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ICD-10-CM Expert for Skilled Nursing Facilities and Inpatient Rehabilitation Facilities The complete official code set

Codes valid from October 1, 2021 through September 30, 2022 SAMPLE

2022 optum360coding.com Contents

Preface...... iii Chapter 8. of the Ear and Mastoid Process ICD-10-CM Official Preface ...... iii (H60-H95) ...... 633 Characteristics of ICD-10-CM ...... iii Chapter 9. Diseases of the Circulatory System (I00-I99) ...... 647 Chapter 10. Diseases of the Respiratory System (J00-J99) ...... 693 How to Use ICD-10-CM Expert for Skilled Nursing Facilities and Inpatient Rehabilitation Facilities 2022 ...... iv Chapter 11. Diseases of the Digestive System (K00-K95) ...... 711 Introduction ...... iv Chapter 12. Diseases of the Skin and Subcutaneous Tissue What’s New for 2021 ...... iv (L00-L99) ...... 735 Conversion Table ...... iv Chapter 13. Diseases of the Musculoskeletal System and 10 Steps to Correct Coding ...... iv Connective Tissue (M00-M99) ...... 759 Official ICD-10-CM Guidelines for Coding and Reporting ...... iv Chapter 14. Diseases of the Genitourinary System Indexes ...... v (N00-N99) ...... 851 Index to Diseases and Injuries ...... v Chapter 15. Pregnancy, Childbirth and the Puerperium Neoplasm Table...... v (O00-O9A) ...... 871 Table of Drugs and Chemicals ...... v Chapter 16. Certain Conditions Originating in the Perinatal External Causes Index ...... v Period (P00-P96) ...... 911 Index Notations ...... v Chapter 17. Congenital Malformations, Deformations and Tabular ...... vi Chromosomal Abnormalities (Q00-Q99) ...... 925 Code and Code Descriptions...... vi Chapter 18. Symptoms, Signs and Abnormal Clinical and Tabular Notations ...... vi Laboratory Findings (R00-R99) ...... 945 Official Notations ...... vi Chapter 19. Injury, Poisoning and Certain Other Consequences Optum360 Notations ...... vii of External Causes (S00-T88) ...... 965 Icons ...... vii Color Bars ...... ix Chapter 20. External Causes of Morbidity (V00-Y99)...... 1173 Chapter-Level Notations ...... ix Chapter 21. Factors Influencing Health Status and Contact Appendixes ...... ix With Health Services (Z00-Z99) ...... 1237 Illustrations ...... ix Chapter 22. Codes for Special Purposes (U00-U85)...... 1273

What’s New for 2022 ...... x Appendixes ...... Appendixes–1 Official Updates ...... x Appendix A: Valid 3-character ICD-10-CM Codes...... Appendixes–1 Proprietary Updates ...... xvii Appendix B: Pharmacology List 2021...... Appendixes–3 Appendix C: Z Codes for Long-Term Drug Use with Conversion Table of ICD-10-CM Codes ...... xix Associated Drugs ...... Appendixes–23 Appendix D: Z Codes Only as Principal/First-Listed 10 Steps to Correct Coding...... xx Diagnosis ...... Appendixes–26 Appendix E: Skilled Nursing Facility Prospective ICD-10-CM Official Guidelines for Payment System Overview ...... Appendixes–27 Coding and Reporting ...... Coding Guidelines–1 Appendix F: PDPM Comorbid Conditions ...... Appendixes–31 Appendix G: PDPM Return-to-Provider Code List..... Appendixes–35 ICD-10-CM Index to Diseases and Injuries ...... 1 Appendix H: Skilled Nursing Facility Active Diagnosis List...... Appendixes–49 ICD-10-CM Neoplasm Table ...... 335 Appendix I: Inpatient Rehabilitation Facility Prospective Payment System (PPS) Overview...... Appendixes–51 ICD-10-CM Table of Drugs and Chemicals ...... 354 Appendix J: Rehabilitation Impairment Categories (RIC)...... Appendixes–58 ICD-10-CM Index to External Causes...... 403 Appendix K: RIC Comorbid Conditions ...... Appendixes–63 Appendix L: Coding Issues for Long-Term ICD-10-CM Tabular List of Diseases and Injuries ...... 439 Care (LTC)...... Appendixes–70 Chapter 1. Certain InfectiousSAMPLE and Parasitic Diseases (A00-B99) ...... 439 Illustrations...... Illustrations–1 Chapter 2. Neoplasms (C00-D49) ...... 465 Chapter 3. Diseases of the Blood and Blood-forming Organs and Certain Disorders Involving the Immune Chapter 3. Diseases of the Blood and Blood-forming Mechanism (D50–D89) ...... Illustrations–1 Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) ...... 505 Red Blood Cells ...... Illustrations–1 White Blood Cell ...... Illustrations–1 Chapter 4. Endocrine, Nutritional and Metabolic Diseases Platelet ...... Illustrations–2 (E00-E89) ...... 519 Coagulation ...... Illustrations–2 Chapter 5. Mental, Behavioral, and Neurodevelopmental Spleen Anatomical Location and Disorders (F01-F99) ...... 543 External Structures ...... Illustrations–3 Chapter 6. Diseases of the Nervous System (G00-G99) ...... 569 Spleen Interior Structures ...... Illustrations–3 Chapter 7. Diseases of the Eye and Adnexa (H00-H59) ...... 593

ICD-10-CM 2022 i Contents Chapter 4. Endocrine, Nutritional and Metabolic Upper Respiratory System ...... Illustrations–27 Diseases (E00–E89) ...... Illustrations–4 Lower Respiratory System ...... Illustrations–27 Endocrine System ...... Illustrations–4 Paranasal Sinuses ...... Illustrations–27 Thyroid ...... Illustrations–5 Lung Segments ...... Illustrations–28 Thyroid and Parathyroid Glands ...... Illustrations–5 Alveoli ...... Illustrations–28 Pancreas ...... Illustrations–6 Chapter 11. Diseases of the Digestive System Anatomy of the Adrenal Gland ...... Illustrations–6 (K00–K95) ...... Illustrations–29 Structure of an Ovary ...... Illustrations–7 Digestive System ...... Illustrations–29 Testis and Associated Structures ...... Illustrations–7 Omentum and Mesentery ...... Illustrations–30 Thymus ...... Illustrations–8 Peritoneum and Retroperitoneum ... Illustrations–30 Chapter 6. Diseases of the Nervous System Chapter 12. Diseases of the Skin and Subcutaneous (G00–G99) ...... Illustrations–9 Tissue (L00–L99) ...... Illustrations–31 Brain ...... Illustrations–9 Nail Anatomy ...... Illustrations–31 Cranial Nerves ...... Illustrations–9 Skin and Subcutaneous Tissue ...... Illustrations–31 Peripheral Nervous System ...... Illustrations–10 Chapter 13. Diseases of the Musculoskeletal System Spinal Cord and Spinal Nerves ...... Illustrations–11 and Connective Tissue (M00–M99) ...... Illustrations–32 Nerve Cell ...... Illustrations–12 Bones and Joints ...... Illustrations–32 Chapter 7. Diseases of the Eye and Adnexa Shoulder Anterior View ...... Illustrations–33 (H00–H59) ...... Illustrations–13 Shoulder Posterior View ...... Illustrations–33 Eye ...... Illustrations–13 Elbow Anterior View ...... Illustrations–33 Posterior Pole of Globe/Flow of Elbow Posterior View ...... Illustrations–33 Aqueous Humor ...... Illustrations–13 Hand ...... Illustrations–33 Lacrimal System ...... Illustrations–14 Hip Anterior View ...... Illustrations–34 Eye Musculature ...... Illustrations–14 Hip Posterior View ...... Illustrations–34 Eyelid Structures ...... Illustrations–14 Knee Anterior View ...... Illustrations–34 Chapter 8. Diseases of the Ear and Mastoid Knee Posterior View ...... Illustrations–34 Process (H60–H95) ...... Illustrations–15 Foot ...... Illustrations–34 Ear Anatomy ...... Illustrations–15 Muscles...... Illustrations–35 Chapter 9. Diseases of the Circulatory Chapter 14. Diseases of the Genitourinary System (I00–I99) ...... Illustrations–16 System (N00–N99) ...... Illustrations–36 Anatomy of the Heart ...... Illustrations–16 Urinary System ...... Illustrations–36 Heart Cross Section ...... Illustrations–16 Male Genitourinary System ...... Illustrations–37 Heart Valves ...... Illustrations–17 Female Internal Genitalia ...... Illustrations–37 Heart Conduction System ...... Illustrations–17 Female Genitourinary Tract Lateral Coronary Arteries ...... Illustrations–18 View ...... Illustrations–37 Arteries ...... Illustrations–19 Chapter 15. Pregnancy, Childbirth and the Veins ...... Illustrations–20 Puerperium (O00–O9A) ...... Illustrations–38 Internal Carotid and Vertebral Term Pregnancy – Single Arteries and Branches ...... Illustrations–21 Gestation ...... Illustrations–38 External Carotid Artery and Twin Gestation–Dichorionic– Branches ...... Illustrations–21 Diamniotic (DI-DI) ...... Illustrations–38 Branches of Abdominal Aorta ...... Illustrations–22 Twin Gestation–Monochorionic– Portal Venous Circulation ...... Illustrations–22 Diamniotic (MO-DI) ...... Illustrations–39 Lymphatic System ...... Illustrations–23 Twin Gestation–Monochorionic– Axillary Lymph Nodes ...... Illustrations–24 Monoamniotic (MO-MO) ...... Illustrations–39 Lymphatic System of Head Chapter 19. Injury, Poisoning and Certain Other and Neck ...... Illustrations–24 Consequences of External Causes Lymphatic Capillaries ...... Illustrations–25 (S00-T88) ...... Illustrations–40 Lymphatic Drainage ...... Illustrations–25 Types of Fractures ...... Illustrations–40 Chapter 10. Diseases of the Respiratory Salter-Harris Fracture Types ...... Illustrations–40 System (J00–J99) ...... Illustrations–26 Respiratory System SAMPLE...... Illustrations–26

ii ICD-10-CM 2022 ICD-10-CM 2022 How to Use ICD-10-CM Expert for Skilled Nursing Facilities and Inpatient Rehabilitation Facilities 2022 How t o U se ICD-10-C M Indexes Default Codes In the index, the default code is the code listed next to the main term and represents the condition most commonly associated with that main term. Index to Diseases and Injuries This code may be assigned when documentation does not support The Index to Diseases and Injuries is arranged in alphabetic order by terms reporting a more specific code. Alternatively, it may provide an specific to a , condition, illness, injury, eponym, or abbreviation as unspecified code for the condition. well as terms that describe circumstances other than a disease or injury that may require attention from a health care professional. Hemiatrophy R68.89 cerebellar G31.9 Neoplasm Table face, facial, progressive (Romberg) G51.8 Expert f or Ski lled Nursing F acilities a nd In patient Rehabilitation F acilities The Neoplasm Table is arranged in alphabetic order by anatomical site. tongue K14.8 Codes are then listed in individual columns based upon the histological Parentheses behavior (malignant, in situ, benign, uncertain, or unspecified) of the Parentheses in the indexes enclose nonessential modifiers, neoplasm. supplementary words that may be present or absent in the statement of a disease without affecting the code. Table of Drugs and Chemicals The Table of Drugs and Chemicals is arranged in alphabetic order by the Pseudomeningocele (cerebral) (infective) (post-traumatic) specific drug or chemical name. Codes are listed in individual columns G96.198 based upon the associated intent (poisoning, adverse effect, or postprocedural (spinal) G97.82 underdosing). Brackets External Causes Index ICD-10-CM has a coding convention addressing code assignment for The External Causes Index is arranged in alphabetic order by main terms manifestations that occur as a result of an underlying condition. This that describe the cause, the intent, the place of occurrence, the activity, convention requires the underlying condition to be sequenced first, and the status of the patient at the time the injury occurred or health followed by the code or codes for the associated manifestation. In the condition arose. index, italicized codes in brackets identify manifestation codes. Polyneuropathy (peripheral) G62.9 Index Notations alcoholic G62.1 With amyloid (Portuguese) E85.1 [G63] The word “with” or “in” should be interpreted to mean “associated with” or transthyretin-related (ATTR) familial E85.1 [G63] “due to.” The classification presumes a causal relationship between the two conditions linked by these terms in the index. These conditions Shaded Guides should be coded as related even in the absence of provider Exclusive vertical shaded guides in the Index to Diseases and Injuries and documentation explicitly linking them unless the documentation clearly External Causes Index help the user easily follow the indent levels for the states the conditions are unrelated or when another guideline specifically subentries under a main term. Sequencing rules may apply depending on requires a documented linkage between two conditions (e.g., the sepsis the level of indent for separate subentries. guideline for “acute organ dysfunction that is not clearly associated with the sepsis”). For conditions not specifically linked by these relational terms Hemicrania in the classification or when a guideline requires explicit documentation congenitalmalformationQ00.0 of a linkage between two conditions, provider documentation must link continuaG44.51 meaning— seealsoMigraineG43.909 the conditions to code them as related. paroxysmalG44.039 202 2 chronic G44.049 The word “with” in the index is sequenced immediately following the intractable G44.041 main term, not in alphabetical order. not intractable G44.049 episodic G44.039 Dermatopolymyositis M33.90 intractable G44.031 with not intractable G44.039 myopathy M33.92 intractable G44.031 respiratory involvement M33.91 not intractable G44.039 specified organ involvement NEC M33.99 in neoplastic disease — see also Neoplasm D49.9 [M36.0] Following References The Index to Diseases and Injuries includes following references to assist See in locating out-of-sequence codes in the tabular list. Out-of-sequence When the instruction “see” follows a term in the index, it indicates that codes contain an alphabetic character (letter) in the third- or another term must be referencedSAMPLE to locate the correct code. fourth-character position. These codes are placed according to the classification rules — according to condition — not according to Hematoperitoneum — see Hemoperitoneum alphabetic or numeric sequencing rules. See Also The instructional note “see also” simply provides alternative terms the Carcinoma (malignant) — see also Neoplasm, by site, malignant see also coder may reference that may be useful in determining the correct code neuroendocrine — Tumor, neuroendocrine high grade, any site C7A.1 (following C75) but are not necessary to follow if the main term supplies the appropriate poorly differentiated, any site C7A.1 (following C75) code.

Hematinuria — see also Hemaglobinuria malarial B50.8

ICD-10-CM 2022 v How to Use ICD-10-CM Expert for Skilled Nursing Facilities and Inpatient Rehabilitation Facilities 2022 ICD-10-CM 2022

2 Additional Character Required code. This convention is especially useful when the codes describe The Index to Diseases and Injuries, Neoplasm Table, and External Causes laterality, such as the following codes from subcategory H40.22: Index provide an icon after certain codes to signify to the user that additional characters are required to make the code valid. The tabular list d H40.22 Chronic angle-closure glaucoma should be consulted for appropriate character selection. Chronic primary angle-closure glaucoma e H40.221 Chronic angle-closure glaucoma, right eye W e H40.222 Chronic angle-closure glaucoma, left eye W Fall, falling (accidental) W19 S e H40.223 Chronic angle-closure glaucoma, bilateral W building W20.1 S e H40.229 Chronic angle-closure glaucoma, unspecified eye W bilitation Facilities 202 Facilities bilitation Tabular List of Diseases Tabular Notations ICD-10-CM codes and descriptions are arranged numerically within the Official parenthetical notes as well as Optum360’s supplementary

Reha tabular list of diseases with 19 separate chapters providing codes notations are provided at the chapter, code block, category, subcategory, associated with a particular body system or nature of injury or disease. and individual code level to help the user assign proper codes. The There is also a chapter providing codes for external causes of an injury or information in the notation can apply to one or more codes depending on health conditions, a chapter for codes that address encounters with where the citation is placed. healthcare facilities for circumstances other than a disease or injury, and finally, a chapter for codes that capture special circumstances such as new diseases of uncertain etiology or emergency use codes. Official Notations Includes Notes Code and Code Descriptions The word 1 appears immediately under certain categories to ICD-10-CM is an alphanumeric classification system that contains further define, clarify, or give examples of the content of a code category. categories, subcategories, and valid codes. The first character is always a letter with any additional characters represented by either a letter or Inclusion Terms number. A three-character category without further subclassification is Lists of inclusion terms are included under certain codes. These terms equivalent to a valid three-character code. Valid codes may be three, four, indicate some of the conditions for which that code number may be used. five, six, or seven characters in length, with each level of subdivision after Inclusion terms may be synonyms with the code title, or, in the case of a three-character category representing a subcategory. The final level of “other specified” codes, the terms may also provide a list of various conditions included within a classification code. The inclusion terms are lities and Inpatient and Faci lities Nursing Skilled subdivision is a valid code. not exhaustive. The index may provide additional terms that may also be for Boldface assigned to a given code. Boldface type is used for all codes and descriptions in the tabular list. Excludes Notes Italics ICD-10-CM has two types of excludes notes. Each note has a different Italicized type is used to identify manifestation codes, those codes that definition for use. However, they are similar in that they both indicate that should not be reported as first-listed diagnoses. codes excluded from each other are independent of each other. Deleted Text Excludes 1 Strikethrough on a code and code description indicates a deletion from An 1 note is a “pure” excludes. It means “NOT CODED HERE!” An the classification for the current year. Excludes 1 note indicates mutually exclusive codes: two conditions that cannot be reported together. An Excludes 1 note indicates that the code Key Word excluded should never be used at the same time as the code above the Green font is used throughout the Tabular List of Diseases to differentiate Excludes 1 note. An Excludes 1 is used when two conditions cannot occur the key words that appear in similar code descriptions in a given category

E xpert IC D-10-CM U se t o How together, such as a congenital form versus an acquired form of the same or subcategory. The key word convention is used only in those categories condition. in which there are multiple codes with very similar descriptions with only a few words that differentiate them. An exception to the Excludes 1 definition is when the two conditions are unrelated to each other. If it is not clear whether the two conditions For example, refer to the list of codes below from category H55: involving an Excludes 1 note are related or not, query the provider. For example, code F45.8 Other somatoform disorders, has an Excludes 1 note b H55 Nystagmus and other irregular eye movements for “sleep related teeth grinding (G47.63)” because “teeth grinding” is an c H55.0 Nystagmus inclusion term under F45.8. Only one of these two codes should be H55.00 Unspecified nystagmus W assigned for teeth grinding. However, psychogenic dysmenorrhea is also H55.01 Congenital nystagmus W an inclusion term under F45.8, and a patient could have both this H55.02 Latent nystagmus W condition and sleep-related teeth grinding. In this case, the two H55.03 Visual deprivation nystagmus W conditions are clearly unrelated to each other, so it would be appropriate H55.04 DissociatedSAMPLE nystagmus W H55.09 Other forms of nystagmus W to report F45.8 and G47.63 together. Excludes 2 The portion of the code description that appears in green font in the An 2 note means “NOT INCLUDED HERE.” An Excludes 2 note tabular list helps the coder quickly identify the key terms and the correct indicates that although the excluded condition is not part of the condition it is excluded from, a patient may have both conditions at the same time. Therefore, when an Excludes 2 note appears under a code, it may be acceptable to use both the code and the excluded code together if supported by the medical documentation.

vi ICD-10-CM 2022 10 Steps to Correct Coding

Follow the 10 steps below to correctly code encounters for health care • “NEC,” abbreviation for “not elsewhere classified,” follows some main services. terms or subterms and indicates that there is no specific code for the condition even though the medical documentation may be very specific. Step 1: Identify the reason for the visit or encounter (i.e., a sign, symptom, diagnosis and/or condition). • “NOS,” abbreviation for “not otherwise specified,” follows some main The medical record documentation should accurately reflect the patient’s terms or subterms and is the equivalent of unspecified; NOS signifies condition, using terminology that includes specific diagnoses and that the information in the medical record is insufficient for assigning symptoms or clearly states the reasons for the encounter. a more specific code. 10 Steps to Correct Coding Coding Correct to Steps 10 • Following references help coders locate alphanumeric codes that are Choosing the main term that best describes the reason chiefly responsible out of sequence in the tabular section. for the service provided is the most important step in coding. If symptoms are present and documented but a definitive diagnosis has not yet been • Check-additional-character symbols flag codes that require determined, code the symptoms. For outpatient cases, do not code additional characters to make the code valid; the characters available conditions that are referred to as “rule out,” “suspected,” “probable,” or to complete the code should be verified in the tabular section. “questionable.” Diagnoses often are not established at the time of the Step 6: Choose a potential code and locate it in the initial encounter/visit and may require two or more visits to be tabular list. established. Code only what is documented in the available outpatient To prevent coding errors, always use both the alphabetic index (to identify records and only to the highest degree of certainty known at the time of a code) and the tabular list (to verify a code), as the index does not include the patient’s visit. For inpatient medical records, uncertain diagnoses may the important instructional notes found in the tabular list. An added be reported if documented at the time of discharge. benefit of using the tabular list, which groups like things together, is that Step 2: After selecting the reason for the encounter, while looking at one code in the list, a coder might see a more specific one consult the alphabetic index. that would have been missed had the coder relied solely on the The most critical rule is to begin code selection in the alphabetic index. alphabetic index. Additionally, many of the codes require a fourth, fifth, Never turn first to the tabular list. The index provides cross-references, sixth, or seventh character to be valid, and many of these characters can essential and nonessential modifiers, and other instructional notations be found only in the tabular list. that may not be found in the tabular list. Step 7: Read all instructional material in the tabular Step 3: Locate the main term entry. section. The alphabetic index lists conditions, which may be expressed as nouns or The coder must follow any Includes, Excludes 1 and Excludes 2 notes, and eponyms, with critical use of adjectives. Some conditions known by other instructional notes, such as “Code first” and “Use additional code,” several names have multiple main entries. Reasons for encounters may be listed in the tabular list for the chapter, category, subcategory, and located under general terms such as admission, encounter, and subclassification levels of code selection that direct the coder to use a examination. Other general terms such as history, status (post), or different or additional code. Any codes in the tabular range A00.0- presence (of) can be used to locate other factors influencing health. through T88.9- may be used to identify the diagnostic reason for the encounter. The tabular list encompasses many codes describing disease Step 4: Scan subterm entries. and injury classifications (e.g., infectious and parasitic diseases, Scan the subterm entries, as appropriate, being sure to review continued neoplasms, symptoms, nervous and circulatory system etc.). lines and additional subterms that may appear in the next column or on the next page. Shaded vertical guidelines in the index indicate the Codes that describe symptoms and signs, as opposed to definitive indentation level for each subterm in relation to the main terms. diagnoses, should be reported when an established diagnosis has not been made (confirmed) by the physician. Chapter 18 of the ICD-10-CM Step 5: Pay close attention to index instructions. code book, “Symptoms, Signs, and Abnormal Clinical and Laboratory • Parentheses ( ) enclose nonessential modifiers, terms that are Findings, Not Elsewhere Classified” (codes R00.-–R99), contains many, but supplementary words or explanatory information that may or may not not all, codes for symptoms. appear in the diagnostic statement and do not affect code selection. ICD-10-CM classifies encounters with health care providers for • Brackets [ ] enclose manifestation codes that can be used only as circumstances other than a disease or injury in chapter 21, “Factors secondary codes to the underlying condition code immediately Influencing Health Status and Contact with Health Services” (codes preceding it. If used, manifestation codes must be reported with the Z00–Z99). Circumstances other than a disease or injury often are recorded appropriate etiology codes. as chiefly responsible for the encounter. • Default codes are listed next to the main term and represent the condition most commonly associated with the main term or the A code is invalid if it does not include the full number of characters unspecified code for the main term. (greatest level of specificity) required. Codes in ICD-10-CM can contain from three to seven alphanumeric characters. A three-character code is to •“See” cross-references, identified by italicizedSAMPLE type and “code by” be used only if the category is not further subdivided into four-, five-, six-, cross-references indicate that another term must be referenced to locate or seven-character codes. Placeholder character X is used as part of an the correct code. alphanumeric code to allow for future expansion and as a placeholder for •“See also” cross-references, identified by italicized type, provide empty characters in a code that requires a seventh character but has no alternative terms that may be useful to look up but are not mandatory. fourth, fifth, or sixth character. Note that certain categories require • “Omit code” cross-references identify instances when a code is not seventh characters that apply to all codes in that category. Always check applicable depending on the condition being coded. the category level for applicable seventh characters for that category. • “With” subterms are listed out of alphabetic order and identify a Step 8: Consult the official ICD-10-CM conventions and presumed causal relationship between the two conditions they link. guidelines. • “Due to” subterms identify a relationship between the two conditions The ICD-10-CM Official Guidelines for Coding and Reporting govern the use they link. of certain codes. These guidelines provide both general and chapter-specific coding guidance.

xx ICD-10-CM 2022 Admission ICD-10-CM 2022 Admission — continued Admission — continued Aftercare — continued examination at health care facility — seealso Examina- removal of — continued following surgery (for) (on) tion — continued drains Z48.03 amputation Z47.81 vision — continued dressing (nonsurgical) Z48.00 attention to Index infant or child (over 28 days old) Z00.129 implantable subdermal contraceptive Z30.46 drains Z48.03 with abnormal findings Z00.121 intrauterine contraceptive device Z30.432 dressings (nonsurgical) Z48.00 fitting (of) neuropacemaker (brain) (peripheral nerve) (spinal surgical Z48.01 artificial cord) Z46.2 sutures Z48.02 arm — see Admission, adjustment, artificial, arm implanted Z45.42 circulatory system Z48.812 eye Z44.2 S staples Z48.02 delayed (planned) wound closure Z48.1 leg — see Admission, adjustment, artificial, leg surgical dressing Z48.01 digestive system Z48.815 brain neuropacemaker Z46.2 sutures Z48.02 explantation of joint prosthesis (staged procedure) implanted Z45.42 ureteral stent Z46.6 hip Z47.32 breast prosthesis (external) Z44.3 S respirator [ventilator] use during power failure Z99.12 knee Z47.33 colostomy belt Z46.89 restoration of organ continuity (poststerilization) Z31.0 shoulder Z47.31 contact lenses Z46.0 aftercare Z31.42 genitourinary system Z48.816 cystostomy device Z46.6 sensitivity test — see also Test, skin joint replacement Z47.1 dental prosthesis Z46.3 allergy NEC Z01.82 neoplasm Z48.3 dentures Z46.3 Mantoux Z11.1 nervous system Z48.811 device NEC tuboplasty following previous sterilization Z31.0 oral cavity Z48.814 abdominal Z46.89 aftercare Z31.42 organ transplant nervous system Z46.2 vasoplasty following previous sterilization Z31.0 bone marrow Z48.290 implanted — see Admission, adjustment, aftercare Z31.42 heart Z48.21 device, implanted, nervous system vision examination Z01.00 heart-lung Z48.280 orthodontic Z46.4 with abnormal findings Z01.01 kidney Z48.22 prosthetic Z44.9 following failed vision screening Z01.020 liver Z48.23 breast Z44.3 S with abnormal findings Z01.021 lung Z48.24 dental Z46.3 infant or child (over 28 days old) Z00.129 multiple organs NEC Z48.288 eye Z44.2 S with abnormal findings Z00.121 specified NEC Z48.298 substitution waiting period for admission to other facility Z75.1 orthopedic NEC Z47.89 auditory Z46.2 Adnexitis (suppurative) — see Salpingo-oophoritis planned wound closure Z48.1 implanted — see Admission, adjustment, Adolescent X-linked adrenoleukodystrophy E71.521 removal of internal fixation device Z47.2 device, implanted, hearing device Adrenal (gland) — see condition respiratory system Z48.813 nervous system Z46.2 Adrenalism, tuberculous A18.7 scoliosis Z47.82 implanted — see Admission, adjustment, Adrenalitis, adrenitis E27.8 sense organs Z48.810 device, implanted, nervous system autoimmune E27.1 skin and subcutaneous tissue Z48.817 visual Z46.2 meningococcal, hemorrhagic A39.1 specified body system implanted Z45.31 Adrenarche, premature E27.0 circulatory Z48.812 hearing aid Z46.1 Adrenocortical syndrome — see Cushing's, syndrome digestive Z48.815 ileostomy device Z46.89 Adrenogenital syndrome E25.9 genitourinary Z48.816 intestinal appliance or device NEC Z46.89 acquired E25.8 nervous Z48.811 neuropacemaker (brain) (peripheral nerve) (spinal congenital E25.0 oral cavity Z48.814 cord) Z46.2 salt loss E25.0 respiratory Z48.813 implanted Z45.42 Adrenogenitalism, congenital E25.0 sense organs Z48.810 orthodontic device Z46.4 Adrenoleukodystrophy E71.529 skin and subcutaneous tissue Z48.817 orthopedic device (brace) (cast) (shoes) Z46.89 neonatal E71.511 teeth Z48.814 prosthesis Z44.9 X-linked E71.529 specified NEC Z48.89 arm — see Admission, adjustment, artificial, arm Addison only phenotype E71.528 spinal Z47.89 breast Z44.3 S Addison-Schilder E71.528 teeth Z48.814 dental Z46.3 adolescent E71.521 fracture — code to fracture with seventh character D eye Z44.2 S adrenomyeloneuropathy E71.522 involving leg — see Admission, adjustment, artificial, leg childhood cerebral E71.520 removal of specified type NEC Z44.8 other specified E71.528 drains Z48.03 spectacles Z46.0 Adrenomyeloneuropathy E71.522 dressings (nonsurgical) Z48.00 follow-up examination Z09 Adventitious bursa — see Bursopathy, specified type staples Z48.02 intrauterine device management Z30.431 NEC surgical dressings Z48.01 initial prescription Z30.014 Adverse effect — see Table of Drugs and Chemicals, sutures Z48.02 mental health evaluation Z00.8 categories T36-T50, with 6th character 5 neuropacemaker (brain) (peripheral nerve) (spinal cord) requested by authority Z04.6 Advice — see Counseling Z46.2 observation — see Observation Adynamia (episodica) (hereditary) (periodic) G72.3 implanted Z45.42 orthopedic NEC Z47.89 Papanicolaou smear, cervix Z12.4 Aeration lung imperfect, newborn — see Atelectasis postprocedural — see Aftercare, following surgery for suspected malignant neoplasm Z12.4 Aerobullosis T70.3 S After-cataract — see Cataract, secondary plastic and reconstructive surgery following medical Aerocele — see Embolism, air procedure or healed injury NEC Z42.8 Agalactia (primary) O92.3 Aerodermectasia elective, secondary or therapeutic O92.5 plastic surgery, cosmetic NEC Z41.1 subcutaneous (traumatic) T79.7 S postpartum observation Agammaglobulinemia(acquired (secondary) (nonfamil- Aerodontalgia T70.29 S ial) D80.1 immediately after delivery Z39.0 Aeroembolism T70.3 S routine follow-up Z39.2 with Aerogenes capsulatus infection A48.0 immunoglobulin-bearing B-lymphocytes D80.1 poststerilization (for restoration) Z31.0 Aero-otitis media T70.0 S aftercare Z31.42 lymphopenia D81.9 Aerophagy, aerophagia (psychogenic) F45.8 autosomal recessive (Swiss type) D80.0 procreative management Z31.9 Aerophobia F40.228 prophylactic (measure) — seealso Encounter, prophy- Bruton's X-linked D80.0 SAMPLEAerosinusitis T70.1 S common variable (CVAgamma) D80.1 lactic measures Aerotitis T70.0 S organ removal Z40.00 congenital sex-linked D80.0 Affection — see Disease breast Z40.01 hereditary D80.0 fallopian tube(s) Z40.03 Afibrinogenemia — see also Defect, coagulation D68.8 lymphopenic D81.9 with ovary(s) Z40.02 acquired D65 Swiss type (autosomal recessive) D80.0 ovary(s) Z40.02 congenital D68.2 X-linked (with growth hormone deficiency) (Bruton) specified organ NEC Z40.09 following ectopic or molar pregnancy O08.1 D80.0 testes Z40.09 in abortion — see Abortion, by type, complicated by, Aganglionosis (bowel) (colon) Q43.1 vaccination Z23 afibrinogenemia Age (old) — see Senility psychiatric examination (general) Z00.8 puerperal O72.3 Agenesis requested by authority Z04.6 African adrenal (gland) Q89.1 radiation therapy (antineoplastic) Z51.0 sleeping sickness B56.9 alimentary tract (complete) (partial) NEC Q45.8 reconstructive surgery following medical procedure or tick fever A68.1 upper Q40.8 healed injury NEC Z42.8 trypanosomiasis B56.9 anus, anal (canal) Q42.3 removal of gambian B56.0 with fistula Q42.2 cystostomy catheter Z43.5 rhodesian B56.1 aorta Q25.41 Aftercare — see also Care Z51.89 Admission — Agenesis 14 S Additional Character Required — Refer to the Tabular List for Character Selection 2 Subterms under main terms may continue to next column or page Chapter 4. Endocrine, Nutritional and Metabolic Diseases 519

-year 10 Guidelines and Examples and Guidelines (E00–E89) Underdosing of insulin and oral hypoglycemic hypoglycemic oral and insulin of Underdosing [antidiabetic] drugs, subsequent encounter 2 hyperglycemia mellitusType with chronic 2 diabetic mellitusType with diabetes disease kidney disease renal stage End Breakdown (mechanical) of insulin pump, pump, insulin of (mechanical) Breakdown encounter subsequent Breakdown (mechanical) of insulin pump, pump, insulin of (mechanical) Breakdown subsequent encounter hypoglycemic and oral by insulin Poisoning [antidiabetic] drugs, accidental (unintentional), subsequent encounter withdiabetes hypoglycemia 2 mellitus Type without coma : The complication code for the mechanical : The complication code for the mechanical Type mellitus 2 diabetes complications without Long term (current) use of insulin : Do not assume that a patient requiring insulin use must -year-old female with is found on the floor 70 Explanation breakdownof the pump is sequenced followed first, codeby the any associated with diabetes of type and poisoning for subsequent for is used D character seventh The complications. encounter. T38.3X6D E11.65 E11.22 N18.6 Explanation breakdownof the pump is sequenced followed first, by the with diabetes of type the for code and code underdosing assign are present, complications diabetic other If complication. seventh The complication. each capture to needed codes all encounter. for a subsequent D used is character A T85.614D T38.3X1D E11.649 A 76-year-old male with diabetic ESRD is admitted for for admitted is ESRD diabetic with male 76-year-old A insulin had an He has hyperglycemia. develops and rehabilitation to noted is ER, the from returning after and years 14 for pump that malfunction pump a to due hyperglycemia experienced have caused too little insulin to be administered. On return, the blood aresugars resolving. T85.614D thatis noted return from the hospital,it On her to the ER. sentand insulin excess insulinthat caused pump of her failure a administration was the cause of hypoglycemia, resulting in her condition. The principal or first-listed code for an encounter due to an insulin insulin an to due encounter an for code first-listed or The principal pumpoverdoseinsulin,be resultingan should malfunction also of in T85.6-, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, followed by code T38.3X1-, Poisoning by insulin and oral hypoglycemic [antidiabetic] (unintentional). accidental drugs, An underdose of insulin due to an insulin pump failure should be complication Mechanical T85.6, subcategory from a code to assigned of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the Underdosing by code T38.3X6-, followed code, first-listed or principal of insulin and oral hypoglycemic [antidiabetic] drugs. Additional any associated and mellitus diabetes of type the for codes complications due to the underdosing should also be assigned. history of diabetes requiring daily insulin use. Patient referredis with documented provider notes reporting E11.9 Z79.4 Explanation have . The default for diabetes without further specification defaults to type 2. Add the code for long-term use of insulin. (b) Overdose of insulin dueto pump of insulin Overdose insulin (b) failure See Section I.C.15. Diabetes mellitus in pregnancy. in mellitus Diabetes I.C.15. Section See induced) diabetes (pregnancy I.C.15. Gestational See Section failure (a) pump insulin to due insulin of Underdose 4) pregnancy Diabetes mellitus and in gestationaldiabetes 5) Complications due insulin pump malfunction to

d with both oral Endocrine, Nutritional and Metabolic Diseases Metabolic and Nutritional Endocrine, .”

00 Chapter 4. -CM Official Guidelines for for Guidelines Official -CM 0 SAMPLE the patient is treate determining factor, though most type s that describe more than one If the patient is treated with treated insulin both If the is patient Type 2 diabetes mellitus withoutType 2 mellitus diabetes complications Essential (primary) hypertension Type 1 diabetes mellitus withoutType 1 mellitus diabetes complications : Since the oftype diabetes was not documented and no : Although most type 1 diabetics are diagnosed in Type 2 diabetes mellitus with 2Type polyneuropathy mellitus diabetic diabetes Type 2 diabetes mellitus with 2Type mellitus diabetes hyperglycemia with 2 diabetic mellitus unspecified Type diabetes retinopathy macular with edema Code Z79.4 should not be assigned if insulin is given : Use as many codes to describe the diabetic complications as complications diabetic the describe to codes many as : Use E11.9 I10 Explanation complications were noted, the default code is E11.9. E10.9 Explanation Patient is referred with new diagnoses reported in provider clinical hypertension. and diabetes as notes A 45-year-old patient is diagnosed with type 1 diabetes. in itadults. can also begin adolescence, or childhood injectable non-insulin drugs non-insulin injectable the documentationIf medicalin a recordindicatenot type doesthe of 2 Type E11-, code insulin, uses patient the that indicate does but diabetes diabetes mellitus, should be assigned. An additional code should be assigned fromcategory Z79toidentify the long-term (current) useof If drugs. hypoglycemic oral or insulin If the typeofIf diabetesmellitus is not documented the medicalrecord in the default is E11.-, Type 2 diabetes mellitus. The age of a patient is not the sole reasonthis For puberty. thebefore develop condition diabetics reaching 1 type1diabetes mellitusis also referred to as juvenilediabetes. medications medications and insulin, only the usecode of for long-term (current) insulin should be assigned. temporarilyto type patient’s a 2 bring blood sugar under control during an encounter. and an injectable non-insulin antidiabetic drug, assign codes Z79.4, codes drug, assign antidiabetic non-insulin injectable anand Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. is If patient treated with the both oral antidiabetic hypoglycemic non-insulin and injectable drugs an drug, assign codes Z79.84, Long-term (current) use of oral drug (current) long-term Other Z79.899, and drugs, hypoglycemic therapy. E11.65 E11.311 E11.42 Explanation codecombination are Many needed. condition. “Uncontrolled” hypo- reference or may based hyperglycemia, documentation. provider available upon Patient is admitted with reported diagnoses of uncontrolled diabetes, diabetictype with 2, polyneuropathy diabetic and retinopathywith of HgA1c current a indicate notes clinical Endocrinology edema. macular 12.4and “persistent blood glucose elevationsover3 3) oral and hypoglycemics, use and of insulin, the Diabetes mellitus 2) mellitus documented not of diabetes Type 1) diabetes of Type The diabetes mellitus codes are combination codes that include the type of of type the include that codes combination are codes mellitus diabetes The affecting complications the and affected, system body the mellitus, diabetes are as category a particular within As many codes system. body that necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason afor particular encounter. of all identify to needed as E08–E13 categories from codes many as Assign associatedthe conditionsthat the patient has. The chapter-specific guidelines from the ICD-1 Chapter4. Nutritional Endocrine, and Metabolic Diseases Examples Coding with Guidelines Chapter-specific guidelines these with Along below. provided been have Reporting and Coding are coding examples, contained in the shaded boxes, that have been developed these in foundsequencing guidance coding and/or the illustrate to help guidelines. a. Diabetes mellitus ICD-10-CM 2022 2 202 ICD-10-CM J63–J70.0 Chapter 10. Diseases of the Respiratory System ICD-10-CM 2022 b J63 Pneumoconiosis due to other inorganic dusts b J68 Respiratory conditions due to inhalation of chemicals, gases, 1 pneumoconiosis with tuberculosis, any type in A15 (J65) fumes and vapors Code first (T51-T65) to identify cause J63.0 Aluminosis (of lung) Use additional code to identify associated respiratory conditions, such J63.1 Bauxite fibrosis (of lung) as: J63.2 acute respiratory failure (J96.0-) J63.3 Graphite fibrosis (of lung) J68.0 and pneumonitis due to chemicals, gases, fumes J63.4 Siderosis and vapors WA AHA: 2019,3Q,8 Chemical bronchitis (acute) J63.5 Stannosis AHA: 2019,2Q,31 J63.6 Pneumoconiosis due to other specified inorganic dusts RIC Excl: 15 Pulmonary J64 Unspecified pneumoconiosis J68.1 Pulmonary edema due to chemicals, gases, fumes and 1 pneumonoconiosis with tuberculosis, any type in A15 (J65) vapors WA Chemical pulmonary edema (acute) (chronic) J65 Pneumoconiosis associated with tuberculosis pulmonary edema (acute) (chronic) NOS (J81.-) Any condition in J60-J64 with tuberculosis, any type in A15 1 RIC Excl: 15 Pulmonary Silicotuberculosis J68.2 Upper respiratory inflammation due to chemicals, gases, b J66 Airway disease due to specific organic dust fumes and vapors, not elsewhere classified W 2 allergic alveolitis (J67.-) J68.3 Other acute and subacute respiratory conditions due to asbestosis (J61) chemicals, gases, fumes and vapors W bagassosis (J67.1) Reactive airways dysfunction syndrome farmer's lung (J67.0) J68.4 Chronicrespiratoryconditionsduetochemicals,gases,fumes hypersensitivity pneumonitis due to organic dust (J67.-) and vapors W reactive airways dysfunction syndrome (J68.3) Emphysema (diffuse) (chronic) due to inhalation of chemicals, gases, fumes and vapors Chapter 10. Diseases of the Respiratory System J66.0 Airway disease due to cotton dust Obliterative bronchiolitis (chronic) (subacute) due to inhalation of chemicals, gases, fumes and vapors J66.1 Flax-dressers' disease Pulmonary fibrosis (chronic) due to inhalation of chemicals, J66.2 Cannabinosis gases, fumes and vapors J66.8 Airway disease due to other specific organic dusts 1 chronic pulmonary edema due to chemicals, gases, b J67 Hypersensitivity pneumonitis due to organic dust fumes and vapors (J68.1) 1 allergic alveolitis and pneumonitis due to inhaled organic J68.8 Other respiratory conditions due to chemicals, gases, fumes dust and particles of fungal, actinomycetic or other and vapors W origin J68.9 Unspecified respiratory condition due to chemicals, gases, 1 pneumonitis due to inhalation of chemicals, gases, fumes or fumes and vapors W vapors (J68.0) b J69 Pneumonitis due to solids and liquids J67.0 Farmer's lung 1 neonatal aspiration syndromes (P24.-) Harvester's lung postprocedural pneumonitis (J95.4) Haymaker's lung AHA: 2017,1Q,24 Moldy hay disease DEF: Pneumonitis: Noninfectious inflammation of the walls of the alveoli J67.1 Bagassosis in the lung tissue due to inhalation of food, vomit, oils, essences, or other Bagasse disease solids or liquids. Bagasse pneumonitis J69.0 Pneumonitis due to inhalation of food and vomit %A J67.2 Bird fancier's lung Aspiration pneumonia NOS Budgerigar fancier's disease or lung Aspiration pneumonia (due to) food (regurgitated) Pigeon fancier's disease or lung Aspiration pneumonia (due to) gastric secretions J67.3 Suberosis Aspiration pneumonia (due to) milk Corkhandler's disease or lung Aspiration pneumonia (due to) vomit Corkworker's disease or lung Code also any associated foreign body in respiratory tract (T17.-) J67.4 Maltworker's lung 1 chemical pneumonitis due to anesthesia (J95.4) Alveolitis due to Aspergillus clavatus obstetric aspiration pneumonitis (O74.0) J67.5 Mushroom-worker's lung AHA: 2020,2Q,11,28; 2019,3Q,17; 2019,2Q,6,31 J67.6 Maple-bark-stripper's lung TIP: Aspiration pneumonia is not classified to respiratory infection Alveolitis due to Cryptostroma corticale codes and does not warrant the assignment of J44.0 Chronic Cryptostromosis obstructive pulmonary disease with acute lower respiratory J67.7 Air conditioner and humidifier lung infection, when present concurrently with COPD. Allergic alveolitis due to fungal, thermophilic actinomycetes RIC Excl: 15 Pulmonary and other organisms growing in ventilation [air J69.1 Pneumonitis due to inhalation of oils and conditioning] systems essences W%A J67.8 Hypersensitivity pneumonitis due to other organic dusts Exogenous lipoid pneumonia Cheese-washer's lung Lipid pneumonia NOS Coffee-worker's lung Code first (T51-T65) to identify substance Fish-meal worker's lung 1 endogenous lipoid pneumonia (J84.89) Furrier's lung SAMPLERIC Excl: 15 Pulmonary Sequoiosis J69.8 Pneumonitis due to inhalation of other solids and J67.9 Hypersensitivity pneumonitis due to unspecified organic liquids W%A dust Pneumonitis due to aspiration of blood Allergic alveolitis (extrinsic) NOS Pneumonitis due to aspiration of detergent Hypersensitivity pneumonitis NOS Code first (T51-T65) to identify substance RIC Excl: 15 Pulmonary b J70 Respiratory conditions due to other external agents J70.0 Acute pulmonary manifestations due to radiation T Radiation pneumonitis Use additional code (W88-W90, X39.0-) to identify the external

J63–J70.0 cause

T Non-therapy Ancillary S Speech-Language Pathology W Return To Provider % RIC Dx u Primary Dx A RIC CC Condition Manifestation Unspecified Dx 704 ICD-10-CM 2022 K21–K26.3 Chapter 11. Diseases of the Digestive System ICD-10-CM 2022 b K21 Gastro-esophageal reflux disease K22.711 Barrett's esophagus with high grade 1 newborn esophageal reflux (P78.83) dysplasia W K22.719 Barrett's esophagus with dysplasia, s c K21.0 Gastro-esophageal reflux disease with esophagitis unspecified W Reflux esophagitis K22.8 Other specified diseases of esophagus WA l K21.00 Gastro-esophageal reflux disease with esophagitis, Hemorrhage of esophagus NOS without bleeding esophageal varices (I85.-) Reflux esophagitis 2 Paterson-Kelly syndrome (D50.1) l K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding AHA: 2020,1Q,16 K21.9 Gastro-esophageal reflux disease without esophagitis W RIC Excl: 15 Pulmonary Esophageal reflux NOS K22.9 Disease of esophagus, unspecified W AHA: 2016,1Q,18 K23 Disorders of esophagus in diseases classified elsewhere W b K22 Other diseases of esophagus Code first underlying disease, such as: congenital syphilis (A50.5) 2 esophageal varices (I85.-) 1 late syphilis (A52.79) K22.0 Achalasia of cardia megaesophagus due to Chagas' disease (B57.31) Achalasia NOS tuberculosis (A18.83) Cardiospasm 1 congenital cardiospasm (Q39.5) b K25 Gastric ulcer DEF: Esophageal motility disorder that is caused by absence of 1 erosion (acute) of stomach the esophageal peristalsis and impaired relaxation of the lower pylorus ulcer (peptic) esophageal sphincter. It is characterized by dysphagia, stomach ulcer (peptic) regurgitation, and heartburn. Use additional code to identify:

Chapter 11. Diseases of the Digestive System c K22.1 Ulcer of esophagus alcohol abuse and dependence (F10.-) Barrett's ulcer 1 acute gastritis (K29.0-) Erosion of esophagus peptic ulcer NOS (K27.-) Fungal ulcer of esophagus AHA: 2017,3Q,27 Peptic ulcer of esophagus K25.0 Acute gastric ulcer with hemorrhage WA Ulcer of esophagus due to ingestion of chemicals K25.1 Ulcer of esophagus due to ingestion of drugs and medicaments Acute gastric ulcer with perforation WA Ulcerative esophagitis K25.2 Acute gastric ulcer with both hemorrhage and perforation WA Code first poisoning due to drug or toxin, if applicable (T36-T65 with fifth or sixth character 1-4 or 6) K25.3 Acute gastric ulcer without hemorrhage or perforation W Use additional code for adverse effect, if applicable, to identify K25.4 Chronic or unspecified gastric ulcer with drug (T36-T50 with fifth or sixth character 5) hemorrhage WA 1 Barrett's esophagus (K22.7-) K25.5 Chronic or unspecified gastric ulcer with perforation WA AHA: 2018,3Q,22; 2017,3Q,27 K25.6 Chronic or unspecified gastric ulcer with both hemorrhage K22.10 Ulcer of esophagus without bleeding W and perforation WA Ulcer of esophagus NOS K25.7 Chronic gastric ulcer without hemorrhage or K22.11 Ulcer of esophagus with bleeding W perforation W 2 bleeding esophageal varices (I85.01, K25.9 Gastric ulcer, unspecified as acute or chronic, without I85.11) hemorrhage or perforation W K22.2 Esophageal obstruction Compression of esophagus Gastrointestinal Ulcers Constriction of esophagus Stenosis of esophagus Esophagus Stricture of esophagus Esophageal ulcer 1 congenitalstenosisorstrictureofesophagus(Q39.3) K22.3 Perforation of esophagus A Rupture of esophagus 1 traumatic perforation of (thoracic) esophagus Stomach (S27.8-) K22.4 of esophagus Corkscrew esophagus Duodenal ulcer Diffuse esophageal spasm Spasm of esophagus Gastric 1 cardiospasm (K22.0) ulcer K22.5 Diverticulum of esophagus, acquired W Small Esophageal pouch, acquired intestine 1 diverticulum of esophagus (congenital) (Q39.6) K22.6 Gastro-esophageal laceration-hemorrhage syndrome W Mallory-Weiss syndrome b K26 Duodenal ulcer c K22.7 Barrett's esophagus SAMPLE1 erosion (acute) of duodenum Barrett's disease duodenum ulcer (peptic) Barrett's syndrome postpyloric ulcer (peptic) 1 Barrett's ulcer (K22.1) Use additional code to identify: malignant neoplasm of esophagus (C15.-) alcohol abuse and dependence (F10.-) DEF: Metaplastic disorder in which specialized columnar epithelial 1 peptic ulcer NOS (K27.-) cells replace the normal squamous epithelial cells. Secondary to AHA: 2017,3Q,27 chronic gastroesophageal reflux damage to the mucosa, this K26.0 Acute duodenal ulcer with hemorrhage WA disorder increases the risk of developing adenocarcinoma. K26.1 Acute duodenal ulcer with perforation WA K22.70 Barrett's esophagus without dysplasia W K26.2 Acute duodenal ulcer with both hemorrhage and Barrett's esophagus NOS perforation WA d K22.71 Barrett's esophagus with dysplasia K26.3 Acute duodenal ulcer without hemorrhage or K21–K26.3 K22.710 Barrett's esophagus with low grade perforation W dysplasia W

T Non-therapy Ancillary S Speech-Language Pathology W Return To Provider % RIC Dx u Primary Dx A RIC CC Condition Manifestation Unspecified Dx 718 ICD-10-CM 2022 ICD-10-CM 2022 Chapter 19. Injury, Poisoning and Certain Other Consequences of External Causes S34–S35.19

b S34 Injury of lumbar and sacral spinal cord and nerves at abdomen, e S34.123 Incomplete lesion of L3 level of lumbar Causes External of Consequences Other Certain and Poisoning Injury, 19. Chapter lower back and pelvis level spinal cord % NOTE Code to highest level of lumbar cord injury. Incomplete lesion of lumbar spinal cord Injuries to the spinal cord (S34.0 and S34.1) refer to the cord level 3 level and not bone level injury, and can affect nerve roots e S34.124 Incomplete lesion of L4 level of lumbar at and below the level given. spinal cord % Incomplete lesion of lumbar spinal cord Code also any associated: level 4 fracture of vertebra (S22.0-, S32.0-) e S34.125 Incomplete lesion of L5 level of lumbar open wound of abdomen, lower back and pelvis (S31.-) spinal cord % transient paralysis (R29.5) Incomplete lesion of lumbar spinal cord The appropriate 7th character is to be added to each code from level 5 category S34. e S34.129 Incomplete lesion of unspecified level of A initial encounter lumbar spinal cord % D subsequent encounter d S34.13 Other and unspecified injury to sacral spinal cord S sequela Other injury to conus medullaris c S34.0 Concussion and edema of lumbar and sacral spinal cord e S34.131 Complete lesion of sacral spinal g S34.01 Concussion and edema of lumbar spinal cord % cord % Complete lesion of conus medullaris g S34.02 Concussion and edema of sacral spinal cord % e S34.132 Incomplete lesion of sacral spinal cord % Concussion and edema of conus medullaris Incomplete lesion of conus medullaris c S34.1 Other and unspecified injury of lumbar and sacral spinal cord e S34.139 Unspecified injury to sacral spinal d S34.10 Unspecified injury to lumbar spinal cord cord % e S34.101 Unspecified injury to L1 level of lumbar Unspecified injury of conus medullaris spinal cord % c S34.2 Injury of nerve root of lumbar and sacral spine Unspecified injury to lumbar spinal cord g S34.21 Injury of nerve root of lumbar spine % level 1 g S34.22 Injury of nerve root of sacral spine % e S34.102 Unspecified injury to L2 level of lumbar spinal cord % g S34.3 Injury of cauda equina % Unspecified injury to lumbar spinal cord g S34.4 Injury of lumbosacral plexus % level 2 g S34.5 Injury of lumbar, sacral and pelvic sympathetic nerves e S34.103 Unspecified injury to L3 level of lumbar Injury of celiac ganglion or plexus spinal cord % Injury of hypogastric plexus Unspecified injury to lumbar spinal cord Injury of mesenteric plexus (inferior) (superior) level 3 Injury of splanchnic nerve e S34.104 Unspecified injury to L4 level of lumbar spinal cord % g S34.6 Injury of peripheral nerve(s) at abdomen, lower back and pelvis level Unspecified injury to lumbar spinal cord level 4 g S34.8 Injury of other nerves at abdomen, lower back and pelvis level S34.105 Unspecified injury to L5 level of lumbar e S34.9 Injury of unspecified nerves at abdomen, lower back and spinal cord % g pelvis level Unspecified injury to lumbar spinal cord level 5 b S35 Injury of blood vessels at abdomen, lower back and pelvis level e S34.109 Unspecifiedinjurytounspecifiedlevelof Code also any associated open wound (S31.-) lumbar spinal cord % The appropriate 7th character is to be added to each code from d S34.11 Complete lesion of lumbar spinal cord category S35. e S34.111 Complete lesion of L1 level of lumbar A initial encounter spinal cord % D subsequent encounter Complete lesion of lumbar spinal cord level S sequela 1 c S35.0 Injury of abdominal aorta S34.112 Complete lesion of L2 level of lumbar e injury of aorta NOS (S25.0) spinal cord % 1 Complete lesion of lumbar spinal cord level g S35.00 Unspecified injury of abdominal aorta 2 g S35.01 Minor laceration of abdominal aorta e S34.113 Complete lesion of L3 level of lumbar Incomplete transection of abdominal aorta spinal cord % Laceration of abdominal aorta NOS Complete lesion of lumbar spinal cord level Superficial laceration of abdominal aorta 3 g S35.02 Major laceration of abdominal aorta e S34.114 Complete lesion of L4 level of lumbar Complete transection of abdominal aorta spinal cord % Traumatic rupture of abdominal aorta Complete lesion of lumbar spinal cord level S35.09 Other injury of abdominal aorta 4 g e S34.115 Complete lesion of L5 level of lumbar c S35.1 Injury of inferior vena cava SAMPLEspinal cord % Injury of hepatic vein Complete lesion of lumbar spinal cord level 1 injury of vena cava NOS (S25.2) 5 g S35.10 Unspecified injury of inferior vena cava e S34.119 Complete lesion of unspecified level of g S35.11 Minor laceration of inferior vena cava lumbar spinal cord % Incomplete transection of inferior vena cava S34.12 Incomplete lesion of lumbar spinal cord d Laceration of inferior vena cava NOS S34–S35.19 e S34.121 Incomplete lesion of L1 level of lumbar Superficial laceration of inferior vena cava spinal cord % S35.12 Major laceration of inferior vena cava Incomplete lesion of lumbar spinal cord g level 1 Complete transection of inferior vena cava e S34.122 Incomplete lesion of L2 level of lumbar Traumatic rupture of inferior vena cava spinal cord % g S35.19 Other injury of inferior vena cava Incomplete lesion of lumbar spinal cord level 2

SAdditional Character Req g Placeholder Alert 8 Newborn: 0 9 Pediatric: 0-17 x Maternity: 9-64 y Adult: 15-124 wx Revised Text l New Code s Revised Code Title ICD-10-CM 2022 1007 Appendix A: Valid 3-character ICD-10-CM Codes Appendixes–1 s associated with physiological with s associated a substance or known substance physiologicala or diseases classified elsewhere classified diseases

physiological condition condition elsewhere classified diseases factors and physical disturbances elsewhere elsewhere classified elsewhere

E43E45 Unspecified severe protein-calorie malnutrition E46 Retarded developmentfollowing protein-calorie malnutrition E52 Unspecified protein-calorie malnutrition E54 [pellagra] deficiency Niacin E58 acid deficiency Ascorbic E59 deficiency calcium Dietary E60 deficiency selenium Dietary E65 deficiency zinc Dietary E68 adiposity Localized F04hyperalimentation of Sequelae F05 condition to known due physiological disorder Amnestic F09 due to known physiological condition F21 Unspecified mental disorder due to knownF22 physiological condition disorder Schizotypal F23 disorders Delusional F24disorder psychotic Brief F28 Shared psychotic disorder Other psychoticdisordernot due substance to a known or F29 to Unspecified psychosis not due F39F42 Unspecified mood[affective] disorder F54 Obsessive-compulsive disorder Psychologicalbehavioraldisorders and associated or factors with F59 syndrome behavioral Unspecified F66F69 Other sexual disorders F70 Unspecified disorder of adult personalityF71 and behavior Mild intellectual disabilities F72 Moderate intellectual disabilities F73 Severe intellectual disabilities F78 Profound intellectual disabilities F79 Other intellectual disabilities F82 Unspecified intellectual disabilities F88 Specific developmental disorder of motor function F89 Other disordersof psychological development F99 Unspecified disorderpsychological of development G01 specified otherwise not disorder, Mental G02 elsewhere classified diseases bacterial in and Meningitisother infectious parasitic diseases in classified G07 Intracranialand intraspinal abscess andgranuloma G08 indiseases G09 Intracranialand intraspinal phlebitisand thrombophlebitis G10 system nervous central of diseases inflammatory of Sequelae G14 Huntington's disease G20 Postpolio syndrome G26 disease Parkinson's Extrapyramidal and movement disorders in diseases classified G35G53 Multiple sclerosis G55in disorders nerve Cranial G59 Nerve root and plexus compressions in diseases classified elsewhereG63 Mononeuropathy in diseases classified elsewhere G64 elsewhere classified diseases in Polyneuropathy G92 Other disorders of peripheral nervous system G94 Toxic encephalopathy H22 elsewhere classified in diseases of brain disorders Other H28 Disorders of iris and ciliary body in diseases classified elsewhere H32 elsewhere classified in diseases Cataract H36 elsewhere classified diseases in disorders Chorioretinal H42elsewhere in diseases classified Retinal disorders elsewhere classified in diseases Glaucoma SAMPLE [defibrination A syndrome] ation lymorphonuclear neutrophils lymorphonuclear n centralof nervous system membrane lesions membrane elsewhere classified A09A33 Infectious and colitis, unspecified A34 neonatorum Tetanus A35 Obstetrical tetanus A46 Other tetanus A55 Erysipelas A57(venereum) lymphogranuloma Chlamydial A58 Chancroid A64 Granuloma inguinale A65 Unspecified sexually transmitted disease A70 Nonvenereal syphilis A78 Chlamydia psittaci infections A86 Q fever A89 encephalitis viral Unspecified A90 infectio viral Unspecified A91fever dengue] [classical Dengue A94 fever hemorrhagic Dengue A99 fever viral arthropod-borne Unspecified B03 fever viral Unspecified hemorrhagic B04 Smallpox B09 Monkeypox mucous and skin by characterized infection viral Unspecified D77 Other disorders of blood and blood-forming organs in diseases Appendixes ICD-10-CM 3-character Codes Valid A: Appendix B20B49 [HIV] disease virus immunodeficiency Human B54 mycosis Unspecified B59 Unspecified malaria B64 Pneumocystosis B72 disease protozoal Unspecified B75 Dracunculiasis B79 Trichinellosis B80 Trichuriasis B86 Enterobiasis B89 Scabies B91 disease parasitic Unspecified B92 Sequelaepoliomyelitis of C01 Sequelae ofleprosy C07 Malignant neoplasm of base of tongue C12 Malignant neoplasm of parotid gland C19 Malignant neoplasm of pyriform sinus C20 Malignant neoplasm of rectosigmoid junction C23 Malignant neoplasm of rectum C33 Malignant neoplasm of gallbladder C37 Malignant neoplasm of trachea C52 Malignant neoplasm of thymus C55 Malignant neoplasm of vagina C58 Malignant neoplasm of uterus, unspecified part C61 Malignant neoplasm of placenta C73 Malignant neoplasm of prostate D34 Malignant neoplasm of thyroid gland D45 thyroid gland of neoplasm Benign D62 vera Polycythemia D65anemia posthemorrhagic Acute D66 Disseminated intravascular coagul D67 deficiency VIII factor Hereditary D71deficiency IX factor Hereditary Functionalof po disorders E02E15 Subclinical iodine-deficiency hypothyroidism E35 Nondiabetic hypoglycemiccoma E40 Disorders of endocrine glands in diseases classified elsewhere E41 Kwashiorkor E42 marasmus Nutritional kwashiorkor Marasmic ICD-10-CM 2022 Appendix H: Skilled Nursing Facility Active Diagnosis List X X X X X X X X X X PDPM Component Appendixes–49 Metabolic Nutritional Neurological Musculoskeletal malnutrition nephropathy, neuropathy) nephropathy, hyperthyroidism, Hashimoto’s thyroiditis) osteoarthritis, rheumatoid arthritis [RA]) to current status, treatments, monitoring (e.g., trochanter the of and fractures fractures subcapital neck) femoral and attack (TIA), or stroke ; vascular or multi-infarct dementia; mixed dementiadementia; frontotemporal assuch Pick’s disease; and dementia related to stroke, Parkinson’s disease or diseases) Creutzfeldt-Jakob schizophreniform disorders) Section I: MDS Item Description Section Item MDS I:

I5600 Malnutrition (protein or calorie) or at risk for MDS Item Number I2900I3100 retinopathy, diabetic (e.g., (DM) mellitus Diabetes I3200I3300 Hyponatremia I3400 Hyperkalemia hypercholesterolemia) (e.g., Hyperlipidemia Thyroid disorder (e.g., hypothyroidism, I3700I3800 Arthritis degenerative (e.g., joint disease [DJD], I3900 Osteoporosis Hip fracture hip (any fracture has that a relationship I4000I4200 Other fracture I4300I4400 Alzheimer’s disease I4500 Aphasia palsy Cerebral I4800 ischemic transient (CVA), accident Cerebrovascular Non-Alzheimer’s Lewy-Body Dementia (e.g., I4900I5000I5100 Hemiplegia or hemiparesis I5200 Paraplegia I5250 Quadriplegia I5300 Multiple sclerosis (MS) I5350 Huntington’s disease disease I5400 Parkinson’s I5500 syndrome Tourette’s Seizure disorder or epilepsy (TBI) injury brain Traumatic I5700I5800I5900 Anxiety disorder than bipolar) (other I5950 Depression I6000 disorder (other Psychotic than schizophrenia) I6100 and schizoaffective (e.g., Schizophrenia (PTSD) disorder stress Post-traumatic

X X X X X X PDPM PDPM Component though provider should the complete SAMPLE Cancer Infections Genitourinary Gastrointestinal Heart/Circulation disease (ESRD) (e.g., esophageal,(e.g., gastric, and peptic ulcers) disease bowel primary reason admission for sickle cell) tachycardias) bradycardias, heart disease atherosclerotic infarction, myocardial [ASHD]) pulmonary or embolus (PE), thrombo-embolism (PTE) edema) pulmonary Section I: MDS Item Description Item MDS I: Section This This is information based on the final release of the MDS 3.0, version I1550I1650 bladder Neurogenic uropathy Obstructive I1700I2000I2100 Multidrug-resistant organism (MDRO) I2200 Pneumonia I2300 Septicemia I2400 Tuberculosis I2500 Urinary tract infection (UTI) (last 30 days) hepatitis and hepatitis E) Viral A, C, (e.g., D, B, Wound infection (other than foot) I1400I1500 Benign prostatic hyperplasia (BPH) renal or end-stage failure, renal insufficiency, Renal I1100I1200 Cirrhosis I1300 Gastroesophageal disease reflux (GERD) or ulcer Ulcerative colitis, Crohn’s disease, or inflammatory I0100I0200 Cancer (with or without metastasis) I0300 pernicious, deficiency, iron aplastic, (e.g., Anemia I0400 Atrial fibrillation or other dysrhythmias (e.g., angina, (e.g., (CAD) artery Coronary disease I0500 Deep venous thrombosis (DVT), pulmonary I0600I0700 [CHF], failure heart congestive (e.g., Heart failure I0800 Hypertension hypotension Orthostatic MDS Item Item MDS Number I0020 resident’s the indicates that code ICD-10-CM Note: Appendix H: Skilled Nursing Facility Active Diagnosis List Diagnosis Active Facility Nursing Skilled H: Appendix homes in nursing residents all for is completed Set 3.0 (MDS) Data Minimum The certified by Medicare orMedicaid and residents in noncritical access hospitals with Medicare swing bed agreements. Al includes resource this theitemsassessmentof resident, the MDSrelevant to all only those items from sections and I of J the MDS that diagnostic provide and/or of more or one for score the case-mix calculate to needed information surgical the PDPM components. Additional from information other sections of the MDS, to order in berequired services also specific or may such as treatment provided, component PDPM individual the on depending elements, these score methodology. ICD-10-CM 2022 1.17.2. The finalized release of this file, effective October 1, 2020, can be found at: at: found be can 2020, 1, October effective file, this of release finalized The 1.17.2. https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. ICD-10-CM 2022 Illustrations Arteries

Middle temporal a. Transverse facial a. Superficial temporal a.

External carotid a. Internal carotid a. Common carotid a. Superior thyroid a. Vertebral a. Inferior thyroid a. Subclavian a. Innominate a. Arch of aorta

Ascending aorta Pulmonary a. Axillary a. Internal thoracic a. (mammary) Descending aorta Brachial a. Common hepatic a. L. gastric a. Celiac trunk (artery) Splenic a. R. gastric a. Renal a. Superior mesenteric a.

R. colic a. Abdominal aorta L. colic a. Radial a. Inferior mesenteric a. Ulnar a. Common iliac a. Internal iliac a. External iliac a. Uterine a.

Femoral a. SAMPLEPopliteal a. Anterior tibial a. Peroneal a.

Posterior tibial a.

ICD-10-CM 2022 Illustrations–19