1. SEQUENCING – How well do you remember the rules?
Icd-10 gUIDELINES
SEQUENCING – How well do you remember the rules?
Lorri Tolliver CPC- CPC-I, CPMA, CEMC, CCS, CRC
Orlando AAPC Chapter – Education Officer

2. ICD-10 sequencing – what comes first?
DISCLAIMER: This presentation is far from covering all guidelines on Sequencing rules. It is not all-inclusive. Please read your guidelines to complete your understanding.

3. Is it confusing? Discussion topics – General coding Guidelines
Chapter Specific coding guidelines
Examples – HIV, Sepsis, Cancer vs. Chemo, Acute vs Chronic, Anemia, Sequela
question/answer/discussion
We won’t be able in this short time to cover all of the specifics of the guidelines. It’s important for you to read the guidelines.
Cross map your page #’s from guideline to code selection. Make notes in your tabular of the guidelines that are hard to remember.

4. What are some of the general Sequencing Rules?
“Code Also” – two codes may be required to fully describe a condition “Use additional code” –Some single conditions require adding a secondary code, “if known” or “If applicable” “Code First” – These notes are found under certain codes that are not specifically manifestation codes but may be due to an underlying cause. “code if applicable, any causal condition first” – this code may be assigned as a principle diagnosis with the causal condition is unknown or not applicable.
Code Also – Sequencing will depend on the circumstances of the encounter
Use Add’l Code – example: bacterial infections not included in chapter 1, a secondary code from category B95 – Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96
These may be required to identify the bacterial organism that caused the infection. In these cases, your note to “Use additional code” will be found at the infectious disease code. Ie.
Code First – If there is a known underlying cause that is present, the underlying condition is sequenced first. Guidelines state there is a Etiology/Manifestation Convention:
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For these conditions, the convention requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Whenever this is the case, you’ll find an instruction: “Code first” or “Use additional Code” on certain codes that are not part of an etiology/manifestation combination. The “Use Additional Code” will be at the Etiology Code and The “Code first” will be at the manifestation. These will guide you in the proper sequencing order. Etiology followed by Manifestation
Code if applicable - If a causal condition is known, then the code for that condition should be sequenced first as the principle or first-listed diagnosis
What are some of the general
Sequencing Rules?

5. Ask yourself – Why is the patient here? Why are they being seen?
Answering this question will help guide you - The first diagnosis is always going to be the reason for the encounter. Generally, you find the reason in the Chief Complaint or the HPI paragraph – “Patient is here for….”
If they list signs and symptoms – Ie. “Patient is here due to cough and cold symptoms” You’re going to have to revert to the Assessment to see if a definitive diagnosis has been given so not to just code the S & S’s first.
From there sequencing will depend on the circumstances of that visit/encounter.

6. Human Immunodeficiency Virus (HIV)
Is admission or visit - HIV-Related or Unrelated?
If admission is HIV-related –
1) Principle dx: B20 HIV Disease
2) Followed by all reported related conditions.
(See instructional note)
If admission is unrelated to HIV – ie. Traumatic injury –
1) Principle dx: the unrelated condition/Injury.
2) Other unrelated Diagnoses or S & S
3) B20 or Z21(Asymptomatic HIV)
4) Related HIV Diagnoses.
Important: Make for sure you know if the patient has had a confirmed diagnosis of HIV or AIDs. Code only confirmed cases.
RE: confirmation -The only necessary documentation is the provider stating that the patient is HIV positive or has an HIV related illness.
If admission is HIV related: instructional note states – Code first HIV complicating pregnancy, childbirth or puerperium, if applicable (O98.7)
Code additional dx to identify all manifestations of HIV infection.
Important: Is the patient’s reason for the visit HIV related? Maybe the patient is Asymptomatic HIV coming in for an unrelated problem?
2nd bullet point: in this case: for a traumatic injury – you would report the traumatic injury first and any other unrelated confirm Dx or S&S, then the HIV code B20 or Asymptomatic HIV Z21 and other HIV related Dxs.
Human Immunodeficiency Virus (HIV)

7. Human Immunodeficiency Virus (HIV)
Encounter for HIV testing
Z11.4 Encounter for Screening for HIV
Use additional code for any associated high risk behavior
Patient with Signs & Symptoms presents for HIV Testing
Code first signs and symptoms
Additional Counseling code: Z71.7 if provided during this encounter for the test
Patient returns for HIV test results
Test result is negative Z71.7 – HIV Counseling
Test result is positive Follow previous guidelines given.
Encounter for Testing: To determine the patients status
Human Immunodeficiency Virus (HIV)

8. Human Immunodeficiency Virus (HIV)
Other Important points about HIV Diagnoses:
Z21 – Asymptomatic HIV – applied when patient has no documentation of symptoms but is listed as “HIV positive”, “Known HIV” or “HIV test positive” or similar.
If the term “AIDS” is used or if patient is treated for an HIV related illness – do not use Z21 – revert to B20
HIV infection in Pregnancy, Childbirth and the Puerperium:
A pregnant patient admitted for an encounter for an HIV related illness – Principle Dx: O98.7 HIV complicating pregnancy
Followed by Dx: B20
Followed by Dx: Other HIV related illnesses
(Chapter 15 codes always take sequencing priority)
B20 – HIV Disease also includes AIDS
Human Immunodeficiency Virus (HIV)

9. Note:
Page 1344 gives specific guidelines for Infectious agents as the cause of diseases classified to other chapters
Page 1344 In 2018 AAPC’s ICD-10 Guidelines section: There are specific instructions how to sequence when certain infections are in other chapters and what to use as additional codes when an organism is identified or if it is not.
Watch instructional notes on conditions that require an additional code to identify the organism and apply if known.

10. Severe Sepsis Guidelines – Requires a minimum of 2 codes:
When Diagnosis is Sepsis –
Assign code for underlying systemic infection
-with no known causal organism – A41.9 Sepsis, unspecified organism
Sepsis & associated acute organ dysfunction or multiple organ dysfunction (MOD) – follow guidelines for coding Severe Sepsis.
Acute organ dysfunction not clearly associated with Sepsis – do not assign a code from R65.2 – Severe Sepsis
Severe Sepsis Guidelines – Requires a minimum of 2 codes:
The underlying Systemic Infection
A code from subcategory R65.2 Severe Sepsis
If the causal organism is not documented – code A41.9 Sepsis, unspecified organism
3) If acute organ dysfunction – additional code required for specific organ dysfunction. Ie. Acute kidney failure, Acute respiratory failure – See R65.2
Note: A code from subcategory R65.2 Severe Sepsis should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented
Point 3 – acute organ dysfunction related to a medical condition other than sepsis – do not code from R65.2 Severe Sepsis – An acute organ dysfunction must be associated to sepsis to use this code. If the documentation is not clear as to whether an acute organ dysfunction is related or not – you’ll have to query the provider.
Note: Look at R65.2 – it confirms that it is infection with assoc. acute organ dysfunction, with MOD and there is a laundry list of Instructions with code first underlying infection and Use additional code to identify specific acute organ dysfunction.

11. Septic shock
Septic Shock refers to circulatory failure associated with severe sepsis, and therefore a type of acute organ dysfunction.
Sequencing is as follows:
Code for systemic infection
R65.21 Severe sepsis w/septic shock
or T81.12 Post procedural septic shock
3) Code for other acute organ dysfunctions
Instructions state septic shock cannot be assigned as a principal diagnosis.

12. Case Example
Diagnosis: Pseudomonal Septic Shock with Acute Respiratory Failure A41.52 R65.21 J96.00
Septic shock in and of itself is a type of acute organ dysfunction and should therefore be coded according to the guidelines for the coding of severe sepsis.
In this case the 5th character for the code from subcategory R65.2 will be a “1”, indicating severe sepsis with septic shock.
If other acute organ dysfunction is present, additional codes should be assigned for those conditions.
Diagnosis: Pseudomonal septic shock with Acute Respiratory Failure = A41.52, R65.21, J96.00
If no organ dysfunction - Coding this would have only required two codes as R65.21 is a combination code that reports both severe sepsis and septic shock. 
With the organ dysfunction:
A41.52 Sepsis due to Pseudomonos – Sepsis has combinations with underlying infection – look for specificity
R Sever Sepsis without Septic Shock
It has an additional instructional note – Use Add’l code to identify specific acute organ dysfunction – J96.0- For acute respiratory failure – requires add’l digit.
J96.00 – Acute respiratory failure, unspecified whether with hypoxia or hypercapnia (J96.9 – was not noted as acute – so J96.0- was more specific)

13. Sequencing of severe sepsis – at time of admission or not?
If severe sepsis is present on admission & meets definition of principle diagnosis –
1) the underlying systemic infection should be assigned first or as principle dx.
followed by R65.2
If severe sepsis develops during an encounter (not present on admission) –
Code the underlying systemic infection
Code R65.2
Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.

14. Sepsis & severe sepsis with localized infection
Scenario: Reason for admission is both sepsis or severe sepsis & a localized infection
ie. Pneumonia or cellulitis
Code underlying systemic infection
Localized infection

15. Cases example
Patient admitted for acute pyelonephritis secondary to Enterococcus. During admission, the pyelonephritis advanced to severe sepsis with acute renal failure = N10 B95.2 A41.81 R65.20 N17.9
Coding this scenario requires 5 codes. The acute enterococcal pyelonephritis is coded first because it was the reason for admission. This diagnosis needs two codes, a code for the acute pyelonephritis and a code that identifies the causative organism. Because the severe sepsis developed after admission the sepsis codes are sequenced following the codes for the localized infection. This diagnosis requires 3 codes, a code for the systemic infection, a code for severe sepsis without septic shock and a code for the acute organ dysfunction. This patient did not have severe sepsis at the time of admission but rather during admission.
So we have:
N10 – Acute pyelonephritis – instruction below the code state – use add’l code to identify infectious agent B95-B97
B95.2 Enterococcus in diseases classified elsewhere. – Everything else in this range has specificity not stated in this note.
A Specific to: Sepsis due to Enterococcus – Enterococcus was present first, causing the Acute Pyelonephritis causing Severe sepsis and subsequently acute renal failure
R65.20 – Sever Sepsis without Septic Shock – listed under this code gives the instruction to “Code First” A41.9 – but you have a more specific code so important to remember the rule to look above and below your code to be sure you’ve selected the most specific
It has an additional instructional note – Use Add’l code to identify specific acute organ dysfunction – N for Acute Kidney Failure is listed. Renal = Kidney
N17.9 Acute Renal Failure

16. Case example
Diagnosis: Patient admitted with sepsis secondary to staphylococcal pneumonia = A41.2 J15.20
Sepsis often stems from a localized infection.
When both a localized infection (e.g., pneumonia or UTI) and associated sepsis/severe sepsis are present on admission,
the code for the systemic infection is sequenced first
the code for the localized infection is sequenced as a secondary code.
If the sepsis is severe and additional code R65.2 code and any applicable codes for acute organ dysfunction should be assigned.
In this case: the patient had sepsis at the time of admission but was not diagnosed as severe sepsis and no organ dysfunction noted.
Diagnosis: Patient admitted with sepsis secondary to staphylococcal pneumonia =
A41.2 – Sepsis due to unspecified staphylococcus
J15.20 – Pneumonia due to staphylococcus, unspecified – Always look for instructions at the top of the category – in this case J there are add’l instructions to code if applicable.

17. Sepsis / Severe Sepsis / Septic shock
Associated with a Non-infectious process
Ie. Trauma related or Burn or other serious injury:
If it meets the definition for principle diagnosis
Code first: noninfectious condition
Followed by: code for resulting infection
If severe sepsis: R any organ dysfunction, if applicable
It is not necessary to assign code R65.1 Systemic Inflammatory response syndrome (SIRS) of non- infectious origin for these cases.
If infection meets principle dx: code first
Followed by non-infectious condition. *
Due to post-procedural infection without septic shock
Code choices – Code first:
T80.2 Infection following infusion, transfusion, and therapeutic injection.
T81.4 Infection following a procedure
T88.0 Infection following an immunization
O86.0 Infection of obstetric surgical wound
Followed by: Code for specific infection
If Severe Sepsis and Organ Dysfunction –
Code additionally – R65.2 and code for type of organ dysfunction
General rule: Like all post-procedural complications, code assignment is based on the providers documentation of the relationship between the infection and procedure.
* On Last point of first column (See add’l specific guidelines – page 1345)
Due to time constraint - we will not cover sequencing of Sepsis due to MRSA and MSSA conditions but there are sequencing rules to read on page 1345 of your guidelines.

18. Sequencing for Neoplasm / chemo/immunotherapy/radiation therapy
Neoplasm Documentation: Related Conditions Coding
Note: Code assignment is based on the provider’s documentation of the relationship between a condition and the underlying neoplastic disease.
Conditions related to neoplasms must be documented by the provider and linked to the neoplasm.
Look for terms such as "due to," "secondary to," "caused by," or "resulting from" that connect the neoplasm with associated conditions or complications.
For example:
Anemia due to adenocarcinoma of the colon
Diabetes mellitus secondary to pancreatic carcinoma
Pathological fracture resulting from metastatic stage 4 ovarian carcinoma

19. What’s In the documentation?
Look for documentation of chemotherapy, radiation, or immunotherapy, and conditions caused by treatments which may require evaluation, monitoring, treatment, or hospitalization.
Neoplasm Documentation:
Treatment For example:
Immunotherapy for cancer of the prostate
Anemia as an adverse effect of radiation therapy
Intravenous rehydration for dehydration due to malignancy
Coding Note: When coding surgical removal of a neoplasm followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis.
Coding Note: When coding surgical removal of a neoplasm followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis.

20. Sequencing for Neoplasm / chemo/immunotherapy/radiation therapy con’d
When a patient with a primary neoplasm with metastasis is admitted, and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
Coding Note: Additional diagnoses are reported for any other conditions that coexist at the time of admission or develop subsequently, or which impact the patient’s care.

21. Neoplasm Sequencing Examples
Patient admitted with Breast Cancer with Metastasis to the bones. A Mastectomy is performed and the secondary sites are evaluated.
Patient admitted with cancer of the trachea with metastasis to the cervical lymph nodes. The primary site of the trachea is monitored and the affected lymph nodes are resected.
The primary malignancy of the breast will be the principal diagnosis. The secondary site of the bone is coded as an additional diagnosis.
The secondary metastatic site (cervical lymph nodes) is the principal diagnosis. The primary site (trachea) is coded as an additional diagnosis
What is the reason for the encounter and what is being treated?
Neoplasm Sequencing Examples

22. Neoplasm Sequencing Examples
Patient admitted to rule out metastatic bone cancer originating from the breast. The breast cancer was treated with mastectomy and adjunct chemotherapy 3 years ago
Patient with leukemia documented as "in remission" is admitted for autologous bone marrow transplantation.
Report the codes for:
Z08 Examination for follow-up examination after completed treatment for malignant neoplasm
Personal history of malignant neoplasm of breast (Z85.3)
Use the appropriate code to designate the type of leukemia and in remission. C95.91
Encounter for screening of a malignant neoplasm Z12. - is for a patient being screening due to a family history of a malignancy but this patient is asymptomatic.
Once treatment has been completed and no medications are being taken for prevention, the Cancer is no longer coded as cancer but rather a history of….
The codes for personal history and in remission are only assigned when the documented by the provider.
Neoplasm Sequencing Examples

23. Neoplasms Reason for Medical Care
Correctly Identify the reason for the medical care – what caused the admission? ? Therapy – Chemo, Immuno, Radiation ? Pain Control or Management ? Treatment of a complication – resulting from surgery or care ? Aftercare following surgery for neoplasm ? Follow up care for completed treatment of a malignancy ? Prophylactic organ removal for prevention of malignancy Guidelines state: Code first the diagnosis, condition, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided. Next, list additional codes that describe any coexisting conditions. In some cases – the first listed code may be a symptom when a definitive diagnosis has not been established by the physician.
Neoplasms
Reason for Medical Care

24. Examples
Patient presents for chemotherapy for metastatic lung cancer to the bone.
Z51.11 – Chemo treatment
C79.51 – Secondary malignant neoplasm of Bone
C34.90 – Lung, unspecified part of lung, unspecified bronchus or lung
Encounter is specifically for administration of chemo, immuno, or radiation therapy
Z51.0 Encounter for antineoplastic radiation therapy
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy
Instructional note: Code also condition requiring Care
The lung is the primary site, the bone is the secondary site – both are being treated by the chemo but the bone would be considered the more acute since it is the newest of the cancer to be diagnosed.
Reason for encounter is the first listed code: Chemo treatment, So 1st CA code is the secondary CA, followed by the primary CA
If patient is seen for two sites – neither are documented as primary or secondary and treatment (excision is for both) – either can be the primary code followed by the other.
Note: if the patient is admitted for excision of the primary and/or secondary cancer and postoperatively received chemo – Code first the primary or secondary following the same rules as above, additional code for Administration of chemo code.

25. There are many more guidelines and sequencing rules for neoplasm
There are many more guidelines and sequencing rules for neoplasm. Refer to your Chapter Specific Guidelines for neoplasms to review more. Coding is all about guidelines and coding concepts – it’s up to you to know them! Do your due diligence!

26. Anemia Anemia due to underlying malignancy
Code first: Malignancy even when treatment is directed at anemia only.
Followed by: Anemia
Instructional note states: code first the Neoplasm
Anemia due to CKD or ESRD
Code first: CKD or ESRD, even if treatment is directed at the anemia –
Followed by: the anemia
Instructional note states: code first underlying cause.
Manifestation code would not be appropriate as the principle dx.
What’s the exception?
Anemia due to Rheumatoid Arthritis or Lupus
Anemia due to underlying malignancy: Exception: When reviewing the record – You as Coders should look for documentation to see if this is anemia of the malignancy or if this is due to the treatment of the malignancy (surgical blood loss anemia or drug induced anemia). If not due to the malignancy but due to the treatment of the malignancy then anemia may be appropriate as the principle diagnosis.
Treatment is directed at correcting the anemia – The underlying chronic condition of rheumatoid or lupus would be Primary. – Instructional note states: code first the underlying chronic condition.
Followed by anemia.

27. Additional sequencing guidelines
Multiple Diagnoses: Acute vs Chronic conditions – Examples to Discuss
A patient with chronic kidney disease (CKD) who is also hypertensive should always have hypertensive chronic kidney disease coded (I12.-), followed by the CKD stage (N18.-).  
A patient with diabetic foot ulcer would require multiple diagnosis codes describing the type of diabetes with foot ulcer (E or E11.621), along with the laterality, specific foot location, and stage of the non-pressure foot ulcer (L97.4- or L97.5-). 
If a patient has multiple burns of varying degrees or thickness, list the most severe burn first. Generally, 3rd degree burns should be listed before 2nd degree burns, which are listed before 1st degree/ superficial burns. Additional codes should be assigned for the percentage of TBSA of the burn and the percentage involving third degree burns.
A patient may present with leg pain, but upon evaluation be found to have bilateral pedal edema secondary to new onset congestive heart failure requiring admission for further evaluation and treatment. Although the chief complaint may have been leg pain, the diagnosis of new onset CHF is more serious and would be listed as the first diagnosis. Whenever a patient requires admission to the hospital, the first diagnosis should clearly indicate the primary reason for admission.
If a patient has multiple fractures, list the most severe fracture as the primary diagnosis.
If multiple medical problems were addressed and multiple diagnosis are needed to reflect the complexity of the care delivered, list the most important or serious condition the patient was treated for first.
A chronic condition requiring evaluation, treatment or factors into your decision-making process when determining management options should also be listed as a diagnosis. These are often referred to as co-morbidities. For example: a patient may present with cellulitis, but is found to have uncontrolled diabetes or hypertension during their visit, It would be appropriate to list the uncontrolled diabetes and hypertension as diagnoses.

28. The residual or late effect of an injury generally requires two codes
The residual or late effect of an injury generally requires two codes. The primary diagnosis must describe the nature of the sequela.
The secondary diagnosis describes the original injury and usually has an “S” in the 7th position to indicate sequela. (Sequela of cerebrovascular disease is an exception.)
Example: treatment of ankle instability following a sprain:
M Disorder of ligament, right ankle
S93.411S - Sprain of calcaneofibular lig., right ankle, sequela
S93.411S is not accepted as a primary diagnosis because instructions require the residual condition be coded first.
Sequela (Late Effect)

29. FINAL EXAMPLE – AHHH!!
It’s a hot summer day, the kids are playing a game in the pool. Johnny decides to play Super Ninja and leaps from the ladder landing on top of his brother at the bottom of the pool. After a few x-rays at the ED, diagnosis of Salter-Harris IV fracture of the left lower tibia is made and he will need surgical repair. Follow up appointment is made with Ortho. The ER doctor simply places a short leg splint on his leg and sends him home.
S89.142A – Salter-Harris IV physeal fracture lower end left tibia, initial encounter, closed
W16.522A – Jumping or diving into swimming pool striking bottom causing injury, initial encounter
Y93.39 – Activity, other involving climbing, rappelling and jumping off
Y – Swimming pool in single family (private) house or garden as the place of occurrence
Johnny has returned two years after his Ninja jump off the pool deck. He has decided to play basketball and during tryouts he’s developed some pain in his knees and back. He presents today for an evaluation to determine if his injury may be the cause. X-rays now show he has a leg length discrepancy that has developed due to his prior Salter IV fracture through the growth plate causing partial physeal arrest.
M – Unequal limb length (acquired), left tibia
M – Partial physeal arrest, left distal tibia
S89.142S – Salter-Harris IV physeal fracture lower end left tibia, sequela
W16.522S – Jumping or diving into swimming pool striking bottom causing injury, sequela

30. CMS.gov – 2018 Coding Guidelines 2018 CPT Book -Expert - AAPC HC Pro – online articles Elsevier – online articles
Resources

31. Answers to pre-presentation quiz
SEQUENCING – ICD-10 GUIDELINES

32. When a patient has a condition that is both acute and chronic and there are separate entries for both, how is it reported? a.
Code only the acute code b.
Code both sequencing the chronic first c.
Code both sequencing the acute first d.
Code only the chronic code
Answer: C
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.

33. 2. What is the sequencing order when coding a sequela (late effect)?
The cause of the late effect is coded first and the residual condition is coded second. b.
The symptom is coded first followed by the residual condition and the late effect code. c.
The cause of the late effect is coded first; the residual condition is coded second followed by the symptoms. d.
The residual condition is coded first, and the code(s) for the cause of the late effect are coded as secondary.
Answer: D
Rationale: Per ICD -10-CM guideline 1.B.10 coding of sequela (late effects) generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first and the late effect code is sequenced second. Exceptions to this guideline are those instances where the code for the late effect is followed by a manifestation code in the Tabular List and title or the late effect code has been expanded to include the manifestation

34. 3. According to ICD-10-CM guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported? a.
Anemia is the only condition reported. b.
The malignancy is the only condition reported. c.
The malignancy is reported first, followed by the code for the anemia. d.
Anemia is reported first, followed by the code for the malignancy.
Answer: C
Rationale: ICD-10-CM guideline I.C.2.c.1, when the patient is being seen for management of the anemia associated with malignancy, the code for the malignancy is reported first, followed by the appropriate code for the anemia (for example D63.0 Anemia in neoplastic disease).

35. 4. 45 year-old patient is scheduled to have an INFUSAID pump installed
4. 45 year-old patient is scheduled to have an INFUSAID pump installed. He has primary liver cancer and the pump is being inserted for continuous administration of 5-FU. A pocket is created just under the skin and the pump is placed in the pocket. A catheter is attached to the pump and to the subclavian vein. The pump is filled with a chemotherapy agent provided by the hospital and the patient is observed for adverse reaction and discharged to home. What ICD-10-CM codes are reported? a.
C22.9, Z51.12 c.
C22.8, Z51.11 b.
Z51.11, C22.9 d.
Z51.11, C22.8
Answer: D
Rationale: ICD-10-CM Guideline I.C.2.e.2 indicates an encounter for chemotherapy code is to be reported as the primary code with a code for the cancer as secondary when the reason for the visit is solely for chemotherapy. Look in the ICD-10-CM Alphabetic Index for Chemotherapy (session) (for)/cancer Z For the malignancy, look in the ICD-10-CM Table of Neoplasms for liver/primary and use the code from the Malignant Primary column which directs the coder to C22.8. Verify code selection in the Tabular List

36. 5. Patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. She developed severe vomiting secondary to the radiation. What ICD-10-CM code(s) is/are reported? a.
C79.51, C80.1 c.
C79.51, C80.1, R11.10, Z51.0 b.
R11.10 d.
Z51.0, C79.51, C80.1, R11.10
Answer: D
Rationale: The reason for the encounter is for radiation therapy. ICD-10-CM guideline I.C.2.e.3 states if a patient admission is for the purpose of radiotherapy, immunotherapy, or chemotherapy and develops complications, assign code Z51.0 Encounter for antineoplastic radiation therapy, or Z51.11 Encounter for antineoplastic chemotherapy, or Z51.12 Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis, followed by any codes for the complications. ICD-10-CM guideline I.C.2.b states the secondary cancer is listed first when the treatment is directed toward the secondary site only. In the ICD-10-CM Alphabetic Index look for Encounter (with health service) (for)/radiation therapy (antineoplastic), guiding you to code Z51.0. Next, look in the Alphabetic Index for Metastasis, metastatic/cancer/from specified site and you are directed to see Neoplasm, malignant, by site. In the ICD-10-CM Table of Neoplasms. Look for Neoplasm, neoplastic/bone (periosteum) and select the code from the Malignant Secondary column which directs you to C When the site of the primary cancer is unknown, look for Neoplasm, neoplastic and select from the Malignant Primary column which directs the coder to C80.1. The last code is for the vomiting that developed during treatment. Look in the Alphabetic Index for Vomiting directing you to code R Verify the code selection in the Tabular List.

37. 6. What diagnosis code(s) is/are reported for pneumonia due to SARS?
J12.81 c.
J18.9 b.
J12.81, B97.21 d.
J18.9, B97.21
Answer: A
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 J You can also look for Pneumonia/SARS-associated coronavirus J Verify code selection in the Tabular List.

38. Thank you!! My email is: Lorri@JLHealthcareServices.com
Questions ??
Thank you!!
My is: