Updates
ICD-10-CM and ICD-10-PCS Preview Exercises
AHIMA Product AC216009
Changes to reflect code updates as of January 2011
Note: Any question or solution that has been updated appears in this list, and this
version of the question or solution should be substituted in full for the original question
or solution published in the book. To help readers see what changes that have been
made, any text that has been added or changed appears in
red
. In most cases, text that
has been deleted is not shown; however, in some instances, for clarity, deleted text is
also shown in strikethrough font.
Updates are presented in the same sections as appear in the text:
Part 1: ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional Exercises
Part 1: Solutions to ICD-9-CM to ICD-10-CM and ICD-10-PCS Transitional
Exercises
Part 2: Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding Exercises
Part 2: Solutions to Basic ICD-9-CM to ICD-10-CM and ICD-10-PCS Coding
Exercises
Updates to Part 1 Questions:
ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Transitional Exercises
13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant.
The patient was in the process of preparation of the meat for cooking.
ICD-9-CM: __________________________________________________________
ICD-10-CM: _________________________________________________________
18. Postoperative pulmonary
artery
embolism, initial encounter
ICD-9-CM: _____________________________________________________________
ICD-10-CM: ____________________________________________________________
40. Crush syndrome with hemorrhaging; lacerations of small and large intestines.
Ten-year-old
patient was rough housing with his brother
in the shop and a sheet of drywall accidentally fell
on the patient. The patient was immediately sent to the operating room where an open repair
of the lacerations of the small and large intestines due to the crushing injury was performed
(code both diagnosis and procedure codes)
ICD-9-CM: _________________________________________________________________
_____________________________________________________________________________
ICD-10-CM: _____________________________________________________________
_____________________________________________________________________________
ICD-10-PCS: ______________________________________________________________
Updates to Part 1 Solutions:
Solutions to ICD‐9‐CM to ICD‐10‐CM and ICD‐10‐PCS Transitional Exercises
1. Decubitus ulcer of the right side of the lower back, Stage III
ICD-9-CM ICD-10-CM Code(s) Assigned
707.03 Pressure ulcer of lower back 707.23 Pressure ulcer stage III
L89.133 Pressure ulcer of right lower back, stage 3
Index and Tabular Volumes
Alphabetic Index:
Ulcer
decubitus – (see also Ulcer, pressure)
Ulcer pressure back lower 707.03 stage III 707.23 Tabular: 707.0 Pressure ulcer Decubitus ulcer
Use additional code to identify pressure ulcer stage (707.20–707.25)
707.03 Lower back 707.2 Pressure ulcer stages
Code first site of pressure ulcer (707.00–707.09)
707.23 Pressure ulcer, stage III
Alphabetic Index:
Ulcer
decubitus – see Ulcer, pressure, by site
Ulcer
pressure
back L89.1—
Tabular:
L89 Pressure ulcers
Includes: decubitus ulcers
L89.13 Pressure ulcer of right lower back L89.133 Pressure ulcer of right lower back, Stage 3
Code Comparisons
One code category for all chronic skin ulcers (decubitus and non-decubitus)
Two codes required to completely code a pressure ulcer
One code to identify site One code to identify stage
Three code categories for chronic skin ulcers: L89 pressure ulcer
L97 non-pressure chronic ulcer of lower limb, NEC L98.4xx non-pressure chronic ulcer of skin, NEC One code used to classify both the site, including laterality of pressure ulcer, as well as the stage
Documentation Needed
Specification that the skin ulcer is a decubitus Specific site of decubitus ulcer
Depth of the ulcers (coders will need to be able to recognize what depth is associated with specific stages of ulcers)
Specification that the skin ulcer is a decubitus Specific site, including the specific region and left or
right side
Depth of the ulcer (coders will need to be able to recognize what depth is associated with specific stages of ulcers)
5. Appendectomy
Supporting documentation: The operative report indicates that the entire appendix was
removed via an open abdominal incision
ICD-9-CM ICD-10-PCS Code(s) Assigned
47.09 Other appendectomy 0DTJ0ZZ
0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) T Resection (root operation)
J Appendix (body part) 0 Open (approach) Z None (device) Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Appendectomy (with drainage) 47.09
incidental 47.19 laparoscopic 47.11 laparoscopic 47.11 Tabular: 47.0 Appendectomy 47.01 Laparoscopic appendectomy 47.09 Other appendectomy Alphabetic Index: Appendectomy
– see Excision, Appendix 0DBJ – see Resection, Appendix 0DTJ
Resection
Appendix 0DTJ
Tabular (Tables):
Reference the table for 0DT (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body part is appendix (J), the approach is open (0), and there is no device or qualifier (Z).
Code Comparisons
Classification of appendectomy is laparoscopic or other with no specific code for an open approach
Classification of appendectomy does not provide further specificity as to whether a partial or total procedure was performed
Specifies if appendectomy is incidental or not
Specificity as to whether appendectomy is partial or total
Code includes the operative approach
There is no code for an incidental appendectomy Resection is the correct root operation not excision
o Resection: cutting out or off, without replacement, all of a body part o Excision: cutting out or off, without
replacement, a portion of a body part
Documentation Needed
Whether the appendectomy was incidental
Whether it was performed laparoscopically The reason for the appendectomy (incidental or not) is not a criteria for selection of the code The operative approach must be known (open
versus laparoscopic)
The coding professional must be able to determine whether the appendix was removed in part or in total
Excerpt from the ICD-10-PCS Tables
0: Medical Surgical
D: Gastrointestinal system
T: Resection: Cutting out or off, without replacement, all of a body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Esophagus, upper 2 Esophagus, middle 3 Esophagus, lower 4 Esophagogastric junction 5 Esophagus 6 Stomach 7 Stomach, pylorus 8 Small intestine 9 Duodenum A Jejunum B Ileum C Ileocecal valve E Large intestine F Large intestine, right G Large intestine, left H Cecum J Appendix K Ascending colon L Transverse colon M Descending colon N Sigmoid colon P Rectum Q Anus 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening
8 Via Natural or Artificial Opening Endoscopic Z None Z None R Anal sphincter S Greater omentum T Lesser omentum 0 Open 4 Percutaneous Endoscopic Z None Z None
7. Arthroscopic partial meniscectomy, left knee
Supporting documentation: The operative report indicates the surgeon utilized an arthroscope to
perform a partial meniscectomy of the left knee
ICD-9-CM ICD-10-PCS Code(s) Assigned
80.6 Excision of semilunar cartilage of knee 0SBD4ZZ
0 Medical and surgical section (procedure type) S Lower joints (body system)
B Excision (root operation) D Knee joint, left (body part)
4 Percutaneous endoscopic (approach) Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Meniscectomy (knee) NEC 80.6
Tabular:
80.6 Excision of semilunar cartilage of knee
Excision of meniscus of knee
Alphabetic Index:
Meniscectomy
– see Excision, lower joints 0SB – see Resection, lower joints OST
Excision
Joint Knee Left 0SBD
Tabular (Tables):
Reference the table for 0SB (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body part is the left knee joint (D), the approach is
arthroscopic (4), and there is no device or qualifier (Z).
Code Comparisons
Very little specificity, no way to indicate if the meniscectomy was complete or partial The code does not indicate that the procedure
was arthroscopic (application of a separate code to denote this, 80.26, is inappropriate as the surgical approach is not reported in ICD-9-CM)
Many more characters, appropriate code is “built” rather than selected in the Tabular
Specificity as to whether meniscectomy is partial or total
Code specifies laterality of joint Code specifies the operative approach
Documentation Needed
Documentation of the procedure performed The operative approach must be known (open versus arthroscopic) Whether the meniscus was removed in part or in total
Excerpt from the ICD-10-PCS Tables
0: Medical Surgical S: Lower Joints
B: Excision: Cutting out or off, without replacement, a portion of a body part Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
0 Lumbar vertebral joint 2 Lumbar vertebral disc 3 Lumbosacral joint 4 Lumbosacral disc 5 Sacrococcygeal joint 6 Coccygeal joint 7 Sacroiliac joint, right 8 Sacroiliac joint, left 9 Hip joint, right B Hip joint, left C Knee joint, right D Knee joint, left F Ankle joint, right G Ankle joint, left H Tarsal joint, right J Tarsal joint, left
K Metatarsal-tarsal joint, right L Metatarsal-tarsal joint, left M Metatarsal-phalangeal joint, right
N Metatarsal-phalangeal joint, left
P Toe phalangeal joint, right Q Toe phalangea joint, left
0 Open 3 Percutaneous
4 Percutaneous Endoscopic
Z None X Diagnostic Z None
11. Permanent tracheostomy, open approach
ICD-9-CM ICD-10-PCS Code(s) Assigned
31.29 Other permanent tracheostomy 0B110F4
0 Medical and surgical section (procedure type) B Respiratory system (body system)
1 Bypass (root operation) 1 Trachea (body part) 0 Open (approach) F Tracheostomy (device) 4 Cutaneous (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Tracheostomy (emergency) (temporary) (for
assistance in breathing) permanent NEC 31.29
Tabular:
31.29 Other permanent tracheostomy
Code also any synchronous bronchoscopy
if performed (33.21–33.24, 33.27) Excludes: that with laryngectomy (30.3– 30.4)
Alphabetic Index:
Tracheostomy – see Bypass, Respiratory
System 0B1
Bypass
Trachea 0B11
Tabular (Tables):
Reference the table for 0B1 (see Excerpt from the ICD-10-PCS Tables) to look up the
remaining characters of the code. In this case the specific body part is the trachea (1), the approach is open (0), the device is a tracheostomy device (F), and the qualifier of cutaneous (4) applies.
Code Comparisons
Classifies the anticipated duration of the tracheostomy use, temporary versus permanent and whether the intervention is revision of the tracheostomy
Distinguishes the opening of the trachea by the surgical approach used
Distinguishes the type of device remaining at the end of the procedure
Documentation Needed
Clarity is needed regarding whether the intervention is intended for short term or long-term use
Documentation distinguishing the intervention as revising an existing tracheostomy or an initial placement
Documentation must specify the approach to accurately assign the fifth character
Documentation must specify if a device was left remaining at the end of the procedure and if so the type of device
Excerpt from the ICD-10-PCS Tables
0: Medical and Surgical B: Respiratory System
1: Bypass: Altering the route of passage of the contents of a tubular body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
1 Trachea 0 Open D Intraluminal device 6 Esophagus
1 Trachea 0 Open 3 F Tracheostomy device Z No device 4 Cutaneous 1 Trachea 3 Percutaneous 4 Percutaneous Endoscopic F Tracheostomy device Z No Device 4 Cutaneous
13. Laceration of the left index finger with a knife while slicing meat at work in a restaurant.
The patient was in the process of preparation of the meat for cooking.
ICD-9-CM ICD-10-CM Code(s) Assigned
883.0 Open wound of finger without mention of
complication
E920.3 Accidents caused by knifes, swords, and
daggers
E849.6 Place of occurrence, public building E015.0 Food preparation and clean up
E000.0 External cause status, civilian activity done
for income or pay
S61.211A Laceration without foreign body of left
index finger without damage to the nail, initial encounter
W26.0xxA Contact with knife, initial encounter Y92.511 Restaurant or café as the place of
occurrence of the external cause
Y93.G1 Activity, food preparation and clean up Y99.0 External Cause Status, civilian activity done
for income or pay
Index and Tabular Volumes
Alphabetic Index:
Wound, open
finger(s) (nail) (subungual) 883.0
Index to External Causes:
Cut
by
knife E920.3
Accident
occurring (at) (in) restaurant E849.6
Activity
food preparation and clean up E015.0
External cause status
for income E000.0
Tabular:
883.0 Open wound of finger(s) without mention of complication
E920.3 Accidents caused by knives, swords, and daggers
E849.6 Place of occurrence, public building Restaurant
E015.0 Food preparation and clean up E000.0 External cause status, civilian activity done for income or pay
Alphabetic Index:
Laceration
finger(s) index
left S61.211
Index to External Causes:
Cut, cutting (any part of body) (accidental)
– see also Contact, with, by object or machine
Contact with knife W26.0 Place of Occurrence restaurant Y92.511 Activity
Food preparation and clean up Y93.G1 External Cause Status
Civilian activity done for income or pay Y99.0 Tabular:
S61 Open wound of wrist, hands and finger(s) The appropriate seventh character is to be
added to each code from category S61: A initial encounter
D subsequent encounter S sequela
S61.211 Laceration without foreign body of left index finger without damage to nail
W26 Contact with knife, sword or dagger The appropriate seventh character is to be
added to each code from category W26: A initial encounter
D subsequent counter S sequela
W26.0 Contact with knife
Y92.511 Restaurant or café as the place of occurrence of the external cause
Y93 Activity codes
Y93.G Activities involving food preparation, cooking and grilling
Y93.G1 Activities involving food preparation and clean up
Y99 External Cause Status
Y99.0 Civilian activity done for income or pay
Code Comparisons
Anatomic location of the wound is nonspecific as to which finger
Place of occurrence is much less specific Additional codes indicate not only where, but
also what the person was doing when injured
Anatomic location of the laceration classifies specifically which finger (left index) was injured The extension clarifies that this is the initial
encounter
Additional codes indicate not only where, but also what the person was doing when injuredDocumentation Needed
The site of injury (finger)
Whether or not there is delayed healing, delayed treatment, foreign body, or infection of the wound (denoted “complicated”)
Where the accident occurred and what activity the patient was doing when the injury occurred
How the accident occurred
Whether the injury was work related, military, or a student
Specific anatomic site of the injury (laterality and which finger)
The extent of the injury, whether or not the nail was involved
Whether the encounter is the initial episode, subsequent episode, or for sequela
Where the injury occurred and what activity the patient was doing when the injury occurred
Whether the injury was work related, military, or15. Common bile duct exploration, open approach
ICD-9-CM ICD-10-PCS
Code(s) Assigned 51.51 Other incision of bile duct, exploration of
common duct
0FJB0ZZ
0 Medical and surgical section (procedure type) F Hepatobiliary system and pancreas (body system) J Inspection (root operation)
B Hepatobiliary Duct 0 Open (approach) Z None (device) Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Exploration – see also Incision
common bile duct 51.51
Tabular:
51.5 Other incision of bile duct
51.51 Exploration of common duct
Alphabetic Index:
Exploration – see Inspection
Inspection
Duct
Hepatobiliary 0FJB
Tabular (Tables):
Reference the table for 0FJ (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining
characters of the code. In this case the specific body part is the hepatobiliary duct (9), the approach is open (0), and there is no device or qualifier (Z).
Code Comparisons
No further classification as to operative approaches
The code specifies that the inspection of the common bile duct was done during an open approach
Documentation Needed
Documentation specifying the common bile duct was explored
Documentation must clearly describe the
approach to accurately assign the fifth character Definition of “inspection”
Excerpt from the ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
J: Inspection: Visually and/or manually exploring a body part
Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Liver
1 Liver, right lobe 2 Liver, left lobe 3 Liver, caudate lobe
4 Gallbladder G Pancreas 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Z No Device No Qualifier
5 Hepatic duct, right 6 Hepatic duct, left 7 Hepatic duct, caudate 8 Cystic duct
9 Common bile duct
B Hepatobiliary duct
C Ampulla of Vater
D Pancreatic duct
F Pancreatic duct, Accessory
0 Open
2
3 Percutaneous 4 Percutaneous
Endoscopic
7 Via Natural or Artificial
Opening
8 Via Natural or Artificial
Opening Endoscopic
17. Coronary artery bypass graft (CABG) x 3 using saphenous vein grafts, with
cardiopulmonary bypass
ICD-9-CM ICD-10-PCS Code(s) Assigned
36.13 (Aorto)coronary bypass of three coronary
arteries
39.61 Cardiopulmonary bypass
021209W
0 Medical and surgical section (procedure type) 2 Heart and great vessels (body system) 1 Bypass (root operation)
2 Coronary arteries, three sites (body part) 0 Open (approach)
9 Autologous venous tissue (device) W Aorta (qualifier)
05A1221Z
5 Extracorporeal Assistance and Performance (procedure type)
A Physiological Systems (body system) 1 Performance (root operation)
2 Cardiac (body part) 2 Continuous (duration) 1 Output (device) Z None (qualifier)
5A1935Z
5 Extracorporeal Assistance and Performance (procedure type)
A Physiological Systems (body system) 1 Performance (root operation)
9 Respiratory (body part)
3 Less than 24 Consecutive Hours (duration) 5 Ventilation (function)
Z No Qualifier (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Bypass
aortocoronary (catheter stent) (with
prosthesis) (with saphenous vein graft) (with vein graft)
three coronary vessels 36.13
Bypass cardiopulmonary 39.61 Alphabetic Index: Bypass by Body Part Artery
Coronary, Three Sites 0212
Extracorpeal Assistance and Performance
– see Performance Performance Cardiac Continuous Output 5A1221Z Performance Respiratory
Less than 24 consecutive hours, ventilation 5A1935Z
Tabular:
36.1 Bypass anastomosis for heart revascularization
Code also any:
Cardiopulmonary bypass (39.61)
36.13 (Aorta)coronary bypass of three
coronary arteries
39.61 Extracorporeal circulation auxiliary to open heart surgery
Tabular (Tables):
Reference the table for 021 (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is coronary arteries, three (2), the approach is open (9), the device is autologous venous tissue (saphenous vein grafts) (9), and the qualifier is the aorta (W).
Reference the table for 5A1 (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the body part is cardiac (2), the duration is continuous (2), the function is output (1), and the qualifier is none (Z). Lastly reference the table for 5A1 (see the Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the body part is respiratory (9), the duration is less than 24 consecutive hours (3), the function is ventilation (5) and the qualifier is none (Z).
Code Comparisons
One subcategory: 36.1x
Differentiated by number of grafts only Additional code required for cardiopulmonary
bypass
Four subcategories:
0210 (one coronary artery) 0211 (two coronary arteries) 0212 (three coronary arteries) 0213 (four or more coronary arteries) Differentiated by number of grafts, open versus
percutaneous endoscopic and type of graft Additional code required for cardiopulmonary
bypass
Documentation Needed
Number of aortocoronary grafts
Use of cardiopulmonary bypass Number of aortocoronary grafts Open versus closed Use of cardiopulmonary bypass Type of graft used
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical 2: Heart and Greater Vessels
1: Bypass Altering the route of passage of the contents of a tubular body part Body Part Character 4 Approach Character 5 Device Character 6 Qualifier Character 7
0 Coronary Artery, One Site 1 Coronary Artery, Two Sites 2 Coronary Artery, Three Sites 3 Coronary Artery, Four or
More Sites 0 Open 9 Autologous Venous Tissue A Autologous Arterial Tissue J Synthetic Substitute K Nonautologous Tissue Substitute 3 Coronary Artery 8 Internal Mammary, Right 9 Internal Mammary, Left C Thoracic Artery F Abdominal Artery W Aorta
Excerpt from ICD-10-PCS Tables
5: Extracorporeal Assistance and Performance A: Physiological Systems
1: Performance Completely taking over a physiological function by extracorporeal means
Body Part Character 4 Duration Character 5 Device Character 6 Qualifier Character 7
2 Cardiac 0 Single 1 Output 2 Manual
2 Cardiac 1 Intermittent 3 Pacing Z No Qualifier
2 Cardiac 2 Continuous 1 Output
3 Pacing
Z No Qualifier
9 Respiratory 3 Less than 24 Consecutive Hours 4 24-96 Consecutive Hours 5 Greater than 96 Consecutive Hours 5 Ventilation Z No Qualifier
18. Postoperative pulmonary
artery
embolism, initial encounter
ICD-9-CM ICD-10-CM Code(s) Assigned
415.11 Iatrogenic pulmonary embolism and
infarction
T81.718A Complication of other artery following a
procedure, not elsewhere classified, initial encounter
I26.99 Other pulmonary embolism without acute
cor pulmonale
Index and Tabular Volumes
Alphabetic Index:
Embolism
pulmonary (artery) (vein) postoperative 415.11
Complication respiratory
postoperative NEC 997.39
Tabular:
415.11 Iatrogenic pulmonary embolism and infarction
997.3 Respiratory complications
Excludes: iatrogenic pulmonary embolism
(415.11) Alphabetic Index: Embolism postoperative artery specified NEC T81.718 Embolism
pulmonary (artery)(vein) I26.99
Tabular:
T81 Complications of procedures, not elsewhere classified
The appropriate seventh character is to be
Added to each code from category T81: A initial encounter
D subsequent encounter S sequela
T81.718 Complication of other artery following a procedure, not elsewhere classified
I26 Pulmonary embolism
Excludes 2: pulmonary embolism due to complications of surgical and medical care (T80.0, T81.7-, T82.8-)
Code Comparisons
Classified as a disease of pulmonary system (section 415–417)
Code description specifically denotes pulmonary embolism
Classified as a complication of surgical and medical care (Section T80–T88)
Code description does not specifically denote pulmonary embolism
Seventh character specifies the episode of care (encounter)
Documentation Needed
Diagnosis of pulmonary embolism specified as postoperative
Diagnosis of pulmonary embolism following a surgical procedure
19. Aftercare encounter for management of a subtrochanteric fracture of the left femur. Patient
fell and fractured the left femur two weeks earlier.
ICD-9-CM ICD-10-CM Code(s) Assigned
V54.13 Aftercare for healing traumatic fracture of
hip
S72.22xD Displaced subtrochanteric fracture of left
femur, subsequent encounter for closed fracture with routine healing
W19.xxxD Fall, falling (accidental) Index and Tabular Volumes
Alphabetic Index: Aftercare fracture healing traumatic hip V54.13 Tabular:
V54.13 Aftercare for healing traumatic fracture of hip
Alphabetic Index:
Aftercare
fracture–code to fracture with extension D
Fracture, traumatic femur
subtrochanteric (region) (section) (displaced) S72.2-
External Cause Index
Fall, falling (accidental) W19
Tabular:
S72 Fracture of femur
A fracture not indicated as displaced or nondisplaced should be coded as displaced A fracture not designated as open or closed should be coded to closed
The appropriate seventh character is to be added to each code from category S72 (following is part of list of seventh character): A initial encounter for closed fracture
D subsequent encounter for closed fracture with routine healing
K subsequent encounter for closed fracture with nonunion
P subsequent encounter for closed fracture with malunion
S sequela
S72.22 Displaced subtrochanteric fracture of left femur
W19 Unspecified fall
The appropriate 7th character is to be added to code W19:
A – initial encounter D – subsequent encounter S - sequelae
Code Comparisons
Traumatic fractures are coded using the acute fracture codes (800–829) while the patient is receiving active treatment for the fracture Fractures are coded using aftercare codes
(subcategories V54.0, V54.1, V54.2, or V54.8) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase
Subcategories V54.1 (aftercare for healing traumatic fracture) and V54.2 (aftercare for healing pathologic fracture) have been created to identify the fracture site being treated
Codes that represent reasons for encounters are Z codes not V codes
Z codes for aftercare are not used if treatment is directed at the current injury––instead, the injury code should be reported with a seventh
character extension to signify subsequent encounter
The injury code specifies laterality
Extension codes must always be the seventh character; to apply an extension to a code that is not a full six characters, a lower case x is utilized as a placeholder
Documentation Needed
The purpose for the encounter (that is, initial encounter versus subsequent)
The general type and location of the fracture
The purpose for the encounter (that is, initial encounter versus subsequent)
The specific type and location of the fracture
21. Diagnostic left-heart catheterization
ICD-9-CM ICD-10-PCS Code(s) Assigned
37.22 Left heart cardiac catheterization 4A023N7
4 Measurement and monitoring (procedure type) A Physiological systems (body system)
0 Measurement (root operation) 2 Cardiac (body system)
3 Percutaneous (approach)
N Sampling and pressure (function/device) 7 Left heart (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Catheterization cardiac
left 37.22
Tabular:
37.2 Diagnostic procedures on heart and pericardium
37.22 Left heart cardiac catheterization
Alphabetic Index:
Catheterization
Heart, see Measurement, Cardiac 4A02
Measurement
Cardiac
Sampling and Pressure Left Heart 4A02 Tabular (Tables):
Reference the table for 4A0 (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the approach is percutaneous (3), the function/device is sampling and pressure (N), and the qualifier is the left heart (7).
Code Comparisons
One code category; 37 Other operations on heart and pericardium
Third digit classification based on the type of operation performed
Fourth digit differentiates the part of heart; left or right
Fourth character classifies body system (cardiac) Fifth character classifies the approach
Sixth character for function/device used Seventh character classifies area of heart that
was catheterized (left, right, bilateral)
Documentation Needed
Type of procedure performed
Side of the heart procedure performed on: o Left
o Right o Combined
Reason for procedure Type of procedure performed Approach used
o Open
o Percutaneous
Side of the heart procedure performed on o Left
o Right o Bilateral
Function or type of device used
Excerpt from ICD-10-PCS Tables
4: Measurement and Monitoring A: Physiological Systems
0: Measurement Determining the level of a physiological or physical function at a point in time Body System Character 4 Approach Character 5 Function/Device Character 6 Qualifier Character 7 2 Cardiac 0 Open 3 Percutaneous 4 Electrical Activity 9 Output C Rate F Rhythm H Sound P Action Currents Z No Qualifier 2 Cardiac 0 Open 3 Percutaneous
N Sampling and Pressure 6 Right Heart 7 Left Heart 8 Bilateral 2 Cardiac X External 4 Electrical Activity
9 Output C Rate F Rhythm H Sound P Action Currents Z No Qualifier
22. Down’s syndrome
ICD-9-CM ICD-10-CM Code(s) Assigned
758.0 Down’s syndrome Q90.9 Down’s syndrome, unspecified
Index and Tabular Volumes
Alphabetic Index:
Down’s disease or syndrome (mongolism) 758.0 Syndrome
Down’s (mongolism) 758.0 Tabular:
758 Chromosomal anomalies
Use additional codes for conditions associated
with the chromosomal anomalies 758.0 Down’s syndrome
Mongolism
Translocation Down’s Syndrome Trisomy: 21 or 22 G Alphabetic Index: Down syndrome Q90.9 Syndrome
Down (see also Down syndrome) Q90.9
Tabular:
Q90 Down Syndrome
Q90.0 Trisomy 21, nonmosaicism Q90.1 Trisomy 21, mosaicism Q90.2 Trisomy 21, translocation Q90.9 Down’s syndrome, unspecified
Code Comparisons
One category, 758, Chromosomal abnormalities
Classification based on the Trisomy number Multiple categories (Q90–Q99) for chromosomal abnormalities
Documentation Needed
Documentation of type of chromosomal abnormality
Documentation of type of chromosomal abnormality
27. Left liver lobectomy, open
Supporting documentation: The operative report indicates the surgeon removed the entire
left lobe of the liver
ICD-9-CM ICD-10-PCS
Code(s) Assigned
50.3 Lobectomy of liver 0FT20ZZ
0 Medical and surgical section (procedure type)
F Hepatobiliary system and pancreas (body system)
T Resection (root operation) 2 Liver, left lobe (body part) 0 Open (approach)
Z None (device) Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Lobectomy
liver (with partial excision of adjacent lobes) 50.3
Tabular:
50.3 Lobectomy of liver
Total hepatic lobectomy with partial excision of other lobe
Alphabetic Index:
Lobectomy
– see Resection, Hepatobiliary Systems and Pancreas
Resection Liver Left lobe 0FT2 Tabular (Tables):
Reference the table for 0FT (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the left lobe of the liver (2), the approach is open (0), and there is no device or qualifier (Z).
Code Comparisons
Lobe laterality not defined Approach not defined
Code includes partial lobectomy of another lobe of the liver
Approach of the procedure is defined in the code, open versus percutaneous endoscopic Lobe laterality is required for proper code
assignment
Documented Needed
The entire lobe was removed Laterality of lobe that was removed The approach used to remove the lobe Whether or not the entire lobe (resection) or
part of the lobe (excision) was removed
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Liver
1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 4 Percutaneous Endoscopic Z No Device Z No Qualifier
29. Excision of fallopian tubes, bilateral, endoscopic
ICD-9-CM ICD-10-PCS Code(s) Assigned
66.51 Bilateral excision of fallopian tubes 0UT74ZZ
0 Medical and surgical section (procedure type) U Female reproductive system (body system) T Resection (root operation)
7 Fallopian tubes, bilateral (body part) 4 Percutaneous endoscopic (approach) Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Salpingectomy (bilateral) (total) (transvaginal)
66.51
Tabular:
66.5 Total bilateral salpingectomy
66.51 Removal of both fallopian tubes at same operative episode
Alphabetic Index:
Salpingectomy
– see Excision, Female Reproductive System 0UB – see Resection, Female Reproductive System 0UT
Resection
Fallopian Tubes, Bilateral 0UT7 Tabular (Tables):
Reference the table for 0UT (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case, the specific body part is the fallopian tubes, bilateral (7), the approach is
percutaneous endoscopic (4), and there is no device or qualifier (Z).
Code Comparisons
Differentiated by single, bilateral tube removal
The approach is not identified The specific approach for the procedure is identified Identifies bilateral or unilateral removal of tube
Documentation Needed
Total or partial excision Diagnostic reason for excision Bilateral or unilateral excision
Total (resection) or partial (excision) removal Bilateral or unilateral excision; if unilateral then right
or left
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
U: Female Reproductive System
T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Ovary, Right 1 Ovary, Left 2 Ovaries, Bilateral 5 Fallopian Tube, Right 6 Fallopian Tube, Left 7 Fallopian Tubes, Bilateral 9 Uterus 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic F Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
Z No Device Z No Qualifier
31. Right kidney transplantation, open, zooplastic donor
ICD-9-CM ICD-10-PCS Code(s) Assigned
55.69 Other Kidney Transplantation 0TY00Z2
0 Medical and surgical section (procedure type) T Urinary system (body system)
Y Transplantation (root operation) 0 Kidney, right (body part)
0 Open (approach) Z None (device) 2 Zooplastic (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Transplant, Transplantation
kidney NEC 55.69
Tabular:
55.6 Transplant of kidney
Note: To report donor source—see codes 00.91–00.93
55.69 Other kidney transplantation
Alphabetic Index:
Transplantation Kidney
Right 0TY00Z
Tabular (Tables):
Reference the table for 0TY (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the right kidney (0), the approach is open (0), the devices is none (Z), and the qualifier is zooplastic donor (2).
Code Comparisons
Only one code is offered for a kidney transplantation (55.69 NEC).
Additional codes for donors only include transplants from live related donor, live nonrelated donor, and from a cadaver. Nonspecific as to type of approach Nonspecific as to which kidney is
transplanted (right or left)
Multiple codes are included for kidney transplantation
Code distinguishes which kidney was transplanted
Code specifies the approach
More options for donor source are available and included in the code eliminating the need for a second code
Documentation Needed
Organ that was transplanted Donor source
Which organ was transplanted including if it was right or left
Approach used Donor source
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical T: Urinary System
Y: Transplantation Putting in or on all or a portion of a living body part taken from another
individual or animal to physically take the place and/or function of all or a portion of a similar body part.
Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Kidney, Right 1 Kidney, Left 0 Open Z No Device 0 Allogeneic 1 Syngeneic 2 Zooplastic
33.Classical migraine
ICD-9-CM ICD-10-CM Code(s) Assigned
346.00 Classical migraine, without mention of
intractable migraine, without mention of status migrainosus
G43.109 Migraine with aura, not intractable, without status migrainosus
Index and Tabular Volumes
Alphabetic Index:
Migraine
classic(al) 346.0
Tabular:
346 Migraine
The following fifth-digit subclassification is for use with category 346:
0 without mention of intractable migraine without mention of status migrainosus 1 with intractable migraine, so stated without mention of status migrainosus
2 without mention of intractable migraine with status migrainosus
3 with intractable migraine, so stated, with status migrainosus
346.0 Migraine with aura Classic migraine
Alphabetic Index:
Migraine
Classical – see Migraine, with aura
Migraine
with aura (acute-onset) (prolonged) (typical) (without headache) G43.109
Tabular:
G43 Migraine
G43.10 Migraine, with aura, not intractable
Classic migraine
G43.109 Migraine, with aura, not intractable, without status migrainosus
Code Comparisons
One code category with subcategories at the fourth digit level for the type of migraine Fifth digit specifies with or without intractable
migraine and with or without status migrainosus
One combination code which classifies the type of migraine, whether or not intractable and whether or not with status migrainosus
Documentation Needed
Diagnosis of migraine
Documentation of whether migraine is intractable and status migrainosius
Diagnosis of migraine
Documentation of whether migraine is intractable and status migrainosis
35. Macular degeneration, atrophic
ICD-9-CM ICD-10-CM Code(s) Assigned
362.51 Exudative senile macular degeneration H35.30 Unspecified macular degeneration
(age-related)
Index and Tabular Volumes
Alphabetical Index:
Degeneration, degenerative
macula (acquired) (senile) atrophic 362.51 Tabular:
362.5 Degeneration of macula and posterior pole
362.51 Nonexudative senile macular degeneration
Alphabetical Index:
Degeneration, degenerative
macula, macular (acquired) (atrophic) (exudative) (senile) H35.30
Tabular:
H35.3 Degeneration of macula and posterior pole H35.30 Unspecified macular degeneration (age related)
Code Comparisons
One code subcategory for degeneration of macula and posterior pole
Fifth digit provides further specification of complications
One code subcategory for degeneration of macula and posterior pole
Fifth character provides further specification of complications
Some codes are further subdivided with a sixth character specifying right, left, bilateral, or unspecified eye
Documentation Needed
Any complications or manifestations of the degeneration
Type of degeneration
Any complications or manifestations of the degeneration
Type of degeneration
36. Cervical esophagostomy, open
ICD-9-CM ICD-10-PCS Code(s) Assigned
42.11 Cervical esophagostomy 0D110Z4
0 Medical and surgical (procedure type) D Gastrointestinal system (body system) 1 Bypass (root operation)
1 Esophagus, upper (body part) 0 Open (approach)
Z None (device) 4 Cutaneous (qualifier)
Index and Tabular Volumes
Alphabetical Index: Esophagostomy cervical 42.11 Tabular: 42.1 Esophagostomy 42.11 cervical esophagostomy Alphabetical Index: Esophagostomy
– see Bypass, Gastrointestinal System 0D1
Bypass
Esophagus Upper 0D11 Tabular (Tables):
Reference the table for 0D1 (see Excerpt from the ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is esophagus upper (1), the approach is open (0), the device is none (Z), and the qualifier is cutaneous (4).
Code Comparisons
One code category with subcategories at the fourth character level for further specification Classification does not specify the approach
Classification differentiates the three sections of the esophagus (upper, middle, and lower) Code specifies the operative approach
Code specifies any devices remaining at the end of the operation
Code specifies the destination of the bypass (qualifier)
Documentation Needed
Location or site of the esophagostomy Location or site of the esophagostomy Operative approach
Any devices remaining at the end of the operation The destination of the bypass
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical D: Gastrointestinal System
1: Bypass: Altering the route of passage of the contents of a tubular body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Esophagus, upper 2 Esophagus, middle 3 Esophagus, lower 5 Esophagus 0 Open 4 Percutaneous Endoscopic
8 Via Natural or Artificial Opening Endoscopic 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device 4 Cutaneous 6 Stomach 9 Duodenum A Jejunum B Ileum
40. Crush syndrome with hemorrhaging; lacerations of small and large intestines.
Ten-year-old
patient was rough housing with his brother
in the shop and a sheet of drywall accidentally fell on
the patient. The patient was immediately sent to the operating room where an open repair of the
lacerations of the small and large intestines due to the crushing injury was performed (code both
diagnosis and procedure codes)
ICD-9-CM ICD-10-CM Diagnosis Code(s) Assigned
958.5 Traumatic anuria
459.0 Hemorrhage, unspecified
863.30 Injury to small intestine, with open wound
into cavity, unspecified site
863.50 Injury to colon, with open wound into cavity,
unspecified site
E916 Struck accidently by falling object
E849.3 Place of occurrence, industrial place and
premises
E029.2 Rough housing and horseplay E000.8 Other external cause status
T79.5xxA Traumatic anuria, initial encounter R58 Hemorrhage, not elsewhere classified S36.439A Laceration of unspecified part of small
intestine, initial encounter
S36.539A Laceration of unspecified part of colon,
initial encounter
W20.8xxA Other cause of strike by thrown, projected,
or falling object
Y92.513 Shop as the place of occurrence of the
external cause
Y93.83 Activity, rough housing and horseplay Y99.8 Other external cause status
Index and Tabular Volumes
Alphabetic Index:
Syndrome
Crush 958.5
Hemorrhage, hemorrhagic 459.0
Laceration
internal organ (abdomen) (chest) (pelvic) NEC –
see Injury, internal, by site
Injury Internal
intestine NEC large NEC
with open wound into cavity 863.50 small NEC
with open wound into cavity 863.30 Index to External Causes:
Hit, hitting by object falling E916 Accident (to) occurring shop E849.3 Alphabetic Index: Syndrome Crush T79.5 Hemorrhage, hemorrhagic R58 Laceration intestine large colon S36.539 small S36.439
Index to External Causes:
Struck by object
falling W20.8
Place of occurrence
Activity
rough housing and horseplay E029.2
External Cause Status
specified NEC E000.8 Tabular:
958 Certain early complications of trauma 958.5 Traumatic anuria
Crush syndrome
459 Other disorders of circulatory system 459.0 Hemorrhage, unspecified
Internal Injury of Thorax, Abdomen, and Pelvis (860–869)
Includes: laceration of internal organs
863 Injury to gastrointestinal tract
863.3 Small intestine, with open wound into cavity
864.30 Small intestine, unspecified site
863.5 Colon or rectum, with open wound into cavity
863.50 Colon, unspecified site
E916 Struck accidentally by falling object
E849 Place of occurrence
E849.3 Industrial place and premises Shop
E029 Other Activity
E029.2 Rough housing and horseplay
E000 External cause status
E000.8 Other external cause status
Activity
rough housing and horseplay Y93.83
External Cause Status
specified NEC Y99.8
Tabular:
T79 Certain early complications of trauma, not elsewhere classified
The appropriate seventh character is to be added
to each code from category T79: A initial encounter
D subsequent encounter S sequela
T79.5 Traumatic anuria
Crush syndrome
R58 Hemorrhage, not elsewhere classified Includes: hemorrhage NOS
Excludes 1: hemorrhage included with underlying conditions, such as:
acute duodenal ulcer with hemorrhage (K26.0)
acute gastritis with bleeding (K29.01) ulcerative enterocolitis with rectal bleeding (K51.01)
S36 Injury of intra-abdominal organs
Code also any associated open wound (S31.-)
The appropriate seventh character is to be added to each code from category S36:
A initial encounter D subsequent encounter S sequela
S36.4 Injury of small intestine
S36.43 Laceration of small intestine S36.439 Laceration of unspecified part of small intestine S36.5 Injury of colon S36.53 Laceration of colon S36.539 Laceration of
unspecified part of colon
W20 Struck by thrown, projected, or falling object The appropriate seventh character is to be
added to each code from category W20: A initial encounter
D subsequent encounter S sequela
W20.8 Other cause of strike by thrown, projected, or falling object
Y92.513 Shop as the place of occurrence of the external cause
Y93 Activity Codes
Y93.8 Activities, other specified
Y93.83 Activity, rough housing and horseplay
Y99 External Cause Status
Y99.8 Other external cause status Code Comparisons
Laceration of an internal organ is classified as injury of the organ with open wound into the cavity
Laceration of an internal organ is classified as a laceration to that internal organ with a separate code for any associated open wound of the abdominal wall
Documentation Needed
Documentation of site of laceration External cause of the injury and place of
occurrence in additional to type of activity being performed
Documentation of specific site of large and small intestine that were lacerated
Whether or not there was an associated open wound of the abdominal wall
External cause of the injury and place of occurrence in addition to type of activity being performed
ICD-9-CM ICD-10-PCS Procedure Code(s) Assigned
46.73 Suture of laceration of small intestine 46.75 Suture of laceration of large intestine
0DQ80ZZ Repair of small intestines
0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) Q Repair (root operation)
8 Small intestines (body part) 0 Open (approach)
Z None (device) Z None (qualifier)
0DQE0ZZ Repair of large intestines
0 Medical and surgical section (procedure type) D Gastrointestinal system (body system) Q Repair (root operation)
E Large intestine (body part) 0 Open (approach)
Z None (device) Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index:
Repair
laceration – see Suture, by site
Suture (laceration)
intestine large 46.75 small 46.73
Tabular:
46.7 Other repair of intestine
46.73 Suture of laceration of small intestine, except duodenum
46.75 Suture of laceration of large intestine
Alphabetic Index:
Suture –
Laceration repair see Repair
Repair Intestine Large 0DQE Small 0DQ8 Tabular (Tables):
Reference the table for 0DQ (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body parts are the large intestine (E) and small intestine (8), the approach is open (0), and there is no device or qualifier (Z).
Code Comparisons
Classification only provides three codes for suture repair of laceration of small and large intestine:
o Small intestines o Large intestines o Duodenum
Classification does not provide the ability to differentiate suture repair of specific parts of small and large intestines except for duodenum Classification does not differentiate the approach
Classification provides a code for each specific body part of the small intestine and large intestines Classification includes the approach
Documentation Needed
Location of laceration and suture repair Location of laceration and suture repair Approach
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical D: Gastrointestinal System
Q: Repair Restoring, to the extent possible, a body part to its normal anatomic
structure and function
Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction 5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine F Large Intestine, Right G Large Intestine, Left H Cecum J Appendix K Ascending Colon L Transverse Colon M Descending Colon N Sigmoid Colon P Rectum 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic Z No Device Z No Qualifier
42. Laparoscopic cholecystectomy, converted to an open procedure
ICD-9-CM ICD-10-PCS Code(s) Assigned
V64.41 Laparoscopic surgical procedure
converted to open procedure
51.22 Cholecystectomy
0FT40ZZ
0 Medical and surgical section (procedure type) F Hepatobiliary system and pancreas (body system)
T Resection (root operation) 4 Gallbladder (body part) 0 Open (approach) Z None (device) Z None (qualifier)
0FJ44ZZ
0 Medical and surgical section (procedure type) F Hepatobiliary System and Pancreas (body system)
J Inspection (root operation) 4 Gallbladder (body part)
4 Percutaneous endoscopic (approach) Z None (device)
Z None (qualifier)
Index and Tabular Volumes
Alphabetic Index (Diseases):
Laparoscopic surgical procedure converted to open procedure V64.41
Alphabetic Index (Procedures):
Cholecystectomy (total) 51.22
Tabular (Diseases):
V64.41 Laparoscopic surgical procedure converted to open procedure
Tabular (Procedures):
51.2 Cholecystectomy 51.22 Cholecystectomy
Alphabetic Index:
Cholecystectomy
– see Resection, Gallbladder 0FT4
Resection
Gallbladder 0FT4
Inspection
Gallbladder 0FJ4 Tabular (Tables):
Reference the table for 0FT (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the gallbladder (4), the approach is open (0), and there is no device or qualifier (Z). Reference the table for 0FJ (see the Excerpt from ICD-10-PCS Tables) to look up the remaining characters of the code. In this case the specific body part is the gallbladder (4), the approach is percutaneous endoscopic (4), and there is no device or qualifier (Z).
Code Comparisons
In ICD-9-CM when a laparoscopic procedure is converted to an open procedure, the coding rule is to only code the open procedure and assign V64.41 as an additional diagnosis code
Type of approach is not classified except for laparoscopic
Fourth digit indicates laparoscopic partial or total or other partial cholecystectomy
In ICD-10-PCS when a laparoscopic procedure is converted to an open procedure, the coding rule is to code an endoscopic inspection (for laparoscopic procedure) and then code the actual open procedure
Approach is specified
Documentation Needed
Laparoscopic procedure converted to open
Whether total or partial excision Laparoscopic procedure converted to open Approach for the procedure Whether total (resection) or partial (excision)
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Resection Cutting out or off, without replacement, all of a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Liver
1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 4 Percutaneous Endoscopic Z No Device Z No Qualifier
Excerpt from ICD-10-PCS Tables
0: Medical and Surgical
F: Hepatobiliary System and Pancreas
T: Inspection Visually and/or manually exploring a body part Body System Character 4 Approach Character 5 Device Character 6 Qualifier Character 7 0 Liver
1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Z No Device Z No Qualifier
44. Atherosclerotic heart disease of native coronary artery; unstable angina pectoris
ICD-9-CM ICD-10-CM Code(s) Assigned
414.01 Atherosclerotic heart disease of native
coronary artery
411.1 Unstable angina
I25.110 Atherosclerotic heart disease of native
coronary artery with unstable angina pectoris
Index and Tabular Volumes
Alphabetic Index:
Atherosclerosis – see Arteriosclerosis Arteriosclerosis, arteriosclerotic
heart (disease) (see also Arteriosclerosis, coronary) coronary (artery) 414.00 native artery 414.01 Angina Unstable 411.1 Tabular: 414.0 Coronary atherosclerosis:
Arteriosclerotic heart disease [ASHD] Atherosclerotic heart disease Coronary (artery): arteriosclerosis arteritis or endarteritis atheroma sclerosis stricture
Use additional code, if applicable, to identify chronic total occlusion of coronary artery (414.2)
414.01 Of native coronary artery 411.1 Intermediate coronary syndrome: Impending infarction
Preinfarction angina Preinfarction syndrome Unstable angina
Alphabetic Index:
Atherosclerosis – see also Arteriosclerosis
coronary artery I25.10
with angina pectoris – see also Arteriosclerosis, coronary (artery)
Arteriosclerosis, arteriosclerotic
coronary (artery) I25.10 native vessel
with
angina pectoris I25.119 specified type NEC I25.118 unstable I25.110
Tabular:
I25.1 Atherosclerotic heart disease of native coronary artery
Atherosclerotic cardiovascular disease Coronary (artery) atheroma
Coronary (artery) atherosclerosis Coronary (artery) disease Coronary (artery) sclerosis
Excludes2: atheroembolism (I75.-)
atherosclerosis of coronary artery bypass graft(s) and transplanted heart (I25.7-)
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
Atherosclerotic heart disease NOS I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
Excludes 1: unstable angina without atherosclerotic heart disease (I20.0)
Code Comparisons
In ICD-9-CM, two codes are required to code atherosclerotic heart disease of native coronary artery; unstable angina pectoris Because two codes are required to fully
describe the condition, this may result in a sequencing dilemma; many issues of Coding Clinic have addressed this issue
Only one code is needed to represent all of the detail concerning this condition
Combination codes are common in ICD-10-CMDocumentation Needed
Type of ASHD (native versus bypass graft)
Type of angina Type of ASHD (native versus bypass graft) Type of angina
46. Patient with a large splenic mass is admitted for a laparoscopic splenectomy (code both
diagnosis and procedure codes)
ICD-9-CM ICD-10-CM Diagnosis Code(s) Assigned
789.2 Splenomegaly R16.1 Splenomegaly, not elsewhere classified
Index and Tabular Volumes
Alphabetic Index:
Mass
splenic 789.2 Tabular:
789 Other symptoms involving abdomen and pelvis
Excludes: symptoms referable to genital organs: female (625.0–625.9) male (607.0–608.9) psychogenic (302.70–302.79) 789.2 Splenomegaly Enlargement of spleen Alphabetic Index: Mass splenic R16.1 Tabular:
Symptoms and signs involving the digestive system and abdomen (R10–R19)
Excludes 1: congenital or infantile pylorospasm (Q40.0) gastrointestinal hemorrhage (K92.0–K92.2) intestinal obstruction (K56.-)
newborn gastrointestinal hemorrhage (P54.0–P54.3) newborn intestinal obstruction (P76.-)
pylorospasm (K31.3)
signs and symptoms involving the urinary system (R30–R39)
symptoms referable to female genital organs (N94.-) symptoms referable to male genital organs male (N48–N50)
R16 Hepatomegaly and splenomegaly, not elsewhere classified
R16.1 Splenomegaly, not elsewhere classified