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Rheumatology

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 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

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

Ch 6: Pain Nervous System

Notes

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

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