1. PhilHealth Updates on ICD-10
Lifted from lecture of:
REGGIE R. GUILLEN
Quality Assurance Research and Policy Development Group

2. Philippine ICD-10 M0difications
ICD-10 Modifications on Certain Diseases, Conditions and Related Health Problems in Health Care Facilities in the Philippines
First Edition
October 2008

3. Outline Introduction: ICD Modifications
Different Modified Guidelines on Coding Diseases

4. INTRODUCTION
A global classification system for classifying mortality and morbidity as the standard for international comparison for categorization of diseases across countries & health systems (WHO,1990)
It has enabled the reporting, investigation & monitoring of deaths, diseases & injuries together w/ their causes w/c allowed the useful exchange of scientific information among a wide range of users for clinical and public health purposes.

5. ICD-10 Modifications
In the Philippines: ICD-10 mandatory through A.O. No. 47,s (DOH)
All hospitals & health facilities are mandated to comply for the issuance & renewal of hospital licenses
PHIC requires all health care providers to comply for accreditation and reimbursemnet of claims.

6. ICD-10 Modifications
DOH through the National ICD-10 TWG initiated the development of Phil ICD-10 Modifications,1st edition
Not intended to replace the principal ICD-10 of WHO but complement them through additional information for their local adoption and usage.
Modifications to some categories were also introduced to facilitate the assignment of codes guided by the basic principles of the original ICD-10

7. ICD-10 Modifications
There are numerous ways physicians in the Phil write their diagnosis, diseases in the book may or may not represent the actual diagnostic statement provided in the patient’s discharge diagnosis or even in the causes of death
Available descriptors, modifiers, or qualifiers of the disease or conditions were used regardless of their position in the diagnostic statement.
ICD-10 codes provided are mostly for less specific cases, for more specific conditions and/or other combined diseases/conditions: applicable notes are given under related categories for guidance

8. ICD-10 Modifications
Modifications were developed with the concerned medical societies in the country and coding expert from Australia

9. PHIC Updates Philhealth Benchbook
Adoption of these modifications/guidelines

10. Coding of suspected conditions, symptoms and abnormal findings and non-illness situations
If discharge diagnosis is still recorded as "suspected", "probable", "questionable", "T/C (to consider)", and there is no further information or clarification, the suspected diagnosis is coded as if definite.

11. Example: T/C acute cholecystitis
Code as acute cholecystitis (K81.0)
Example: Suspected malaria
Code as malaria (B54)

12. If discharge diagnosis is a combination of a definite condition and another case that is "suspected", "probable", "questionable", "T/C (to consider)", and there is no further information or clarification, only the definite condition is coded. The same applies if the description of the definite condition is also suspected.

13. Example: Gastritis T/C acute cholecystitis Code as gastritis (K29
Example: Gastritis T/C acute cholecystitis Code as gastritis (K29.7) Example: Acute gastroenteritis probably viral Code as acute gastroenteritis (A09.9)

14. If discharge diagnosis is recorded only as "ruled out (R/O)", the r/o diagnosis is coded as a "medical observation for the condition" (Z03)
Example: R/O myocardial infarction Code as observation for suspected myocardial infarction (Z03.4) Example: R/O breast CA Code at observation for suspected malignant neoplasm (Z03.1)

15. If discharge diagnosis is a combination of a definite condition and another "ruled out (R/O)" condition, only the definite condition is coded.
Example: PUD. R/O myocardial Infarction Code as peptic ulcer unspecified as acute or chronic without hemorrhage or perforation (K27.9) Example: Breast mass R/O breast CA Code to unspecified lump in breast (N63)

16. Synonyms
Bleeding = Hemorrhage Example: Massive subarachnoid bleed Code to subarachnoid hemorrhage (I60.9) Calculous = stone = lithiasis Example: Chronic calculous cholecystitis Code to cholecystitis with cholelithiasis (K80.1)

17. Coding conditions where there is no exact entry in the Volume 3.
Use of the word “mass” Do not immediately assume it is a neoplasm or cancer

18. In coding “masses” , first lead term is mass
In coding “masses” , first lead term is mass. If there is no code indexed, use the lead term "Disease, specific organ". If there is still none, use the lead term "neoplasm" and choose site code from column "uncertain or unknown behavior".
Example: Nasopharyngeal mass Code to neoplasm of the nasopharynx of unknown or uncertain behavior (D37.0 M8000/1)

19. Example: Breast Mass Code to unspecified lump in breast (N63) Example: Bladder mass t/c transitional cell CA Code to unspecified bladder disorder (N32.9)

20. Coding contiguous sites not listed in the index as separate codes.
If there is no indexed code for the contiguous sites it should be coded separately. Example: cervicovaginitis Code to cervicitis (N72) and Vaginitis (N76.0).

21. ICD-10 Coding Guidelines
Department Circular No. 33, i of Department of Health provides ICD-IO Coding Guideline for the following conditions:
Pregnancy, Childbirth and the Puerperium
Cataract and Disorder of Lens
Influenza
Pneumonia
Pulmonary Tuberculosis
Conditions with no Direct Index

22. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Note: Use of categories O80-O84 (Method of Delivery) as primary code in morbidity coding is only allowed in situation where there are no other maternal conditions recorded complicating labor and delivery.
Caesarian delivery with no maternal / clinical reason/ indication code only for the method of delivery plus additional code for the outcome of delivery
Example:
NSD to a live baby boy - O80.9, Z37.0
LTCS to a live baby girl - O82.0, Z37.0

23. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Caesarean Delivery
Caesarean delivery with maternal/ clinical reason/ indication the primary code would be for the maternal / fetal indication but this would depend on whether the CS is elective or emergency.
Example:
PUFT delivered to a live baby boy sec. to
Frank breech presentation, LTCS
O32.1, O82.0, Z37 .0
LTCS II for cephalopelvic disproportion, live baby girl
O33.9, O82.0, Z37.0

24. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example Emergency CS for breech presentation, live baby girl O64.1, O82.1,Z37.0 LTCS for breech presentation, live baby girl* O32.1,O82.0,Z37.0 If it is not indicated whether the CS is elective or emergency, the coder should seek clarification from the attending physician. Otherwise, it would be considered as elective CS.

25. Example LTCS secondary to fetal distress, live baby girl
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example LTCS secondary to fetal distress, live baby girl
O36.3, O82.0,Z37.0
All CS with an indication or due to fetal distress will automatically be considered under obstructed labor. Thus should be considered as emergency CS.
O68.9,O82.1,Z37.0

26. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
For repeat cesarean delivery, it is essential to know if there is obstructed labor
Example
Repeat CS, live baby girl
Delivery
- cesarean
-- previous
--- Cesarean Section
Repeat CS, (emergency) live baby girl
O34.2, O82.0,Z37.0
O34.2
O65.5,O82.1,Z37.0

27. Preterm Labor/Delivery:
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Preterm Labor/Delivery:
For purposes of classification, the following definitions should be considered:
PRETERM LABOR - is a false labor occurring before 37 completed weeks of gestation
PRETERM DELIVERY - is a spontaneous onset of delivery before 37 weeks of gestation
It is necessary for the coder to verify if the patient gave birth or not
If not, consider it as FALSE LABOR.
If yes, consider it as PRETERM DELIVERY.
Example
PU 32 weeks, preterm labor, live baby boy O60, Z37.0

28. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example:
PU 32 weeks, pre-term labor, delivered
O60, Z37.9
PU 32 weeks, pre-term labor, controlled
O47.0
PU 38 weeks, threatened pre-term labor
047.1
PU 38 weeks, pre-term labor
verify the outcome first whether the patient delivered or not

29. Abortion/ Pregnancy with abortive outcome Imminent abortion
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Abortion/ Pregnancy with abortive outcome
Imminent abortion
Inevitable abortion
are considered admitting impressions thus, could not be used as final diagnosis. The medical coder should ask the attending physician for the final diagnosis.
"If clarification is no longer possible this is coded as spontaneous abortion”

30. Abortion/Pregnancy with abortive outcome:
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Abortion/Pregnancy with abortive outcome:
Abortion described as non-Induced implies. It is spontaneous and given the code O03.-.
If the diagnosis does not indicate if it is induced or non-induced, the medical coder should verify this with the attending physician.
If it is no longer possible to verify this, the code used is OO6.-.

31. Abortion/Pregnancy with abortive outcome:
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Abortion/Pregnancy with abortive outcome:
If the word "completed" is used in the final diagnosis, this refers to the fact that a procedure was done to the patient for her "incomplete abortion".
Hence the 4th character code to be used should be (.0 to .4)

32. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example Incomplete abortion, non-septic, non-induced O03.4 Incomplete abortion, s/p D&C O06.4 Completed abortion, non-septic, non-induced Abortion, incomplete, blighted ovum O02.0 Abortion, completed Abortion, completed, weeks, IUFD 036.4, P95

33. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Elderly Primigravid: The description "elderly primigravid" is sometimes used in the final diagnosis for CS cases, indicating it was the reason for the procedure. However, it is not an automatic indication for a CS.

34. Example: LTCS, Elderly Primigravid Option 1: Delivery
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, Elderly Primigravid
Option 1: Delivery
- cesarean (for) Delivery
Option 2: Delivery
Complicated
primipara, elderly or old
code as Delivery, complicated by specific condition
If there is no other condition, go back to option 1.

35. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Failure of descent vs. Arrest in descent Arrest in descent occurs during the 2nd stage of labor, after full cervical dilatation (1st stage of labor). - POGS
Failure of descent -> before full cervical dilatation
(1st stage of labor)
Arrest In descent -» after full cervical dilatation
(2nd stage of labor)

36. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, arrest in cervical dilatation, live born baby
Mother's chart:
Delivery
- complicated
- - dilatation
- - - cervix incomplete, poor or slow
O62.0
Failure
cervical dilatation in labor O62.0
Final code: O62.0, O82.0, Z37.0

37. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, failure of descent, live born baby
Mother's chart:
Failure, failed
descent of head (at term) (mother)
O32.4
Delivery
- cesarean (for)
- - high head at term 032.4
Final code: 032.4, O82.0, Z37.0

38. Example: LTCS, arrest in descent, live born baby Mother's chart:
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, arrest in descent, live born baby
Mother's chart:
Delivery
- cesarean (for)
- - prolonged labor NEC 063.9
- complicated
- - prolonged labor
- second stage 063.1
Final code: 063.1, O82.0 Z37.0

39. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, Thickly meconium
stained baby, live born baby
Mother's chart:
Delivery
- cesarean (for)
- - meconium in liquor 036.3
- complicated
- - meconium in liquor 068.1

40. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Mother's chart:
Meconium
- in liquor (see Distress, fetal;
- - complicating labor and delivery 068.1
Distress
- fetal
- - affecting
- - - labor and delivery O68.-
- - complicating labor and delivery
O68.-
Final code: 068.1, O82.0, Z37.0

41. ICD-10 Coding Guidelines No. 001 s
ICD-10 Coding Guidelines No. 001 s (Subject Pregnancy, Childbirth and the Puerperium)
Example: LTCS, Thickly meconium
stained baby, live born baby
Baby's chart:
Meconium
- in liquor - see Distress, fetal
Distress
- fetal (syndrome) P20.-
- - first noted
- - - before onset of labor P20.0
- - - during labor and delivery P20.1
Final code: Z38.0, P20.9

42. ICD-10 Coding Guidelines (Subject Diseases of the Genitourinary System)
Endometrial cyst:
The word "endometrium" refers to the lining of the uterus. Hence, endometrial cyst refers to a cyst originating from the lining of the uterus.
An endometrial cyst is "ectopic" if it is found outside the uterus. It is also called an "endometriosis".

43. ICD-10 Coding Guidelines (Subject Diseases of the Genitourinary System)
Example: Endometrial cyst, ovary refers to a cyst originating from the lining of the uterus but is now found in the ovary. Cyst - endometrium, endometrial (uterus) N85.8 — ectopic (see also Endometriosis) N80.9 Endometiosis - Ovary N80.1

44. ICD-10 Coding Guidelines Disease of the Respiratory System
Example: Parapneumonic pleural effusion Effusion Pleura, pleural J90 J91* pleural effusion in disease classified elsewhere J18 pneumonia Final Code: J J91*

45. ICD-10 Coding Guidelines No. 005, s. 2004 Pulmonary Tuberculosis
For purposes of classification, the following definitions should be considered:
PTB Class 1 - with exposure, (-) skin test, (-) x-ray
PTB Class 2 - with exposure, (+) skin test, (-) x-ray
PTB Class 3- PTB active, (+) bacteriologic studies,
(+) AFB, (+/-) MTB culture
PTB Class 4- previously treated (known history)
PTB Class 5- PTB Suspect

46. ICD-10 Coding Guidelines No. 005, s. 2004 Pulmonary Tuberculosis
To standardized classification of certain conditions related to Pulmonary Tuberculosis (PTB) the following ICD-10 codes are hereby assigned:
ICD-10 CODE
CATEGORY/DIAGNOSIS
REMARKS
Z.20.1
CONTACT WITH AND EXPOSURE TO TUBERCULOSIS
Pulmonary Tuberculosis (PTB) Class 1,2
A15.0
TUBERCULOSIS OF LUNG, CONFIRMED BY SPUTUM MICROSCOPY WITH OR WITHOUT CULTURE
Pulmonary Tuberculosis (PTB) Class 3 by sputum confirmation
This includes PTB Class 3 with (+) sputum microscopy and (+) x-ray
A15.1
TUBERCULOSIS OF LUNG. CONFIRMED BY CULTURE ONLY
MDRTB confirmed by culture

47. ICD-10 Coding Guidelines No. 005, s. 2004 Pulmonary Tuberculosis
ICD-10 CODE
CATEGORY/DIAGNOSIS
REMARKS
A 16.0
TUBERCULOSIS OF LUNG, BACTERIOLOGICAI.LY AND HISTOLOGICALLY NEGATIVE
Pulmonary Tuberculosis (PTB) Class 3, 4 by x-ray confirmation and bacteriologically and histologically negative
This includes PTB class 3,4 with (+) x-ray and (-) sputum microscopy
A16.1
TUBERCULOSIS OF LUNG, BACTERIOLOGICAL AND HISTOLOGICAL CONFIRMATION NOT DONE
Pulmonary Tuberculosis (PTB) class 3, 4 by x-ray confirmation and bacteriological and histological confirmation not done
This includes PTB class 3, 4 with (+) x-ray and it was recorded that no sputum microscopy examinations was done

48. ICD-10 Coding Guidelines No. 005, s. 2004 Pulmonary Tuberculosis
ICD-10 CODE
CATEGORY/DIAGNOSIS
REMARKS
A 16.2
TUBERCULOSIS OF LUNG, WITHOUT MENTION OF BACTERIOLOGIC OR HISTOLOGIC CONFIRMATION
Pulmonary Tuberculosis (PTB)
Pulmonary Tuberculosis (PTB) Class 3, 4 by x-ray confirmation without mention of bacteriological confirmation
This includes PTB class 3,4 with (+) x-ray and without information no sputum microscopy examination (whether it is done or not)
Z03.0
OBSERVATION OF SUSPECTED TUBERCOLOSIS
Pulmonary Tuberculosis (PTB) Class 5
MDRTB without culture sensitivity

49. Diagnosis / Categories
ICD-10 Coding Guidelines No. 006, s (Conditions with no direct index in ICD-10)
There are conditions that do not really have direct index in the iCD-10, but they have to be coded as well, thus, the following ICD-10 codes are assigned for some of those conditions that have been identified:
ICD-10 Code
Diagnosis / Categories
K31.8
Acid Peptic Disease
J45.9
Bronchial Asthma in Acute Exacerbation [BAIAE]
J18.9
Community Acquired Pneumonia
M94.08
Costochondritis
E78.9
Dyslipldemia
A01.0
Enteric Fever
J68.3
Hyperactive Airways Disease
J18.9.V95
Nosocomial Pneumonia (Hospital Acquired Pneumonia)
B34.9
Systemic Viral Infection

50. ICD-10 Coding Guidelines Diseases of the Respiratory System
Example:
Malignant pleural effusion
Effusion:
Pleura, pleural
malignant C78.2
C78.2 Secondary malignant neoplasm of pleura
Final Code: C78.2 M8000/6

51. ICD-10 Coding Guidelines Diseases of the Nervous System
Example: Thrombotic Infarct, parietal lobe Thrombosis Parietal (see also Infarct, myocardium) I21.9 HOWEVER, Parietal lobe brain, whereas Myocardium heart

52. ICD-10 Coding Guidelines Diseases of the Nervous System
Example: Thrombotic Infarct, parietal lobe Infarct - Brain (see also Infarct, cerebral) Cerebral due to cerebral venous thrombosis, non pyogenic Cerebral arteries Precerebral arteries 163.0

53. THANK YOU!