1. CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)

2. Certain Infectious and Parasitic Diseases, Chapter 1
A00-B99
Classified according to etiology (cause) of disease
Combination coding = 1 code to fully describe DX
B37.0 Candidiasis infection of mouth
Multiple coding = 2 or more to fully describe DX
N39.0 (UTI), B96.2 (E. coli)
• In this chapter, there are many instances of multiple coding and combination coding.
• How are these codes divided? (Mainly by the etiology or cause of disease)
• What type of infection is candidiasis? (Fungal)

3. Resistant Infections & Sepsis
Resistant to antibiotics
Examples:
Methicillin-resistant Staphylococcus aureus (MRSA)
Multi-drug-resistant Mycobacterium tuberculosis (MDR-TB)
First-listed DX = Infection
Followed by Z16, Infection with drug resistant microorganism
• Multiple coding is acceptable when it takes more than one code to fully describe the condition.
• Which comes first, the disease, disorder, or the cause? (The disease or disorder)

4. Sepsis, Severe Sepsis, and Septic Shock
Sepsis = systemic inflammatory response syndrome (SIRS)
Report infection first, followed by code for organism
If unknown organism, report A41.9, Sepsis, unspecified
Severe sepsis = multiple organ dysfunction (MOD), hypotension or collection of fluid in tissues (hypoperfusion)—must be documented
Report infection, followed by an R65.2 code
Septic shock = circulatory failure associated with severe sepsis
Report infection first, followed by R65.21
• It is important to know the correct definitions of the septic terms since they are so close in nature.
• Septicemia is infection in the blood.
• Septic Shock is when the infection is so bad the body systems start to shut down.

5. Human Immunodeficiency
B20 reports HIV and includes AIDS
Positive serology or culture, but no symptoms, report:
Z21, Asymptomatic HIV status
HIV exposure, but no symptoms, report:
Z20.6, contact/exposure to HIV
Inconclusive serology, R75
(Cont’d…)
• Only confirmed cases of HIV infection/illness should be coded because the diagnosis stays in the patient’s record forever.
• If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions.
• Z21, Asymptomatic HIV infection, is to be applied when the patient without any documentation of symptoms is listed as HIV positive, known HIV, HIV test positive or similar terminology.

6. Human Immunodeficiency
(…Cont’d)
HIV testing, report Z11.4, Encounter for screening for HIV
Assign additional codes for known high-risk behavior:
Z72.51, High risk heterosexual behavior
Z72.52, High risk homosexual behavior
Z72.53, High risk bisexual behavior
• If the visit is for a patient’s HIV status, code B20 first followed by any additional diagnoses that may exist.
• If the patient goes to the physician due to a sore throat and happens to be HIV positive, code the sore throat first and the HIV second.

7. Neoplasms, Chapter 2 D10-D36, Benign D37-D48, Uncertain C00-D49
C00-C96, Malignant neoplasms
Primary and secondary
D00-D09, Ca in situ (CIS)
Not invasive
D10-D36, Benign
D37-D48, Uncertain
Not clearly benign or malignant
D49, Unspecified behavior
Not stated as to behavior
• Neoplastic conditions can affect all parts of the body.
• First, locate the type of the neoplasm in the Index.
• To properly code a neoplasm, it is necessary to determine from the medical documentation whether the neoplasm is benign, in situ, malignant, or of uncertain histologic behavior.
• If malignant, any secondary sites should also be determined.

8. Stages of Neoplams Staging for renal cancer staged
Stage I tumor of kidney capsule only
Stage II tumor invading renal capsule/vein but within fascia
Stage III tumor extending to regional lymph node/vena cava
Stage IV other organ metastasis
Pathology report & staging information will be documented in medical record
• Staged neoplasms means that they are evaluated for placement on a grading scale based on the level of invasion.

9. Sequencing and Complications
Treatment directed at
primary site, sequence primary first
secondary site, sequence secondary first
Types :
Chemotherapy, Z51.11
Immunotherapy, Z51.12
Radiation therapy, Z51.0
Complications, sequence complication first

10. History of Neoplasm Codes
History of neoplasm codes are only reported when neoplasm eradicated and is no longer present with no active treatment
Example:
Z85 personal history of malignant neoplasm
If active treatment, such as chemo, no history code can be reported
• If a neoplasm is being treated following surgical removal of the cancer, report the neoplasm as if it still exists.
• Do not report a “history of” Z codes.
• The patient must be free of disease and no longer under any treatment for his or her cancer. This includes chemotherapy and/or radiation therapy.

11. Chapter 3, ICD-10-CM
Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89)
Frequently reported codes:
Anemia, D50-D64
Coagulation Defects, D65-D69
Other Disorders of Blood and Blood-Forming Organs, D70-D77
• This is the chapter where codes for blood disorders will be found.
• These are not only disorders of the blood but also of the blood forming organs.
• Anemia is the most common blood disease.
• Under the main term of anemia are many subterms that relate to the type or cause of the anemia.

12. Endocrine, Nutritional, and Metabolic Diseases, Chapter 4
E00-E90
Diabetes codes E08-E13
Due to conditions classified elsewhere, E08
Drug or chemical induced DM, E09
Type 1 DM, E10
Type 2 DM, E11
Other specified DM, E13
• The Endocrine System consists of glands that are located throughout the body and are responsible for secreting hormones into the bloodstream.
• What are some examples of Endocrine Disorders/Diseases? (Diabetes, goiters, hyperthyroidism, hypothyroidism, Vitamin deficiencies, dehydration)

13. Diabetes Mellitus
DM codes are combination codes that include type of DM, body system affected, and complications
Example: E10.21 Type 1 diabetes mellitus with diabetic nephropathy
If type of DM not stated, query physician
• Diabetes mellitus (E08-E13), frequently used codes in Chapter 4 of
the I-10.
• Combination codes that include:
Type of diabetes
Body system involved
Complications affecting that body system

14. Mental and Behavioral Disorders, Chapter 5
F01-F99
Alcohol dependence and use, F10
Opioid, cannabis, sedatives, cocaine, stimulants, hallucinogens, nicotine, F11-F19
Psychological disorders, F20-F29
Mood disorders, F30-F39
Such as, bipolar disorder
(Cont’d…)
• Understanding of the definitions of mental disorders is necessary to code accurately.
• Report only the diagnosis documented in the medical record.

15. Mental and Behavioral Disorders Codes
(…Cont’d)
Anxiety, stress-related, etc., F40-F48
Behavior syndromes, F50-F59
Such as eating and sleep disorders
Adult personality and behavior, F60-F69
Mental retardation, F70-F79
Developmental disorders, F80-F89
Child or adolescent behavioral and emotional disorders, F90-F98
Unspecified mental disorder, F99

16. Pain Pain disorders related to psychological factors, report Dementia
G89 for pain and
F45.41 for pain related to psychological factors
Dementia
F01 (vascular dementia)
F02 (dementia in diseases classified elsewhere
F03 (unspecified dementia)

17. Diseases of the Nervous System, Chapter 6
G00-G99
Many combination codes
Example
G06.0 Intracranial abscess and granuloma
Manifestation codes
G21.11 Neuroleptic induced parkinsonism
Code first (T43.3-T43.5) to identify drug
• This chapter uses some combination codes in which one code identifies both the manifestation and the etiology.
• The chapter also includes some conditions that are manifestations of other diseases. These categories appear in italics in the Tabular List and instruct the coder to code the underlying disease process first.

18. Non-Psychological Pain
Localized pain is reported with codes throughout the I-10
Example, eye pain (H92.0-) or limb pain (M79.6-)
Category G89 is NEC pain
Example, G89.11 NEC acute pain due to trauma or G89.21 NEC chronic pain due to trauma
R52 reports unspecified pain that is:
Acute, chronic, generalized, or NOS

19. Dominant and Nondominant Sides
Dominant side: right or left handed
Paralysis (plegia) is reported based on dominant or nondominant side
Example
G81.10 Spastic hemiplegia affecting unspecified side
G81.11 Spastic hemiplegia affecting right dominant side
G81.12 Spastic hemiplegia affecting left dominant side
G81.13 Spastic hemiplegia affecting right nondominant side
G81.14 Spastic hemiplegia affecting left nondominant side
If dominant unknown, report dominant
• For ambidextrous patients, the default should also be dominant.

20. Diseases of the Eye and Adnexa, Chapter 7
H00-H59
Does not contain all the eye and adnexa codes
Chapter Excludes2 directs to other categories, such as:
injury (trauma) of eye and orbit (S05.-)
injury, poisoning and certain other consequences of external causes (S00-T98)
neoplasms (C00-D48)
• The terminology within Chapter 7 is complex.
• A good medical dictionary is a must when reporting services with H codes.

21. Structure of Eye and Ocular Adnexa
Figure: 10.15
Eye and Ocular Adnexa 21

22. Hordeolum and Chalazion
Hordeolum = infection of sebaceous glands (stye) reported on location and type
Right or left upper/lower, or unspecified
External, report H00.01-
Internal, report H00.02-
Chalazion = infection of eyelid that forms mass reported on location
H00.1
• Hordeolum is an inflammatory staphylococcal infection of the sebaceous glands at the base of the eyelashes
• Chalazion is a staphylococcal infection of the eyelid that forms a mass.

23. Entropion/Ectropion Entropion = turning inward of eyelid, H02.0-
From Frazier MS, Drzymkowski JW: Essentials of Human Diseases and Conditions, ed 4, St. Louis, 2009, Saunders.
Figure: 10.19A
Ectropion = turning outward of eyelid, H02.1-
From Frazier MS, Drzymkowski JW: Essentials of Human Diseases and Conditions, ed 4, St. Louis, 2009, Saunders.
Figure: 10.18A 23

24. Lacrimal System Category H04
Codes reported on right, left, bilateral, unsepcified, such as:
H Lacrimal cyst right lacrimal gland
H Lacrimal cyst left lacrimal gland
H Lacrimal cyst bilateral lacrimal glands
H Lacrimal cyst unspecified lacrimal gland
• Disorders of the lacrimal system include:
Dacryoadenitis
Dacryops
Epiphora
Dacryolith
Figure: 10.17 24

25. Diseases of the Ear and Mastoid Process, Chapter 8
H60-H95
Excludes2 indicates other categories for reporting other ear conditions, such as:
endocrine, nutritional and metabolic diseases (E00-E90)
injury, poisoning and certain other consequences of external causes (S00-T98)
neoplasms (C00-D48)
H60-H95 codes report diseases of external, middle, and inner ear, as well as mastoid, other, and surgical complications NEC
• Divided based on the structure of the ear (external, middle and mastoid, and inner)

26. Diseases of the Circulatory System, Chapter 9
I00-I99
Excludes2 note indicates other categories for other circulatory conditions, such as:
neoplasms (C00-D48)
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
systemic connective tissue disorders (M30-M36)
I00-I99 reports such as rheumatic fever, hypertension, ischemic heart disease, cerebrovascular diseases, etc.
• This chapter contains codes for diseases of the heart and blood vessels.
• Hypertension is one of the most common conditions coded in this chapter.

27. Hypertension
Report I10; includes arterial, benign, essential, malignant, primary, and systemic
Arterial: Increased arterial blood pressure, hypertension
Systemic: Arterial BP exceeds norm for several months
Primary: Essential, cause unknown
Secondary: Due to underlying condition
Malignant: Severe form
Benign: Mild form
• Uncontrolled hypertension is considered malignant.
• Do not use malignant or benign unless the documentation supports this designation.
(Cont’d…)

28. Hypertension
Transient: Temporary, R03.0, elevated BP without DX of hypertension
During or due to pregnancy, O13.- or O14.-

29. Hypertension with Heart Disease
I11, Hypertensive heart disease
Includes conditions reported with I51.4-I51.9 (myocarditis, cardiomegaly, ill-defined or unspecified heart disease) when condition due to hypertension
I11.0 Hypertensive heart disease with heart failure
Hypertensive heart failure
Use additional code to identify type of heart failure (I50.-)
I11.9 Hypertensive heart disease without heart failure
Hypertensive heart disease NOS
(Cont’d…)
• Hypertensive heart disease refers to secondary effects on the heart of prolonged, sustained, or systemic hypertension.
• Heart conditions are assigned to a code from category I11 when a causal relationship is stated (due to hypertension) or implied (hypertensive).
• Use an additional code from category I50.- to identify type of heart failure in those patients with heart failure.

30. Hypertension with Heart Disease
(…Cont’d)
Same heart condition not stated to be “due to hypertension” or “hypertensive”, report the heart disease and hypertension separately

31. Kidney Disease and Hypertension
Assume a relationship between the kidney disease and the hypertension
I13, combination code for hypertensive heart and chronic kidney disease
If heart disease is present, assign a category I50 code
(Cont’d…)
• The appropriate code from category N18, chronic kidney disease, is reported as a secondary code to I12.9.
• To identify the stage of chronic kidney disease.

32. Kidney Disease and Hypertension
(…Cont’d)
CRF/CKD/CRI + hypertension I N18.9
CKD stage 1 + hypertension I N18.1
CKD stage 2 + hypertension I N18.2
CKD stage 3 + hypertension I N18.3
CKD stage 4 + hypertension I N18.4
CKD stage 5 + hypertension I N18.5
CKD stage 6 or ESRD or on dialysis + I N18.6
Patient with CKD on any type of dialysis I N Z99.2
• If the physician does not state the stage of renal dysfunction, query the physician.

33. Myocardial Infarction
Acute heart attack with occlusion of coronary artery
STEMI, ST elevation MI, most severe, total occlusion
Example: I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
NSTEMI, non- ST elevation MI, less severe, partial occlusion
Example, I21.4 Non-ST elevation (NSTEMI) myocardial infarction
(Cont’d...)
• Myocardial infarction (MI) is an acute heart attack that occurs when a coronary artery in blocked.
• Category I21, MI, requires specific documentation in the medical record to indicate the infarction site.

34. Myocardial Infarction
(…Cont’d)
Subsequent STEMI or NSTEMI are reported with I22.-
Example, I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
Complications within 28 days of initial MI, I23
Example, I23.1 Atrial septal defect as current complication following acute myocardial infarction
• When the infarction site is not indicated:
Query the physician
Assign the default code I21.3

35. Diseases of the Respiratory System, Chapter 10
J00-J99
Some codes are combination codes that identify condition and causative organism
Example: J03.01 Acute recurrent streptococcal tonsillitis
Other codes require separate reporting of organism
Example: J01.01 Acute recurrent maxillary sinusitis (Use additional code (B95-B97) to identify infectious agent )
• Chapter 10 includes diseases and disorders of the respiratory tract.
• Beginning with the nasal passages, following a path to the lungs.

36. CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)
Conclusion CHAPTER 10
CHAPTER-SPECIFIC GUIDELINES (ICD-10-CM CHAPTERS 1-10)