AAPC Chapter 3

The word AND should be interpreted to mean ______ when it appears in a title.

"And" or "or" - patient may have either or both Rationale: According to the ICD-10-CM guideline 1.A.14 the word AND should be interpreted to mean either "and" or "or" when it appears in an ICD-10-CM description.

Purpose of ICD-10

1. International standard diagnostic classification for all general epidemiological, many health management purposes, and clinical use. 2. Analysis of the general health situation of population groups 3. Monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables (such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality, and guidelines) 4. Classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. 5. Enabling the storage and retrieval of diagnostic information for clinical, epidemiological, and quality purposes 6. provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States.

Determinants of medical necessity

1. Knowledge of the emergent nature or severity of the patient's complaint or condition. 2. All signs, symptoms, complaints, or background facts describing the reason for care. 3. The facts must be substantiated by the patient's medical record, and that record must be available to payers on request.

Sequelae (Late Effects)

A sequela is the residual effect (condition produced) after the acute portion of an illness or injury has terminated. There is no time limit on when a sequela code can be used. Two codes usually are required when coding sequelae. The residual condition is coded first, and the code(s) for the cause of the sequelae are reported as secondary. (It may be necessary for you to go to the External Cause of Injuries Index to identify and reference the appropriate sequela of an external cause). The documentation in the medical record should support the manifestation or residual effect, as well as the cause. The code for the cause of the sequela may be used as a principal diagnosis when no residual diagnosis is identified. The following terminology may be used to document sequelae: · Due to an old injury · Due to a previous illness The code for the acute phase of an illness or injury that leads to the sequela is never used with a code for the cause of the sequela. The following examples are causes of sequelae: · Malunion due to old fracture of the left ankle · Traumatic arthritis following fracture of the left wrist · Hemiplegia one year following cerebrovascular thrombosis · Scarring of the left leg due to third degree burns · Contracture of the left heel tendons due to poliomyelitis

A 30-year-old female patient was seen in the ED with complaints of diarrhea for the past four days. She was also complaining of lower abdominal pain. After examination, the patient was diagnosed with viral gastroenteritis. She was instructed to drink plenty of fluids and to begin eating solids only after the diarrhea has subsided. What diagnosis code(s) would be reported for this encounter?

A08.4 Rationale: Lower abdominal pain and diarrhea are symptoms of the viral gastroenteritis. See ICD-10-CM guideline I.B.5. Look in the ICD-10-CM Alphabetic Index for Gastroenteritis/viral NEC which directs the coder to A08.4. Code selection is confirmed in the Tabular List.

Chlamydial inflammation of the testes

A56.19

NEC and NOS are _____used in the ICD-10-CM codebook.

Abbreviations Rationale: ICD-10-CM guideline I.A.6 states NEC and NOS are abbreviations. NEC is an abbreviation for Not Elsewhere Classifiable and NOS is an abbreviation for Not Otherwise Specified.

Borderline Diagnosis

Borderline diagnoses are coded as confirmed diagnoses unless there is an index entry of borderline for that classification.

Example of a combination code

Code K80.00 reports both gallbladder calculus and acute cholecystitis. ICD-10-CM guideline I.B.9 for the definition of a combination code.

Coding for Healthcare Encounters in Hurricane Aftermath

Code X37.- is only assigned when the injury is a direct result of a Hurricane. Reporting of injuries resulting from a hurricane should include a code for the external cause of morbidity. The appropriate injury code should be reported first, followed the external cause code. For injuries as a direct result of a hurricane, or when an injury is incurred because of flooding caused by a levee breaking related to a hurricane, assign X37.0- Hurricane, and any other applicable external cause of injury codes.

When a patient has a condition that is both acute and chronic and there are separate entries for both, how is it reported?

Code both sequencing the acute first Rationale: According to the ICD-10-CM guideline 1.B.8 if the same condition is described as both acute (subacute) and chronic and separate entries exist in the ICD-10-CM Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) first.

When coding for an ambulatory surgical procedure, how is the diagnosis determined?

Code the postoperative diagnosis because it is the most definitive. Rationale: For ambulatory surgery, if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding because it is the most definitive. Refer to ICD-10-CM guideline IV.N.

Documentation for BMI, Depth of Nonpressure Ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale

Codes for body mass index (BMI), depth of nonpressure chronic ulcers, pressure ulcer stages, coma scale, and NIH Stroke scale (NIHSS) codes can be reported based on documentation from any clinician involved in the patient's case but the patient's provider must document the underlying condition, such as diabetes or obesity. The BMI, coma scale, NIHSS codes, and categories Z55-Z65 should only be reported as secondary diagnoses.

Conditions that are Not an Integral Part of the Disease Process

Codes for signs and symptoms that are not routinely associated with other definite diagnoses should be reported.

Conditions that are an Integral Part of a Disease Process

Codes for symptoms, signs, and ill-defined conditions are not to be reported as diagnoses when a related definitive diagnosis has been established

Essential hypertension

D.I10 (find rationale)

Sickle-cell anemia

D57.1

Cyclic neutropenia is coded with D70.4 Cyclic neutropenia. There are additional coding instructions for this code listed under the category D70 Neutropenia. Using those instructions, how would you report a patient with cyclic neutropenia with an associated fever?

D70.4, R50.81

Ruptured spleen (not due to an injury)

D73.5

In the ICD-10-CM Alphabetic Index what is the code next to the main term called?

Default Code Rationale: The Alphabetic Index utilizes the same main term/subterm indexing systems. In ICD-10-CM, the code listed next to the main term is considered the default code. The default code represents the condition most commonly associated with the main term. As with all code assignment, always verify the default code in the Tabular List to assure proper reporting. Refer to ICD-10-CM guideline I.A.18.

Uncontrolled diabetes with diabetic cataracts

E11.36

Type 2 diabetes mellitus and diabetic dermatitis

E11.620 Type 2 diabetes mellitus with diabetic dermatitis. Instead of reporting the diabetes and dermatitis with two separate codes, it is coded with the combination code.

Amyloid heart disease

E85.4, I43 In the ICD-10-CM Alphabetic Index, look for Disease, diseased/heart (organic)/amyloid. Two codes are listed on the same line — E85.4 [I43]. This indicates both codes are required to describe this diagnosis. In the Tabular List, verify the codes. Notice under the code I43 the instructional note "Code first underlying disease, such as: amyloidosis (E85.-)." This statement indicates that E85.4 Organ-limited amyloidosis should be listed first, followed by I43.

Who was ICD-10 endorsed by and when?

ICD-10 was endorsed by the 43rd World Health Assembly in May 1990 and came into use in World Health Organization (WHO) Member States in 1994

A 20-year-old comes into the ED with symptoms of a severe headache, vomiting, stiff neck, and fever. The ED physician suspects meningitis and performs a lumbar puncture. The ED physician reviews the results and the patient is admitted in the hospital for meningitis which is suspected to be bacterial. Which ICD-10-CM code(s) is/are reported by the ED physician?

G03.9 Rationale: The symptoms for this scenario (headache, vomiting, stiff neck, and fever) are associated with meningitis (definitive diagnosis). ICD-10-CM guideline I.B.4 states signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes. Per ICD-10-CM guidelines IV.D and II.H do not code a diagnosis documented as probable, suspected, questionable, rule out, or working diagnosis. Look in the Alphabetic Index for Meningitis G03.9. Verify code selection in the Tabular List.

Classical migraine

G43.109 Rationale: Look in the ICD-10-CM Alphabetic Index for Migraine/classical and you are directed to see migraine with aura. Migraine/with aura directs you to G43.109. Verify code selection in the Tabular List. The list under G43.1 includes "classical migraine."

Chronic non-intractable common migraine headache with status migrainosus

G43.701

A 50-year-old female presents to her provider with symptoms of insomnia and upset stomach. The provider suspects she is premenopausal. She is diagnosed with impending menopause. What diagnosis code(s) should be reported?

G47.00, K30 Rationale: ICD-10-CM guideline I.B.11 states to reference the ICD-10-CM Alphabetic Index to determine if the condition has a subentry for impending or threatened and reference main term entries for Impending and Threatened. If the subterms are listed, assign the given code. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. Look in the Alphabetic Index for Impending. There is not a subterm for menopause; therefore, the symptoms are coded. Look for Insomnia (organic) which directs the coder to G47.00. Next, look for Upset/stomach which directs the coder to K30. Verify code selection in the Tabular List.

Eyestrain

H53.10 Rationale: Look in the ICD-10-CM Alphabetic Index for Eyestrain and you are directed to see Disturbance, vision, subjective. Disturbance/vision/subjective directs you to H53.10. Verify code selection in the Tabular List.

Otitis media left ear

H66.92

Which diagnosis code(s) below reports pain in the left and right ears?

H92.03 Rationale: ICD-10-CM allows for the reporting of laterality (right, left, bilateral). For bilateral sites, the final character of the code indicates laterality. ICD-10-CM guideline I.B.13 indicates if no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. There is a bilateral code provided for pain in the left and right ears H92.03. You would not report two separate codes.

The physician's documentation indicates that the patient has stable, benign hypertension, with a new onset of nausea and blurred vision

I10. R11.0, H53.8

Hypertensive heart disease

I11.9

A patient is discharged with an impending myocardial infarction.

I20.0 In the ICD-10-CM Alphabetic Index, look for Impending/myocardial infarction. You are referred to I20.0. Code I20.0 reports unstable angina or preinfarction angina. (Impending or Threatened Condition)

Acute myocardial infarction

I21.9

COPD

J44.9 Chronic obstructive pulmonary disease, unspecified. COPD: This acronym is not found in the ICD-10-CM Alphabetic Index. A medical dictionary can tell you that COPD is an abbreviation for chronic obstructive pulmonary disease (a condition of the lungs). With this information, you will be able to identify the main term in the Alphabetic Index. In the Alphabetic Index, COPD can be found under Obstruction, obstructed, obstructive/lung/disease, chronic. Could also locate it under Disease, diseased/pulmonary/chronic obstructive or Disease, diseased/lung/obstructive (chronic).

Signs and symptoms (Inpatient)

In the inpatient setting for facility diagnosis coding, it is appropriate to report suspected or rule out diagnoses as if the condition does exist. This is only true for facility reporting for inpatient services for all diagnoses except HIV. HIV is the only condition that must be confirmed if it is to be reported in the inpatient setting.

Signs and symptoms (Outpatient)

In the outpatient setting, do not code a diagnosis unless it is certain. When a definitive diagnosis has not been determined, code the signs, symptoms, and abnormal test result(s) or other reasons for the visit.

Fatigue, suspect iron deficiency anemia

In this instance, fatigue (R53.83) is reported as the diagnosis because the physician has not confirmed the diagnosis for iron deficiency anemia. To locate the code, look for Fatigue in the ICD-10-CM Alphabetic Index. No other subterms apply in this example. The code referred to in the Alphabetic Index is R53.83. The Tabular List confirms Fatigue NOS (not otherwise specified) is reported with R53.83. (Signs and symptoms (Outpatient))

A middle-aged male presents with a complaint of constant facial pain. The physician ordered diagnostic tests to determine the source of the pain.

Initial patient visit is completed with the diagnosis of facial pain (R51.9) because a definitive diagnosis had not yet been determined.

Acute asthma exacerbation

J45.901

GERD

K21.9

A 10-month-old comes into the pediatrician's office for a harsh, bark-like cough. She is diagnosed with croup. The mother also wants the pediatrician to look at a rash that has developed on her leg. The pediatrician prescribes over the counter medication of acetaminophen for the croup and hydrocortisone cream for the rash on the leg. She is to follow up in five days or return earlier if the conditions worsen. What ICD-10-CM code(s) should be reported for this visit?

J05.0, R21 Rationale: Signs and symptoms that are associated with a disease process should not be reported, refer to ICD-10-CM guideline I.B.5. ICD-10-CM code R05 is not reported because cough is a symptom of croup. Codes for signs and symptoms that are not routinely associated with a definitive diagnosis should be reported, according to ICD-10-CM guidelines 1.B.4 and I.B.5. The rash is reported because it is not related or associated with croup. Look for Croup in the ICD-10-CM Alphabetic Index referring you to code J05.0. Look for Rash in the Alphabetic Index referring you to code R21. Verify both codes in the Tabular List.

A patient presents with runny nose and cough. The provider diagnoses the patient with an upper respiratory infection (URI). The patient also complains of right shoulder pain.

J06.9, M25.511 In this example, a code is selected for the URI and the right shoulder pain. The runny nose and cough are symptoms of the URI (J06.9) and should not be reported. Right shoulder pain (M25.511) is not related to the URI, and should be coded separately. URI is found in the ICD-10-CM Alphabetic Index under Infection/respiratory (tract)/upper (acute) NOS. Right shoulder pain is found in the Alphabetic Index under Pain(s)/joint/shoulder. Verification in the Tabular List identifies the 6th character to indicate laterality. (Conditions that are Not an Integral Part of the Disease Process)

Novel H1N1 flu

J10.1

Bronchitis and the flu

J11.1 Rationale: Look in the ICD-10-CM Alphabetic Index for Bronchitis/with/influenza, flu or grippe which states to see Influenza, with, respiratory manifestations NEC. Look for Influenza/with/respiratory manifestations NEC J11.1. Verify code selection in the Tabular List.

Pneumonia due to SARS?

J12.81 Rationale: ICD-10-CM guideline I.B.9 indicates that a combination code is a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation). Multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis. In the ICD-10-CM Alphabetic Index look for Syndrome/severe acute respiratory (SARS) guiding you to code J12.81. You can also look for Pneumonia/SARS-associated coronavirus J12.81. Verify code selection in the Tabular List.

Headache

R51.9 Rationale: Look in the ICD-10-CM Alphabetic Index for Headache. You are directed to R51.9. You can also find the code by going to Pain/head which refers the user to headache. Verify code selection in the Tabular List.

Fatigue

R53.83

A patient presents with severe abdominal pain, nausea, and vomiting. The provider diagnoses the patient with acute appendicitis.

K35.80 In this case, only a code for the appendicitis is reported because the abdominal pain, nausea, and vomiting are symptoms of appendicitis. To locate the code, look for Appendicitis in the ICD-10-CM Alphabetic Index. Then, look for the subterm acute. No additional subterms apply in this example. The code referred to in the Alphabetic Index is K35.80, which must be confirmed by reviewing the code in the Tabular List. (Conditions that are an Integral Part of a Disease Process)

A 22-year-old is in an outpatient facility for an inguinal hernia repair. Just before surgery, the surgeon discovers the patient is positive for MRSA and the surgery is canceled. Which ICD-10-CM code(s) should be reported for the outpatient service?

K40.90, A49.02, Z53.09 Rationale: ICD-10-CM guidelines for outpatient services IV.A.1 states to report the reason for surgery as the first listed diagnosis even if the surgery is canceled due to a contraindication. Look in the ICD-10-CM Alphabetic Index for Hernia/inguinal referring you to code K40.90. Next, look for MRSA (Methicillin resistant Staphylococcus aureus)/infection referring you to code A49.02. Lastly, look for Canceled procedure (surgical)/because of/contraindication referring you to code Z53.09. Verify code selection in the Tabular List.

Acute cholecystitis with chronic cholecystitis

K81.2

Cellulitis of the arm

L03.119

Hives

L50.9 Rationale: Look in the ICD-10-CM Alphabetic Index for Hives and you are directed to see Urticaria. Urticaria directs you to L50.9. Verify code selection in the Tabular List.

Keloid scar on the foot

L91.0 Rationale: Look in the ICD-10-CM Alphabetic Index for Scar/keloid L91.0. The location does not affect code selection. Verify code selection in the Tabular List.

Bilateral hip pain

M25.551, M25.552

Acute and chronic cystitis

N30.00, N30.20 Rationale: ICD-10-CM guideline.I.B.8 states when the same condition is described as both acute and chronic and separate subentries exist, code both and sequence the acute code first.

A patient is seen in the ED for severe abdominal pain and urinary frequency. After examination and urinalysis, the patient is diagnosed with a urinary tract infection (UTI). What ICD-10-CM code(s) is/are reported

N39.0 Rationale: Refer to ICD-10-CM guideline I.B.5. The abdominal pain and urinary frequency are not reported because they are symptoms of the UTI. Look in the ICD-10-CM Alphabetic Index for Infection, infected, infective/urinary (tract) which directs the coder to N39.0. Verification in the Tabular List confirms code selection.

What ICD-10-CM code(s) is/are reported for enlargement of the prostate with a symptom of urinary retention?

N40.1, R33.8 Rationale: Look in the ICD-10-CM Alphabetic Index for Enlargement, enlarged/prostate/with lower urinary tract symptoms (LUTS). You are directed to N40.1. In the Tabular List under code N40.1 there is an instructional note that indicates to use additional code to identify symptoms. You report code R33.8 for urinary retention as the second code.

Benign prostatic hyperplasia with urinary retention?

N40.1, R33.8 (find rationale)

A 32-year-old sees her obstetrician about a lump in the lower outer quadrant of the right breast. Her mother and aunt both have a history of breast cancer. What diagnosis code(s) should be reported?

N63.13, Z80.3 Rationale: In the ICD-10-CM Alphabetic Index look for Lump/breast/right/lower outer quadrant N63.13. Next look for History/family (of)/malignant neoplasm (of)/breast which directs the coder to Z80.3. According to ICD-10-CM guideline IV.J history codes (Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Verify code selection in the Tabular List.

A 6-year-old patient is seen in the office for acute otitis media, coded as H66.90. This is an example of a ____ code.

NOS Rationale: H66.90 is Not Otherwise Specified. ICD-10-CM guideline I.A.9.b codes titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. The inclusion terms under H66.9 include NOS in the description.

Syncope

R55

NEC

Not elsewhere classifiable- Abbreviation is used when the ICD-10-CM system does not provide a code specific for the patient's condition. Selecting a code with the NEC classification means that the provider documented more specific information regarding the patient's condition, but there is not a code in ICD-10-CM to report the condition accurately.

NOS

Not otherwise specified- Abbreviation is the equivalent of unspecified and is used only when you lack the information necessary to code to a more specific diagnosis.

What month does the new ICD-10-CM codebook take effect each year?

October Rationale: The new ICD-10-CM codebook is effective October 1 of each year.

The instructions and conventions of the classification take precedence over ________.

Official Coding Guidelines Rationale: ICD-10-CM guidelines state the instructions and conventions of the classification take precedence over guidelines.

What is an example of an eponym?

Paget's disease Rationale: An eponym is a word derived from someone's name. Paget's disease is a disorder that involves abnormal bone destruction and regrowth which results in deformity. It was described by surgeon and pathologist Sir James Paget.

What diagnosis codes should be reported for fragilitas ossium, osteogenesis imperfecta and osteopsathyrosis?

Q78.0 Rationale: Look in the ICD-10-CM Alphabetic Index for Fragilitas/ossium Q78.0. Next look for Osteogenesis imperfect Q78.0. Look for Osteopsathyrosis Q78.0. The Tabular List includes all the conditions in the code Q78.0.

Cough

R05 Rationale: Look in the ICD-10-CM Alphabetic Index for Cough. Without further description you are directed to R05. Verify code selection in the Tabular List.

Epigastric pain

R10.13

Nausea

R11.0 Rationale: Look in the ICD-10-CM Alphabetic Index for Nausea. You are directed to R11.0. There is no mention of vomiting. Verify code selection in the Tabular List.

Nausea and vomiting

R11.2

A 32-year-old male is in a diagnostic center to have an ultrasound of his neck due to difficulty swallowing. The patient's father had esophageal cancer. What is/are the appropriate code(s) to report for the diagnostic service?

R13.10, Z80.0 Rationale: For a patient receiving a diagnostic service (for example, ultrasound, MRI, diagnostic colonoscopy) report the condition or problem as a primary code to indicate the reason for the test.. Codes for other diagnoses, such as chronic conditions or history are reported as an additional diagnosis. In this case the family history code is reported as an additional diagnosis since it has an impact on current care or influence treatment. Refer to ICD-10-CM guideline IV.K. In the ICD-10-CM Alphabetic Index look for Difficult, difficulty (in)/swallowing which states to see Dysphagia. Look in the Alphabetic Index for Dysphagia which directs the coder to code R13.10. In the Alphabetic Index look for History/family (of)/malignant neoplasm (of)/gastrointestinal tract referring you to code Z80.0. Verify code selection in the Tabular List.

Chest mass

R22.2

Fever

R50.9

A male patient with convulsions is sent for a computerized axial tomogram (CT scan) of the brain with contrast. What diagnosis code is reported as the reason for the CT scan?

R56.9 Rationale: Look in the ICD-10-CM Alphabetic Index for Convulsions which directs the coder to R56.9. Verification in the Tabular List confirms code selection.

Laterality

Reporting of laterality (right, left, bilateral). For bilateral sites, the final character of the code indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

Left outer cheek abrasion, initial encounter

S00.81XA

Right eyebrow laceration, subsequent encounter

S01.111D

What is the ICD-10-CM code for a laceration on the left shoulder, subsequent encounter?

S41.012D Rationale: Look in the ICD-10-CM Alphabetic Index for Laceration/shoulder/left which directs the coder to S41.012-. In the Tabular List 6 th character 2 is selected for the left shoulder. No foreign body is noted. This code also indicates a 7 th character is required. D is selected for the subsequent encounter.

Initial encounter for a closed fracture of the right wrist?

S62.101A Rationale: Look in the ICD-10-CM Alphabetic Index for Fracture/wrist which directs the coder to S62.10-. In the Tabular List the 6th character 1 is selected for the right wrist. This code also indicates a 7th character is required. A is selected for the initial encounter.

Bruised left knee, initial encounter?

S80.02XA (find rationale)

Right and left ankle fractures

S82.891A, S82.892A (find rationale)

Intellectual disability due to previous poliomyelitis

The correct codes are F79 Unspecified intellectual disabilities and B91 Sequelae of poliomyelitis. Intellectual disability is the principal diagnosis code. The sequela (or late effect) of poliomyelitis is the secondary diagnosis. Sequelae (Late Effects)

Patient presents to the outpatient clinic complaining of abdominal cramps. The physician performed a complete history and physical examination and could not determine the cause of the cramps

The diagnosis code reported for this encounter is based on the symptom, which is the abdominal cramps (R10.9).

Outpatient Surgery

The reason for the surgery is the first-listed diagnosis even if the surgery is not performed due to complications. When the patient presents for outpatient surgery and develops complications requiring admission to observation, the reason for the surgery is the first-listed diagnosis followed by the codes for the complication(s).

Documentation of Complications of Care

To code a complication of care, there must be a cause-and-effect relationship between the care provided and the condition that the patient has contracted due to the surgery or medical care. The provider must also specifically document that the condition is a complication.

What do brackets [] indicate in the ICD-10-CM Alphabetic Index?

Use the code(s) in brackets in addition to the disease or condition to identity an associated manifestation. Rationale: ICD-10-CM guideline I.A.7 states brackets that appear in the ICD-10-CM Alphabetic Index indicates manifestation codes.

[ ] Brackets

Used in the Tabular List to enclose synonyms, alternate wording, or explanatory phrases. Brackets are used in the ICD-10-CM Alphabetic Index to identify manifestation codes in which multiple coding and sequencing rules will apply. The code in the brackets is always sequenced after the code that appears before the brackets.

( ) Parentheses

Used to enclose supplementary words that may be present or absent in the statement of a disease or procedure, without affecting the code number to which it is assigned. The terms in the parentheses are referred to as nonessential modifiers.

Combination code

Used to fully identify an instance in which two diagnoses, (or a diagnosis with an associated secondary process (manifestation) or complication), are included in the description of a single code. Assign a combination code only when that code fully identifies the diagnostic conditions involved, or when instructed in the ICD-10-CM Alphabetic Index.

Bilateral conditions

When a bilateral condition exists, and there is a bilateral code, the bilateral code is reported even if only one side is being treated for that encounter. For example, a patient has cataracts in both eyes but is having cataract surgery on one eye. For this encounter, the diagnosis of bilateral cataracts is reported. If the surgery corrects the cataract on one side, and the patient is seen for cataract surgery on the other side, a unilateral condition is reported because the patient no longer has bilateral cataracts

Impending or Threatened Condition

When a patient is discharged with a condition described as impending or threatened, review the ICD-10-CM Alphabetic Index for the subterm impending or threatened under the main term of the condition. If a subterm does not exist, reference Impending or Threatened as the main term, with the condition as a subterm. If a suitable code does not exist, report the signs and symptoms that led the provider to suspect an impending or threatened condition.

Acute and Chronic

When both an acute and a chronic condition are documented, and there is a separate code for each, report both codes, with acute sequenced first. Chronic conditions treated on an ongoing basis may be coded as many times as required for treatment and care of the patient, or when applicable to the patient's care plan. Do not code conditions previously treated, or those that no longer exist. A history of previous conditions should be coded using a Z code if the history affects patient care or provides the need for a patient to seek medical attention.

Syndromes

When coding syndromes, if the syndrome is not located in the ICD-10-CM Alphabetic Index, code the patient's signs and symptoms. For example, a patient is diagnosed with Alstrom syndrome (a rare genetic disease). In the Alphabetic Index, Syndrome/Alstrom also is not listed; nor is there a listing for Alstrom as a main term in the Alphabetic Index. Review the documentation to report the patient's signs and symptoms.

What type of code is assigned when the provider documents a reason for a patient seeking healthcare that is not an injury or disease?

Z code (Z00-Z99) Rationale: ICD-10-CM guideline IV.E indicates to use codes from Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99). These codes are also known as Z codes and are provided to record healthcare encounters for circumstances other than a disease or injury. ICD-10-CM Chapter 21 states Z codes provide codes to deal with encounters for circumstances other than a disease or injury.

A 65-year-old is seen by her cardiologist for preoperative evaluation for clearance for removal of her gallbladder due to gallstones. The cardiologist notes that she has hypertension. Medication is given to control her hypertension. What diagnosis codes are reported?

Z01.810, K80.20, I10 Rationale: When a patient is receiving a preoperative evaluation only, a Z code from subcategory code Z01.81- is reported first. Then assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Next code any finding(s) related to the pre-operative evaluation. Refer ICD-10-CM guideline IV.M. The evaluation code is located in the ICD-10-CM Alphabetic Index for Examination/pre-procedural (pre-operative)/cardiovascular referring you to code Z01.810. Next, look for Gallstone which directs you to see also Calculus, gallbladder. Look in the Alphabetic Index for Calculus/gallbladder referring you to K80.20. There is no documentation that the gallstones are causing an obstruction making the correct 5 th character zero. Look in the Alphabetic Index for Hypertension referring you to code I10. Verify code selection in the Tabular List.

The provider orders the following serum blood tests as part of a pre-employment physical exam: Complete Blood Count (CBC) automated and automated differential White Blood Count (WBC) count, Comprehensive Metabolic Panel (CMP), and a Thyroid Stimulating Hormone (TSH) assay, which are all part of the general health panel. A drug screen for multiple drug classes was also collected. What diagnosis code is reported?

Z02.1 Rationale: Look in the ICD-10-CM Alphabetic Index for Examination/medical/pre-employment which directs the coder to Z02.1. Verification in the Tabular List confirms code selection.

Patient presents for follow-up visit after completing treatment for a malignant neoplasm.

Z08 To locate the diagnosis code, look in the ICD-10-CM Alphabetic Index for Examination/follow-up (routine) (following)/malignant neoplasm to locate Z08.