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INTERNATIONAL STATISTICAL OF DISEASES AND RELATED HEALTH PROBLEMS TENTH REVISION THAI MODIFICATION Volume 5 STANDARD CODING GUIDELINES SECOND EDITION MINISTRY OF PUBLIC HEALTH BANGKOK 2006 Contents CONTENTS Introduction 1 General guidelines GN0001 Principal diagnosis 4 GN0002 Comorbidity 6 GN0003 Complication 7 GN0004 Other diagnoses 8 GN0005 External cause of injury and poisoning 8 GN0009 Pricipal diagnosis coding 10 GN0010 Combined coding 11 GN0011 Multiple disease coding 11 GN0012 Ambiguous codee avoidance 13 GN0013 Symptom and sign coding 14 GN0014 Operation / operating room procedure 15 GN0015 Non-operating room procedures 15 GN0016 Operative approach coding 16 GN0017 Main operation coding 17 GN0018 Most specific diagnostic term selection 18 GN0019 Document supported coding 19 Certain infectious and parasitic diseases MD0101 Diarrhoea 21 MD0102 Food poisoning 21 MD0103 Septicaemia / Sepsis 22 GY0101 Trichomoniasis 23 GY0102 Genital herpes simplex infection 23 GY0103 Condyloma acuminata 23 GY0104 Human papilloma virus [HPV] 24 MD0104 Hepatic encephalopathy 25 MD0105 HIV / AIDS 25 GY0105 Candidiasis of vulva and vagina 28 PD0101 Neonatal candidiasis 28 MD0106 Helicobacter / Campylobacter 28 Neoplasms ON0201 Principal diagnosis as malignancy 30 ON0202 Complications associated with malignancy 31 SG0201 Breast cancer 32 GY0201 Malignant neoplasm of cervix uteri 32 GY0202 Malignant neoplasm of corpus uteri 33 OT0201 Exostosis 34 GY0203 Leiomyoma of uterus 34 GY0204 Neoplasm of ovary 34 ICD-10-TM Standard Coding Guidelines 2005 i Contents GY0205 Gestational trophoblastic tumour 35 Diseases of the blood and blood-forming organs MD0301 Stem cell / Bone marrow procurement 36 MD0302 Anaemia 36 MD0303 Pancytopenia / Bicytopenia 38 Endocrine, nutritional and metabolic diseases MD0401 Hypothyroidism 39 MD0402 Hyperthyroidism 39 MD0403 Diabetes mellitus [DM] 40 MD0404 Dyslipidaemia 43 MD0405 Euthyroid goitre 44 MD0406 Thyroiditis 44 MD0407 Abnormal thyroid function in medical illness 45 MD0408 Inappropriate thyroid stimulating hormone secretion 45 MD0409 Pituitary and hypothalamic tumour 45 Nervous system MD0601 Chronic inflammatory demyelinating polyneuropathy 46 RM0601 Hemiplegia / Paraplegia / Tetraplegia 46 MD0602 Syncope 46 MD0603 Transient ischaemic attack [TIA] 47 PD0601 Hydrocephalus 47 Eye EY0701 Conjunctivitis 48 EY0702 Pinguecula and pterygium 49 EY0703 Disorders of cornea 50 EY0704 Contact lens intolerance 50 EY0705 Iridocyclitis [Anterior uveitis] 51 EY0706 ICE syndrome 53 EY0707 Cataract 53 EY0708 Ophthalmic complications of diabetes mellitus 55 EY0709 Retinal diseases 55 EY0710 Refractive error 57 EY0711 Operative complications 58 EY0712 Pterygium excision 59 EY0713 Operation for conjunctival lesion 59 EY0714 Scleral operation 59 EY0715 Secondary insertion of intraocular lens 60 EY0716 Repair of eyelid 60 EY0717 Dry eye 60 EY0718 Ocular myasthenia gravis 61 EY0719 Disorders of visual pathways 61 ii ICD-10-TM Standard Coding Guidelines 2005 Contents Ear EN0801 Otitis externa 62 EN0802 Otitis media 62 EN0803 Glue ear 62 EN0804 Peripheral vertigo 62 EN0807 Tympanoplasty 63 EN0808 Eagle’s syndrome 63 EN0809 Hearing loss 64 Circulatory system MD0901 Hypertension 65 MD0902 Atherosclerotic heart disease 65 MD0903 Cardiomyopathy 66 MD0904 Cardiac arrest 66 MD0905 Congestive heart failure 66 MD0906 Acute pulmonary oedema 67 MD0907 Cerebrovascular accident [CVA] 67 MD0908 Brugada syndrome 69 MD0909 Chronic ischaemic heart disease 69 MD0910 Acute ischaemic heart disease 70 MD0911 Procedures for circulatory diseases 71 Respiratory system EN1001 Sinusitis 74 EN1002 Pharyngitis 74 EN1003 Tonsillitis 74 EN1004 Upper respiratory infection of multiple sites 75 MD1001 Pneumonia 75 EN1005 Laryngeal stenosis 76 MD1002 COPD 77 PD1001 Wheezing associated respiratory illness [WARI] 77 MD1003 Asthma 77 EN1006 Endoscopic sinus surgery 78 EN1007 CWL operation 78 EN1008 Direct laryngoscopy / bronchoscopy 79 EN1009 Snoring and obstructive sleep apnea 79 EN1010 Uvulopalatopharyngoplasty & Laser assisted uvulopalatoplasty 80 EN1011 Intubation granuloma of larynx 80 EN1012 Fracture of larynx 80 EN1013 Phonosurgery 81 MD1004 Respiratory failure 81 ICD-10-TM Standard Coding Guidelines 2005 iii Contents Digestive system DT0001 Modification of oral and dental and maxillofacial surgery codes 82 DT0002 Tooth nomenclature 82 DT0003 Root operation for dental procedures 84 DT0004 Intraoral procedures 85 DT1101 Diseases of pulp and periapical tissue and related diseases 86 DT1102 Orthodontic treatment 86 DT1103 Temporomandibular disorders 88 DT1104 Preprosthetic surgery 89 DT1105 Craniofacial implant 90 DT1106 Oro-facial infection 91 EN1101 Deep neck infection 93 MD1101 Oesophagitis 93 MD1102 Gastric ulcer with gastritis 94 MD1103 Appendicitis 94 MD1104 Noninfective gastroenteritis 94 MD1105 Adhesions 94 MD1106 Alcoholic liver disease 95 MD1107 Viral cirrhosis 95 MD1108 Jaundice 95 MD1109 Mesenteric adenitis with appendectomy 95 MD1110 Gastointestinal haemorrhage 95 MD1111 Redundant colon 96 MD1112 Free peritoneal fluid 96 MD1113 Per-rectal bleeding 96 MD1114 Gastritis 97 MD1115 Spontaneous bacterial peritonitis 97 MD1116 Ruptured hepatoma 97 MD1117 Hepatic failure 97 MD1118 Gastrointestinal tract procedures 98 Skin and subcutaneous tissue MD1201 Infected excoriated wound 100 MD1202 Erythema multiforme 100 MD1203 Cracked foot 100 MD1204 Arsenic keratosis and acquired keratosis plinaris 101 SG1201 Paraffinoma of penis 101 MD1205 Picker nodules 101 Musculoskeletal system and connective tissue OT1301 Pseudogout 102 OT1302 OA knee 102 OT1303 Erosion of knee 102 OT1304 Clubfoot 103 OT1305 Patello-femoral syndrome 103 OT1306 ACL deficiency / PCL deficiency 103 iv ICD-10-TM Standard Coding Guidelines 2005 Contents OT1307 Excessive lateral pressure syndrome 103 OT1308 Plica syndrome or medial plica 103 RM1301 Scoliosis 104 OT1309 Spondylosis / Spondylolisthesis / Retrolisthesis 104 OT1310 Spondylosis with neurodeficit 104 OT1311 Disc disorders with myelopathy 104 OT1312 Herniated necleolus palposus 105 OT1313 Disc syndrome 105 OT1314 Compartment syndrome 105 MD1301 Necrotizing fasciitis 106 EN1301 Hyoid arch syndrome 106 RM1302 Myofascial pain syndrome 106 OT1315 Nonunion 106 OT1316 Infected nonunion 107 OT1317 Bone loss or bone defect with fracture 107 OT1318 Bone loss from tumour or infection 107 OT1319 Costochondritis 107 OT1320 Postlaminectomy syndrome 108 OT1321 Periprosthetic fracture 108 OT1322 Biomechanical lesions 108 OT1323 Coding of fractures from different causes 109 OT1324 Failed patella 110 Genitourinary system MD1401 Ig A nephropathy 111 MD1402 Ig M nephropathy 111 MD1403 Renal failure 111 MD1404 Urinary tract infection 112 MD1405 Glomerular disease 113 RM1401 Overactive bladder 114 GY1401 Pelvic inflammatory disease [PID] 114 GY1402 Pelvic peritoneal adhesions 115 GY1403 Bartholin’s abscess and cyst 115 GY1404 Endometriosis 115 GY1405 Genital prolapse 116 GY1406 Twisted ovarian tumour 116 GY1407 Vaginal bleeding 116 GY1408 Postcoital and contact bleeding 117 GY1409 Female hormonal replacement therapy 117 GY1410 Female infertility 117 Pregnancy, childbirth and the puerperium OB1501 Ovarian pregnancy 119 OB1502 Abortion 119 OB1503 Complications following abortion and ectopic and molar pregnancy 121 OB1504 Termination of pregnancy 121 ICD-10-TM Standard Coding Guidelines 2005 v Contents OB1505 Threatened abortion 122 OB1506 Pre-eclampsia 122 OB1507 Hyperemesis gravidarum 123 OB1508 Diabetes mellitus in pregnancy 123 OB1509 Malpresentaion, disproportion and abnormality of pelvic organs 124 OB1510 Previous caesarean section 125 OB1511 Decreased fetal movement 125 OB1512 Premature rupture of membranes [PROM] 126 OB1513 Labour pain 126 OB1514 Prolonged pregnancy 127 OB1515 Preterm labour 127 OB1516 Preterm delivery 127 OB1517 Prolonged second stage of labour 127 OB1518 Fetopelvic disproportion 128 OB1519 Intrapartum and postpartum haemorrhage 128 OB1520 Perineal laceration 129 OB1521 Maternal exhaustion 129 OB1522 Mode of delivery 129 OB1523 Infections complicating pregnancy 130 OB1524 Conditions complicating pregnancy 130 OB1525 Coding for delivered patients 131 Perinatal period PD1601 Perinatal period 132 PD1602 Fetus and newborn affected by maternal factors and by complications of pregnancy, labour and delivery 132 PD1603 Newborn / Neonate 133 PD1604 Prematurity / Low birth weight 134 PD1605 Intraventricular haemorrhage [IVH] 135 PD1606 Birth asphyxia 135 PD1607 Chronic bronchitis 135 PD1608 Congenital pneumonia 135 PD1609 G6PD deficiency 136 PD1610 Neonatal jaundice 136 PD1611 Hypoxic ischaemic encephalopathy [HIE] 136 PD1612 Stillbirth and neonatal death 137 PD1613 Neonatal abstinence syndrome 137 PD1614 Meconium aspiration syndrome 137 Congenital malformations, deformations and chromosomal abnormalities GY1701 Parovarian cyst 138 GY1702 Hydatid cyst of Morgagni 138 OT1701 Torticollis 138 vi ICD-10-TM Standard Coding Guidelines 2005 Contents Symptoms, signs and abnormal clinical and laboratory findings DT1801 Haemorrhage in dentistry 139 PD1801 Febrile convulsion 139 OT1801 Osteopenia 139 Injury, poisoning and certain other consequences of external causes DT1901 Maxillofacial injury 140 EY1901 Eye accident 142 OT1901 Multiple injuries 143 OT1902 Soft tissue injury 143 OT1903 Superficial injury 143 OT1904 Open wound 144 OT1905 Spinal (cord) injury 144 OT1906 Fracture and dislocation 145 OT1907 Old fracture 145 OT1908 Sprain and strain 146 OT1909 Ligamentous injury of knee 147 OT1910 Pulled elbow 147 OT1911 Finger tip injury 148 OT1912 Ruptured flexor
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