Coding Steps and Examples
Coding using the ICD-10-CM coding system involves several steps. These steps include:
Reviewing the medical documentation: The first step in coding using the ICD-10-CM coding system is to review the medical documentation to determine the appropriate code(s) to use. This documentation may include physician notes, diagnostic tests, and other relevant information.
Identifying the main diagnosis: Once the medical documentation has been reviewed, the coder must identify the patient’s main diagnosis or reason for seeking medical care. This will be the primary code used to represent the patient’s condition.
Identifying any secondary diagnoses: In addition to the main diagnosis, the coder must also identify any secondary diagnoses or comorbidities that the patient may have. These diagnoses may impact the patient’s treatment and care, and should be coded as appropriate.
Coding using the ICD-10-CM coding system involves several steps. These steps include:
Selecting the appropriate code(s): After identifying the main diagnosis and any secondary diagnoses, the coder must select the appropriate code(s) from the ICD-10-CM coding system. This involves reviewing the coding guidelines, conventions, and format to ensure that the correct code(s) are selected and reported.
Sequencing the codes: Once the appropriate code(s) have been selected, they must be sequenced in the correct order based on the patient’s condition and any underlying causes or complications.
Here are some examples of ICD-10-CM coding:
Patient presents with chest pain and is diagnosed with unstable angina.
Main diagnosis: Unstable angina ICD-10-CM code: 120.0
Patient presents with a fracture of the right femur due to a fall.
Main diagnosis: Fracture of the right femur ICD-10-CM code: S72.001A (initial encounter for closed fracture)
Here are some examples of ICD-10-CM coding:
Patient presents with type 2 diabetes and hypertension.
Main diagnosis: Type 2 diabetes ICD-10-CM code: E11.9 (unspecified type of diabetes mellitus) Secondary diagnosis: Hypertension ICD- 10-CM code: 110 (essential hypertension)
Patient presents with acute bronchitis.
Main diagnosis: Acute bronchitis ICD-10-CM code: J20.9 (unspecified acute bronchitis)
Here are some examples of ICD-10-CM coding:
Patient presents with abdominal pain and is diagnosed with acute appendicitis.
Main diagnosis: Acute appendicitis ICD-10-CM code: K35.80 (unspecified acute appendicitis without perforation or gangrene)
Patient presents with a history of breast cancer.
Main diagnosis: Personal history of breast cancer ICD-10-CM code: Z85.3 (personal history of malignant neoplasm of breast)
Patient presents with a skin rash due to an allergic reac- tion to medication.
Main diagnosis: Allergic contact dermatitis due to medication ICD- 10-CM code: L23.7 (allergic contact dermatitis due to drugs and medicines in contact with skin)
challenges
In addition to these examples, there are thousands of codes in the ICD- 10-CM coding system that cover a wide range of medical conditions, diseases, and injuries.
The accuracy of coding in the ICD-10-CM system is important because it impacts many aspects of healthcare, including patient care, billing and reimbursement, public health initiatives, and medical research. Inaccurate coding can lead to improper treatment, incorrect reimbursement, and inaccurate statistical data, which can impact healthcare policies and decisions.
There are a few challenges associated with ICD-10-CM coding. One of the biggest challenges is ensuring that coders have the knowledge and skills necessary to accurately assign codes based on the medical documentation. Additionally, the sheer number of codes in the ICD-10-CM system can be overwhelming, making it important for coders to have access to reliable resources and tools.
Another challenge is keeping up with updates and changes to the coding system. As mentioned earlier, the ICD-10-CM system is updated annually to reflect changes in medical practice, technology, and research. Staying up-to-date with these changes requires ongoing education and training for healthcare providers and coders.
Scenario 1: Abdominal Pain
SCENARIO DETAILS
CHIEF COMPLAINT
“My stomach hurts and I feel full of gas.”
HISTORY
47 year old male with mid-abdominal epigastric pain , associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
Has had an estimated 13 pound weight loss over the past month.
Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.
Patient admits to a history of alcohol dependence. Consuming 5 – 6 beers per day now, down from 10 – 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.
EXAM
VS: T 99.8°F, otherwise normal.
Mild jaundice noted.
Abdomen distended and tender across the upper abdomen. Guarding is present. Bowel sounds diminished in all four quadrants.
Oral mucosa dry, chapped lips, decreased skin turgor
ASSESSMENT AND PLAN
Dehydration and suspected acute pancreatitis.
Admit to the hospital. Orders written and sent to on-call hospitalists.
1L IV NS started in the office. Blood drawn for labs.
Recommend behavioral health counseling for substance abuse assessment and possible treatment.
Patient’s wife was notified of the plan; she will be transported to hospital by private vehicle.
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
Describe the pain as specifically as possible based on location.
When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.
Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.
ICD-10-CM Diagnosis Code R10.13 [convert to ICD-9-CM]
Epigastric pain
Abdominal pain, epigastric; Dyspepsia (indigestion); Indigestion; functional dyspepsia (K30); Dyspepsia
ICD-10-CM Diagnosis Code R10.819 [convert to ICD-9-CM]
Abdominal tenderness, unspecified site
ICD-10-CM Diagnosis Code F10.20 [convert to ICD-9-CM]
Alcohol dependence, uncomplicated
ICD-10-CM Diagnosis Code R17 [convert to ICD-9-CM]
Unspecified jaundice
ICD-10-CM Diagnosis Code E86.0 [convert to ICD-9-CM]
Dehydration
CODING
ICD-9-CM DIAGNOSIS CODES
789.06 Abdominal pain, epigastric
789.60 Abdominal tenderness, unspecified site
782.4 Jaundice NOS
276.51 Dehydration
303.90 Other and unspecified alcohol dependence, unspecified
CODING
ICD-10-CM DIAGNOSIS CODES
R10.13 Epigastric pain
R10.819 Abdominal tenderness, unspecified site
R17 Unspecified jaundice
E86.0 Dehydration
F10.20 Alcohol dependence, uncomplicated
OTHER IMPACTS
No specific impacts noted.
Scenario 2: Annual Physical Exam
SCENARIO DETAILS
CHIEF COMPLAINT
“I’m here for my annual check-up.1”
HISTORY
73 year old male with history of coronary artery disease, stent placement, hyperlipidemia, HTN and GERD.
Recent admission to hospital following a hypertensive crisis. Discharged home on olmesartan medoxomil 20 mg daily.
Patient stopped taking olmesartan medoxomil due to side effects 2, including a headache that began after starting the medication and still exists, and tiredness.
Regular activity includes walking, golfing. Active social life. No complaints of chest pain, or dyspnea on exertion.
Last colonoscopy was 9 months ago. No significant pathology found; some diverticular disease.
Medications were reviewed.
EXAM
Chest clear. Heart sounds normal. Mental status exam intact.
EKG shows no changes from prior EKG.
Vitals: BP is 159/95, otherwise normal. Per patient, he had good control of BP on meds, but it has risen without medication.
BUN/creatinine normal limits.
ASSESSMENT AND PLAN
HTN noted on exam today. Change from olmesartan medoxomil to metoprolol tartrate 50 mg once daily, will titrate dosage every two weeks until BP normalizes.
Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP medication as prescribed; he verbalizes understanding.
Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy, and repeat BUN/creatinine.
ICD-10-CM Diagnosis Code Z00.01 [convert to ICD-9-CM]
Encounter for general adult medical examination with abnormal findings
ICD-10-CM Diagnosis Code T46.5X6A [convert to ICD-9-CM]
Underdosing of other antihypertensive drugs, initial encounter
ICD-10-CM Diagnosis Code I10 [convert to ICD-9-CM]
Essential (primary) hypertension
ICD-10-CM Diagnosis Code G44.40 [convert to ICD-9-CM]
Drug-induced headache, not elsewhere classified, not intractable
ICD-10-CM Diagnosis Code Z91.12
Patient’s intentional underdosing of medication regimen
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes). In this situation, the patient is requesting an encounter without a complaint, suspected or reported diagnosis.
Document that the patient is noncompliant with his medication. This “underdosing” concept can often be coded, along with the patient’s reason for not taking the prescribed medications. Document if there is a medical condition linked to the underdosing that is relevant to the encounter, and ensure the connection is clearly made. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. In this note the side effects of stopping the medication include headache, which remains as a patient complaint for this encounter. When documenting headache do differentiate if intractable versus non-intractable.
CODING
ICD-9-CM DIAGNOSIS CODES
V70.0 Routine medical exam
401.9 Unspecified essential hypertension
339.3 Drug-induced headache, not elsewhere classified
ICD-10-CM DIAGNOSIS CODES
Z00.01 Encounter for general adult medical examination with abnormal findings
I10 Essential (primary) hypertension
G44.40 Drug-induced headache, not elsewhere classified, not intractable
T46.5X6A Underdosing of other antihypertensive drugs, initial encounter
Z91.128 Patient’s intentional underdosing of medication regimen for other reason
OTHER IMPACTS
Assess if the new patient-centric preventative health incentives for annual exams are relevant to your practice.
For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.
Scenario 3: Earache
SCENARIO DETAILS
CHIEF COMPLAINT
Right earache and ear pain.
HISTORY
This 20 year old male is an established patient and well known to me. He is a full-time college student, and presents with a right sided ear pain, noted 8/10. The symptoms started yesterday and continue to worsen with no pain relief using acetaminophen. Denies discharge, hearing loss, or ringing/roaring. He denies trauma or recent barotrauma to ear. He denies fever, sore throat, and cough today. He reports recently having an URI that resolved with OTC medications.
He is up to date on his influenza, HPV, Tdap, and meningococcal immunizations.
Patient does not use tobacco, alcohol, or illicit drugs. He denies exposure to secondhand smoke.”ETS” environmental tobacco smoke
Medical history includes major depressive disorder with recurrent episodes of mild severity, and bipolar II disorder. His current medications include aripiprazole, and duloxetine.
No known allergies.
16 point review of systems negative except for notations above.
EXAM
Healthy appearing male. He appears calm and is cooperative.
Vital signs: BP: 130/78 HR: 70 bpm T: 99.8 °F Wt: 235 lbs Ht: 5’ 10”.
ENT: auricle and external canals normal bilaterally. Right ear: erythematous membrane, bulging, with loss of landmarks. Pharynx, teeth, and nose exam normal. No cervical adenopathy bilaterally.
Integumentary: Skin is flushed, warm, and dry with no edema. Mucous membranes are moist.
Respiratory: Lungs clear CTA with normal respiratory effort. CT angiography
Abdomen: non-tender, no organomegaly.
ASSESSMENT AND PLAN =
New onset AOM AD, suppurative, with pain unrelieved by acetaminophen.AOM = Acute Otitis Media , Auris, Dextra Right Ear
Prescriptions: amoxicillin for AOM; ibuprofen for pain.
Return in one week if symptoms persist.
Summary of ICD-10-CM Impacts
CLINICAL DOCUMENTATION
In diagnosing otitis media using ICD-9-CM you should document items such as acute, chronic, not specified as acute or chronic, nonsuppurative or suppurative, and with or without spontaneous rupture of the eardrum. In ICD-10-CM, you will need to document these characteristics plus left, right or bilateral that are affected and is the problem initial or recurrent to assign a correct code.
In this fictional test case we gave this young male a diagnosis of bipolar II disorder. You would not report the bipolar disorder unless it affects treatment at today’s encounter. Conditions that are not treated or that do not affect patient treatment nor are treated should not be reported.
CODING
ICD-9-CM DIAGNOSIS CODES
382.00 Acute suppurative otitis media without spontaneous rupture of eardrum
ICD-10-CM DIAGNOSIS CODES
H66.001 Acute.suppurative otitis media without spontaneous rupture of eardrum, right ear
ICD-10-CM Diagnosis Code H66.004 [convert to ICD-9-CM]
Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
OTHER IMPACTS
No specific impact noted.
ICD-10-CM Diagnosis Code H66.001 [convert to ICD-9-CM]
Acute suppurative otitis media without spontaneous rupture of ear drum, right ear
Scenario 4: Anemia
SCENARIO DETAILS
CHIEF COMPLAINT
Discuss laboratory results.
HISTORY
38 year old established female seen by me over one week ago for decreased exercise tolerance and general malaise over the past four weeks when doing her daily aerobics class. Labs were ordered on that visit. She presents today with pale skin, weakness, and epigastric pain; symptoms are unchanged since previous visit. Laboratory studies reviewed today are as follows: HGB 8.5 gm/dL, HCT 27%, platelets 300,000/mm3, reticulocytes 0.24%, MCV 75, serum iron 41 mcg/dL, serum ferritin 9 ng/ml, TIBC 457 mcg/dL; Fecal occult blood test is positive.=FOBT
She takes Esomeprazole daily for GERD with esophagitis and reports taking OTC antacids at bedtime for epigastric pain for the past three months. She also uses ibuprofen as needed for headaches.
Current pain is 0/10.
Medical history significant for GERD, peptic ulcer, pre-eclampsia with last pregnancy.
LMP: two weeks ago, normal flow, unchanged in last three months.
Last Menstrual Period
Married; three children ages 15, 12, and 1 year old.
Patient does not use tobacco, alcohol, or illicit drugs.
No known allergies.
No changes in interval history and review of systems noted from encounter 8 days ago.
EXAM
Well-nourished, well groomed, pleasant female who shows good judgment and insight. Oriented X 3. Good recent and remote memory. Appropriate mood and affect.
Vital signs: T 98.7, RR 18, BP: 118/75, standing 120/60, HR: 90.
HEENT: PERRLA.
HEAD, EYES, EARS,NOSE,THROAT = HEENT
Pupils, Equal, Round, React to light, Accommodation
Neck: Supple. No thyromegaly.
Lungs: clear to auscultation with normal respiratory effort.
Cardiovascular: Regular rate and rhythm. No pedal edema.
Integumentary: Pale, clear of rashes and lesions, no ulcers. Early cheilosis ( chelilitis) noted.
Rectal: No gross blood on exam one week ago; stool sample results noted above.
Lymphatics: No lymphadenopathy.
Musculoskeletal: The patient had good, stable gait.
Assessment and Plan
Iron-deficiency anemia secondary to blood loss.
Continue esomeprazole as prescribed.
Replace ibuprofen use with acetaminophen extra strength for headaches, dosage as per label.
Prescribed iron sulfate supplements for three month trial. Counseled patient on appropriate use of iron supplementation and side effects.
Patient to return in one week for repeat laboratory studies.
ICD-10-CM Diagnosis Code D50.0 [convert to ICD-9-CM]
Iron deficiency anemia secondary to blood loss (chronic)
ICD-10-CM Diagnosis Code K21.9 [convert to ICD-9-CM]
Gastro-esophageal reflux disease without esophagitis
ICD-10-CM Diagnosis Code K21.0
Gastro-esophageal reflux disease with esophagitis
Reflux esophagitis
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
In ICD-10-CM, gastroesophageal reflux disease is differentiated by noting “with esophagitis” versus “without esophagitis.” “With esophagitis” must be documented in the record.
CODING
ICD-9-CM Diagnosis Codes
280.0 Iron deficiency anemia secondary to blood loss (chronic)
530.81 Disease, Gastroesophageal reflux (GERD)
ICD-10-CM DIAGNOSIS CODES
D50.0 Iron deficiency anemia secondary to blood loss (chronic)
K21.0 Gastroesophageal reflux disease with esophagitis
OTHER IMPACTS
530.11 Reflux esophagitis is not coded when GERD is coded in ICD-9-CM because 530.11 is an “excluded code” from 530.81 in ICD-9-CM but it is a combination code in ICD-10-CM.
Scenario: COPD with Acute Pneumonia Example
SCENARIO DETAILS
CHIEF COMPLAINT
“I just got out of the hospital 2 days ago. I’m a little better, but still can barely breathe.”
HISTORY
67-year-old male with 40 pack/year history of cigarette use (still smoking) and severe oxygen dependent COPD developed cough with increased production of green/gray sputum 2 weeks prior to office visit. Admitted to hospital through Emergency Department with diagnosis of presumed pneumonia superimposed on severe COPD. Hospital exam confirmed acute RLL pneumococcal pneumonia. Patient treated with an IV cephalosporin as he has known penicillin allergy, and was discharge from hospital to home 2 days prior to office visit.
PMH ( Past Medical History) shows severe O2 dependent COPD, with type II diabetes mellitus secondary to chronic prednisone therapy, which is treated with oral hypoglycemics.
Patient also has known hypertension, on ACE inhibitor therapy.
REVIEW OF SYSTEMS, PHYSICAL EXAM, LABORATORY TESTS
T 99, BP 145/105, P 92 and irregular, RR 28
Chest exam shows decreased lung sounds throughout all lung fields except in RLL where there were mild rhonchi and wheezes noted
ABG’s on 2L O2 by nasal cannula show PO2 62, PCO2 47, pH 7.40
CXR shows hyperinflation of lungs with small RLL alveolar infiltration. Comparison to CXR from hospitalization shows approximately 75% resolution of pneumonia.
ECG reveals persistent atrial fibrillation which was not present on previous ECG of 6 months earlier, but had been found at time of recent hospitalization. Labs show finger stick glucose of 195mg%.
ASSESSMENT AND PLAN
Acute Community Acquired Pneumococcal Pneumonia: continue oral cephalosporin. Schedule office follow up visit in 1 week with repeat CXR.
Severe COPD: continue O2, low dose Prednisone, and inhaled bronchodilator.
Chronic Hypoxemic, Hypercarbic Respiratory Failure
Persistent Atrial Fibrillation: continue digoxin initiated during recent hospitalization
Hypertension: continue ACE inhibitor therapy
Diabetes Mellitus, Type II, secondary to prednisone therapy; continue oral hypoglycemic therapy
Penicillin Allergy
Tobacco Dependence
DM 2
Underlying disease E08
Due to Drug E09
Other specific Codition (post pancreatectomey) E13
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
ICD-10-CM separates pneumonia by infectious agent. Document the infectious agent of pneumonia, as there are discrete ICD-10-CM codes for each type.
ICD-10-CM separates by acuity of respiratory failure, and hypoxia or hypercapnia, if present.
Document drug allergies with ICD-10-CM status” Z” codes from Chapter 21 to identify these.
Document the type of cardiac arrhythmia. Atrial fibrillation in ICD-10-CM separates into paroxysmal, persistent, chronic, typical, atypical, unspecified. Acute atrial fibrillation defaults to unspecified in ICD-10-CM.
ICD-10-CM Diagnosis Code J13 [convert to ICD-9-CM]
Pneumonia due to Streptococcus pneumoniae
ICD-10-CM Diagnosis Code J44.0 [convert to ICD-9-CM]
Chronic obstructive pulmonary disease with (acute) lower respiratory infection
ICD-10-CM Diagnosis Code J96.12 [convert to ICD-9-CM]
Chronic respiratory failure with hypercapnia
Chronic hypercapnic respiratory failure; Hypercapnic respiratory failure, chronic; Chronic respiratory acidosis
ICD-10-CM Diagnosis Code I48.1
Persistent atrial fibrillation
Atrial fibrillation, persistent; Atrial flutter; Atrial flutter, chronic; Atrial flutter, paroxysmal; Chronic atrial flutter; Paroxysmal atrial flutter; Permanent atrial fibrillation (I48.21)
ICD-10-CM Diagnosis Code I10 [convert to ICD-9-CM]
Essential (primary) hypertension
ICD-10-CM Diagnosis Code E09.9 [convert to ICD-9-CM]
Drug or chemical induced diabetes mellitus without complications
ICD-10-CM Diagnosis Code Z88.0 [convert to ICD-9-CM]
Allergy status to penicillin
ICD-10-CM Diagnosis Code F17.210 [convert to ICD-9-CM]
Nicotine dependence, cigarettes, uncomplicated
Nicotine dependence due to cigarettes; Tobacco dependence caused by cigarettes
ICD-10-CM Diagnosis Code T38.0X5A [convert to ICD-9-CM]
Adverse effect of glucocorticoids and synthetic analogues, initial encounter
The Table of Drugs & Chemicals has a code assignment for Adverse effect of the drug that would be followed by the secondary diabetes code. Go to the Volume 3 Index to Table of Drugs and Chemicals. Along the left hand side proceed alphabetically to “Glucocorticoids” and then move horizontally across to the column for Adverse Effect”. In Volume 1 (Tabular List) the instruction at the beginning of the code category T38 are the instructions for the 7th character.
Note: Drug-induced Diabetes Mellitus is a secondary type of diabetes due to the use of glucocorticoids. This code can only be coded as an “additional code” and would never be first-listed
The code categories for secondary diabetes are :
Due to underlying disease (E08)
Due to drug (E09)
Due to other specified condition such as post pancreatectomy. (E13)
These three categories can never be first-listed per ICD-10-CM guidelines. The underlying cause would be first-listed diagnosis.
CODING
ICD-9-CM DIAGNOSIS CODES
481 Pneumonia, Pneumococcal
496 COPD
V46.2 Oxygen dependence
427.31 Atrial fibrillation
249.00 Diabetes, secondary, drug induced
E932.0 Therapeutic use of Prednisone
401.9 HTN
V14.0 Allergy, Penicillin
305.1 Tobacco dependence
ICD-10-CM DIAGNOSIS CODES
J13 Pneumonia due to Streptococcus pneumoniae
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
Z99.81 Dependence on supplemental oxygen
I48.1 Persistent atrial fibrillation
E09.9 Drug or chemical induced diabetes mellitus without complications
T38.0x5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
I10 Essential (primary) hypertension
Z88.0 Allergy status to penicillin
F17.210 Nicotine dependence, cigarettes, uncomplicated
Scenario: Cervical Disc Disease
SCENARIO DETAILS
CHIEF COMPLAINT
“My neck hurts and I have a tingling pain sensation going down my right arm.”
HISTORY
Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history.
REVIEW OF SYSTEMS, PHYSICAL EXAM, LABORATORY TESTS
Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm.
Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand.
MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted.
ASSESSMENT AND PLAN
Cervical transforaminal injection at C5-6
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
Subcategory M50.1 describes cervical disc disorders. M50.12 Cervical disc disease that includes degeneration of the disc as a combination code. The 5th character differentiates various regions of the cervical spine (high cervical C2-3 and C3-4; mid-cervical C4-5, C5-6, and C6-7; cervicothoracic C7-T1 and the associated radiculopathies at each level). This is a combination code that includes the disc degeneration and radiculopathy
CODING
ICD-9-CM DIAGNOSIS CODES
722.0 Cervical disc displacement without myelopathy
722.4 Degeneration of cervical intervertebral disc
ICD-10-CM DIAGNOSIS CODES
M50.12 Cervical disc disorder with radiculopathy, mid-cervical region
OTHER IMPACTS
Management of chronic conditions such as COPD, Diabetes Mellitus, Hypertension, and Atrial Fibrillation should be described in the record.
Scenario: Abdominal Pain
SCENARIO DETAILS
CHIEF COMPLAINT
“My stomach hurts.”
HISTORY
Patient is a 65-year-old male admitted to the hospital with abdominal pain. He has a history of Crohn’s disease of the large intestine. He also has a history of coronary artery disease, had a heart attack 5 years ago, but has had no problems since then. He smoked cigarettes for 45 years, but quit after his myocardial infarction. He also has a history of allergic reactions to Penicillins and Cephalosporins.
REVIEW OF SYSTEMS, PHYSICAL EXAM, LABORATORY TESTS
99.8
Abdomen: diffuse tenderness over entire abdomen
CT scan of abdomen: abscess secondary to Crohn’s disease of descending colon
Crohn’s disease = IBD
Inflation , irritation digestive track
ASSESSMENT AND PLAN
Crohn’s disease, large intestine with abscess.
Awaiting GI consultation
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
Crohn’s disease in ICD-10-CM is separated by small, large intestine or both (small and large intestine), with or without complications of rectal bleeding, obstruction, fistula, or abscess (combination codes).
ICD-10-CM Diagnosis Code K50.114 [convert to ICD-9-CM]
Crohn’s disease of large intestine with abscess
ICD-10-CM Diagnosis Code I25.2 [convert to ICD-9-CM]
Old myocardial infarction
ICD-10-CM Diagnosis Code Z88.0 [convert to ICD-9-CM]
Allergy status to penicillin
ICD-10-CM Diagnosis Code Z88.1 [convert to ICD-9-CM]
Allergy status to other antibiotic agents
ICD-10-CM Diagnosis Code Z87.891 [convert to ICD-9-CM]
Personal history of nicotine dependence
CODING
ICD-9-CM DIAGNOSIS CODES
555.1 Regional enteritis, large intestine
567.22 Abscess, abdominal
412 Old myocardial infarction
V15.82 History of tobacco use
V14.0 History of allergy to Penicillin
V14.1 History of allergy to other antibiotic (cephalosporins)
ICD-10-CM DIAGNOSIS CODES
K50.114 Crohn’s disease of the large intestine with abscess
I25.2 Old myocardial infarction
Z87.891 Personal history of nicotine dependence or personal history of tobacco use.
Z88.0 Allergy status to Penicillin
Z88.1 Allergy status to other antibiotic agent
Scenario: Diabetes
SCENARIO DETAILS
CHIEF COMPLAINT
“I am here for my quarterly evaluation of my diabetes.”
HISTORY
Patient is a 50-year-old woman with Type 1 diabetes since childhood. She has been on insulin since age 13. As a result of her diabetes she has chronic kidney disease and is currently on dialysis for ESRD. She also has diabetic neuropathy affecting both lower extremities.
REVIEW OF SYSTEMS, PHYSICAL EXAM, LABORATORY TESTS
No changes in underlying condition during the last 3 months. She continues to perform selftesting of her blood sugar levels on a daily basis, is on dialysis every other day, most recently 24 hours ago, and has not noticed any changes in the numbness in her legs.
BP 140/75, P 80, R 16 and T 98.8
Dialysis fistula without any signs of infection
Decreased sensation over lower extremities below the knees
ESRD = End stage renal Dieases
CODING
Lab: BUN/Cr nl, K+ 3.5, glu 105, Hgb A1c 7.9
ASSESSMENT AND PLAN
Continue BS checks daily with sliding scale as previously prescribed
Start Capsaicin topically and defer to nephrologist for any Rx at this time. She has an appointment 10 am tomorrow.
ICD-10-CM Diagnosis Code E10.22 [convert to ICD-9-CM]
Type 1 diabetes mellitus with diabetic chronic kidney disease
ICD-10-CM Diagnosis Code E10.42 [convert to ICD-9-CM]
Type 1 diabetes mellitus with diabetic polyneuropathy
ICD-10-CM Diagnosis Code Z99.2 [convert to ICD-9-CM]
Dependence on renal dialysis
ICD-10-CM Diagnosis Code N18.6 [convert to ICD-9-CM]
End stage renal disease
ICD-9-CM DIAGNOSIS CODES
250.41 Diabetes with renal manifestations, type 1, not stated as uncontrolled
585.6 End stage renal disease
250.61 Diabetes with neurological manifestations, type 1, not stated as uncontrolled
357.2 Polyneuropathy in diabetes
V45.11 Renal dialysis status
ICD-10-CM DIAGNOSIS CODES
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
N18.6 End-stage renal disease
Z99.2 Dependence on renal dialysis Presence of AV shunt for dialysis
E10.42 Type 1 diabetes mellitus with polyneuropathy
Scenario: ER Follow Up
SCENARIO DETAILS
CHIEF COMPLAINT
“Seen in the ER over the weekend.”
History
Mrs. Jones is a 64-year-old female, with a history of morbid obesity, type 2 diabetes with nephropathy, and asthma, presents here for follow-up ER visit two days ago for shortness of breath. Patient was discharged with a diagnosis of bronchitis, an Albuterol and Beclomethasone inhaler prescription, along with five day course of Z pack and a six-day steroid dose pack. Patient is improving on the regimen. She is no longer wheezing and her phlegm is now scant. Her sugars however, have been poorly controlled with the Prednisone with fasting sugars greater than 200.
Patient has long-standing asthma with 2-3 exacerbations per week and daily need for rescue inhalers. Patient is still smoking half a pack a day. She is compliant with her inhalers when she is not feeling well.
Patient has diabetes with overt proteinuria with her last creatinine of 1.3
Hypertension
Morbid Obesity
Review of Systems, Physical Exam, Laboratory Tests
BMI 44; central adiposity; no respiratory distress; able to speak in full sentences
BP 142/64 HR94 RR 12 Sats: 98% on RA = Room Air
HEENT: TM clear; conjunctiva clear; no sinus tenderness; mallampati 3 airway
Neck: thick; no adenopathy
Lungs: scattered wheezing; no consolidation prolonged expiratory phase
Ext: thin no edema
Assessment and Plan
Asthma: moderate persistent, with acute exacerbation
Bronchitis
Current Smoker
Diabetes Type 2 with nephropathy and poorly controlled hyperglycemia secondary to prescribe use of steroid medication
ICD-10-CM Diagnosis Code J45.41 [convert to ICD-9-CM]
Moderate persistent asthma with (acute) exacerbation
ICD-10-CM Diagnosis Code J40 [convert to ICD-9-CM]
Bronchitis, not specified as acute or chronic
ICD-10-CM Diagnosis Code E11.21 [convert to ICD-9-CM]
Type 2 diabetes mellitus with diabetic nephropathy
ICD-10-CM Diagnosis Code E11.65 [convert to ICD-9-CM]
Type 2 diabetes mellitus with hyperglycemia
ICD-10-CM Diagnosis Code F17.210 [convert to ICD-9-CM]
Nicotine dependence, cigarettes, uncomplicated
ICD-10-CM Diagnosis Code I10 [convert to ICD-9-CM]
Essential (primary) hypertension
ICD-10-CM Diagnosis Code T38.0X5A [convert to ICD-9-CM]
Adverse effect of glucocorticoids and synthetic analogues, initial encounter
ICD-10-CM Diagnosis Code E66.01 [convert to ICD-9-CM]
Morbid (severe) obesity due to excess calories
ICD-10-CM Diagnosis Code E66.01 [convert to ICD-9-CM]
Morbid (severe) obesity due to excess calories
SUMMARY OF ICD-10-CM IMPACTS
CLINICAL DOCUMENTATION
Choosing the first-listed diagnosis in this scenario is determined by the Section IV Guidelines of ICD-10-CM found in Volume 2 of ICD-10-CM
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
Selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/ visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
Asthma was chosen as first-listed in this scenario.
Asthma is classified as mild, moderate and severe with additional detail as intermittent, persistent and severe; include if there is acute exacerbation or status asthmaticus. Bronchitis was not specified as “acute” so the assignment is made to not specify as acute or chronic. In ICD-10-CM both bronchitis and asthma are reported separately.
Bronchitis is reported separately from asthma per ICD-10-CM guidelines. Bronchitis was not specified as acute or chronic and the default code would be J40.
Conditions involving infectious processes will have “acute” versus “chronic” choice. Providers should document whenever possible “acute” or “chronic”.
Guidelines require reporting of tobacco use or exposure for respiratory, vascular and some other chronic illnesses such as oral and esophageal cancer codes.
Step-by-step guide for ICD-10 coding
Review the medical record and identify the diagnosis or reason for the healthcare encounter. This includes reviewing physician notes, lab/test results, imaging reports, etc.
Determine the main diagnosis or chief complaint that is primarily responsible for the services provided. This will be your first listed diagnosis code.
Identify any other conditions that co-exist or develop during the encounter. These will be additional diagnosis codes.
Step-by-step guide for ICD-10 coding
Translate the medical terminology into appropriate ICD-10 terminology and codes using an ICD-10 codebook, encoder software or online coding tools.
Verify the selected ICD-10 codes match the documentation in the medical record. Codes must be specific to capture detailed medical data.
Sequence the codes properly following ICD-10 guidelines. The main diagnosis code should be listed first, followed by codes for other conditions in descending order of importance.
Step-by-step guide for ICD-10 coding
Add any applicable seventh character extensions for codes that provide additional specificity like stage, trimester, encounter type etc.
Use placeholders “X” as necessary for codes less than 6 characters to fill out the code to full 6 characters.
Consult the official ICD-10 guidelines in the front of the codebook if there are any questions or ambiguities related to code selection or sequencing.
Step-by-step guide for ICD-10 coding
Conduct internal audits periodically to ensure selected codes accurately reflect the medical record and coding rules are followed properly.
Update coding practices if needed based on latest guidelines.
ICD10
Canada
Australia ICD-10-AM
ICD-10-CA
Own version additional details system
ICD-10 I10
ICD-10-AM I10.0 Benign essential hypertension
ICD-10-CA I10.1 ( Malignant essential hypertension )
