANSWER-Head fr - 41/2% bk - 41/2% Chest f - 9% bk - 9% Abdomen f - 9% bk - 9% arms Lft f - 41/2% Lft bk - 41/2% arms Rt f - 41/2% Rt bk - 41/2% legs Lft f - 9% Lft bk - 9% legs Rt f - 9% Rt bk - 9% genitals 1%