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2021 CODING GUIDELINES INCLUDED EXPERT

ICD-10-CM Expert for Hospitals The complete official code set

Codes valid from October 1, 2020 through September 30, 2021 SAMPLE

2021 optum360coding.com Contents

Preface ...... iii Chapter 9. Diseases of the Circulatory System (I00-I99) ...... 643 ICD-10-CM Official Preface ...... iii Chapter 10. Diseases of the Respiratory System (J00-J99) ...... 691 Characteristics of ICD-10-CM ...... iii Chapter 11. Diseases of the Digestive System (K00-K95) ...... 709 How to Use ICD-10-CM Expert for Hospitals ...... iv Chapter 12. Diseases of the Skin and Subcutaneous Tissue Introduction ...... iv (L00-L99) ...... 735 What’s New ...... iv Chapter 13. Diseases of the Musculoskeletal System and Conversion Table ...... iv Connective Tissue (M00-M99) ...... 759 10 Steps to Correct Coding ...... iv Chapter 14. Diseases of the Genitourinary System (N00-N99)..853 Official ICD-10-CM Guidelines for Coding and Reporting ...... iv Chapter 15. Pregnancy, Childbirth and the Puerperium Indexes ...... iv (O00-O9A) ...... 873 Index to Diseases and Injuries ...... iv Chapter 16. Certain Conditions Originating in the Perinatal Neoplasm Table ...... iv Period (P00-P96) ...... 917 Table of Drugs and Chemicals ...... v Chapter 17. Congenital Malformations, Deformations and External Causes Index ...... v Chromosomal Abnormalities (Q00-Q99) ...... 931 Index Notations ...... v Chapter 18. Symptoms, Signs and Abnormal Clinical and Tabular ...... v Laboratory Findings Not Elsewhere Code and Code Descriptions ...... vi Classified (R00-R99) ...... 953 Tabular Notations ...... vi Chapter 19. Injury, Poisoning and Certain Other Consequences Official Notations ...... vi of External Causes (S00-T88) ...... 975 Optum360 Notations ...... vii Chapter 20. External Causes of Morbidity (V00-Y99)...... 1211 Icons ...... vii Chapter 21. Factors Influencing Health Status and Contact Color Bars ...... ix With Health Services (Z00-Z99) ...... 1273 Footnotes ...... ix Chapter-Level Notations ...... ix Appendixes ...... Appendixes–1 Appendixes ...... x Appendix A: Valid 3-character ICD-10-CM Codes ...... Appendixes–1 Illustrations ...... x Appendix B: Pharmacology List 2020...... Appendixes–3 Appendix C: Z Codes for Long-Term Drug Use What’s New ...... xi with Associated Drugs...... Appendixes–21 Official Updates ...... xi Appendix D: Major Complication and Comorbidity Proprietary Updates ...... xv (MCC) Code List...... Appendixes–25 Conversion Table of ICD-10-CM Codes ...... xvi Appendix E: Complication and Comorbidity (CC) Code List...... Appendixes–31 10 Steps to Correct Coding ...... xviii Appendix F: Present on Admission (POA) Tutorial ...... Appendixes–51 ICD-10-CM Official Guidelines for Appendix G: Hospital Acquired Conditions...... Appendixes–55 Coding and Reporting ...... Coding Guidelines–1 Appendix H: Centers for Medicare & Medicaid ICD-10-CM Index to Diseases and Injuries ...... 1 Services Hierarchical Condition Categories (CMS-HCC) ...... Appendixes–83 ICD-10-CM Neoplasm Table ...... 330 Appendix I: Long-term Care Hospital Prospective Payment System Overview ...... Appendixes–85 ICD-10-CM Table of Drugs and Chemicals ...... 349 Appendix J: Long-Term Care Hospital Quality ICD-10-CM Index to External Causes...... 398 Reporting Program...... Appendixes–91 Appendix K: Severe Wound Diagnosis Codes by ICD-10-CM Tabular List of Diseases and Injuries ...... 433 Category...... Appendixes–95 Chapter 1. Certain Infectious and Parasitic Diseases (A00-B99) ...... 433 Illustrations ...... Illustrations–1 Chapter 3. Diseases of the Blood and Blood-forming Organs and Chapter 2. Neoplasms (C00-D49) ...... 461 Certain Disorders Involving the Immune Chapter 3. Diseases of the Blood and Blood-forming Mechanism (D50–D89) ...... Illustrations–1 Organs andSAMPLE Certain Disorders Involving the Red Blood Cells ...... Illustrations–1 Immune Mechanism ( ) ...... 503 D50-D89 White Blood Cell ...... Illustrations–1 Chapter 4. Endocrine, Nutritional and Metabolic Diseases ...... Illustrations–2 (E00-E89) ...... 515 Coagulation ...... Illustrations–2 Chapter 5. Mental, Behavioral, and Neurodevelopmental Anatomical Location and External Disorders (F01-F99) ...... 541 Structures ...... Illustrations–3 Chapter 6. Diseases of the Nervous System (G00-G99) ...... 569 Spleen Interior Structures ...... Illustrations–3 Chapter 7. Diseases of the Eye and Adnexa (H00-H59) ...... 593 Chapter 4. Endocrine, Nutritional and Metabolic Diseases (E00–E89) ...... Illustrations–4 Chapter 8. Diseases of the Ear and Mastoid Process (H60-H95) ...... 631 Endocrine System ...... Illustrations–4 Thyroid ...... Illustrations–5

ICD-10-CM 2021 i Contents ICD-10-CM 2021 Thyroid and Parathyroid Glands ...... Illustrations–5 Chapter 11. Diseases of the Digestive System Pancreas ...... Illustrations–6 (K00–K95) ...... Illustrations–29 Anatomy of the Adrenal Gland ...... Illustrations–6 Digestive System ...... Illustrations–29 Structure of an Ovary ...... Illustrations–7 Omentum and Mesentery ...... Illustrations–30 Testis and Associated Structures ...... Illustrations–7 Peritoneum and Retroperitoneum ... Illustrations–30 Thymus ...... Illustrations–8 Chapter 12. Diseases of the Skin and Subcutaneous Chapter 6. Diseases of the Nervous System Tissue (L00–L99) ...... Illustrations–31 (G00–G99) ...... Illustrations–9 Nail Anatomy ...... Illustrations–31 Brain ...... Illustrations–9 Skin and Subcutaneous Tissue ...... Illustrations–31 Cranial Nerves ...... Illustrations–9 Chapter 13. Diseases of the Musculoskeletal System Peripheral Nervous System ...... Illustrations–10 and Connective Tissue (M00–M99) ...... Illustrations–32 Spinal Cord and Spinal Nerves ...... Illustrations–11 and Joints ...... Illustrations–32 Nerve Cell ...... Illustrations–12 Shoulder Anterior View ...... Illustrations–33 Chapter 7. Diseases of the Eye and Adnexa Shoulder Posterior View ...... Illustrations–33 (H00–H59) ...... Illustrations–13 Elbow Anterior View ...... Illustrations–33 Eye ...... Illustrations–13 Elbow Posterior View ...... Illustrations–33 Posterior Pole of Globe/Flow of Hand ...... Illustrations–33 Aqueous Humor ...... Illustrations–13 Hip Anterior View ...... Illustrations–34 Lacrimal System ...... Illustrations–14 Hip Posterior View ...... Illustrations–34 Eye Musculature ...... Illustrations–14 Knee Anterior View ...... Illustrations–34 Eyelid Structures ...... Illustrations–14 Knee Posterior View ...... Illustrations–34 Chapter 8. Diseases of the Ear and Mastoid Foot ...... Illustrations–34 Process (H60–H95) ...... Illustrations–15 Muscles...... Illustrations–35 Ear Anatomy ...... Illustrations–15 Chapter 14. Diseases of the Genitourinary Chapter 9. Diseases of the Circulatory System (N00–N99) ...... Illustrations–36 System (I00–I99) ...... Illustrations–16 Urinary System ...... Illustrations–36 Anatomy of the Heart ...... Illustrations–16 Male Genitourinary System ...... Illustrations–37 Heart Cross Section ...... Illustrations–16 Female Internal Genitalia ...... Illustrations–37 Heart Valves ...... Illustrations–17 Female Genitourinary Tract Lateral Heart Conduction System ...... Illustrations–17 View ...... Illustrations–37 Coronary Arteries ...... Illustrations–18 Chapter 15. Pregnancy, Childbirth and the Arteries ...... Illustrations–19 Puerperium (O00–O9A) ...... Illustrations–38 Veins ...... Illustrations–20 Term Pregnancy – Single Internal Carotid and Vertebral Gestation ...... Illustrations–38 Arteries and Branches ...... Illustrations–21 Twin Gestation–Dichorionic– External Carotid Artery and Diamniotic (DI-DI) ...... Illustrations–38 Branches ...... Illustrations–21 Twin Gestation–Monochorionic– Branches of Abdominal Aorta ...... Illustrations–22 Diamniotic (MO-DI) ...... Illustrations–39 Portal Venous Circulation ...... Illustrations–22 Twin Gestation–Monochorionic– Lymphatic System ...... Illustrations–23 Monoamniotic (MO-MO) ...... Illustrations–39 Axillary Lymph Nodes ...... Illustrations–24 Chapter 19. Injury, Poisoning and Certain Other Lymphatic System of Head Consequences of External Causes and Neck ...... Illustrations–24 (S00-T88) ...... Illustrations–40 Lymphatic Capillaries ...... Illustrations–25 Types of Fractures ...... Illustrations–40 Lymphatic Drainage ...... Illustrations–25 Salter-Harris Fracture Types ...... Illustrations–40 Chapter 10. Diseases of the Respiratory System (J00–J99) ...... Illustrations–26 Respiratory System ...... Illustrations–26 Upper Respiratory System ...... Illustrations–27 Lower Respiratory System ...... Illustrations–27 Paranasal Sinuses ...... Illustrations–27 Lung Segments ...... Illustrations–28 Alveoli ...... SAMPLE Illustrations–28

ii ICD-10-CM 2021 ICD-10-CM 2021 How to Use ICD-10-CM Expert for Hospitals 2021 How to Use ICD-10-CM Expert for Hospitals 2020 2020 for Hospitals Expert ICD-10-CM How to Use Table of Drugs and Chemicals Parentheses The Table of Drugs and Chemicals is arranged in alphabetic order by the Parentheses in the indexes enclose nonessential modifiers, specific drug or chemical name. Codes are listed in individual columns supplementary words that may be present or absent in the statement of a based upon the associated intent (poisoning, adverse effect, or disease without affecting the code. underdosing). Pseudomeningocele (cerebral) (infective) (post-traumatic) G96.19 External Causes Index postprocedural (spinal) G97.82 The External Causes Index is arranged in alphabetic order by main terms Brackets that describe the cause, the intent, the place of occurrence, the activity, ICD-10-CM has a coding convention addressing code assignment for and the status of the patient at the time the injury occurred or health manifestations that occur as a result of an underlying condition. This condition arose. convention requires the underlying condition to be sequenced first, followed by the code or codes for the associated manifestation. In the Index Notations index, italicized codes in brackets identify manifestation codes. With The word “with” or “in” should be interpreted to mean “associated with” or Polyneuropathy (peripheral) G62.9 alcoholic G62.1 “due to.” The classification presumes a causal relationship between the amyloid (Portuguese) E85.1 [G63] two conditions linked by these terms in the index. These conditions transthyretin-related (ATTR) familial E85.1 [G63] should be coded as related even in the absence of provider documentation explicitly linking them unless the documentation clearly Shaded Guides states the conditions are unrelated or when another guideline specifically Exclusive vertical shaded guides in the Index to Diseases and Injuries and requires a documented linkage between two conditions (e.g., the External Causes Index help the user easily follow the indent levels for the guideline for “acute organ dysfunction that is not clearly associated with subentries under a main term. Sequencing rules may apply depending on the sepsis”). For conditions not specifically linked by these relational terms the level of indent for separate subentries. in the classification or when a guideline requires explicit documentation of a linkage between two conditions, provider documentation must link the conditions to code them as related. Hemicrania congenitalmalformationQ00.0 The word “with” in the index is sequenced immediately following the continuaG44.51 main term, not in alphabetical order. meaningmigraine‰seealsoMigraineG43.909 paroxysmalG44.039 chronic G44.049 Dermatopolymyositis M33.90 intractable G44.041 with not intractable G44.049 myopathy M33.92 episodic G44.039 respiratory involvement M33.91 intractable G44.031 specified organ involvement NEC M33.99 not intractable G44.039 in neoplastic disease — see also Neoplasm D49.9 [M36.0] intractable G44.031 not intractable G44.039

See Following References When the instruction “see” follows a term in the index, it indicates that The Index to Diseases and Injuries includes following references to assist another term must be referenced to locate the correct code. in locating out-of-sequence codes in the tabular list. Out-of-sequence codes contain an alphabetic character (letter) in the third- or Hematoperitoneum — see Hemoperitoneum 4th-character position. These codes are placed according to the classification rules — according to condition — not according to See Also alphabetic or numeric sequencing rules. The instructional note “see also” simply provides alternative terms the coder may reference that may be useful in determining the correct code Carcinoma (malignant) — see also Neoplasm, by site, malignant but are not necessary to follow if the main term supplies the appropriate neuroendocrine — see also Tumor, neuroendocrine code. high grade, any site C7A.1 (following C75) poorly differentiated, any site C7A.1 (following C75) Hematinuria — see also Hemaglobinuria malarial B50.8 Additional Character Required The Index to Diseases and Injuries, Neoplasm Table, and External Causes Default Codes Index provide an icon after certain codes to signify to the user that In the index, the default code is the code listed next to the main term and additional characters are required to make the code valid. The tabular list represents the condition most commonly associated with that main term. should be consulted for appropriate character selection. This code may be assigned when documentation does not support reporting a more specific code.SAMPLE Alternatively, it may provide an Fall, falling (accidental) W19 S unspecified code for the condition. building W20.1 S

Headache R51 allergic NEC G44.89 Tabular List of Diseases associated with sexual activity G44.82 chronic daily R51 ICD-10-CM codes and descriptions are arranged numerically within the tabular list of diseases with 19 separate chapters providing codes associated with a particular body system or nature of injury or disease. There is also a chapter providing codes for external causes of an injury or health conditions and finally a chapter for codes that address encounters with healthcare facilities for circumstances other than a disease or injury.

ICD-10-CM 2021 v How to Use ICD-10-CM Expert for Hospitals 2021 ICD-10-CM 2021 Code and Code Descriptions conditions included within a classification code. The inclusion terms are ICD-10-CM is an alphanumeric classification system that contains not exhaustive. The index may provide additional terms that may also be categories, subcategories, and valid codes. The first character is always a assigned to a given code. letter with any additional characters represented by either a letter or number. A three-character category without further subclassification is Excludes Notes ICD-10-CM has two types of excludes notes. Each note has a different equivalent to a valid three-character code. Valid codes may be three, four, definition for use. However, they are similar in that they both indicate that five, six, or seven characters in length, with each level of subdivision after codes excluded from each other are independent of each other. a three-character category representing a subcategory. The final level of subdivision is a valid code. Excludes 1 An 1 note is a “pure” excludes. It means “NOT CODED HERE!” An Boldface Excludes 1 note indicates mutually exclusive codes: two conditions that Boldface type is used for all codes and descriptions in the tabular list. cannot be reported together. An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Italics Excludes1 note. An Excludes1 is used when two conditions cannot occur Italicized type is used to identify manifestation codes, those codes that together, such as a congenital form versus an acquired form of the same should not be reported as first-listed diagnoses. condition. Deleted Text An exception to the Excludes 1 definition is when the two conditions are Strikethrough on a code and code description indicates a deletion from unrelated to each other. If it is not clear whether the two conditions the classification for the current year. involving an Excludes 1 note are related or not, query the provider. For

How to Use ICD-10-CMHow Expert for Hospitals 2020 Key Word example, code F45.8 Other somatoform disorders, has an Excludes 1 note Green font is used throughout the Tabular List of Diseases to differentiate for “sleep related teeth grinding (G47.63)” because “teeth grinding” is an inclusion term under F45.8. Only one of these two codes should be the key words that appear in similar code descriptions in a given category or subcategory. The key word convention is used only in those categories assigned for teeth grinding. However, psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this in which there are multiple codes with very similar descriptions with only a few words that differentiate them. condition and sleep-related teeth grinding. In this case, the two conditions are clearly unrelated to each other, so it would be appropriate For example, refer to the list of codes below from category H55: to report F45.8 and G47.63 together.

b H55 Nystagmus and other irregular eye movements Excludes 2 c H55.0 Nystagmus An 2 note means “NOT INCLUDED HERE.” An Excludes 2 note H55.00 Unspecified nystagmus indicates that although the excluded condition is not part of the condition H55.01 Congenital nystagmus it is excluded from, a patient may have both conditions at the same time. H55.02 Latent nystagmus Therefore, when an Excludes 2 note appears under a code, it may be H55.03 Visual deprivation nystagmus acceptable to use both the code and the excluded code together if H55.04 Dissociated nystagmus supported by the medical documentation. H55.09 Other forms of nystagmus Note The portion of the code description that appears in green font in the The term “NOTE” appears as an icon and precedes the instructional tabular list helps the coder quickly identify the key terms and the correct information. These notes function as alerts to highlight coding code. This convention is especially useful when the codes describe instructions within the text. laterality, such as the following codes from subcategory H40.22: Code First/Use additional code These instructional notes provide sequencing instruction. They may d H40.22 Chronic angle-closure glaucoma Chronic primary angle-closure glaucoma appear independently of each other or to designate certain e H40.221 Chronic angle-closure glaucoma, right eye etiology/manifestation paired codes. These instructions signal the coder e H40.222 Chronic angle-closure glaucoma, left eye that an additional code should be reported to provide a more complete e H40.223 Chronic angle-closure glaucoma, bilateral picture of that diagnosis. e H40.229 Chronic angle-closure glaucoma, unspecified eye In etiology/manifestation coding, ICD-10-CM requires the underlying condition to be sequenced first, followed by the manifestation. In these Tabular Notations situations, codes with “In diseases classified elsewhere” in the code description are never permitted as a first-listed or principal diagnosis code Official parenthetical notes as well as Optum360’s supplementary and must be sequenced following the underlying condition code. notations are provided at the chapter, code block, category, subcategory, and individual code level to help the user assign proper codes. The Code Also information in the notation can apply to one or more codes depending on A “code also” note alerts the coder that more than one code may be where the citation is placed. SAMPLErequired to fully describe the condition. The sequencing depends on the circumstances of the encounter. Factors that may determine sequencing Official Notations include severity and reason for the encounter. Includes Notes Revised Text The word 1 appears immediately under certain categories to The revised text wx “bow ties” alert the user to changes in official further define, clarify, or give examples of the content of a code category. notations for the current year. Revised text may include the following: Inclusion Terms • A change in a current parenthetical description Lists of inclusion terms are included under certain codes. These terms • A change in the code(s) associated with a current parenthetical note indicate some of the conditions for which that code number may be used. Inclusion terms may be synonyms with the code title, or, in the case of • A change in how a current parenthetical note is classified (e.g., an “other specified” codes, the terms may also provide a list of various Excludes 1 note that changed to an Excludes 2 note)

vi ICD-10-CM 2021 10 Steps to Correct Coding

Follow the 10 steps below to correctly code encounters for health care • “Due to” subterms identify a relationship between the two conditions services. they link. Step 1: Identify the reason for the visit or encounter (i.e., a • “NEC,” abbreviation for “not elsewhere classified,” follows some main sign, symptom, diagnosis and/or condition). terms or subterms and indicates that there is no specific code for the The medical record documentation should accurately reflect the patient’s condition even though the medical documentation may be very condition, using terminology that includes specific diagnoses and specific. symptoms or clearly states the reasons for the encounter. • “NOS,” abbreviation for “not otherwise specified,” follows some main 10 Steps to Correct Coding Coding Correct to Steps 10 Choosing the main term that best describes the reason chiefly responsible terms or subterms and is the equivalent of unspecified; NOS signifies for the service provided is the most important step in coding. If symptoms that the information in the medical record is insufficient for assigning are present and documented but a definitive diagnosis has not yet been a more specific code. determined, code the symptoms. For outpatient cases, do not code • Following references help coders locate alphanumeric codes that are conditions that are referred to as “rule out,” “suspected,” “probable,” or out of sequence in the tabular section. “questionable.” Diagnoses often are not established at the time of the initial encounter/visit and may require two or more visits to be • Check-additional-character symbols flag codes that require established. Code only what is documented in the available outpatient additional characters to make the code valid; the characters available records and only to the highest degree of certainty known at the time of to complete the code should be verified in the tabular section. the patient’s visit. For inpatient medical records, uncertain diagnoses may Step 6: Choose a potential code and locate it in the be reported if documented at the time of discharge. tabular list. Step 2: After selecting the reason for the encounter, To prevent coding errors, always use both the alphabetic index (to identify consult the alphabetic index. a code) and the tabular list (to verify a code), as the index does not include The most critical rule is to begin code selection in the alphabetic index. the important instructional notes found in the tabular list. An added Never turn first to the tabular list. The index provides cross-references, benefit of using the tabular list, which groups like things together, is that essential and nonessential modifiers, and other instructional notations while looking at one code in the list, a coder might see a more specific one that may not be found in the tabular list. that would have been missed had the coder relied solely on the alphabetic index. Additionally, many of the codes require a fourth, fifth, Step 3: Locate the main term entry. sixth, or seventh character to be valid, and many of these characters can The alphabetic index lists conditions, which may be expressed as nouns or be found only in the tabular list. eponyms, with critical use of adjectives. Some conditions known by several names have multiple main entries. Reasons for encounters may be Step 7: Read all instructional material in the tabular located under general terms such as admission, encounter, and section. examination. Other general terms such as history, status (post), or The coder must follow any Includes, Excludes 1 and Excludes 2 notes, and presence (of) can be used to locate other factors influencing health. other instructional notes, such as “Code first” and “Use additional code,” listed in the tabular list for the chapter, category, subcategory, and Step 4: Scan subterm entries. subclassification levels of code selection that direct the coder to use a Scan the subterm entries, as appropriate, being sure to review continued different or additional code. Any codes in the tabular range A00.0- lines and additional subterms that may appear in the next column or on through T88.9- may be used to identify the diagnostic reason for the the next page. Shaded vertical guidelines in the index indicate the encounter. The tabular list encompasses many codes describing disease indentation level for each subterm in relation to the main terms. and injury classifications (e.g., infectious and parasitic diseases, neoplasms, symptoms, nervous and circulatory system etc.). Step 5: Pay close attention to index instructions. • Parentheses ( ) enclose nonessential modifiers, terms that are Codes that describe symptoms and signs, as opposed to definitive supplementary words or explanatory information that may or may diagnoses, should be reported when an established diagnosis has not not appear in the diagnostic statement and do not affect code been made (confirmed) by the physician. Chapter 18 of the ICD-10-CM selection. code book, “Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (codes R00.-–R99), contains many, but • Brackets [ ] enclose manifestation codes that can be used only as not all, codes for symptoms. secondary codes to the underlying condition code immediately preceding it. If used, manifestation codes must be reported with the ICD-10-CM classifies encounters with health care providers for appropriate etiology codes. circumstances other than a disease or injury in chapter 21, “Factors Influencing Health Status and Contact with Health Services” (codes • Default codes are listed next to the main term and represent the Z00–Z99). Circumstances other than a disease or injury often are recorded condition most commonly associated with the main term or the as chiefly responsible for the encounter. unspecified code for the mainSAMPLE term. A code is invalid if it does not include the full number of characters •“See” cross-references, identified by italicized type and “code by” (greatest level of specificity) required. Codes in ICD-10-CM can contain cross-references indicate that another term must be referenced to from three to seven alphanumeric characters. A three-character code is to locate the correct code. be used only if the category is not further subdivided into four-, five-, six-, •“See also” cross-references, identified by italicized type, provide or seven-character codes. Placeholder character X is used as part of an alternative terms that may be useful to look up but are not mandatory. alphanumeric code to allow for future expansion and as a placeholder for empty characters in a code that requires a seventh character but has no • “Omit code” cross-references identify instances when a code is not fourth, fifth, or sixth character. Note that certain categories require applicable depending on the condition being coded. seventh characters that apply to all codes in that category. Always check • “With” subterms are listed out of alphabetic order and identify a the category level for applicable seventh characters for that category. presumed causal relationship between the two conditions they link.

xviii ICD-10-CM 2021 Admission ICD-10-CM 2021 Admission — continued Admission — continued Aftercare — continued fitting — continued vision examination — continued following surgery — continued device — continued following failed vision screening Z01.020 organ transplant — continued prosthetic — continued with abnormal findings Z01.021 kidney Z48.22 Index dental Z46.3 infant or child (over 28 days old) Z00.129 liver Z48.23 eye Z44.2 S with abnormal findings Z00.121 lung Z48.24 substitution waiting period for admission to other facility Z75.1 multiple organs NEC Z48.288 auditory Z46.2 Adnexitis (suppurative) — see Salpingo-oophoritis specified NEC Z48.298 implanted — see Admission, adjustment, Adolescent X-linked E71.521 orthopedic NEC Z47.89 device, implanted, hearing device Adrenal (gland) — see condition planned wound closure Z48.1 nervous system Z46.2 Adrenalism, tuberculous A18.7 removal of internal fixation device Z47.2 implanted — see Admission, adjustment, Adrenalitis, adrenitis E27.8 respiratory system Z48.813 device, implanted, nervous system autoimmune E27.1 Z47.82 visual Z46.2 meningococcal, hemorrhagic A39.1 sense organs Z48.810 implanted Z45.31 Adrenarche, premature E27.0 skin and subcutaneous tissue Z48.817 hearing aid Z46.1 Adrenocortical syndrome — see Cushing's, syndrome specified body system ileostomy device Z46.89 Adrenogenital syndrome E25.9 circulatory Z48.812 intestinal appliance or device NEC Z46.89 acquired E25.8 digestive Z48.815 neuropacemaker (brain) (peripheral nerve) (spinal congenital E25.0 genitourinary Z48.816 cord) Z46.2 salt loss E25.0 nervous Z48.811 implanted Z45.42 Adrenogenitalism, congenital E25.0 oral cavity Z48.814 orthodontic device Z46.4 Adrenoleukodystrophy E71.529 respiratory Z48.813 orthopedic device (brace) (cast) (shoes) Z46.89 neonatal E71.511 sense organs Z48.810 prosthesis Z44.9 X-linked E71.529 skin and subcutaneous tissue Z48.817 arm — see Admission, adjustment, artificial, arm Addison only phenotype E71.528 teeth Z48.814 breast Z44.3 S Addison-Schilder E71.528 specified NEC Z48.89 dental Z46.3 adolescent E71.521 spinal Z47.89 eye Z44.2 S adrenomyeloneuropathy E71.522 teeth Z48.814 leg — see Admission, adjustment, artificial, leg childhood cerebral E71.520 fracture — code to fracture with seventh character D specified type NEC Z44.8 other specified E71.528 involving spectacles Z46.0 Adrenomyeloneuropathy E71.522 removal of follow-up examination Z09 Adventitious bursa — see Bursopathy, specified type drains Z48.03 intrauterine device management Z30.431 NEC dressings (nonsurgical) Z48.00 initial prescription Z30.014 Adverse effect — see Table of Drugs and Chemicals, staples Z48.02 mental health evaluation Z00.8 categories T36-T50, with 6th character 5 surgical dressings Z48.01 requested by authority Z04.6 Advice — see Counseling sutures Z48.02 observation — see Observation Adynamia (episodica) (hereditary) (periodic) G72.3 neuropacemaker (brain) (peripheral nerve) (spinal cord) Papanicolaou smear, cervix Z12.4 Aeration lung imperfect, newborn — see Atelectasis Z46.2 implanted Z45.42 for suspected malignant neoplasm Z12.4 T70.3 S Aerobullosis orthopedic NEC Z47.89 plastic and reconstructive surgery following medical Aerocele — see Embolism, air procedure or healed injury NEC Z42.8 postprocedural — see Aftercare, following surgery Aerodermectasia After-cataract — see Cataract, secondary plastic surgery, cosmetic NEC Z41.1 subcutaneous (traumatic) T79.7 S postpartum observation Agalactia (primary) O92.3 Aerodontalgia T70.29 S elective, secondary or therapeutic O92.5 immediately after delivery Z39.0 Aeroembolism T70.3 S routine follow-up Z39.2 Agammaglobulinemia(acquired (secondary) (nonfamil- Aerogenes capsulatus infection A48.0 poststerilization (for restoration) Z31.0 ial) D80.1 S aftercare Z31.42 Aero-otitis media T70.0 with procreative management Z31.9 Aerophagy, aerophagia (psychogenic) F45.8 immunoglobulin-bearing B-lymphocytes D80.1 prophylactic (measure) — seealso Encounter, prophy- Aerophobia F40.228 lymphopenia D81.9 lactic measures Aerosinusitis T70.1 S autosomal recessive (Swiss type) D80.0 organ removal Z40.00 Aerotitis T70.0 S Bruton's X-linked D80.0 breast Z40.01 Affection — see Disease common variable (CVAgamma) D80.1 fallopian tube(s) Z40.03 Afibrinogenemia — see also Defect, coagulation D68.8 congenital sex-linked D80.0 with ovary(s) Z40.02 acquired D65 hereditary D80.0 ovary(s) Z40.02 congenital D68.2 lymphopenic D81.9 specified organ NEC Z40.09 following ectopic or molar pregnancy O08.1 Swiss type (autosomal recessive) D80.0 testes Z40.09 in abortion — see Abortion, by type, complicated by, X-linked (with growth hormone deficiency) (Bruton) vaccination Z23 afibrinogenemia D80.0 psychiatric examination (general) Z00.8 puerperal O72.3 Aganglionosis (bowel) (colon) Q43.1 requested by authority Z04.6 African Age (old) — see Senility radiation therapy (antineoplastic) Z51.0 sleeping sickness B56.9 Agenesis reconstructive surgery following medical procedure or tick fever A68.1 adrenal (gland) Q89.1 healed injury NEC Z42.8 trypanosomiasis B56.9 alimentary tract (complete) (partial) NEC Q45.8 removal of gambian B56.0 upper Q40.8 cystostomy catheter Z43.5 rhodesian B56.1 anus, anal (canal) Q42.3 drains Z48.03 Aftercare — see also Care Z51.89 with fistula Q42.2 dressing (nonsurgical) Z48.00 following surgery (for) (on) aorta Q25.41 implantable subdermal contraceptive Z30.46 amputation Z47.81 appendix Q42.8 intrauterine contraceptive device Z30.432 attention to arm (complete) Q71.0- S neuropacemaker (brain) (peripheral nerve) (spinal drains Z48.03 with hand present Q71.1- S cord) Z46.2 dressings (nonsurgical) Z48.00 artery (peripheral) Q27.9 implanted Z45.42 surgical Z48.01 brain Q28.3 staples Z48.02 sutures Z48.02 coronary Q24.5 surgical dressing Z48.01 SAMPLEcirculatory system Z48.812 pulmonary Q25.79 sutures Z48.02 delayed (planned) wound closure Z48.1 specified NEC Q27.8 ureteral stent Z46.6 digestive system Z48.815 umbilical Q27.0 respirator [ventilator] use during power failure Z99.12 explantation of joint prosthesis (staged procedure) auditory (canal) (external) Q16.1 restoration of organ continuity (poststerilization) Z31.0 hip Z47.32 auricle (ear) Q16.0 aftercare Z31.42 knee Z47.33 bile duct or passage Q44.5 sensitivity test — see also Test, skin shoulder Z47.31 bladder Q64.5 allergy NEC Z01.82 genitourinary system Z48.816 Q79.9 Mantoux Z11.1 joint replacement Z47.1 brain Q00.0 tuboplasty following previous sterilization Z31.0 neoplasm Z48.3 part of Q04.3 aftercare Z31.42 nervous system Z48.811 breast (with nipple present) Q83.8 vasoplasty following previous sterilization Z31.0 oral cavity Z48.814 with absent nipple Q83.0 aftercare Z31.42 organ transplant bronchus Q32.4 vision examination Z01.00 bone marrow Z48.290 canaliculus lacrimalis Q10.4 with abnormal findings Z01.01 heart Z48.21 carpus — see Agenesis, hand heart-lung Z48.280 Admission — Agenesis 14 S Additional Character Required — Refer to the Tabular List for Character Selection 2 Subterms under main terms may continue to next column or page Sodium — Strychnine Table of Drugs and Chemicals Sodium 390 Spasmolytic Sodium pne absorbable Sponge, Spiroperidol Spironolactone Spirilene Spirapril Spiramycin Spiperone inactivator Spindle Spigelia Spermicide Speed Spectinomycin Sparteine Sparine fly Spanish Spacoline Soysterol Sotradecol Sotalol Sorbitol nitrate Sorbide Sopor syrup Soothing Soneryl Somonal Somnos Sominex Somatropin Somatrem Somatotropin Somatostatin Somatorelin Soma NEC industrial Solvent, substance Solid fluid Soldering Solasulfone lotion Solar Solapsone dulcamara Solanum Solanine soap Soft resin Sodium-removing salt Sodium-free s (neutral) Spirit(s) Spider ooii drug Soporific Soporific fsl — salt of versenate valproate tyropanoate (L)-triiodothyronine tolbutamide thiosulfate thiosalicylate thiopental sulfate tetradecyl sulfoxone sulfate stibogluconate NEC salt surgical mineral industrial beverage antivenin NEC muscle skeletal ammonium quaternary NEC bronchial autonomic anticholinergics NEC type specified NEC specified petroleum naphtha NEC specified berries berries selenate (gelatin) bt)(venom) (bite) — (root) Substance see continued yrclrcacid Hydrochloric NEC diinlCaatrMyB eurd—Rfrt h aua itfrCaatrSelection Character for List Tabular the to Refer — Required Be May Character Additional T42.8X1 T37.1X1 T49.3X1 T37.1X1 T50.3X1 T50.6X1 T42.6X1 T50.8X1 T38.1X1 T38.3X1 T50.6X1 T41.1X1 T46.8X1 T37.1X1 T47.4X1 T37.3X1 T50.3X1 T45.7X1 T43.4X1 T50.0X1 T46.4X1 T36.3X1 T43.4X1 T50.4X1 T37.4X1 T49.8X1 T36.5X1 T48.1X1 T44.3X1 T48.6X1 T44.3X1 T44.3X1 T48.0X1 T43.3X1 T49.8X1 T44.3X1 T46.6X1 T46.8X1 T44.7X1 T47.4X1 T46.3X1 T42.6X1 T42.6X1 T42.3X1 T42.3X1 T42.6X1 T45.0X1 T52.8X1 T52.0X1 T52.0X1 T62.1X1 T62.2X1 T62.1X1 T62.2X1 T55.0X1 T60.2X1 T51.0X1 T52.0X1 T51.0X1 T51.0X1 T51.0X1 T50.Z11 T38.991 T38.891 T50.901 T39.091 T43.591 T43.621 T50.901 T38.811 T38.811 T38.811 T65.891 T65.891 T63.391 T52.91 T65.91 T42.71 T42.71 Poisoning, Accidental (unintentional) T42.8X2 T37.1X2 T49.3X2 T37.1X2 T50.3X2 T50.6X2 T42.6X2 T50.8X2 T38.1X2 T38.3X2 T50.6X2 T41.1X2 T46.8X2 T37.1X2 T47.4X2 T37.3X2 T50.3X2 T45.7X2 T43.4X2 T50.0X2 T46.4X2 T36.3X2 T43.4X2 T50.4X2 T37.4X2 T49.8X2 T36.5X2 T48.1X2 T44.3X2 T48.6X2 T44.3X2 T44.3X2 T48.0X2 T43.3X2 T49.8X2 T44.3X2 T46.6X2 T46.8X2 T44.7X2 T47.4X2 T46.3X2 T42.6X2 T42.6X2 T42.3X2 T42.3X2 T42.6X2 T45.0X2 T52.8X2 T52.0X2 T52.0X2 T62.1X2 T62.2X2 T62.1X2 T62.2X2 T55.0X2 T60.2X2 T51.0X2 T52.0X2 T51.0X2 T51.0X2 T51.0X2 T50.Z12 T38.992 T38.892 T50.902 T39.092 T43.592 T43.622 T50.902 T38.812 T38.812 T38.812 T65.892 T65.892 T63.392 T52.92 T65.92 SAMPLET42.72 T42.72 Poisoning, Intentional Self-harm T42.8X3 T37.1X3 T49.3X3 T37.1X3 T50.3X3 T50.6X3 T42.6X3 T50.8X3 T38.1X3 T38.3X3 T50.6X3 T41.1X3 T46.8X3 T37.1X3 T47.4X3 T37.3X3 T50.3X3 T45.7X3 T43.4X3 T50.0X3 T46.4X3 T36.3X3 T43.4X3 T50.4X3 T37.4X3 T49.8X3 T36.5X3 T48.1X3 T44.3X3 T48.6X3 T44.3X3 T44.3X3 T48.0X3 T43.3X3 T49.8X3 T44.3X3 T46.6X3 T46.8X3 T44.7X3 T47.4X3 T46.3X3 T42.6X3 T42.6X3 T42.3X3 T42.3X3 T42.6X3 T45.0X3 T52.8X3 T52.0X3 T52.0X3 T62.1X3 T62.2X3 T62.1X3 T62.2X3 T55.0X3 T60.2X3 T51.0X3 T52.0X3 T51.0X3 T51.0X3 T51.0X3 T50.Z13 T38.993 T38.893 T50.903 T39.093 T43.593 T43.623 T50.903 T38.813 T38.813 T38.813 T65.893 T65.893 T63.393 T52.93 T65.93 T42.73 T42.73 Poisoning, Assault T42.8X4 T37.1X4 T49.3X4 T37.1X4 T50.3X4 T50.6X4 T42.6X4 T50.8X4 T38.1X4 T38.3X4 T50.6X4 T41.1X4 T46.8X4 T37.1X4 T47.4X4 T37.3X4 T50.3X4 T45.7X4 T43.4X4 T50.0X4 T46.4X4 T36.3X4 T43.4X4 T50.4X4 T37.4X4 T49.8X4 T36.5X4 T48.1X4 T44.3X4 T48.6X4 T44.3X4 T44.3X4 T48.0X4 T43.3X4 T49.8X4 T44.3X4 T46.6X4 T46.8X4 T44.7X4 T47.4X4 T46.3X4 T42.6X4 T42.6X4 T42.3X4 T42.3X4 T42.6X4 T45.0X4 T52.8X4 T52.0X4 T52.0X4 T62.1X4 T62.2X4 T62.1X4 T62.2X4 T55.0X4 T60.2X4 T51.0X4 T52.0X4 T51.0X4 T51.0X4 T51.0X4 T50.Z14 T38.994 T38.894 T50.904 T39.094 T43.594 T43.624 T50.904 T38.814 T38.814 T38.814 T65.894 T65.894 T63.394 T52.94 T65.94 T42.74 T42.74 Poisoning, Undetermined T42.8X5 T37.1X5 T49.3X5 T37.1X5 T50.3X5 T50.6X5 T42.6X5 T50.8X5 T38.1X5 T38.3X5 T50.6X5 T41.1X5 T46.8X5 T37.1X5 T47.4X5 T37.3X5 T50.3X5 T45.7X5 T43.4X5 T50.0X5 T46.4X5 T36.3X5 T43.4X5 T50.4X5 T37.4X5 T49.8X5 T36.5X5 T48.1X5 T44.3X5 T48.6X5 T44.3X5 T44.3X5 T48.0X5 T43.3X5 T49.8X5 T44.3X5 T46.6X5 T46.8X5 T44.7X5 T47.4X5 T46.3X5 T42.6X5 T42.6X5 T42.3X5 T42.3X5 T42.6X5 T45.0X5 T50.Z15 T38.995 T38.895 T50.905 T39.095 T43.595 T43.625 T50.905 T38.815 T38.815 T38.815 T42.75 T42.75 Adverse Effect T42.8X6 T37.1X6 T49.3X6 T37.1X6 T50.3X6 T50.6X6 T42.6X6 T50.8X6 T38.1X6 T38.3X6 T50.6X6 T41.1X6 T46.8X6 T37.1X6 T47.4X6 T37.3X6 T50.3X6 T45.7X6 T43.4X6 T50.0X6 T46.4X6 T36.3X6 T43.4X6 T50.4X6 T37.4X6 T49.8X6 T36.5X6 T48.1X6 T44.3X6 T48.6X6 T44.3X6 T44.3X6 T48.0X6 T43.3X6 T49.8X6 T44.3X6 T46.6X6 T46.8X6 T44.7X6 T47.4X6 T46.3X6 T42.6X6 T42.6X6 T42.3X6 T42.3X6 T42.6X6 T45.0X6 T50.Z16 T38.996 T38.896 T50.906 T39.096 T43.596 T43.626 T50.906 T38.816 T38.816 T38.816 T42.76 T42.76 ———————————————————————— —— —————————— —— Under- dosing tv gas Stove Stimulant Strychnine Strophantin-g Strophantin Strophanthus Strophanthin Strofantina Strobane Stripper Streptozotocin Streptozocin Streptovarycin Streptonivicin Streptomycin Streptoduocin Streptodornase Stramonium Stoxil Stovarsal Stovaine battery Storage Stilboestrol Stilbestrol Stilbamidine Stibophen Stibogluconate Stibine Steroid gas Sternutator Sterculia Stepronin Stemetil Stelazine stavesacre or Staphisagria Stanozolol Stanolone fluoride Stannous Stains cucumber Squirting Squill viscosity-lowering Sputum Spurges flax Spurge Spray Sporostacin Streptokinase drug Stone-dissolving Starch pcfe otn — content specified — pesticides aua state natural (surface) topical spinal (peripheral) block nerve (subcutaneous) infiltration NEC topical preparation ophthalmic agent ENT hormone antineoplastic, androgenic anabolic poison rat cosmetic medicinal respiratory — system nervous central NEC medicinal (acid) antagonist opiate analeptics estrogen (pediculicide) (cathartic) drug psiie (salts) (pesticide) NEC specified — NEC psychotherapeutic substance (plexus) also (aerosol) drug also pit (solvent) (paint) Psychostimulant Substance — Psychotherapeutic (nonmedicinal) see (isetionate) g (k) (g) (derivative) see (cells) a,stove Gas, Pesticides 2 see utrsudrmi em a otnet etclm rpage or column next to continue may terms main under Subterms specific see see T65.1X1 T46.0X1 T46.0X1 T46.0X1 T46.0X1 T46.0X1 T60.1X1 T52.8X1 T45.1X1 T45.1X1 T36.5X1 T36.5X1 T36.5X1 T36.5X1 T45.3X1 T62.2X1 T48.6X1 T49.5X1 T37.8X1 T41.3X1 T41.3X1 T41.3X1 T41.3X1 T41.3X1 T54.2X1 T50.7X1 T50.7X1 T38.5X1 T38.5X1 T37.3X1 T37.4X1 T37.3X1 T49.0X1 T49.5X1 T49.6X1 T38.5X1 T38.7X1 T38.7X1 T38.7X1 T38.0X1 T47.4X1 T48.4X1 T43.3X1 T43.3X1 T49.0X1 T38.7X1 T38.7X1 T49.7X1 T65.6X1 T47.2X1 T60.4X1 T46.0X1 T48.4X1 T62.2X1 T62.2X1 T49.0X1 T56.891 T59.891 T65.891 T48.291 T45.611 T50.901 T48.901 T43.691 T43.601 T43.601 T50.901 T50.901 T65.91 Poisoning, Accidental (unintentional) T65.1X2 T46.0X2 T46.0X2 T46.0X2 T46.0X2 T46.0X2 T60.1X2 T52.8X2 T45.1X2 T45.1X2 T36.5X2 T36.5X2 T36.5X2 T36.5X2 T45.3X2 T62.2X2 T48.6X2 T49.5X2 T37.8X2 T41.3X2 T41.3X2 T41.3X2 T41.3X2 T41.3X2 T54.2X2 T50.7X2 T50.7X2 T38.5X2 T38.5X2 T37.3X2 T37.4X2 T37.3X2 T49.0X2 T49.5X2 T49.6X2 T38.5X2 T38.7X2 T38.7X2 T38.7X2 T38.0X2 T47.4X2 T48.4X2 T43.3X2 T43.3X2 T49.0X2 T38.7X2 T38.7X2 T49.7X2 T65.6X2 T47.2X2 T60.4X2 T46.0X2 T48.4X2 T62.2X2 T62.2X2 T49.0X2 T56.892 T59.892 T65.892 T48.292 T45.612 T50.902 T48.902 T43.692 T43.602 T43.602 T50.902 T50.902 T65.92 Poisoning, Intentional Self-harm T65.1X3 T46.0X3 T46.0X3 T46.0X3 T46.0X3 T46.0X3 T60.1X3 T52.8X3 T45.1X3 T45.1X3 T36.5X3 T36.5X3 T36.5X3 T36.5X3 T45.3X3 T62.2X3 T48.6X3 T49.5X3 T37.8X3 T41.3X3 T41.3X3 T41.3X3 T41.3X3 T41.3X3 T54.2X3 T50.7X3 T50.7X3 T38.5X3 T38.5X3 T37.3X3 T37.4X3 T37.3X3 T49.0X3 T49.5X3 T49.6X3 T38.5X3 T38.7X3 T38.7X3 T38.7X3 T38.0X3 T47.4X3 T48.4X3 T43.3X3 T43.3X3 T49.0X3 T38.7X3 T38.7X3 T49.7X3 T65.6X3 T47.2X3 T60.4X3 T46.0X3 T48.4X3 T62.2X3 T62.2X3 T49.0X3 T56.893 T59.893 T65.893 T48.293 T45.613 T50.903 T48.903 T43.693 T43.603 T43.603 T50.903 T50.903 T65.93 Poisoning, Assault T65.1X4 T46.0X4 T46.0X4 T46.0X4 T46.0X4 T46.0X4 T60.1X4 T52.8X4 T45.1X4 T45.1X4 T36.5X4 T36.5X4 T36.5X4 T36.5X4 T45.3X4 T62.2X4 T48.6X4 T49.5X4 T37.8X4 T41.3X4 T41.3X4 T41.3X4 T41.3X4 T41.3X4 T54.2X4 T50.7X4 T50.7X4 T38.5X4 T38.5X4 T37.3X4 T37.4X4 T37.3X4 T49.0X4 T49.5X4 T49.6X4 T38.5X4 T38.7X4 T38.7X4 T38.7X4 T38.0X4 T47.4X4 T48.4X4 T43.3X4 T43.3X4 T49.0X4 T38.7X4 T38.7X4 T49.7X4 T65.6X4 T47.2X4 T60.4X4 T46.0X4 T48.4X4 T62.2X4 T62.2X4 T49.0X4 T56.894 T59.894 T65.894 T48.294 T45.614 T50.904 T48.904 T43.694 T43.604 T43.604 T50.904 T50.904 T65.94 Poisoning, Undetermined ICD-10-CM T46.0X5 T46.0X5 T46.0X5 T46.0X5 T46.0X5 T45.1X5 T45.1X5 T36.5X5 T36.5X5 T36.5X5 T36.5X5 T45.3X5 T48.6X5 T49.5X5 T37.8X5 T41.3X5 T41.3X5 T41.3X5 T41.3X5 T41.3X5 T50.7X5 T50.7X5 T38.5X5 T38.5X5 T37.3X5 T37.4X5 T37.3X5 T49.0X5 T49.5X5 T49.6X5 T38.5X5 T38.7X5 T38.7X5 T38.7X5 T38.0X5 T47.4X5 T48.4X5 T43.3X5 T43.3X5 T49.0X5 T38.7X5 T38.7X5 T49.7X5 T47.2X5 T46.0X5 T48.4X5 T49.0X5 T48.295 T45.615 T50.905 T48.905 T43.695 T43.605 T43.605 T50.905 T50.905 Adverse Effect T46.0X6 T46.0X6 T46.0X6 T46.0X6 T46.0X6 T45.1X6 T45.1X6 T36.5X6 T36.5X6 T36.5X6 T36.5X6 T45.3X6 T48.6X6 T49.5X6 T37.8X6 T41.3X6 T41.3X6 T41.3X6 T41.3X6 T41.3X6 T50.7X6 T50.7X6 T38.5X6 T38.5X6 T37.3X6 T37.4X6 T37.3X6 T49.0X6 T49.5X6 T49.6X6 T38.5X6 T38.7X6 T38.7X6 T38.7X6 T38.0X6 T47.4X6 T48.4X6 T43.3X6 T43.3X6 T49.0X6 T38.7X6 T38.7X6 T49.7X6 T47.2X6 T46.0X6 T48.4X6 T49.0X6 T48.296 T45.616 T50.906 T48.906 T43.696 T43.606 T43.606 T50.906 T50.906 2021

—— ———— —— —— —— —— ———————— ————Under- dosing Chapter 9. Diseases of the Circulatory System 643

Guidelines and Examples and Guidelines ase, first assign the appropriate the appropriate assign first ase, nt therapeuticregimen. In either underlying condition. Two codes are condition. Two underlying to category I27, OtherI27, to category pulmonary renal artery atherosclerosis artery renal dual codes for hypertension, heart heart hypertension, codes for dual sive emergency or unspecified categories I11 and I12. Do not report Do not report I12. I11 and categories both on may refer to untreated hypertension or Renovascular hypertension hypertension Renovascular Atherosclerosis of renal artery Hypertensive heart and chronic kidney disease with chronic disease kidney Hypertensive heart and heart failure stage and 1 through stage 4 chronic chronic or unspecified kidney disease kidney disease, unspecified failure, Heart (mild) stage 2 disease, kidney Chronic from hemorrhage subarachnoid Nontraumatic artery unspecified intracranial hypertension (primary) Essential : Secondary hypertension requires two codes: a code to : Combination codes in category I13 are used reportto disease requires cerebrovascular : Hypertensive two codes: the appropriate I60–I69 code followed by the appropriate hypertension hypertension appropriate the by followed code I60–I69 appropriate the code. conditions classifiable to I11 and I12 separately. Use additional codes to to codes additional Use separately. I12 and I11 to classifiable conditions CKD. of and stage failure heart of type report Renovascularhypertension due to I15.0 I70.1 Explanation code. I15 appropriate the and etiology the identify Hypertensive heart and kidney disease with congestive heart failure and and failure heart congestive with disease and kidney heart Hypertensive stage 2 chronic kidney disease I13.0 I50.9 N18.2 Explanation conditions classifiable to hypertension by malignant caused aneurysm cerebral of Rupture I60.7 I10 Explanation required: one to identify the underlying etiology and one from category category from and one etiology underlying the identify to one required: I15 to identify the hypertension.Sequencing codes of isdetermined by admission/encounter. for reason the Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an diagnosisestablished of Gestational hypertension. [pregnancy-induced] O13.-, Assign code hypertensionsignificant withoutO14.-,Pre-eclampsia, proteinuria, or for pregnancy. of hypertension transient of state to an existing refers usually statement diagnostic This from code appropriate the Assign therapy. by control under hypertension diseases. Hypertensive I10-I15, categories Uncontrolled hypertensi hypertension not responding to curre Hypertensive I10-I15, code categories from appropriate the case, assign diseases. documented for crisis, Hypertensive I16, category code from a Assign hypertensive hyperten urgency, disease hypertensive identified any also Code crisis. hypertensive (I10-I15). The sequencing is based on the reason for the encounter. is classified I27.2-), (I27.1, hypertension pulmonary secondary For diseases. heart toxins. or drugs of effects adverse or conditions any associated code also For hypertensive cerebrovascular dise cerebrovascular For hypertensive hypertension appropriate the by followed I60-I69, categories from code code. changes, vascular and retinal retinopathy Background H35.0, Subcategory should be used withcode a from category I10 – I15, Hypertensive disease the on based is sequencing The hypertension. systemic the include to for the reason encounter. Secondary hypertension is due to an from shouldused, I13 indivinot be or I12. I11 from or codes disease, chronic kidney and disease For patients with both acute renal failure and chronic kidney disease, an required. is failure renal acute for code additional (I00–I99) 7) transient Hypertension, 8) Hypertension, controlled 9) Hypertension, uncontrolled 10)crisis Hypertensive hypertension 11)Pulmonary 4) Hypertensive cerebrovascular disease 5) Hypertensive retinopathy 6) secondary Hypertension, Chapter 9. Diseases of the Circulatory System Circulatory the of 9.Diseases Chapter

-CM Official Guidelines for for Guidelines Official -CM 0 8, Chronic kidney disease, should ronic kidney disease, then a code ifically linkedby relational terms ion classifiable to categoryN18, assified to I50.- or I51.4-I51.7, hypertensionwithheart both and an assumed causalrelationship, and e e conditions in order to code them as related. SAMPLE Chronic kidney disease, stage 4 disease, kidney (severe) Chronic Polycystic kidney, unspecified Essential (primary) hypertension Hypertensive heart disease with heart failure heart with disease Hypertensive unspecified failure, ventricular Left : A combinationdescribing code relationship a between : Without diagnostic a statementcontrary,theto Diseases of the Circulatory System System Circulatory the of Diseases hypertension and CKD is not used because the physician physician the because used not is CKD and hypertension for cause the as disease kidney the polycystic identifies documentation the CKD. I10 Explanation Patient is admitted with stage IV chronic kidney disease (CKD) due to polycystic kidney disease. Patient also is on lisinopril for hypertension. N18.4 Q61.3 I11.0 I50.1 Explanation hypertension and heart failure have the code to identify An additional used. be code should a combination hearttype(I50.-) failurebe provided. of should also Patient is admitted in left heart failure. Patient also has a history of hypertension managed by medication. Assign codes from combination category Hypertensive I13, heart and is there when disease, kidney chronic code an additional assign is present, failure heart If involvement. kidney categoryfrom heart to identifytype failure. the I50 of N1 category code from appropriate The be used as a secondary code with a code from category I13 to identify the disease. kidney chronic of stage disease. kidney Chronic I.C.14. Section See disease, kidney chronic and heart Hypertensive I13, category in codes The and disease heart hypertension, include that codes combination are the that specifies I13 at note The Includes disease. kidney chronic conditions included at I11 and I12 are included together in I13. If a patient ch and disease heart hypertension, has Assign codes from category I12, Hypertensive chronic kidney disease, disease, kidney chronic Hypertensive I12, category from Assign codes when both hypertension and a condit as coded be not should CKD present. are (CKD), disease kidney Chronic hypertensive if the provider indicates the CKD is not related to the hypertension. a secondary as be used should N18 category code from appropriate The code with a code from category to I12 identify the stage of chronic kidney disease. disease. kidney Chronic I.C.14. Section See renal acute and disease kidney chronic hypertensive has patient a If required. is failure renal acute the for code additional an failure, Hypertension with conditionsheart cl I51.89,I51.9, areassigned to aidentify to code failure, from Heart I50, category category from code(s) additional Use I11, disease. Hypertensiveheart the type(s) of heart failure in those patients with heart failure. with I51.9) I51.89, I51.4-I51.7, (I50.-, conditions heart same The hypertension are coded separately if the provider has documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter. 3) heart and Hypertensive chronic kidney disease 2) disease chronic kidney Hypertensive The classification presumes a causal relationship between hypertension and and hypertension between relationship a causal presumes classification The heartinvolvement and between hypertensionand kidney involvement,as the two conditions are linked by the term “with”in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. and conditions not spec hypertensionFor such as “with,” “associated with” or “due to” in the classification, provider documentation must link th 1) Hypertension heart with disease The chapter-specific guidelines from the ICD-1 Chapter 9. Examples Coding with Guidelines Chapter-specific guidelines these with Along below. provided been have Reporting and Coding are coding examples, contained in the shaded boxes, that have been developed these in foundsequencing guidance coding and/or the illustrate to help guidelines. a. Hypertension ICD-10-CM 2021 1 202 ICD-10-CM J84.9–J93.82 Chapter 10. Diseases of the Respiratory System ICD-10-CM 2021 J84.9 Interstitial pulmonary disease, unspecified < J91.8 Pleural effusion in other conditions classified A Interstitial NOS elsewhere Code first underlying disease, such as: Suppurative and necrotic conditions of the lower respiratory filariasis (B74.0-B74.9) tract (J85-J86) influenza (J09.X2, J10.1, J11.1) AHA: 2015,2Q,15 b J85 Abscess of lung and mediastinum TIP: Assign this code as a secondary diagnosis to congestive heart Use additional code (B95-B97) to identify infectious agent failure (I50.-) only if is specifically evaluated or CC Excl: For MCC codes in category J85, unless otherwise noted: PDX treated. collection 749 CC Excl: PDX collection 752 J85.0 Gangrene and necrosis of lung a< Pleural Effusion J85.1 Abscess of lung with pneumonia a< Code also the type of pneumonia Right lung J85.2 Abscess of lung without pneumonia a< Left lung Abscess of lung NOS J85.3 Abscess of mediastinum a< CC Excl: PDX collection 750 b J86 Pyothorax Pleura Use additional code (B95-B97) to identify infectious agent Pleural 1 abscess of lung (J85.-) space pyothorax due to tuberculosis (A15.6) DEF: Collection of pus in the pleural space that is commonly caused by an infection that spreads from the lung, such as bacterial pneumonia or Chapter 1 0 . Diseases of the Respiratory System a lung abscess. J86.0 Pyothorax with fistula a