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Basic ICD 10-CM/PCS and ICD-9-CM Coding

2012 EditionUpdated for 10/1/11 Code Changes

Instructor Guide

Lesson Plans, Student Activities, and Review Questions

Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA

Instructor and Student ActivitiesThis Instructor Guide is designed to assist the instructor in reviewing the important topics in the

Introduction and each of the 24 chapters of BasicICD-10-CM/PCS and ICD-9-CM Coding, 2012 Edition. Objectives for each chapter are given and important points highlighted.

Instructor responsibilities and activities

The following are suggested responsibilities and activities for instructors in order to use the book to their own and the students' advantage:

1. All instructors must have access to AHA Coding Clinic for ICD-9-CM through subscription (1-800- 621-6902) or http://www.ahacentraloffice.org/ahacentraloffice/html/products.html. AHA Coding Clinic for ICD-9-CM is an essential tool for teaching and for reference. A subscription for this quarterly publication is $196 per year for American Hospital Association (AHA) members. AHIMA members receive a special online price of $250. The nonmember price is $290 per year. As of August 2011, there was a price of $30.00 listed for “Educator.” The importance of this reference must be communicated during the college/school's budget process for inclusion as an expense item. If the school or department has an alumni fund of donations, this may be a realistic expenditure from the fund.

All instructors must read each quarterly AHA Coding Clinic for ICD-9-CM newsletter. Many questions and answers published in each edition can be used in class to clarify a coding rule or to give an example of a coding rule that is applied to a coding inquiry. Coding guidelines and rules may change based on a Coding Clinic publication of a question and answer. Instructors are obligated to stay current with all rules and interpretations to completely prepare the students for competency exams and professional practice.

2. All instructors must be very familiar with the current ICD-9-CM Official Guidelines for Coding and Reporting. The guidelines included in this textbook were effective October 1, 2011.

The new set of revised ICD-9-CM Official Guidelines for Coding and Reporting, effective 10-1-2011 is available in PDF format in August 2011 at http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines.

Instructors should review the new guidelines and refer their students to this websitefor the most current information, especially regarding the use of the new External Cause of Injury (E) codes.

Many of the guidelines are incorporated into the chapters within this book. The guidelines, in addition to the rules and conventions within the ICD-9-CM codebook, are the foundation for coding practice. Students must be required to read the guidelines, and questions from the guidelines should be included in coding examinations.

Copyright © 2012 by the American Health Information Management Association. All Rights Reserved. 1

http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines

http://www.ahacentraloffice.org/ahacentraloffice/html/products.html

3. Instructors should incorporate the ICD-9-CM Official Guidelines for Coding and Reporting into each chapter of the text during the lecture and class discussion, especially the chapter-specific guidelines that appear in the Guidelines Section 1, Part C1–C19. Review with students the fact that adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1–2) have been adopted under HIPAA for all healthcare settings. Volume 3 procedures have been adopted for inpatient procedures reported by hospitals.

4. A set of review questions for each chapter in the book is included in this instructor guide. These questions may be assigned in addition to the exercises within each chapter. Another alternative is to use the chapter review questions as a quick quiz during a class, as part of a midterm, final, or other examination, or as extra-credit assignments.

5. A set of PowerPoint (.ppt) overhead slides is included with this instructor guide to capture the highlights and outline of each chapter. The slides may be used as transparencies for class presentation. A printout of the slides in 3/page or 6/page fashion may be distributed to the students as budgets permit. The PowerPoint slides are intended to give the instructor the important points to emphasize for each chapter.

6. A coding self-test is included in the back of the textbook. These questions may be used for quiz or test questions or assigned as extra-credit practice. Several questions for each chapter are included.

7. A CD is included with the textbook. The appendices that were previously included in the textbook are now included on the CD. The CD contains:

Appendix A, Glossary, contains important coding terms that are defined and highlighted in a bold font within the book’s chapters.

Appendix B, Abbreviations, is a list includes some common abbreviations for diagnoses, procedures, and tests that a coder is likely to encounter in health records every day. The list is far from complete but highlight basic abbreviations that the coding student should master by the time they complete their first coding course.

Appendix C, Microorganisms, is a reference for use with the chapters most closely aligned with infections, such as Chapters 4, 11, 13, and 15. While obviously not a complete list of all bacteria with the common diseases produced, it may give the student a quick reference for the organism names.

Appendix D, Commonly Used Drugs, is intended to be a quick reference of common medications used for treatment of certain diseases. The fact that a patient is receiving a particular drug may be important information in determining if a diagnosis code should be applied. This appendix includes a suggested exercise for the purpose of learning about commonly used drugs.


Appendix E, Morphology Terminology, should be examined as part of the study of coding neoplasms in Chapter 5. The student could use the list to identify names of malignant neoplasms as opposed to benign neoplasms to help in the assignment of correct codes.

Appendix F, Sample UB-04 and CMS-1500 Billing Forms, should be examined during the coding course to learn where diagnosis codes eventually appear on the forms for the billing process. The UB-04 form is used for institutions such as hospitals, home care agencies, and skilled nursing facilities. The CMS-1500 is used for professional fee billing by physicians and non-physician healthcare providers. Instructors who are not familiar with the billing forms may find assistance through the Medicare website, where complete instructions for each form are located, or through the state's Medicare fiscal intermediary (Part A) or carrier (Part B) websites. Another resource may be the State UB, or Uniform Billing Committee, which is typically coordinated through the state hospital association.

Appendix G, Ethics in Coding, contains the AHIMA Code of Ethics (2004) and the AHIMA Standards for Ethical Coding (2008.) A discussion should occur early in the course instruction to emphasize the student's obligation as a future coding professional to recognize and uphold the ethical standards of correct coding and reporting.

In Appendix H, AHIMA’s “Managing and Improving Data Quality (updated),” AHIMA’s Statement on Quality Healthcare Data and Information, and AHIMA’s Statement on Consistency of Healthcare Diagnostic and Procedural Coding are included to describe the coding professional's role of ensuring accurate, complete, and reliable coded data for a variety of purposes, including research, epidemiology, reimbursement, management and financial planning, quality of care, and outcomes review.

Appendix I contains the most current version of the ICD-9-CM Official Guidelines for Coding and Reporting at of the time of publication of the 2011 version of this book. The updated guidelines are usually released in August or September to be effective October 1 each year can be found at the following website: http://www.cdc.gov/nchs/icd.htm

Appendix J, the ICD-10-CM Official Guidelines for Coding and Reporting, effective 2011.

Appendix K, the ICD-10-PCS Coding Guidelines and Reference Manual


http://www.cdc.gov/nchs/icd.htm

Sequence of textbook chapters for coding courses

The author has used the Basic ICD-9-CM Coding as the textbook for Basic ICD-10-CM/PCS and ICD-9-CM Coding courses in three different formats. Here is how she sequenced the chapters for each type of course:

1. Basic ICD-9-CM Coding: 8-week course, 3 semester-hour credits, class meeting twice a week for 2 hours. Course is required for health information technology (HIT) program and coding certificate program. Students are required to have medical terminology, introductory health information management, and computer basics credit courses as prerequisites classes before the coding class. Both are accredited programs under AHIMA–CAHIIM standards.

Chapter exercises are assigned as homework after some exercises in each chapter are done in class. No class time is used for tests or quizzes other than the final exam. This is an ambitious course outline that has challenged the minimally competent student. Another instructor told me the schedule was workable for an online course with highly motivated students. See more commentary below.

Four quizzes are administered to students in the college’s testing center. Quiz 1 covers chapters 1–3 due at end of week 2. Quiz 2 covers chapters 4–8 due at end of week 3. Quiz 3 covers chapters 9–13 due at end of week 4. Quiz 4 covers chapters 14–17 due at end of week 6. Final exam is comprehensive for chapters 1–23. The typical schedule for this 8-week course is:

Week 1 Class 1: Introduction to course, syllabus review, Chapter 1Class 2: Chapters 2, 3, 4

Week 2 Class 3: Chapter 5Class 4: Chapters 6, 7

Week 3 Class 5: Chapters 8, 9Class 6: Chapter 10

Week 4 Class 7: Chapters 11, 12, 13Class 8: Chapter 14

Week 5 Class 9: Chapters 15, 16, 17Class 10: (usually Thanksgiving holiday)

Week 6 Class 11: Chapters 18, 19Class 12: Chapter 20

Week 7 Class 13: Chapters 21, 22Class 14: Chapter 23, 24

Week 8 Class 15: ReviewClass 16: Final Exam

The weekly outline above is an ambitious schedule. Some classes of students (and instructors) can handle this much information, but other groups of students may not be able to complete it. The author has found that some chapters have to be eliminated or shortened in their presentation to students because of time constraints. For example, the author has shortened the presentation of chapters 15, 16, and 17 and eliminated chapters 21 and 22


during the semesters when students needed more time to absorb the other chapters. This academic year other adjustments will be made to include the new ICD-10-CM and ICD-10-PCS information.

2. Introduction to ICD-9-CM Coding: 12 weeks, no academic credit, class meeting once a week for 3 hours. This was a continuing education course sponsored by an academic medical center for clinic coding and billing personnel. No academic credit was awarded. Students were required to take medical terminology before this course.

This was a “pass-fail” course where students were evaluated based on attendance, short quizzes, and a final examination. A passing score was 70%. The coding exercises provided in the instructor guide for each chapter were used for weekly “Quick Quizzes” in class, allowing about 15 minutes per quiz.

Not all of the chapters in the textbook were used. For example, no instruction was provided for ICD-9-CM procedure coding as the students would be using CPT coding for their professional fee billing. The sequence of chapters was adjusted based on the students’ areas of practice. This is the schedule followed for this continuing education course:

Week 1 Introduction, Chapter 1Week 2 Chapter 18, 23Week 3 Chapters 4, 6Week 4 Chapter 5Week 5 Chapter 7, 10Week 6 Chapter 11, 12Week 7 Chapter 9, 13Week 8 Chapter 14 Week 9 Chapter 16, 17Week 10 Chapter 19Week 11 Chapter 20Week 12 Final ExamNote: Chapters 2, 3, 8, 15, 21, 2, and 24 were not used

3. Introduction to ICD-9-CM Coding: 8 weeks, no academic credit, class meeting once a week for 3 hours. This was a continuing education course offered by a community college. It was intended to serve physician office, home care, long-term care, or other healthcare personnel who already were doing some coding, as well as being an exploratory course for individuals considering enrolling in the college’s coding certificate program. No academic credit was awarded. Students were encouraged to take medical terminology before this course.

This was a continuing education/exploratory course where no student evaluation was performed. Homework was given each week using the chapter exercises and reviewed in the next class. However, the only form of evaluation was a test given the last night of class for the students to perform a “self assessment” of their knowledge and skills. The answers were reviewed by the class. The test was not collected or graded by the instructor.


Not all of the chapters in the textbook were used. The course was not intended to be a comprehensive review of the ICD-9-CM coding system. This is the schedule followed for this continuing education course:

Week 1 Introduction and Chapter 1Week 2 Chapter 18, 23Week 3 Chapters 2, 4, 6Week 4 Chapter 5, 7, 9Week 5 Chapter 10, 11, 22Week 6 Chapter 12, 13, 16Week 7 Chapter 19, 20Week 8 Self assessment test Note: Chapters 3, 8, 14, 15, 17, 21 and 24 were not used.


Student assignments and activities

The following are suggested general student assignments and activities for this text.

1. Have the student search the Internet for information related to each chapter. Most chapters of this instructor guide list some of the better resources available on the Internet if the student's search is unsuccessful.

2. Have the student review the major websitesrelated to ICD-9-CM coding. Require/encourage the student to review the following:

a. AHA Central Office on ICD-9-CM for coding information, coding products, continuing education, and assistance with coding questions in the future when the student may be employed by an AHA-member hospital or other organization.

The Central Office on ICD-9-CM website is http://www.ahacentraloffice.com/ahacentraloffice/index.shtml.

b. AHIMA's website, especially for coding certification (CCA, CCS, CCS-P) examinations, publications for continuing education, and membership for the advantages of student membership. If the student is an AHIMA student member, monitor one of the various coding Communities of Practice (CoPs) located at http://www.ahima.org/.

c. ICD-9-CM Classification home page at the National Center for Health Statistics. Several pages or sites are available that describe ICD-9-CM and ICD-10. A starting point may be http://www.cdc.gov/nchs/icd.htm.

d. The Centers for Disease Control and Prevention’s ICD page contains valuable information, such as an online copy of the ICD-9-CM Official Guidelines for Coding and Reporting, a Conversion Table for all code changes between 1986–2011, and the Addenda, or the annual update to ICD-9-CM. The Data Warehouse is found at http://www.cdc.gov/nchs/icd.htm.

e. The ICD-9-CM Coordination and Maintenance Committee coordinates all updates and changes to the ICD-9-CM system each year. This federal committee is co-chaired by a representative of the National Center for Health Statistics (NCHS) to represent the diagnosis portion and a representative from the Centers for Medicare and Medicaid Services (CMS) to represent the procedure portion of the classification. Proposals for code additions and changes and minutes of the semi-annual meetings can be found at the NCHS (diagnosis code proposals and meeting minutes) and at CMS (procedural code proposals and meeting minutes) websites. Refer the student to http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm.


http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm



http://www.ahima.org/

http://www.ahacentraloffice.com/ahacentraloffice/index.shtml

3. Have the student research new diseases or conditions included in the 20110 ICD-9-CM codebook using the Internet. Areas of interest might be a basic description of the physical condition or problem, treatment/procedure/service required for the condition, along with the code assignment, and any related services that would be coded.

4. There are an endless number of websites available for medical information. The student must be encouraged to rely only on the trusted and proven reliable sites, because anyone can profess to provide medical information. Some reliable sites and resources are listed below.

Medline is a reputable and very useful website. Medline is sponsored by the U.S. National Library of Medicine and the National Institutes on Health and can be found at www.nlm.nih.gov/medlineplus

Other government sites include:http://www.healthfinder.gov/ for a health mega-site sponsored by the government for

consumer health and human services informationhttp://www.nlm.nih.gov/ for the National Institutes of Healthhttp://www.fda.gov/ for the Food and Drug Administrationhttp://www.hhs.gov/ for the Department of Health and Human Serviceshttp://www.cancer.gov/ for the National Cancer Institutehttp://www.drugabuse.gov for the National Institute on Drug Abuse

5. Other mega websites for health information are:http://www.Webmd.com/http://www.healthcentral.com/http://www.medscape.com/http://www.intelihealth.com/ http://www.mayoclinic.com/ , a trusted source of medical information from Mayo Clinichttp://www.oncolink.upenn.edu/ for oncology related topicshttp://ncadi.samhsa.gov/ for the National Clearinghouse for Alcohol and Drug Informationhttp://www.hsph.harvard.edu/for the Harvard University School of Public Healthhttp://www.netwellness.org/ for a non-profit consumer health websitethat is sponsored by Case Western Reserve University, The Ohio State University, and the University of Cincinnati.http://www.nmha.org/ for the National Mental Health Associationhttp://www.lib.uiowa.edu/hardin/md/ for the University of Iowa Hardin Library for the Health Scienceshttp://www.hon.ch for the Health on the Net Foundation, a Swiss foundation that has become one of the most respected not-for-profit portals to medical information on the Internet. The foundation sponsors the “HON Code of Conduct” to acknowledge a site’s provision of trustworthy, authoritative Web-based medical information.www.google.com/health for Google Health’s website, which provides a site for the healthcare consumer to organize their personal health information.http://www.vh.org for the Virtual Hospital, a digital library of health information After 13 years of service, on January 1, 2006, Virtual Hospital/Virtual Children's Hospital, the


http://www.vh.org/

http://www.google.com/health

http://www.hon.ch/

http://www.lib.uiowa.edu/hardin/md/

http://www.nmha.org/

http://www.netwellness.org/

http://www.hsph.harvard.edu/

http://ncadi.samhsa.gov/

http://www.oncolink.upenn.edu/

http://www.mayoclinic.com/

http://www.intelihealth.com/

http://www.medscape.com/

http://www.healthcentral.com/

http://www.webmd.com/

http://www.drugabuse.gov/

http://www.cancer.gov/

http://www.hhs.gov/

http://www.fda.gov/

http://www.nlm.nih.gov/

http://www.healthfinder.gov/

Internet's first medical websites, ceased operations after serving over 80 million users, due to a lack of funding. But a web page remains with valuable links to other sites and services at http://www.uihealthcare.com/vh/ .

Medical news sites and online medical journals provide additional information. Reputable sites include the Journal of the American Medical Association (http://jama.ama-assn.org/) the New England Journal of Medicine (http://www.nejm.org/), and Reuters Daily Medical News (http://www.reutershealth.com/).

6. For general anatomy and physiology, a good websiteexists for students to review:http://www.getbodysmart.com/index.htm


http://www.getbodysmart.com/index.htm%20

http://www.reutershealth.com/

http://www.nejm.org/

http://jama.ama-assn.org/

http://www.uihealthcare.com/vh/

Introduction to ICD-9-CMThis lesson will focus on the following topics:

An introduction to ICD-9-CM coding Review of current and future ICD-9-CM coding systems and HIPAA-designated code sets

ObjectivesAfter completing this chapter, the student should be able to:

Define coding and key terms related to coding Compare the current ICD-9-CM and the proposed ICD-10-CM and ICD-10-PCS coding

systems Identify the designated code sets to be used under the HIPAA rule Describe the Official Addendum to ICD-9-CM and identify the effective date of yearly code

changes

Suggested Student Activities

1. Require students to use the Internet to locate key ICD-9-CM websitesincluding the American Hospital Association, American Health Information Management Association, National Center for Health Statistics, and the Centers for Medicare and Medicaid Services.

Key Points for Lecture Notes1. The “Introduction” gives a history of coding and classification, the future prospects of ICD-

10-CM, and the current standards under the HIPAA electronic transactions and coding standards rules.

2. Review the current status of ICD-10-CM and ICD-10-PCS with the students and discuss the implementation in terms of the HIPAA rule. Each chapter contains an introduction to ICD-10-CM and ICD-10-PCS and could be used for beginning instruction on the two new coding systems. The following website contains official information about ICD-10-CM and its implementation: http://www.cdc.gov/nchs/icd.htm or www.cdc.gov/nchs/icd/icd10cm.htm.

The following website contains official information about ICD-10-PCS and its implementation: http://www.cms.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp.

3 Introduce the student to the purpose of the ICD-9-CM Official Guidelines for Coding and Reporting, which appears in Appendix I of the textbook.

4. No exercises are included in this chapter.

Copyright © 2012 by the American Health Information Management Association. All Rights Reserved.

10

http://www.cms.gov/ICD9ProviderDiagnosticCodes/08_ICD10.asp

http://www.cdc.gov/nchs/icd/icd10cm.htm


Chapter 1

Characteristics of ICD-9-CMThis lesson will focus on the following topics:

Characteristics of ICD-9-CM Basic steps in ICD-9-CM coding

Learning ObjectivesAt the conclusion of this chapter, the student should be able to:

1. Identify the characteristics of the ICD-9-CM classification system2. Describe the format of volume 1, Tabular List of Diseases and Injuries3. Identify and define the sections, categories, subcategories, residual

subcategories, and fifth-digit subclassifications used in ICD-9-CM4. Identify the two supplementary classifications within ICD-9-CM5. Identify the contents of the Appendices of ICD-9-CM6. Describe the format of volume 2, Alphabetic Index to Diseases7. Identify and define the main terms, subterms, carryover lines, nonessential

modifiers, and eponyms used in ICD-9-CM and ICD-10-CM.8. Explain how to accommodate the fact that all terms located in the Alphabetic

Index are not included in the Tabular List9. Identify and define the cross-reference terms and instructional notes used in

ICD-9-CM and ICD-10-CM.10.Describe the rules for multiple coding11.Explain how connecting words are used in the Alphabetic Index12.Define the symbols, punctuations, and abbreviations used in ICD-9-CM and ICD-

10-CM.13.List the basic steps in ICD-9-CM and ICD-10-CM coding14. Assign diagnosis codes using the Alphabetic Index and Tabular List15.Identify the main differences between the ICD-9-CM and ICD-10-CM systems for

diagnosis coding. 16. Describe the characteristics and conventions of the ICD-10-CM system.


1. Require students to use the Internet to locate key ICD-9-CM and ICD-10-CM/PCS websitesincluding the American Hospital Association, American Health Information Management Association, National Center for Health Statistics, and the Centers for Medicare and Medicaid Services.

2. Require students to read the Introduction to ICD-9-CM, which appears on many publishers' versions of the ICD-9-CM code book.


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3. Require students to completely familiarize themselves with the organization of the ICD-9-CM code book so that the student is comfortable locating the Alphabetic Index to Diseases, the Table of Drugs and Chemicals, the Alphabetic Index to External Causes, the Disease Tabular, the Procedure Index, the Procedure Tabular, and the Appendices.

4. Encourage students to read or view everything possible about medical science, such as medical articles in local papers or science- and medicine-based television programs, including cable television stations like the Discovery Channel. Furthering their understanding of medicine will enable the students to be better coders.

5. Encourage students to reread their medical terminology textbooks. The terminology might be more meaningful as they begin to practice coding.

Key Points for Lecture Notes

1. Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter. Handouts of the slides (6 to a page) can be printed for distribution to students as the photocopying budgets permit.

2. Take time to completely review Chapter 1, Characteristics of ICD-9-CM, because it forms the foundation for all coding studies to follow. Work through some of the questions in the coding exercises to help student become familiar with the content and the structure of ICD-9-CM.

3. Practice identifying main terms to be used with the Alphabetic Index. Emphasize that main terms represent the patient's problem, such as a disease, condition, or complaint, and not the body part or organ affected.

4. Emphasize the importance of looking up the code in the Tabular List and reading the instructional notations. Demonstrate the correct use of the Includes notes and the Excludes notes.

5. Emphasize the importance of using all fourth or fifth digits when applicable.

6. Review examples of inclusion terms under the 3-, 4-, and 5-digit codes that describe other phrases or conditions that have the same meaning as the title of the code. Instruct the student that all possible phrases will not appear as inclusion terms in the Tabular. There are many more entries in the Index than appear in the Tabular List as code titles or inclusion terms. Emphasize the importance of trusting and following the Alphabetic Indexes and the hazards of selecting a code simply by searching through the Tabular List for what might appear to be appropriate.

7. Review the relationship between ICD-9-CM and CPT coding systems: diagnosis coding versus procedure coding.


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8. Inform the student of the persons authorized to form a diagnosis (licensed physician or other healthcare provider) and the importance of documentation in the health record to support the diagnosis made.

9. Take time to review the exercises 1.1-1.11 and the review exercises at the conclusion of the chapters with the students to reinforce the basic coding concepts presented in this chapter.

10. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM.

Chapter 1 Review Questions

Instructions: Fill in the answer, complete the matching, or choose the best answer among the multiple-choice options for the following questions.

1. What is the complete description of the abbreviation ICD-9-CM? International Classification of Diseases, 9th Revision, Clinical Modification

2. Matching: Identify whether each ICD-9-CM classification listed below is a chapter, section, category, subcategory, or fifth-digit subclassfication code.A. ChapterB. SectionC. CategoryD. SubcategoryE. Fifth-digit subclassification

__A___ Disease of the Respiratory System (460–519)

__B___ Pneumonia and Influenza (480–487)

__C___ Emphysema (492)

__D___ Acute Bronchitis (466.0)

__E___ Stenosis of Larynx (478.74)

__A___ Neoplasms (140–239)

__B___ Benign Neoplasms (210–229)

__C___ Lymphoid Leukemia (204)

__D___ Malignant Neoplasm of Pancreas, Head of Pancreas (157.0)


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__E__ Multiple Myeloma without mention of remission (203.00)

3. What does the “E” stand for in codes E800–E999?External Causes of Injury and Poisoning

4. Underline the main term for each diagnosis and procedure and identify where the main term is found in volumes 1, 2 or 3.

a. Comminuted fracture of radiusDisease Index: Fracture

b. Carotid artery occlusionDisease Index: Occlusion

c. Double right uretersDisease Index: Double

d. Acute myocardial infarctionDisease Index: Infarction

e. Alcoholic cardiomyopathyDisease Index: Cardiomyopathy or Alcoholic

f. Enlargement of liverDisease Index: Enlargement

g. Admission for chemotherapyDisease Index: Admission (for) or Chemotherapy

h. Benign prostatic hypertrophyDisease Index: Hypertropy

i. Endometrial ablationProcedure Index: Ablation

j. Extracorporeal shockwave lithotripsyProcedure Index: Extracorporeal or Lithotripsy

k. Carpal tunnel neurolysisProcedure Index: Neurolysis

l. Ventriculo-abdominal shuntProcedure Index: Shunt

m. Aortocoronary bypass graftProcedure Index: Bypass graft


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ICD-10-CM Review Questions

1. What do the characters of a seven character ICD-10-CM diagnosis represent?

First three characters are the three-character category code that identifies the disease. Characters four, five and six are used to identify the etiology, anatomic site or severity of the disease. The seventh character, or extension, describes more specific information about a particular code.

2. What is the purpose of the placeholder character “X” used in ICD-10-CM?

The placeholder X has two purposes:a. The X provides for future expansion without disturbing the overall code

structure.b. When a code has less than six characters and a seventh character extension is

required, the X is assigned for all characters less than six in order to meet the requirements of coding to the highest level of specificity.

3. What are the two previous supplementary classification chapters that are included in the core classification in ICD-10-CM?

a. External Causes of Injury and Poisonings, previously known as E codes in ICD-9-CM.

b. Factors Influencing Health Status and Contact with Health Services, previously known as V codes in ICD-9-CM.

4. What are the abbreviations used in ICD-10-CM?

a. ICD-10-CM uses the same abbreviations with the same definitions as ICD-9-CM:

i. NEC: not elsewhere classifiedii. NOS: not otherwise specified

5. What punctuation marks are used in ICD-10-CM?

a. The same punctuations used in ICD-9-CM appear in ICD-10-CMi. Brackets [ ]

1. Used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.

ii. Parentheses ( )1. Used in both Alphabetic Index and Tabular List to enclose

supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code numbers to which they are assigned. The terms within the parentheses are referred to as “nonessential modifiers.”


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iii. Colon :1. Used in the Tabular List after an incomplete term that needs one

or more modifiers following the colon to make it assignable to a given category

6. What are the Instructional Notes contained in ICD-10-CM?

a. Includes Notes clarify the conditions included within a particular chapter, section, category, subcategory, or code

b. Exclusion Notesi. Excludes1 note is a pure excludes notes and mean “not coded here”. It

indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.

ii. Excludes2 note means “note included here” and means the condition excluded is not part of the condition represented by the code, but a patient with both conditions at the same time may have both codes assigned.

7. What does “And/With” and “With” mean in ICD-10-CM?

a. The word “And” should be interpreted to mean “and/or” when it appears in a code title in ICD-10-CM Tabular List.

b. The word “With” should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetic Index or in an instructional note in the Tabular List. The term “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order.

8. How is the Alphabetic Index organized in ICD-10-CM?

Two parts: The Index to Diseases and Injury and the Index to External Causes of Injury. Similar to ICD-9-CM, with the Index to Diseases and Injury, there is a Neoplasm Table and a Table of Drugs and Chemicals. The Alphabetic Index is formatted the same way as the Index in ICD-9-CM. Main terms set in boldface are listed in alphabetic order. Indented beneath the main term are applicable subterm or essential modifiers in alphabetic order. The Alphabetic Index includes both “See” and “See Also” instructions following the main term to indicate another term should be referenced. A “Code Also” note appears in ICD-10-CM meaning that two codes may be required to fully describe a condition. ICD-10-CM refers to the code listed next to the main term in the Alphabetic Index as the “default code” or the condition that is most commonly associated with the main term or is the unspecified code for the condition.

9. What are the basic steps in ICD-10-CM coding?

a. Identify all main terms included in the diagnostic statementb. Locate each main term in the Alphabetic Index


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c. Refer to any subterms indented under the main term. The subterms form individual line entries and describe essential differences by site, etiology, or clinical type

d. Follow cross-reference instructions if the needed code is not located under the first main entry consulted

e. Verify the code selected in the Tabular Listf. Read and be guided by any instructional terms in the Tabular Listg. Assign codes to their highest level of specificity, up to a total of seven characters

if applicableh. Continue coding the diagnosis statement until all the component elements are

fully identified.


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Chapter 2

ProceduresThis lesson will focus on the following topics:

Volume 3 of ICD-9-CM Content and outline of the Alphabetic Index to Procedures and the Tabular List of Procedures ICD-9-CM conventions in Volume 3 Coding open, endoscopic, completed, canceled, incomplete, or failed procedures Selection of principal and secondary procedure codes


1. Describe the content and purpose of volume 3 in ICD-9-CM2. Identify the healthcare setting in which ICD-9-CM volume 3 codes are used3. Explain the classification used to organize the chapters in ICD-9-CM volume 34. Describe the format of the ICD-9-CM Tabular List and the procedure codes5. Describe the format of the ICD-9-CM Alphabetic Index6. Identify and define the main terms, subterms, connecting words, and eponyms

used in the Alphabetic Index of ICD-9-CM volume 37. Identify and define the conventions used in Alphabetic Index of ICD-9-CM

volume 38. Explain the basic instructions for ICD-9-CM procedural coding9. Assign procedure codes using the Alphabetic Index and Tabular List of ICD-9-

CM volume 310. Compare and contrast ICD-9-CM procedure codes with ICD-10-PCS codes.11. Explain the ICD-10-PCS code structure12. Understand the overall organization of ICD-10-PCS13. Understand the ICD-10-PCS attributes, characteristics and definitions14. Describe the ICD-10-PCS components and table structure15. Describe the Medical and Surgical Section16. Explain the basic instructions for ICD-10-PCS codes17. Assign ICD-10-PCS codes for procedure statements


1. Review the CMS website for current information about ICD-9-CM procedure codes.

2. Review the CMS website for current information about the proposed ICD-10-PCS coding system.

3. Make a list of every surgical procedure the students have experienced, that their family members or friends have experienced, or that they have heard described in the media. After


18

the completion of the chapter exercises, these procedures can be used as additional exercises to practice using Volume 3 of ICD-9-CM. This exercise will also help students identify the correct medical terminology for procedures and give students additional practice using the Alphabetic Index to Volume 3 to locate procedure codes.

4. Identify the physician specialties that perform surgical procedures: for example, general surgery, orthopedic surgery, neurosurgery, cardiothoracic surgery, ear-nose-throat, ophthalmology, podiatry, and gynecology. Students may simply use the local yellow pages to identify the branches of medicine or access the websiteof a local hospital to search for physicians by specialty.

5. Encourage students to read or view everything possible about medical science, such as Discovery channel or other cable stations with science or medical programs. Furthering their understanding of medicine will enable the student to be a better coder.

6. Encourage students to reread their medical terminology textbooks, especially the portion related to surgical procedures or terminology.


1. Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter. Handouts of the slides (6 to a page) can be printed for distribution to students as photocopying budgets permit.

2. Describe the users of Volume 3 procedure codes for inpatient coding in institutions and facilities. Briefly compare ICD-9-CM with the CPT coding system used by physicians and other healthcare providers.

3. Practice identifying main terms for the Alphabetic Index to Procedures. Main terms are generally “action” words, such as procedure or operation medical terms or verbs, describing what action is being performed.

4. Emphasize the importance of reading the “code also” notes to identify when additional surgical procedure codes are required.

5. Emphasize the importance of reading the “omit code” instructions for exploratory portions of a procedure, the usual surgical approach, the routine lysis of adhesions, and the closure of the procedure.

6. Describe what is meant by an “open” procedure that requires an incision, a percutaneous procedure (entering through the skin), and an endoscopic procedure that uses a device such as a laparoscope or arthroscope.

7. Describe the use of an “open” procedure code when a separate endoscopic code is not available. In this instance, no code is assigned to describe the fact an endoscope was used, but rather, the definitive procedure is coded.


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8. Describe how to code an endoscopic procedure that is converted to an open procedure.

9. Review the V64 Category within the disease portion of ICD-9-CM and describe when subcategory codes V64.1 through V64.4 are used.

10. Review the rules, using examples, for coding canceled procedures, coding incomplete procedures, and coding failed procedures.

11. Emphasize how to code biopsy procedures performed percutaneously, endoscopically, or with a needle; how to code biopsy procedures when performed with a more extensive surgical procedure; and the required sequencing of the codes.

12. Depending on the objectives of the course using this textbook, review the ICD-10-PCS introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM Volume 3.


Instructions: Choose the best answer for each of the following questions.

1. ICD-9-CM procedure codes are required to be used to code patients in which of the following settings? Check all that apply.

__X___ Hospital inpatient settings______ Physician offices______ Hospital outpatient departments______ Hospital emergency departments

2. What is the maximum number of digits in a valid ICD-9-CM procedure code?______ Two______ Three___X__ Four______ Five

3. Underline the main term for each procedure:

a. Percutaneous biopsy of prostateProcedure Index: Biopsy

b. Laparoscopic appendectomyProcedure Index: Appendectomy

c. Exploratory laparotomy of abdomenProcedure Index: Laparotomy


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d. Suture repair of laceration of footProcedure Index: Suture or Repair

e. Closed reduction of fracture of left radiusProcedure Index: Reduction

4. Code the following procedures with ICD-9-CM procedure code(s):

a. Mayo bunionectomy 77.59

b. Esophagogastroduodenoscopy with closed biopsy 45.16

c. Ventral herniorrhaphy 53.59

d. Open biopsy of breast 85.12

e. Transfusion of packed cells 99.04

f. Laparoscopic cholecystectomy converted to open51.22 [Remind students that diagnosis code V64.41 must be used as an additional diagnosis code with the patient’s diagnosis codes.]

g. Flexible sigmoidoscopy completed after colonoscopy elected not to be performed

45.24

h. Low cervical Cesarean delivery 74.1

i. Moh's chemosurgery of skin 86.24

j. Tonsillectomy for chronic tonsillitis canceled due to patient having acute tonsillitis on the day of surgery. (Diagnosis codes only as no procedure was performed.)

474.00, 463 [Diagnosis code V64.1, must be used to indicate that the procedure was cancelled due to the contraindication of acute tonsillitis. Note-there is no procedure code assigned because no procedure was performed.]


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ICD-10-PCS Review Questions

1. How does ICD-10-PCS compare to ICD-9-CM Volume 3 codes?

ICD-9-CM vs. ICD-10-PCSICD-9-CM volume 3 follows the structure of the ICD-9-CM diagnosis codesICD-9-CM codes are a fixed or finite set in list formICD-9-CM codes are numericICD-9-CM codes are 3-4 digits long

ICD-10-PCS codes were designed as a procedure code systemCodes are constructed from flexible code components or values using tablesCodes are alphanumericAll ICD-10-PCS codes are seven characters long

2. What are the seven characters of the ICD-10-PCS codes?

a. Character 1 = Sectionb. Character 2 = Body systemc. Character 3 = Root operationsd. Character 4 = Body parte. Character 5 = Approachf. Character 6 = Deviceg. Character 7 = Qualifier

See page 51–52 for the text book for definitions

3. What is the overall organization of ICD-10-PCS?

a. ICD-10-PCS is composed of 16 sections, represented by numbers 0 through 9 and letters B through D and F through H.

b. The 16 sections are contained in three main sections: Medical and Surgical section, Medical and Surgical-related section and Ancillary Section

c. The first section, Medical and Surgical section, contains the majority of procedures typically reported in an inpatient setting. All procedure codes in this section begin with the value of “0”(zero)

d. The Medical and Surgical related sections contains section values 1 through 9 for obstetrics, placement, administration, measurement and monitoring, extracorporeal assistance and performance, extracorporeal therapies, osteopathic, other procedures and chiropractic.

e. The Ancillary section contains section values B through D and F through H for such procedures as imaging, nuclear medicine, radiation oncology, physical rehabilitation and diagnostic audiology, mental health and substance abuse treatment.


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4. What are the root operations in ICD-10-PCS?

a. The third character in the Medical and Surgical section is the root operations. There are a total of 31 root operations divided into nine groups that share similar attributes.

i. Procedures that take out some/all of a body part1. Excision, resection, detachment, destruction and extraction

ii. Procedures that take out solids/fluids/gases from a body part1. Drainage, extirpation and fragmentation

iii. Procedures involving cutting or separation only1. Division and release

iv. Procedures that put in/put back or move some/all of a body part1. Transplantation, reattachment, transfer, and reposition

v. Procedures that alter the diameter/route of a tubular body part1. Restriction, occlusion, dilation and bypass

vi. Procedures that always involve a device1. Insertion, replacement, supplement, change, removal and revision

vii. Procedures that involve examination only1. Inspection and map

viii. Procedures that include other repairs1. Repair and control

ix. Procedures that include other objectives1. Fusion, alteration, and creation

5. How does ICD-10-PCS define “approach” and what are the approaches identified?

a. Approach is the technique used to reach the site of the procedure. For the Medical and Surgical section there are seven different approaches:

i. Openii. Percutaneous

iii. Percutaneous endoscopiciv. Via natural or artificial openingv. Via natural or artificial opening endoscopic

vi. Via natural or artificial opening endoscopic with percutaneous endoscopic assistance

vii. External

6. How does ICD-10-PCS define “ device” as the sixth character in the Medical and Surgical section?

a. The device is specified in the sixth character and is only used to specify devices that remain after the procedure is completed. There are four general types of devices”

i. Biological and synthetic material that takes the place of all or a portion of a body part

ii. Biological or synthetic material that assists or prevents a physiological function


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iii. Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part

iv. Mechanical or electronic appliances used to assist, monitor, take the place of or prevent a physiological function

7. How is an ICD-10-PCS code assigned?

a. An ICD-10-PCS code is constructed by assigning values for each of the characters. b. The procedure term is referenced in the Index. The main terms in the Index can be

either root operation phrases, such as resection, with a subterm gallbladder, or a common procedure term, such as cholecystectomy.

c. The Index will usually give the coder the first 3 characters of the ICD-10-PCS code.d. The next step is to access for the 3 character code, such as 0FT, in the PCS book.e. Using the following, the remaining 4 characters are assigned. The values for each of

the characters must be from the same rowf. For example, a laparoscopic total cholecystectomy would have the first 3 characters

of 0FT, with body part 4 being gallbladder (value 4), approach percutaneous endoscopic (value 4), no device (value Z) and no qualified (value Z) for a complete code of 0FT44ZZ.

Additional ICD-10-PCS Review Exercises

1. Sigmoidoscopy with sigmoid polypectomya. 0DBN8ZZ Excision, Colon, Sigmoid (0BDN)

2. Percutaneous needle biopsy of right breasta. 0HBT3ZX Excision, breast, right (0HBT)

3. Right ankle joint amputationa. 0Y6M0Z0 Detachment foot, right (0Y6M0Z)

4. Cryotherapy of three warts on left handa. 0H5GXZD Destruction skin hand left (0H5GXZ)

5. Non-excisional debridement of skin ulcer on backa. 0HD6XZZ Extraction skin back (0HD6XZZ)\

6. Incision and drainage of external perianal abscessa. 0D9QXZZ Drainage anus (0D9Q)

7. Forceps removal foreign body left nostrila. 09CKXZZ Expiration, nose (09CK)

8. ESWL left uretera. 0TF7XZZ Fragmentation, ureter, left (0TF7)

9. Right shoulder arthroscopy with coracoacromial ligament releasea. 0MN14ZZ Release bursa and ligament, shoulder right

10. Open fracture reduction, displaced fracture right humeral heada. 0PSC0ZZ Reposition humeral head right


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Chapter 3

Introduction to the Uniform Hospital Discharge Data Set and Official Coding Guidelines

This lesson will focus on the following topics:

Uniform Hospital Discharge Data Set (UHDDS) Uniform Bill-04 (UB-04) Selection of principal diagnosis Reporting of other or additional diagnoses


1. Describe the purpose of the Uniform Hospital Discharge Data Set and identify its data elements

2. Define the terms principal diagnosis, other diagnoses, complication, comorbidity, significant procedure, and principal procedure

3. Identify the number of ICD-9-CM diagnosis and procedure codes that can appear on the Uniform Bill-04

4. Explain the purpose of the “present on admission” indicator with diagnosis codes

5. Understand the ICD-9-CM Official Guidelines for Coding and Reporting guidelines for selecting the principal diagnosis for inpatient care and reporting of additional diagnoses

Special Note to Instructors: This chapter could be eliminated from a basic coding course, especially if the students in the coding program are being prepared for physician-based coding positions and are not likely to use ICD-9-CM Volume 3 codes. UHDDS and UB-04 information is related to hospital coding and may be of limited value to coders outside of hospitals.

Another alternative might be to review this chapter at the end of a basic coding course to introduce the concepts of UHDDS, UB-04 and the definitions of principal and secondary diagnoses. Time may be better spent on the principles of coding for the majority of introductory courses.


1. Review the National Center for Health Statistics or the CMS websitefor current information about the Uniform Hospital Discharge Data Set (UHDDS).


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2. Review the ICD-9-CM Official Guidelines for Coding and Reporting, especially Section II, Selection of Principal Diagnosis and Section III, Reporting Additional Diagnosis. Remember that UHDDS definitions were most recently published in the July 31, 1985 Federal Register (Volume 50, Number 147). Since that time, the application of the UHDDS definition has been expanded to include all nonoutpatient settings (acute care, short term, long-term, and psychiatric hospitals; home health agencies; rehab facilities, nursing homes, etc.) Remember, the definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits.

3. Locate the websitefor the National Uniform Billing Committee and determine the organization within the state for coordinating the UB-04 locally.

4. Review the CMS websitefor various Medicare prospective payment systems, for example, acute care short term hospitals, skilled nursing facilities, home care agencies, rehabilitation units or hospitals.


Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter. Handouts of the slides (6 to a page) can be printed for distribution to students as photocopying budgets permit.

1. Describe the purpose of the UHDDS.

2. Locate the UHDDS data elements on the UB-04 form.

3. Work through the examples of the selection of principal diagnosis, using its definition and the Official Coding Guidelines. Emphasize the aspect of "established after study to be chiefly responsible" as part of the definition.

4. Review the description of “most significant diagnosis” and compare it to the definition of principal diagnosis.

5. Depending on the objectives of the course using this textbook, review the ICD-10-CM Official Guidelines for Coding and Reporting, and compare how similar these guidelines are written in comparison to the existing ICD-9-CM coding guidelines. http://www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf.


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http://www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf


There are no review questions for this chapter in the Instructor’s Guide. There are 22 questions in the review exercises at the end of chapter 3 in the textbook.


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Chapter 4

Infectious and Parasitic Diseases This lesson will focus on the following topics:

Coding of communicable, infectious, and parasitic diseases Common diseases such as tuberculosis and septicemia Coding of the late effects of infectious and parasitic diseases Differentiating between HIV infection, HIV disease, and AIDS for coding purposes


1. Describe the organization of the conditions and codes included in chapter 1 of ICD-9-CM, Infectious and Parasitic Diseases (001–139.)

2. Describe the organization of the conditions and codes included in chapter 1 of ICD-10-CM, Certain infectious and parasitic diseases (A00–B99).

3. Define the term combination codes as it pertains to ICD-9-CM and ICD-10-CM.4. Explain how the etiology/manifestation convention applies to chapter 1 codes in both ICD-9-CM and ICD-10-CM.

4. Explain the circumstances in which codes from ICD-9-CM categories 041 and 079 are used

5. Explain the circumstances in which codes from ICD-10-CM categories B95-B97 are used

6. Define and explain the differences among the following terms: Bacteremia Septicemia Systemic Inflammatory Response Syndrome Sepsis Severe sepsis Septic shock Human immunodeficiency infection Human immunodeficiency disease

7. Understand the coding guidelines for human immunodeficiency Infection (HIV) disease reporting

8. Assign diagnosis codes for infectious and parasitic diseases

Special Note to Instructors: This is a short chapter that emphasizes the coding of common infectious conditions such as tuberculosis, septicemia and severe sepsis, and HIV infection and related disease. Only one set of exercises is included in the chapter for ICD-9-CM.



28

1. Locate the reputable websitesfor infectious and parasitic diseases, such as the Centers for Disease Control and Prevention (CDC) (http://www.bt.cdc.gov/) for public health emergency preparedness and response for anthrax and smallpox, the Association for Professionals in Infection Control and Epidemiology (http://www.apic.org/), HIV InSite (http://hivinsite.ucsf.edu/), Journal of American Medical Association HIV/AIDS information page, and the USFDA AIDS and AIDS activities sites.

2. Determine what information is available at your state or city government's public health department regarding the reporting of communicable diseases. If there is a mandated reportable list, assign ICD-9-CM diagnosis codes to the conditions listed.


1. Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter.

2. Review the Official Coding Guidelines for chapter-specific guidelines, Section I, Part C1, A for human immunodeficiency virus (HIV) infections.

3. Emphasize what is needed to code infectious and parasitic diseases:

a. Body site when infection is present

b. Severity of disease: acute or chronic

c. Specific bacterial, viral, or other organism involved

d. Etiology of infection, such as food poisoning or insect bite

e. Associated signs, symptoms, and manifestations of the disease

4. Examine combination codes within the chapter that identify the condition and the causative organism, such as candidiasis (category 112) or trichomoniasis (category 131). Note the inclusion of many venereal diseases within this chapter.

5. Emphasize the mandatory multiple coding as identified in the Alphabetic Index of Disease through the use of two codes, with the manifestation listed in slanted brackets. Remind students of the coding convention regarding slanted brackets: use both codes and list in the same sequence as listed in the Alphabetic Index.

6. Review the use of the main term “Infection” to locate additional codes to identify the bacterial or viral organism to be used with codes assigned for specific diseases, such as urinary tract infection.


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http://hivinsite.ucsf.edu/

http://www.apic.org/

http://www.bt.cdc.gov/

7. Refer and read with the students the “Note” under Category 041 for the intent of the use of this code. Emphasize that category 041 is most commonly used as a secondary code and not for primary tabulation.

8. Refer and read with the students the “Note” under Category 079 for the intent of the use of this code. In comparison to category 041, codes from this category can be used as the first listed code because of the nature of the illness. For example, viral syndrome, a common phrase found in primary care and emergency medicine, is coded to 079.99 because the phrase lacks specificity as to the location and exact nature of the illness.

9. Review the evolving terminology of sepsis, severe sepsis, septicemia, and septic shock, and the codes for each condition.

10. Read Coding Clinic's description of the SIRS codes in Fourth Quarter 2002, page 71–73. Also read Coding Clinic's article in Fourth Quarter, 2003, pp. 79–81, for further clarification.

11. Review the Official Coding Guidelines for chapter-specific guidelines, Section I, Part C1, B for septicemia, systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock . These guidelines have been updated since the Coding Clinic articles were published in 2002 and 2003.

12. Emphasize the difference between codes V08 for asymptomatic HIV infection and 042 for human immunodeficiency virus (HIV) disease.

13. Review how records with qualified statements, such as suspected AIDS or possible HIV infection must be returned to the physician for clarification in any healthcare setting. The practice of coding “probable-possible-questionable” for inpatient records as if the condition is confirmed does not apply to HIV infection or HIV disease.

14. Review the coding and sequencing guidelines for HIV disease.



Code the following with ICD-9-CM diagnosis codes:

1. Gram negative septicemia038.40

2. Enteritis due to rotavirus008.61


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3. Postmeasles pneumonia055.1

4. Candidiasis of mouth112.0

5. Head lice132.0

6. Reiter's Disease with arthropathy099.3, 711.10

7. Chickenpox, uncomplicated052.9

8. Condyloma acuminatum078.11

9. Respiratory syncytial virus (RSV)079.6

10. Salmonella gastroenteritis003.0


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1. What word has replaced “septicemia” in ICD-10-CM Chapter 1?

Sepsis

2. How many codes does “severe sepsis” require in ICD-10-CM?

Two ICD-10-CM diagnosis codes: (1) code for the underlying systemic infection and (2) code from category R65.2, severe sepsis.

3. Can the diagnosis of “possible” HIV infection be coded in ICD-10-CM?

No, only confirmed cases of HIV infection or illness are coded. Patients with inconclusive laboratory evidence of HIV are coded with another code, R75.

4. How would bacterial infections resistant to current antibiotics be coded in ICD-10-CM?

Code Z16, Infection with drug resistant microorganisms is coded following the infection code for a patient with a current infection with an antibiotic resistance.

5. What do ICD-10-CM categories B95–B97 represent?

Categories B95–B97 are provided for use as an additional code to identify the infectious agent(s) in diseases classified elsewhere, such as;

B95: Streptococcus, Staphylococcus and EnterococcusB96: Other bacterial agentsB97: Viral agents

These categories in ICD-10-CM are similar to the ICD-9-CM categories 041 and 079.


1. Gram negative septicemiaA41.50

2. Enteritis due to rotavirusA08.0

3. Postmeasles pneumoniaB05.2

4. Candidiasis of mouthB37.0

5. Head liceB85.0


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6. Reiter's Disease with arthropathyM02.30

7. Chickenpox, uncomplicatedB01.9

8. Condyloma acuminatumA63.0

9. Respiratory syncytial virus (RSV)B97.4

10. Salmonella gastroenteritisA02.0


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Chapter 5

NeoplasmsThis lesson will focus on the following topics:

Classification of all types of neoplasms: malignant, benign, uncertain behavior, and unspecified nature

Instructions on the use of the Alphabetic Index Neoplasm Table Determination of the primary and secondary site(s) of malignant neoplasms Role of morphology codes The use of V codes to describe certain patients with current or past neoplastic disease


1. Describe the organization of the conditions and codes included in chapter 2 of ICD-9-CM, Neoplasms (140–239)

2. Describe the organization of the conditions and codes included in chapter 2 of ICD-10-CM, Neoplasms

3. Define the term neoplasm4. Identify the three criteria used to classify neoplasms5. Define the seven specific types of neoplasm behavior6. Describe the organization of the neoplasm table in ICD-9-CM and ICD-10-CM 7. Explain the purpose of morphology codes8. Understand the guidelines for using ICD-9-CM V codes to describe patients with neoplasms9. Understand the guildeines for using ICD-10-CM Z codes to describe patients with neoplasms10. Describe how to use the Alphabetic Index and Tabular List to locate a neoplasm code11. Define and explain the terms primary site and secondary site for a neoplasm12. Identify the purpose of the asterisk (*) in the ICD-9-CM neoplasm table13. Identify the purpose of the dash (-) in the ICD-10-CM neoplasm table14. Define the term contiguous sites and explain how ICD-9-CM and ICD-10-CM accommodates the

coding of them15. Describe how to code a primary malignant neoplasm according to its site16. Describe how to code a secondary malignant neoplasm according to its site17. Explain the differences among the following phrases and how they are coded:

metastatic from metastatic to direct extension to spread to extension to

18. Explain how to code a condition that describes a metastatic neoplasm of one site19. Identify the ICD-9-CM codes for neoplasm-related pain20. Assign ICD-9-CM diagnosis and procedure codes for neoplasms21. Assign ICD-10-CM codes for neoplasms


34

Special Note to Instructors: This can be a difficult chapter for students to grasp. Take time to review the Table of Neoplasms closely, including the boxed note at the beginning.


1. Review Appendix E on the CD-Rom that accompanies the textbook for morphology terminology.

2. Review reputable scientific websitesregarding cancer and prevention, such as the American Cancer Society, the Harvard Center for Cancer Prevention, the National Cancer Institute, the National Institutes of Health, and various cancer centers, such as the Dana-Farber Cancer Institute, M.D. Anderson Cancer Center, or Memorial Sloan-Kettering Cancer Center. For example, www.cancer.gov or www.oncolink.upenn.edu for oncology- related topics.



2. Review the Official Coding Guidelines for chapter-specific guidelines related to neoplasms. See Section I, Part C2, Neoplasms, and Part C6, Diseases of the Nervous System and Sense Organs, for classifying neoplasms and neoplasm-related pain.

3. Emphasize the criteria used to classify neoplasms:

a. Behavior of the neoplasm, such as malignant or benignb. Anatomical site involvedc. Morphology type, such as carcinoma, leukemia, melanoma

4. Review the Neoplasm Table in ICD-9-CM with the students, including the listing of anatomical sites, the seven columns, and the use of the asterisk as described in the boxed note at the beginning of the table. Review the “Notes” box that appears on the first page of the Neoplasm Table. Pay particular attention to the second point “Sites marked with the sign * (e.g., face NEC*) should be classified to malignant neoplasm of skin of these sites if the variety of neoplasm is squamous cell carcinoma or an epidermoid carcinoma, and to benign of skin of these sites if the variety of neoplasm is a papilloma (any type).

5. Review the purpose of the Morphology Codes (M codes). Locate the M codes in the ICD-9-CM codebook, usually in Appendix A. Emphasize how the fifth digit of an M code describes the behavior of the neoplasm.

6. Examine the coding guidelines for the use of V10 and V58 with neoplasm codes. Review the diagnosis code V58.11, Encounter for antineoplastic chemotherapy, and the code V58.12, Encounter for antineoplastic immunotherapy.


35

http://www.oncolink.upenn.edu/

http://www.cancer.gov/

7. Emphasize the importance of using the entire Alphabetic Index to Diseases in ICD-9-CM and not strictly the Neoplasm Table to locate a code. Review the Alphabetic Index instructions carefully with the students.

8. Show examples of the ICD-9-CM Tabular List instructions to use an additional code for functional activity with certain neoplasms, and examine the variation in categories 150 and 201 that essentially have duplicate codes for the same condition.

9. Review how to determine the primary site and the secondary site(s) based on the diagnostic statement.

10. Review how to determine the primary site and the secondary site(s) based on the diagnostic statement that includes the phrase “metastatic” but only lists one anatomic site (page 100 of textbook). Review the list of exceptions to the rule for sites that are typically secondary sites.

11. Review the fifth-digit terms of remission and relapse used to describe different stages of leukemia.

12. Work through one or two questions with the students for each of the ICD-9-CM exercises in the chapter to emphasize the coding steps for using the Alphabetic Index, the Neoplasm Table, and the Tabular List correctly.




1. Carcinoma in situ of breast, left233.0

2. Malignant melanoma, skin of lower leg, right172.7

3. Acute lymphoblastic leukemia 204.00


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4. Metastatic carcinoma of the liver; carcinoma of descending colon197.7, 153.2

5. Oat cell carcinoma162.9

6. Admission for chemotherapy; ovarian carcinomaV58.11, 183.0

7. Histiocytic nodular lymphoma200.00

8. Malignant neoplasm of head and neck195.0

9. Squamous cell carcinoma of back173.52

10. Islet cell carcinoma157.4


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1. How is the ICD-10-CM Neoplasm Table organized?

The ICD-10-CM Neoplasm Table is organized into columns, with the left column listing the anatomic site and the next six columns providing codes for primary malignant, secondary malignant, CA in situ, benign, uncertain and unspecified behavior for each anatomic site.

2. What is a new feature in ICD-10-CM as it relates to neoplasms?

The concept of laterality. Codes listed in the ICD-10-CM Neoplasm Table with a “dash” (-) following the code have a required fifth character for laterality. The Tabular List must be reviewed for the complete code. Neoplasm codes are specific as to whether the location is the right or left organ when a tumor is present in an organ that exists bilaterally.

3. What is the exception to the Guideline I.C.2.a, Treatment directed at the malignancy?

The only exception to this guideline is if a patient admission or encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.—code as the first listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

4. If a patient had a primary malignancy previously excised and there is no treatment to that site and no evidence of existing malignancy at that site, how is this condition coded according to the coding guidelines?

A code from category Z85, Personal history of primary and secondary malignant neoplasm should be coded to indicate the former site of the malignancy according to Guideline I.C.2.d.

5. What instructional notes appear in ICD-10-CM Chapter 2, Neoplams, for the coder to follow?

Instruction notes appear in Chapter 2 to code additional diagnoses such as multiple endocrine neoplasia syndrome, carcinoid syndrome, alcohol abuse and dependence, alcohol dependence in remission, tobacco dependence and history of tobacco use. Also an additional code from Chapter 4 may be used to identify functional activity associated with any neoplasm.


1. Carcinoma in situ of breast, leftD05.92

2. Malignant melanoma, skin of lower leg, rightC43.71


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3. Acute lymphoblastic leukemia C91.00

4. Metastatic carcinoma of the liver; carcinoma of descending colonC78.7, C18.6

5. Oat cell carcinomaC34.90

6. Admission for chemotherapy; ovarian carcinomaZ51.11, C56.9

7. Histiocytic nodular lymphomaC85.90 (C81.00?)

8. Malignant neoplasm of head and neckC76.0

9. Squamous cell carcinoma of backC44.59

10. Islet cell carcinomaC25.4


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Chapter 6

Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders


Diseases of the endocrine glands, nutritional disorders, and metabolic and immunity disorders Classification of all types of diabetes, including the secondary complications of diabetes Coding of metabolic disorders


1. Describe the organization of the conditions and codes included in chapter 3 of ICD-9-CM, Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders

2. Describe the organization of the conditions and codes included in chapter 4 of ICD-10-CM, Endocrine, nutritional and metabolic diseases (E00–E89.)

3. Define the term diabetes mellitus4. Describe the different types of diabetes and how the types of diabetes impacts

code selection in ICD-9-CM and ICD-10-CM. 5. Explain what the fourth and fifth digits indicate in ICD-9-CM when used to

describe diabetes and diabetic conditions6. Identify the codes included in chapter 3 of ICD-9-CM that describe metabolic

and immunity disorders such as gout, fluid and electrolyte imbalances, cystic fibrosis and graft-versus-host disease.

7. Assign ICD-9-CM diagnosis and procedure codes for endocrine, nutritional and metabolic diseases, and immunity disorders

8. Assign ICD-10-CM codes for endocrine, nutritional and metabolic diseases.

Special Note to Instructors: Students frequently overlook assigning the fifth digit to diabetes codes and have difficulty understanding the difference between Type I and Type II diabetes. Review with students the older alternate terminology for diabetes, including insulin dependent and non-insulin dependent. The phrase “insulin requiring” may still be used and should be considered Type II diabetes. If the disease pathology is not well understood, refer to the American Diabetes Association and other reputable medical or scientific websitesfor a review.


1. Review reputable scientific websitesregarding diabetes, cystic fibrosis, and thyroid disorders, including the National Institutes of Health’s National Diabetes Information


40

Clearinghouse at http://diabetes.niddk.nih.gov. Other sites with good information are http://www.diabetes.org/ and http://www.endocrineWeb.com.



2. Review the types of conditions included in this chapter of ICD-9-CM to identify commonly diagnosed illnesses.

3. Review the fourth digit subcategories with category 250, Diabetes mellitus, to emphasize the required coding of all identified complications and manifestations.

4. Review the Alphabetic Index entry for diabetes for codes in slanted brackets to emphasize the correct coding of such conditions.

5. Review the fifth digit subclassification with category 250, Diabetes mellitus, to emphasize the terminology that describes Type I and Type II diabetic conditions.

6. Emphasize how an unspecified type of diabetes is classified with Type II diabetes.

7. Review the fifth digit note regarding “insulin-requiring” diabetes that is assigned to Type II diabetes.

8. Emphasize the difference between Type I and Type II diabetes and explain that the fact that a patient is taking insulin does not make the patient a Type I diabetic. Review the fifth digits under category 250, Diabetes Mellitus. Include in the review the fact that code V58.67, long-term (current) use of insulin, should be used if the patient with Type II or unspecified diabetes is currently taking insulin. Code V58.67 is not used with codes for Type I diabetes as it is expected the patient will be taking insulin.

9. Emphasize the rule that only a physician can make the determination that a patient's diabetes is “uncontrolled.” The coder cannot use blood glucose or other laboratory results or the patient history to assign the fifth digit for uncontrolled status. In addition, Second Quarter 2002 Coding Clinic stated that “poorly controlled” or “diabetes in poor control” should not be assumed to mean the condition is uncontrolled without clarification by the physician.

10. Review category 249 codes for secondary diabetes mellitus and how this condition differs from category 250, diabetes mellitus.

11. Review the different forms of metabolic and immunity disorders described by category 276 codes.


41

http://www.diabetes.org/

http://diabetes.niddk.nih.gov/

12. Review the codes for cystic fibrosis (277.00–277.09) that better describe the extent of the illness.

13 . Review the Official Coding Guidelines for chapter-specific guidelines related to diabetes, see Section I, Part C3, Endocrine .


Chapter 6 Review QuestionsCode the following with ICD-9-CM diagnosis codes:

1. Uncontrolled Type I diabetes250.03

2. Type II diabetes with retinopathy250.50, 362.01

3. Diabetes mellitus, Type II, with polyneuropathy250.60, 357.2

4. Hyperkalemia276.7

5. Electrolyte imbalance276.9

6. Vitamin B12 deficiency266.2

7. Malnutrition, moderate 263.0

8. Reactive hypoglycemia251.2

9. Hypertrophy of thymus254.0

10. Group A hyperlipidemia272.0

11. Uncontrolled secondary diabetes mellitus with ketoacidosis249.11


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12. Secondary diabetes mellitus with macula edema249.50, 362.07


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1. What are the five new categories for coding diabetes mellitus in ICD-10-CM?

E08, Diabetes mellitus due to underlying conditionsE09, Drug or chemical induced diabetes mellitusE10, Type 1 diabetes mellitusE11, Type 2 diabetes mellitusE13, Other specified diabetes mellitus

2. Explain what conditions are included in the new diabetes combination codes in ICD-10-CM?

Diabetes codes are combination codes that include the type of diabetes (type 1, type 2, due to underlying condition or due to drug or chemical), the body system affected, and the complications affecting that body system.

3. What other conditions may be required to be coded in addition to the ICD-10-CM diabetes codes to fully describe diabetes and the related conditions?

Diabetes due to underlying condition requires the underlying condition to be coded first. Diabetes or chemical induced diabetes requires a T36–T65 code to be coded first to identify the drug or chemical involved. Some diabetes codes require an additional code to identify the stage of a complication, such as the stage of chronic kidney disease involved. Also an additional code is available to indicate the use of insulin.

4. If the diabetes is unspecified by the physician as to what type of diabetes the patient has, what code is used in ICD-10-CM to describe it?

Diabetes of an unspecified type defaults to Type 2.

5. What other forms of diabetes are coded in ICD-10-CM chapters other than chapter 4?

Other forms of diabetes coded elsewhere are gestational diabetes (O24.44) and neonatal diabetes mellitus (P70.2)


1. Uncontrolled Type I diabetesE10.65

2. Type II diabetes with retinopathyE11.319

3. Diabetes mellitus, Type II, with polyneuropathyE11.43


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4. HyperkalemiaE87.5

5. Electrolyte imbalanceE87,8

6. Vitamin B12 deficiencyE53.8

7. Malnutrition, moderate E44.0

8. Reactive hypoglycemiaE16.1

9. Hypertrophy of thymusE32.0

10. Group A hyperlipidemiaE78.0

11. Uncontrolled secondary diabetes mellitus with ketoacidosisE13.10 (E08.10?)

12. Secondary diabetes mellitus with macula edemaE13.311


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Chapter 7

Diseases of the Blood and Blood-Forming Organs


Classification of various types of diseases of blood and blood-forming organs including:o anemiaso coagulation disorderso purpura and other hemorrhagic conditionso diseases of the white blood cellso other blood and blood-forming organ diseases


1. Describe the organization of the conditions and codes included in chapter 4 of ICD-9-CM, Diseases of the Blood and Blood-Forming Organs (280–289)

2. Describe the organization of the condition and codes included in chapter 3 of ICD-10-CM, Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89).

3. Define anemia and identify the causes of the specific types of anemia—deficiency, hemolytic, aplastic, and antineoplastic chemotherapy-induced.

4. Define the term coagulation defects, give specific examples of these conditions, and briefly describe their treatment

5. Describe primary and secondary thrombocytopenia and briefly describe their treatments

6. Identify diseases of the white blood cells and give examples of these conditions7. Assign ICD-9-CM diagnosis and procedure codes for blood and blood-forming

organs8. Assign ICD-10-CM codes for conditions categorized in ICD-10-CM chapter 3.

Special Note to Instructors: This is a short chapter that is not difficult to understand if the student/coder is given the necessary information to code specific conditions. The most commonly misunderstood concept in this chapter is the difference between a true coagulation defect and a disorder that a patient suffers while on anticoagulant (e.g., Coumadin) therapy, which produces bleeding, or a hemorrhagic condition. Emphasize the fact that patients on anticoagulants frequently experience adverse effects or reactions from the drug therapy. Students may not have reviewed the Table of Drugs and Chemicals at this point of the instruction to understand how to locate the E code for therapeutic use of an anticoagulant.


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1. Review reputable scientific websitesfor various types of anemias, including sickle-cell and other familial anemias such as http:// www.nhlbi.nih.gov and http:// www.cooleysanemia.org/ . The National Institute of Health’s Hematologic Diseases Information Services at http://hematologic.niddk.nih.gov is another trusted source of information.



2. Review the types of blood disorders included in this chapter, such as anemias, platelet disorders, coagulation defects, purpura, and white blood cell diseases, and their known causes.

3. Emphasize that the coding of anemia or other blood disorders is not difficult if the student/coder is given the specific information as to the type of blood disorder.

4. Review the Official Coding Guidelines for chapter-specific guidelines related to anemias,

see Section I, Part C4, Diseases of Blood and Blood Forming Organs.



Code the following with ICD-9-CM diagnosis codes: 1. Iron deficiency anemia due to inadequate dietary intake

280.1

2. Secondary thrombocytopenia due to hypersplenism289.4, 287.49

3. Sickle-cell trait282.5

4. Chronic lymphadenitis289.1

5. Allergic vasculitis287.0


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http://hematologic.niddk.nih.gov/

http://www.cooleysanemia.org/

http://www.nhlbi.nih.gov/

6. Pernicious anemia281.0

7. Idiopathic eosinophilia288.3

8. Anemia due to acute blood loss285.1

9. Coagulation deficiency due to vitamin k deficiency286.7

10. Autoimmune hemolytic disease283.0


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ICD-10-CM Review Exercises

1. What diagnosis codes were moved to chapter 3 of ICD-10-CM when compared to the ICD-9-CM chapter for blood and blood-forming organs?

The immunodeficiency disorders have been reclassified from chapter 4: Endocrine, nutritional and metabolic diseases, and immunity disorders in ICD-9-CM to chapter 3 in ICD-10-CM: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism.

2. What are examples of additional diagnosis codes uses with codes from chapter 3 of ICD-10-CM?

There are “code first” instructions to use a code from T36–T50) to identify the drug for anemias that are drug induced, such as, D61.1, drug-induced aplastic anemia. Another example of a “code first” note is to code the poisoning by, adverse effects of, and underdosing of drugs to identify the drug involved with agranulocytosis.

3. How has the guideline changed for sequencing of codes to describe anemia associated with malignancy?

The revised ICD-10-CM guideline states when the admission or encounter is for management of anemia associated with the malignancy, and the treatment is only for the anemia, the appropriate code for the malignancy is sequenced first with an additional code D63.0, anemia in neoplastic disease.


1. Iron deficiency anemia due to inadequate dietary intake D50.8

2. Secondary thrombocytopenia due to hypersplenismD69.51, D73.1

3. Sickle-cell traitD57.3

4. Chronic lymphadenitisI88.1

5. Allergic vasculitisD69.0

6. Pernicious anemiaD51.0


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7. Idiopathic eosinophiliaD72.1

8. Anemia due to acute blood lossD62

9. Coagulation deficiency due to vitamin k deficiencyD68.4

10. Autoimmune hemolytic diseaseD59.1


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Chapter 8

Mental DisordersThis lesson will focus on the following topics:

Coding of behavioral health or psychiatric disorders including psychoses, neurotic disorders, personality disorders, and other nonpsychotic mental disorders

The use of multiple codes to identify both psychiatric and neurological disorders that exist in the same patient

The distinction between substance abuse and substance dependence and the correct coding of these conditions

Classification of mental retardation diagnoses


1. Describe the organization of the conditions and codes included in chapter 5 of ICD-9-CM, Mental, Behavorial and Neurodevelopmental Disorders (290–319)

2. Describe the organization of the conditions and codes includeed in chapter 5 of ICD-10-CM, Mental and behavioral disorders, F01, F99.

3. Describe the DSM-IV-TR and explain its purposes4. Describe the multiple coding rules related to the coding of mental disorders5. Review the inclusion and exclusion notes for the classification of mental

disorders6. Define and differentiate between the terms alcoholism, alcohol abuse and

alcohol use.7. Define and differentiate between the terms drug dependence, drug abuse and

drug use8. Describe the ICD-9-CM coding guidelines for the selection of principal diagnosis

for patients admitted for alcohol or drug dependence treatment.9. Define the terms detoxification and rehabilitation as related to alcohol and drug

dependence treatment10. Assign ICD-9-CM diagnosis and procedure codes for mental, behavioral and

neurodevelopmental disorders.11. Assign ICD-10-CM codes for mental and behavioral disorders

Special Note to Instructors: The most commonly misunderstood concept in this chapter is the difference between substance abuse and substance addiction or dependence, a problem compounded by the inconsistent terminology used by the physicians outside of addiction medicine. Emphasize the special concerns for privacy of mental health, psychiatric, and substance abuse treatment records and diagnoses codes, as protected by specific state and Federal laws.


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1. Review reputable websites, such as the National Institute of Mental Health and Substance Abuse (http://www.mentalhealth.org/) and the Mental Health Services Administration of the Federal Government (http://www.samhsa.gov/index.aspx).

2. Locate a website for DSM-IV, such as the American Psychiatric Association (http://www.appi.org/).



2. Review the purpose and structure of the multi-axial system in DSM-IV and compare its use with ICD-9-CM.

3. Compare the terminology of ICD-9-CM “Mental Disorders” with the more contemporary descriptions of this branch of medicine, such as behavioral health, psychiatry, and substance abuse.

4. Encourage close attention to the requirements for multiple coding when a patient has both a psychiatric and neurological condition, such as Alzheimer's dementia.

5. Encourage close attention to the Includes and Excludes notes within the chapter for direction on appropriate code assignment.

6. Review the definitions of “addiction,” “dependence,” and “abuse.”

7. Review the correct use of the fifth digits for categories 303, 304, and 305 based on physician documentation.

8. Review the guidelines for selecting the principal diagnosis for patients admitted for alcohol or drug dependence treatment.

9. Review the definitions of detoxification and rehabilitation related to alcohol and drug treatment.



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http://www.appi.org/

http://www.samhsa.gov/index.aspx

http://www.mentalhealth.org/



1. Paranoid schizophrenia in remission295.35

2. Moderate mental retardation—see Disability, Intellectual, moderate318.0

3. Chronic alcoholism, continuous form303.91

4. Acute alcoholic intoxication in a patient with alcoholism303.00

5. Cocaine addiction, episodic form304.22

6. Cocaine abuse, episodic form305.62

7. Acute depression, recurrent episode, moderate296.32

8. Bipolar affective disorder, mild296.7

9. Chronic paranoid psychosis297.1

10. Passive-dependent personality disorder301.6


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1. When the provider documentation refers to use, abuse, and dependence of the same substance, such as alcohol or cannabis, how many codes should be assigned for that encounter?

Only one code should be assigned to identify the pattern of use based on the following hierarchy: If both use and abuse are documented, assign only the code for abuse. If both abuse and dependence are documented, assign only the code for dependence. If use, abuse and dependence are all documented, assign only the code for

dependence If both use and dependence are documented, assign only the code for dependence

2. In the DSM-IV-TR multiaxial system, what axes identify diagnostic information?

Axis I—Clinical disorders and other conditionsAxis II—Personality disorders and mental retardationAxis III—Presence of general medical conditions

3. How is “history of drug or alcohol dependence” coded in ICD-10-CM?

History of drug or alcohol dependence is coded as “in remission” but the diagnosis of history of or in remission requires the provider’s clinical judgment and must be specifically documented in the patient’s record.


1. Paranoid schizophrenia in remissionF20.0

2. Moderate mental retardation – see Disability, Intellectual, moderateF71

3. Chronic alcoholism, continuous formF10.20

4. Acute alcoholic intoxication in a patient with alcoholismF10.220 (F10.229?)

5. Cocaine addiction, episodic formF14.29

6. Cocaine abuse, episodic formF14.19


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7. Acute depression, recurrent episode, moderateF33.9

8. Bipolar affective disorder, mildF31.9

9. Chronic paranoid psychosisF22

10. Passive-dependent personality disorderF60.7


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Chapter 9

Diseases of the Nervous System and Sense Organs


Diseases of the central nervous system Diseases of the peripheral nervous system Diseases and disorders of the sense organs, such as the eye, adnexa, ear, and mastoid process


1. Describe the organization of the conditions and codes included in chapter 6 of ICD-9-CM, Diseases of the Nervous System and Sense Organs (320-389)

2. Describe the organization of the conditions and codes included in chapter 6 of ICD-10-CM, Diseases of the nervous system (G00-G99)

3. Describe the organization of the conditions and codes included in chapter 7 of ICD-10-CM, Diseases of the eye and adnexa (H00-H59)

4. Describe the organization of the conditions and codes included in chapter 8 of ICD-10-CM, Diseases of the ear and mastoid process (H60-H95)

5. Describe meningitis, including the circumstances in which two ICD-9-CM codes are required to classify the condition

6. Describe the types of codes ICD-9-CM includes for pain7. Define the terms hemiplegia and hemiparesis8. Define and differentiate between epilepsy, seizures and convulsions9. Describe the different ICD-9-CM codes used to identify epilepsy, seizures, and

convulsions 10.Describe different types of headaches, including intractable and chronic

headaches, and differentiate among these terms11.Identify and describe the various types of eye disorders, including retinopathy,

glaucoma, and cataract12.Identify and describe the various types of ear infections, including otitis externa

and otitis media13.Identify and describe the various types of hearing loss14. Assign ICD-9-CM diagnosis and procedure codes for diseases of the nervous system and sense

organs15. Assign ICD-10-CM codes for disease of the nervous system and sense organs

Special Note to Instructors: A commonly misunderstood concept in this chapter relates to cataracts and the adjectives “senile” or “mature.” Students may use the adjective to describe the patient, not the type of cataract, and assume that all elderly patients have “senile” or “mature” cataracts in the absence of physician documentation.


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1. Review reputable websites for nervous system disorders, such as the American Brain Tumor Association, American Stroke Association, the Epilepsy Foundation, National Multiple Sclerosis Society, National Headache Foundation, or UCLA Neurosurgery.

2. Review the website http:// www.michaeljfox.org sponsored by Michael J. Fox, the actor who suffers from Parkinson'sDisease, and review his efforts to raise research funds and draw public attention to the disease.



2. Review the requirement for ICD-9-CM two codes for some forms of meningitis by examining the Alphabetic Index entries for meningitis.

3. Review the new ICD-9-CM category 338, Pain, Not Elsewhere Classified, in the Tabular List. Codes were added for central pain syndrome, acute pain, chronic pain, neoplasm-related pain, and chronic pain syndrome. Many other codes exist in ICD-9-CM for pain of a specific site. This new category provides codes for conditions that previously were classified to a particular site but did not recognize the “syndrome” of pain

4. Review the fact that ICD-9-CM codes 342–344 may be used to code patients with a current cerebral vascular accident diagnosis as well as patients with longstanding paralytic conditions.

5. Note the requirement for a fifth digit with the ICD-9-CM category 345, Epilepsy, based on physician documentation of the intractable form of the disease.

6. Review ICD-9-CM category 345, Epilepsy and Recurrent Seizures. The diagnoses of epilepsy, recurrent seizures, and seizure disorder are now indexed to category 345. Other diagnostic statements of convulsions, convulsive disorder, or convulsive seizures are indexed to code 780.39. This is a significant change in coding. Review the Alphabetic Index and the Tabular List for these different phrases.

7. Review the two ICD-9-CM categories of codes, 339 and 346, for different forms of headaches that can be classified with these codes.

8. Review the ICD-9-CM codes for critical illness neuropathy and myopathy.

9. Examine the Alphabetic Index entries for the various forms of glaucoma and the correct coding of each.


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http://www.michaeljfox.org/

10. Examine the Alphabetic Index entries for the various forms of cataract and the correct coding of each. Emphasize the adjectives used as describing the nature of the cataract, not the patient.

11. Examine ICD-9-CM categories 380, 381, and 382 for the various codes that can be used to describe different forms of ear infections (otitis.)

12. Examine the Alphabetic Index entries for deafness or hearing loss for the various forms and the correct coding of each type.

13. Review the Official Coding Guidelines for category 338, pain; for chapter-specific rules, see Section I, C6




1. Meningitis due to sarcoidosis 135, 321.4

2. Reye's syndrome 331.81

3. Grand mal epilepsy 345.10

4. Guillain-Barré syndrome 357.0

5. Progressive, degenerative myopia 360.21

6. Cystoid macular degeneration (CMD)362.53

7. Primary open-angle glaucoma 365.11

8. Alternating convergent concomitant strabismus378.00


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9. Vitreous floaters 379.24

10. Mixed conductive and sensorineural hearing loss389.2


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1. How have the codes in ICD-10-CM changed for Alzheimer’s disease?

Codes have been expanded to reflect early versus late onset of Alzheimer’s disease

2. What does the coding guideline for ICD-10-CM category G81, hemiplegia and hemiparesis specify whether a code for dominant or non-dominant side should be used?

If the affected side of the body that has the hemiplegia or hemiparesis is documented, but not specified as dominant or non-dominant, and the ICD-10-CM classification does not indicate a default, code selection is as follows: For ambidextrous patients, the default should be dominant If the left side is affected, the default is non-dominant If the right side is affected, the default is dominant

3. What conditions have been moved from ICD-9-CM chapter 7, Diseases of the Circulatory System, to ICD-10-CM chapter 6, Diseases of the Nervous System?

Codes that were moved in ICD-10-CM to chapter 6, Diseases of the Nervous System are basilar and carotid artery syndrome, transient global amnesia, and transient cerebral ischemic attack.

4. With ICD-10-CM category G40, epilepsy and recurrent seizures and G43, migraine, what terms are considered equivalent to “intractable?”

The terms pharmacoresistant, pharmacologically resistant, treatment resistant, refractory, medically refractory and poorly controlled are considered equivalent to the coding term of “intractable.”

5. What terminology in ICD-10-CM replaces the phrase “senile cataract” from ICD-9-CM?

Age-related cataract is the new descriptor in ICD-10-CM.

6. How is laterality recognized in the ICD-10-CM codes for diseases of the eye and adnexa?

Codes exist for right side, left side and bilateral for specific conditions of the eye and adnexa.

7. What are some examples of specific complications of the eye due to a procedure included in chapter 7 of ICD-10-CM?

Two examples are keratopathy (bullous aphakia) following cataract surgery and cataract (lens) fragments in eye following cataract surgery.


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8. How are the codes for diseases of the ear and mastoid process arranged in the new chapter 8 of ICD-10-CM, Diseases of the ear and mastoid process?

The diseases are arranged into blocks, such as conditions occurring in the external ear, middle ear, and inner ear. A separate block is used for other conditions of the ear and a fifth block contains codes for intraoperative and postprocedural complications.

9. How is the condition of otitis media with perforation of the tympanic membrane coded differently in ICD-10-CM compared to ICD-9-CM?

In ICD-9-CM, there is one code for otitis media with performation of tympanic membrane. In ICD-10-CM, the associate otitis media is coded first with an additional code for performation of tympanic membrane.

10. How is laterality recognized in the ICD-10-CM codes for diseases of the ear and mastoid process?

Codes exist for right side, left side and bilateral for specific conditions of the ear and mastoid process.


1. Meningitis due to sarcoidosis D86.81

2. Reye's syndrome G93.7

3. Grand mal epilepsy G40.809

4. Guillain-Barré syndrome G61.0

5. Progressive, degenerative myopia H44.20

6. Cystoid macular degeneration (CMD)H35.359

7. Primary open-angle glaucoma H40.11

8. Alternating convergent concomitant strabismusH50.05


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9. Vitreous floaters H43.399

10. Mixed conductive and sensorineural hearing lossH90.8


62

Chapter 10

Diseases of the Circulatory SystemThis lesson will focus on the following topics:

Common conditions of the heart and circulatory system Diseases of the cerebrovascular system Diseases of arteries, veins, and lymphatic structures


1. Describe the organization of the conditions and codes included in chapter 7 of ICD-9-CM, Diseases of the Circulatory System (390-459)

2. Describe the organization of the conditions and codes included in chapter 9 of ICD-10-CM, Disease of the Circulatory System (I00-I99)

3. Define rheumatic fever4. Define chronic rheumatic heart disease and identify the Alphabetic Index

entries for the types of heart valve diseases associated with it5. Describe the format of the hypertension table in the Alphabetic Index6. Define the various forms of hypertension: malignant, benign, and unspecified7. Describe the coding guidelines for the use of the combination codes for

hypertensive heart disease and hypertensive kidney disease8. Describe the coding guidelines for the use of multiple codes or combination

codes to describe hypertension with other illnesses9. Apply the correct fourth- and fifth-digit subclassification ICD-9-CM codes for

acute myocardial infarction10.Apply the ICD-10-CM coding guidelines for the correct coding of current and

subsequent acute myocardial infarctions11.Describe the ICD-9-CM coding sequencing rule of angina and coronary disease12.Explain the differences between the ICD-9-CM codes 414.00-414.07 used to

describe chronic ischemic heart disease13.Briefly describe the diagnosis and treatment of heart failure14.Identify the ICD-9-CM codes that describe various types of cardiac arrhythmias

and conduction disorders15.Describe the circumstances in which the ICD-9-CM code 427.5 for cardiac arrest

is assigned for a patient16.Identify the ICD-9-CM code for acute cerebrovascular accident (CVA) and

describe the circumstances in which additional codes are used with the CVA code to identify associated conditions

17.Describe the circumstances in which the ICD-9-CM category code 438 is used to describe the late effect of cerebrovascular disease and contrast them with those in which a subcategory code V12.5 is used

18. Briefly describe the ICD-9-CM procedure coding for cardiac catheterization, coronary angiography, and percutaneous transluminal coronary angioplasty


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19.Name the coronary arteries that may be described during coronary artery bypass graft surgery

20.Briefly describe the ICD-9-CM procedure coding for cardiac pacemakers and automatic implantable cardioverter-defibrillator devices

21.Briefly describe the ICD-9-CM procedure coding for diagnostic cardiac procedures such as angiography, arteriography, and ventriculography

22. Assign ICD-9-CM diagnosis and procedure codes for chapter 7 of ICD-9-CM, Diseases of the Circulatory System

23. Assign ICD-10-CM codes for ICD-10-CM chapter 9, Diseases of the Circulatory System

Special Note to Instructors: This is a large chapter that requires more time than might have been devoted to previous chapters in the textbook, with the exception of the chapter on neoplasms, which requires similar attention. Because of the wide prevalence of cardiac and cerebrovascular disease in the general population, students need a solid understanding of the coding of these conditions.


1. Review reputable websites for circulatory system disorders, such as the American Heart Association; Heart Failure Society of America; National Heart, Lung and Blood Institute; American Stroke Association; American College of Cardiology, etc.

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the structure of the circulatory system, including the chambers and vessels of the heart and the lobes of the brain.



2. Review the Official Coding Guidelines for chapter-specific rules for the circulatory system, Section I, C7

3. Compare and contrast the codes for acute and chronic rheumatic fever. Review the Alphabetic Index entries when both mitral and aortic valves are involved and the ICD-9-CM assumption is that this is a rheumatic heart condition. Compare these codes to category 424, which is more appropriately used when the physician describes the heart valve disease as nonrheumatic.

4. Take time to review the organization of the Hypertension Table within the ICD-9-CM Alphabetic Index to Disease. Review the two types of hypertension and the fact that the "unspecified" column is used frequently because physicians rarely use the ICD-9-CM terminology of benign hypertension, which is the type most frequently occurring in the general population.


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5. Review the differences between primary/essential hypertension and secondary hypertension. Emphasize the requirement of two codes for secondary hypertension when the cause of the hypertension is known (e.g., Cushing's disease). Review the hypertension guidelines in the ICD-9-CM Official Coding Guidelines (Section I, C., 7, a,).

6. Review the coding guideline that states the physician must make a connection or a causal relationship between hypertension and heart disease in order to appropriately use the ICD-9-CM category 402, hypertensive heart disease. The statement “due to” or “hypertensive” makes that connection. The simple statement that both hypertension and heart disease exists in the same patient does not mean category 402 should be used.

7. Review the ICD-9-CM coding guideline that states the physician does NOT have to make a connection or causal relationship between hypertension and chronic renal failure or chronic kidney disease in order to appropriately use the category 403, hypertensive chronic kidney disease. The fact that hypertension (401) and chronic kidney disease (585) exist in the same patient allows the coder to make an assignment within category 402. ICD-9-CM presumes a relationship between hypertension and chronic renal failure or chronic kidney disease. Review the revisions to the titles of the fifth digits used with category 403, Hypertensive chronic kidney disease. The patient with hypertensive kidney disease will have one of several stages of chronic kidney disease. The fifth digits identify the stage of chronic kidney disease occurring in the patient. There is no option for “without” chronic kidney disease. An additional code (585.1–585.9) is required with the category 403 code.

8. Review the ICD-9-CM coding guidelines for the correct use of category 404, Hypertensive Heart and Chronic Kidney Disease. Note both categories 402 and 404 require an additional code for the type of heart failure involved. Review the revisions to the titles of the fifth digits used with category 404 codes. The patient with hypertensive heart and kidney disease will have one of several stages of chronic kidney disease. The patient may or may not have heart failure. The fifth digits identify what form of chronic kidney disease is present in the patient and whether or not the patient has heart failure. An additional code (585.1–585.9) is required with the category 404 code.

9. Review the other ICD-9-CM hypertensive coding guidelines for correct coding of cerebrovascular disease and eye disease with hypertension.

10. Review the ICD-9-CM code 796.2 and the Alphabetic Index entries for elevated blood pressure readings or transient hypertension.

11. Describe the differences between fifth digits 0, 1, and 2 for acute myocardial infarction, ICD-9-CM category 410.

12. Review the ICD-9-CM terminology of subcategory 410.7, subendocardial infarction, which is more likely to be described as Non-ST elevation myocardial infarction or NSTEMI by physicians. The other codes within category 410 are considered to be ST-elevation myocardial infarction (STEMI) of different myocardial sites of the heart.


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13. Review the ICD-9-CM sequencing rules for angina with its known cause, which is typically coronary arteriosclerosis.

14. Review the ICD-9-CM Alphabetic Index entries for coronary artery disease or coronary arteriosclerosis/atherosclerosis to locate the correct subcategory for 414.0 instead of 414.9 for CAD. Review the descriptions of the fifth digits of 414.0 to identify the location of the disease, or which coronary vessel is involved.

15. Review ICD-9-CM category 428, heart failure, codes for the various forms of heart failure that can be coded.

16. Review the various forms of cardiac arrhythmias and conduction disorders classified to ICD_9-CM categories 426-427).

17. Review when cardiac arrest (ICD-9-CM code 427.5) is coded and when it is not coded.

18. Compare the ICD-9-CM categories of 430–435 with category 436 to distinguish between various forms of cerebrovascular “accidents” and the unspecified description of CVA.

19. Describe when secondary or residual conditions resulting from the CVA should be coded in ICD-9-CM.

20. Review the ICD-9-CM combination code of 438 for previous CVA with current disabilities. Examine the Alphabetic Index entry for “Late, effects, cerebrovascular disease, with” to locate these codes.

21. Examine the ICD-9-CM code V12.59 that describes a history of cerebrovascular disease but indicates no residual condition is present.

22. Review the ICD-9-CM terms “venous thromboembolism or VTE and “deep vein thrombosis” or DVT and how this condition is coded depending where it occurs in the body. Review the differences between acute and chronic forms of these conditions; what is the default code if acute or chronic is not stated. Review the terminology of superficial and deep veins and their anatomy.

23. Review the ICD-9-CM procedure coding of cardiac catheterization, PTCA, stent placement, and related imaging procedures. Additional codes are required to identify the number of vessels treated and the number of stents placed.

24. Review the ICD-9-CM procedure coding of coronary artery bypass graft procedures including the names of the coronary arteries usually treated.

25. Review the ICD-9-CM procedure coding of cardiac pacemakers and automatic implantable cardioverter-defibrillator (AICD) and the multiple codes that may be required depending on the device inserted.


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26. Review the ICD-9-CM procedure coding of diagnostic cardiac procedures including coronary angiography, coronary arteriography, and ventriculography.




1. Second degree heart block426.13

2. Acute myocardial infarction, anterior wall, admitted two weeks after first hospital stay for more studies

410.12

3. Cerebral thrombosis with no infarction434.00

4. Old CVA with late effect of dysphagia438.82

5. Congestive heart failure, hypertension428.0, 401.9

6. Coronary artery disease in vein bypass graft414.02

7. Pulmonary embolism415.19

8. Acute cerebrovascular insufficiency437.1

9. Atherosclerosis of arteries of legs with intermittent claudication440.21

10. Deep vein thrombosis of leg (not specified as acute or chronic)453.40


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1. How does ICD-10-CM categorize the type of hypertension to be coded, such as benign, malignant or unspecified?

In ICD-10-CM, hypertension codes no longer classify the type of hypertension a patient may have. Also the Hypertension table was eliminated in ICD-10-CM and replaced with regular Alphabetic Index entries. There is only one code for essential hypertension (I10).

2. Compared to ICD-9-CM, what is the stated number of weeks a specific category of codes for acute myocardial infarction may be used in ICD-10-CM?

In ICD-9-CM the note with category 410 refers to an 8 week or less time period. In ICD-10-CM the specific category must be used within four weeks (28 days) or less from onset.

3. What assumption is made in ICD-10-CM in terms of coding hypertension and chronic kidney disease?

A coder can assume a relationship exists between hypertension and chronic kidney disease whether or not the condition is so stated in the health record.

4. What is the sequencing guideline for use of ICD-10-CM category code I22, Subsequent ST elevation (STEMI) or non-ST elevation (NSTEMI) myocardial infarction?

If a patient is in the hospital due to an initial acute myocardial infarction (AMI) and has a subsequent AMI while still in the hospital, code I21 for the initial AMI is sequenced first with a code I22, subsequent AMI is sequenced as a secondary code.

If a patient has a subsequent AMI after discharge for the care of the initial AMI and the reason for admission is the subsequent AMI, the I22 code for subsequent AMI should be sequenced first followed by the I21 code for the initial AMI. An I21 code must accompany the I22 code to identify the site of the initial AMI and to indicate that the patient is still within the 4-week time frame of healing from the initial AMI.

5. How is atherosclerotic heart disease with angina pectoris coded in ICD-10-CM?

ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris: I25.11 for Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7 for Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris. It is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris unless the documentation indicates the angina is due to something other than atherosclerosis.


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6. What is the title of the category of codes in ICD-10-CM that identify the late effects of cerebrovascular disease?

The category for late effects of cerebrovascular disease has been retitled “Sequelae of cerebrovascular disease” and has been restructured by expanding all subcategory codes. This expansion involves laterality, changing subcategory titles, making terminology changes, adding sixth characters, and providing greater specificity in general. Sequelae of cerebrovascular disease are differentiated by type of stroke, such as, hemorrhage or infarction.

7. What are some examples of intraoperative and postprocedural circulatory complications coded in ICD-10-CM?

Examples include intraoperative versus postprocedural cardiac arrest, postprocedural hypertension, postprocedural heart failure, intraoperative and postprocedural cerebral infarction, accidental puncture or laceration during circulatory system procedure and accidental puncture or laceration of a circulatory system organ during another body system procedure.


1. Second degree heart blockI44.1

2. Acute myocardial infarction, anterior wall, admitted two weeks after first hospital stay for more studies

I21.09

3. Cerebral thrombosis with no infarctionI66.9

4. Old CVA with late effect of dysphagiaI69.31, R13.10

5. Congestive heart failure, hypertensionI50.9, I10

6. Coronary artery disease in vein bypass graftI25.810

7. Pulmonary embolismI26.99

8. Acute cerebrovascular insufficiencyI67.8


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9. Atherosclerosis of arteries of legs with intermittent claudicationI70.213 (legs=bilateral)

10. Deep vein thrombosis of leg (not specified as acute or chronic)I84.209


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Chapter 11

Diseases of the Respiratory SystemThis lesson will focus on the following topics:

Acute respiratory and other upper respiratory tract infections and diseases Pneumonia, influenza, chronic obstructive pulmonary diseases Respiratory failure and respiratory procedures


1. Describe the organization of the conditions and codes included in chapter 8 of ICD-9-CM, Diseases of the Respiratory System (460-519)

2. Describe the organization of the conditions and codes included in chapter 10 of ICD-10-M, Diseases of the respiratory system (J00-J99)

3. Define bronchitis and identify the different ICD-9-CM and ICD-10-CM codes used to describe it

4. Understand how ICD-9-CM organizes the codes for various types of pneumonia5. Define asthma and identify the different ICD-9-CM codes used to describe it6. Define bronchiectasis and identify the different ICD-9-CM codes used to

describe it7. Define chronic obstructive pulmonary disease and identify the various

conditions that may be described as forms of COPD8. Define respiratory failure and understand the coding and sequencing rules for

assigning respiratory failure codes9. Briefly describe theICD-9-CM procedure coding of mechanical ventilation and

the procedures associated with it10. Assign ICD-9-CM diagnosis and procedure codes for diseases of the respiratory

system11. Assign ICD-10-CM codes for diseases of the respiratory system

Special Note to Instructors: The coding challenges within this chapter include identifying the various forms of asthma and applying the fifth digits correctly; identifying various forms of COPD and following the includes and excludes notes within the section; and applying the coding guidelines for respiratory failure to determine when respiratory failure may be assigned as a principal diagnosis. Review Coding Clinic, First Quarter 2005, pp 3–8 for the new directions for assigning respiratory failure codes.


1. Review reputable websites for respiratory system disorders, such as the American Lung Association (www.lungusa.org); Allergy, Asthma, and Immunology (www.acaai.org and


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http://www.acaai.org/

www.aaaai.org) ; National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov); and JAMA Asthma Treatment Center (http://jama.ama-assn.org/cgi/collection/asthma)

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the structure of the respiratory system.



2. Review the ICD-9-CM Official Coding Guidelines for chapter-specific rules for the respiratory system, Section I, C8.

3. Compare the similar ICD-9-CM codes for acute and chronic respiratory infections that emphasize the importance of the adjectives, acute and chronic: 460–466 and 470–478.

4. Review the ICD-9-CM Alphabetic Index entry for pneumonia to demonstrate the coding based on the causative organism.

5. Examine the fifth digits available for use with ICD-9-CM category 493, Asthma.

6. Review the entire ICD-9-CM section of chronic obstructive pulmonary disease and allied conditions (490–496) to examine the specific forms of COPD, such as bronchitis, emphysema, and asthma.

7. Review the important note under ICD-9-CM category 496 that describes what is not coded with category 496 and the “Excludes” note that specifies how to code COPD when described with a specific chronic lung condition.

8. Examine the different forms of respiratory failure under ICD-9-CM subcategory 518.8.

9. Review the ICD-9-CM coding guidelines for the selection of respiratory failure as either a principal or secondary diagnosis as published in Coding Clinic, First Quarter 2005, page 3–8. The textbook has been revised to include these new directions for assigning respiratory failure codes.

10. Review ICD-9-CM coding of respiratory procedures, especially the endoscopic procedures and the correct coding for mechanical ventilation, including the required second code for either endotracheal tube insertion or tracheostomy.

11. Review the commonly performed respiratory endoscopic ICD-9-CM procedures.

12. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification


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http://www.aaaai.org/

system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM.12



1. Pneumonia due to group A streptococcus482.31

2. Upper respiratory infection (URI)465.9

3. COPD with emphysema492.8

4. Acute exacerbation of COPD491.21

5. Acute bronchitis with bronchospasm466.0

6. Pneumonia due to Klebsiella482.0

7. Acute exacerbation of chronic asthma493.92

8. Tracheostomy infection519.01

9. Black lung disease500

10. Influenza with pneumonia487.0


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1. What instructional note appears at the beginning of ICD-10-CM chapter 10 concerning tobacco?

A note instructs the coding professional to use an additional code, where applicable to identify: exposure to environmental tobacco smoke (Z77.22), exposure to tobacco smoke in the perinatal period (P96.81), history of tobacco use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17.-), or tobacco use (Z72.0) Since these instructions appear at the beginning of the chapter, they should be followed when assigning any code from this chapter.

2. How has the terminology for asthma been updated in ICD-10-CM?

The following terms have been added to describe asthma in the ICD-10-CM codes: mild, intermittent and three degrees of persistent—mild persistent, moderate persistent and severe persistent.

3. When a respiratory condition is described as occurring in more than one respiratory site and it is not specifically indexed, how is it classified in ICD-10-CM?

The respiratory condition occurring in more than one site and not specifically indexed in ICD-10-CM should be classified to the lower anatomic site, for example, tracheobronchitis is coded to bronchitis in J40.


1. Pneumonia due to group A streptococcusJ15.4

2. Upper respiratory infection (URI)B99.9 (See J06.9 for acute URI)

3. COPD with emphysemaJ44.9

4. Acute exacerbation of COPDJ44.1

5. Acute bronchitis with bronchospasmJ20.9

6. Pneumonia due to KlebsiellaJ15.0


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7. Acute exacerbation of chronic asthmaJ45.901

8. Tracheostomy infectionJ95.02

9. Black lung diseaseJ60

10. Influenza with pneumoniaJ11.00


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Chapter 12

Diseases of the Digestive SystemThis lesson will focus on the following topics:

Disorders of the upper and lower GI tract Infections of the GI tract Other diseases of the GI tract, including hernia and ulcer


1. Describe the organization of the conditions and codes included in chapter 9 of ICD-9-CM, Diseases of the Digestive System (520–579)

2. Describe the organization of the conditions and coded included in chapter 11 of ICD-10-CM, Diseases of the Digestive System (K00–K94)

3. Identify the ICD-9-CM codes for the various ulcers of the gastrointestinal tract, including the required fourth and fifth digits

4. Identify the definitions of various types of hernia conditions that can be classified with ICD-9-CM

5. Identify various types of noninfectious enteritis and colitis conditions that can be classified with ICD-9-CM

6. Identify the ICD-9-CM codes for the various types of gallbladder disease and calculus, including the required fourth and fifth digits

7. Understand the use of ICD-9-CM category 578, Gastrointestinal hemorrhage, and its relationship with other digestive conditions

8. Briefly describe the methods of repairing various digestive system hernias 9. Describe the types of procedures that can be performed endoscopically within

the digestive system10.Define the terms gastrostomy, colostomy, ileostomy, and enterostomy and

explain the ICD-9-CM coding of these procedures11.Identify the types of procedures performed for intestinal resection and

anastomosis.12. Assign ICD-9-CM diagnosis and procedure codes for diseases of the digestive

system.13. Assign ICD-10-CM codes for disease of the digestive system.

Special Note to Instructors: The challenges in this chapter include identifying cholecystitis, cholelithiasis, and choledocholithiasis; coding for intestinal resections with anastomosis; and when to assign an additional code for the anastomosis. Because of the prevalence of digestive disorders in all patient groups, a complete review of the chapter is essential.


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1. Review reputable websites for digestive system disorders such as physicians' professional groups representing such specialties as general surgery, gastroenterology, and colorectal surgery, including the American College of Surgeons (www.facs.org). The National Digestive Diseases Information Clearinghouse (NDDIC) provides good information at http://digestive.niddk.nih.gov.

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the structure of the digestive system.



2. Examine the ICD-9-CM codes under subcategory 530.1, Esophagitis, including 530.11, Reflux esophagitis, and 530.81, Esophageal reflux, with an “excludes” note under 530.81. Code 530.11 includes both the reflux and the esophagitis aspects of the condition.

3. Compare the ICD-9-CM categories for ulcers (531, 532, 533, and 534) and examine the common descriptions for the fourth and fifth digits for all ulcer codes. Review code 533 to emphasize the unspecified nature of the category.

4. Examine the different types of gastritis and duodenitis included in ICD-9-CM category 535.

5. Review the ICD-9-CM Alphabetic Index entries for cholecystitis, cholelithiasis, and choledocholithiasis, including the connecting term “with” that is used when both conditions exist. Remind the coder to use the term cholelithiasis or choledocholithiasis first in the Alphabetic Index when coding a patient with both cholecystitis and gallstones or bile duct stones. There are frequent mistakes using category 574 and 575 codes.

6. Review ICD-9-CM category 578, especially the “excludes” note that describes how GI conditions with hemorrhage are coded.

7. Review the ICD-9-CM hernia categories 550–553 with emphasis on the types of hernias included here and the definition of “obstruction” and the correct use of the fifth digits.

8. Review the ICD-9-CM procedure coding of laparoscopic and open repair of hernia.

9. Review the ICD-9-CM procedure coding of commonly performed endoscopic procedures on the gastrointestinal tract.

10. Review the intestinal resection, anastomosis, and ostomy codes within ICD-9-CM Volume 3. Make note of the “code also any synchronous” instructions.


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11. Review the ICD-9-CM subcategory 54.1, Laparotomy, within Volume 3 for the correct use of laparotomy codes and when to omit the code when it represents the approach.

12. Review the ICD-9-CM procedure code for the application of an adhesion barrier (99.77.)



Code the following with the applicable ICD-9-CM diagnosis and procedure codes:

1. Acute perforated gastric ulcer531.10

2. Chronic cholecystitis with cholelithiasis 574.10

3. Recurrent inguinal hernia left side; open repair of inguinal hernia550.91, 53.00

4. Acute generalized peritonitis567.21

5. Gastroesophageal reflux530.81

6. Active chronic hepatitis571.49

7. Macrogenia524.05

8. Acute appendicitis; laparoscopic appendectomy540.9, 47.01

9. Ischiorectal abscess; I&D ischiorectal abscess566, 49.01


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10. Calculus of gallbladder and bile ductLaparoscopic cholecystectomy with endoscopic removal of stones from bile duct (biliary

tract)574.90, 51.23, 51.88


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1. Give two examples of how ICD-10-CM uses the terminology of “bleeding” versus “hemorrhage” in chapter 11.

The term bleeding is used when classifying gastritis, duodenitis, diverticulosis and diverticulitis. The term hemorrhage is used when referring to ulcers.

2. What does the sixth character in ICD-10-CM category K50, Crohn’s disease, represent?

The sixth character further classifies the specific complication when present with Crohn’s disease.

3. What factor about gastrointestinal ulcers has been eliminated from the ICD-10-CM codes?

The codes for gastric, duodenal, peptic and gastrojejunal ulcers do not include the diagnosis of obstruction. Descriptors of acute, chronic, with and without obstruction and gangrene are still part of the ICD-10-CM codes for these ulcers.


1. Acute perforated gastric ulcerK25.1

2. Chronic cholecystitis with cholelithiasis K80.10

3. Recurrent inguinal hernia left side; open repair of inguinal herniaK40.91, 0YQ60ZZ

4. Acute generalized peritonitisK65.0

5. Gastroesophageal refluxK21.9

6. Active chronic hepatitisK73.2

7. MacrogeniaM26.05

8. Acute appendicitis; laparoscopic appendectomyK35.80, 0DTJ4ZZ

9. Ischiorectal abscess; I&D ischiorectal abscess


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K61.3, 0D9Q3ZZ

10. Calculus of gallbladder and bile ductLaparoscopic cholecystectomy with endoscopic removal of stones from bile duct (biliary

tract)K80.70, 0FT44ZZ, 0FC94ZZ


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Chapter 13

Diseases of the Genitourinary SystemThis lesson will focus on the following topics:

Urinary system disorders Diseases of the male genital system Disorders of breast Inflammatory disease of female pelvic organs and other disorders of the female genital tract


1. Describe the organization of the conditions and codes included in chapter 10 of ICD-9-CM, Diseases of the Genitourinary System (580-629)

2. Describe the organization of the conditions and codes included in chapter 14 of ICD-10-CM, Diseases of the Genitourinary System (N00-N99)

3. Identify the types of conditions considered to be chronic kidney disease4. Define the term cystitis and describe the various ICD-9-CM codes that are

available to classify these conditions5. Define the term benign prostatic hypertrophy (BPH) and identify the associated

urinary conditions that can be coded6. Review the types of female genital tract disorders that can be classified using

ICD-9-CM codes7. Define the abbreviations of CIN I, CIN II, CIN III, and VIN I, VIN II, VIN III8. Describe the circumstances in which subcategory codes 795.0 are used in place

of codes described in ICD-9-CM chapter 10, Diseases of the Genitourinary System

9. Identify the options for coding various types of menopause states in ICD-9-CM10. Assign ICD-9-CM diagnosis and procedure codes for diseases of the

genitourinary system.11. Assign ICD-10-CM codes for diseases of the genitourinary system

Special Note to Instructors: This is a relatively straightforward chapter. Make a distinction between chronic kidney disease and acute renal failure. Emphasize the need for infectious organism codes when documentation supports them. Codes within the hyperplasia of prostate category, 600, include fifth digits that indicate the presence or absence of urinary obstruction with the hyperplasia.



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1. Review reputable websites for digestive system disorders and physicians' professional groups representing specialties such as nephrology, urology, general surgery, and gynecology, including the American College of Obstetricians and Gynecologists. The National Institute of Health’s National Kidney and Urologic Diseases Information Clearinghouse at http://kidney.niddk.nih.gov is another trusted source of information

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the structure of the urinary and reproductive systems.



2. Review the ICD-9-CM Official Coding Guidelines for chapter-specific rules for diseases of the genitourinary system, Section I, C10.

3. Review the excludes note at the beginning of ICD-9-CM section 580–589, nephritis, nephrotic syndrome, and nephrosis, as well as the italicized codes, which require the coding of the underlying condition.

4. Compare the ICD-9-CM codes for acute (category 584) versus chronic kidney disease (category 585), including a review of the differences between these conditions. Review the stages of chronic kidney disease that are identified with the codes in the range of 585.1–585.9. End stage renal disease, 585.6, includes the diagnosis of chronic kidney disease requiring chronic dialysis.

5. Review the different types of hematuria that can be coded in ICD-9-CM with 599.70-599.72 codes.

6. Review the revised “use additional code to identify symptoms” direction within ICD-9-CM category 600, Hyperplasia of prostate. Additional codes are used with codes 600.01, 600.21, and 600.91 to identify the specific symptom or manifestation that may occur in the patient with BPH with urinary obstruction. The terminology of other “lower urinary symptoms” or LUTS has been added to the code descriptions.

7. Emphasize the need for additional codes to identify the causative organism for urinary and genital tract infections when known.

8. Review the italicized ICD-9-CM subcategory codes within the chapter that require the coding of the underlying condition as the first code.

9. Compare the ICD-9-CM codes for symptomatic menopause (627), asymptomatic status (V49.81), and ovarian failure or premature menopause (256.3).


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http://kidney.niddk.nih.gov/

10. Review the differences in coding abnormal Pap smear findings. ICD-9-CM diagnosis codes of dyplasia or CIN I and II are included in this chapter. Other abnormal finding codes under subcategory 795.0 are available to describe the results of abnormal Pap smear tests.




1. Benign prostatic hypertrophy with urinary retention; percutaneous needle biopsy of prostate600.01, 788.20, 60.11

2. Acute pyelonephritis due to E. coli590.10, 041.9

3. Cervical dysplasia, CIN II; D&C622.12, 69.09

4. Chlamydial cystitis595.4, 099.53

5. Menometrorrhagia626.2

6. Chronic kidney disease, stage III585.3

7. Orchitis due to streptococcus 604.0, 041.00

8. Endometriosis of ovaries and tubes617.1, 617.2

9. Corpus luteum cyst with rupture; laparoscopic oophorectomy, right 620.1, 65.31

10. Postartificial menopause syndrome627.4


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1. How is chronic kidney disease classified in ICD-10-CM?

Chronic kidney disease is classified with ICD-10-CM category N18 with specific codes for stage I, II, III, IV, and V.

2. What terminology has replaced “benign prostatic hypertrophy or hyperplasia” in ICD-10-CM?

Category N40 has the title of “enlarged prostate” which replaces the terminology of BPH.

3. Give two examples of combination codes have been created in ICD-10-CM for genitourinary conditions.

Two examples of combination codes are N30.00, acute cystitis without hematuria and N30.01, acute cystitis with hematuria


1. Benign prostatic hypertrophy with urinary retention; percutaneous needle biopsy of prostateN40.1, R33.8, 0VBB03ZX

2. Acute pyelonephritis due to E. coliN10, B96.2

3. Cervical dysplasia, CIN II; D&CN87.1, 0UDB7ZZ

4. Chlamydial cystitisA56.01

5. MenometrorrhagiaN92.1

6. Chronic kidney disease, stage IIIN18.3

7. Orchitis due to streptococcus N45.2, B95.5

8. Endometriosis of ovaries and tubesN80.1, N80.2

9. Corpus luteum cyst with rupture; laparoscopic oophorectomy, right


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N83.1, 0UT04ZZ

10. Postartificial menopause syndromeN95.1


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Chapter 14

Complications of Pregnancy, Childbirth, and the Puerperium


Ectopic and molar pregnancy Pregnancy with abortive outcome Complications related to pregnancy, labor, and delivery Complications of the puerperium


1. Describe the organization of the conditions and codes included in chapter 11 of ICD-9-CM, Complications of Pregnancy, Childbirth, and the Puerperium (630-679)

2. Describe the organization of the conditions and coded included in chapter 15 of ICD-10-CM, Pregnancy, Childbirth and the Puerperium (O00-O99)

3. Define the term abortion and identify the different ICD-9-CM categories used to classify the diagnosis of abortion, including the meaning of the fifth digits used with these codes

4. Identify the different ICD-10-CM categories used to classify the diagnosis of abortion

5. Identify the circumstances in which ICD-9-CM category code 639, Complications following abortion and ectopic and molar pregnancies, is used to describe a woman’s condition

6. Define the phrase early onset of delivery and describe circumstances in which ICD-9-CM code 644.21 should be assigned

7. Define the terms missed abortion, threatened abortion, and recurrent pregnancy loss.

8. Define the term pregnancy and describe the ICD-9-CM guidelines for determining preterm, term, and postterm pregnancies

9. Define the term puerperium10.Briefly describe the ICD-9-CM guidelines for the sequencing of diagnosis codes

related to pregnancy11.Define the term ectopic pregnancy and explain the meaning of the fifth digits

used with the ICD-9-CM codes12.Explain the definitions of the fifth-digit subclassification numbers used with ICD-

9-CM pregnancy codes13.Define the term normal delivery and describe the procedures that can be

performed with a normal delivery14.Identify and describe the ICD-9-CM category V27 codes and describe the

circumstances in which these codes are used with a delivery code


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15.Identify the ICD-10-CM category Z37 codes and describe the circumstances in whichh these codes are used with a delivery code.

16.Identify and describe the various obstetrical and non-obstetrical conditions included in the ICD-9-CM category codes of 642–649

17.Identify and describe the four stages of labor18.Briefly describe the ICD-9-CM procedure codes used to identify delivery

procedures19.Briefly describe the pregnancy, labor, and delivery codes described in ICD-9-CM

categories 650-65920.Briefly describe the complication codes associated with labor and delivery

described in ICD-9-CM categories 660–66921.Describe the various types of perineal lacerations22.Identify and describe the various complication codes described by the ICD-9-CM

categories 673–67923.Assign diagnosis and procedure codes for chapter 11 of ICD-9-CM24.Assign diagnosis codes for chapter 15 of ICD-10-CM

Special Note to Instructors: The chapter on pregnancy coding is one of the more difficult chapters for instructors to teach and for students to learn. Extra class time is required to review the rules and conventions within ICD-9-CM Chapter 11. Take time to work through the exercises with the students using the Alphabetic Index to Disease and the Tabular List.


1. Review reputable websites for women's health, reproductive medicine, and obstetrics including the American Congress of Obstetricians and Gynecologists (http:// www.acog.org ), which has been very proactive in requesting new ICD-9-CM codes over the past several years.

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the structure of the reproductive systems.


1. Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter. Numerous slides are included to help work through the many rules related to pregnancy.

2. Review the Official Coding Guidelines for chapter-specific rules for the complications of pregnancy, childbirth, and the puerperium, Section I, C11 This is a lengthy guideline with important information to discuss.

3. Review the differences between spontaneous, induced, threatened, and missed abortions (ICD-9-CM code categories 632-638 and 640).

4. Review when “early onset of delivery” (ICD-9-CM code 644.21) is coded.


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http://www.acog.org/

5. Review the definitions for the fourth digits used with ICD-9-CM categories 634–638 that appear above code 634 in the code book.

6. Review the “Note” under ICD-9-CM category 639, Complications following abortion and ectopic and molar pregnancies. These codes can be used in two different situations. First, the codes may be used when the complication itself is responsible for the episode of care. Second, the codes may be used as an additional code when the complications are immediate complications of ectopic and molar pregnancies classifiable to 630–633 where they cannot be identified at fourth-digit level. Review the inclusion terms under category 639 to identify the conditions included within these subcategories.

7. Emphasize the ICD_9-CM time periods associated with the phrases “preterm” (before 37 completed weeks of gestation), “term” (during 38th week through the 40th week of gestation), “postterm” (over 40 completed weeks to 42 completed weeks gestation), and “prolonged” (advanced beyond 42 completed weeks of ) pregnancy.

8. Review the fifth digits used with ICD-9-CM codes 640–648 and 651–676, including which codes are used at the time of delivery, during the antepartum, and during the postpartum period. Explain the difference between fifth digits 1 and 2, which are distinguished by the fact a complication may have occurred prior to delivery or after delivery but prior to discharge from the hospital.

9. Review the definition of normal delivery and the procedures that can be used with ICD-9-CM category 650.

10. Review the requirements for use of an additional code to further specify the condition intended by the ICD-9-CM codes within categories 647 and 648.

11. Review ICD_9-CM category code 649, Other conditions or status of the mother complicating pregnancy, childbirth, or the puerperium. Subcategory codes are available to describe a pregnant woman with various conditions including tobacco use disorder, obesity, bariatric surgery status, coagulation defects, epilepsy, spotting complicating pregnancy, and uterine size date discrepancy. Additional codes are required to identify the type of obesity and the type of epilepsy present.

12. Review the ICD_9-CM definitions of elderly primigravida, elderly multigravida, and very young maternal age (codes 659.5, 659.5, and 659.8).

13. Review the “code first” notes under ICD_9-CM categories 652–654 and the “use additional code” notes under category 660 to examine the relationship between the categories.

14. Review ICD-9-CM category 672, which require a zero (0) inserted as the fourth digit before applying the appropriate fifth digit.


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15. Practice using the ICD-9-CM Alphabetic Index to Diseases with the student to locate pregnancy chapter codes.

16. Refer the student to the ICD-9-CM Alphabetic Index entries of delivery, labor, and pregnancy, as well as using a non-obstetrical condition as the access point when it includes a subterm that connects the condition to the fact that a pregnancy exists; for example, thrombophlebitis, pregnancy, or puerperal.

17. Review the rule that an ICD-9-CM pregnancy chapter code with a fifth digit of 3 can be used with an abortion code to explain the reason or cause of the abortive outcome of the pregnancy.




1. Pregnancy, delivered, with premature labor, single liveborn infant644.21, V27.0

2. Pregnancy, delivered, 40 weeks, liveborn infant, vaginal delivery, normal650, V27.0

3. Normal pregnancy, visit to OB clinic for prenatal supervision, 30 weeks gestation, first baby

V22.0

4. Spontaneous abortion, 12 weeks, incomplete, complicated by sepsis; dilation and curettage following abortion

634.01, 69.02

5. Pregnancy, twins, undelivered, 32 weeks651.03

6. Pregnancy, delivered, 35 weeks; single liveborn infant; postpartum fever of unknown origin; patient with known continuous marijuana drug dependence

644.21, V27.0, 672.02, 648.31, 304.31

7. Elective abortion, 12 weeks; fetus diagnosed with anencephaly (reason for abortion);dilation and curettage to terminate pregnancy635.92, 655.03, 69.01


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8. Ruptured ectopic tubal pregnancy, right-sided salpingectomy to remove pregnancy 633.10, 66.62

9. Pelvic peritonitis following elective abortion completed 5 days ago; patient admitted today with high fever

639.0

10. Gestational diabetes, undelivered, 30 weeks648.83 (If the patient required the use of insulin to treat the gestational diabetes, an additional code of V58.67, Long term (current) use of insulin, would be used.)


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1. What has replaced “episode of care” as part of the classification of pregnancy conditions?

Episode of care is no longer a secondary axis of classification for most conditions in Chapter 15. Instead ICD-10-CM identifies the trimester in which the condition occurred at the fifth- or sixth-character level.

2. What abortion code has been moved to another chapter in ICD-10-CM?

Codes for elective (legal or therapeutic) abortion (without complication) have been moved to code Z33.2, Encounter for elective termination of pregnancy, in Chapter 21 of ICD-10-CM.

3. What is the ICD-10-CM definition of “trimesters?”

Trimesters are counted from the first day of the last menstrual period and are defined as follows:

1st trimester = less than 14 weeks, 0 days2nd trimester = 14 weeks 0 days to less than 28 weeks 0 days3rd trimester = 28 weeks 1 days until delivery

4. What are the two possible ICD-10-CM category codes for prenatal outpatient visits?

For routine prenatal outpatient visits when there is no complication present, a code from category Z34 for the encounter for supervision of normal pregnancy is used as the first-listed code. If the prenatal outpatient visit is to manage a high-risk pregnancy, a code from Chapter 15 category O09, Supervision of high-risk pregnancy, is used as the first-listed code.

5. What ICD-10-CM category code replaces the ICD-9-CM code for outcome of delivery?

In ICD-10-CM a code from category Z37, Outcome of delivery, is used on every maternal record when a delivery occurs. This category of codes is equivalent to the ICD-9-CM category V27 codes for the outcome of delivery.

6. What is the definition of “normal delivery” in ICD-10-CM?

The definition of normal delivery in ICD-10-CM is the same as in ICD-9-CM: A full-term normal delivery occurs when the woman has no complications during the antepartum period, during delivery or postpartum during the delivery episode, and delivers a single, healthy infant. Code O80, encounter for full-term uncomplicated delivery, in ICD-10-CM replaces code 650 in ICD-9-CM. Code O08 is not used with any other code from chapter 15.


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7. What terminology has changed in the ICD-10-CM abortion codes as compared to ICD-9-CM?

The ICD-10-CM system does not contain codes for illegally induced abortions or unspecified abortions. Also removed from ICD-10-CM are the equivalent of ICD-9-CM’s fifth digits for abortion codes that indicate “complete,” “incomplete,” or “unspecified” status of the abortion.

8. What “abortion” code is not contained with the OB codes in Chapter 15?

The ICD-10-CM code for uncomplicated elective termination of pregnancy, Z33.2, is found in Chapter 21, Factors influencing health status and contact with health services, and not in Chapter 15 with the obstetric codes.

9. What time frames are used in ICD-10-CM related to maternal and fetal codes?

(1) The time frame for differentiating the abortion and fetal death codes has changed from 22 weeks to 20 weeks (category O36.4)

(2) The time frame for differentiating early and late vomiting in pregnancy has changed from 22 weeks to 20 weeks (category O21)

(3) Preterm labor is defined as before 37 completed weeks of gestation (category O60)

10. What codes are included in Chapter 21, Factors influencing health status and contact with health services, are related to obstetrical conditions?

The following categories relate to the pregnant female: Z32, Encounter for pregnancy test and childbirth and childcare instruction Z33, Pregnant state Z34, Encounter for supervision of normal pregnancy Z36, Encounter for antenatal screening of mother Z37, Outcome of delivery Z39, Encounter for maternal postpartum care and examination


1. Pregnancy, delivered, with premature labor, third trimester, single liveborn infantO60.14X0, Z37.0

2. Pregnancy, delivered, 40 completed weeks, liveborn infant, vaginal delivery, normalO48.0, Z37.0

3. Normal pregnancy, visit to OB clinic for prenatal supervision, 30 weeks 1 day gestation, first babyZ34.03


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4. Spontaneous abortion, 12 weeks, 1 day gestation, incomplete, complicated by sepsis; dilation and curettage following abortionO03.37, 10D17ZZ

5. Pregnancy, twins, undelivered, 32 weeksO30.003

6. Pregnancy, delivered, 35 weeks; single liveborn infant; postpartum fever of unknown origin; patient with known continuous marijuana drug dependence during pregnancyO60.14X0, O86.4, 099.323, F12.20, Z37.0

7. Elective abortion, 12 weeks; fetus diagnosed with anencephaly (reason for abortion); dilation and curettage to terminate pregnancyZ33.2, O35.0XX0, 10A07ZZ

8. Ruptured ectopic tubal pregnancy, right-sided salpingectomy to remove pregnancy O00.1, 0UT50ZZ

9. Pelvic peritonitis following elective abortion completed 5 days ago; patient admitted today with high feverO04.5

10. Gestational diabetes, undelivered, 30 weeksO24.419


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Chapter 15

Diseases of the Skin and Subcutaneous Tissue This lesson will focus on the following topics:

Infections of the skin and subcutaneous tissue Other inflammatory conditions of the skin and subcutaneous tissue Other diseases of skin, nails, hair follicles, sweat glands, and sebaceous glands Chronic ulcers of skin, urticaria, and other disorders.


1. Describe the organization of the conditions and codes included in chapter 12 of ICD-9-CM, Diseases of the Skin and Subcutaneous Tissue (680-709)

2. Describe the organization of the conditions and codes included in chapter 12 of ICD-10-CM, Diseases of the Skin and Subcutaneous Tissue (L00-L99)

3. Define and differentiate between the terms cellulitis and abscess4. Define the term erythema5. Describe the different stages of decubitus or pressure ulcers6. Briefly describe the types of procedures that can be performed on the breast,

as well as on skin and subcutaneous tissue7. Define and differentiate between the terms excisional and nonexcisional

débridement8. Assign ICD-9-CM diagnosis and procedure codes for diseases of the skin and subcutaneous tissue9. Assign ICD-10-CM codes for diseases of the skin and subcutaneous tissue

Special Note to Instructors: This chapter is straightforward and could be presented briefly with the students completing the exercises in order to review the nature of the conditions classified here. When necessary, this chapter could be assigned as an independent activity.


1. Review reputable websites for dermatology and wound care, such as American Academy of Dermatology (http://www.aad.org/).

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the layers of skin and subcutaneous tissue.


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http://www.aad.org/



2. Review the Official Coding Guidelines for chapter-specific rules for the diseases of skin and subcutaneous tissue, particularly pressure ulcer stage codes, Section I, C12

3. Review the “use additional code” note with several categories in this chapter to identify the causative organism, if known, of the skin infection.

4. Review the options for coding dermatitis due to various causes.

5. Review the coding of decubitus or pressure ulcers based on the body location and the stage of the ulcer. Review the descriptions of the four ulcer stages.

6. Review the “code, if applicable, any causal condition first” note with subcategory 707.1. This instruction directs the coder to assign the causal condition first when such a condition is identified. However, a chronic ulcer of the lower limbs may exist without an identified cause and the subcategory codes 707.10–707.19 may be used as a single code.

7. Review the procedure codes, particularly operations on the breast (85.0–85.99) and operations on the skin and subcutaneous tissue (86.01–86.99), because these procedures are commonly performed in a variety of healthcare settings.

8. Review the Coding Clinic directive in Second Quarter 2002, Second Quarter 2004 and Fourth Quarter 2004, which states that excisional debridement (86.22) can be assigned when it is performed by any healthcare provider, including non-physicians. In addition, nonexcisional or sharp debridement (86.28) may be coded when performed by either physicians or non-physicians.




1. Dermatitis of hands due to laundry detergent692.0

2. Chronic ulcer of right ankle due to atherosclerosis of extremities707.13


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3. Cellulitis of both feet682.7

4. Paronychia of finger681.02

5. Acute dermatitis due to sun exposure692.72

6. Acne rosacea695.3

7. Severe sunburn due to a tanning bed692.82An E code may be added to identify cause of condition: E926.2, exposure to radiation (including a tanning bed.)

8. Actinic keratosis of temple; excision of benign skin lesion702.11, 86.3

9. Foreign body granuloma; incision and drainage with removal of foreign body, skin of back709.4, 86.05

10. Localized scleroderma701.0


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1. How has ICD-10-CM Chapter 12 for Diseases of skin and subcutaneous tissue be restructured compared to the same chapter in ICD-9-CM?

Complete restructuring to bring together groups of diseases that are related Greater specificity added to many codes at the fourth-fifth-sixth character level There are nine block of codes in ICD-10-CM compared to three subchapters in ICD-9-CM.

2. How are pressure ulcer codes changed in ICD-10-CM?

ICD-9-CM required two codes to describe a pressure ulcer and the ulcer stage. In ICD-10-CM one code provides the site, laterality and the stage all in one code.

3. What term is used synonymously with dermatitis in categories L20–L30?

Eczema

4. What code must be coded first with any allergic or irritant contact dermatitis?

The instruction states “code first (T36–T65) to identify drug or substance.

5. What documentation is required to code the patient’s body mass index score or the pressure ulcer stage in ICD-10-CM?

As long as the diagnosis of obesity or overweight or pressure ulcer is documented by the patient’s provider, code assignment of the body mass index or pressure ulcer stage may be coded based on the documentation of another health care practitioner such as a dietitian or nurse according to ICD-10-CM coding guideline I.B.14.

6. What must be coded first with L97, Non-pressure chronic ulcers if an underlying condition is documented as the cause of the ulcer?

The associated underlying condition is coded first.


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7. What are the underlying conditions that can be assumed as a causal condition when documented with a lower extremity ulcer?

Atherosclerosis of the lower extremities Chronic venous hypertension Diabetes ulcers Postphlebitic syndrome Postthrombotic syndrome Varicose ulcer Or Any associated gangrene


1. Dermatitis of hands due to laundry detergent (irritant)T65.891AL23.5

2. Chronic ulcer of right ankle due to atherosclerosis of extremitiesI70.0233L97.311

3. Cellulitis of both feet (left and right)L03.115L03.116

4. Paronychia of fingerL03.019

5. Acute dermatitis due to sun exposureL56.8

6. Acne rosaceaL71.9

7. Severe sunburn, third degree, due to a tanning bedL55.2. W89.1xxA (assuming initial encounter)

8. Actinic keratosis of temple; excision of benign skin lesionL57.00HB1XZZ

9. Foreign body granuloma; incision and drainage with removal of foreign body, skin of backL92.30J973ZZ

10. Localized scleroderma


99

L94.0


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Chapter 16

Diseases of the Musculoskeletal System and Connective Tissue


Disorders of joints and connective tissue including various forms of arthritis Back disorders including spondylosis and herniated intervertebral disc Disorders of muscles, tendons and their attachments, and other soft tissue Other diseases of bone and cartilage, including infections and acquired deformities.


1. Describe the organization of the conditions and codes included in chapter 13 of ICD-9-CM, Diseases of the Musculoskeletal System and Connective Tissue (710-739)

2. Describe the organization of the conditions and coded included in chapter 13 of ICD-10-CM, Diseases of the musculoskeletal system and connective tissues (M00-M99)

3. Describe the types of arthritic conditions classified to ICD-9-CM categories 711–716 codes

4. Describe the conditions classified as dorsopathies using ICD-9_CM categories 720–724 codes

5. Define the two types of compartment syndrome6. Define and differentiate between the terms pathologic, malunion, nonunion,

and stress fractures7. Briefly describe the types of arthroscopic surgery that can be performed in the

musculoskeletalystem, including the circumstances in which to code “arthroscopy”in ICD-9-CM and in which to omit the ICD-9-CM codes when it serves as the operative approach8. Assign ICD-9-CM diagnosis and procedure codes for diseases of the musculoskeletal system and

connective tissue9. Assign ICD-10-CM codes for diseases of the musculoskeletal system and connective tissue

Special Note to Instructors: This chapter requires the student to follow the directions of the Alphabetic Index and Tabular List closely. Many codes require fifth digits. The student should be reminded to read the full description of the fifth digits that appear at the beginning of the chapter and apply to various codes throughout the chapter.



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1. Review reputable websites for neurology, neurosurgery, and orthopedic surgery, for example, http:// www.aaos.org , http:// www.neurology.org or http://www.neurosurgery.org/ . Another informative site is http:// www.spine-health.com .

2. Review medical terminology textbooks or anatomy and physiology textbooks for a solid understanding of the musculoskeletal system.


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http://www.spine-health.com/

http://www.neurosurgery.org/

http://www.neurology.org/

http://www.aaos.org/



2. Review the Official Coding Guidelines for chapter-specific rules for the coding of pathologic fractures, Section I, C13

3. Review the full descriptions of the fifth digits that appear at the beginning of the chapter and are used with a range of codes in the chapter.

4. Explain that these musculoskeletal and connective tissue conditions are often chronic, long term, and debilitating for the patient.

5. Review the definitions of pathologic or spontaneous fracture, malunion fracture, nonunion fracture, and stress fracture.

6. Compare the Alphabetic Index entries of osteoarthritis and osteoarthrosis to demonstrate the “see also” note and the choice of subterms available.

7. Review the Alphabetic Index entry of radiculopathy or radiculitis due to displacement of intervertebral disc to demonstrate the “see” note directing the coder to neuritis and eventually to find that the condition is an integral component of the disc displacement.

8. Review the coding of arthroscopic surgery of a joint including when a code for the arthroscopic approach is not needed.

9. Review the use of an additional procedure code to identify the different types of bearing surface materials used in hip replacement surgery.




1. Displacement lumbar intervertebral disc; laminectomy with excision of herniated intervertebral disc, lumbar

722.10, 80.51

2. Spontaneous fracture, fibula, due to drug-induced osteoporosis; application of external fixator device, fibula

733.16, 733.09, 78.17


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3. Internal derangement of knee in the lateral anterior horn717.42

4. Osteoarthritis, generalized in multiple sites715.09

5. Ganglion cyst in wrist tendon; excision of ganglion, right727.42, 82.21

6. Hallux valgus of left great toe; bunionectomy with arthrodesis735.0, 77.52

7. Acquired kyphosis, L1, percutaneous vertebroplasty, L1737.10, 78.49

8. Complete tear of rotator cuff of shoulder nontraumatic with rotator cuff surgical repair 727.61, 83.63

9. Prepatellar bursitis; injection of anti-infective drug into bursa in knee726.65, 83.96, 99.22

10. Polyarthropathy due to erythema nodosum695.2, 713.3


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1. What are three examples of codes that have been moved from various chapters in ICD-9-CM to Chapter 13 in ICD-10-CM?

New code M10, Gout was previously in ICD-9-CM chapter 3, Endocrine, nutritional and metabolic diseases and immunity disordersNew code M83, Adult osteomalacia was also previously in ICD-9-CM chapter 3.New code M26.4, Malocclusion was previously in ICD-9-CM chapter 9, Diseases of the Digestive system

2. What is the definition of “direct infection of joint” in ICD-10-CM?

Direct infection of joint is where organisms invade synovial tissue and microbial antigen is present in the joint.

3. What are the type types of indirect infection?

a. Reactive arthropathy where microbial infection of the body is established but neither organisms or antigens can be identified in the joint.

b. Postinfective arthropathy where microbial antigen is present but recovery of an organism is inconstant and evidence of local multiplication is lacking.

4. What is the age definition of “juvenile” in the diagnosis of juvenile idiopathic scoliosis?

Juvenile is defined as 5 through 10 years of age

5. What are the seventh-characters used with pathological or stress fracture codes in chapter 13 of ICD-10-CM?

1. initial encounter for fracture care2. D-subsequent encounter for fracture with routine healing3. G-subsequent encounter for fracture with delayed healing4. K-subsequent encounter for fracture with nonunion5. P-subsequent encounter for fracture with malunion6. S-sequela

6. What are examples of subsequent treatment included for encounter for fracture with routine healing (seventh-character “D”)?

Examples of subsequent treatment are cast change or removal, removal of external or internal fixation device, medication adjustment, or other aftercare and follow up visits.


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7. What are four types of pathologic fractures classified in chapter 13 of ICD-10-CM?

1. M80, Osteoporosis with current pathological fractures2. M84.4, Pathological fracture, not elsewhere classified3. M84.5, Pathological fracture in neoplastic disease4. M84.6, Pathological fracture in other disease

8. What is the definition of “fragility fracture” in chapter 13 of ICD-10-CM?

A fracture sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone.

9. What are the differences in bone, joint and muscle conditions in ICD-10-CM chapter 13 compared to chapter 19 of ICD-10-CM?

Codes in chapter 13 are bone, joint or muscle conditions that are the result of a healed injury and recurrent bone, joint, or muscle condition. Chronic or recurrent conditions should generally be coded with a code from chapter 13. Any current, acute injury should be coded to the appropriate injury code from chapter 19, Injury, poisoning and certain other consequences of external causes.

10. How has almost every code in chapter 13 of ICD-10-CM been changed?

Almost every code has been expanded in some way, with the expansion including very specific sites as well as laterality


1. Displacement lumbar intervertebral disc; laminectomy with excision of herniated intervertebral disc, lumbarM51.260SB20ZZ (excision) [Compare to resection if documented: 0ST40ZZ]

2. Spontaneous fracture, right fibula, due to drug-induced osteoporosis; application of external fixator device, fibula, monoplanar, percutaneous approachM80.8614A0QHJ353

3. Internal derangement of left knee in the lateral meniscus, anterior horn, old tearM23.242

4. Osteoarthritis, primary, generalized in multiple sitesM15.0


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5. Ganglion in wrist tendon; excision of ganglion, rightM67.4310LB50ZZ

6. Hallux valgus of left great toe metatarsal; open bunionectomy with arthrodesisM20.120QBP0ZZ0SGL0ZZ

7. Acquired kyphosis, L1, percutaneous vertebroplasty, L1M40.2050SQ03ZZ

8. Complete tear of rotator cuff of right shoulder nontraumatic with open rotator cuff surgical repair M75.110RQJ0ZZ

9. Prepatellar bursitis; injection of anti-infective drug into bursa in kneeM70.403E0U329

10. Polyarthropathy due to erythema nodosumL52M14.89


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Chapter 17

Congenital Anomalies and Certain Conditions Originating in the Perinatal Period


Congenital anomalies or conditions present since birth Coding for newborns and neonatal conditions


1. Describe the organization of the conditions and codes included in chapters 14 and 15 of ICD-9-CM, Congenital Anomalies (740-759) and Certain Conditions Originating in the Perinatal Period (760-779)

2. Describe the organization of the conditions and codes included in ICD-10-CM chapter 15, Certain conditions originating in the perinatal period (P00-P96) and chapter 17, Congenital malformation, deformations and chromosomal abnormalities (Q00-Q99)

3. Briefly describe the newborn ICD-9-CM coding guidelines, including how to sequence the newborn, congenital, and perinatal codes

4. Describe the newborn or perinatal period5. Define the term congenital anomaly6. Describe the process for coding a pediatric syndrome that is not listed in the

Alphabetic Index of ICD-9-CM7. Describe the process for coding a pediatric syndrome that is not listed in the

Alphabetic Index of ICD-10-CM8. Briefly describe the types of common congenital anomalies classified in chapter

14 of ICD-9-CM9. Describe the circumstances in which a code from chapter 15 of ICD-9-CM can

be assigned in terms of the age of the patient who has the condition10.Describe the circumstances In which a code from chapter 16 of ICD-10-CM can

be assigned in terms of the age of the patient who has the condition11.Describe the types of conditions classified in ICD-9-CM categories 760–763,

Maternal causes of perinatal morbidity and mortality, that may affect the fetus or newborn

12.Describe the circumstances in which codes from ICD-9-CM categories 764 and 765 are used on a newborn or perinatal record, including weeks of gestation and birth weight

13.Define the term meconium and describe the conditions associated with the passage of meconium

14.Review the types of respiratory infections and cardiac dysrhythmias that can occur in newborn and perinatal infants


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15. Assign ICD-9-CM diagnosis and procedure codes for congenital anomalies and certain conditions originating in the perinatal period

16. Assign ICD-10-CM codes for congenital anomalies and certain conditions originating in the perinatal period

Special Note to Instructors: This chapter in the textbook is addressing two chapters in the ICD-9-CM system: Chapter 14, Congenital Anomalies (740–759), and Chapter 15, Certain Conditions Originating in the Perinatal Period (760–779).


1. Review reputable websites for neonatology and pediatrics, such as the American Academy of Pediatrics, http://www.aap.org/.

2. Ask the students to identify other congenital anomalies than the ones described in the text book.

3. Determine how many grams equal a pound to understand birthweight statements.



2. Review the Official Coding Guidelines for chapter-specific rules for congenital anomalies, Section I, C14 , and for perinatal conditions, Section I, C15 . This section also discusses the use of V codes for newborns.

3. Define congenital anomaly.

4. Review the ICD-9-CM Alphabetic Index to Diseases for conditions that could be either congenital or acquired during a lifetime to compare the entries. For example, pes abductus or pes planus.

5. In the event that ICD-9-CM V-Codes have not been discussed at the time this chapter is presented, it is recommended that the instructor review the V30–V39 codes for liveborn infants according to type of birth. This would include review of the Alphabetic Index entries for newborn and the Tabular List.

6. Review the coding and sequencing of codes for a newborn identified as having a congenital anomaly at the time of birth. For example, ICD-9-CM V30.00, liveborn infant, and 745.2, Tetralogy of Fallot.

7. Review the coding and sequencing of codes for an infant transferred or re-admitted to a hospital for treatment of a congenital condition after the birth-hospital stay.


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http://www.aap.org/

8. Review the fact that congenital conditions can be coded for a person as long as the condition exists. These codes are not just assigned at the time of birth. Give an example: 40 -year-old woman with Down's syndrome would be coded 758.0, as would an infant born with the same condition.

9. Review the various types of congenital anomalies or birth defects that can be coded.

10. Review the "Includes" note that appears at the beginning of Chapter 15 in ICD-9-CM, categories 760–779. The conditions in this chapter have their origin in the perinatal period, before birth through the first 28 days after birth, even though death or morbidity occurs later. The condition could affect the individual beyond the first 28 days of life.

11. Review how many grams are equal to one pound (454 grams = 1 pound; 1000 gr = 2 lbs.) so students can appreciate the size of infants when birthweight is stated in grams. (Average birthweight is about 7 lbs; average length is 20 inches.)

12. Review the short gestation and low birthweight ICD-9-CM codes, 765.0 and 765.1. Review the “use additional code” note after 765.0 and 765.1 requiring the use of 765.2 for the weeks of gestation. Remind students that subcategory 765.2 is ONLY used with category 764, Slow fetal growth and fetal malnutrition, and with subcategory codes 765.0 and 765.1, Short gestation or low birthweight (preterm) babies. Codes within 765.2 are not used with infants who are full term births.

13. Remind students that the terms “newborn,” “neonatal,” and “perinatal” may be interchanged in medical language and in the ICD-9-CM Alphabetic Index to Diseases.

14. Review an ICD-9-CM Alphabetic Index entry to observe the use of a subterm for newborn or neonatal, for example, a newborn with septicemia or neonatal jaundice.

15. Review the ICD-9-CM codes for meconium passage during delivery (763.84), meconium staining (779.84), meconium aspiration (770.11), and meconium aspiration syndrome (770.12) as these describe different neonatal conditions

16. Review the Includes note under ICD-9-CM category 771, Infections specific to the perinatal period. These codes include infections acquired before or during birth or via the umbilicus during the first 28 days after birth.

17. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM17.




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1. Cleft lip and cleft palate749.20


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2. Patent ductus arteriosus747.0

3. Hypoplastic left heart syndrome746.7

4. Premature baby, 2000 gm. birthweight, 35 weeks of gestation, born in Hospital #1 and transferred to Hospital #2 (Code for hospital #2)765.18, 765.28

5. Premature baby, 990 gm. birthweight, 29 weeks of gestation, born in Hospital #1 and transferred to Hospital #2 (Code for hospital #2)765.04, 765.25

6. Fragile X syndrome759.83

7. Grade II intraventricular hemorrhage, 2-day-old infant transferred to this hospital for care772.12

8. Congenital atresia of colon751.2

9. Drug withdrawal in an infant born to a mother who is dependent on drugs779.5

10. Five-day-old infant, light-for-dates, 2200 gm. birthweight, 35 week gestational age at birth 764.08765.28


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Chapter 16, Certain conditions originating the perinatal period (P00–P96)

1. What has been removed from the code titles in ICD-10-CM chapter 16 as compared to the similar ICD-9-CM codes?

The terms “fetus” and “newborn” used in many ICD-9-CM code titles have been removed in ICD-10-CM code titles

2. Are the ICD-10-CM codes in chapter 16 used for only confirmed conditions?

No, the phrase “suspected to be” is included in the code title in ICD-10-CM as a nonessential modifier to indicate that the codes are for use when the listed maternal condition is specified as the cause of confirmed or suspected newborn morbidity or potential morbidity.

3. When both birth weight and gestational age of the newborn is documented, what is the sequencing of the codes for these conditions?

Both conditions, birth weight and gestational age, are coded with birth weight code sequenced before gestational age.

4. Are the codes from ICD-10-CM chapter 16 limited to use when the patient is a newborn?

No, should a condition originate in the perinatal period continue through the life of the child, the perinatal code should continue to be used regardless of the age of the patient. The condition must have occurred before birth and through the 28th day following birth.

5. How are the immaturity and prematurity codes organized in ICD-10-CM chapter 16?

In ICD-10-CM, the codes are divided into two subcategories. Subcategory P07.2 is used for extreme immaturity of newborn, defined as less than 28 completed weeks, with specific codes for less than 24 completed weeks, 24-26 completed weeks, and 27 completed weeks. Subcategory P07.3 is used for other preterm newborn, defined as 28 completed weeks or more but less than 37 completed weeks with specific codes for 28-31 completed weeks and 32-36 completed weeks.

Chapter 17, Congenital malformations, deformations and chromosomal abnormalities, Q00–Q99

1. How are congenital anomalies or syndromes coded in ICD-10-CM when no specific code exists for a specific syndrome?

If there is no specific code for a specific syndrome or anomaly, a code should be assigned for each manifestation of the syndrome, from any chapter in ICD-10-CM.


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2. Are the codes for Chapter 17, congenital conditions, restricted for a certain age group in patients?

No, a code from chapter 17 is not only coded at birth or when it is first diagnosed. If a congenital condition remains throughout the life of the patient, the condition may be coded with a code from ICD-10-CM chapter 17.

3. What is the main difference in the codes in ICD-10-CM for chromosomal abnormalities?

While chromosomal anomalies are classified to category 758 in ICD-9-CM, there are nine categories (Q90, Q91, Q92, Q93, Q95, Q96, Q97, Q98 and Q99) for chromosomal abnormalities not elsewhere classified.

4. Are manifestations of congenital anomaly or chromosomal abnormality coded separately?

When the code assignment specifically identifies the malformation, deformation or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are not an inherent component.

5. If a congenital anomaly has been corrected, how is the condition coded?

If the congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity.


1. Cleft lip and cleft palateQ37.9

2. Patent ductus arteriosusQ25.0

3. Hypoplastic left heart syndromeQ23.

4. Premature baby, 2000 gm. birthweight, 35 weeks of gestation, born in Hospital #1 and transferred to Hospital #2 (Code for hospital #2)Premature baby, 990 gm. birthweight, 29 weeks of gestation, born in Hospital #1 and transferred to Hospital #2 (Code for hospital #2)P07.18P07.32

6. Fragile X syndromeQ99.2

7. Grade II intraventricular hemorrhage, 2-day-old infant transferred to this hospital for care


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P52.1

8. Congenital atresia of colonQ42.9

9. Drug withdrawal in an infant born to a mother who is dependent on drugsP96.1

10. Five-day-old infant, light-for-dates, 2200 gm. birthweight, 35 week gestational age at birth P05.08


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Chapter 18

Symptoms, Signs, and Ill-Defined Conditions This lesson will focus on the following topics:

Subjective physical symptoms reported by patients as reasons for healthcare visits Objective signs, abnormal physical findings, abnormal diagnostic test results and ill-defined

conditions reported by the healthcare provider/physician for a patient Determining the appropriate coding of signs and symptoms according to coding rules and the

outpatient coding guidelines


1. Describe the organization of the conditions and codes included in chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-Defined Conditions (780-799)

2. Describe the organization of the conditions and codes included in chapter 18 of ICD-10CM, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, not elsewhere classified (R00-R99)

3. Define and differentiate between the terms signs and symptoms4. Describe the circumstances in which a coder should use a code from chapter 16

of ICD-9-CM5. Describe the ICD-9-CM guidelines for the assignment of a symptom code with

an established disease code6. Explain how symptom codes are organized in chapter 16 of ICD-9-CM7. Describe the types of conditions classified to the ICD-9-CM categories 790–796

for nonspecific abnormal findings8. Identify the ICD-9-CM Alphabetic Index entries for locating nonspecific

abnormal findings in order to code them9. Referring to the ICD-9-CM Official Guidelines for Coding and Reporting, briefly

describe the use of sign and symptom codes for hospital inpatients as a principal or additional diagnosis

10.Describe the differences in coding of qualified diagnosis, such as possible or probable, when the patient is an inpatient in the hospital as opposed to an outpatient in any healthcare setting

11.Describe when ICD-10-CM codes fro coma scale (R40.1-R40.23) are used12. Assign ICD-9-CM diagnosis and procedure codes for symptoms, signs, and ill-

defined conditions13. Assign ICD-10-CM codes for symptoms, signs and abnormal findings

Special Note to Instructors: This chapter is straightforward to present. Some instructors prefer to present the lessons of chapter 18 at the beginning of the coding course as the material is easy for the student to understand. Codes from this chapter are very common in the outpatient and physician office settings. The ICD-9-CM Official Guidelines for Coding


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and Reporting should be reviewed for statements regarding the use of sign and symptom codes as principal or other diagnoses in inpatient settings and as primary or other diagnoses in the outpatient setting.


1. Review the ICD-9-CM Official Guidelines for Coding and Reporting and identify each statement in the guidelines that addresses the use of codes for signs and symptoms.



2. Review the Official Coding Guidelines for general coding guidelines regarding the coding of signs and symptoms (Section I), for selection of principal diagnosis (Section II), and diagnostic coding and reporting guidelines for outpatient services (Section IV).

Make particular note of the outpatient coding guideline that describes how symptoms codes are frequently used in the outpatient setting in place of a statement such as “rule out pneumonia” because the physical signs and symptoms would reflect the highest degree of certainty as to the patient’s condition.

Codes from this chapter in ICD-9-CM are very commonly used in the physician office, outpatient hospital, or other ambulatory settings to describe the reason(s) for the patient’s visit.

3. Define sign and symptom.

4. Describe when to use a code from ICD-9-CM Chapter 16.

5. Review the coding of signs or symptoms found in Chapter 16 of ICD-9-CM in addition to the established diagnosis that may explain the presence of the sign or symptom.

6. Review when it is acceptable to use test results or findings to assign an ICD-9-CM diagnosis code.

7. Review when a sign or symptom code may be used as a principal diagnosis for an inpatient encounter.

8. Review when a sign or symptom code may be used as an additional diagnosis for an inpatient encounter.9. Review the coding of signs, symptoms and abnormal test results as outpatient diagnosis codes


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Consider the following coding examples as outpatient visits. Assign the correct ICD-9-CM code for each outpatient visit.

1. Fever of unknown origin; rule out sepsis780.60

2. Abnormal liver function study 794.8

3. Positive TB (tuberculin) skin test 795.51

4. Abnormal prothrombin time790.92

5. Generalized abdominal pain, suspect pancreatitis 789.07

6. Microcalcifications found on mammogram; possible neoplasm of breast793.81

7. Burning and tingling sensation of toes782.0

8. Coin lesion of lung793.11

9. Abnormal cardiovascular function study, MUGA test794.39

(A MUGA test is a specific form of a cardiovascular function test, so code 794.30 is not used because it is an “unspecified” code).

10. Elevated lithium level in blood, no symptoms in patient, taking lithium as prescribed790.6


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1. What types of conditions are included in Chapter 18 of ICD-10-CM?

In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically, all categories in the chapter could be designated “not otherwise specified”, “unknown etiology”, or “transient.”

2. When is the diagnosis of “hematuria” not coded in chapter 18 of ICD-10-CM?

When hematuria is included with the underlying condition such as acute cystitis with hematuria, that condition is coded to chapter 14, Diseases of the genitourinary system and not in chapter 18 of ICD-10-CM.

3. How are the abnormal findings grouped in blocks in ICD-10-CM?

Abnormal findings without a diagnosis are grouped according to examination of: blood urine other body fluids, substances and tissues diagnostic imaging and in function studies. In addition, abnormal tumor markers are grouped together

4. What are the main terms used in the ICD-10-CM Alphabetic Index to access the symptom and abnormal finding codes?

Such terminology used in the Alphabetic Index include terms such as “abnormal, abnormalities, elevated, elevation, findings-abnormal-inconclusive-without-diagnosis, and positive.” These terms are similar to those used in ICD-9-CM.

5. The Glasgow Coma Scale codes are likely to be used with what type of disease codes?

The Glasgow Coma Scale codes are used in conjunction with traumatic brain injury or sequelae of cerebrovascular disease codes.

Assign the ICD-10-CM code for each outpatient visit for the following ten statements.

1. Fever of unknown origin; rule out sepsisR50.9

2. Abnormal liver function study R94.5


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3. Positive TB (tuberculin) skin test R76.1

4. Abnormal prothrombin timeR79.1

5. Generalized abdominal pain, suspect pancreatitis R10.84

6. Microcalcifications found on mammogram; possible neoplasm of breastR92.0

7. Burning and tingling sensation of toesR20.8, R20.2

8. Coin lesion of lungR91

9. Abnormal cardiovascular function study, MUGA testR94.39(A MUGA test is a specific form of a cardiovascular function test, so a code for a specific test is used.

10. Elevated lithium level in blood, no symptoms in patient, taking lithium as prescribedR78.89


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Chapter 19

Injury and Poisoning IThis lesson will focus on the following topics:

Traumatic Injuries Conditions coded to the range of ICD-9-CM codes from 800–959


1. Describe the organization of the conditions and codes included in chapter 17 of ICD-9-CM, with a focus on injuries, categories 800-959.

2. Describe the organization of the conditions and codes included in chapter 19 of ICD-10-CM with a focus on injuries, categories S00-T34

3. Define the term fracture4. Identify the terms synonymous with the descriptions of closed and open

fracture5. Identify circumstances in which to use the acute traumatic fracture codes and

the fracture aftercare codes in ICD-9-CM6. Define the term dislocation and describe closed and open dislocation7. Define and differentiate between the terms of sprain and strain and be familiar

with the Alphabetic Index entries for both terms8. Briefly describe the different forms of intracranial injury classified to category

codes 850–854 of ICD-9-CM9. Identify terminology that is synonymous with the term open wound in ICD-9-CM10.Explain the meaning of complicated as it pertains to open wound11.Briefly describe first-degree, second-degree, third-degree, and deep, full-

thickness burns12.Explain the ICD-9-CM coding guidelines for assigning diagnosis codes for burns,

including the late-effect conditions of burns13.Describe the types of injuries that are classified as superficial injuries in

category codes 910–919 of ICD-9-CM14.Explain the ICD-9-CM coding sequencing rule used to describe patients who

have both an open wound and an injury to blood vessels, nerves, or spinal cord15.Describe the process of ICD-9-CM coding for the presence of a foreign body

entering through a natural orifice as compared to the presence of a foreign body within an open wound or within an operative wound

16.Identify the correct seventh character extension required for reporting certain injury codes in ICD-10-CM

17. Assign ICD-9-CM diagnosis codes for injuries18. Assign ICD-10-CM codes for injuries

Special Note to Instructors: This chapter contains many definitions and instructions regarding the coding of injuries as the result of trauma. This chapter may take more time to


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present than several of the preceding chapters in the textbook. It is important to stress the Official Coding Guidelines that correspond to the coding of injuries; see Section I, C17.


1. Review reputable websites regarding emergency medicine services, such as:http://www.acep.org/ for the American College of Emergency Physicianshttp://www.sccm.org/ for the Society for Critical Care Medicine.

2. Locate the website for emergency medical services at a local hospital or academic medical center.

3. For a collection of photographs related to EMS services, visit http://www.911pictures.com/.



2. Review the Official Coding Guidelines for chapter-specific rules for the coding of injury and poisoning, Section I, C17

3. Review main terms or entries to use in the ICD-9-CM Alphabetic Index for injuries (type of injury followed by location).

4. Emphasize the importance of fifth digits with injury codes to describe specific conditions.

5. Review definition of open and closed fracture, including the assumption that a fracture is closed unless described by the physician as open.

6. Point out that a radiologist’s description or impression in a radiology report may be used to further describe the site of a fracture (i.e., shaft of femur) if the physician had documented the presence of a fracture in the record. (Coding Clinic, First Quarter 1999)

7. Review the definitions of dislocation and subluxation.

8. Compare the ICD-9-CM Alphabetic Index entries for Strain and Sprain with respect to use of the “see also” note.

9. Review the ICD-9-CM Alphabetic Index entry for Injury and review the extensive list of subterms, such as internal and superficial.

10. Define open wound and complicated open wound. In addition, review the “includes” and “excludes” notes and the note that appears at the start of the section for Open Wounds (ICD-9-CM codes 870–897).


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http://www.911pictures.com/

http://www.sccm.org/

http://www.acep.org/

11 Review the definitions of first-, second-, and third-degree burns and the appropriate coding and sequencing.

12. Review the standard that superficial injuries are not coded when present at the same site with more serious injuries.

13. Review the standard that injuries to peripheral blood vessels and nerves may be assigned as the primary injury or as an additional code, depending on what is the most severe injury.

14. Review the ICD-9-CM Alphabetic Index entries for nerve injuries and spinal cord injuries to emphasize the specificity included.

15. Review the coding of traumatic complications and unspecified injuries, ICD-9-CM category codes 958-959.

16. Review the coding of foreign bodies entering through orifices, ICD-9-CM category codes 930-939.

17. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM


Assign the correct ICD-9-CM code for each patient.

1. Fracture, radius, lower end813.42

2. Dislocation elbow, lateral832.04

3. Open wound, laceration, hand, with foreign body882.1

4. Foreign body in conjunctiva930.1

5. Burn, second- and third-degree, of lower legs945.34

6. Laceration of scalp with infection present873.1


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7. Burn, first- and second-degree, of chest942.22

8. Contusions of face, chest, and arms920, 922.1, 923.9

A student may ask why code 924.8, Contusion of multiple sites not elsewhere classified, cannot be used instead of three individual codes. If the number of reportable codes was limited and the patient had other more serious conditions that required reporting, the use of the multiple contusion code would be reasonable. However, three specific individual codes are preferred to report the patient’s actual injuries.

9. Fracture of nasal bones802.0

10. Insect bites on lower extremities916.4


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1. What is the significant modification made to the organization of Chapter 19?

Specific types of injuries are arranged by body region beginning with the head and concluding with the ankle and foot. All injuries of the specific site are grouped together rather than groupings of one type of injury as was done in ICD-9-CM.

2. What two alphabetic characters are used in Chapter 19 codes?

The S section provides codes for the various types of injuries related to a single body region. The T section covers injuries to unspecified body regions as well as poisonings and certain other consequences of external causes.

3. What additional code(s) are used with chapter 19 codes?

A note refers to the entire chapter: Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause as part of the T code do not require an additional external cause code.

4. What specificity has been added to the ICD-10-CM fracture codes?

Some of the information found in fracture codes includes the type of fracture, specific anatomical site, whether the fracture is displaced or not, laterality, routine versus delayed healing, nonunions and malunions. Identification of type of encounter (initial, subsequent, sequel) are also included in the code expansion.

5. What is the ICD-9-CM guideline concerning the use of the terminology of displaced versus nondisplaced and open versus closed for fractures?

A fracture not indicated as displaced or nondisplaced should be coded to displaced. A fracture not designated as open or closed should coded to closed.

6. What treatment is included in the terminology of “initial encounter?”

Initial encounter is used when a patient is receiving active treatment for an injury such as surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

7. What is meant by “subsequent encounter” for the injury codes?

Subsequent encounter extension is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. For example, cast change or removal, removal of external or internal fixation device, medical adjustment, other aftercare and follow up visits following injury treatment.


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8. How is the extension “S” for sequel used?

Extension S, sequel, is used for complications or conditions that arise as a direct result of an injury, such as a scar formation after a burn. When using extension S, it is necessary to use both the injury code that precipitated the sequel and the code for the sequela itself. The “S” extension is only added to the injury code to identify the injury responsible for the sequela. The specific type of sequel is sequenced first, followed by the injury code.

9. Are the aftercare Z codes used with the injury codes?

No, the aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, the acute injury code is assigned with the appropriate seventh character extension for “subsequent encounter.”

10. What is the difference between the coding terms “burns” versus “corrosions?”

The burn codes identify thermal burns, except for sunburns, that come from a heat source. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals.

Assign the correct ICD-9-CM code for each patient’s initial visit for the condition.

1. Fracture, radius, lower end, leftS52502A

2. Dislocation elbow, lateralS53146A

3. Open wound, laceration, right hand, with foreign bodyS61421A

4. Foreign body in conjunctiva, leftT1512xA

5. Burn, second- and third-degree, of lower legsT24301AT24302A

6. Laceration of scalp with infection presentS0101xA

7. Burn, first- and second-degree, of chestT2121xA


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8. Contusions of face, chest, and armsS0083xAS20219AS40021AS40022A

9. Fracture of nasal bonesS022xxA

10. Insect bites on lower legsS80861AS80862A


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Chapter 20

Injury and Poisoning IIThis lesson will focus on the following topics:

Poisoning and adverse effects of drugs Complications of surgical and medical care, not classified elsewhere


1. Describe the organization of the conditions and codes included in chapter 17 of ICD-9-CM, Injury and Poisoning, with a focus on poisoning, adverse effects of drugs, and complications, categories 960-999

2. Describe the organization of the conditions and codes included in chapter 19 of ICD-10-CM, Injury and poisoning, with a focus on poisoning and certain other consequences of external causes, categories T36-T88.

3. Describe the circumstances in which an adverse effect of a drug can occur in a patient

4. Explain the instructions for coding current adverse effects of drugs to identify which ICD-9-CM code is sequenced first and which other codes may be assigned

5. Explain the instructions for coding the late effects of an adverse effect of drugs to identify which ICD-9-CM code is sequenced first and which other codes may be assigned

6. Identify the terminology that may be used in the health record to identify an unspecified adverse effect of drugs

7. Explain the instructions for coding unspecified adverse effects of drugs to identify which ICD-9-CM code is sequenced first and which other codes may be assigned

8. Define the term poisoning9. Explain the instructions for coding current poisonings to identify which ICD-9-

CM code is sequenced first and which other codes may be assigned10.Explain the instructions for coding the late effects of a poisoning to identify

which ICD-9-CM code is sequenced first and which other codes may be assigned11.Define the term underdosing12.Describe the organization of the Table of Drugs and Chemicals in ICD-9-CM and

identify which E codes are used with poisonings and which E codes are used to report adverse effects of drugs

13.Describe the organization of the ICD-10-CM Table of Drugs and Chemicals and identify which codes are used for which of the following circumstances: poisoning, adverse effect, and underdosing

14. Describe the circumstances in which a complication of surgical and medical care code from ICD-9-CM categories 996–999 may be used

15. Identify the types of conditions that are reported with codes from categories 996-999 and describe the circumstances in which an additional code is required


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16. Explain the instructions for coding complications to identify the various main terms found in the ICD-9-CM Alphabetic Index to locate the codes

17. Identify the correct seventh character extension required for reporting certain codes in ICD-10-CM18. Assign ICD-9-CM diagnosis and procedure codes for poisoning and adverse effects of drugs,

poisoning, and complications of surgical and medical care19. Assign ICD-10-CM codes for adverse effects, poisonings, underdosing, and complications of

surgical and medical care

Special Note to Instructors: Students often have difficulty distinguishing between the adverse effects of drugs and poisonings by drugs and other chemicals. The importance of the physician's documentation that a causal relationship exists between a condition and the preceding medical or surgical care must be emphasized.


1. Review reputable websites to gain more information about drugs and medicine:http://www.pdrhealth.com/ or http://www.pdr.net or http://www.rxlist.com/.



2. Review the Official Coding Guidelines for chapter-specific rules for the coding of injury and poisoning and for external cause codes, Section I, C17 and Section I, C19

3. Review the ICD-9-CM Table of Drugs and Chemicals, including the instructions at the beginning.

4. Using the ICD-9-CM Table of Drugs and Chemicals, emphasize that an E code for therapeutic use is never assigned with a poisoning diagnosis code.

5. Review Figures 20.1 and 20.2 in the textbook to compare the differences in coding adverse reactions to drugs and poisonings.

6. Explain that a poisoning diagnosis describes a situation where something was done WRONG: wrong drug, wrong dose, wrong person, or wrong combination with another drug or chemical, such as alcohol.

7. Explain an adverse effect diagnosis describes a situation where everything was done RIGHT: right person, right drug, right dose, but the person became ill as a result of ingesting or using the drug or substance.

8. Emphasize that the only E codes that are required in ICD-9-CM are those that describe the therapeutic use of drugs, E930–E949. All other E codes for trauma and for poisonings are optional.


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http://www.rxlist.com/

http://www.pdr.net/

http://www.pdrhealth.com/

9. Encourage the students to read carefully all includes, excludes, and inclusion terms within the ICD-9-CM code range 996–999 to accurately describe complications.

10. Describe the difference between the codes within ICD-9-CM category 996 that describe the mechanical complication of a device and other codes that describe the body’s infection or inflammatory reaction to the presence of a device, as well as other complications due to the presence of a device.

11. Emphasize the instruction to use an additional code with ICD-9-CM category 997 to further describe the nature of the complication.

12. Encourage students to verify the presence of postoperative and other complications of medical care with the attending physician if the documentation is unclear.

13. Review ICD-9-CM Alphabetic Index to Disease entries to identify possible postoperative or postprocedural complications, such as Pneumothorax, postoperative.

14. Review the entry “Complications” in the ICD-9-CM Alphabetic Index to Disease with the students to locate the various entries for complications due to a device, implant or graft, mechanical complications, or complications resulting from surgical care.

15. Review the specific steps in the ICD-9-CM coding of complications -

16. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM


Assign the correct ICD-9-CM code for each patient.

1. Coma due to barbiturate overdose; attempted suicide967.0, 780.01, E950.1 [Poisoning code must be used first.]

2. Two-year-old child ingested mother’s birth control pills by accident; no symptoms or illness in child

962.2, E858.0 [Poisoning code must be used first.]

3. Ataxia due to prescription Valium consumed with alcohol969.4, 980.0, 781.3, E980.3, E980.9 [Poisoning code must be used first.]


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4. Generalized convulsions due to accidental Darvon overdose 965.8, 780.39, E850.8 [Poisoning code must be used first.]

5. Hypotension due to Methadone poisoning, undetermined cause965.02, 458.9, E980.0 [Poisoning code must be used first.]

6. Premature atrial beats due to prescribed digitalis427.61, E942.1 [Premature atrial beats are the “adverse effect” of digitalis.]

7. Infant with a high fever after correct administration of diphtheria toxoid vaccine780.60, E948.5 [Fever is the adverse effect.]

8. Hematuria due to an accumulative effect of anticoagulant therapy599.70, E934.2 [Hematuria is the adverse effect.]

9. Blurred vision due to allergic reaction to antihistamine368.8, E933.0 [Blurred vision is the adverse effect.]

10. Parkinson's disease secondary to correct use of haloperidol332.1, E939.2 [Secondary Parkinson’s disease is the adverse effect.]

11. Infection due to the presence of a knee joint prosthesis996.66

12. Transfusion reaction999.89

13. Urinary tract infection due to the presence of an indwelling urinary catheter996.64, 599.0


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1. Are there separate category of codes in ICD-10-CM for poisoning, adverse effect and underdosing of particular drugs?

No, in ICD-10-CM a single category for a specific drug exists with codes for poisoning, adverse effects and underdosing of that particular drug as well as the external cause. No additional external cause code is required for poisonings, toxic effects, adverse effects, and underdosing codes.

2. What is the definition of underdosing in ICD-10-CM?

Underdosing is defined as taking less of a medication than is prescribed by a provider or the manufacturer’s instructions with a resulting negative health consequence.

3. What additional code may be used with the T36-T50, Poisoning by, adverse effect of and underdosing of drugs, medicaments and biological substances?

A code from categories T36-T50 is sequenced first, followed by the code(s) that specify the nature of the poisoning, adverse effect, or toxic effect. This instruction does NOT apply to the underdosing codes.

4. What may be coded with the underdosing codes?

Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition is coded first with an additional code to identify the underdosing of the particular drug. In addition, noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.61, Y63.8-Y63.9) codes are used with the underdosing code to indicate intent, if known.

5. When the intent of the poisoning (accidental, intentional self harm, assault or undetermined) is not indicated in the documentation, how is it coded?

When the intent is not stated, the condition is coded to accidental intent. Different from ICD-9-CM, undetermined intent is only for use when there is specific documentation in the record that the intent of the poisoning cannot be determined.

6. Are external cause of injury and poisoning codes used with the T36-T50 codes?

No, the external cause is included within the T36-T50 codes themselves so no additional cause of injury code is required.


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7. What is the definition of adverse effect and poisoning in ICD-10-CM?

Adverse effect is a hypersensitivity or reaction to a substance correctly prescribed and properly administered. In comparison, poisoning is an overdose of a substance or the wrong substance given or taken in error.

8. How is the ICD-10-CM Table of Drugs and Chemicals organized?

The ICD-10-CM Table of Drugs and Chemicals is organized into seven columns with rows for the substances involved. The first, left-most column contains the name of the drug, chemical, or biological substance. The next six columns contains:1. Poisoning, accidental (nonintentional)2. Poisoning, intentional self-harm3. Poisoning, assault4. Poisoning, undetermined5. Adverse effect6. Underdosing

Assign the correct ICD-10-CM code for each patient—consider all of these as initial treatment visits.

1. Coma due to barbiturate overdose; attempted suicideT42.3x2A, R40.20[Poisoning code must be used first.]

2. Two-year-old child ingested mother’s birth control pills by accident; no symptoms or illness in childT38.4x1A

3. Ataxia due to prescription Valium consumed with alcoholT42.4x1A, T51.91xAR27.0[Poisoning code must be used first.]

4. Generalized convulsions due to accidental Darvon overdose T39.8x1A, R56.9[Poisoning code must be used first.]

5. Hypotension due to Methadone poisoning, undetermined causeT40.3x4AI95.2[Poisoning code must be used first.]


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6. Premature atrial beats due to correctly prescribed digitalisT46.0x5AI49.1[Premature atrial beats are the “adverse effect” of digitalis.]

7. Infant with a high fever after correct administration of diphtheria toxoid vaccineT50.a95aR50.2[Fever is the adverse effect.]

8. Hematuria due to an accumulative effect of anticoagulant therapyT45.515A, R31.9[Hematuria is the adverse effect.]

9. Blurred vision due to allergic reaction to antihistamineT45.0x5AH53.8[Blurred vision is the adverse effect.]

10. Parkinson's disease secondary to correct use of haloperidolT65.891AG21.19 [Secondary Parkinson’s disease is the adverse effect.]

11. Infection due to the presence of a knee joint prosthesisT84.53xA

12. Transfusion reactionT80.89xA

13. Urinary tract infection due to the presence of an indwelling urinary catheterT83.51xAN39.0


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Chapter 21

Supplementary Classifications—E CodesThis lesson will focus on the following topics:

External cause of injury and poisoning code (E800–E999) Guidelines for coding external causes of injuries


1. Describe the organization of the ICD-9-CM supplementary classification chapter for External Causes of Injury and Poisoning codes (E000-E999)

2. Define the “E” in ICD-9-CM E codes and describe what the codes represent3. Be familiar with the separate ICD-9-CM Alphabetic Index to External Causes of

Injury and Poisoning and identify the terminology used as main terms to access this Index

4. Identify which ICD-9-CM E codes are optional and which are required to be reported by healthcare providers

5. Explain the sequencing of ICD-9-CM E codes in comparison with diagnosis codes6. Identify the circumstances in which an ICD-9-CM E code may be assigned for

the treatment of an injury, poisoning, or adverse effect in terms of the initial treatment versus the subsequent treatment

7. Determine how many ICD-9-CM E codes may be assigned according to the general E code guidelines

8. Describe the ICD-9-CM multiple-cause coding guidelines for E codes, focusing on the priority given to particular E codes in terms of sequencing and reporting

9. Identify the way in which ICD-9-CM E codes should be used to report child or adult abuse according to the coding guidelines

10.Describe the ICD-9-CM “place of occurrence” E codes and identify the circumstances in which the codes can be reported

11.Explain the types of ICD-9-CM E codes available to report a terrorism event12.Describe the way in which ICD-9-CM E codes can be used to describe the late

effect of an illness or injury13. Assign ICD-9-CM E codes from the supplementary classification to describe the external cause of

injury, including the place of occurrence14. Describe the organization of the codes included in chapter 30 of ICD-10-CM, External causes of

morbidity (V00-Y99)15. Identify the types of entries found in the ICD-10-CM Index to External Causes that are used to

locate the code for the external cause16. Identify the correct seventh character extension required for reporting certain codes in ICD-10-CM17. Assign ICD-10-CM codes for external causes of morbidity.

Special Note to Instructors: Students often find the use of the Alphabetic Index to External Causes to be challenging because they must shift their thought process of identifying the


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main term from a disease state to an event. Encourage the student to read all the notes and definitions included in this chapter.


1. Practice assigning E codes for events and accidents described in the local news to make the use of E codes more realistic.



2. Review the ICD-9-CM Official Coding Guidelines for chapter-specific rules for E codes for external causes, Section I, C19 .

3. Emphasize that ICD-9-CM E codes do not substitute for diagnosis or injury codes.

4. Emphasize that an ICD-9_CM E code can never be the principal or first-listed diagnosis.

5. Practice using the ICD-9-CM Alphabetic Index to External Causes by identifying terms that describe accidents, disasters, and other events that cause injuries.

6. Review the ICD-9-CM E code guidelines, especially the multiple cause guidelines that describe a hierarchy among E codes, with E codes for child and adult abuse taking priority over all other E codes.

7. Emphasize the reading of notes and instructions in the ICD-9-CM Tabular List of E Codes.

8. Review the ICD-9-CM Place of Occurrence E codes (E849.0–E849.9). E code E849.9, unspecified place, is not used if the specific place of occurrence is not stated in the documentation.

9. Review the classification of death and injury resulting from terrorism through the use of ICD-9-CM E codess

10. Review the use of ICD-9-CM E codes for late effects and the related coding guidelines.

11. Review the ICD-9-CM E codes for wrong surgery, wrong patient and wrong body part surgery.

12. Review the ICD-9-CM E codes for military operations as cause of injury.

13. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification


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system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CM


Assign the correct E codes only for each patient. Assign place of occurrence code if the location is stated. Note –these answers do not include the new E codes for external cause status or activity

1. Patient slipped on icy sidewalk E885.9

2. Driver of auto in collision with another vehicle on expressway E812.0

3. Passenger injured in accidental train derailment E802.1

4. Patient's clothes caught fire in kitchen accident at home (two E codes)E893.0, E849.0

5. Patient fell down stairs E880.9

6. Motorcyclist fell off her motorcycle on a city street without having a collision with another vehicle

E818.2, E849.5

7. Parachutist killed while skydivingE844.7

8. Child bitten by neighbor's dog at the neighborhood parkE906.0, E849.4

9. Accidental drowning in swimming pool at private home E910.2, E849.0

10. Fireman burned in an apartment building fireE890.3, E849.0

11. Coma due to barbiturate overdose; attempted suicide(Diagnosis codes 967.0, 780.01) E950.1



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1. What type of external cause of morbidity events are included in Chapter 20 of ICD-10-CM?

Examples of external cause of morbidity events in Chapter 20 of ICD-10-CM are transport accidents, falls, drowning, exposure to smoke and fire, exposure to forces of nature, complications of medical and surgical care and misadventures to patients during surgical and medical care among other external causes. Other entries exist for assignment of the activity of the person, place of occurrence, and status of external cause, such as civilian, leisure, student activity, etc.

2. What does the seventh character extension indicate in Chapter 20 of ICD-10-CM ?

The seventh character extension indicate whether the episode of care was the initial, subsequent or a secondary encounter, or the condition is a result of an event or sequelae.

A = initial encounterD = subsequent encounterS = sequela

3. How is the ICD-10-CM category Y92, Place of occurrence used ?

Category codes Y92 are used in conjunction with the activity code, Y93 Category Y93 indicates the activity of the person seeking healthcare for an injury or health condition. Also the place of occurrence should be recorded ONLY at the initial encounter for treatment. Also only one code from category Y92 should be recorded on the medical record. If the place of occurrence is not stated, a code form Y92 is not used.

4. When are the ICD-10-CM external cause of injury codes, other than Y92, used?

The external cause code, with the appropriate seventh character (initial encounter, subsequent encounter or sequela,) is assigned for EACH encounter for which the injury or condition is being treated. This is new to ICD-10-CM because the E codes in ICD-9-CM were only assigned for the initial encounter for an injury, poisoning or adverse effect.

5. What is the first character of the chapter 20, External causes of morbidity codes and when are these codes used ?

The first character of the chapter 20 codes are either V, W, X, or Y. Most often these codes are used with conditions classifiable to Chapter 19, injury, poisoning and certain other consequences of external causes (S00-T88) Other conditions that may be stated to be due to external causes are classified in chapters 1 to 18. The external cause codes are used to provide additional information as to the cause of the condition. The external cause codes are always used as an additional code, never a principal or first listed code.


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6. What is the definition of a transport accident in ICD-10-CM ?

A transport accident is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident. The definitions of transport vehicles are provided in the classification and should be reviewed.

7. When are the category Y93 codes used ?

The activity codes from category Y93 are used to indicate the activity of the person seeking healthcare for an injury or health condition which resulted from the activity or was contributed to by the activity. These codes are appropriate for use for both acute injuries, such as those form Chapter 19 and conditions that are due to the long-term cumulative effects of an activity.

The Y93 code are also appropriate for use with external cause codes for cause and intent. These codes should be used in conjunction with codes for external cause status (Y99) and place of occurrence (Y92).

The activity code Y93 is used only ONCE, at the initial encounter for treatment. Only ONE Y93 code should be recorded on the encounter. The activity code are not applicable to poisonings, adverse effects, misadventures,

or late effects. Do not assign Y93.9, unspecified activity, if the activity is not stated.

8. When are the category Y99 codes used?

Category Y99, external cause status codes, should be assigned whenever any other external cause code is assigned for an encounter, including an activity code, except for the events noted in the classification. Category Y99 is used to indicate the work status of the person at the time the event occurred.

The external cause status codes are not applicable to poisoning, adverse effects, misadventures, or late effects.

Category Y99 is only assigned with other external cause codes. It is not assigned if no other external cause codes are applicable.

Code Y99.9 is not assigned if the status is not stated The external cause status is used only once, at the initial encounter for treatment Only one code from Y99 is recorded on a medical record

9. How is the seventh character used if the code from category Y99 is less than 6 characters ?

The seventh character of an external cause code must alway be the seventh character in the data field. If a code that requires a seventh character is not six characters, a placeholder ‘x’ must be used to fill in the empty characters.


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10. What types of external cause codes are contained in the block of Y90-Y99, Supplementary factors related to causes of morbidity classified elsewhere ?

Examples of codes in this section include :Y90, evidence of alcohol involvement determined by blood alcohol level.Y92, place of occurrenceY93, activity codesY95, nosocomial conditionY99, external cause status

ASSIGN THE ICD-10-CM EXTERNAL CAUSE CODES—INITIAL ENCOUNTER

Assign the correct V-Y codes only for each patient. Assign place of occurrence code if the location is stated. Note–these answers do not include the external cause status or activity

1. Patient slipped on icy sidewalk W00.0XXA

2. Driver of auto in collision with another vehicle on expressway V43.52XA, Y92.411

3. Passenger injured in accidental train derailment V81.7XXA

4. Patient's clothes caught fire in kitchen accident at home X06.2XXA, Y92.019

5. Patient fell down stairs W10.9XXA

6. Motorcyclist fell off her motorcycle on a city street without having a collision with another vehicleV28.0XXA, Y92.410

7. Parachutist killed while skydivingV97.29XA

8. Child bitten by neighbor's dog at the neighborhood parkW54.0XX0, Y92.019

9. Accidental drowning in swimming pool at private home W67.XXXA, Y92.019

10. Fireman burned in an apartment building fireX02.0XXA, Y92.039


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Chapter 22

Late Effects This lesson will focus on the following topics:

Coding the residual condition(s) that remain(s) after the acute phase of an injury or illness has ended, including the cause of the residual condition known as the late effect

Using the Alphabetic Index to Diseases correctly to identify both conditions


1. Define the terms late effect, sequela and residual effect2. Identify the minimum of two codes that are usually required to report a late

effect condition3. Identify the late effect conditions that are frequently associated with

cerebrovascular disease4. Give examples of medical terminology used in health records to describe the

fact that a patient has a late effect condition5. Explain what period of time is associated with the occurrence of late effect

conditions6. Identify the thirteen ICD-9-CM category codes that describe late effects7. Examine the ICD-9-CM Alphabetic Index entry under the main term “Late” and

the subterm “effect(s) (of)”8. Examne the ICD-10-CM Alphabetic Index entry under the main term "Sequela"9. State the coding guidelines for the coding and sequencing of codes to describe

late effect conditions10.Describe the coding guideline exceptions11.Explain how to code the residual effect when it is not stated in the physician’s

written diagnostic statement12.Describe the ICD-9-CM Alphabetic Index rule that requires different sequencing

of the codes for the residual condition and the late effect condition13. Practice assigning late effect codes from the various chapters of ICD-9-CM to describe the residual

condition and the late effect condition14. Assign late effect or sequel codes from various chapters of ICD-10-CM

Special Note to Instructors: Some instructors may skip this chapter due to a lack of time or the need to cover other chapters with more widespread use in coding.

At the very least, students should be instructed on the coding of a common late effect—the late effect of a cerebrovascular accident (CVA). Using the Alphabetic Index entry for Late, effects, cerebrovascular disease (430–437), demonstrate how the combination code from category 438 is applied to patients who have a disability or residual condition following the acute phase of treatment for the CVA.


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1. In order to remember the term “late” as the main term to locate these conditions, make personal entries in the ICD-9-CM code book. For example, under the main term, Old, write: see Late, effect, cerebrovascular disease, for patients who are described as having an “old CVA.”



2. Review the Official Coding Guidelines for chapter-specific rules for coding of late effects. Guidelines concerning late effects appear in various sections. The sections to be reviewed are:

Coding Guidelines Section I, B. General Coding Guidelines, 12. Late Effects, Section I, C. Chapter Specific Guidelines, 7. Chapter 7 Circulatory System, d1-d3, Late Effects, Cerebrovascular Diseases, Category 438,

Section I, C. Chapter Specific Guidelines, 11. Chapter 11, Complications of Pregnancy, Childbirth and Puerperium, j. Code 677 Late Effects of Complications of Pregnancy,

Section I, C. Chapter Specific Guidelines, 17. Chapter 17, Injuries & Poisonings, c. Coding of Burns, c7–c8, Late Effects of Burns,

Section I, C. Chapter Specific Guidelines, 19, Supplemental Classification of External Causes of Injury and Poisonings, h. Late Effect of External Cause Guidelines,

3. Review the limited number of category codes for late effects that appear in several chapters of ICD-9-CM

4. Review the coding guideline that states that the residual condition is listed first, followed by the cause of the late effect with a second code. The residual condition is the condition the patient is currently experiencing or the condition the patient has today. The late effect code describes the original condition that has been resolved. Usually, the code for the residual condition is listed first, followed by the code for the late effect.

5. Review the exceptions to the coding guidelines for late effects.

6. Review what should be coded when the diagnostic statement does not identify the residual condition.

7. Review how the Alphabetic Index must be followed for some conditions so that the late effect code is listed first and the manifestation, in italics, is listed second.


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8. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system

compared to the material in this chapter about ICD-9-CMChapter 22 Review Questions

Assign the correct ICD-9-CM code(s) for each patient. Do not assign E codes.

1. Nonunion fracture, neck of femur, suffered in bar brawl three months ago733.82, 905.3

2. Post-traumatic scars of face due to old accidental laceration 709.2, 906.0

3. Anoxic brain damage due to previous intracranial injury three years ago348.1, 907.0

4. Right-sided hemiplegia (dominant side) due to old CVA438.21

5. Scoliosis due to poliomyelitis at age 12 (patient now age 60)138, 737.43

6. Aphasia due to old stroke438.11

7. Quadriplegia due to spinal cord injury344.00, 907.2

8. Sensory hearing loss due to previous adverse effect of antibiotic medication389.11, 909.5, E930.9

9. Late effects of viral encephalitis139.0

10. Wrist contracture due to old compound fracture of left radius718.43, 905.2


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ICD-10-Review Exercises

1. What chapter in ICD-10-CM contains the late effect or sequelae codes?

ICD-10-CM does not contain a single chapter for the coding of late effects or sequelae of conditions. These codes are defined into the various body system chapters. For example, codes in category I69, Sequelae of cerebrovascular disease, are found in Chapter 9, Diseases of the Circulatory System.

2. What is the main term used in the ICD-10-CM Alphabetic Index to locate the late effect or sequelae?

In ICD-10-CM Index to Diseases or Injuries, the main term of “Late, effect(s)” directs the coder to see another main term, “Sequelae.” The terminology has changed in ICD-10-CM with the words “late effect” in a diagnosis replaced generally by the term “sequel”.

3. What does ICD-10-CM Guideline I. B. 10, Late Effects state as the definition of late effects or sequel?

A late effect is the residual effect or condition produced after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used.

4. What is the ICD-10-CM sequencing guidelines for late effect or sequelae conditions?

Coding of late effects generally requires two codes sequenced in the following order: the condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to the above guideline are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

5. How is the ICD-10-CM category I69, Sequelae of cerebrovascular disease used?

Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of late effects (neurologic deficits) themselves classified elsewhere. These late effects include neurological deficits that persist after initial onset of conditions classifiable to I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

6. Can codes from category I69 be assigned on a health record with codes from I60-I67?

Yes, codes from category I69 may be assigned with codes from I60-I67 if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.

7. When is code O94, Sequelae of complication of pregnancy, childbirth and the puerperium used?


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Code O94 is used in the encounter when an initial complication of a pregnancy develops a sequelae requiring care and treatment at a future date after the pregnancy, childbirth and the puerperium has concluded. It may be used at any time after the initial postpartum period. Like all late effect codes, O94 is sequenced following the code describing the sequelae of the complication.

8. How are the “sequelae” codes used in Chapter 19, Injury, poisoning and certain other consequences of external causes?

Most categories in chapter 19 have seventh character extension that are required for each applicable code. Extension “S” for sequel are used for complications or conditions that arise as a direct result of an injury, such as a scar formation after a burn. When using extension “S”, it is necessary to code both the injury code that precipitated the sequelae and the code for the sequela itself. The “S” is added only to the injury code, not the sequelae code. The “S” extension identifies the injury responsible for the sequelae. The specific type of sequel (that is, scar) is sequenced first, followed by the injury code.

Assign the correct ICD-10-CM code(s) for each patient. Do not assign External cause codes.

1. Nonunion fracture, neck of femur, suffered in bar brawl three months agoS72.009K

2. Post-traumatic scars of face due to old accidental laceration L90.5, S01.81XS

3. Anoxic brain damage due to previous intracranial injury three years agoG93.1, S06.330S

4. Right-sided hemiplegia (dominant side) due to old CVAI69.359

5. Scoliosis due to poliomyelitis at age 12 (patient now age 60)M41.9, B91

6. Aphasia due to old strokeI69.320

7. Quadriplegia due to spinal cord injuryG82.50, S14.109S

8. Sensory hearing loss due to previous adverse effect of antibiotic medicationT36.9XS

9. Late effects of viral encephalitisB94.1


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10. Wrist contracture due to old compound fracture of left radiusM24.539, S52.92XS


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Chapter 23

Supplementary Classification—V Codes This lesson will focus on the following topics:

The use of V codes to describe patients and their reasons for healthcare services Using the Alphabetic Index to Diseases correctly to identify V codes


1. Describe the organization of the ICD-9-CM supplementary classification of factors influencing health status and contact with health services (V01-V91)

2. Describe the four types of healthcare situations in which ICD-9-CM V codes are intended to be used

3. Identify examples of main terms that are used in the ICD-9-CM Alphabetic Index to locate V codes

4. Identify the ICD-9-CM V codes that describe a patient with asymptomatic human immunodeficiency virus (HIV) status

5. Identify examples of conditions that are described with ICD-9-CM personal history V codes

6. Briefly describe and differentiate among the various ICD-9-CM V codes related to reproduction and development (V20–V29)

7. Identify the purpose of the fourth and fifth digits used with ICD-9-CM category V30 codes for liveborn infants

8. Identify examples of how ICD-9-CM status codes in the range of V40–V49 categories are used to describe a patient

9. Describe the circumstances in which ICD-9-CM aftercare codes in the range of V50–V59 are used to describe a patient

10.Identify the other types of conditions that should be reported with codes for the patient encounters described with ICD-9-CM category codes V56, V57, and V58

11.Describe the purpose of the patient’s encounter with healthcare when an ICD-9-CM V59 code is reported

12.Explain the way in which ICD-9-CM category V64 codes are used to describe the reason that a particular healthcare service was not completed

13.Describe the circumstances in which ICD-9-CM code V66.7 for palliative care would be used

14. Explain the meaning of the note under ICD-9-CM category code V67, “follow up examination,” and describe the correct use of the code

15.Identify the circumstances in which ICD-9-CM category codes V70–V72 should be used

16.Define the term screening as it is used to describe examinations identified with ICD-9-CM category codes V72–V83.

17.Explain why the information given with ICD-9-CM category V86 codes, Estrogen receptor status, is important


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18.Review the rules for sequencing of ICD-9-CM V codes, especially which codes should only be reported as the first-listed code

19. Assign V codes from ICD-9-CM to describe the reason for a healthcare encounter and patient care20. Describe the organization of the codes included in chapter 21 of ICD-10-CM, Factors influencing

health status and contact with health services (Z00-Z99)21. Assign ICD-10-CM codes for factors influencing health status and contact with health services

Special Note to Instructors: The fact that V codes are addressed as the last chapter in the textbook is not intended to mean it is least important. The V codes should probably be included as one of the first chapters taught in an ICD-9-CM course, in sequence, for example, with the ICD-9-CM Chapter 16 codes for signs and symptoms. These conditions are frequently used for outpatient visits and are essential for students to understand.

Students frequently confuse V codes with procedures codes because the V diagnosis code appears to describe an event or procedure such as chemotherapy. Emphasize to the students that V codes are diagnosis codes, and a procedure code, either ICD-9-CM or CPT, must be used to describe the actual procedure performed.

Think of V codes as describing a reason the patient is seeking healthcare services (general medical examination required), a fact about the patient (newborn or has a pacemaker in place), or additional details about the patient's health status (infection with drug-resistant organisms or current artificial opening/stoma status).


1. Make a list of situations in which people visit physicians or healthcare centers when they are not ill but need some type of healthcare service. Determine if these situations can be described with V codes.



2. Review the Official Coding Guidelines for chapter-specific rules for V codes for external causes, Section I, C18, Classification of Factors Influencing Health Status and Contact with Health Services

3. Describe the four main situations in which V codes are best used to describe a patient:

a. When an individual is well but seeking health services for a particular reason

b. When a circumstance or problem influences the patient's current health status but itself is not a problem

c. When a patient seeks healthcare for a specific treatment or therapy


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d. At the time an infant is born


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4. Review the V Code Table that is included in the ICD-9-CM Official Guidelines for Coding and Reporting . Certain V codes are only acceptable as principal or first listed diagnoses. For example, V58.0, Encounter for radiotherapy, is only acceptable as a principal or first listed diagnosis code. Other V codes may only be used as additional codes, not principal or first listed. For example, V22.2, Pregnancy state, incidental, is only acceptable as an additional code. The V Code Table also includes V codes that may be used as principal or first listed codes or as additional codes.

5. Encourage the review of all includes and excludes notes, other notes, and instructions in the Tabular List of V codes to ensure accurate use.

6. Review certain terminology used with V codes that may not be consistent with the language of physicians:

a. “History” in ICD-9-CM means that the medical condition no longer exists or the patient is cured of the disease. The term “history” used by a physician may mean the patient is currently under treatment for an active condition. For example, if the physician states “history of diabetes mellitus,” the patient most likely is still being treated for the condition.

b. “Aftercare” in ICD-9-CM means that the patient requires continued care during the healing or recovery phase. Physicians may not use the term “aftercare” at all but may describe the patient as “follow up” or “status post.”

c. “Status post” in ICD-9-CM describes a fact or statement about a person’s health status, for example, that a device is present or a past surgery has been performed. “Status post” to a physician may mean that the patient recently had surgery or was recently diagnosed and treated for an illness. “Status post” as used in physician documentation may be what ICD-9-CM describes as “aftercare” or the statement may reflect a historical event that is not necessary to code.

d. “Follow-up” in ICD-9-CM means the patient's condition has been fully treated and no longer exists. Using a code for follow-up means that patient did not receive any treatment but rather had an examination for surveillance purposes. Physicians may use the term follow-up to describe a patient who continues to need treatment of a condition or recovery from an illness.

7. Review each category of V codes described in the textbook using the examples provided in the textbook of what the codes are intended to describe in terms of the patient’s condition or health status.

8. Depending on the objectives of the course using this textbook, review the ICD-10-CM introductory material provided at the end of the chapter to examine the new classification system’s characteristics including what is similar and different in the new coding system compared to the material in this chapter about ICD-9-CMabout ICD-9-CM.


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Assign the correct ICD-9-CM V code(s) for each patient. Do not assign E codes.

1. History of carcinoma of large intestineV10.05

2. Patient on long-term anti-coagulant therapyV58.61

3. Status post aortocoronary bypass graftV45.81

4. Examination following treatment of fractureV67.4

5. Admission for chemotherapyV58.11

6. Admission for removal of internal fixation deviceV54.01

7. Observation for suspected mental condition not foundV71.09

8. Routine postpartum follow-up visitV24.2

9. Admission for physical therapy rehabilitationV57.1

10. Preoperative cardiovascular examinationV72.81


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1. What are the equivalent “V” codes in ICD-10-CM?

What are known as “V” codes in ICD-9-CM are “Z” codes in ICD-10-CM. Z codes are diagnosis codes and represent reasons for the encounter or visit. The codes are used for circumstances other than a disease or injury that are the reason for the health care services.

2. What are examples of the blocks of ICD-10-CM codes?

Examples of ICD-10-CM blocks of codes are:a. Persons encountering health services for examinationb. Persons encountering health services in circumstances related to reproductionc. Encounters for other specific health care

3. When are “Z” codes used?

According to a note at the beginning of the chapter, Z codes represent reasons for encounters. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury, or external cause classifiable to categories A00-Y89 are recorded as “diagnoses” or “problems.” The codes are used when:a. A person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to done an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.b. When some circumstance or problem is present which influences the person’s health status but is not in itself a current illness or injury.

4. What are some examples in ICD-10-CM where the code/category has less specificity than the equivalent ICD-9-CM codes?

1. There is only one ICD-10-CM category Z16 to represent infection with drug-resistant microorganisms. In ICD-9-CM there are subclassifications to identify the specific drug in which the microorganisms was resistant.2. In ICD-10-CM code Z23 is less specific as “encounter for immunization” and is not further classified. In ICD-9-CM, category V03, V04, V05, and V06 codes are used to identify the types of immunizations.

5. What does guideline I.C.21.a state in terms of sequencing of “Z” codes?

Z codes may be used as either a first-listed (or principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis.

6. Give an example of a health status that has been eliminated from ICD-10-CM and what has been added as a Z code in ICD-10-CM?


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a. There is no code in ICD-10-CM comparable to the ICD-9-CM category V57, Care involving use of rehabilitation procedures. Instead the underlying condition for which therapy is being provided, such as an injury, with the appropriate seventh character extension indicating subsequent encounter.

b. A category Z67 to identify the patient’s blood type was added to ICD-10-CM that does not exist in ICD-9-CM.

7. Are Z codes for aftercare used with fracture codes to indicate aftercare encounters?

No, aftercare Z codes in ICD-10-CM should not be used for aftercare of fractures. For aftercare of a fracture, assign the acute fracture code with the seventh character extension of “D” for subsequent encounter.


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Chapter 24

Coding and ReimbursementThis lesson will focus on:

The relationship between coding and reimbursement of health services.

Learning Objectives1. Define the terms DRG and MS-DRG2. Briefly describe the hospital inpatient prospective payment system, including how base payment rates

are determined and the formula for computing the hospital payment.3. Describe the purpose and activities of quality improvement organizations and recovery audit

contractors.4. Define the term medical necessity and explain its relationship to ICD-9-CM diagnosis codes5. Define the term advance beneficiary notice and explain its purpose.

Special Note to Instructors:

This chapter is new to the book in the 2012 edition. It is intended to be a brief introduction to the relationship between the classification systems or coding and the reimbursement systems that depend correct coding to produce appropriate reimbursement.

Previous editions of the book contained Chapter 3, Introduction to the Prospective Payment System and the Uniform Hospital Discharge Data Set. This chapter 24 contains many of the same concepts previously discussed in the previous chapter 3.

Suggested Student Activities1. Have the students review the current websites for the Medicare inpatient and outpatient prospective

payment systems at http://www.cms.gov/home/medicare.asp.

2. Have the students review the Medicare website to identify the appropriate state or regional fiscal intermediary or Medicare Administrative Contractor for your location at https://www.cms.gov/ContractingGeneralInformation/Downloads/02_ICdirectory.pdf.

3. Review the Medicare website about the Recovery Audit Contractors and the RAC applicable to your location https://www.cms.gov/Recovery-Audit-Program/.

Key Points for Lecture Notes1 Use the accompanying PowerPoint slides for a lecture outline to emphasize the highlights of the chapter. 2. Spend time with the students to review the recommended websites noted above. 3. Review the fundamentals of the hospital inpatient prospective payment system


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4. Review the formula for computing the hospital payment for each MS-DRG.5. Review the purpose and process of Medicare coding reviews with the QIOs, FIs, MACs, and CERTs.6. Review the purpose of the Recovery Audit Contractors7. Discuss the process for establishing medical necessity for Medicare beneficiaries.


1. What is the goal of the MS-DRG system?

The goal was to significantly improve Medicare’s ability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to the sicker patient and decrease payments for treating less severely ill patients.The MS-DRGs represent an inpatient classification system designed to categorize patients who are medically related with respect to diagnoses and treatment and who are statistically similar in their lengths of stay. Each DRG has a present reimbursement amount that the hospital receives whenever the MS-DRG is assigned.

2. How is the base payment rate for each DRG determined?

First, each MS-DRG is assigned a relative weight. The relative weight represents the average resources required to care for cases in that particular DRG relative to the national average resources used to treat all Medicare cases.The second source that determines MS-DRG payment rate is the individual hospital’s payment rate per case. This payment rate is based on a regional or national adjusted standardized amount that considers the type of hospital; designation of hospital as large urban, other urban or rural; and a wage index for the geographic area in which the hospital is located.The actual amount the hospital is reimbursed for each Medicare inpatient is determined by multiplying the hospital’s individual payment rate by the relative weight of the DRG, less any applicable deductible amount.The formula for computing the hospital payment for each MS-DRG is as follows:

DRG Relative Weight x Hospital Base Rate = Hospital Payment

3. In addition to the base payment rate, what other payments are made to certain hospitals by Medicare?

Medicare provides for an additional payment for other factors related to a particular hospital’s business. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the MS-DRG adjusted base payment rate. This is known as the disproportionate share hospital (DSH) adjustmentIf the hospital is an approved teaching hospital, it receives a percentage add-on payment for each Medicare discharge paid under IPPS, known as the indirect medical education (IME) adjustment.Additional payments may be made for Medicare beneficiaries that involve new technologies or medical services that have been approved for special add-on payments.


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4. How are certain hospitals paid differently by Medicare?

Some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year. Sole community hospitals (SCHs) are the sole source of care in their area and Medicare-dependent, small rural hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries.

5. What coded information determines the MS-DRG assignment?

The MS-DRG assignment is based on coded information, that is, a. Diagnoses (principal and secondary)b. Surgical procedures (principal and secondary)c. Discharge disposition or statusd. Presence of major or other complications and comorbidities (MCC or CC) as

secondary diagnoses

6. What type of reviews are performed by quality improvement organizations (QIO)?

a. Quality of care reviews due to beneficiary complaints, complaints other than from beneficiaries and quality of care reviews referred by CMS or CMS designated entities.

b. Utilization reviews for hospital requested higher weighted diagnosis related group (DRG) payments

c. Utilization reviews referred by CMS or CMS designated entities for cases involving issues such as transfers and readmittions.

d. Review of Emergency Medical Treatment Active Labor Act (EMTALA) casese. Performance of expedited determinations, andf. Provider education on quality of care issues and other issues under their purview

(that is, hospital requested higher weighted DRG review.)

7. What type of reviews are performed by FIs and MACs?

FIs and MACs perform medical review of acute IPPS hospitals and long term care hospital claims to ensure that the payments are for covered, correctly coded, and reasonable and necessary services. The reviews are performed on either a pre-payment or post-payment basis. They may conduct claim adjustments as needed. Also FIs and MACs provide feedback to the providers based on their review findings.


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8. What type of reviews are done by CERT contractors?

The CERT contract reviews claims for the purpose of measuring error rates for acute IPPS hospital and LTCH claims. The reviews are performed on a post-payment basis in order to determine the degree to which the FIs and MACs are paying appropriately in accordance with coverage, coding and medical necessity guidelines.

9. What is a major area of focus for the RAC reviews?

The examination of the ICD-9-CM coding is a major area of focus for the RACs because the diagnosis and procedure codes create the MS-DRGs that are the basis of payment for acute care hospitals. The ICD-9-CM and CPT coding in other healthcare organizations, such as rehabilitation hospitals and units and physician offices, determines reimbursement to the provider.

10. What three factors define medical necessity of a diagnostic test, procedure or treatment according to Medicare?

1. The likelihood that a proposed healthcare service will have a reasonable beneficial effect on the patient’s physical condition and quality of life at a specific point in his or her illness or lifetime.

2. Healthcare services and supplies that are proven or acknowledged to be effective in the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms and to be consistent with the community’s accepted standard of care. Under medical necessity, only those services, procedures, and patient care warranted by the patient’s condition are provided.

3. The concept that procedures are only reimbursed as a covered benefit when they are performed for a specific diagnosis or specified frequency.


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