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Ch 3: Blood Disorders

ICD-9-CM

Most Intra-operative & Post- procedural complications are included in Chapter 17 – Injury and Poisoning.

Ch 3: Blood Disorders

ICD-10-CM Requirements

Anemia, document:

  • Nutritional, specify:
    – Iron deficiency
    – Vitamin B12 deficiency
    – Folate deficiency (dietary or drug-induced)
    – Other (protein, megaloblastic)
  • Hemolytic, specify:
    – Due to enzyme disorders
    – Sickle-cell disorders
    – Other hereditary or acquired
  • Aplastic
  • In other chronic diseases (specify the underlying disease)

Spleen document Intra-operative & Post-procedural complications, specify:

  • Intra-operative (during) or Post-procedural (following)
  • Hemorrhage, hematoma, accidental puncture or accidental laceration of the spleen
  • Procedure on the spleen or other procedure

Ch 3: Blood Disorders

Notes

Intra-operative & Post-procedural complications are also included in other chapters based on specific site/system documentation.

Ch 4: Diabetes & Metabolic Disorders

ICD-9-CM

Diabetes: Distinguished as “Uncontrolled” or “Not stated as uncontrolled”.

Ch 4: Diabetes & Metabolic Disorders

ICD-10-CM Requirements

Diabetes, document:

  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus (default, if not specified)
  • Drug or chemically induced diabetes mellitus
  • Secondary diabetes mellitus (specify the cause)
  • Specify complication(s), when applicable
  • Specify use of insulin, when applicable

Obesity, document:

  • Due to excess calories
  • Drug-induced
  • Identify body mass index

Ch 4: Diabetes & Metabolic Disorders

Notes

Diabetes: Distinguished as “With complications” or “Without complications”.
Gestational diabetes (in pregnancy) is reported in Chapter 15.

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