GUIDE FOR ICD-10’S AND AMBULANCE SERVICES
Amanda Jimeson, CPC, CAC Angela Lehman, RHIA Rebecca B. Williamson, BA, RN, NRP TABLE OF CONTENTS Contents
ICD-10-CM’s ______1 ICD-10-CM Concepts ______7 General Mapping Equivalence ______22 Condition Codes ______25 Payor Specific ______26 Understanding Medical Terminology ______31 Anatomy and Physiology______32 Vocabulary ______33 Abbreviations ______42 Understanding Lab Values and Vitals ______49 Medications ______54 Symptoms, Signs and Abnormal Clinical Laboratory Findings ______56 Great Resource ______62 Certain Infectious and Parasitic Diseases ______63 Diseases of Blood, Blood-Forming Organs or Hemorrhage ______64 Endocrine, Nutritional and Metabolic Diseases ______66 Behavioral Health ______85 Diseases of the Nervous System ______98 Diseases of the Circulatory System ______119 Diseases of the Respiratory System ______143 Diseases of the Digestive System ______156 Disease of the Skin and Subcutaneous Tissues ______160 Diseases of the Musculoskeletal System ______164 Genitourinary ______169 Pregnancy, Childbirth and the Puerperium ______174 Injury, Poisoning and Certain Other Consequences of External Causes ______178 External Causes of Morbidity ______189 Factors Influencing Health Status and Contact Health Services ______190 Documentation ______192 TABLE OF CONTENTS Moving Forward ______195 Resources ______200 Appendix ______203
ICD-10-CM’S
ICD-10-CM’s
OVERVIEW
The International Statistical Classification of Disease and Related Health Problems, ICD- 10, is a medical classification system for coding of: Diseases Injuries Symptoms Procedures and more
This is the first major change in U.S. coding in more than 30 years.
Some call it healthcare’s version of Y2K.
Expands diagnosis code selections to 68,000+ compared to 14,000 ICD-9-CM selections.
CURRENT REGULATION
Effective January 1, 2012, ICD-9’s were required to be submitted on electronic ambulance claims to represent a patient’s condition. The determination of what is submitted is based on the Medicare Administrative Contractors (MAC’s).
• Option 1: Suppliers may choose codes from the Medical Conditions List provided by the Centers for Medicare & Medicaid Services (CMS) that corresponds to the condition of the beneficiary at the time of pickup and report the codes in the diagnosis field on the claim. The codes in the Medical Conditions List are taken from the ICD-9-CM diagnosis code set.
Page 1 ICD-10-CM’S
• Option 2: Suppliers may report an ICD-9-CM (or ICD-10-CM when appropriate) diagnosis code that is provided to them by the treating physician or other practitioner. • Option 3: Suppliers may report ICD-9-CM diagnosis code 799.9 unspecified illness. • Some ambulance services submit ICD-9 codes based on their MAC’s local coverage determination policy (LCD).
COMPLIANCE DATE
On August 24, 2012, the Department of Health and Human Services (HHS) issued a Final Rule that delayed the compliance date for the new ICD-10 diagnosis and procedure codes until October 1, 2014.
The previous compliance deadline of October 1, 2014 was delayed again when President Barack Obama signed a new law on April 1, 2014. This law ordered HHS to not set an ICD- 10 deadline any sooner than October 1, 2015. The U.S. Department of Health and Human Services (HHS) issued in September 2014, a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.
Any provider covered by the Health Portability and Accountability Act (HIPAA) must make the transition to ICD-10’s (MLN Matters Number SE1239).
Claims for services provided on or after the compliance date should be submitted with ICD-10 diagnosis codes.
Claims for services provided prior to the compliance date should be submitted with ICD-9 diagnosis codes.
Page 2 ICD-10-CM’S
DEPARTMENT OF HEALTH AND HUMAN SERVICES
MEDLEARN Matters-SE 1409
Effective October 1, 2015
ICD-10 Claims Submission Alternatives
For from dates of services for professional and supplier claims, or discharge dates on institutional claims on or after October 1, 2015 entities covered under the Health Insurance Portability Act (HIPAA) are required to use the ICD-10 code sets adopted under HIPAA. If a provider or supplier is unable to complete the necessary system changes to submit claims with ICD-10 codes by October 1, 2015, or find they are unable to submit claims on or after October 1, 2015, due to issues with their billing software, vendor, or clearing house, the following claims submission alternatives are available:
NOTE: claim submission alternatives still REQUIRE the use of ICD-10 code sets for FROM dates of service (on professional and supplier claims) or date of discharge (on institutional claims) on or after October 1, 2015.
Free Billing Software • Free billing software is offered by CMS via the Electronic Data Interchange (EDI) via each MAC’s website. • This billing software only works for submitting Fee-for-Service claims to Medicare. It is intended to provide submitters with an ICD-10 compliant claims submission format; it does not provide coding assistance.
NOTE: Submitting electronic claims to Medicare using the free billing software does not change the requirement for ICD-10 compliant claims to be submitted for FROM dates of
Page 3 ICD-10-CM’S
service on or after October 1, 2015. Any claims containing ICD-9 codes for FROM dates of service on or after October 1, 2015, will be rejected by Medicare.
Direct data entry • Providers that bill institutional claims are also permitted to submit claims electronically via direct data entry (DDE) screens. For more information about DDE, go to http://medicare.fcso.com/Direct_data_entry/. • A request to submit claims via DDE must be done by prior to October 1, 2015.
Please note that claims submitted via DDE must contain ICD-10 codes for dates of discharge/through dates on or after October 1, 2015. Those submitted containing ICD-9 codes for dates of discharge/through dates on or after October 1, 2015, will be returned to provider (RTP).
Paper claims • In limited situations, provider and suppliers may submit paper claims with ICD-10 codes to Medicare. To find more information on when you may submit paper claims, visit http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/ASCAWai ver.html • A wavier must be submitted before October 1, 2015.
NOTE: Submitting paper claims to Medicare, even if approved for an ASCA waiver, does not change the requirement for ICD-10 compliant claims to be submitted for FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2015.
Letter from CMS
On July 6, 2015, CMS provided a letter to providers and suppliers detailing that CMS will be:
Page 4 ICD-10-CM’S
Flexible in claims auditing and quality reporting process. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10’s. CMS will create an ICD-10 Ombudsman to help triage physician and provider issues. Further information can be found at www.cms.gov/ICD10.
GEARING UP FOR CHANGE
Change is not easy to embrace, even if the outcome is for the better. Reasons for change: o We have to change because the current process is broke; or o There is a better way to accomplish a task or goal.
WHY THE CHANGE?
Clinical
Better outcomes because of better documentation. Paints a better picture due to specificity, laterality, and more detailed information about the disease process. Improvement of care due to the documentation on higher acuity patients. Help to design better protocols. Provides more precise information reporting to the State and other Public Health entities. Improved tracking of patient illnesses. Provides more data for research to develop better patient outcomes; current system (ICD-9) is archaic compared to other countries.
Operational
Improved definitions of patient conditions.
Page 5 ICD-10-CM’S
For institutional providers, helps with greater specificity to define co-morbidities and complications. The ability to share better data based on patient and population.
Financial
Better documentation, which gives ability to understand the patient complexity and level of care; therefore, supporting reimbursement for the level of care provided. Allows for better comparison for benchmarking patient conditions. May aid in lowering audits due to more specific codes supported by greater documentation.
Page 6 ICD-10-CM CONCEPTS
ICD-10-CM Concepts
ICD-9-CM Only 17 Chapters
ICD-10-CM
21 Chapters
Page 7 ICD-10-CM CONCEPTS
DOCUMENTATION FOCUS AREAS
Disease type Disease acuity Disease stage Site specific Laterality Combination Codes Changes in timeframes with certain codes
DIFFERENCES
Page 8 ICD-10-CM CONCEPTS
Page 9 ICD-10-CM CONCEPTS
Page 10 ICD-10-CM CONCEPTS
Page 11 ICD-10-CM CONCEPTS
INITIAL VS. SUBSEQUENT VS. SEQUELA Initial Encounter is While Receiving Active Treatment o Surgical treatment o Emergency treatment o Those who seek a delay in treatment. Subsequent has completed active care and now in the healing processes. o Cast change o Removal of devices o Follow-up doctor’s visits Sequela o Late effect o A chronic or residual condition that is a complication of an acute condition that occurs after the acute disease, illness or injury.
Page 12 ICD-10-CM CONCEPTS
Page 13 ICD-10-CM CONCEPTS
Page 14 ICD-10-CM CONCEPTS
ICD-10-CM Official Coding Guidelines
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: o The American Hospital Association (AHA), o The American Health Information Management Association (AHIMA), o CMS, and o NCHS. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.
Page 15 ICD-10-CM CONCEPTS
Page 16 ICD-10-CM CONCEPTS
Page 17 ICD-10-CM CONCEPTS
Page 18 ICD-10-CM CONCEPTS
Page 19 ICD-10-CM CONCEPTS
Page 20 ICD-10-CM CONCEPTS
Page 21 GENERAL MAPPING EQUIVALENCE
General Mapping Equivalence
Identification of potential corresponding codes between ICD-9 and ICD-10. Mappings are bi-directional, and goes backwards and forwards. GEMS are not direct crosswalks; there is not an exact match between more complex ICD-10-CM codes. This may limit the likely hood of an exact match. A single ICD-9 code may map to multiple ICD-10 codes. o There are new concepts in ICD-10 codes that were not available in ICD-9 codes. o More than one ICD-9-CM Code may be possible translation of a given ICD- 10-CM.
Page 22 GENERAL MAPPING EQUIVALENCE
o More than one ICD-9-CM Code may be required to convey the complete meaning of a given ICD-10-CM.
NATIVE CODING AND UNSPECIFIED CODES
Native coding means to assign an ICD-10 diagnosis code directly based on clinical documentation. Providers are encouraged to natively code using ICD-10 code reference sources instead of using crosswalks, which should be used for general knowledge. Specific codes reflecting the most appropriate level of certainty known for an encounter should be evaluated first: o Specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition. o If the end of the encounter has not established a definitive diagnosis, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. o When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, coding should comply with the payer guidelines for the use of unspecified codes.
Page 23 GENERAL MAPPING EQUIVALENCE
Page 24 CONDITION CODES
Condition Codes
Page 25 PAYOR SPECIFIC
Payor Specific
Workers’ compensation and auto insurance companies are considered non-covered entities under HIPAA. Will they have to switch to ICD-10-CM?
Answer: Workers' compensation and auto insurance companies are considered non- covered entities and are not covered under HIPAA; however, since the ICD-9-CM codes will no longer be maintained after the implementation of ICD-10-CM it is recommended that that they use the new coding system.
Payor Specific Information is based on information available as of July 1, 2015.
Page 26 PAYOR SPECIFIC
Page 27 PAYOR SPECIFIC
Page 28 PAYOR SPECIFIC
Page 29 PAYOR SPECIFIC
Page 30 UNDERSTANDING MEDICAL TERMINOLOGY
Understanding Medical Terminology
Medical billers and medical coders need to be comfortable using and understanding medical terms in order to apply the correct codes to describe services delivered to patients.
Very often within the clinical environment, medical terminology is composed of abbreviations and understanding them makes reading documentation much faster and easier.
Many of the words used by physicians, surgeons, and other healthcare providers consist of Greek and Latin root words that are combined to create a multi-syllabic term that carries a precise meaning.
Most medical terms consist of three basic components: o root word (the base of the term), o prefixes (letter groups in front of the root word) and o suffixes (letter groups at the end of the root word). For example, the term sub hepatic, “sub” is the prefix meaning “below or under.” The word root hepat-means “liver” and the suffix –ic means “pertaining to”. While a medical biller or coder knows what a layperson means when they say that someone has suffered a heart attack, this term means nothing for coding or billing purposes. Medical terminology precisely defines a condition. Professional medical billers are able to understand the specifics of this terminology in order to communicate it to third-party payers for accurate reimbursement. Some of the more commonly used words for EMS documentation are included in the next few pages.
Page 31 ANATOMY AND PHYSIOLOGY
Anatomy and Physiology
Anatomy Study of normal body structures.
Physiology Study of normal, healthy, bodily functions.
Pathophysiology Study the changes of normal mechanical, physical and biochemical functions.
By understanding the basics of A&P, Billing and Coding can: • Gain understanding how diseases affect healthy functions of the organs and body system. • Be better equipped to ask intelligent questions if they need query the documentation for clarity to ensure appropriate level of billing.
Page 32 VOCABULARY
Vocabulary
a- no; not; without an- no; not; without ab- away from ad- toward -ad toward aden/o gland -al pertaining to -algia pain all/o other amphi- around, on both sides, about -an pertaining to andi/o vessel (blood) ante- before; forward anter/o front anti- against -ar pertaining to arter/o artery arteri/o artery arthr/o joint -ary pertaining to -ation process; condition axill/o armpit bi- two bi/o life bil/i bile; gall brady- slow cac/o bad carcin/o cancerous; cancer cardi/o heart -centesis surgical puncture to remove fluid cephal/o head chem/o drug; chemical -chezia defecation; elimination of wastes chol/e bile; gall
Page 33 VOCABULARY
chondr/o cartilage chrom/o color -cide killing circum- around cis/o to cut con- together with consci/o awareness; aware contra- against; opposite contus/o to bruise coron/o heart corpor/o body cost/o rib crani/o skull cutane/o skin cyan/o blue cyst/o urinary bladder; cyst; sac of fluid -cyt/o cell -cytosis condition of cells; slight increase in numbers de- lack of; down; less; removal of derm/o skin -derma skin -desis to bind; tie together dextr/o right dia- complete; through -dilation widening; stretching; expanding dilat/o to enlarge; expand dipl/o double dis- apart; to separate dist/o far; distant dolor/o pain dors/o back (of body) dorsi- back -dote to give duct/o to lead; carry -dynia pain
Page 34 VOCABULARY
dys- bad; painful; difficult; abnormal -eal pertaining to ec- out; outside -ectasia/s dilation; dilatation; widening ecto- out; outside -ectomy removal; excision; resection -edema swelling em- in -ema condition -emesis vomiting -emia blood condition -emic pertaining to blood condition -en in; within encephal/o brain end- in; within endo- in; within enter/o intestines (usually small intestine) epi- above; upon; on epitheli/o skin; epithelium equi- equality; equal -er one who erythem/o flushed; redness erythro red -esis action; condition; state of eso- inward eti/o cause eu- good; normal ex/o- out; away from extra- outside fore- before; in front -form resembling; in the shape of frig/o cold -fusion to pour; to come together gastr/o stomach -gen substance that produces
Page 35 VOCABULARY
-genesis producing; forming -genic produced by or in ger/o old age gest/o pregnancy gloss/o tongue gluc/o glucose; sugar glyc/o glucose; sugar -grade to go -gram record -graph instrument for recording graph/o writing gravid/o pregnancy gynec/o woman; female hapl/o simple; single hem/o blood hemat/o blood hemi- half hepat/o liver hist/o tissue holo- entire, complete home/o sameness; unchanging; constant hydr/o water hyper- above; excessive hypo- deficient; below; under; less than normal -ia condition -iac pertaining to -iasis abnormal condition -ic pertaining to -ical pertaining to -icle small in- in; into; not -in/e a substance; chemical, chemical compound -ine pertaining to infra- below; inferior; beneath inter- between
Page 36 VOCABULARY
intra- within; into -ion process -ior pertaining to ir- in is/o same; equal -ism process; condition -itis inflammation labi/o lip lal/o speech -lalia speech lapar/o abdominal wall; abdominal -lapse to slide; fall; sag later/o side -lepsy seizure levo- left lex/o word; phrase lexia word; phrase lingu/o tongue -lipsis omit; fail -logist specialist log/o study -logy study (process of) -lysis breakdown; separation; destruction; loosening -lytic to reduce; destroy; separate; breakdown macro- large mal- bad -malacia softening -mania obsessive preoccupation medi/o middle mega large -megaly enlargement meso- middle meta- change; beyond -meter measure -metry process of measuring
Page 37 VOCABULARY
mi/o smaller; less micro- small mon/o one; single multi- many my/o muscle myc/o fungus mydr/o wide necr/o death neo- new nephr/o kidney neur/o nerve noct/o night nos/o disease ocul/o eye -oid resembling; derived from -ole little; small olig/o scanty -oma tumor; mass; fluid collection onc/o tumor one mono; uni -opia vision condition -or one who or/o mouth orth/o straight os opening; mouth -ose full of; pertaining to -osis condition (usually abnormal) oste/o bone -ous pertaining to pale/o old pali- recurrence; repetition palp/o to touch gently plapit/o flutter; throbbing pan- all par- other than; abnormal
Page 38 VOCABULARY
para- near; beside; abnormal; apart from; along the side of -paresis weakness path/o disease -pathy disease; emotion ped/o child; foot -penia deficiency per- through peri- surrounding phag/o eat; swallow phas/o speech -phasia speech -phoresis carrying; transmission physi/o nature; function -plasia development; formation -plasty surgical repair -plegia paralysis -pnea breathing pneum/o lung; air; gas poly- many; much post- after; behind pre- before; in front of pro- before; forward proxim/o near pseudo- false psych/o mind -ptosis droop; sag; prolapse; protrude py/o pus quadri- four; square quant- how much quasi- to some degree; as if re- back; again; backward retro- behind; back; backward rhe/o flow; current; stream rhin/o nose rot/o turn; revolve
Page 39 VOCABULARY
-rrhage bursting forth (of blood) -rrhea flow; discharge -sclerosis hardening -scope instrument for visual examination sect/o to cut semi- half -sepsis putrefaction seps/o infection sept/o partition -sis state of; condition somat/o body -spasm sudden contraction of muscles -stasis to stop; control, place -stat device/instrument for keeping something stationary -stenosis tightening; stricture stomat/o mouth -stomy new opening sub- under or below super- above; beyond supra- above; upper sym- together; with syn- together; with tachy- fast -tension pressure -therapy treatment thorac/o chest thromb/o clot -tic pertaining to -tomy process of cutting trans- across; through -trophy nourishment; development (condition of) -ule little; small ultra- beyond; excess -um structure; tissue; thing uni- one
Page 40 VOCABULARY
-us structure; thing vascul/o vessel (blood) ven/o vein ven/i vein -verse to turn -ward in the direction of -where location -wise direction with- together; united -y condition; process
Page 41 ABBREVIATIONS
Abbreviations
• Billers and Coders need a list of approved abbreviations used by the Paramedics and EMT’s in order to understand their documentation.
• As abbreviations are updated they need to be shared with the billing staff.
Page 42 ABBREVIATIONS
AAA abdominal aortic aneurysm ABC airway, breathing, circulation abd abdominal AC antecubital (inside of the elbow) a.c. before meals ACL anterior cruciate ligament ACLS advanced cardiac life support ad lib at liberty (Example: "patient can be up ad lib.") ADL activities of daily living AEMT advanced level emergency medical technician A-fib atrial fibrillation AICD automatic implanted cardiac defibrillator AKA also known as AKA above the knee amputation AMA against medical advice AMI acute myocardial infarction A/O alert and oriented (as in "A/O x 4) A/P anterior/posterior APRN Advanced Practice Registered Nurse ASA aspirin B Basic (as in: EMT-B) BBB bundle branch block b.i.d. twice a day BKA below the knee amputation BLS basic life support BMI body mass index BP or B/P blood pressure bpm beats per minute BS blood sugar BSA body surface area Ca cancer CABG coronary artery bypass graph CAD coronary artery disease CAT (scan) computerized axial tomography CBD complete blood count
Page 43 ABBREVIATIONS
C/C chief complaint CCEMTP Certified Critical Care Emergency Medical Technician Paramedic CHF congestive heart failure CNM Certified Nurse Midwife c with cm centimeter c-spine cervical spine CMS circulation, movement, sensation CNS central nervous system C/O complaint of COPD chronic obstructive pulmonary disease CP cerebral palsy CPAP continuous positive airway pressure CPR cardio pulmonary resuscitation CSW Clinical Social Worker CT computed tomography CTA clear to auscultation CVA cerebrovascular accident (stroke) D5W dextrose 5% in water D50 dextrose 50% DKA diabetes ketoacidosis DM diabetes mellitus DNR do not resuscitate DOE dyspnea on exertion DO Doctor of Osteopathy DOA dead on arrival d/t due to DVT deep vein thrombosis dx diagnosis ECG electrocardiograph EJ external jugular (vein) EKG electrocardiograph EMR Emergency Medical Responder EMT Emergency Medical Technician EMT-P Emergency Medical Technician - Paramedic
Page 44 ABBREVIATIONS
ePCR electronic patient care report ESRD end stage renal disease ESRF end stage renal failure ETA estimated time of arrival ETOH alcohol ET / ETT endotracheal tube FBS finger stick blood sugar FBS fasting blood sugar FHT fetal heart tones Fx fracture G-P gravida / Para GSW gunshot wound gtt drop / drops Gm gram HA head ache HEENT head, eyes, ears, nose, throat H&P history and physical H/O history of HPI history of present illness h.s. at bedtime hx history HTN hypertension ICF intermediate care facility ICP intracranial pressure IDDN insulin dependant diabetes mellitus IM intramuscular IV intravenous IVP IV Push K potassium KCl potassium chloride Kg kilogram L liter L&D labor and delivery LE law enforcement LLE left lower extremity
Page 45 ABBREVIATIONS
LLL left lower lobe (of lung) LLQ left lower quadrant (abdominal) LUQ left upper quadrant (abdominal) LMP last menstrual period LPN Licensed Practical Nurse MCL medial collateral ligament MD Medical Doctor ME Medical Examiner Mg milligrams MI myocardial infarction ("heart attack") Ml milliliters MRI magnetic resonance imaging MRSA methicillin resistant staph aureus MS morphine sulfate MVA motor vehicle accident MVC motor vehicle crash NC nasal cannula NKA no known allergy NKDA no known drug allergy NRB non-rebreather (oxygen mask) NS normal saline NTG nitroglycerine N/V nausea and vomiting N/V/D nausea, vomiting, and diarrhea Na sodium NG nasogastric (tube) NP Nurse Practioner npo nothing by mouth NRP Nationally Registered Paramedic NSR normal sinus rhythm NSTEMI Non-elevated ST segment myocardial infarction O2 oxygen OD overdose O.D right eye O.S. left eye
Page 46 ABBREVIATIONS
O.U. both eyes OT occupational therapy OTC over the counter ORIF open reduction and internal fixation (such as for a hip fx) P Paramedic P pulse p after PA Physician Assistant PCR patient care report PD police department PE pulmonary embolus PE physical exam PEG percutaneous endoscopic gastrostomy (PEG tube) PERLA pupils equal, reactive to light and accommodation PERRLA pupils equal, round, reactive to light and accommodation PICC peripherally inserted central catheter (IV line) PMH past medical history PMS pulse, movement, sensation PPE personal protective equipment prn as needed pt patient PT physical therapy PTA prior to arrival PTAA prior to ambulance arrival q every q.d each day q.i.d. four times a day q2h every two hours RLE right lower extremity RLL right lower lobe (of lung) ROM range of motion ROM rupture of membranes (pregnancy related) RN Registered Nurse R/O rule out RLQ right lower quadrant (abdomen)
Page 47 ABBREVIATIONS
RUQ right upper quadrant (abdomen) Rx prescription s without s/p status post SNF skilled nursing facility SNT soft, nontender SOA shortness of air SOB shortness of breath SQ subcutaneous STEMI ST elevation myocardial infarction Sx symptoms s/sx signs and symptoms sz seizure T temperature t.i.d. three times a day TKO to keep open (Example: "IV NS TKO") Tx treatment UA urinary analysis US ultrasound UTI urinary tract infection V-fib ventricular fibrillation V-Tach ventricular tachycardia WNL within normal limits wt weight y/o year old (Example: "42 y/o female...")
Page 48 UNDERSTANDING LAB VALUES AND VITALS
Understanding Lab Values and Vitals
• A lab value or vital sign reported as lower or higher than a normal range may not necessarily indicate a disorder, but: o It can help support medical necessity; therefore, a biller/coder needs to understand the normal values. o It can tell the story of what is going on with the patient and help to define their disease process. o Provide information to help a biller/coder to decide the appropriate diagnosis.
Blood Pressure • When measuring blood pressure, your doctor or nurse will use a stethoscope to listen to the blood moving through an artery. • The cuff is inflated to a pressure that’s known to be higher than your systolic blood pressure. As the cuff deflates, the first sound heard through the stethoscope is the systolic blood pressure. It sounds like a whooshing noise. When this noise goes away, that indicates the diastolic blood pressure. • The systolic blood pressure number is always said first, and then the diastolic blood pressure number is given. For example, your blood pressure may be read as "120 over 80" or written as 120/80. • Blood pressure is measured in millimeters of mercury (mm Hg).
http://www.webmd.com/hypertension -high-blood-pressure/guide/diastolic-and-systolic-blood-pressure-know-your-numbers
Page 49 UNDERSTANDING LAB VALUES AND VITALS
What can the Blood Pressure tell a biller/coder?
Pulse Ox A procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).
http://www.hopkinsmedicine.org/healthlibrary/test_procedures/pulmonary/oximetry_92,P07754/ What can the Pulse Oximetry tell a biller/coder?
Blood Glucose Test • Is a way of testing the concentration of glucose in the blood (glycemia). • A blood glucose test is performed by piercing the skin (typically, on the finger) to draw blood, then applying the blood to a chemically active disposable 'test-strip'.
Page 50 UNDERSTANDING LAB VALUES AND VITALS
• Different manufacturers use different technology, but most systems measure an electrical characteristic, and use this to determine the glucose level in the blood. • The test is usually referred to as capillary blood glucose.
https://en.wikipedia.org/wiki/Blood_glucose_monitoring
What can the Blood Glucose Test tell a biller/coder?
ETCO2(End-Tidal CO2) • The level of carbon dioxide released at the end of an exhaled breath (expiration). • Carbon dioxide (CO2) reflects cardiac output and pulmonary blood flow as the gas is transported by the venous system to the heart and then pumped to the lungs. • Carbon dioxide concentration reaches a maximum at the end of exhalation. • When carbon dioxide diffuses out of the lungs into the exhaled air, the partial pressure or maximal concentration of the gas at the end of exhalation can be measured.
What can the ETCO2 Test tell a biller/coder? • A high ETCO2 reading in a patient with altered mental status or severe difficulty breathing may indicate hypoventilation and a possible need for the patient to be intubated. • Low ETCO2 readings on patients may indicate hyperventilation.
Page 51 UNDERSTANDING LAB VALUES AND VITALS
https://en.wikipedia.org/wiki/Capnography
Heart Rate
The heart rate, or pulse, is the number of times your heart beats per minute.
What can the Heart Rate tell a biller/coder?
https://en.wikipedia.org/wiki/Heart_rate
Hemoglobin • Protein in red blood cells that carries oxygen • Each red blood cell contains several hundred thousand hemoglobin molecules, which transport oxygen. Normal values: Male: 13.8 to 17.2 gm/dL Female: 12.1 to 15.1 gm/dL Note: gm/dL = grams per deciliter What can the Hemoglobin Test tell a biller/coder? • Low hemoglobin could indicate anemia. o Signs and Symptoms: pale skin, weakness, SOB, fainting, palpitations, chest pain, and restless leg syndrome
Page 52 UNDERSTANDING LAB VALUES AND VITALS
• High hemoglobin could indicate a lung disease, bone marrow disorders, overdose or inappropriate use of the drug epoetin alpha.
Hematocrit (Hct) • Number and size of red blood cells • Performed due to anemia, diet deficiency, and leukemia. Normal values: Male: 40.7-50.3% Female: 36.1-44.3% What can the Hematocrit Test tell a biller/coder?
• Low hematocrit could indicate anemia, bleeding, leukemia, malnutrition, iron, folate, B12 & B6 deficiency, or over-hydration. • High hematocrit could be a sign of right-sided heart failure, dehydration, hypoxia, pulmonary fibrosis, bone marrow disease and congenital heart disease.
Page 53 MEDICATIONS
Medications
Medication can help a biller/coder to recognize a patient that has a certain condition, such insulin for diabetes, or a patient on tamoxifen for breast cancer. Billing learns important information from medications taken by the patients and can: o Help a biller/coder to look for certain conditions and procedures. o Understand some of the signs and symptoms. Important Terms Interosseous-Percutaneous placement of an intravenous catheter into a marrow cavity provides an alternative route for the administration of fluids and medication when peripheral blood vessels are collapsed or inaccessible. For EMS purposes, the proximal tibia or the humerus are the most frequently used sites. Intramuscular-Within a muscle. Intranasal-Taken by Nose. NTG-Used for the prophylaxis and treatment of angina pectoris, the treatment of congestive heart failure and myocardial infarction Oral-Taken by mouth. Subcutaneous-Located, found, or placed just beneath the skin; hypodermic. Sublingual-Refers to the pharmacological route of administration by which drugs diffuse into the blood through tissues under the tongue. Intravenous-Is the infusion of liquid substances directly into a vein IV Bolus-A large volume of fluid or dose of a drug given intravenously and rapidly at one time. IV Drip or Infusion-It is commonly referred to as a drip because many systems of administration employ a drip chamber, which prevents air from entering the blood stream (air embolism), and allows an estimation of flow rate.
Page 54 MEDICATIONS
IV Push -Method of quickly injecting medications into a vein. Number of Dosages-The amount of a therapeutic agent administered. Routes-Is the path by which a drug, fluid, poison, or other substance is taken into the body.
Page 55 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
Symptoms, Signs and Abnormal Clinical Laboratory Findings
In medicine a symptom is generally subjective while a sign is objective.
SIGN Is a disease observed by the doctor, nurse, family members and the patient, such as blood in the stool, a skin rash.
SYMPTOM However, stomach, lower-back pain, fatigue, for example, can only be detected or sensed by the patient - others only know about it if the patient tells them.
Light headache - this can only be a symptom. • A light headache can only be a symptom because it is only ever detected by the patient.
High blood sugar - this can only be a sign • High blood sugar can only be a sign because the patient cannot detect it; it can only be measured in a medical laboratory.
ICD-10-CM 1. Consist of codes for cases when more specific diagnosis cannot be made even after all the facts bearing the case have been investigated; and 2. Signs and symptoms existing at the time of the encounter that proved to be the reason for the encounter. Many signs and symptoms are grouped by body part or relevant group. In ambulance transports, code the sign and symptom diagnosis that is the reason for transport and use any additional codes to support the need for the transport.
Page 56 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
In ICD-10 coding guidelines, it is acceptable to use signs and symptoms when a definitive diagnosis cannot be determined, which often times is the case with emergency transports. If signs and symptoms are used, it’s a good rule to document in the narrative box 19 on the CMS claim form. If a more precise diagnosis is available, refer to your payor guidelines when coding. PAIN Pain is the reason for the transport. Acute onset or bed-confining. Pain is severity of 7–10 on 10-point severity scale despite pharmacologic intervention. Patient needs specialized handling to be moved. Other emergency conditions are present or reasonably suspected. Signs of other life- or limb-threatening conditions are present. Associated cardiopulmonary, neurologic, or peripheral vascular signs and symptoms are present.
Page 57 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
ICD-10 Code Code Description
R52 Pain unspecified
FEVER Significantly high fever unresponsive to pharmacologic intervention. Adult >102 F after pharmacologic intervention. Child > 104 F after pharmacologic intervention. ICD-10 Code Code Description
R50.81 Fever presenting with other conditions
R50.82 Post procedural fever
R50.83 Post vaccination fever
R50.9 Fever unspecified
HYPOTHERMIA
A disorder characterized by an abnormally low body temperature. Treatment is required when the body temperature is 35c (95f) or below. Abnormal low body temperature Abnormally low body temperature. Treatment is required when the body temperature is 35c (95f) or below. Symptoms include decreased mental function, lethargy, and disorientation.
ICD-10 Code Code Description
R68.0 Hypothermia not associated with weather
Page 58 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
OTHER MALAISE AND FATIGUE
A disorder characterized by a feeling of general discomfort or uneasiness, an out-of- sorts feeling.
A feeling of general discomfort or uneasiness, an out-of-sorts feeling.
A mental disorder characterized by chronic fatigue and concomitant physiologic symptoms.
Malaise: a vague feeling of physical discomfort or apprehension.
The property of lacking physical or mental strength; liability to failure under pressure or stress or strain.
ICD-10 Code Code Description
R53.81 Other malaise
R53.83 Other fatigue
R53.1 Weakness
Page 59 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
OTHER GENERAL SYMPTOMS
ABNORMALITIES OF MOVEMENT Disorders characterized by lack of coordination of muscle movements resulting in the impairment or inability to perform voluntary activities. Impairment of the ability to coordinate the movements required for normal ambulation (walking), which may result from impairments of motor function or sensory feedback.
ICD-10 Code Code Description
R26.0 Ataxia gait
Page 60 SYMPTOMS, SIGNS AND ABNORMAL CLINICAL LABORATORY FINDINGS
R26.1 Paralytic gait
R26.89 Other abnormalities of gait and mobility
R26.9 Unspecified abnormalities of gait and mobility
R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
R29.6 Repeated falls
Page 61 GREAT RESOURCE
Great Resource
http://www.roadto10.org/action-plan/phase-2-train/common-codes-other/
Many of the examples were taken from the CMS website.
Page 62 CERTAIN INFECTIOUS AND PARASITIC DISEASES
Certain Infectious and Parasitic Diseases
Infections are grouped by Infections. o Sexual o Viral Hepatitis o Many of the codes have been expanded to reflect manifestations of the disease; and o Septicemia is replaced with Sepsis, ALL bloodstream infections are classified as Sepsis.
WHAT IS SEPSIS?
It is a life threatening system bloodstream infection, originating in the:
Urinary Tract Lungs GI Tract Surgical Wound
Page 63 DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR HEMORRHAGE
Diseases of Blood, Blood-Forming Organs or Hemorrhage
ANEMIA
Grouped by conditions
• Nutritional Anemias • Hemolytic Anemias • Aplastic and Other Anemias and Other Bone Marrow Failure Syndromes. • Coagulation Defects, Purpura and Other Hemorrhagic Conditions • Other Disorders of Blood Forming Organs. • Intraoperative and post procedural complications of the spleen. • Certain disorders involving the immune system.
HEMORRHAGE
Potentially life-threatening hemorrhage Uncontrolled bleeding Signs of shock and active severe bleeding (quantity identified) Ongoing or recent bleeding, with potential of immediate re-bleeding In ICD-9-CM, 459.0-Hemorrhage could be found in the Disease of the Circulatory System
ICD-10 Code Code Description
Page 64 DISEASES OF BLOOD, BLOOD-FORMING ORGANS OR HEMORRHAGE
R58 Hemorrhage, Not Elsewhere Classified
Page 65 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Endocrine, Nutritional and Metabolic Diseases
DIABETES MELLITUS
• Increased level of specificity • The diabetes mellitus codes are combination codes that includes: o The type of body system effected. o The complications affecting the body system. Diabetes Mellitus is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin. Insulin, a hormone released from the pancreas, controls the amount of sugar in the blood. It allows sugar to move from the blood into the cells. Once inside the cells, sugar is converted to energy.
Types: Type 1 • Formerly called insulin-dependent or juvenile-onset diabetes. • More than 90% of the insulin-producing cells of the pancreas are permanently destroyed. • The body does not produce enough insulin. • Most people with type I diabetes develop the disease before age 30. Type 2 • Formerly called non-insulin dependent diabetes or adult-onset diabetes. • The pancreas continues to produce insulin, sometimes even at higher than normal levels. • Body develops resistance to the effects of insulin, so there is not enough insulin to meet the body’s needs. • May occur in children and adolescents, but usually begins in people older than 30 and becomes progressively more common with age.
Page 66 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Drug or Chemical Induced Due to Underlying Condition Secondary Diabetes Gestational
No longer classified as controlled/uncontrolled • Only classified as diabetes with Hyperglycemia or Hypoglycemia. • Defined by out of control, inadequate control, or poorly controlled. • If Hypoglycemia it’s coded separately, or • Hyperglycemia maybe coded without diabetes. Complications: • What if any other body systems are affected by the diabetes condition? I.e. foot ulcer. Treatment: • Is the patient on Insulin?
CODING CHANGES
There are five (5) Diabetes Mellitus categories in the ICD-10-CM. They are:
• E08 Diabetes Mellitus due to an underlying condition • E09 Drug or chemical induced diabetes mellitus • E10 Type I diabetes mellitus • E11 Type 2 diabetes mellitus • E13 Other specified diabetes mellitus
Diabetes mellitus codes expanded to include the classification of the diabetes and the manifestation.
Page 67 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
ICD-10 Code Code Description
E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract
Page 68 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis
E08.621 Diabetes mellitus due to underlying condition with foot ulcer
E08.622 Diabetes mellitus due to underlying condition with other skin ulcer
E08.628 Diabetes mellitus due to underlying condition with other skin complications E08.630 Diabetes mellitus due to underlying condition with periodontal disease
E08.638 Diabetes mellitus due to underlying condition with other oral complications E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma
Page 69 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition without complications
E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy
E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
Page 70 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract
E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy E09.620 Drug or chemical induced diabetes mellitus with diabetic dermatitis
E09.621 Drug or chemical induced diabetes mellitus with foot ulcer
E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer
Page 71 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Drug or chemical induced diabetes mellitus with periodontal disease
E09.638 Drug or chemical induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia
E09.69 Drug or chemical induced diabetes mellitus with other specified complication E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus without complications
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
Page 72 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
Page 73 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E10.65 Type 1 diabetes mellitus with hyperglycemia
E10.69 Type 1 diabetes mellitus with other specified complication
E10.8 Type 1 diabetes mellitus with unspecified complications
E10.9 Type 1 diabetes mellitus without complications
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
Page 74 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
Page 75 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E11.8 Type 2 diabetes mellitus with unspecified complications
E11.9 Type 2 diabetes mellitus without complications
E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma
E13.10 Other specified diabetes mellitus with ketoacidosis without coma
E13.11 Other specified diabetes mellitus with ketoacidosis with coma
E13.21 Other specified diabetes mellitus with diabetic nephropathy
E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease
Page 76 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
Page 77 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
E13.8 Other specified diabetes mellitus with unspecified complications
E13.9 Other specified diabetes mellitus without complications
E16.1 Other hypoglycemia
E16.2 Hypoglycemia, unspecified
Page 78 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
O24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester O24.02 Pre-existing diabetes mellitus, type 1, in childbirth
O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, first trimester
O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, second trimester O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, third trimester O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.410 Gestational diabetes mellitus in pregnancy, diet controlled
O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419 Gestational diabetes mellitus in pregnancy, unspecified control
Page 79 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
O24.420 Gestational diabetes mellitus in childbirth, diet controlled
O24.424 Gestational diabetes mellitus in childbirth, insulin controlled
O24.429 Gestational diabetes mellitus in childbirth, unspecified control
O24.430 Gestational diabetes mellitus in the puerperium, diet controlled
O24.434 Gestational diabetes mellitus in the puerperium, insulin controlled
O24.439 Gestational diabetes mellitus in the puerperium, unspecified control
O24.811 Other pre-existing diabetes mellitus in pregnancy, first trimester
O24.812 Other pre-existing diabetes mellitus in pregnancy, second trimester
O24.813 Other pre-existing diabetes mellitus in pregnancy, third trimester
O24.819 Other pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.82 Other pre-existing diabetes mellitus in childbirth
O24.83 Other pre-existing diabetes mellitus in the puerperium
O24.911 Unspecified diabetes mellitus in pregnancy, first trimester
O24.912 Unspecified diabetes mellitus in pregnancy, second trimester
O24.913 Unspecified diabetes mellitus in pregnancy, third trimester
O24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimester
O24.92 Unspecified diabetes mellitus in childbirth
O24.93 Unspecified diabetes mellitus in the puerperium
Z79.4 Long term (current) use of insulin
Page 80 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
Z86.31 Personal history of diabetic foot ulcer
Z86.32 Personal history of gestational diabetes
HYPERGLYCEMIA
• High blood glucose happens when the body has too little insulin or when the body can’t use insulin properly. • Symptoms : • increased thirst o fatigue o nausea and vomiting o dry mouth o rapid heartbeat ICD-10 Code Description
R73.0 Abnormal glucose
R73.09 Other Abnormal glucose
HYPOGLYCEMIA
• Abnormally low levels of sugar (glucose) in the blood, usually less than 70 mg/dl. • Low levels of sugar in the blood interferes with the function of many organ systems. The brain is particularly sensitive to low sugar levels, because sugar is the brain’s major energy source. • Symptoms: o shakiness or nervousness o fatigue o sweating
Page 81 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
o hunger o nausea o irritability o irregular or racing heartbeat o difficulty speaking o confusion ICD-10 Code Description
E16.0 Drug induced hypoglycemia without coma
E16.1 Other hypoglycemia
E16.2 Hypoglycemia unspecified
HYPOGLYCEMIC COMA
• Life threatening complication that causes unconsciousness. • Diabetes, with either dangerously high blood sugar or dangerously low blood sugar, can lead to a diabetic coma. ICD-10 Code Description
E15 Nondiabetic hypoglycemic coma, includes drug-induced insulin coma in nondiabetic, includes hypoglycemic coma NOS
OBESITY
• Documentation should give the patient’s height/weight. • Any special handling and/or equipment used or the use of extra manpower should also be documented. • BMI > 80 (Morbid Obesity)
Page 82 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
ICD-10 Code Description
E66.3 Overweight
E66.8 Other obesity
E66.9 Obesity unspecified
VOLUME DEPLETION
Depletion of total body water.
ICD-10 Code Description
E86 Volume depletion
E86.0 Dehydration
E86.9 Volume depletion unspecified
HYPOVOLEMIA
Depletion of blood volume. Could be caused due to internal bleeding from intestine or stomach, external bleeding from injury or loss of blood volume and body fluid associated with diarrhea, vomiting, dehydration or burns.
Signs and symptoms: edema and ascites ICD-10 Code Description
E86.1 Hypovolemia (Depletion of volume of plasma
Page 83 ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES
DEHYDRATION
• Occurs when the body loses more water than it takes in. • Vomiting, diarrhea, the use of diuretics, profuse sweating, and decreased water intake can all lead to dehydration. • Symptoms include – thirst – reduced sweating – reduced skin elasticity – reduced urine production – and dry mouth ICD-10 Code Description
E86.0 Dehydration
Page 84 BEHAVIORAL HEALTH
Behavioral Health
BEHAVIORAL DOCUMENTATION
• Expressing active signs and/or symptoms of uncontrolled psychiatric condition or acute substance withdrawal. • Is a threat to self or others requiring restraint (chemical or physical). • Monitoring and/or intervention of trained medical personnel during transport for patient and crew safety. • Transport required by state law/court order. • Disorientation • Suicidal Ideations • Attempts and gestures • Hallucinations • Violent or disruptive behavior • DT’s • Drug withdrawal symptoms • Severe anxiety • Acute episode or exacerbation of paranoia
ANXIETY
Normal human emotion that everyone experiences at times. The symptoms vary widely but interfere significantly with normal functioning.
There are several types of anxiety disorders including:
Page 85 BEHAVIORAL HEALTH
• Mixed Anxiety • Panic disorder • Social Anxiety Disorder • Specific Phobias • Generalized Anxiety Disorder • Phobias • PTSD and Acute Stress Disorder • Anxiety caused by physiological or external causes • Separation Anxiety • Adjustment Disorder • Anxiety due to Substance ICD-10 Code Code Description
F06.4 Anxiety disorder due to known physiological condition
F40.00 Agoraphobia, unspecified
F40.01 Agoraphobia with panic disorder
F40.02 Agoraphobia without panic disorder
F40.10 Social phobia, unspecified
F40.11 Social phobia, generalized
F40.210 Arachnophobia
F40.218 Other animal type phobia
F40.220 Fear of thunderstorms
F40.228 Other natural environment type phobia
Page 86 BEHAVIORAL HEALTH
F40.230 Fear of blood
F40.231 Fear of injections and transfusions
F40.232 Fear of other medical care
F40.233 Fear of injury
F40.240 Claustrophobia
F40.241 Acrophobia
F40.242 Fear of bridges
F40.243 Fear of flying
F40.248 Other situational type phobia
F40.290 Androphobia
F40.291 Gynephobia
F40.298 Other specified phobia
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia
F41.1 Generalized anxiety disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
Page 87 BEHAVIORAL HEALTH
F42 Obsessive-compulsive disorder
F43.0 Acute stress reaction
F43.10 Post-traumatic stress disorder, unspecified
F43.11 Post-traumatic stress disorder, acute
F43.12 Post-traumatic stress disorder, chronic
F43.20 Adjustment disorder, unspecified
F43.21 Adjustment disorder with depressed mood
F43.22 Adjustment disorder with anxiety
F43.23 Adjustment disorder with mixed anxiety and depressed mood
F43.24 Adjustment disorder with disturbance of conduct
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct F43.29 Adjustment disorder with other symptoms
F51.02 Adjustment insomnia
F93.0 Separation anxiety disorder of childhood
R45.7 State of emotional shock and stress, unspecified
R46.6 Undue concern and preoccupation with stressful events
Z60.0 Problems of adjustment to life-cycle transitions
Z86.51 Personal history of combat and operational stress reaction
Page 88 BEHAVIORAL HEALTH
DELIRIUM
• Serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. • Delirium can be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.
Symptoms: • Reduced awareness of the environment – Inability to stay focused on a topic – Wandering attention – Being easily distracted by unimportant things • Poor thinking skills (cognitive impairment) – Poor memory, particularly of recent events – Difficulty speaking or recalling words – Difficulty understanding speech • Behavior changes – Seeing things that don’t exist (hallucinations) – Restlessness, agitation, irritability or combative behavior – Disturbed sleep habits
DEMENTIA
Symptoms
Memory impairment, difficulty with speech, difficulty with motor activity, difficulty identifying objects, and may have the inability to plan and organize.
Generally in older adults
ICD-10 Code Code Description
Page 89 BEHAVIORAL HEALTH
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F10.27 Alcohol dependence with alcohol-induced persisting dementia
F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia
F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia F13.97 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting dementia F18.17 Inhalant abuse with inhalant-induced dementia
F18.27 Inhalant dependence with inhalant-induced dementia
F18.97 Inhalant use, unspecified with inhalant-induced persisting dementia
F19.17 Other psychoactive substance abuse with psychoactive substance- induced persisting dementia F19.27 Other psychoactive substance dependence with psychoactive substance- induced persisting dementia F19.97 Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
Page 90 BEHAVIORAL HEALTH
G30.9 Alzheimer's disease, unspecified
R41.81 Age-related cognitive decline
ALCOHOL OR DRUG INTOXICATION
A pattern of abuse of alcohol, drugs, chemicals or external agents.
• Severe intoxication • Unable to care for self • Unable to ambulate • Altered level of consciousness
ALCOHOL WITHDRAWAL
Symptoms most often occur within 48-96 hours after the last drink. Symptoms can include: • Body tremors • Changes in mental function • Agitation, irritability • Confusion, disorientation • Decreased attention span • Delirium • Hallucinations • Quick mood changes • Restlessness, excitement • Sensitivity to light, sound, touch • Stupor, sleepiness, fatigue
Page 91 BEHAVIORAL HEALTH
ALCOHOL WITHDRAWAL DELIRIUM (AWD)
• Alcohol withdrawal delirium is the most serious form of alcohol withdrawal. It causes sudden and severe problems in the brain and nervous system. • Approximately 5% of hospital patients being treated for alcohol withdrawal also experience AWD. • AWD is also known as delirium tremens or DT’s.
Coding Changes
• ICD-9-CM subcategory 305.0, alcohol abuse, provides information on whether the pattern of alcohol use by the patient is continuous, episodic, in remission, or unspecified.
• The classification of continuous or episodic alcohol abuse or dependence is not found in ICD-10-CM. ICD-10 Code Description
F10.10 Alcohol abuse, uncomplicated
F10.120 Alcohol abuse with intoxication, uncomplicated
F10.121 Alcohol abuse with intoxication delirium
F10.129 Alcohol abuse with intoxication, unspecified
HALLUCINATIONS
• Involves seeing things while awake that appear to be real, but instead have been created by the mind. • Common hallucinations include: o Feeling bodily sensations, such as a crawling feeling on the skin.
Page 92 BEHAVIORAL HEALTH
o Hearing sounds, such as music or footsteps. o Hearing voices when no one has spoken. o Seeing patterns, lights, beings, or objects that aren’t there. o Smelling a foul or pleasant odor. ICD-10 Code Description
R44.2 Other hallucinations
R44.3 Hallucinations, unspecified
SCHIZOPHRENIA
Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others. People with schizophrenia — the most chronic and disabling of the major mental illnesses — often have problems functioning in society, at work, at school, and in relationships.
There are nearly 40 ICD-9-CM codes for Schizophrenia, but only 10 in ICD-10-CM. ICD-10 Code Description
F20.0 Paranoid schizophrenia
F20.1 Disorganized schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.5 Residual schizophrenia
F20.8 Other schizophrenia
Page 93 BEHAVIORAL HEALTH
F208.1 Schizophreniform disorder
F208.9 Other schizophrenia
F20.9 Schizophrenia, unspecified
F21 Schizotypal disorder
ALTERED LEVEL OF CONSCIOUSNESS • Any measure of arousal other than normal. • Level of consciousness (LOC) is a measurement of a person’s arousability and responsiveness to stimuli from the environment. • Severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep is lethargy. • State similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states is obtunded. • Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state. • Coma is a state of unarousable unresponsiveness. • Acute condition with Glasgow Coma Scale < 15. • Transient symptoms of dizziness. • Associated with neurologic or cardiovascular symptoms and/or signs. • Abnormal vital signs
GLASGOW COMA SCALE (GCS) • Neurological scale of recording the conscious state of a person.
Page 94 BEHAVIORAL HEALTH
Severe, with GCS < 8–9 Moderate, GCS 8 or 9–12 Minor, GCS ≥ 13.
Comma Scale ICD-10-CM-NEW
The scale below will be used by most other health care providers not EMS in an emergency situation; however, in non-emergency this code may be used if the Coma Scale is going to be utilized from another healthcare provider.
Page 95 BEHAVIORAL HEALTH
When a GCS is taken by the EMS provider the following ICD-10-CM codes can be utilized if needed or required by the payor.
R40.241 Glasgow Coma Scale score 13-15
R40.242 Glasgow Coma Scale score 9-12
R40.243 Glasgow Coma Scale score 3-8
When a Glasgow Coma Scale score is not documented and the patient is in a coma, or when only a partial score is reported, assign code:
R40.244, Other coma, without documented Glasgow coma scale score, or with partial score reported.
Page 96 BEHAVIORAL HEALTH
Primarily used for registries and research use and never should be used as a primary diagnosis. When the total score is provided, then per coding guidelines the ICD-10-CM code R40.241-R40.243 should be used, R40.21, R40.22 and R40.23 is to only be used when the total GCS is not available.
ICD-10 Code Description
R40.20 Unspecified coma
R40.0 Somnolence
R40.1 Stupor
R40.3 Persistent vegetative
R41.0 Disorientation, unspecified
R41.81 Age related cognitive decline
R41.82 Altered mental status, unspecified
R41.89 Other symptoms and signs of cognitive functions and awareness
R41.9 Unspecified symptoms involving cognitive functions and awareness
Page 97 DISEASES OF THE NERVOUS SYSTEM
Diseases of the Nervous System
SLEEP DISORDERS
Coding Changes
• Are now in the Disease of the Nervous System instead of Signs and Symptoms.
ALTIZHIMERS
Coding Changes
• Now reflects onset versus late effects.
EPILEPSY
Epilepsy is a disorder that results from the surges in electrical signals inside the brain, causing recurring seizures. Seizure symptoms vary. Some people with epilepsy simply stare blankly for a few seconds during a seizure, while others have convulsions where a person’s muscles contract and relax repeatedly.
Coding Changes
Terminology
• Localization-related to idiopathic • Generalized idiopathic • Special epileptic syndromes Provide Specificity for:
• Seizures of localized onset
• Complex partial seizures
• Intractable
Page 98 DISEASES OF THE NERVOUS SYSTEM
• Status epilepticus
– A continuous series of generalized tonic-clonic seizure without return of consciousness, or any prolonged series of similar seizures without return to full consciousness between them.
ICD-10 Code Description Code F44.5 Conversion disorder with seizures or convulsions
G40.001 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, with status epilepticus G40.009 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, not intractable, without status epilepticus G40.011 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with status epilepticus G40.019 Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus G40.101 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus G40.109 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus G40.111 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus G40.119 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus G40.201 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus
Page 99 DISEASES OF THE NERVOUS SYSTEM
G40.209 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus G40.211 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, with status epilepticus G40.219 Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus G40.309 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus G40.401 Other generalized epilepsy and epileptic syndromes, not intractable, with status epilepticus G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus G40.501 Epileptic seizures related to external causes, not intractable, with status epilepticus G40.509 Epileptic seizures related to external causes, not intractable, without status epilepticus G40.801 Other epilepsy, not intractable, with status epilepticus
G40.802 Other epilepsy, not intractable, without status epilepticus
G40.803 Other epilepsy, intractable, with status epilepticus
G40.804 Other epilepsy, intractable, without status epilepticus
Page 100 DISEASES OF THE NERVOUS SYSTEM
G40.811 Lennox-Gastaut syndrome, not intractable, with status epilepticus
G40.812 Lennox-Gastaut syndrome, not intractable, without status epilepticus
G40.813 Lennox-Gastaut syndrome, intractable, with status epilepticus
G40.814 Lennox-Gastaut syndrome, intractable, without status epilepticus
G40.821 Epileptic spasms, not intractable, with status epilepticus
G40.822 Epileptic spasms, not intractable, without status epilepticus
G40.823 Epileptic spasms, intractable, with status epilepticus
G40.824 Epileptic spasms, intractable, without status epilepticus
G40.89 Other seizures
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G40.A01 Absence epileptic syndrome, not intractable, with status epilepticus
G40.A09 Absence epilehallptic syndrome, not intractable, without status epilepticus G40.A11 Absence epileptic syndrome, intractable, with status epilepticus
G40.A19 Absence epileptic syndrome, intractable, without status epilepticus
G40.B01 Juvenile myoclonic epilepsy, not intractable, with status epilepticus
G40.B09 Juvenile myoclonic epilepsy, not intractable, without status epilepticus
Page 101 DISEASES OF THE NERVOUS SYSTEM
G40.B11 Juvenile myoclonic epilepsy, intractable, with status epilepticus
G40.B19 Juvenile myoclonic epilepsy, intractable, without status epilepticus
G83.84 Todd's paralysis (postepileptic)
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions
PARALYSIS
• Dominant • Non-Dominant • Unspecified
Hemiplegia Category (G81) – Monoplegia Category (G83.3)
If documentation does not define dominant or non-dominant: • Ambidextrous, the default is dominant • Left Side, the default is non-dominant • Right Side, the default is dominant
SEIZURES
• Physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. • The term “seizure” is often used interchangeably with “convulsion”. • Convulsions occur when a person’s body shakes rapidly and uncontrollably. • Some seizures only cause a person to have staring spells. These may go unnoticed.
Symptoms depend on what part of the brain is involved. They may include:
Page 102 DISEASES OF THE NERVOUS SYSTEM
• Brief blackout followed by a period of confusion
• Drooling or frothing at the mouth
• Eye movements
• Grunting and snorting
• Loss of bladder or bowel control
• Shaking of entire body
• Tasting a bitter or metallic flavor
• Teeth clenching
• Uncontrollable muscle spasms with twitching and jerking limbs.
Conditions include:
• New onset or untreated seizures
• Significant change in baseline control of seizure activity
• Ongoing seizure activity
• Post-ictal neurologic dysfunction
ICD-10 Code Code Description
R56.00 Simple febrile convulsions
R56.01 Complex febrile convulsions
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions
Page 103 DISEASES OF THE NERVOUS SYSTEM
TRANSICHEMIC ATTACK (TIA) • When blood flow to part of the brain stops for a brief period of time. • A person will have stroke like symptoms up to 24 hours, but in most cases for 1-2 hours.
CEREBROVASCULAR ACCIDENT (CVA)
• A stroke occurs when blood flow to a part of the brain stops. • If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. • Brain cells can die, causing lasting damage. • This can lead to complete or partial loss of function in the area of the body that is controlled by the part of the brain that is damaged.
Terms of Cerebrovascular System • Frontal lobe-conscious thought; damage can result in mood changes, social differences, etc. The frontal lobes are the most uniquely human of all the brain structures. • Parietal lobe-plays important roles in integrating sensory information from various senses, and in the manipulation of objects; portions of the parietal lobe are involved with visuospatial processing. • Occipital lobe-sense of sight; lesions can produce hallucinations
Page 104 DISEASES OF THE NERVOUS SYSTEM
• Temporal lobe-senses of smell and sound, as well as processing of complex stimuli like faces and scenes. • Limbic lobe-emotion, memory. • Insular cortex-pain, some other senses.
Types of stroke: • Ischemic stroke o Occurs when an artery to the brain is blocked. The brain depends on its arteries to bring fresh blood from the heart and lungs. o Is site specific by artery • Intracerebral hemorrhage o Occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain. (The name means within the cerebrum or brain) o Specified by location in the brain. • Subarachnoid hemorrhage o Bleeding in the space between the brain and the surrounding membrane (subarachnoid space). o Specified by specific artery in the brain causing the hemorrhage
Symptoms of a Stroke
• Sudden weakness or paralysis of an arm, a leg, or one side of the body.
• Sudden dimness or loss of vision, particularly in one eye.
• Sudden confusion, with difficulty speaking and understanding speech.
• Loss of balance and coordination, leading to falls.
• Sudden severe headache with no apparent cause.
Page 105 DISEASES OF THE NERVOUS SYSTEM
• Abnormal sensations or loss of sensation in an arm or a leg or on one side of the body.
CODING CHANGES
Identifies various forms of CVA’s. Cerebral hemorrhage Infraction due to thrombosis Embolism or Unspecified occlusion or stenosis in the cerebral vessel. Sequela of Cerebrovascular Disease (Late Effects in ICD-9-CM)
• Conditions classifiable to categories I60-I67 as the cause of sequelae (neurologic deficits) which are classified elsewhere. • Identified by type of stroke o Hemorrhage or infarction • The symptoms persist after the initial cerebrovascular disease. • May arise at any time after the onset of the disease.
ICD-10 Code Description Code R42 Dizziness and giddiness
R20.8 Other disturbances of skin sensation
R20.9 Unspecified disturbance of skin sensations
R51 Headache
R29.5 Transient paralysis
Page 106 DISEASES OF THE NERVOUS SYSTEM
R29.810 Facial weakness
R29.90 Unspecified signs and symptoms involving the nervous system
R47.01 Aphasia
R47.02 Dysphasia
R47.81 Slurred speech
R47.89 Other speech disturbances
MIGRANES
Must include documentation of: • Intractable (pharmacologically or treatment resistant, medically and poorly controlled) • Not Intractable • With/Without Status of Migrainosus • With Vomiting, etc. Status of Migrainosus-Is having visions changes, nausea, vomiting, and difficulty thinking.
ICD-10 Code Description Code G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus
Page 107 DISEASES OF THE NERVOUS SYSTEM
G45.0 Vertebro-basilar artery syndrome
G45.1 Carotid artery syndrome (hemispheric)
G45.2 Multiple and bilateral precerebral artery syndromes
G45.8 Other transient cerebral ischemic attacks and related syndromes
G45.9 Transient cerebral ischemic attack, unspecified
G46.3 Brain stem stroke syndrome
G46.4 Cerebellar stroke syndrome
G97.51 Postprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure G97.52 Postprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery I60.11 Nontraumatic subarachnoid hemorrhage from right middle cerebral artery I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral artery
I60.20 Nontraumatic subarachnoid hemorrhage from unspecified anterior communicating artery I60.21 Nontraumatic subarachnoid hemorrhage from right anterior communicating artery I60.22 Nontraumatic subarachnoid hemorrhage from left anterior communicating artery I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery
Page 108 DISEASES OF THE NERVOUS SYSTEM
I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating artery I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating artery I60.4 Nontraumatic subarachnoid hemorrhage from basilar artery
I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral artery
I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral artery
I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial arteries
I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery I60.8 Other nontraumatic subarachnoid hemorrhage
I60.9 Nontraumatic subarachnoid hemorrhage, unspecified
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical
I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
I61.3 Nontraumatic intracerebral hemorrhage in brain stem
I61.4 Nontraumatic intracerebral hemorrhage in cerebellum
I61.5 Nontraumatic intracerebral hemorrhage, intraventricular
I61.6 Nontraumatic intracerebral hemorrhage, multiple localized
I61.8 Other nontraumatic intracerebral hemorrhage
I61.9 Nontraumatic intracerebral hemorrhage, unspecified
Page 109 DISEASES OF THE NERVOUS SYSTEM
I62.00 Nontraumatic subdural hemorrhage, unspecified
I62.01 Nontraumatic acute subdural hemorrhage
I62.02 nontraumatic subacute subdural hemorrhage
I62.03 Nontraumatic chronic subdural hemorrhage
I62.1 Nontraumatic extradural hemorrhage
I62.9 Nontraumatic intracranial hemorrhage, unspecified
I63.00 Cerebral infarction due to thrombosis of unspecified precerebral artery
I63.011 Cerebral infarction due to thrombosis of right vertebral artery
I63.012 Cerebral infarction due to thrombosis of left vertebral artery
I63.019 Cerebral infarction due to thrombosis of unspecified vertebral artery
I63.02 Cerebral infarction due to thrombosis of basilar artery
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.039 Cerebral infarction due to thrombosis of unspecified carotid artery
I63.09 Cerebral infarction due to thrombosis of other precerebral artery
I63.10 Cerebral infarction due to embolism of unspecified precerebral artery
I63.111 Cerebral infarction due to embolism of right vertebral artery
I63.112 Cerebral infarction due to embolism of left vertebral artery
I63.119 Cerebral infarction due to embolism of unspecified vertebral artery
Page 110 DISEASES OF THE NERVOUS SYSTEM
I63.12 Cerebral infarction due to embolism of basilar artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.139 Cerebral infarction due to embolism of unspecified carotid artery
I63.19 Cerebral infarction due to embolism of other precerebral artery
I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries I63.211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries I63.212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries I63.219 Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries I63.239 Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries I63.29 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery
I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery
I63.319 Cerebral infarction due to thrombosis of unspecified middle cerebral artery I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery
Page 111 DISEASES OF THE NERVOUS SYSTEM
I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery
I63.329 Cerebral infarction due to thrombosis of unspecified anterior cerebral artery I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery
I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery
I63.339 Cerebral infarction due to thrombosis of unspecified posterior cerebral artery I63.341 Cerebral infarction due to thrombosis of right cerebellar artery
I63.342 Cerebral infarction due to thrombosis of left cerebellar artery
I63.349 Cerebral infarction due to thrombosis of unspecified cerebellar artery
I63.39 Cerebral infarction due to thrombosis of other cerebral artery
I63.40 Cerebral infarction due to embolism of unspecified cerebral artery
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle cerebral artery
I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery
I63.421 Cerebral infarction due to embolism of right anterior cerebral artery
I63.422 Cerebral infarction due to embolism of left anterior cerebral artery
I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery I63.431 Cerebral infarction due to embolism of right posterior cerebral artery
I63.432 Cerebral infarction due to embolism of left posterior cerebral artery
I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery
Page 112 DISEASES OF THE NERVOUS SYSTEM
I63.441 Cerebral infarction due to embolism of right cerebellar artery
I63.442 Cerebral infarction due to embolism of left cerebellar artery
I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery
I63.49 Cerebral infarction due to embolism of other cerebral artery
I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I63.519 Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery I63.529 Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery I63.539 Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery I63.549 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
Page 113 DISEASES OF THE NERVOUS SYSTEM
I63.8 Other cerebral infarction
I63.9 Cerebral infarction, unspecified
I67.81 Acute cerebrovascular insufficiency
I67.82 Cerebral ischemia
I69.30 Unspecified sequela of cerebral infarction
I69.31 Cognitive deficits following cerebral infarction
I69.320 Aphasia following cerebral infarction
I69.321 Dysphasia following cerebral infarction
I69.322 Dysarthria following cerebral infarction
I69.323 Fluency disorder following cerebral infarction
I69.328 Other speech and language deficits following cerebral infarction
I69.331 Monoplegia of upper limb following cerebral infarction affecting right dominant side I69.332 Monoplegia of upper limb following cerebral infarction affecting left dominant side I69.333 Monoplegia of upper limb following cerebral infarction affecting right non-dominant side I69.334 Monoplegia of upper limb following cerebral infarction affecting left non- dominant side I69.339 Monoplegia of upper limb following cerebral infarction affecting unspecified side I69.341 Monoplegia of lower limb following cerebral infarction affecting right dominant side I69.342 Monoplegia of lower limb following cerebral infarction affecting left dominant side I69.343 Monoplegia of lower limb following cerebral infarction affecting right non-dominant side
Page 114 DISEASES OF THE NERVOUS SYSTEM
I69.344 Monoplegia of lower limb following cerebral infarction affecting left non- dominant side I69.349 Monoplegia of lower limb following cerebral infarction affecting unspecified side I69.351 Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side I69.352 Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side I69.353 Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I69.359 Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side I69.361 Other paralytic syndrome following cerebral infarction affecting right dominant side I69.362 Other paralytic syndrome following cerebral infarction affecting left dominant side I69.363 Other paralytic syndrome following cerebral infarction affecting right non-dominant side I69.364 Other paralytic syndrome following cerebral infarction affecting left non- dominant side I69.365 Other paralytic syndrome following cerebral infarction, bilateral
I69.369 Other paralytic syndrome following cerebral infarction affecting unspecified side I69.390 Apraxia following cerebral infarction
I69.391 Dysphagia following cerebral infarction
I69.392 Facial weakness following cerebral infarction
I69.393 Ataxia following cerebral infarction
I69.398 Other sequela of cerebral infarction
I97.810 Intraoperative cerebrovascular infarction during cardiac surgery
Page 115 DISEASES OF THE NERVOUS SYSTEM
I97.811 Intraoperative cerebrovascular infarction during other surgery
I97.820 Postprocedural cerebrovascular infarction during cardiac surgery
I97.821 Postprocedural cerebrovascular infarction during other surgery
O87.3 Cerebral venous thrombosis in the puerperium
O99.411 Diseases of the circulatory system complicating pregnancy, first trimester
O99.412 Diseases of the circulatory system complicating pregnancy, second trimester O99.413 Diseases of the circulatory system complicating pregnancy, third trimester O99.419 Diseases of the circulatory system complicating pregnancy, unspecified trimester O99.42 Diseases of the circulatory system complicating pregnancy, childbirth
O99.43 Diseases of the circulatory system complicating pregnancy, puerperium
R51 Headache
Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
PAIN
When pain is coding from the nervous system chapter, then signs and symptoms from psychological factors should be included.
Page 116 DISEASES OF THE NERVOUS SYSTEM
ICD-10 Code Code Description
G89 Pain, not elsewhere classified
G89.11 Acute pain, not elsewhere classified-Acute pain due to trauma
G89.12 Acute pain, not elsewhere classified-Acute post-thoracotomy pain
G89.18 Acute pain, not elsewhere classified-Other acute post-procedural pain G89.21 Chronic pain, not elsewhere classified-Chronic pain due to trauma
Page 117 DISEASES OF THE NERVOUS SYSTEM
G89.22 Chronic pain, not elsewhere classified-Chronic post-thoracotomy pain G89.28 Chronic pain, not elsewhere classified-Other chronic post- procedural pain
Page 118 DISEASES OF THE CIRCULATORY SYSTEM
Diseases of the Circulatory System
The circulatory system is an organ system that permits blood and lymph circulation to transport nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones, blood cells, etc. to and from cells in the body to nourish it and help to fight diseases, stabilize body temperature and pH, and to maintain homeostasis.
The circulatory system is made up of the heart and blood vessels.
CARDIAC TERMS
• Right Atrium o Receives oxygen-poor blood from the body. • Right Ventricle o Contracts to pump oxygen-poor blood along the pulmonary arteries to the lungs. • Left Atrium o Receives oxygen rich blood from the pulmonary veins. • Left Ventricle o Contracts to pump oxygen rich blood along the aorta to the body • Pulmonary veins o Return oxygenated blood from each lung to the left atrium of the heart. • Superior Vena Cava o The second largest vein in the human body. Moves blood from the upper half of the body to the heart. • Tricuspid Valve
Page 119 DISEASES OF THE CIRCULATORY SYSTEM
o Separates the right atrium and right ventricle, allowing blood to enter the ventricle but not flow back to the atrium. • Inferior Vena Cava o Largest vein in the human body. It collects blood from the lower body and carries it to the heart. • Pulmonary Valve o Blood flows from the right ventricle through the pulmonic valve into the lungs. • Mitral Valve o Separates the left atrium and left ventricle. • Aortic Valve o Blood flows from the left ventricle to the aorta through the aortic valve.
• Right Coronary Artery
o Supplies blood to the right atrium, right ventricle, and bottom portion of the left ventricle and back of the septum.
• Left Anterior Descending Coronary Artery
o Supplies blood to the front and bottom of the left ventricle and the front of the septum.
• Circumflex Coronary Artery
o Supplies blood to the left atrium and the side and back of the left ventricle.
• Left Main Coronary Artery
o Divides into two branches: the circumflex artery and the left anterior descending artery.
Page 120 DISEASES OF THE CIRCULATORY SYSTEM
HYPERTENSION
An abnormal evaluation of systolic and/or diastolic blood pressure.
Conditions:
Essential, Benign, Malignant Hypertensive Heart and Chronic Kidney Disease Secondary Hypertension
Relationship:
Renal Pulmonary, etc.
Coding Changes • Deletion of the codes: benign, malignant and unspecified. • Hypertension table is no longer necessary. Essential (primary) hypertension I10
Includes: High blood pressure
Hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic)
I 1 0
Overview
Systolic-The top number, higher of the two numbers, measures the pressure in the arteries when the heart beats. (when the heart muscle contracts)
Page 121 DISEASES OF THE CIRCULATORY SYSTEM
Diastolic-The bottom number, lower of the two numbers, measures the pressure in the arteries between heartbeats (when the heart muscle is resting between beats and refilling with blood)
• Prehypertension: Systolic (120-139) or Diastolic (80-89) • High Blood Pressure (Stage 1): Systolic (140-159) or Diastolic (90-99) • High Blood Pressure (Stage 2): Systolic (160 or higher) or Diastolic (100 or higher) • Hypertensive Crisis: Systolic (Higher than 180) or Diastolic (Higher than 110) Uncontrolled-May be untreated hypertension or hypertension not responding to current therapeutic regimen.
Controlled-This diagnostic statement usually refers to an existing state of hypertension under control by therapy.
Standard commonly applied is that a sustained diastolic pressure above 90 mm Hg and a sustained systolic pressure above 140 mm Hg constitutes hypertension.
ICD-10 Code Code Description
H35.031 Hypertensive retinopathy, right eye
H35.032 Hypertensive retinopathy, left eye
H35.033 Hypertensive retinopathy, bilateral
H35.039 Hypertensive retinopathy, unspecified eye
I10 Essential (primary) hypertension
I11.0 Hypertensive heart disease with heart failure
I11.9 Hypertensive heart disease without heart failure
Page 122 DISEASES OF THE CIRCULATORY SYSTEM
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified I13.10 Hypertensivechronic kidney heartdisease and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or I13.11 Hypertensiveunspecified chronic heart kidney and chronic disease kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal I13.2 Hypertensivedisease heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I15.0 Renovascular hypertension
I15.1 Hypertension secondary to other renal disorders
I15.2 Hypertension secondary to endocrine disorders
I15.8 Other secondary hypertension
I15.9 Secondary hypertension, unspecified
I67.4 Hypertensive encephalopathy
O10.011 Pre-existing essential hypertension complicating pregnancy, first trimester O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester O10.013 Pre-existing essential hypertension complicating pregnancy, third trimester O10.019 Pre-existing essential hypertension complicating pregnancy, unspecified trimester O10.02 Pre-existing essential hypertension complicating childbirth
O10.03 Pre-existing essential hypertension complicating the puerperium
O10.111 Pre-existing hypertensive heart disease complicating pregnancy, first trimester
Page 123 DISEASES OF THE CIRCULATORY SYSTEM
O10.112 Pre-existing hypertensive heart disease complicating pregnancy, second trimester O10.113 Pre-existing hypertensive heart disease complicating pregnancy, third trimester O10.119 Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester O10.12 Pre-existing hypertensive heart disease complicating childbirth
O10.13 Pre-existing hypertensive heart disease complicating the puerperium O10.211 Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester O10.212 Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester O10.22 Pre-existing hypertensive chronic kidney disease complicating childbirth O10.23 Pre-existing hypertensive chronic kidney disease complicating the puerperium O10.311 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester O10.312 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth O10.33 Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium O10.411 Pre-existing secondary hypertension complicating pregnancy, first trimester O10.412 Pre-existing secondary hypertension complicating pregnancy, second trimester
Page 124 DISEASES OF THE CIRCULATORY SYSTEM
O10.413 Pre-existing secondary hypertension complicating pregnancy, third trimester O10.419 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester O10.42 Pre-existing secondary hypertension complicating childbirth
O10.43 Pre-existing secondary hypertension complicating the puerperium
O10.911 Unspecified pre-existing hypertension complicating pregnancy, first trimester O10.912 Unspecified pre-existing hypertension complicating pregnancy, second trimester O10.913 Unspecified pre-existing hypertension complicating pregnancy, third trimester O10.919 Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester O10.92 Unspecified pre-existing hypertension complicating childbirth
O10.93 Unspecified pre-existing hypertension complicating the puerperium O11.1 Pre-existing hypertension with pre-eclampsia, first trimester
O11.2 Pre-existing hypertension with pre-eclampsia, second trimester
O11.3 Pre-existing hypertension with pre-eclampsia, third trimester
O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester
HYPOTENTION
When blood pressure is too low, not enough blood reaches all parts of the body; as a result, cells do not receive enough oxygen and nutrients, and waste products are not adequately removed. Systolic: 90 or less Diastolic: 60 or less
Page 125 DISEASES OF THE CIRCULATORY SYSTEM
Symptoms • Dizziness or lightheadedness • Fainting (syncope) • Lack of concentration • Blurred vision • Nausea • Cold, clammy, pale skin • Rapid, shallow breathing • Fatigue • Depression • Thirst
ICD-10 Code Description Code I95.9 Hypotension
Page 126 DISEASES OF THE CIRCULATORY SYSTEM
ELEVATED BLOOD PRESSURE Elevated blood pressure reading Elevated blood pressure reading without diagnosis of hypertension (situation) Elevated blood-pressure reading without diagnosis of hypertension Elevated BP reading without HTN diagnosis Finding of increased blood pressure This category is to be used to record an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an isolated incidental finding. ICD-10 Code Description Code R03.0 Elevated Blood Pressure
ACUTE MYOCARDIAL INFARCTION (AMI)
Coding Changes
Timeframe: An AMI is now “acute” for 4 weeks from the time of incident versus 8 weeks with ICD-9. Episode of Care: ICD-10 does not capture episode of care. (E.g. initial, subsequent sequelae. Subsequent: Use a subsequent code if patient had an MI during the 4 weeks “acute period” of the original AMI.
Page 127 DISEASES OF THE CIRCULATORY SYSTEM
STEMI: ST Segment Elevation Myocardial Infarction
Non-STEMI: NON-ST Segment Elevation Myocardial Infarction
Coding Note
If NSTEMI evolves to STEMI, then a STEMI Code is used, if a STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded to STEMI.
Page 128 DISEASES OF THE CIRCULATORY SYSTEM
And LATERALY is USED
MI’s are now specified by artery causing MI
Right Coronary Left Circumflex
Left Main Artery Other Sights
Left Anterior Descending Unspecified Sites ICD-10 Code Code Description
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
Page 129 DISEASES OF THE CIRCULATORY SYSTEM
I23.0 Hemopericardium as current complication following acute myocardial infarction I23.1 Atrial septal defect as current complication following acute myocardial infarction I23.2 Ventricular septal defect as current complication following acute myocardial infarction I23.3 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction I23.7 Post infarction angina
I23.8 Other current complications following acute myocardial infarction
I25.2 Old myocardial infarction
ATHEROCLEROTIC HEART DISEASE
• Occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body and arteries become thick and stiff-sometimes restricting blood flow to the organs and tissues. • Healthy arteries are flexible and elastic, but over time, the walls in the arteries can harden. • Atherosclerosis is a specific type of arteriosclerosis but the terms are sometimes used interchangeably. • Refers to the buildup of fats, cholesterol and other substances in and on the artery walls (plaques), which can restrict blood flow. • Symptoms (atherosclerosis in heart arteries)
Page 130 DISEASES OF THE CIRCULATORY SYSTEM
o Chest pain or pressure (angina)
Coding Changes
Atherosclerotic Heart Disease with Angina Pectoris
Cause: Assumed to be atherosclerosis
Stability Stable Angina Pectoris or Unstable Angina Pectoris
Vessel: If known, which artery is involved and whether the artery is native or autologous.
Graft
Involvement: If appropriate, whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic. ICD-10 Code Code Description
I25.110 Atherosclerotic hearth disease of a native coronary artery with unstable angina I21.02 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina
ATRIAL FIBRILLATION AND FLUTTER
The two small upper chambers (atria) of the heart do not beat the way they should. Instead of beating in a normal pattern, the atria beat irregularly and too fast, quivering like a bowl of gelatin.
Symptoms • General fatigue • Rapid and irregular heartbeat • Fluttering or thumping in the chest
Page 131 DISEASES OF THE CIRCULATORY SYSTEM
• Dizziness • Shortness of breath and anxiety • Faintness or confusion • Fatigue when exercising • Sweating Location: Atrial, ventricular, supraventricular, etc.
Rhythm Name: Flutter, fibrillation, sick sinus syndrome.
Acuity: Acute, chronic, etc.
Cause: Hyperkalemia, hypertension, alcohol consumption, digoxin, etc.
ICD-10 Code Code Description
I48.0 Paroxysmal atrial fibrillations
I48.1 Persistent atrial fibrillation
I48.2 Chronic atrial fibrillation
I48.3 Typical atrial flutter
I48.4 Atypical atrial flutter
I48.91 Unspecified atrial fibrillation
I48.92 Unspecified atrial flutter
CARDIAC ARRHYTHMIAS
• Symptomatic or potentially life-threatening arrhythmia.
Necessary symptoms include: • Syncope or near syncope. • Chest pain and dyspnea.
Page 132 DISEASES OF THE CIRCULATORY SYSTEM
• Includes severe bradycardia or tachycardia. • Patients are expected to have conditions that require monitoring during and after transportation. ICD-10 Code Code Description
I49.01 Ventricular fibrillation
I49.02 Ventricular flutter
I49.1 Atrial premature depolarization
I49.2 Junctional premature depolarization
I49.3 Ventricular premature depolarization
I49.40 Unspecified premature depolarization
I49.49 Other premature depolarization
I49.5 Sick sinus syndrome
I49.8 Other specified cardiac arrhythmias
I49.9 Cardiac arrhythmia
Page 133 DISEASES OF THE CIRCULATORY SYSTEM
When to use I49.8
A prime example when an ICD-10-CM Codebook will be useful.
PALPITATIONS
Clinical Information A disorder characterized by an unpleasant sensation of irregular and/or forceful beating of the heart. A rapid or irregular heartbeat that a person can feel. An unpleasant sensation of irregular and/or forceful beating of the heart. Signs required include severe bradycardia or tachycardia (rate < 60 or > 120).
Page 134 DISEASES OF THE CIRCULATORY SYSTEM
When to use Bradycardia
When to use Tachycardia
When to Use Palpitations and Abnormal Heart Rate
Page 135 DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code Code Description
R00.0 Tachycardia unspecified
R00.1 Bradycardia unspecified
R00.2 Palpitations
R00.8 Other abnormalities of the heart beat
R00.9 Unspecified abnormalities of heart beat
HEART FAILURE
Congestive Heart Failure when fluids build up in various parts of the body in which the heart cannot pump enough blood to the rest of the body. Type of Heart Failure • Systolic Heart Failure: Heart muscle contracts with too little force, causing less oxygen-rich blood to be pumped (pumping problem). • Diastolic Heart Failure: Heart contracts normally, but ventricle walls don’t relax enough to let the chamber fill (filling problem). Symptoms • Shortness of breath • Persistent coughing or wheezing • Buildup of excess fluid in body tissues (edema)
Page 136 DISEASES OF THE CIRCULATORY SYSTEM
• Fatigue • Lack of appetite or nausea • Impaired thinking • Increased heart rate Conditions: Congestive heart failure Left/right heart failure Systolic/diastolic heart failure Cardiac arrest Failure related to hypertensive disease Acute and chronic heart failure Heart failure in pregnancy due to anesthesia Rheumatic heart failure Coding Changes
Acuity: Acute or Chronic
Decompensation=Chronic
Exacerbation=Acute
Type: Systolic or Diastolic
Page 137 DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code Description
I50.1 Left ventricular failure
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified
CARDIOMYOPATHY
Type: Dilated/congestive, obstructive or non-obstructive hypertrophic, etc.
Location: Endocarditis, right ventricle, etc.
Cause: Congenital, alcohol, etc.
Page 138 DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code Description
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.3 Endomyocardial disease
CHEST PAIN • Pain usually characterized as severe, tight, dull, crushing, substernal, epigastric, or left sided. • Associated pain of the jaw, left arm, neck, back
• GI symptoms (such as nausea or vomiting) • Arrhythmias • Palpitations • Difficulty breathing • Pallor • Diaphoresis • Alteration of consciousness
ICD-10 Code Description
R07.1 Chest pain on breathing
R07.2 Percordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
Page 139 DISEASES OF THE CIRCULATORY SYSTEM
R07.9 Chest pain unspecified
SYNCOPE AND COLLAPSE
• A disorder characterized by spontaneous loss of consciousness caused by insufficient blood supply to the brain. • A spontaneous loss of consciousness caused by insufficient blood supply to the brain. • A spontaneous loss of consciousness caused by insufficient blood to the brain. • A transient loss of consciousness and postural tone caused by diminished blood flow to the brain (i.e., brain ischemia). Presyncope refers to the sensation of lightheadedness and loss of strength that precedes a syncopal event or accompanies an incomplete syncope. • Extremely weak; threatened with syncope. • Fainting due to a sudden fall of blood pressure below the level required to maintain oxygenation of brain tissue. • Fainting usually happens when the blood pressure drops suddenly, causing a decrease in blood flow to the brain. Some causes of fainting include: o heat or dehydration o emotional distress o standing up too quickly o certain medicines o drop in blood sugar o heart problems • Loss of consciousness due to a reduction in blood pressure that is associated with an increase in vagal tone and peripheral vasodilation. ICD-10 Code Description
Page 140 DISEASES OF THE CIRCULATORY SYSTEM
R55 Syncope and collapse
PULMONARY EMBOLISM
• One or more pulmonary arteries in the lungs become blocked. • In most cases, pulmonary embolism is caused by blood clots that travel to the lungs from the legs or rarely other parts of the body. (DVT)
Common signs and symptoms • Shortness of breath • Chest Pain • Cough
Other signs and symptoms that can occur with PE • Leg pain or swelling, or both, usually in calf • Clammy or discolored skin • Excessive Sweating • Rapid or irregular heartbeat • Lightheadedness or dizziness
CARDIAC ARREST • Abrupt loss of heart function in a person who may or may not have diagnosed heart disease. • The term “heart attack” is often mistakenly used to describe cardiac arrest. While a heart attack may cause cardiac arrest and sudden death, the terms don’t mean the same thing. Coding Changes
Cardiac Arrest (427.5) Goes from 1 Code to 1 of 7 Codes.
Page 141 DISEASES OF THE CIRCULATORY SYSTEM
ICD-10 Code Description
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8 Cardiac arrest due to other underlying cardiac condition
I46.9 Cardiac arrest, cause unspecified
I97.120 Postprocedural cardiac arrest following cardiac surgery
I97.121 Postprocedural cardiac arrest following other surgery
I97.710 Intraoperative cardiac arrest during cardiac surgery
I97.711 Intraoperative cardiac arrest during other surgery
Page 142 DISEASES OF THE RESPIRATORY SYSTEM
Diseases of the Respiratory System
• The respiratory system draws oxygen into the body and removes carbon dioxide. • The body cells use oxygen to release the energy they need to live. Energy is released by a process called cell respiration. • This process also releases waste carbon dioxide, which has to be removed before it poisons the body. • The respiratory system consists of the lungs and the air passages that carry air to and from the lungs. • It works by drawing “fresh” air containing oxygen into the body and pushing out “stale” air containing carbon dioxide. • A person can never take a break from breathing. People breathe around 20,000 times a day because their cells need a constant supply of oxygen. Upper respiratory tract: Nose or nostrils, nasal cavity, mouth, throat (pharynx), and voice box (larynx). Lower respiratory tract: Windpipe (trachea) and within the lungs, the bronchi, bronchioles, and alveoli.
RESPIRATORY TERMS
• Mechanical Ventilation Clinically indicated for patient with apnea, acute respiratory failure and impending acute respiratory failure. Invasive mechanical ventilation pumps air into the patient’s lungs even where there is no attempt by the patient to breath on their own. • Nasopharyngeal Airway o Also known as an NPA, nasal trumpet (because of its flared end), or nose hose, a type of airway adjunct, is a tube that is designed to be inserted into the nasal passageway to secure an open airway.
Page 143 DISEASES OF THE RESPIRATORY SYSTEM
• Oral Airway o Is a medical device called an airway adjunct used to maintain or open a patient's airway. It does this by preventing the tongue from covering the epiglottis, which could prevent the person from breathing. • Endotracheal Intubation o Is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. • Kings Airway o Is an airway device is a disposable supraglottic airway and is reported to be the safest and most reliable disposable supraglottic airway tool alternative for emergency ventilation when direct laryngoscopy is not feasible or mask ventilation is deemed insufficient. • Continuous Positive Airway Pressure (CPAP’s) o A machine that increases air pressure in the throat so airway doesn't collapse when a person breathes in.
RESPIRATORY DOCUMENTATION
• Tachypnea • Labored respiration • Hypoxemia • Requiring oxygen administration • Require advanced airway management such as ventilator management • Apnea monitoring for possible intubation • Deep airway suctioning
Page 144 DISEASES OF THE RESPIRATORY SYSTEM
CODING CHANGES
ICD-10-CM codes are grouped by:
Upper and lower respiratory tract infections Diseases of the pleura and intraoperative Post-procedural complications; and Disorders of the respiratory system
ICD-9-CM ICD-10-CM Acute Anatomic site of infection Other Severity Pneumonia Cause Chronic Acute, other, then chronic
Mechanical Ventilation Complications
This was in the Complication Chapter of ICD-9-CM, it is now in the Disease of the Respiratory. ICD-10 Code Description
J95.00 Tracheostomy complications
J95.09 Other tracheostomy complications
J95.850 Mechanical complication of respirator
I95.851 Ventilator associated pneumonia
J95.859 Other complication of respirator ventilator
J95.89 Other post procedure complications and disorders of respiratory system, NEC
Page 145 DISEASES OF THE RESPIRATORY SYSTEM
ASTHMA
• Asthma is a chronic lung disease that inflames and narrows the airways. • Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. o The coughing often occurs at night or early in the morning. • Airways are tubes that carry air into and out of lungs. • People who have asthma have inflamed airways. o The inflammation makes the airways swollen and very sensitive. o The airways tends to react strongly to certain inhaled substances. o When the airways react, the muscles around them tighten. o This narrows the airways, causing less air to flow into the lungs. o The swelling also can worsen, making the airways even narrower. o Cells in the airways might make more mucus than usual. o Mucus is a sticky thick liquid that can further narrow the airways.
Page 146 DISEASES OF THE RESPIRATORY SYSTEM
Coding Changes
Stages of Asthma
Defined by the World Allergy Organization
Page 147 DISEASES OF THE RESPIRATORY SYSTEM
ICD-10 Code Code Description
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
Page 148 DISEASES OF THE RESPIRATORY SYSTEM
COPD
• Chronic obstructive pulmonary disease refers to a group of lung diseases that block airflow and make breathing difficult. • Emphysema and chronic bronchitis are the two most common conditions that make up COPD. • Chronic bronchitis is an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs. • Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed. • The main cause of COPD is tobacco smoking. However, in the developing world, COPD often occurs in women exposed to fumes from burning fuel for cooking and heating in poorly ventilated homes. Symptoms
• Shortness of breath
• Wheezing
• Chest tightness
• Having to clear the throat first thing in the morning due to excess mucus in the lungs.
• A chronic cough that produces sputum that may be clear, white, yellow or greenish.
• Blueness of the lips or fingernail beds (cyanosis).
• Frequent respiratory infections.
• Lack of energy.
• Unintended weight loss (in later stages).
Page 149 DISEASES OF THE RESPIRATORY SYSTEM
COPD Exacerbation • Acute exacerbation of chronic obstructive bronchitis and asthma • Uncomplicated cases • With acute lower respiratory tract infection • Acute exacerbation.
An acute exacerbation is not equivalent to an infection superimposed on a chronic condition.
An exacerbation may be triggered by an infection. ICD-10 Code Code Description
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
J42 Unspecified chronic bronchitis
J43.0 Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1 Panlobular emphysema
J43.2 Centrilobular emphysema
J43.8 Other emphysema
J43.9 Emphysema, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
Page 150 DISEASES OF THE RESPIRATORY SYSTEM
J98.3 Compensatory emphysema
PULMONARY EDEMA
Pulmonary edema is a condition caused by excess fluid in the lungs. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.
Symptoms include: Extreme shortness of breath. A feeling of suffocating or drowning. Wheezing or gasping for breath. Anxiety, restlessness or sense of apprehension. Cough that produces frothy sputum and may be tinged with blood. Chest pain if pulmonary edema is caused by heart disease. A rapid, irregular heartbeat (palpitations). Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around them. The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and difficulty breathing.
ICD-10 Code Code Description
J81.0 Acute pulmonary edema
J81.1 Chronic pulmonary edema
Page 151 DISEASES OF THE RESPIRATORY SYSTEM
PNEUMONIA
Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around them. The air sacs fill with fluid or pus, causing cough with phlegm or pus, fever, chills and difficulty breathing.
Symptoms • Cough that produces sputum • Chest pain • Chills • Fever • Shortness of breath ICD-10 Code Code Description
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
(Acute Pulmonary Insufficiency)
Type of lung failure resulting from many different disorders that cause fluid to accumulate in the lungs and oxygen levels in the blood to be too low. • This deprives the organs of the oxygen they need to function. • Typically occurs in people who are already critically ill or who have significant injuries.
Symptoms • Severe shortness of breath • Labored and unusually rapid breathing • Low blood pressure
Page 152 DISEASES OF THE RESPIRATORY SYSTEM
• Confusion and extreme tiredness ICD-10 Code Code Description
J80.0 Acute respiratory distress syndrome
HYPOXIA AND HYPERCAPNIA
Hypoxia A condition in which the body or a region of the body is deprived of adequate oxygen supply. Hypercapnia
A condition of abnormally elevated carbon dioxide (CO2) levels in the blood.
ICD-10 Code Code Description
R09.02 Hypoxemia
RESPIRATORY FAILURE
Respiratory Failure is a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide becomes dangerously high.
Symptoms • Cyanosis
Page 153 DISEASES OF THE RESPIRATORY SYSTEM
• Confusion • Sleepiness • Deep, rapid breathing • Deteriorating consciousness or unconsciousness • Arrhythmias ICD-10 Code Code Description
J96.00 Acute respiratory failure, unspecified with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
J96.02 Acute respiratory failure with hypercapnia
J96.10 Chronic respiratory failure, unspecified with hypoxia and hypercapnia
J96.11 Chronic respiratory failure with hypoxia
J96.12 Chronic respiratory failure with hypercapnia
J96.20 Acute and chronic respiratory failure, unspecified with hypoxia or hypercapnia J96.21 Acute and chronic respiratory failure with hypoxia
J96.22 Acute and chronic respiratory failure with hypercapnia
J96.90 Unspecified respiratory failure, unspecified with hypoxia or hypercapnia J96.91 Unspecified respiratory failure with hypoxia
J96.92 Unspecified respiratory failure with hypercapnia
RESPIRATORY ABNORMALITY
When the body is short of breath, it's hard or uncomfortable to take in the oxygen the body needs. A person may feel as if they are not getting enough air.
Page 154 DISEASES OF THE RESPIRATORY SYSTEM
Sometimes mild breathing problems are from a stuffy nose or hard exercise. But shortness of breath can also be a sign of a serious disease. If someone has trouble breathing, it is important to find out the cause.
ICD-10 Code Code Description
R06.00 Dyspnea, unspecified
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.3 Periodic breathing
R06.4 Hyperventilation
R06.82 Tachypnea, not elsewhere classified
R06.83 Snoring
R06.89 Other abnormalities of breathing
Page 155 DISEASES OF THE DIGESTIVE SYSTEM
Diseases of the Digestive System
Coding Changes • Hemorrhage is used for ulcers. • Bleeding is used for gastritis, duodenitis, diverticulosis and diverticulitis. • “Obstruction” is no longer an axis of classification. o ICD-9-CM . Acute Gastric Ulcer with hemorrhage and Obstruction. o ICD-10-CM . Acute Gastric Ulcer with Hemorrhage. • Complications of artificial openings, including colostomy, enterostomy and gastrostomy infections and malfunctions are all included in the digestive disease chapter. ICD-10 Code Code Description
K29.00 Acute gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.70 Gastritis, unspecified without bleeding
K56.69 Other intestinal obstruction
K92.2 Gastrointestinal hemorrhage, unspecified
J92.0 Hematemesis
J92.1 Melena
Page 156 DISEASES OF THE DIGESTIVE SYSTEM
J92.2 Gastrointestinal hemorrhage, unspecified
K92.81 Gastrointestinal muscositis
K92.89 Other specified diseases of the digestive system
K92.9 Disease of digestive system unspecified
ABDOMINAL PAIN
Location: Generalized, right upper quadrant, periumbilical, etc. Pain or Tenderness type: Colic, tenderness, rebound, etc. Documentation: Accompanied by other signs or symptoms Associated symptoms include nausea, vomiting, fainting. Associated signs include tender or pulsatile mass, distention, rigidity, rebound tenderness on exam, guarding.
ICD-10 Code Code Description
R10.0 Acute abdominal pain
R10.9 Unspecified abdominal pain
R10.11 Abdominal right upper quadrant pain
R10.12 Abdominal left upper quadrant pain
R10.31 Abdominal right lower quadrant pain
R10.32 Abdominal left lower quadrant pain
Page 157 DISEASES OF THE DIGESTIVE SYSTEM
R10.33 Periumbilical pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
R10.10 Upper abdominal pain, unspecified
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R19.07 Generalized intra-abdominal pelvic swelling, mass, and lump
R19.09 Other intra-abdominal pelvic swelling, mass and lump
R19.30 Abdominal rigidity, unspecified site
R10.819 Abdominal tenderness, unspecified site
R10.829 Rebound abdominal tenderness, unspecified sit
R10.817 Generalized abdominal tenderness
R10.827 Generalized rebound abdominal tenderness
R10.819 Abdominal tenderness, unspecified site
R10.829 Rebound abdominal tenderness, unspecified site
NAUSEA/VOMITING Expelling the contents of the stomach and the sensations associated with it. They are symptoms of an underlying disease or condition and not a specific illness.
Page 158 DISEASES OF THE DIGESTIVE SYSTEM
Nausea and Vomiting in an emergency situation should have other contraindications, such as: vomited for longer than 24 hours blood in the vomit severe abdominal pain headache and stiff neck signs of dehydration, such as dry mouth, infrequent urination or dark urine
ICD-10 Code Code Description
R11.0 Nausea
R11.10 Vomiting unspecified
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.13 Vomiting of fecal mater
R11.14 Billous vomiting
R11.2 Nausea with vomiting, unspecified
Page 159 DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
Disease of the Skin and Subcutaneous Tissues
CELLULITIS
An acute inflammation of a localized area of tissue.
DERMATITIS
Is the inflammation of the skin.
ERYTHEMATOUS CONDITIONS
Is a redness of the skin due to capillary dilation.
PRESSURE ULCER OR DECUBITUS ULCER
Caused by hypoxia secondary to pressure-induced vascular insufficiency.
Documentation Location Size Stage of the ulcer Other information that would explain why a wheelchair or other means of moving the patient other than an ambulance could not be used. Decubitus Ulcer Staging
Stage I: A reddened area on the skin that, when pressed, does not turn white.
Stage II: The skin blisters or forms an open sore. The area around the sore may be
red and irritated.
Stage III: The skin now develops an open, sunken hole called a crater. There is
damage to the tissue below the skin.
Page 160 DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
Stage IV: The pressure ulcer has become so deep that there is damage to the muscle
and bone, and sometimes to tendons and joints.
CODING CHANGES Combination codes identify the site of a pressure ulcer as well as the stage of the ulcer. If the pressure ulcer is documented as completely healed than it is not coded. If the pressure ulcer is healing it should be coded to the highest stage that is healing. Laterality is included with many diagnoses. Dermatitis and Eczema are used synonymously. Non-pressure chronic ulcers are also specified by site, laterality, and severity. Chronic or non-pressure ulcers are usually caused by other conditions and should be coded first, if known. The 6th Character level in L89 denotes the “depth of the Ulcer” i.e. L89.503, “stage 3”, pressure ulcer of the ankle, unspecified.
Page 161 DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
ABNORMAL SKIN SIGNS Includes:
Diaphoresis-Sweating, especially to an unusual degree as a symptom of disease or side effect of a disease. Cyanosis-Bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood. Delayed capillary refill-How long it takes color to return to an external capillary bed after pressure is applied. Diminish skin turgor-The skin’s ability to change shape and return to normal elasticity. Mottled skin-Patch skin color areas where the skin color is irregular.
ICD-10 Code Code Description
R23.0 Cyanosis
R23.1 Pallor
R23.2 Flushing
R23.4 Changes in skin texture
R23.8 Other skin changes
R23.9 Unspecified skin changes
Page 162 DISEASE OF THE SKIN AND SUBCUTANEOUS TISSUES
R60.0 Localized edema
R60.1 Generalized edema
R60.9 Edema unspecified
R61 Generalized hyperhidrosis
Page 163 DISEASES OF THE MUSCULOSKELETAL SYSTEM
Diseases of the Musculoskeletal System
CODING CHANGES Almost all the ICD-10 codes have been expanded.
Most codes provide for laterality and site. LATERALITY
ARTHRITIS In ICD-10-CM, there are specific codes for primary and secondary arthritis. Within the secondary arthritis codes there are specific codes for post-traumatic osteoarthritis and other secondary osteoarthritis. For secondary osteoarthritis of the hip there is also a code for dysplastic osteoarthritis. Arthritis codes in ICD-10-CM is both similar and different than ICD-9-CM.
Page 164 DISEASES OF THE MUSCULOSKELETAL SYSTEM
In ICD-9, osteoarthritis can be described as degenerative, hypertrophic, or secondary to other factors, and the type as generalized or localized. In ICD-10 provides more options for the coding osteoarthritis related encounters, including: o Generalized forms of osteoarthritis or arthritis where multiple joints are involved. o Localized forms of osteoarthritis with more specificity that includes primary versus secondary types, subtypes, laterality, and joint involvement. o Indicate the type, location, and specific bones and joints (multiple sites if applicable) involved in the disease. In addition, describe any related underlying diseases or conditions.
BACK PAIN
Sudden onset, severe non-traumatic pain suggestive of cardiac or vascular origin or requiring special positioning only available by ambulance. 7–10 on 10-point severity scale. Neurologic symptoms and/or signs. Absent leg pulses. Pulsatile abdominal mass, concurrent chest or abdominal pain.
Page 165 DISEASES OF THE MUSCULOSKELETAL SYSTEM
Page 166 DISEASES OF THE MUSCULOSKELETAL SYSTEM
CONTRACTURES Abnormal shortening of muscle tissue, rendering the muscle highly resistant to passive stretching. There should be a description about whether the patient has upper or lower limb contracture(s). The location and severity/degree of the contracture should be documented. Lower extremity contractures must be of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).
Page 167 DISEASES OF THE MUSCULOSKELETAL SYSTEM
Page 168 GENITOURINARY
Genitourinary
HEMATURIA
Hematuria Is the presence of blood in the urine. Gross Hematuria Is presence of blood in the urine in sufficient quantity to be visible to the naked eye. Cause UTI’s Benign Prostatic Hypertrophy Ureteral Calculi Cardinal Sign of bladder cancer.
KIDNEY FAILURE
A clinical syndrome associated with the retention of renal waste products or uremic toxins in the blood. It is usually the result of renal insufficiency. Most uremic toxins are end products of protein or nitrogen catabolism, such as urea or creatinine. Severe uremia can lead to multiple organ dysfunctions with a constellation of symptoms.
A condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance.
Chronic Kidney Disease Has five stages based on the patients glomerular filtration rate (GFR). Care of a patient with stage IV and V is very intense and complicated. Chronic renal insufficiency is a form of chronic kidney disease. A neoplastic or non-neoplastic condition affecting the kidney.
Page 169 GENITOURINARY
Conditions in which the function of kidneys deteriorates suddenly in a matter of days or even hours. It is characterized by the sudden drop in glomerular filtration rate. Impairment of health or a condition of abnormal functioning of the kidney. Pathological processes of the kidney or its component tissues.
Chronic Renal Failure maybe due to:
High Blood Pressure Diabetes Chronic renal failure is irreversible and requires hemodialysis.
Signs and Symptoms Excess in the blood of urea, creatinine and other nitrogenous end products of protein and amino acid metabolism.
End Stage Renal Disease (ESRD) Is the final stage of the loss of kidney function (also referred to as “Stage V”). This stage will require transplant of renal dialysis for survival.
Renal Insufficiency Poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease. Normally, the kidneys regulate body fluid and blood pressure, as well as regulate blood chemistry and remove organic waste.
Acute Renal Failure Occurs suddenly, and usually due to trauma, infection, inflammation or toxicity. It develops quickly and usually reversible as the underlying condition is treated.
Page 170 GENITOURINARY
CODING CHANGES
Many diagnoses are based on gender.
Prostatic hypertrophy is now “enlarged prostrate”.
There are several notes throughout the chapter identifying to use additional codes.
ICD-10 Code Code Description
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease N13.8 Urinary obstruction
N17.8 Other acute kidney failure
N17.9 Acute kidney failure, unspecified
N18.1 Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2
N18.3 Chronic kidney disease, stage 3
N18.4 Chronic kidney disease, stage 4
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
N19 Unspecified kidney failure
N39.41 Urinary incontinence-urge incontinence
Page 171 GENITOURINARY
N39.42 Urinary incontinence-without sensory awareness
N39.43 Urinary incontinence-post-void dribbling
N39.44 Urinary incontinence-nocturnal enuresis
N39.45 Urinary incontinence-continuous leakage
N39.46 Urinary incontinence-mixed incontinence (urge and stress)
N39.490 Other specified urinary incontinence-overflow incontinence
N39.498 Other specified urinary incontinence (reflex or total incontinence)
N39.8 Other specified disorder of urinary system
N39.9 Disorder of urinary system, unspecified
N99.510 Cystostomy hemorrhage
N99.511 Cystostomy infection
N99.512 Cystostomy malfunction
N99.518 Other cystostomy complication
N99.520 Hemorrhage of other external stoma of urinary tract
N99.521 Infection of other external stoma of urinary tract
N99.522 Malfunction of other external stoma of urinary tract
N99.528 Other external stoma of urinary tract
N99.530 Hemorrhage of other stoma of urinary tract
N99.531 Infection of other stoma of urinary tract
Page 172 GENITOURINARY
N99.532 Malfunction of other stoma of urinary tract
N99.538 Other stoma of urinary tract complications
R30 Hematuria
R33.8 Urinary retention
R35.1 Nocturia
R39.11 Urinary hesitancy
R39.12 Weak urinary system
R39.14 Incomplete bladder emptying
R39.15 Urinary urgency
R39.16 Straining on urination
R39.81 Functional urinary incontinence
R39.89 Other symptoms and signs involving the genitourinary system
R39.9 Unspecified symptoms and signs involving the genitourinary system
Z99.2 Dependence on renal dialysis
Page 173 PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
Pregnancy, Childbirth and the Puerperium
Page 174 PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
POSTPARTUM
The period begins immediately after delivery and continues for six weeks following delivery.
A postpartum complication is any complication occurring within the six-week period.
CODING GUIDELINES
If an OB patient with diabetes it’s coded to the Diabetes code in the pregnancy, childbirth and puerperium chapter followed by an E Code from Chapter 4. If Gestational Diabetes only a code from the pregnancy, childbirth and puerperium chapter is coded. If pregnancy complications occur because of alcohol and tobacco use during pregnancy code from the pregnancy, childbirth and puerperium chapter first, followed by a code from chapter 5. If there is a poisoning, toxic effects, adverse effects and underdosing in an OB Patient, code first O9A.2 Injury, poisoning and certain other consequences of external causes should be sequenced first, followed by a code to identify the substance and the condition that is being treated. If a baby is born, then the gestation needs to be coded from the Z34 codes.
ICD-10 Code Code Description
O24.011 Pre-existing diabetes mellitus, type 1, 1st trimester
O24.012 Pre-existing diabetes mellitus, type 1, 2nd trimester
O24.013 Pre-existing diabetes mellitus, type 1, 3rd trimester
O24.019 Pre-existing diabetes mellitus, type 1, unspecified
Page 175 PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
O24.111 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.112 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.113 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.119 Pre-existing diabetes mellitus, type 2, 1st trimester
O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, 1st trimester
O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, 2nd trimester
O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, 3rd trimester
O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.410 Gestational diabetes mellitus in pregnancy, diet controlled
O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419 Gestational diabetes mellitus in pregnancy, unspecified controlled
O24.811 Other pre-existing diabetes mellitus, 1st trimester
O24.812 Other pre-existing diabetes mellitus, 2nd trimester
O24.813 Other pre-existing diabetes mellitus, 3rd trimester
O24.819 Other pre-existing diabetes mellitus, unspecified trimester
O24.911 Unspecified diabetes mellitus, 1st trimester
O24.912 Unspecified diabetes mellitus, 2nd trimester
O24.913 Unspecified diabetes mellitus, 3rd trimester
O24.919 Unspecified diabetes mellitus, unspecified trimester
Page 176 PREGNANCY, CHILDBIRTH AND THE PUERPERIUM
075.9 Complication of labor and delivery, unspecified
O80 Encounter for full-term uncomplicated delivery
O9A.211 Injury, poisoning, and certain external causes complicating pregnancy, 1st trimester O9A.212 Injury, poisoning, and certain external causes complicating pregnancy, 2nd trimester O9A.213 Injury, poisoning, and certain external causes complicating pregnancy, 3rd trimester O9A.219 Injury, poisoning, and certain external causes complicating pregnancy, unspecified trimester
BIRTH If a baby is born while in transport, then an ICD-10 code from the Z38 is coded for live born infant. ICD-10 Code Code Description
Z38.1 Single live born outside of hospital
Z38.4 Twins live born outside of hospital
Z38.7 Multiple live born outside of hospital
R68.13 Apparent life threatening event of an infant
Page 177 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Injury, Poisoning and Certain Other Consequences of External Causes
INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
INJURIES Episode of Care: Initial, subsequent, sequelae Injury site: Be as specific as possible Etiology: How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)? Place of Occurrence: School, work, etc. Initial encounters may also require, where appropriate: Intent: Unintentional or accidental, self-harm, etc. Status : Civilian, military, etc.
FRACTURES Type: o Open, closed, pathological, neoplastic disease, stress Pattern: o Comminuted, oblique, segmental, spiral, transverse Encounter of care: o Initial, subsequent, sequelae Healing status, if subsequent encounter: o Normal healing, delayed healing, nonunion, malunion Localization:
Page 178 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
o Shaft, head, neck, distal, proximal, styloid Displacement: o Displaced, non-displaced Classification: o Gustilo-Anderson, Salter-Harris Any complications, whether acute or delayed: o Direct result of trauma sustained Terminology Pathological Fracture Occurs in existing diseases, which weekends the bones. Malunion Fracture Fracture is reduced, but the bone ends did not align properly during the healing process. Nonunion Fracture Is the failure of the bone ends to align or heal. Stress Fracture May be cause by repetitive forces applied to the bone and its supporting structures. Comminuted A break/splinter of the bone into more than two fragments. Oblique Slanted fractures that occur when a force is applied at any angle. Segmental A fracture in two parts of the same bone. Spiral Is a fracture occurring when a rotating force is applied along the axis of the bone. Transverse
Page 179 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Is a perpendicular break along the axis of the bone from a result of a force applied at an angle. Displaced The bone moves in two or more parts and moves so the two ends do not line up. Non-displaced Then bone cracks either in part or all the way through, but maintains alignment. Gustilo-Anderson System is the most commonly used classification system for Open fractures.
Salter Harris Are epiphyseal plate fractures and are common and important as they can result in premature closure and therefore limb shortening and abnormal growth. o Typically occurs in 10-15 years old
Page 180 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
CODING CHANGES The “S” Codes are for injuries related to a single body region.
The “T” Codes cover injuries to unspecified body regions, as well as poisons.
Page 181 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Injuries Features an expanded category for injuries. Injuries are grouped by anatomical site rather than by injury. Most are seven digits. A seventh character extension identifies the encounter type, with: A- Initial encounter for closed fracture B- Initial encounter for open fracture D- Subsequent encounter for fracture with routine healing G- Subsequent encounter for fracture with delayed healing K- Subsequent encounter for fracture with nonunion P- Subsequent encounter for fracture with malunion S- Sequela
WHEN A FRACTURE IS NOT DESCRIBED AS OPEN OR CLOSED IT SHOULD BE CODED TO A CLOSED FRACTURE.
FRACTURES ARE CODED INDIVIDUALLY TO EACH SPECIFIC SITE.
WHEN THERE IS AFTERCARE OF AN INJURY YOU CODE THE ACUTE INJURY CODE WITH THE “SUBSEQUENT ENCOUNTER” 7th digit.
PATHOLOGICAL FRACTURES ICD-10 identifies for 3 different causes to pathological fractures. o Neoplastic disease o Osteoporosis o Other specified disease M80 Category should be used when it is known the patient has Osteoporosis with a fracture.
Page 182 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
http://www.roadto10.org/whats-different
Burns A new term of Corrosion, which are burns due to chemicals. Drugs Are divided up by: Poisoning Adverse Effect Underdoing Is taking less medication than prescribed by a provider, resulting in a negative health consequences. WHEN CODING BURNS, THE BURN TO THE HIGHEST DEGREE IS CODED FIRST.
Open Wounds ICD-10 provides a laterality distinction to be made and the type of open wound including: Laceration, with or without foreign body
Page 183 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Puncture wound with or without foreign body Open bite Unspecified open wound
GOOD DOCUMENTATION PRACTICE Accident o Where did it occur? Assault o What was the assault and what part of the body? Asphyxiation o Where and how did it occur? Bites o What was the bite from and where did it occur? Burns
st nd rd o Was it 1 , 2 , or 3 degree, and what part of the body? Trauma with one or more of the following: o Glasgow < 14; o systolic BP < 90; o RR < 10 or > 29 o All penetrating injuries to head, neck, torso, extremities proximal to elbow or knee o Flail chest o Combination of trauma and burns o Pelvic fracture o Two or more long-bone fractures o Open or depressed skull fracture o Paralysis
Page 184 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Suspected Fracture/Dislocation Documentation Suspected fracture or dislocation requires splinting/immobilization and renders patient unable to be transported by another vehicle. Includes suspected fractures or dislocations of spine and long bones and joints proximal to knee and elbow. The record will demonstrate history of significant trauma and/or findings to support such suspicions.
BURNS First-degree burns are red, moist, swollen, and painful. Second-degree burns are red, swollen, and painful, and they develop blisters that may ooze a clear fluid. Third-degree burns usually are not painful because the nerves have been destroyed. The skin becomes leathery and may be white, black, or bright red. No blisters develop. Heat burns (thermal burns) are caused by fire, steam, hot objects, or hot liquids. Scald burns from hot liquids are the most common burns to children and older adults. Electrical burns are caused by contact with electrical sources or by lightning. Chemical burns are caused by contact with household or industrial chemicals in liquid, solid, or gas form. Natural foods such as chili peppers, which contain a substance irritating to the skin, can cause a burning sensation. Radiation burns are caused by the sun, tanning booths, sunlamps, x-rays, or radiation therapy for cancer treatment. Friction burns are cause by contact with any hard surface such as roads, carpets, or gym floor surfaces.
Page 185 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Burn Documentation Partial thickness burns > 10% Total Body Surface Area (TBSA). Involvement of face, hands, feet, genitalia, perineum or major joints. Third degree burns Electrical, chemical, inhalation burns with pre-existing medical disorders.
POISONING Requires cardiopulmonary and/or neurologic monitoring and/or urgent pharmacologic intervention. When quantity and identity of agent know to be life threatening. When quantity and identity of agent are not known but there are signs/symptoms of neurologic dysfunction.
Page 186 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Poisoning is an overdose of a substance if the wrong substance is given or taken in error. Coding Changes Types: Poisoning, accidental Poisoning, intentional self-harm Poisoning, undetermined Adverse effect Underdosing Underdosing Refers to taking less medication than prescribed. Codes for under dosing should never be assigned as a principal diagnosis. The medical condition should be coded first. Proper administration of drug When a medication has been taken properly, code the condition first followed by the adverse effect of the drug “T” code. Improper use of drug First assign the overdose or wrong administration of drug “T” code first, followed by manifestations that occurred, including if abuse, or dependence of the drug. Intent If the intent is not documented or not known than the “accidental intent” ICD-10 code is used. The Undetermined intent is only used when there is not documentation that shows it is undetermined.
HEAT EXHAUSTION Excessive loss of salts (electrolytes) and fluids due to heat, leading to decreased blood volume that causes many symptoms, sometimes including fainting or collapse.
Symptoms:
Page 187 INJURY, POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES
Dizziness Light-headedness Weakness Fatigue Headache Blurred Vision Muscle Aches Nausea/Vomiting
HYPOTHERMIA Results when the body loses more heat than can be replaced by increasing metabolism or by increasing warming from external sources, such as a fire or the sun. Initial symptoms include intense shivering and teeth chattering. As body temp falls further, shivering stops and movements become slow and clumsy, reaction time is longer, thinking is blurred, and judgment is impaired.
MEDICAL DEVICE FALIURE Life- or limb-threatening malfunction, failure or complication. Malfunction of internal pacemaker, internal defibrillator, implanted drug delivery device, O2 supply malfunction, and orthopedic device failure.
Page 188 EXTERNAL CAUSES OF MORBIDITY
External Causes of Morbidity
Captures the Cause of the Injury or Health Condition. The Intent o Unintentional or accidental; o Suicide or assault. The Place the Even Occurred. The Activity of the Patient at the Time of the Event. The Person’s Status o Civilian o Military o Most codes require a 7th character.
PER CMS Website If you have not been reporting ICD-9-CM external cause codes, you will not be required to report ICD-10-CM codes found in Chapter 20 unless a new State or payer-based requirement about the reporting of these codes is instituted. If such a requirement is instituted, it would be independent of ICD-10-CM implementation. In the absence of a mandatory reporting requirement, you are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and evaluation of injury prevention strategies.
Page 189 FACTORS INFLUENCING HEALTH STATUS AND CONTACT HEALTH SERVICES
Factors Influencing Health Status and Contact Health Services
o Z Codes Represent Reasons for the encounters. o These codes are provided for occasions when circumstances other than a disease. o Injury, or external cause classifiable to the other categories. o This occurs two ways: o When a person who may or may not be sick encounters healthcare for some specific purpose; or o When circumstances or problem is present which influences the person’s
health status but is not in itself a current illness or injury. Complete Injury Coding
BED CONFINED The patient must meet all of the following three criteria: Unable to get up from bed without assistance. Unable to ambulate Unable to sit in a chair (including wheelchair) Non-emergency ambulance transportation is not covered for patients who are restricted to bed rest by a physician’s instructions but who do not meet the above three criteria. There should be a narrative description that describes the reason the term “bed confined” is being used.
Page 190 FACTORS INFLUENCING HEALTH STATUS AND CONTACT HEALTH SERVICES
Page 191 DOCUMENTATION
Documentation
The patient’s condition should be coded based on the documentation from the personnel on scene. Non-Emergency clearly has to already be specific to the patient’s condition and need for the ambulance. The Diagnosis Code is to support the reason for transport.
Medical Necessity Medicare Benefit Policy-Chapter 10-Ambulance When the patient’s condition requires the vehicle itself and/or the specialized services of the ambulance personnel were provided and clear clinical documentation in the patient’s ePCR validates their medical need and their provision. The patient’s condition, as well as changes in that condition and the treatment provided, must be recorded. These are conditions which may establish medical necessity: o Patient had to be transported due to an emergency (as the result of an accident or injury). o Patient needs to be restrained. o Patient is unconscious or in shock. o Patient requires oxygen or other emergency treatment. o Exhibits signs and symptoms of acute respiratory distress or cardiac distress. o Patient needs to be immobile because of fracture or the possibility of fracture.
Page 192 DOCUMENTATION
o Patient sustains an active stroke or MI. o Patients experiences severe hemorrhaging. o Patient was bed confined or o Needed to be moved by stretcher. Emergency Documentation Chief Complaint History of Present Illness (HPI) has always been critical to obtain Past Medical History (PMH) Any pertinent documentation from family or facility ALS Assessment if performed, documented Vital signs Assessment of head to toe Pain Assessment Treatment and interventions Successful or Unsuccessful Attempts How was the patient moved Patient status while transported
Non-Emergency For nonemergency transports, the crew should generally focus more on the patient’s deficits that prevents transportation by another means, rather than what may appear to be the main diagnosis.
WHY DO YOU HAVE TO BE THERE?
Pain: What was the scale, where is the pain?
Paralysis: Where? Left? Or Right?
Page 193 DOCUMENTATION
Fall Risk: Is the patient a danger to their self or to others and why?
Pressure Ulcers: Where? Left or Right? Upper or Lower? And What is the stage?
Oxygen: Is the patient unable to administer oxygen and why?
Bed Confined: Are they able to sit, stand or ambulate?
Most Important: Does the patient need to be transported by Ambulance?
Page 194 MOVING FORWARD
Moving Forward
Pull your top 25-50 ICD-9-CM Diagnosis Codes
Crosswalk them with available resources
Identify in your organization where ICD-9-CM’s are currently utilized and will need to be updated, i.e. NEMSIS.
Page 195 MOVING FORWARD
• Evaluate the CMS and your MAC’s website. • Order ICD-10 Code Books and various other resources to help educate your team. • Watch for various webinars available for team training. • Have billing, IT and Operations collaborate in implementing of ICD-10’s. • When new procedures, protocols, medicines or equipment is being used, provide in-services for billing staff.
Page 196 MOVING FORWARD
• Determine if there are weaknesses in your documentation and begin correcting immediately. • Update Compliance Plans and policies and procedures to reflect ICD-10-CM. • Consider implementing a query processes for your medics when billing staff needs clarification. This could make a difference in medical necessity and ensuring proper billing.
• Have a clear understanding how your software vendor is implementing ICD- 10-CM’s. • If you have contracts with Commercial Carriers, verify their language and ensure the level of specificity they will require. • Monitor your MAC’s websites for updates and changes.
Page 197 MOVING FORWARD
• Update you billing system with ICD-10-CM’s, test running reports, claims and files. • Once ICD-10-CM’s are implemented continue to monitor system to ensure claims are going out the door appropriately. • Watch for denials due to ICD-10-CM’s and monitor closely.
Page 198 MOVING FORWARD
If the payors receive non-compliant codes OR incorrectly associate ICD-10-CM codes in their systems…then major disruption…and if there’s disruption…
Provider has to call the Payor
Payor answers questions, request more information.
Claims are delayed.
Disruptions in cash flows.
No one is happy.
It is everyone’s best interest to work toward a seamless transition.
Page 199 RESOURCES
Resources
Page 200 RESOURCES
Page 201 RESOURCES
Page 202 APPENDIX
Appendix
American Ambulance Association Top Ambulance ICD-10-CM Diagnosis Codes American Ambulance Association Condition Code List ICD-10 Updated CMS/AMA Announces Efforts to Help Providers Get Ready for ICD-10 CMS Letter to Providers Regarding ICD-10’s CMS Clarifying Q&A’s Related to CMS/AMA Announcement Regarding ICD-10’s
Page 203 APPENDIX
Page 204 APPENDIX
Page 205 APPENDIX
Page 206 APPENDIX
Page 207 APPENDIX
Page 208 APPENDIX
Page 209 APPENDIX
Page 210 APPENDIX
Page 211 APPENDIX
Page 212 APPENDIX
Page 213 APPENDIX
Page 214 APPENDIX
Page 215 APPENDIX
Page 216 APPENDIX
Page 217 APPENDIX
Page 218 APPENDIX
Page 219 APPENDIX
Page 220 APPENDIX
Page 221 APPENDIX
Page 222 APPENDIX
Page 223 APPENDIX
Page 224 APPENDIX
Page 225 APPENDIX
Page 226