Chapter 3 basic coding

external cause index

Chapter 20 in I-10 classifies this. it is located after the table of drugs and chemicals in the I-10. it classifies enviornmental events (tornadoes, floods), circumstances, and other conditions as the cause of injury and other adverse efforts alphabetically.

inoculations and violations

code Z23 is for encounters for ?. it indicates that a pt is being seen to receive a prophylactic inoculation against a disease. procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. code Z23 may be used a secondary code if the inoculation is given as a routine part of preventive health care, such as well-baby visit

guidelines for coding reporting-ambulatory services

for ?, code the diagnosis for which the surgery was performed. if the postop diagnosis is known to be different from the preop diagnosis at the time diagnosis is confirmed, select the postop diagnosis for coding, since it is the most definite

accurate reporting of ICD-10-CM diagnosis codes

for accurate ?, the documentation should describe the patients condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reason for the encounter. there are ICD-10-CM codes to describe all of these. according to guidelines, it is acceptable for symptoms and signs to be reported if no definitive diagnosis has been established by the provider.

Encounters for circumstances other than a disease or injury

ICD-10-CM provides codes to deal ?. the factors influencing health status and contact w/ health services codes (Z00-Z99) are provided to deal w/ occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

Z17

Estrogen receptor status

ICD-10 guidelines for coding and reporting-ICD-10-CM code for the diagnosis, condtion, problem, or other reason for encounter/visit

list 1st the ICD-10-CM code for the diagnosis condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. list additional codes that describe any coexisting conditions. in some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established by the physician

index locations

located at the end of the tabular.

Z29

long-term (concurrent) drug therapy. codes from this category indicate a patients continuous use of a precribed drug (including such things as aspirin therapy) for the long term treatment of a condition or the prophlactic use. it is not for use for patients who have addictions to drugs. this subcategory is not for use of medications for detox or maintencance programs to prevent w/drawal symtpoms in pts with drug dependence (eg., metadone maintenance for opiate dependence). assgn the appropriate code for the drug dependence instead.

chief complaint

most drs document this of the patient for each encounter in the medical record. its the reason the patient presents for the medical visit. it is one of the keys to determining the first-listed diagnosis. its the reason for the visit from the patients perspective.

diagnoses

often are not established at the time of the initial encounter/visit. it may take 2 or more visits before the diagnosis is confirmed

Z78.1

physical restraint status, may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure

Z33.1

pregnant state, incidental. this code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. otherwise, a code from the obstetric chapter is required

Z95

presence of cardiac and vascular implants and grafts

Z97

presence of other devices

Z96

presence of other functional implants

Z05.0-Z05.9

report observations and evaluation Z codes for newborns during neonatal period (1st 28 days of life)observations and evaluation Z codes for newborns during neonatal period (1st 28 days of life) for suspected conditions that are not found. these codes are only reported when a healthy newborn is evaluated for a condition not to be present. if the newborn has signs or symptoms of a suspected problem, you would report the signs or symptoms and not a code from these observation codes.

therapeutic services

report the diagnosis, condition, problem, or other reason for the encounter when a pt presents for this

ICD-10 official guidelines for coding and reporting-observation stay

when a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. when a pt presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis , followed by codes for the complications as secondary diagnoses.

guidelines for coding and reporting-outpatient surgery

when a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis, even if the surgery is not performed due to a contraindication.

pre-op evals only

when the only service is preop exam, report the appropriate Z code along w/ any code that indicate significant conditions

Z15 genetic susceptibility to disease

? indicates that a person has a gene that increases the risk of that person developing the disease. codes from this category should not be used as principal or first listed codes. if the pt has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. if the pt is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. if the purpose of the code Z31.5, encounter for genetic counseling, should be assigned as the first listed code, followed by a code from category Z15. additional codes should be assigned for any applicable family or personal history

Z14 genetic carrier

? status indicates that a person carriers a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. the person does not have the disease and is not at risk of developing the disease

official guidelines for coding and reporting-pts receiving preoperative evaluations only

?, sequence first a code from subcategory Z01.81, encounter for pre-procedural examinations, to describe the pre-op consultations. assign a code for the condition to describe the reason for the surgery as an additional diagnosis. code also findings related to the pre-op evaluation

use of Z codes in any healthcare setting

Z codes are for use in any healthcare setting. Z codes may be used as either a first listed (principal diagnosis code in the inpatient setting) or a secondary code, depending on the circumstances of the encounter. certain Z codes may only be used as first listed or principal diagnosis

Z codes indicate a reason for an encounter

Z codes are not procedure codes. a corresponding procedure code must accompany a Z code to describe any procedure performed

Z codes for pre-op evals

Z018.810-preoperative cardiovascular exam; Z01.811-preoperative respiratory exam; Z01.812-preop lab exam blood and urine tests prior to treatment or procedure; Z01.818-other preprocedural exam

2 categories of Z codes that report observation

Z03 and Z04. these observation codes are reported only as the first listed diagnosis for medical observation for suspected conditions and conditions ruled out. other codes may be reported in addition to the observation codes but only when they that condition or conditions are unrelated to the reason for the observation.

Z codes

assigned to report types of encounters whos information may not pertinent to the care the pt received and to help capture the story accurately. sometimes it will be the first listed code, and sometimes it will be a supplemental code

Z21

asymptomatic HIV infection status

Z76.82

awaiting organ transplant status

Z74.01

bed confinement status

Z67

blood type

Z68

body mass index (BMI). BMI codes should only be assigned when the associated diagnosis (see section III, reporting additional diagnoses). do not assign BMI codes during pregnancy

Z22

carrier of infectious disease. carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection

contact/exposure

category Z20 indicates contact w/, and suspected exposure to, communicable diseases. these codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic. category Z77-other contact with and suspected exposures to hazardous to health, indicates contact with and suspected exposures hazardous to health. ? codes may be used as a first listed code to explain an encounter for testing, or, more commonly, as a secondary code to identify a potential risk

official guidelines for coding and reporting-chronic diseases

chronic diseases treated on an ongoing basis may be coded and reported as many times as the pt receives treatment and care for the conditional

example of status code

code Z94.1, heart transplant status, should not be used with a code subcategory T86.2. complications of heart transplant. the status code does not provide additional information. the complication code indicates that the patient is a heart transplant patient. for encounters for weaning from a mechanical ventilator, assign a code from a subcategory J96.1. chronic respiratory failure, followed by code Z99.11l, dependence on respirator status

official guidelines for coding and reporting-code all documented conditions that coexist

code all documented conditions that coexist at the time of the encounter/visit, and require or affect pt care treatment or management. do not code conditions that were previously treated and no longer exist. however, 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

codes that describe symptoms and signs

codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established by the provider.

categories of Z codes

contact/exposure, inoculations and vaccinations

section IB

contains general guidelines that correspond to the chapters as they are arranged in the classification.

Z99

dependence on enabling machines and devices, not elsewhere classified. note: categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.

guidelines and for coding and reporting-uncertain diagnosis

do not code diagnoses documented as "probable", "suspected", "questionable", "rule out", or "working diagnosis" or other similar terms indicating uncertainty. rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms signs, abnormal test results, or other reason for the visit. please note: this differs from the coding practices used by short-term, acute care, long-term and psychiatric hospitals

Z66

do not resuscitate. this code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay

Z18

estrogen receptor status

guidelines for coding and reporting-pts receiving therapeutic services only

for ? during an encounter/visit, sequence first teh diagnosis, condition, problem, or other reason for encounter/visit shown in the medial record to be chiefly responsible for the outpatient services provided during the encounter/visit. codes for other diagnoses (e.g. chronic conditions) may be sequenced as additional diagnoses. the only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second

patient may not have a chief complaint

the pt requests a physical to qualify for insurance or may be an expectant parent seeking to establish a pediatrician. the reason for these visits can be reported as a first-listed codes using codes: z02.6-encounter for examination for insurance purposes; z76.81 expectant parent(s) prebirth pediatrician visit

Z94

transplanted organ and tissue status

Z28.3

under immunization status

pre-operative clearance

usually, a surgeon will want a ? performed by the pts primary care provider, often due to a chronic or pre-existing condition. when the primary provider reports the diagnosis for this visit, the first listed diagnosis will be the appropriate Z code to indicate the encounter is for preop clearance; then the reason for the upcoming surgery is reported following by the condition requiring the clearance

coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc)

were developed for inpatient reporting and do not apply to outpatients

diagnostic services

when a ? is provided to a pt during an encounter, the reason for the service is the diagnosis stated in the medical record, or when no diagnostic statement is available, report the primary reason the pt presented for the service

Z93

artificial opening status

Z89

acquired absence of limb

Z90

acquired absence of organs, not elsewhere classified

1st listed diagnosis and coexisting conditions

additional codes should be assigned for any coexisting conditions that are present or treated during that visit or encounter. sometimes there is more than one symptom that is present

Z88

allergy status to drugs, medicaments and biological substances. except Z88.9 allergy status to unspecified drgus, medicaments and biological substances status

Z91.0-

allergy status, other than to drug and biological substances

coding guidelines

approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits

external cause codes

are never reported as a first listed diagnosis. these codes are reported to clarify injury or adverse effects. describes the external circumstances under which an accident, injury, or act of violence occurred. the main terms in the index usually represent the type of accident or violence (e.g., assault, collision), with the specific agent or other circumstance listed below the main term. example: look on pg 57. you will not find these codes in the index to disease of the I-10; rather you must look in the ? index. when one is reported it is reported in addition to an injury code from the tabular list of the I-10. most groups of codes have Includes or Excludes notes that provide further detail about assigning the codes

official guideline-pts receiving diagnostic services only

for ? only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. codes fo other diagnoses (e.g. chronic conditions) may be sequenced as additional diagnoses. for encounters fo routine lab/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89. encounter for other specified special exam. if routine testing is performed during the same encounter as a test to evaluated a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. for outpatient encounters for diagnostic tests that have been interpreted by a dr, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. do not code related signs and symptoms as additional diagnosis. please note: this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on tests results

guidelines for coding and reporting-routine prenatal visits

for routine outpatient prenatal visits when no complications are present, a code from category Z34, encounter for supervision of normal pregnancy, should be used as the first listed diagnosis. these codes should not be used in conjunction w/ chapter 15 codes. codes from category 009, supervision of high-risk pregnancy, are intended for use only during the prenatal period . for complications during the labor or delivery episode as a result of a high-risk pregnancy, assign the applicable complication codes from chapter 15. if there are no complications during the labor delivery episode, assign code 080, encounter for full-term uncomplicated delivery. for routine prenatal outpatient visits for pts w/ high-risk pregnancy, should be used as the first-listed diagnosis. secondary chapter 15 codes may be used in conjunction w/ these codes if appropriate

Z19

hormone sensitivity malignancy status

chronic disease

if a pt has a chronic condition that is treated on an ongoing basis, you can report the condition as many times as the pt receives care or treatment for the condition

uncertain diagnoses

in an inpatient setting, ? are reported, but in the outpatient setting these ? are not reported

additional diagnosis

in some cases, these would be reported to describe complications, reasons for canceled procedures, and other coexisting conditions

first-listed diagnosis

in the outpatient setting, this is used in lieu of principal diagnosis. in determining this the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.

section IA

information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the ICD-10-CM tabular list is found in this under guidelines, under "conventions used in the tabular list"

status code

is assigned to indicate that a patient has the sequelae or residual of a past disease or condition or is a current carrier of a disease. there are codes and categories of Z codes assigned to report a status. this includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. its informative, because the status may affect the course of treatment and its outcome. it is distinct from a history code. the history code indicates that the pt no longer has the condition. should not be used w/ a diagnosis code from one of the body system chapters. if the diagnosis code includes the information provided by the status code.

what is the most critical rule?

it involves beginning the search for the correct code assignment through the alphabetic index. never begin searching initially in the Tabular list as this will lead to coding errors

circumstances to assign z codes

most often assigned in outpatient setting (ambulatory care centers physcians offices, outpatient dept of hospitals). 1. when a person who is currently not sick encounters the health services for some specific purpose, such as to act as a donor of an organ or tissue, to receive a preventive vaccination, or to discuss a problem that is in itself not a disease or injury. occurrences such as these, are more common among outpatients as health clinics. 2. a patient with a known disease or injury receives health services for specific treatment of the disease or injury. 3. a circumstances or problem is present and influences a patients health status but is not to itself a current illness or injury. (in these situations the Z code should be used only as a supplementary or secondary code) 4. to indicate the birth status and outcome of the delivery of a newborn.

history of

often, the patient record stats that there is a ? a disease for example, "? type 2 diabetes mellitus w/out complications." this does not mean that the patient no longer has diabetes mellitus, but that the patients medical history include diabetes melitus. you would not assign a Z code to indicate a previous history of diabetes mellitus but instead would assign the code for the current disease, check w/ the physician. you may also want to offer some physician education regarding the documentation of the disease

Z98

other postprocedural status. assign code Z98.85, transplanted organ removal status, to indicate that a transplanted organ has been previously removed. this code should not be assigned for the encounter in which the transplanted organ is removed. the complication necessitating removal of the transplant organ should be assigned for that encounter.

Z78

other specified health status

Z16

resistance to antimicrobial drugs. this code indicates that a patient has a condition that is resistant to antimicorbial drug treatment. sequence the infection code first

when reading patients chart to code

sometimes, important information contributing tot he care of the patient is not an illness. you must ask if the information pertinent to the care provided.

patients complaint

sometimes, its a symptom of a more complex diagnosis. ex: a patient presents with a chief complaint of a backache, after examination, the dr determines that the pt has an acute kidney infection due to E. Coli. the chief complaint is backache, but the first listed diagnosis is acute kidney infection due to E. Coli. backache is a symptom of the the acute kidney infection. N10-acute pyelonephritis; B96.2-escherichia coli (E. Coli) as the cause of the diseases classified elsewhere

the uniform hospital discharge data set (UHDDS)

states the definition of principal diagnosis does not apply to hospital-based outpatient services and provider based office visits

Z92.82

status post administration of tPA (rtPA) in a different facility w/in the last 24 hours prior to admission to current facility. assign code Z92.82. status post administration of tPA (rtPA) in a different facility w/in the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activatior (tPA) within the last 24 hours prior to admission to the current facility. this guideline applies even if the patient is still receiving the tPA at the time they are received into he current facility. the appropriate code for the condition for which the tPA was administered (such as cerbrovascular disease or myocardial infarction) should be assigned first. code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record

guidelines for coding and reporting-codes from A00.00 through T88.9, Z00-Z99

the appropriate code(s) from these must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. guidelines state that it is acceptable to use any of the codes throughout the entire Tabular List to identify the reason(s) for an outpatient visit including the use of Z codes. Z codes are used more frequently in outpatient settings. this guideline assures data integrity by promoting accurate I-10 diagnosis codes that are supported by documentation in the health record. it is important to code all the conditions or problems that are being managed during an encounter