1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 5 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Certain Infectious and Parasitic Diseases, Chapter 1 A00-B99 Classified according to etiology (cause) of disease –Combination coding = 1 code to fully describe DX B37.0 Candidiasis infection of mouth –Multiple coding = 2 or more to fully describe DX N39.0 (UTI), B96.2 (E. coli)

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Resistant Infections & Sepsis Resistant to antibiotics –Examples: Multi-drug-resistant Mycobacterium tuberculosis (MDR-TB) –Exceptions: Methicillin-resistant Staphylococcus aureus (MRSA) Methicillin-susceptible Staphylococcus aureus (MSSA) First-listed DX = Infection Followed by code from category Z16, Infection with drug resistant microorganism

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Sepsis, Severe Sepsis, and Septic Shock Sepsis = septicemia –If unknown organism, report A41.9, Sepsis, unspecified SIRS = inflammatory condition associated with sepsis Severe sepsis = single or multiple organ dysfunction (MOD), must be documented –Report infection, followed by an R65.2 code Septic shock = circulatory failure associated with severe sepsis –Report infection first, followed by R65.21

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Human Immunodeficiency B20 reports HIV infection and includes AIDS Positive serology or culture, but no symptoms, report: –Z21, Asymptomatic HIV status HIV exposure, but no positive serology, report: –Z20.6, contact/exposure to HIV Inconclusive serology, R75 –Used for newborns of AIDS mothers (Cont’d…)

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Human Immunodeficiency (…Cont’d) HIV testing, report Z11.4, Encounter for screening for HIV Assign additional codes for documented high-risk behavior: –Z72.51, High risk heterosexual behavior –Z72.52, High risk homosexual behavior –Z72.53, High risk bisexual behavior

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Neoplasms, Chapter 2 C00-D49 C00-C96, Malignant neoplasms –Primary and secondary D00-D09, Ca in situ (CIS) –Not invasive D10-D3A, Benign D37-D48, Uncertain –Not clearly benign or malignant D49, Unspecified behavior –Not stated as to behavior

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Stages of Neoplams Staging for renal cancer staged –Stage I tumor of kidney capsule only –Stage II tumor invading renal capsule/vein but within fascia –Stage III tumor extending to regional lymph node/vena cava –Stage IV other organ metastasis Pathology report & staging information will be documented in medical record

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Sequencing and Complications Treatment directed at –primary site, sequence primary first –secondary site, sequence secondary first Types: –Chemotherapy, Z51.11 –Immunotherapy, Z51.12 –Radiation therapy, Z51.0 Complications, sequence complication first

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. History of Neoplasm Codes History of neoplasm codes are only reported when neoplasm eradicated and is no longer present with no active treatment –Example: Z85 personal history of malignant neoplasm If active treatment, such as chemo, no history code can be reported

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 3, ICD-10-CM Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) Frequently reported codes: –Anemia, D50-D64 –Coagulation Defects, D65-D69 –Other Disorders of Blood and Blood-Forming Organs, D70-D77

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endocrine, Nutritional, and Metabolic Diseases, Chapter 4 E00-E90 Diabetes codes E08-E13 –Due to conditions classified elsewhere, E08 –Drug or chemical induced DM, E09 –Type 1 DM, E10 –Type 2 DM, E11 –Other specified DM, E13

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diabetes Mellitus DM codes are combination codes that include type of DM, body system affected, and complications Example: E10.21 Type 1 diabetes mellitus with diabetic nephropathy –If type of DM not stated, query physician

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Mental, Behavioral and Neurodevelopmental Disorders, Chapter 5 F01-F99 Alcohol dependence and use, F10 Opioid, cannabis, sedatives, cocaine, stimulants, hallucinogens, nicotine, F11-F19 Psychological disorders, F20-F29 Mood disorders, F30-F39 –Such as, bipolar disorder (Cont’d…)

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Mental, Behavioral and Neurodevelopmental Disorders Codes (…Cont’d) Anxiety, stress-related, etc., F40-F48 Behavior syndromes, F50-F59 –Such as eating and sleep disorders Adult personality and behavior, F60-F69 Intellectual disabilities, F70-F79 Developmental disorders, F80-F89 Child or adolescent behavioral and emotional disorders, F90-F98 Unspecified mental disorder, F99

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Pain Pain disorders related to psychological factors, report –G89 for pain and –F45.41 for pain related to psychological factors Dementia –F01 (vascular dementia) –F02 (dementia in diseases classified elsewhere) –F03 (unspecified dementia)

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diseases of the Nervous System, Chapter 6 G00-G99 Many combination codes –Example G06.0 Intracranial abscess and granuloma Manifestation codes –Example G21.11 Neuroleptic induced parkinsonism –Use additional code for adverse effect, if applicable (T43.3-T43.5) to identify drug

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Non-Psychological Pain Localized pain is reported with codes throughout the I-10 –Example, ear pain (H92.0-) or limb pain (M79.6-) Category G89 is NEC pain –Example, G89.11 NEC acute pain due to trauma or G89.21 NEC chronic pain due to trauma R52 reports unspecified pain that is: –Acute, chronic, generalized, or NOS

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Dominant and Nondominant Sides Dominant side: right or left handed Paralysis (plegia) is reported based on dominant or nondominant side –Example G81.10 Spastic hemiplegia affecting unspecified side G81.11 Spastic hemiplegia affecting right dominant side G81.12 Spastic hemiplegia affecting left dominant side G81.13 Spastic hemiplegia affecting right nondominant side G81.14 Spastic hemiplegia affecting left nondominant side If dominant unknown, report dominant if right- sided

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diseases of the Eye and Adnexa, Chapter 7 H00-H59 Does not contain all the eye and adnexa codes Chapter Excludes2 directs to other categories, such as: –injury (trauma) of eye and orbit (S05.-) –injury, poisoning and certain other consequences of external causes (S00-T88) –neoplasms (C00-D49)

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Structure of Eye and Ocular Adnexa Figure: 5.15 Eye and Ocular Adnexa

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hordeolum and Chalazion Hordeolum = infection of sebaceous glands (stye) reported on location and type –Right or left upper/lower, or unspecified External, report H00.01- Internal, report H00.02- Chalazion = infection of eyelid that forms mass reported on location –H00.1

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Entropion/Ectropion Entropion = turning inward of eyelid, H02.0- From Frazier MS, Drzymkowski JW: Essentials of Human Diseases and Conditions, ed 5, St. Louis, 2013, Saunders. Figure: 5.18A Figure: 5.19A Ectropion = turning outward of eyelid, H02.1-

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Lacrimal System Category H04 Codes reported on right, left, bilateral, unspecified, such as: –H04.131 Lacrimal cyst right lacrimal gland –H04.132 Lacrimal cyst left lacrimal gland –H04.133 Lacrimal cyst bilateral lacrimal glands –H04.139 Lacrimal cyst unspecified lacrimal gland Figure: 5.17 Lacrimal apparatus

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diseases of the Ear and Mastoid Process, Chapter 8 H60-H95 Excludes2 indicates other categories for reporting other ear conditions, such as: –endocrine, nutritional and metabolic diseases (E00-E90) –injury, poisoning and certain other consequences of external causes (S00-T88) –neoplasms (C00-D49) H60-H95 codes report diseases of external, middle, and inner ear, as well as mastoid, other, and surgical complications NEC

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diseases of the Circulatory System, Chapter 9 I00-I99 Excludes2 note indicates other categories for other circulatory conditions, such as: –neoplasms (C00-D49) –symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) –systemic connective tissue disorders (M30-M36) I00-I99 reports conditions such as rheumatic fever, hypertension, ischemic heart disease, cerebrovascular diseases, etc.

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hypertension Report I10; includes arterial, benign, essential, malignant, primary, and systemic –Arterial: Increased arterial blood pressure, hypertension –Systemic: Arterial BP exceeds norm for several months –Primary: Essential, cause unknown –Secondary: Due to underlying condition (Cont’d…)

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hypertension (…Cont’d) Transient: Temporary, R03.0, elevated BP without DX of hypertension During or due to pregnancy, O13.- or O14.-

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hypertension with Heart Disease I11, Hypertensive heart disease –Includes conditions reported with I50.- or I51.4-I51.9 (myocarditis, cardiomegaly, ill-defined or unspecified heart disease) when condition due to hypertension I11.0 Hypertensive heart disease with heart failure Hypertensive heart failure Use additional code to identify type of heart failure (I50.-) I11.9 Hypertensive heart disease without heart failure Hypertensive heart disease NOS (Cont’d…)

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hypertension with Heart Disease (…Cont’d) Same heart condition not stated to be “due to hypertension” or “hypertensive,” report the heart disease and hypertension separately

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chronic Kidney Disease and Hypertension Assume a relationship between the chronic kidney disease and the hypertension I13, combination code for category hypertensive heart and chronic kidney disease If heart disease is present, assign a category I50 code (Cont’d…)

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chronic Kidney Disease and Hypertension (…Cont’d) CRF/CKD/CRI + hypertension I12.9 + N18.9 CKD stage 1 + hypertensionI12.9 + N18.1 CKD stage 2 + hypertensionI12.9 + N18.2 CKD stage 3 + hypertensionI12.9 + N18.3 CKD stage 4 + hypertensionI12.9 + N18.4 CKD stage 5 + hypertensionI12.9 + N18.5 CKD stage 6 or ESRD or on dialysis + I12.9 + N18.6 Patient with CKD on any type of dialysis I12.9 + N18.6 + Z99.2

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Myocardial Infarction Acute heart attack with occlusion of coronary artery STEMI, ST elevation MI, most severe, total occlusion –Example: I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery NSTEMI, non-ST elevation MI, less severe, partial occlusion –Example, I21.4 Non-ST elevation (NSTEMI) myocardial infarction (Cont’d...)

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Myocardial Infarction (…Cont’d) Subsequent STEMI or NSTEMI are reported with I22.- –Example, I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall Complications within 28 days of initial MI, I23 –Example, I23.1 Atrial septal defect as current complication following acute myocardial infarction

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diseases of the Respiratory System, Chapter 10 J00-J99 Some codes are combination codes that identify condition and causative organism –Example: J03.01 Acute recurrent streptococcal tonsillitis Other codes require separate reporting of organism –Example: J01.01 Acute recurrent maxillary sinusitis (Use additional code (B95-B97) to identify infectious agent )

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 5 CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)