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PCP & Urgent Care



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.

Ch 8: Ear

ICD-9-CM

Ch 8: Ear

ICD-10-CM Requirements

General Documentation:

  • Specific disorder/disease
  • Laterality (right, left, bilateral)

Otitis media, document:

  • Acute or chronic
  • Suppurative or nonsuppurative

Perforation tympanic membrane, document:

  • Type:
    – Central
    – Attic
    – Other marginal
    – Multiple
    – Total

Hearing loss (deafness), document:

  • Type:
    – Conductive
    – Sensorineural
    – Mixed
    – Other

Ch 8: Ear

Notes

Moved from Nervous System chapter in ICD-9-CM to its own chapter in ICD-10-CM.

Ch 9: Circulatory

ICD-9-CM

Hypertension (HTN):

  • Benign
  • Malignant
  • Unspecified

Coronary Artery Disease (CAD) (Atherosclerosis/Ischemia):

  • Native Coronary Artery
  • Graft type
  • NonautologousAcute Myocardial Infarction (AMI) defined as duration of 8 weeks or less.

Cerebral Infarction / Cerebrovascular Accident (CVA):

  • Occlusion
  • Thrombosis
  • Embolism

Ch 9: Circulatory

ICD-10-CM Requirements

General Documentation:

  • Site specificity, when applicable
  • Laterality (right, left, bilateral), when applicable

HTN (no distinction of status/type), document if:

  • With heart involvement (and with heart failure, if applicable)
  • With kidney involvement, specify:
    – Stage 1 thru 5, or ESRD
  • Secondary

CAD, document:

  • Specific artery (default is native artery)
  • With angina (specify: stable or unstable) or without angina

AMI (redefined as duration of 4 weeks {28 days} or less), document:

  • Location:
    – Anterior wall (left main, left anterior descending or other coronary artery)
    – Inferior wall (right or other coronary artery)
    – Other sites (left circumflex coronary artery or other site)
  • ST elevation (STEMI) or Non-ST elevation (NSTEMI)

CVA, document:

  • Location:
  • Precerebral artery
    – (vertebral, basilar, carotid)
  •  Cerebral artery
    – (right/left…middle, anterior, posterior, cerebellar)
  •  Due to:
    – Thrombosis, embolism, occlusion or stenosis

Heart Failure/CHF, document:

  • Left ventricle, systolic, diastolic, combined
  • Acute, chronic, acute on chronic (decompensated)

Cardiomyopathy, document:

• Dilated
• Hypertrophic (obstructive, other)
• Endomyocardial
• Endocardial fibroelastosis• Other restrictive
• Due to: alcohol, drug or external agent

Atrial fibrillation, document:

• Paroxysmal, persistent or chronic

Atrial flutter, document:

• Typical or atypica

Ch 9: Circulatory

Notes

No distinction of HTN status/type.
CAD with or without angina inclusive in one code.
AMI redefined as duration of 4 weeks (28 days) or less.

Ch 10: Respiratory

ICD-9-CM
  • Severity

Ch 10: Respiratory

ICD-10-CM Requirements

General Documentation:

  • Document causal organism

Asthma, document:

  • Severity:
    – Mild intermittent
    – Mild persistent
    – Moderate persistent
    – Severe persistent
    – Other
  • Complication:
    – With acute exacerbation o With status asthmaticus o Uncomplicated

Bronchitis, document:

  • Acute, and document causal organism
  • Chronic, and document if simple, mucopurulent or mixed

Allergic rhinitis, document:

  • Pollen
  • Other seasonal
  • Food
  • Animal (cat)(dog) hair and dander
  •  Other

Sinusitis, document:

  • Acute (and if recurrent) or chronic
  • Site:
    – Maxillary
    – Frontal
    – Ethmoidal o Sphenoidal o Pansinusitis

Ch 10: Respiratory

Notes

No documentation changes from ICD- 9-CM to ICD-10-CM. Column to the left are common documentation pitfalls that may have been missed while documenting I-9. Emphasizing the importance of documenting for 1-10.

Ch 11: GI

ICD-9-CM

Ch 11: GI

ICD-10-CM Requirements

Crohn’s disease and Diverticular disease, document:

  • Site:
    – Small intestine
    – Large intestine
    – Both small & large intestine
  • Complication (specify) or w/o complication

Ulcerative Colitis, document:

  • Type:
    – Pancolitis
    – Proctitis
    – Rectosigmoiditis
    – Left sided
    – Other
  •  Complication (specify) or w/o complication

Hemorrhoids, document:

  • Internal
    – Specify degree, grade, state
  •  External

Hernia, document:

  • Site
    –  Inguinal
    –  Femoral
    –  Ventral (specify:  incisional, parastomal)
    –  Diaphragmatic
    –  Other/unspecified abdominal
  • Unilateral or bilateral (applicable to inguinal & femoral)
  • Recurrent or not specified as recurrent (applicable to inguinal & femoral)
  • With obstruction and/or gangrene or w/o obstruction and/or gangrene

Ch 11: GI

Notes

No documentation changes from ICD- 9-CM to ICD-10-CM. Column to the left are common documentation pitfalls that may have been missed while documenting I-9. Emphasizing the importance of documenting for I- 10.

Ch 13: M/S Fracture

ICD-9-CM
  • Site
  • Late Effect

Ch 13: M/S Fracture

ICD-10-CM Requirements

General Documentation:

  • Anatomical Site, when applicable (bone, join or muscle involved)
  •  Laterality (left, right, bilateral), when applicable
  •  Chronic, recurrent or healed musculoskeletal conditions

Fracture, document:

  •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
  •  Late Effect
  •  Type of fracture:
    – Fatigue
    – Stress
    – Pathological
  •  Laterality
  •  Encounter type:
    – Initial
    – Subsequent (specify routine or delayed healing, non-union, malunion)
    – Sequela

Osteoarthritis, document:

  •  Type:
    – Primary (wear and tear)
    – Secondary (caused by other condition)
    – Post-traumatic

Gout, document:

  •  Acute or chronic (with or without tophus)
  •  Idiopathic
  •  Lead-induced
  •  Drug-induced
  •  Due to renal impairment (specify renal disease)
  •  Other secondary gout (specify associated condition)

Ch 13: M/S Fracture

Notes

Fatigue fractures and collapsed vertebra will require a 7th character:

  • A – Initial encounter
  • D – Subsequent with routine healing
  • G – Subsequent with delayed healing
  • S – Sequela (complications, or conditions – i.e. scars)

Stress and Pathological fractures will require a 7th character:

  • A – Initial encounter
  • D – Subsequent with routine healing
  • G – Subsequent with delayed healing
  • K – Subsequent with non-union
  • P – Subsequent with malunion
  • S – Sequela (complications, or conditions – i.e. scars)

Ch 19: Injury/Burns/Wounds/Poisoning

ICD-9-CM

•Location/Site
•Injury
•Type
•Depth
•Percentage

Ch 19: Injury/Burns/Wounds/Poisoning

ICD-10-CM Requirements

General Documentation:

  • Location/site
  •  Laterality
  •  Sequence most serious injury as determined by the provider
  •  Superficial injury/abrasions or contusions should be specified if associated with more severe injuries of the same site.
  • Injury with damage to nerve/blood vessels: document primary injury, followed by nerves and/or blood vessels. (If the primary injury is to the nerve/blood vessel code as primary.)

Fractures, document:

  •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
  •  Open or Closed
  • Late Effect
  •  Type:
    – Displaced or non-displaced
  •  Laterality
  •  Gustilo classification system (specify classification) of open fractures
  •  Encounter type:
    – Initial (during active treatment)
    – Subsequent (i.e. specify routine or delayed healing, non-union, malunion)
    – Sequela

Burns, document:
Distinguish between ‘burns’ and ‘corrosions’

  • If thermal burn, specify heat source (i.e. electricity or radiation)
  • Specify if due to chemicals.

Wounds, document:

  • Location/site
  • Depth
  • Type:
    – Bite
    – Laceration
    – Puncture
  • With or without foreign body

Poisoning:

  • Identify define Drug or Chemical
  • Specify: Adverse effect, Poisoning, Under-dosing or Toxic effects

Ch 19: Injury/Burns/Wounds/Poisoning

Notes

Most codes may require a 7th
character for encounter type. Burns:

  • Sequence code to highest degree of burn(s).
  • Non-healing burns coded as Acute Burn (Necrosis of non- healed burn coded as non- healed burn).
  • Infected burn site, use additional code for infection.
  • Burns are classified by degree/depth, extent and age

Ch 21: Factors Influencing Health

ICD-9-CM

ICD-9 V-codes:

  •  Screening
  •  History of
  •  Contact/Exposure
  •  Follow-up
  •  Pre-Operative

Ch 21: Factors Influencing Health

ICD-10-CM Requirements

General Documentation:

  •  Specific purpose for receiving services
  •  Circumstance that affects the patient’s health status but is not a current illness or injury. Key Terms include:
    – Examination, History, Fitting, Status, Screening, etc…
  •  Contact/Exposure: document if with or suspected to communicable disease.
  •  Inoculations and vaccinations document if:
    – Prophylactic inoculation against disease, or
    – Screening for patient without sign or symptom (e.g. encounter of screening mammogram for malignant neoplasm of breast)
  • Documenting “History of” indicates the condition no longer exists but is being monitored) (e.g. personal history of malignant neoplasm of breast)
  •  Documenting “Follow-up” indicates continued surveillance following completed treatment (e.g. Encounter for routine postpartum follow-up)
  •  Pre-operative for patients receiving preoperative evaluation only (e.g. Encounter for pre-procedural exam [Specify – Cardio/ Resp./lab /other])
  •  Aftercare; Follow-up; Donor; Counseling and Obstetrical services.
    – Specify as applicable.

Ch 21: Factors Influencing Health

Notes

ICD-9-CM V-codes are now Z- codes, which may be used as primary or secondary.
May be used in any healthcare setting.

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