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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

 

(2)

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: ______________________________________________________________

 

(3)

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)

(4)

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

(5)

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

(6)

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

(7)

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

(8)

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

(9)

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

(10)

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

(11)

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 injured

Documentation 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, or

(12)

15. 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”

(13)

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

(14)

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

(15)

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

(16)

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

(17)

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

(18)

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

(19)

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).

(20)

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

(21)

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)

(22)

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

(23)

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

(24)

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).

(25)

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

(26)

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

(27)

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

(28)

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

(29)

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

(30)

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

(31)

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

(32)

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)

(33)

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

(34)

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

(35)

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).

(36)

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

(37)

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)

(38)

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-CM

Documentation 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

References

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