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).
Additional Resources
Coding for ICD-10-CM: More of the Basics MLN Connects Video
For more information contact the AMA.