ICD-10 Coding standards -Chapters I-III

Question 1

Describe the how sepsis must be coded?

Answer 1

• When sepsis is recorded a code that specifically classifies sepsis must always be assigned. When code assignment does not fully classify sepsis then a code must be assigned in any secondary position to classify the sepsis in order to describe the condition fully.
• When clinicians use terms such as urosepsis, biliary sepsis, chest sepsis etc. to mean both sepsis and a localised infection of an organ both conditions must be coded, if a patient however just has an infection in the organ sepsis must not be coded.
• When sepsis is due to a device, implant or graft this means that the patient has both sepsis and a localised infection at the site of the device, both the sepsis and the site of the infection must be coded.
• Sepsis may not always be the main condition treated, sequencing of sepsis with other infections and conditions must follow DGCS.1:Primary diagnosis
• Organ failure must be coded in addition when documented with sepsis

Question 2

How must septic shock be coded?

Answer 2

Whenever septic shock is documented in the medical record by the responsible consultant,
code R57.2 Septic shock must be assigned in any secondary position following the code
that classifies sepsis.

Question 3

How must severe sepsis be coded?

Answer 3

Severe sepsis must be coded as follows:
• The code for sepsis A41.- or specific type of sepsis
• R65.1 SIRS code
• U82.-,U83.- or U84.- (only if the severe sepsis is resistant to antibiotics or anti-microbial drugs)

Question 4

How must neutropenic sepsis be coded?

Answer 4

The following codes and sequence must be used for a documented diagnosis of
neutropenic sepsis:
A41.- Other sepsis (or the specific type of sepsis recorded in the medical record)
R65.1 Systemic inflammatory response syndrome of infectious origin with
organ failure (use only if the sepsis is documented as severe)
U82.- Resistance to betalactam antibiotics, U83.- Resistance to other
antibiotics or U84.- Resistance to other antimicrobial drugs (use only if
the sepsis is resistant to antibiotics or antimicrobial drugs)
D70.X Agranulocytosis

If the responsible consultant has documented that the neutropenic sepsis was due to a drug, then an adverse effects code from Chapter XX must be assigned after D70.X, see DCS.XX.7: Drugs, medicaments and biological substances causing adverse effects
in therapeutic use (Y40-Y59).

Question 5

How must Zika virus be coded?

Answer 5

The following codes and sequencing must be applied when coding confirmed cases of Zika
virus.

Zika Virus:
A92.8 Other specified mosquito-borne viral fevers
U06.9 Emergency use of U06.9

Zika virus in pregnancy:
O98.5 Other viral diseases complicating pregnancy , childbirth and the
puerperium
A92.8 Other specified mosquito-borne viral fevers
U06.9 Emergency use of U06.9

Question 6

How must HIV be coded?

Answer 6

The following must be applied when coding symptomatic HIV:
Only one code from categories B20-B24 is required when this code fully classifies both the HIV and the underlying condition caused by HIV.

When the HIV code from categories B20-B24 does not fully classify the HIV and the condition resulting from HIV, the code that classifies the condition must also be assigned after the HIV code.

If there is more than one condition resulting from HIV classified to the same category in B20-B22 the subdivision .7 from the appropriate category must be used followed by the codes classifying the specific conditions.

When coding HIV resulting in malignant neoplasms the code classifying the malignant neoplasm must be assigned after the code that classifies the HIV from category B21.-

When a patient has HIV resulting in multiple malignant neoplasms then the code B21.7 must be assigned followed by the codes classifying the malignant neoplasms.

Asymptomatic HIV is classified to Z21.X

Question 7

When must codes in range B95-B98 be assigned

Answer 7

The codes in this block must be used as supplementary codes where a site and a
causative organism have been identified and a code that classifies both the site and the
causative agent is not available. These codes must only ever be used in a secondary
position to a code classified outside of Chapter I Certain infections and parasitic diseases.

Question 8

How must complications and symptoms of neoplasms be coded?

Answer 8

All complications and symptoms caused by neoplasms must be coded in addition to the Code classifying the neoplasm. DGCS.1:Primary diagnosis must be applied.
Symptoms classified to Chapter XVIII symptoms and signs must only ever be coded in a secondary position.

Question 9

Describe DChS.II.2: Anaemia in neoplastic disease (C00-D48† and D63.0*)

Answer 9

Anaemia in neoplastic disease is coded to D63.0A with the appropriate code for the neoplasm as the dagger code (C00-D48D)

The responsible consultant must specify the link between the neoplasm and the anaemia to enable the use of D63.0A

Anaemia must not be coded in the neoplastic blood disorders Leukaemia, myeloma and myelodysplasia as it is a natural symptom of these conditions.

Question 10

Describe DChS.II.4: Topography (site) codes and histology (morphology) of neoplasm codes

Answer 10

Site (topography) codes must be assigned using the ICD-10 classification (Chapter II Neoplasms (C00-D48)).

Question 11

How are primary and secondary malignant neoplasms coded?

Answer 11

All malignancies are coded as primary (expect those listed as predominately secondary) unless:
• They are specified as secondary (or metastatic)
Or
• The site stated is marked with a diamond and is a carcinoma or adenocarcinoma of any type other than intraosseous or odontogenic.

Any uncertainty about whether a malignancy is primary or secondary must be referred back to the responsible consultant.

When the primary site has not been identified i.e the site is unspecified code C80.9 must be assigned, unless the classification defaults to a more specific code.

Code C80.0 must only be assigned when the responsible consultant has explicitly documented within the medical record that the primary site is unknown.

Whenever a secondary malignant neoplasm is documented, a primary malignant neoplasm must be assigned even if the site is unknown or unspecified. The exception to this is when the primary malignant neoplasm is no longer present, in which case a code specifying the personal history of the malignant neoplasm must be coded.

When the site(s) of the secondary malignant neoplasm has not been identified or is unknown code C79.9 must be assigned.

Question 12

What are the predominantly secondary sites for malignant neoplasms?

Answer 12

When a malignancy occurs in one of the following sites it must be coded as a secondary
malignancy of that site, unless the responsible consultant confirms that the malignancy is
a primary neoplasm, or when the histological type indicates that it is a primary malignancy:
• bone
• brain and spinal cord (including meninges)
• lymph nodes
• pleura
• peritoneum and retroperitoneum
• heart
• mediastinum and diaphragm
• liver.

Question 13

What are the sequencing rules for malignant neoplasms?

Answer 13

When a primary malignant neoplasm and a secondary malignant neoplasm are both present, the code for the primary malignant neoplasm must be assigned before the code for the secondary malignant neoplasm, unless the secondary malignant neoplasm is the main condition treated or investigated, see DGCS.1: Primary diagnosis.

When the primary malignant neoplasm has been eradicated and the main condition is the
secondary neoplasm, a code from category Z85.- Personal history of malignant neoplasm must be assigned in a secondary position, as this provides additional information about the site of origin.

Question 14

What must be applied when coding metastatic cancer?

Answer 14

The following must be applied when coding metastatic cancer:
Metastatic from

Cancer described as metastatic from a site must be interpreted as a primary neoplasm of the stated site. A code must also be assigned to specify the secondary malignancy either of the specified site or a code for secondary neoplasm of unspecified site.

Metastatic to

Cancer described as metastatic to must be interpreted as a secondary neoplasm of the stated site. A code must be assigned to specify the primary neoplasm site either from the specified site or from C80.9 primary unspecified or C80.0 primary site unknown.
If the primary site has been eradicated, a code specifying the personal history of the neoplasm must be coded in a secondary position.

Question 15

How must malignant neoplasm of overlapping sites be coded?

Answer 15

Primary malignant neoplasm in categories C00-C75 are classified to their point of origin, however when a neoplasm overlaps two or more over sites which are next to each other within the same three character category without any indication of which site is the origin, the fourth character .8 must be assigned. The fourth character .8 is not assigned if:
• The point of origin is known
• The sites are not next to each other
• The alphabetical index directs the coder to a specific code for the combined sites.

Where a neoplasm overlaps different sites within the same body system and the point of origin cannot be identified, one of the subcategories listed at note 5 at the beginning of Chapter II – neoplasms in the tabular list must be assigned. Where one of these codes is not appropriate, code C76.8 must be used.

Question 16

How must multiple independent primary malignant neoplasms be coded?

Answer 16

When a diagnostic statement records two or more independent primary malignant neoplasms none of which clearly predominates, code C97.X must be assigned as the main condition followed by the individual codes for each primary malignant neoplasm.

Where multiple primary neoplasms exist one of which clearly predominates, code C97.x must not be assigned.

Where two or more primary neoplasm exist, none of which predominate, but classify to the same four character code, code C97.x must still be assigned, followed by a single code which classifies all of the neoplasms.

Question 17

How must further excision of a malignant neoplasm be coded?

Answer 17

When a patient undergoes a further/wider excision of a malignant neoplasm, even if the responsible consultant reports that the histology from this surgery is negative, the further excision would still be considered as part of the primary treatment for the malignancy, therefore the malignancy must continue to be recorded.

Question 18

How must metastasis from a haematological malignancy be coded?

Answer 18

Codes to classify secondary neoplasms due to/from a haematological malignancy must never be assigned. Diagnostic statements indicating metastasis resulting from a haematological malignancy (eg lymphoma with bone metastases) must be referred back to the responsible consultant to clarify that this is spread of the haematological malignancy. If this is verified, then only the code classifying the haematological malignancy is required.

Question 19

Describe DCS.II.8: Maintenance treatment for malignant neoplasm of lymphoid,
haematopoietic and related tissues in remission (Z85.6 and Z85.7)

Answer 19

When a patient with leukaemia, or other malignant neoplasms of lymphoid, haematopoietic and related tissues in remission is admitted for maintence chemotherapy to keep their condition in remission then a code from Z85.6 or Z85.7 must be assigned as the primary diagnosis.

Question 20

Describe DCS.II.12: Neoplasms of uncertain or unknown behaviour (D37-D48)

Answer 20

Codes classifying Neoplasms of uncertain or unknown behaviour must only be assigned when directed to by the alphabetical index or it is documented in the medical record that the neoplasm is of uncertain or unknown behaviour.

Codes in this block must not be used when there is a diagnosis of suspected or ? cancer documented in the medical record. In the absence of a definitive diagnosis, only symptoms must be recorded.

Question 21

When must D57.3 Sickle cell trait not be coded?

Answer 21

D57.3 Sickle-cell trait must not be coded when it coexists with a condition classified to
one of the following categories or codes:
• D56.- Thalassaemia
• D57.0 Sickle-cell anaemia with crisis
• D57.1 Sickle-cell anaemia without crisis.

Question 22

How is anaemia in other chronic diseases coded?

Answer 22

When the responsible consultant has clearly stated a link between anaemia and a chronic
condition; code D63.8* Anaemia in other chronic diseases, classified elsewhere must be assigned together with the code for the chronic condition as the associated dagger code. Sequencing must reflect DGCS.5: Dagger and asterisk system.

When a link is not stated by the responsible consultant the conditions must be coded
separately.