Chapter 5 -ICD-10-CM Coding Chapters 12-21 Flashcards
Cellulitis
Bacterial infection of the skin and subcutaneous tissue.
Lymphangitis
Infection of the lymph vessels. Can be a sign that skin infection is getting worse.
Dermatitis
Inflammation of the skin. Seborrheic, atopic, contact are some types.
Eczema
Skin inflammation with red patches, itching and small blisters that burst. Atopic is the most common eczema.
Dermatitis and eczema
Skin inflammation. Used synonymously.
Pressure ulcer completely healed
No code is reported for the pressure ulcer.
Pressure ulcer gets worse after admission
Code for site and stage upon admission followed by highest stage at that site for the day.
Pressure ulcer healed before discharge
Code for the level and site of the pressure ulcer upon admission.
Stage 1 pressure ulcer
Persistent focal edema
Stage 2 pressure ulcer
Partial thickness skin loss involving epidermis, dermis, or both
Stage 3 pressure ulcer
Full thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage 4 pressure ulcer
Necrosis of soft tissue extending to underlying muscle, tendon, or bone
Unstageable ulcer
When the base of the ulcer is covered in eschar or slough so that it cannot be determined how deep the ulcer is. Determined based on documentation. Do not code unstageable if the stage is not documented. Used unspecified.
Multiple site pressure ulcers
Code first for the site being treated. If multiple sites are treated code most severe site first.
Chronic nonpressure ulcers
Can be caused by other disease processes like vascular insufficiency, diabetes or injury. Typically last more than 3 months. Follows same rules as other ulcers.
Hidr/o
Sweat
Ichthy/o
Dry, scaly
Kerat/o
Hard
Ungu/o
Nail
Arthritis
Inflammation of the joints. May involves muscles and connective tissues. Common signs are pain, stiffness, inflammation, and movement limitations
Osteoarthritis
Degenerative joint disease. Chronic condition that results from cartilage in joints wearing down over time.
Primary arthritis
No known cause
Secondary arthritis
Develops as a result of injury or disease
Rheumatoid arthritis
Autoimmune disease that affects the whole body. Common symptoms are joint pain and swelling, stiffness, red puffy hands, and fatigue.
Rheumatoid factor
Antibody present in the blood of most people with rheumatoid arthritis. Coded as with or without when coding rheumatoid arthritis.
Pathologic fracture
Caused typically by another disease such as a neoplasm or osteoporosis.
Stress fracture
Fracture caused by repeated force or overuse.
Malunion fracture
Fracture that healed in an undesirable position
Nonunion fracture
Fracture that is not healing. New bone tissue is not growing to bridge the gap between broken bones.
Osteoporosis
Systemic bone disease that decreases bone density. No code needed for site if there is no fracture. One combo code for pathological fracture and osteoporosis.
GFR
Glomerular filtration rate. Used to stage chronic kidney disease.
Chronic kidney disease and end stage renal disease
Only code the end stage renal disease. Also use a code to identify dialysis status if applicable
Acute renal failure (ARF)
Rapid decrease of the kidneys to function. Rapid onset. Document location of lesion of necrosis if known.
Urge incontinence
Sudden urge to urinate followed by involuntary release of urine
Stress incontinence
Occurs after activity like sneezing, coughing, or exercise.
Urinary tract infection
Code for specific organ if known. Use additional code to identify infectious agent. Depending on organism you will report two codes or one combo code.
Benign Prostatic Hyperplasia (BPH)
Enlargement of the prostate. Code if there are urinary complications or not. Also need to code for symptoms.
Endometriosis
Very painful disorder. Lining of the uterus grows outside the uterus. Code for location if known.
Leiomyoma
Uterine fibroids. Benign uterine tumors.
Submucous leiomyoma
Uterine fibroids beneath the endometrium
Intramural leiomyoma
Uterine fibroid within the uterine wall
Subserous leiomyoma
Uterine fibroid under the serous surface of the uterus.
Cervical Intraepithelial Neoplasia (CIN)
Cervical dysplasia. Abnormal growth or premalignant cells of the cervix. Staged 1-3. Stage is considered carcinoma in situ of the cervix and found in the neoplasm table.
Pregnancy, childbirth, and puerperium codes
Only reported on the maternal record. Have priority over all other codes in ICD-10.
Puerperium
Period immediately after delivery to complete involution of the uterus. Usually define as 42 days or 6 weeks.
First trimester
Less than 14 weeks and 0 days
2nd trimester
14 weeks 0 days to less than 28 weeks 0 days
3rd trimester
28 weeks 0 days until delivery.
Coding trimester when admission crosses trimesters
Code for the date of admission or if it is a complication code for the trimester the complication develops.
Delivery during admission
In childbirth is coded. Used for complications that’s develop that admission as well
Weeks of gestation code
Z3A. Not used for abortive outcomes, elective termination of pregnancy, or postpartum conditions.
Encounter for supervision of normal pregnancy code
Z34
Pregnant state, incidental code
Z33.1. Used when pregnant but seen for another condition. Documentation must note that the condition is not affecting the pregnancy
Supervision of high risk pregnancy code
O09. Only to be used during the prenatal period.
Supervision of elderly primigravida or multigravida code
O09.5. Used for age 35 and older for expected delivery date
Supervision of a young primigravida or multigravida code
O09.6. Used for age of younger than 16 for expected delivery date
HIV in pregnancy, childbirth or the puerperium.
Always code 098.7- first followed by the codes for the HIV illnesses. (Z21 or B20)
Puerperal sepsis
Infection of the genital tract that develops during the postpartum phase. O85. Follows normal sepsis rules after the special code
Drug, alcohol, or tobacco use in pregnancy
Code from O99.3- and also report the specific usage
Code for the outcome of delivery
Required for normal or complicated delivery. Z37.- Subcategory reports the outcome of the delivery.
General Perinatal Period Rule
All clinically significant conditions noted on routine newborn exam should be coded. Should a condition originate in the perinatal period it should continue throughout the life of the patient regardless of age.
Coding for birth of a patient
Use code from Z38 category. Only used once and is the principal diagnosis.
Newborn observed for a suspected condition that is not found code
Z05. Secondary after birth code or primary after the birth if not found.
Prematurity and growth retardation
Only code for this is it documented by the assessing physician. Do not use recorded birth weight or estimated gestational age. When birth weight and gestational age are available code birth weight first.
Perinatal period
Birth to 28 days
Coding for multiple injuries
Code for each site unless a combination code is available. List most serious injury first.
Superficial injuries or contusions when associated with a more serious injury.
Do not code for the minor injury.
Major injury resulting in damage to peripheral nerves or blood vessels
Code primary injury first then the codes to report the additional injury follows
Coding multiple traumatic fractures
Code by site based on severity
Open fracture
Exposed to outside elements. Not coded unless specified in documentation. If unspecified the fracture is considered closed. Do not code for open unless the fracture is diagnosed as such. Closed fractures can be treated with open procedures!
Displaced fracture
Bone breaks into two or more parts so that it is no longer aligned in a normal position. If not indicated as displaced/nondisplaced assigned code for displaced.
Classification of open fractures
Type I, II, IIIA, IIIB, IIIC. If not specified type I or II should be assigned.
Burns
Coded for injury from thermal sources except for sunburn.
Corrosion injury
Burn due to chemicals.
Adverse effect coding
Code at least two codes. First code the manifestations of the adverse effect, then code the drug or agent that caused the adverse reaction.
Coding for poisoning
Code first the drug or chemical and identify the nature. Code second the manifestations of the poisoning and finally any codes for abuse or dependence
No documentation of intent of poisoning code
Code for the accidental column
Underdosing
Codes for underdosing should never be primary diagnosis. When causing relapse the medical condition should be coded first. Also report codes for non-compliance
Complications
Code first the complication if it is the reason for the visit. Code the specific complication in addition if available.
External cause codes
Are supplemental and never coded first. Used for the length of treatment if only required by the payer.
Activity code, place of occurrence, and activity status code
Only reported on initial encounter following external cause of injury
External events sequencing code rules
- Child and adult abuse
- Terrorism
- Cataclysmic events
- Transport accidents
- Activity and external cause status codes are coded after causal (intent) external cause codes
- First listed code should correspond to most serious injury after these rules
Status code for a medical device
Also include the condition for use of the medical device
Abnormality found in a screening
Code first the screening then the abnormality
Aftercare vs follow up care
Aftercare is the healing phase. Follow up is after the condition is fully healed
Nonmosaic trisomy
Affects all cells. Mosaic trisomy only affects some cells
