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Neuro

Ch 5: Behavioral Health

ICD-9-CM

Reserved for future expansion (no specific ICD-9-CM direction).

Ch 5: Behavioral Health

ICD-10-CM Requirements

General Documentation:

  •  Anatomical Site of pain
  •  Pain that is exclusively related to psychological disorders
  • Psychological component for a patient with acute or chronic pain
  •  If in remission, document based on provider’s clinical judgment and must indicate “in remission”

Psychoactive Substance, indicate:

  •  “use”, “abuse” and/or “dependence”
  •  If use is associated with a mental or behavioral disorder

Ch 5: Behavioral Health

Notes

Ch 6: Pain Nervous System

ICD-9-CM
  • Type
  •  Site

Ch 6: Pain Nervous System

ICD-10-CM Requirements

General Documentation:

  • Type of pain:
    – Acute or chronic
    – Post-procedural (specify procedure)
    – Due to trauma
    -Neoplasm related (specify neoplasm and site)
  • Site specificity, when applicable
  • Laterality (right, left, bilateral), when applicable
  • Dominant or Non-dominant side, when applicable

Chronic Pain:

  • Central pain syndrome and Chronic pain syndrome are different than the term ‘chronic pain’ and will be coded based on your specific documentation.

Migraine, document:

  • With or without aura
  • Intractable or not intractable
  • With or without status migrainosus

Epilepsy, document:

  • Localization related or generalized
  • Intractable or not intractable
  • With or w/o status epilepticus

Ch 6: Pain Nervous System

Notes

“Pain” is also included in other chapters based on specific documentation (site, not specified as acute or chronic).

Ch 7: Eye

ICD-9-CM

Glaucoma:

  • Two codes to identify type & stage.
  • Identify the external cause, if applicable, of the eye condition.

Ch 7: Eye

ICD-10-CM Requirements

General Documentation:

  • Specific disorder/disease and external cause, when applicable
  • Laterality (right, left, bilateral)

Cataract, document:

  • Type:
    – Age-related
    – Traumatic
    – Complicated o Drug-induced o Other

Glaucoma, document:

  • Type:
    – Suspect
    – Open-angle
    – Primary angle-closure
    – Secondary due to (specify: trauma, inflammation, drugs)
  • Stage:
    – Mild
    – Moderate
    – Severe
    – Indeterminate (cannot be clinically determined)

Ch 7: Eye

Notes

Moved from Nervous System chapter in ICD-9-CM to its own chapter in ICD-10-CM.
Glaucoma type & stage combined into one code.

Ch 12: Skin

ICD-9-CM

Anatomical site
Specimen type i.e., cyst, tag, abscess, ulcer, scar, etc.
Neoplasm skin and subcutaneous tissues see Chapter 2 guidelines.
Dermatitis, document if:

  • Atopic
  • Seborrheic
  • Diaper
  • Exfoliative
  • Contact (due to…)
    – Irritant contact (due to…) & Unspecified contact (due to…)

Pressure Ulcer

Ch 12: Skin

ICD-10-CM Requirements

General Documentation:

  • Anatomical site
  • Laterality

Pressure ulcer, document:

  • Site
  • Laterality
  • Specify stage:
    – Unstageable (can’t be clinically determined)
    – Stage 1
    – Stage 2
    – Stage 3
    – Stage 4

Dermatitis, document:

  • Atopic
  • Seborrheic
  • Diaper
  • Exfoliative
  • Contact
    – Allergic (specify: due to…)
    – Irritant (specify: due to….)

Non-pressure ulcer, document:

  • Site
  • Laterality (left or right)
  • Severity:

– Limited to breakdown of skin
–  With fat layer exposed
–  With necrosis of muscle
–  With necrosis of bone

Ch 12: Skin

Notes

Neoplasm skin and subcutaneous tissue are included in Chapter 2.
Pressure ulcer staging is generally identified by the clinician.
As with ICD-9-CM, Pathologists may need to work with their referring physician to obtain this information.
Non-pressure ulcers are included in Chapter 19.

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