ICD-9-CM Expert. for Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Hospices Volumes 1, 2 & 3

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ICD-9-CM

for Skilled Nursing Facilities, Inpatient Rehabilitation

Facilities, and Hospices – Volumes 1, 2 & 3

2015 Expert

International Classification of Diseases

10th Revision

Clinical Modification

Sixth Edition

Optum is committed to providing you with the ICD-9-CM code update information you need to

code accurately and to be in compliance with HIPAA regulations. In case of adoption of

additional ICD-9-CM code changes effective April 1, 201

, Optum will provide these code

changes to you at no additional cost! Just check back at ww.optumcoding.com/productalerts

to review the latest information concerning any new code changes.

Codes Valid October 1, 201

, through September 30, 201

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429.83–434.9

Diseases of the Circulatory System

Tabular List

8

Newborn

9

Pediatric

x

Maternity

y

Adult

A

RIC CC Condition

%

RIC Dx wx Revised Text l New Code s Revised Code Title

136 – Volume 1 • October 2012 201 ICD-9-CM

42 9.83–434

.9

Diseas

es

of the C

ir

cula

tor

y

Sy

st

em

Berry Aneurysms 429.83 Takotsubo syndrome

Broken heart syndrome

Reversible left ventricular dysfunction following sudden emotional stress

Stress induced cardiomyopathy

Transient left ventricular apical ballooning syndrome AHA: 4Q, ’06, 87

429.89 Other

#

Carditis

2

that due to hypertension (402.0-402.9)

AHA: 2Q, ’06, 18; 3Q, ’05, 14; 1Q, ‘92, 10

429.9 Heart disease, unspecified

$

Heart disease (organic) NOS Morbus cordis NOS

2

that due to hypertension (402.0-402.9)

AHA: 1Q, ’09, 7; 1Q, ‘93, 19

I51.9 Heart disease unspecified

Cerebrovascular Disease (430-438)

1

with mention of hypertension (conditions classifiable to 401-405)

Use additional code to identify presence of hypertension

2

any condition classifiable to 430-434, 436, 437 occurring

during pregnancy, childbirth, or the puerperium, or specified as puerperal (674.0)

iatrogenic cerebrovascular infarction or hemorrhage (997.02) AHA: 1Q, ‘93, 27; 3Q, ‘90, 3; 2Q, ‘89, 8; M-A, ‘85, 6 430

A

%

Meningeal hemorrhage Ruptured: berry aneurysm

(congenital) cerebral aneurysm NOS

2

berry aneurysm, nonruptured (437.3) syphilitic ruptured cerebral aneurysm (094.87)

RIC Excl: 01 Stroke; 02 Traumatic brain injury; 03 Non-traumatic brain injury

DEF: Bleeding in space between brain and lining.

AHA: 4Q, ’04, 77

431

A

%

Hemorrhage (of): Hemorrhage (of): basilar internal capsule bulbar intrapontine cerebellar pontine cerebral subcortical cerebromeningeal ventricular

cortical Rupture of blood vessel in brain RIC Excl: 01 Stroke; 02 Traumatic brain injury; 03 Non-traumatic brain injury

DEF: Bleeding within the brain.

AHA:w1Q, ’12, 14;x 3Q, ’10, 5-6; 1Q, ’10, 8; 3Q, ‘07, 4; 4Q, ’04, 77

I61.9 Nontraumatic intracerebral hemorrhage unspec

b

432 Other and unspecified intracranial hemorrhage

AHA: 4Q, ’04, 7

432.0

A

%

Nontraumatic epidural hemorrhage

DEF: Bleeding, nontraumatic, between skull and brain lining.

432.1

A

%

Subdural hematoma, nontraumatic

DEF: Bleeding, between outermost and other layers of brain lining.

432.9

%$

Intracranial hemorrhage NOS

b

433 Occlusion and stenosis of precerebral arteries

Use additional code, if applicable, to identify status post

administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (V45.88)

2

insufficiency NOS of precerebral arteries (435.0-435.9)

DEF: Blockage, stricture, arteries branching into brain.

AHA: 2Q, ‘95, 14; 3Q, ‘90, 16

7§

_c

_433.0

_K

[0-1] RIC Excl: 01 Stroke

7§

_c

_433.1

_K

AHA: 1Q, ‘00, 16; For code 433.10: 1Q, ’06, 17; 1Q, ‘02, 7, 10

I65.29 Occlusion and stenosis of unspec carotid artery

I63.239 Cerebrl infarct d/t uns occl/stenosis of uns carotid art

7§

_c

_433.2

_K

7§

_c

_433.3

_K

AHA: 2Q, ‘02, 19

7§

_c

_433.8

_K

_#

7§

_c

_433.9

_K

_$

[0-1] Precerebral artery NOS RIC Excl: 01 Stroke

b

434 Occlusion of cerebral arteries

Use additional code, if applicable, to identify status post

administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (V45.88)

AHA: 2Q, ‘95, 14

7§

_c

_434.0

_K

[0-1] Thrombosis of cerebral arteries RIC Excl: 01 Stroke

AHA: For code 434.01: 4Q, ’04, 77

7§

_c

_434.1

_K

AHA: For code 434.11: 3Q, ‘97, 11; 4Q, ’04, 77

I63.449 Cerbral infarct d/t embo of uns cerebellar art

7§

_c

_434.9

_K

_$

AHA: For code 434.91: 3Q, ’10, 5-6; 4Q, ‘08, 108; 3Q, ‘07, 9; 1Q, ‘07, 23; 4Q, ’04, 77-78; 4Q, ‘98, 87 Anterior communicating artery Posterior cerebral arteries Basilar artery Internal carotid Vertebral arteries 40 % 34% 20 % 4% Berry aneurysm Arrows depict blood flow I-10 Subarachnoid hemorrhage Intracerebral hemorrhage I-10

Nontraumatic extradural hemorrhage

1

embolism narrowing obstruction thrombosis

of basilar, carotid, and vertebral arteries

The following fifth-digit subclassification is for use with category 433:

0 without mention of cerebral infarction

1 with cerebral infarction

%

7 _{Hospice Non-cancer Dx fifth-digit = 1}

§ _{Requires fifth digit. Valid digits are in [brackets] under each code. See appropriate category for codes and definitions.}

The following fifth-digit subclassification is for use with category 434:

0 without mention of cerebral infarction

1 with cerebral infarction

%

Subdural hemorrhage

Unspecified intracranial hemorrhage

Basilar artery Carotid artery

I-10 I-10

Vertebral artery Multiple and bilateral

Other specified precerebral artery Unspecified precerebral artery

Cerebral thrombosis Cerebral embolism

I-10

Cerebral artery occlusion, unspecified

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Additional Digit Required RUG IV Special Care High Dx RUG IV Clinically Complex Dx RUG IV Special Care Low Dx Hospice Non-cancer Dx Manifestation Code

$

Unspecified Code

#

Other Specified Code

201 ICD-9-CM Volume 1 – 151

Tabular List

Diseases of the Respiratory System

482.32–486

Diseas

es

of the R

es

p

ir

at

or

y S

yst

em

482 .3

2–486

b c 3_482.32

_A

_%

RIC Excl: 15 Pulmonary

3_482.39

_A

_%

_#

c

482.4 Pneumonia due to Staphylococcus

AHA: 3Q, ‘91, 16

3_482.40

_A

_%$

3_482.41

_A

_%

Staphylococcus aureus MSSA pneumonia

Pneumonia due to Staphylococcus aureus NOS RIC Excl: 15 Pulmonary

J15.21 Pneumonia due to staphylococcus aureus

3_482.42

_A

_%

AHA: 4Q, ‘08, 69, 71, 72

3_482.49

_A

_%

_#

c

482.8 Pneumonia due to other specified bacteria

2

pneumonia, complicating infectious disease classified elsewhere (484.1-484.8)

AHA: 3Q, ‘88, 11

3_482.81

_A

_%

Bacteroides (melaninogenicus) Gram-negative anaerobes RIC Excl: 15 Pulmonary

3_482.82

_A

_%

3_482.83

_A

_%

_#

Gram-negative pneumonia NOS Proteus

Serratia marcescens

2

gram-negative anaerobes (482.81) Legionnaires' disease (482.84)

AHA: 2Q, ‘98, 5; 3Q, ‘94, 9

TIP: Do not assign based solely on laboratory findings of gram-negative bacteria on gram-stain. Physician substantiation is required.

J15.6 Pneumonia d/t oth aerobic Gram-negative bacteria

3_482.84

_A

_%

DEF: Severe and often fatal infection by Legionella pneumophilia; symptoms include high fever, gastrointestinal pain, headache, myalgia, dry cough, and pneumonia; usually transmitted airborne via air conditioning systems.

AHA: 4Q, ‘97, 38

3_482.89

_A

_%

_#

AHA: 2Q, ‘97, 6

TIP: Do not assign based on documentation of “mixed bacterial pneumonia” or “gram-positive pneumonia.” See instead 482.9.

3_482.9

_A

_%$

AHA: 2Q, ‘98, 6; 2Q, ‘97, 6; 1Q, ‘94, 17

J15.9 Unspecified bacterial pneumonia

b

483 Pneumonia due to other specified organism

AHA: N-D, ‘87, 5

TIP: Do not assign if pneumonia due to candidiasis; see instead code 112.4.

3_483.0

_A

_%

Eaton's agent

Pleuropneumonia-like organism [PPLO] RIC Excl: 15 Pulmonary

3_483.1

_A

_%

AHA: 4Q, ‘96, 31

3_483.8

_A

_%

_#

b

484 Pneumonia in infectious diseases classified elsewhere

484.1

A

%

Code first underlying disease (078.5)

484.3

A

%

Code first underlying disease (033.0-033.9)

484.5

A

%

484.6

A

%

AHA: 4Q, ‘97, 40

484.7

A

%

Code first underlying disease

2

pneumonia in:

candidiasis (112.4) coccidioidomycosis (114.0)

histoplasmosis (115.0-115.9 with fifth-digit 5)

484.8

A

%

Code first underlying disease, as: Q fever (083.0) typhoid fever (002.0)

2

pneumonia in: actinomycosis (039.1) measles (055.1) nocardiosis (039.1) ornithosis (073.0) Pneumocystis carinii (136.3) salmonellosis (003.22) toxoplasmosis (130.4) tuberculosis (011.6) tularemia (021.2) varicella (052.1)

3₄₈₅

_A

_%$

Bronchopneumonia: hemorrhagic terminal Pleurobronchopneumonia Pneumonia: lobular segmental

2

bronchiolitis (acute) (466.11-466.19) chronic (491.8) lipoid pneumonia (507.1)

3₄₈₆

_A

_%$

2

hypostatic or passive pneumonia (514)

inhalation or aspiration pneumonia due to foreign materials (507.0-507.8)

pneumonitis due to fumes and vapors (506.0)

AHA: 4Q, ’10, 135; 1Q, ’10, 3, 12; 3Q, ’09, 16; 4Q, ‘08, 142; 4Q, ‘99, 6; 3Q, ‘99, 9; 3Q, ‘98, 7; 2Q, ‘98, 4, 5; 1Q, ‘98, 8; 3Q, ‘97, 9; 3Q, ‘94, 10; 3Q, ‘88, 11

TIP: Never assume a causal organism based on laboratory or radiology find-ings alone.

J18.9 Pneumonia unspecified organism

3 _{Special Care High = With fever} Group B

Other Streptococcus

Pneumonia due to Staphylococcus unspecified

Methicillin susceptible pneumonia due to Staphylococcus aureus

I-10

Methicillin resistant pneumonia due to Staphylococcus aureus Other Staphylococcus pneumonia

Anaerobes

Escherichia coli [E. coli] Other gram-negative bacteria

I-10

Legionnaires' disease

Other specified bacteria

Bacterial pneumonia unspecified

I-10

Mycoplasma pneumoniae

Chlamydia

Other specified organism

Pneumonia in cytomegalic inclusion disease

Pneumonia in whooping cough

Pneumonia in anthrax

Pneumonia in aspergillosis

Pneumonia in other systemic mycoses

Pneumonia in other infectious diseases classified elsewhere

Bronchopneumonia, organism unspecified

Pneumonia, organism unspecified

I-10 ICD 9 v1 IPA C.book Page 151 Thursday, June 14, 2012 4:19 PM

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b c

Tabular List

Miscellaneous Diagnostic and Therapeutic Procedures

93.14–93.65

Misc

ellaneo

u

s D

iag

nostic

and

Therap

eutic

Proc

edu

res

93.14 –9

3.65

Additional Digit Required RUG IV Special Care High RUG IV Clinically Complex RUG IV Extensive Services Procedure RUG IV Rehab Procedure RUG IV Special Care Low

201 ICD-9-CM Volume 3 – 191

1_93.14

1_93.15

1_93.16

2

manipulation of temporomandibular joint (76.95)

1_93.17

1_93.18

1_93.19

b

93.2 Other physical therapy musculoskeletal manipulation

AHA: N-D, ‘86, 7 1_93.21

2

skeletal traction (93.43-93.44) skin traction (93.45-93.46) spinal traction (93.41-93.42) 1_93.22 1_93.23 1_93.24

Training in crutch walking

1_93.25

1_93.26

DEF: Therapeutic application of force to rupture adhesions restricting movement.

1_93.27

1_93.28

1_93.29

AHA: N-D, ‘85, 11

b

93.3 Other physical therapy therapeutic procedures

1_93.31

1_93.32

1_93.33

1_93.34

1_93.35

Acupuncture with smouldering Infrared irradiation moxa Moxibustion Hot packs Paraffin bath Hyperthermia NEC

2

hyperthermia for treatment of cancer (99.85) DEF: Moxibustion: Igniting moxa, a Chinese plant, for counterirritation of skin.

DEF: Paraffin bath: Hot wax treatment.

1_93.36

DEF: Cardiac rehabilitation regimen following myocardial infarction or coronary bypass graft procedure.

93.37 Prenatal training

Training for natural childbirth

1_93.38

1_93.39

AHA: 2Q, ‘05, 6; 4Q, ’03, 105 -106, 108-110; 3Q, ‘97, 12; 3Q, ‘91, 15

b

93.4 Skeletal traction and other traction

93.41 Spinal traction using skull device

Traction using: caliper tongs Crutchfield tongs halo device Vinke tongs

2

insertion of tongs or halo traction device (02.94)

DEF: Applying device to head to exert pulling force on spine.

AHA: 3Q, ‘01, 8; 3Q, ‘96, 14; 2Q, ‘94, 3

93.42 Other spinal traction

Cotrel’s traction

2

cervical collar (93.52)

DEF: Pulling force exerted on spine without skull device.

93.43 Intermittent skeletal traction

93.44 Other skeletal traction

93.45 Thomas’ splint traction

DEF: Thomas splint: Placement of ring around thigh, attached to rods running length of leg for therapeutic purposes.

93.46 Other skin traction of limbs

Adhesive tape traction Boot traction Buck’s traction Gallows traction

b

93.5 Other immobilization, pressure, and attention to wound

2

external fixator device (84.71-84.73) wound cleansing (96.58-96.59)

93.51 Application of plaster jacket

2

Minerva jacket (93.52)

93.52 Application of neck support

Application of: cervical collar Minerva jacket molded neck support

93.53 Application of other cast 93.54 Application of splint

Plaster splint Tray splint

2

periodontal splint (24.7)

93.55 Dental wiring

2

that for orthodontia (24.7)

93.56

Application of: Gibney bandage Robert Jones’ bandage Shanz dressing

93.57

Porcine wound dressing

AHA: 3Q, ‘02, 23

93.58 Application of pressure trousers

Application of: anti-shock trousers MAST trousers vasopneumatic device

AHA: 3Q, ‘96, 13

93.59 Other immobilization, pressure, and attention to wound

Elastic stockings Electronic gaiter

Intermittent pressure device Oxygenation of wound (hyperbaric) Stereotactic head frame application Strapping (non-traction)

Velpeau dressing

AHA: 3Q, ‘99, 7; 1Q, ‘99, 12, 13; 1Q, ‘91, 11; 1Q, ‘89, 12

b

93.6 Osteopathic manipulative treatment

93.61 Osteopathic manipulative treatment for general mobilization

General articulatory treatment

93.62 Osteopathic manipulative treatment using high-velocity, low-amplitude forces

Thrusting forces

93.63 Osteopathic manipulative treatment using low-velocity, high-amplitude forces

Springing forces

93.64 Osteopathic manipulative treatment using isotonic, isometric forces

93.65 Osteopathic manipulative treatment using indirect forces

1 _{Reported with Extensive Services Procedures = Rehab plus Extensive Services Group.} Training in joint movements

Mobilization of spine Mobilization of other joints

Other passive musculoskeletal exercise Breathing exercise

Exercise, not elsewhere classified Manual and mechanical traction Ambulation and gait training Fitting of orthotic device

Training in use of prosthetic or orthotic device Forced extension of limb

Manual rupture of joint adhesions Stretching of muscle or tendon Stretching of fascia

Other forcible correction of deformity Assisted exercise in pool

Whirlpool treatment Other hydrotherapy Diathermy Other heat therapy

Cardiac retraining

Combined physical therapy without mention of the components Other physical therapy

Bryant’s Dunlop’s Lyman Smith Russell’s

traction

Application of pressure dressing

Application of other wound dressing

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List

of RIC Como

rb

id Condi

tio

ns

201 ICD-9-CM Resources – 19

List of RIC Comorbid Conditions

The following list is that of the comorbid conditions that may qualify for payment adjustment when reported as a secondary diagnosis during admission. The rehabilitation impairment category (RIC) exclusions are identified as well as the comorbidity payment tier for each condition. * Indicate code ranges. All codes in the specified range are included.

Code Title Tier RIC

Exclusion

008.42 PSEUDOMONAS ENTERITIS 2

008.45 INT INF CLSTRDIUM DFCILE 2

011.0* TB LUNG INFILTR-UNSPEC 3 15 011.1* TB LUNG NODULAR 3 15 011.2* TB LUNG W CAVITY 3 15 011.3* TB OF BRONCHUS 3 15 011.4* TB LUNG FIBROSIS 3 15 011.5* TB BRONCHIECTASIS 3 15 011.6* TB PNEUMONIA 3 15 011.7* TB PNEUMOTHORAX 3 15 011.8* PULMONARY TB NEC 3 15 011.9* PULMONARY TB NOS 3 15 012.0* TB PLEURISY 3 15 012.1* TB THORACIC NODES 3 15 012.2* ISOL TRACHEAL TB 3 15 012.3* TB LARYNGITIS 3 15 012.8* RESP TB NEC 3 15 013.0* TB MENINGITIS 3 03,05 013.1* TUBRCLMA MENINGES 3 03,05 013.2* TUBERCULOMA BRAIN 3 03 013.3* TB BRAIN ABSCESS 3 03 013.4* TUBRCLMA SP CORD 3 05 013.5* TB SP CRD ABSCESS 3 05 013.6* TB ENCEPHALITIS 3 03 013.8* CNS TB NEC 3 03,05 013.9* CNS TB NOS 3 03,05 014.0* TB PERITONITIS 3 014.8* INTESTINAL TB NEC 3 015.0* TB OF VERTEBRA 3 03,09 015.1* TB OF HIP 3 09 015.2* TB OF KNEE 3 09 015.5* TB OF LIMB BONES 3 09,10,11 015.6* TB OF MASTOID 3 015.7* TB OF BONE NEC 3 09 015.8* TB OF JOINT NEC 3 09 015.9* TB BONE/JOINT NOS 3 09 016.0* TB OF KIDNEY 3 016.1* TB OF BLADDER 3 016.2* TB OF URETER 3 016.3* TB URINARY NEC 3 016.4* TB EPIDIDYMIS 3

016.5* TB MALE GENIT NEC 3

016.6* TB OVARY & TUBE 3

016.7* TB FEMALE GEN NEC 3

016.9* GU TB NOS 3 017.0* TB SKIN/SUBCUTAN 3 017.1* ERYTHEMA NODOS TB 3 017.2* TB PERIPH LYMPH 3 017.3* TB OF EYE 3 017.4* TB OF EAR 3 017.5* TB OF THYROID 3 017.6* TB OF ADRENAL 3 017.7* TB OF SPLEEN 3 017.8* TB ESOPHAGUS 3 017.9* TB OF ORGAN NEC 3 018.0* ACUTE MILIARY TB 3 018.8* MILIARY TB NEC 3 018.9* MILIARY TB NOS 3 027.0 LISTERIOSIS 3 027.1 ERYSIPELOTHRIX INFECTION 3 027.2 PASTEURELLOSIS 3

027.8 ZOONOTIC BACT DIS NEC 3

027.9 ZOONOTIC BACT DIS NOS 3

036.0 MENINGOCOCCAL MENINGITIS 3 03,05 036.2 MENINGOCOCCEMIA 3 03,05 036.3 MENINGOCOCC ADRENAL SYND 3 05 036.40 MENINGOCOCC CARDITIS NOS 3 14 036.42 MENINGOCOCC ENDOCARDITIS 3 14 036.43 MENINGOCOCC MYOCARDITIS 3 14 037 TETANUS 3 06 038.0 STREPTOCOCCAL SEPTICEMIA 3 038.10 STAPHYLCOCC SEPTICEM NOS 3

038.11 METH SUSC STAPH AUR SEPT 3

038.12 MRSA SEPTICEMIA 3

038.19 STAPHYLCOCC SEPTICEM NEC 3

038.2 PNEUMOCOCCAL

SEPTICEMIA 3

038.3 ANAEROBIC SEPTICEMIA 3

038.40 GRAM-NEG SEPTICEMIA NOS 3

038.41 H. INFLUENAE SEPTICEMIA 3

038.42 E COLI SEPTICEMIA 3

038.43 PSEUDOMONAS SEPTICEMIA 3

038.44 SERRATIA SEPTICEMIA 3

038.49 GRAM-NEG SEPTICEMIA NEC 3

038.8 SEPTICEMIA NEC 3

038.9 SEPTICEMIA NOS 3

041.7 PSEUDOMONAS INFECT NOS 2

042 HUMAN IMMUNO VIRUS DIS 3

047.8 VIRAL MENINGITIS NEC 3 03,05

047.9 VIRAL MENINGITIS NOS 3 03,05

048 OTH ENTEROVIRAL CNS DIS 3 03,05

049.0 LYMPHOCYTIC

CHORIOMENING 3 03,05

049.9 VIRAL ENCEPHALITIS NOS 3 03

Exclusion

052.0 POSTVARICELLA ENCEPHALIT 3 03

052.1 VARICELLA PNEUMONITIS 3 15

053.0 HERPES ZOSTER MENINGITIS 3 03,05

053.13 POSTHERPES

POLYNEUROPATH 3 06

054.3 HERPETIC ENCEPHALITIS 3 03

054.5 HERPETIC SEPTICEMIA 3 03

054.72 H SIMPLEX MENINGITIS 3 03,05

054.74 HERPES SIMPLEX MYELITIS 3

054.79 H SIMPLEX COMPLICAT NEC 3

055.0 POSTMEASLES ENCEPHALITIS 3 03

055.1 POSTMEASLES PNEUMONIA 3 15

058.21 HUMAN HERPESVIR 6

ENCEPH 3 03

058.29 HUMAN HERPESVR ENCPH

NEC 3 03

070.20 HPT B ACTE COMA WO DLTA 3 03

070.21 HPT B ACTE COMA W DLTA 3 03

070.22 HPT B CHRN COMA WO DLTA 3 03

070.23 HPT B CHRN COMA W DLTA 3 03

070.41 HPT C ACUTE W HEPAT COMA 3 03

070.42 HPT DLT WO B W HPT COMA 3 03

070.43 HPT E W HEPAT COMA 3 03

070.44 CHRNC HPT C W HEPAT

COMA 3 03

070.49 OTH VRL HEPAT W HPT COMA 3 03

070.6 VIRAL HEPAT NOS W COMA 3 03

070.71 HPT C W HEPATIC COMA NOS 3 03

072.1 MUMPS MENINGITIS 3 03,05

072.2 MUMPS ENCEPHALITIS 3 03

072.3 MUMPS PANCREATITIS 3

079.50 RETROVIRUS, UNSPECIFIED 3

079.51 HTLV-1 INFECTION OTH DIS 3 06

079.52 HTLV-II INFECTN OTH DIS 3 06

079.53 HIV-2 INFECTION OTH DIS 3

079.59 OTH SPECFIED RETROVIRUS 3

090.42 CONGEN SYPH MENINGITIS 3 03,05

093.20 SYPHIL ENDOCARDITIS NOS 3 14

093.82 SYPHILITIC MYOCARDITIS 3 14

094.2 SYPHILITIC MENINGITIS 3 03,05

094.87 SYPH RUPT CEREB ANEURYSM

3 01,03

098.89 GONOCOCCAL INF SITE NEC 3

112.4 CANDIDIASIS OF LUNG 3 15 112.5 DISSEMINATED CANDIDIASIS 3 112.81 CANDIDAL ENDOCARDITIS 3 14 112.83 CANDIDAL MENINGITIS 3 03,05 112.84 CANDIDAL ESOPHAGITIS 3 114.2 COCCIDIOIDAL MENINGITIS 3 03,05 115.00 HISTOPLASMA CAPSULAT NOS 3 15 115.01 HISTOPLASM CAPSUL MENING 3 03,05

115.02 HISTOPLASM CAPSUL RETINA 3

115.03 HISTOPLASM CAPS PERICARD 3 14

Exclusion IPA C Resources revised.fm Page 19 Friday, June 22, 2012 1:58 PM

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201ICD-9-CM xv

ICD-10-CM Coding and Documentation Proficiency

Self-Assessment

Introduction

This self-assessment covers ICD-10-CM coding guidance and the required level of detail for clinical documentation of heart disease, diabetes, and pneumonia. These high-volume diagnoses have numerous coding guidelines and documentation requirements. The assessment also covers ICD-10-CM conventions that are new or problematic. Use this self-assessment to identify the areas that may require additional coding training or documentation improvement before ICD-10-CM is implemented on October 1, 2014.

Instructions

Code assignments are based upon the 2012 ICD-10-CM diagnosis code set for all reportable diagnoses, including external causes of morbidity (V00–Y99), as appropriate, according to the instructions in ICD-10-CM conventions and the 2012 ICD-10-CM Draft Official Guidelines for Coding and Reporting. Answer each question based on the information provided. Note that for some questions, the codes in the answer are not based upon the information provided, requiring that the provider be queried for specific information because the documentation is insufficient to assign codes correctly.

Self-Assessment Questions

1. In ICD-10-CM what are the two anatomical classifications of pneumonia and the sites of the lung affected by each?

2. The attending physician’s final diagnosis on the progress note on the day of discharge: atypical pneumonia. Sputum results: normal flora. Chest x-ray: bilateral lower lobe consolidation.

A Assign J18.9 Pneumonia, unspecified organism.

B Documentation does not follow guidelines and/or the physician must be queried to determine the following:

• Clinical significance of the sputum results • Clinical significance of the chest x-ray

3. What is the appropriate diagnosis code assignment(s) for ESRD due to type I diabetes on chronic dialysis via right arm AV shunt and hypertension as documented by the provider?

Code assignment:___________________________

4. Attending admission note: Patient is a 42-year-old female who presents with diabetes with hypoglycemia.

A Assign E11.649 Type II diabetes mellitus with hypoglycemia without coma.

• Type of diabetes mellitus • Cause of the hypoglycemia

5. Assign the appropriate code(s) for a diagnosis by the provider of ischemic heart disease and coronary artery disease without history of coronary bypass and current smoker.

Code assignment:___________________________

6. Assign the appropriate code(s) for a patient diagnosed by the provider with community-acquired pneumonia who presented with hemoptysis, productive cough, fever, and an increased respiratory rate with sputum culture stain showing gram-negative bacilli.

Code assignment:___________________________

7. Discharge summary: 1. VAP, with sputum stain identifying

Klebsiella pneumoniae, sensitivity performed and Keflex administered. 2. Vent-dependent patient.

A Assign J95.851 Ventilator associated pneumonia, B96.1 Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere, and Z99.11 Dependence on respirator [ventilator] status. B Documentation does not follow guidelines and/or the physician

must be queried to determine the following:

• Clinical significance of the sputum results

• Pneumonia: present on admission or post admission

8. Assign the appropriate diagnosis code(s) for diabetes II with Charcôt joint, left hallux with ulcer, with dry gangrene and with chronic osteomyelitis. The patient is admitted for amputation due to osteomyelitis documented in the surgeon’s admission note.

Code assignment:___________________________

9. What is the appropriate code assignment for a diagnosis of ischemic cardiomyopathy and coronary artery disease, as documented by the provider?

Code assignment:___________________________

10. Discharge summary: Patient was admitted from the ED for work-up of precordial chest pain, elevated troponin; history of CABG, congestive heart failure, hypertension. Final diagnosis: ASCAD with USA, s/p CABG, CHF. Most recent diagnostic left heart

catheterization showed clean vein and mammary grafts with 90% atherosclerotic stenosis of the native LAD portion. Plans are for future coronary angioplasty as an outpatient. Continue Lasix, Norvasc, and Nitrolingual.

A Assign I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina, I11.9 Hypertensive heart disease without heart failure, I50.9 Heart failure, unspecified, Z95.1 Presence of aortocoronary bypass graft.

• Description of relationship between the hypertension and congestive heart failure

• Type of congestive heart failure

11. What is the appropriate diagnosis code assignment for the postobstructive pneumonia, right middle lobe, due to hilar lung cancer right lobe when the treatment is directed only toward the pneumonia as documented in the admission note by the resident?

Code assignment:___________________________