PCP & Urgent Care
- Ch 3: Blood Disorders D50-D89
- Ch 4: Diabetes & Metabolic Disorders E00-E90
- Ch 8: Ear H60-H95
- Ch 9: Circulatory 100-199
- Ch 10: Respiratory J00-J99
- Ch 11: GI K00-K93
- Ch 13: M/S Fracture M00-M99
- Ch 19: Injury/Burns/Wounds/Poisoning S00-T98
- Ch 21: Factors Influencing Health Z00-Z99
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.
Additional Resources
Coding for ICD-10-CM: More of the Basics MLN Connects Video
For more information contact the AMA.