Urology
Ch 2: Neoplasms
ICD-9-CM
Anatomical site
Histologic behavior:
- Malignant Primary
- Malignant Secondary
- In situ
- Benign
- Uncertain
- Unspecified behavior
Skin neoplasms:
- Basal cell carcinoma
- Squamous cell carcinoma
- Specified type NEC
Ch 2: Neoplasms
ICD-10-CM Requirements
General Documentation:
- Anatomical Site
- Laterality (left, right)
- Histologic behavior:
– Benign
– Malignant, primary and secondary sites if metastatic
– In situ
– Uncertain
– Unspecified behavior - Histologic Type:
– Carcinoma
– Basal Cell
– Squamous Cell
– Adenoma - Complications or Adverse effects of antineoplastic or immunosuppressive drugs
- Previous excision or eradication
Breast, in-situ, document:
- Lobular
- Intraductal
Leukemia, Multiple Myeloma, Malignant plasma cell neoplasms, document:
- Relapse
- Remission
- Not having achieved remission
Ch 2: Neoplasms
Notes
Pathologists may need to work with their referring physician to obtain this information.
When patients have more than one malignant tumor in the same organ document the primary and metastatic disease.
Ch 14: GU Kidney Disease
ICD-9-CM
- Chronic
- Stage
Ch 14: GU Kidney Disease
ICD-10-CM Requirements
Chronic Kidney Disease, document:
- Stage 1
- Stage 2 (mild)
- Stage 3 (moderate)
- Stage 4 (severe)
- Stage 5
- Co-morbidities (e.g. DM, HTN)
- Specify any associated kidney failure
Urinary Incontinence, document:
- Stress
- Urge
- Without sensory awareness
- Post-void dribbling
- Nocturnal enuresis
- Continuous leakage
- Mixed
- Overflow
Hematuria, document:
- Recurrent
- Persistent
- Any applicable underlying condition(s)
Neurogenic bladder, document:
- Uninhibited
- Reflex
- Flaccid
- Any associated urinary incontinence
Prolapse, document:
- Site
- Complete (3rd degree) or incomplete (1st/2nd degree)
Ch 14: GU Kidney Disease
Notes
Codes from Chapter 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly.
Ch 17: Congenital/ Chromosomal
ICD-9-CM
- Unilateral, Bilateral
- Type
Ch 17: Congenital/ Chromosomal
ICD-10-CM Requirements
General Documentation:
- Laterality (right, left, unilateral, bilateral)
- Specify distinction between existing malformation or deformity vs. personal history.
Cleft palate, document:
- Hard
- Soft
- Hard w/soft
Cleft lip, document:
- Bilateral
- Median
- Unilateral
Hypospadias, document:
- Site of the urethral opening:
– Balanic
– Penile
– Penoscrotal
– Perineal
– Congenital chordae
– Other specified
Ch 17: Congenital/ Chromosomal
Notes
Malformation, deformation or chromosomal abnormality may be the principal / first-listed diagnosis or a secondary diagnosis.
Although present at birth malformation, deformation or chromosomal abnormality may not be identified until later in life.
Conditions listed in Chapter 17 may be used throughout the life of the patient
Additional Resources
Coding for ICD-10-CM: More of the Basics MLN Connects Video
For more information contact the AMA.