How

to master
ICD-10 y s
Doc u m e n t a t io n in 1 0 D a
Specia lty Clinica l Scen a rios
Oct Docu mentation Ga p A n a lysis
01 Glossa ry of Most Co m mon ICD-10 Codes
 About this Workbook

Dear Provider,

ICD-10 is a watershed moment in US Healthcare. There is no consensus, at the moment, about the exact
magnitude of impact this transition will have on your practice. Thus, the writing on the wall is to prepare for
the worst. We agree, its easier said than done. But its possible. Simply use your time, whatever remains of it,
wisely.

If CureMD ICD-10 eBook was a good start to understand the transition process, this ICD-10 Documentation
Worksheet will help you in the last leg of the race and beyond.

We are condent that this publication will be your best friend for the next few months.

Best of Luck,

Team CureMD

01
 We just made your Life Easier!
Providers will have to make the most adjustments post ICD-10 and have the least time
to prepare for it. Read on for a comprehensive ICD-10 Documentation coverage.

Specialty based Document Gap Analysis

A walk through the ICD-10 clinical documentation changes, for common conditions
associated with your Specialty.

Clinical Scenario
This section has sample, outpatient focused, scenarios that illustrate the proper level of detail
required for a specic diagnosis; for creating an acceptable claim for the service rendered.

Common Codes for your specialty

A glossary of common ICD-9 and related ICD-10 codes to guide you in the initial days
of documentation.

02
 ICD-10 Introduction

The current ICD-9 diagnosis codes (International

Classication of Diseases, 9th Edition) for patient encounters
have been in use in the U.S. since 1979. The codes have become
outdated, and many countries have replaced these codes with a
newer, more exible, and up-to-date version; ICD-10,
the 10th edition of the International Classication of
Diseases.

In March last year, a U.S. Senate vote concluded that ICD-10

would replace ICD-9, and be implemented in all practices across
the country on October 1, 2015. In simpler terms, starting
October, insurance carriers will only reimburse you for services
provided if you send out bills containing the relevant ICD-10
codes.

03
 How is this Code Set Different?

The ICD-10 code set is structurally and conceptually different from its ICD-9 counterpart. This eBook has been created with the purpose to
notify, educate, and train your team so that you can effectively manage clinical documentation for your specialty prior to October 1, 2015.

ICD-9 vs. ICD-10: The Differences in Diagnosis Code Sets

Before we progress to the clinical adjustments that you need to make for these codes, here is an overview of how these code sets differ.

Code Sets ICD-9 ICD-10

More codes 13,000 codes 68,000 codes

Longer Codes 3-5 characters 3-7 characters

More complex codes 1st digit: alpha/numeric, digits 2-5: numeric 1st digit: alpha, digits 2-3: numeric, digits 4-7:
alpha/numeric

Allow addition Limited space for new codes Flexibility for code addition

Have laterality Lacks laterality Codes differ for different sides of the body

X X X X X X X
Category Etiology Anatomic Severity Extension
04
 Gap analysis of Physician Documentation

Where should you focus?

Physician documentation will be considerably altered as a result of the ICD-10 implementation. If you do not appropriately
document a patient encounter, your medical biller or coder will not be able to assign an accurate ICD-10 code to correspond
with the encounter.
If that happens, you simply wont get paid. To avoid the hassle of claim rejections and denials, you must prioritize training
your clinical staff for ICD-10 documentation. Heres how to go about it:

Review existing documentation

1. Step 1 is to see how your practice is currently documenting records. View several patient encounters and check
how well your documentation would fare with respect to the ICD-10 requirements. This will help identify
inadequacies in your existing documentation.

Immediately upgrade your documentation techniques

2. Begin implementing the ICD-10 documentation requirements right now; this way youll be able to avert much
of the pressure the October 1 conversion will bring. This would mean that youd have to document more
information for every encounter, even before October 1, however; you'd end up getting more practice.

Post-October Review

3. After the conversion date, you must periodically review your documentation to identify areas where your staff
is falling behind. Your EHR Report & Analytics feature should help you with this.

05
Where do you stand?
For any process, preparation is the key. ICD-10 is no different; the more time you spend, the better off youll be. Get
acquainted with the documentation requirements, the new codes, and a reformed practice workow for the conversion.

This e-book has been designed to assist your specialty in understanding the documentation requirements for ICD-10,
introduce you to the new codes that your practice will need to learn, and prepare you for a smoother ICD-10 transition. If
you require additional guidance , you can contact our ICD-10 implementation experts.

The devil is in the detail

There were only 13,000 ICD-9 codes. The gure stands at around 68,000 for ICD-10. The 55,000 additional codes all point
towards specicity in diagnosis. Additional details will be required to distinguish one diagnosis code from the other.

For example, a mere pain in limb associated with ICD-9 code 729.5 will not be enough to get you paid. For your coder to
send out the correct code, you will have to provide a more detailed account specifying which limb has been affected (arm,
leg, etc).

Additionally, if the pain is in the left upper arm, its code will differ from that of the patients left arm, the code for the right
upper arm wont be the same as pain in ngers, thighs, and so on. In short, if youre not specic in your documentation, your
billers wont have much of a chance of getting you reimbursed for services provided.

More is better . Dont leave out the small details, as they could be crucial for coding

06
Must Know Secrets for Easier
EHR Documentation

Learn what EHR Cha mpions are doing right

07
 ICD-10: Interactive Guide Menu
Please click on your specialty below

01 02 03 04 05
Family Medicine OB/GYN Dermatology Pediatrics Cardiology

08
 Family Medicine

Documentation Most Common

Clinical Scenario
Analysis Codes
 Documentation Analysis

Specialty: Family Practice

The clinical staff at a Family Practice must adequately document these elds in order to fulll the ICD-10 coding requirements:

Laterality Nervous System

Bilateral Primary vs. secondary: cause & disease
Right Intractable disease
Left Paralysis: type & level
Multiple locations
Respiratory System
Infections
Linkage between disease process & infective organism Chronic disease exacerbation
Asthma: intermittent vs. persistent & mild, severe or
moderate
Disease Status
Primary Circulatory System
Secondary
Heart failure: Systolic vs. diastolic, right vs. left
Acute
Acute myocardial infarction (time period = 4 weeks)
Intermittent
Disease: Rheumatic vs. nonrheumatic
Transient
Atherosclerosis: Native artery (or vein) vs. graft
Chronic
Linkage of complications with hypertension
Recurrent
Cerebral hemorrhage: traumatic vs. nontraumatic, cause
of hemorrhage/infarction, artery
Diabetes
Type I, Type II - long-term insulin use or other cause
Due to other disease/drug: specify other disease, or drug/chemical if any
Linkage with complications

10
 Documentation Analysis

Skin Digestive System

Disease linkage with cause or infectious agent Linkage of complications with disease: bleeding,
Pressure ulcer: laterality, stage, & site stula, perforation, obstruction, abscess, gangrene
Non pressure ulcer (chronic): laterality, site, skin Hernia: unilateral vs. bilateral
breakdown, muscle necrosis, bone necrosis, fat-layer Constipation: slow transit / outlet dysfunction
exposed
Neoplasms
General Injuries Malignant vs. benign, in situ, primary, secondary
Location: head, proximal, shaft, etc Locations details
Tendon type: exor / extensor Overlapping vs. distinct locations
Care episode: initial/ subsequent/ sequela Leukemia: in remission / in relapse

Injury Cause Eye & Ear

Reason: e.g. fell from stairs Upper vs. lower eyelid
Location: e.g. stadium Cataract: age, drug-related, or traumatic
Activity: e.g. collecting tickets Disease: primary vs. secondary
Tobacco usage/ exposure impact on ear disease
Dislocations
Traumatic vs. stress: open vs. closed, displaced vs. Musculoskeletal
non-displaced Previous trauma, infection, other disease courses
Healing: routine, nonunion, delayed, malunion Disease linkage with cause or infectious agent
Pathological fracture (with osteoporosis)A Primary, secondary, or post-traumatic disease
Age relation vs. other category Cause: pathological fracture due to osteoporosis,
neoplastic disease, or other
Genitourinary
Disease: primary vs. secondary
Stage: chronic kidney disease
Disease linkage with cause or infectious agent

11
 Clinical Scenario

Chief Complaint
Stomach ache, feeling gassy and queasy.

History
40 year old Caucasian male with mid abdominal epigastric pain, coupled with
severe vomiting and nausea; not able to keep down any liquid or food. Pain is
severe & constant.
Weight loss over past 40 days estimated at around 17 pounds.
Patient believes consuming around 6 pieces of meat at home four days ago for
lunch at home triggered his symptoms.
Patient validated alcohol dependence history. Consuming 4-5 beers per day at the
moment, previously 9-11 each day around six months ago. Reports being nauseous,
sweaty & shaky when he does not consume beer.
Exam
Vitals: temperature 99.8; otherwise normal.
Mild-jaundice noted.
Oral mucosa dry, chapped lips, decreased skin turgor.
Abdomen distended & tender across upper abdomen. Guarding is present. Bowel sounds diminished
in all (4) quadrants.

Assessment & Plan

Suspected acute pancreatitis & dehydration.
1L IV NS started in ofce. Blood drawn for labs.
Hospital admission orders written & forwarded to on-call hospitalist.
Recommendation of behavioral health therapy for substance abuse estimation & possible treatment.
Patients relatives notied of arrangement; they will arrange private transport to hospital.

12
 Clinical Scenario

ICD-10 CM Impacts
Clinical Documentation
Pain needs to be described comprehensively (specically), and including location details to the maximum extent.
Alcohol-related disorders must be distinguished according to: use, abuse, & dependence. ICD-10-CM terminology and requirements for coding substance
abuse disorders is new. In this case, based on suspected acute pancreatitis, and his alcohol consumption status, the relevant alcoholism code is given.
Abdominal tenderness should be included in coding. While more specicity is preferred (including laterality) to generate a more specic code, R10.819 for
Abdominal tenderness, unspecied site is used here as we do not have more information to make a more thorough judgment.

ICD-9 CM Diagnosis ICD-10 CM Diagnosis

Codes Codes

789.06 Abdominal pain, epigastric R10.13 Epigastric pain

789.60 Abdominal tenderness, unspecied site R10.819 Abdominal tenderness, unspecied site

782.4 Jaundice NOS R17 Unspecied jaundice

276.51 Dehydration E86.0 Dehydration

303.90 Other and unspecied alcohol dependence, Alcohol dependence, uncomplicated

unspecied F10.20

Other Impacts
None

13
 Common Codes

List of the most common ICD-10 codes for the Family Practice specialty.
*Always utilize more specic codes rst.

ABDOMINAL PAIN ICD-9-CM Codes: 789.00 - 789.09 ACUTE RESPIRATORY ICD-9-CM Codes: 462, 465.9, 466.0
INFECTIONS
ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis (Specify organisms where possible)

R10.0 Acute abdomen J02.8 Acute pharyngitis due to other specied organisms
R10.10 Upper abdominal pain, unspecied J02.9* Acute pharyngitis, unspecied
R10.11 Right upper quadrant pain J06.9* Acute upper respiratory infection, unspecied
R10.12 Left upper quadrant pain J20.0 Acute bronchitis due to Mycoplasma pneumonia
R10.13 Epigastric pain J20.1 Acute bronchitis due to Hemophilus inuenza
R10.2 Pelvic and perineal pain J20.2 Acute bronchitis due to streptococcus
R10.30 Lower abdominal pain J20.3 Acute bronchitis due to coxsackievirus
R10.31 Right lower quadrant pain J20.4 Acute bronchitis due to parainuenza virus
R10.32 Left lower quadrant pain J20.5 Acute bronchitis due to respiratory syncytial virus
R10.33 Periumbilical pain J20.6 Acute bronchitis due to rhinovirus
R10.84 Generalized abdominal pain J20.7 Acute bronchitis due to echovirus
R10.9* Unspecied abdominal pain J20.8 Acute bronchitis due to other specied organisms
J20.9* Acute bronchitis, unspecied

14
 Common Codes
BACK AND NECK PAIN ICD-9-CM Codes: 723.1, 724.1, 724.2, 724.5 CHEST PAIN ICD-9-CM Codes: 786.50 - 786.59
(SELECTED)
ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

M54.2 Cervicalgia R07.1 Chest pain on breathing

M54.5 Low back pain R07.2 Precordial pain
M54.6 Pain in thoracic spine R07.81 Pleurodynia
M54.89 Other dorsalgia R07.82 Intercostal pain
M54.9* Dorsalgia, unspecied R07.89 Other chest pain
R07.9* Chest pain, unspecied

DIABETES MELLITUS W/O ICD-9-CM Code: 250.00 GENERAL MEDICAL EXAMINATION ICD-9-CM Code: V70.0
COMPLICATIONS TYPE 2
ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis
Encounter for general adult medical exam
E11.9 Type 2 diabetes mellitus Z00.00 without abnormal ndings

without complications Encounter for general adult medical

Z00.01 exam with abnormal ndings

HEADACHE ICD-9-CM Code: 784.0 HYPERTENSION ICD-9-CM Codes: 401.9

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

R51 Headache I10 Essential (primary) hypertension

without complications

View the complete list of codes here

15
 OB/GYN

Documentation Clinical Most Common

Analysis Scenario Codes
 Documentation Analysis

Specialty: Obstetrics & Gynecology

The clinical staff at an Obstetrics & Gynecology practice must adequately document these elds in order to fulll the ICD-10 coding requirements:

Laterality Nutritional
Bilateral Specify deciencies
Right Malnutrition: complications & severity
Left Overweight vs. obesity vs. morbid obesity
Multiple locations
Female Reproductive
Infections
Linkage between disease process & infective organism Infertility source
Prolapsed extent & location: Midline/ lateral, incomplete/
Disease Status complete
Acute
Sub-acute Neoplasms
Intermittent Malignant vs. benign, in situ, primary, secondary
Transient Locations details, laterality
Chronic Overlapping vs. distinct locations
Recurrent
Obstetrics Diabetes
C-section reason (as principal diagnosis) Type I, Type II, or due to other cause (disease/ drug)
Trimester (when complication arose) Due to other disease/ drug: specify other disease, or drug/
Abortion: completion, success, & related complications chemical if any
High-risk pregnancy: Hx of infertility, molar, or Linkage with complications
ectopic pregnancy Gestational vs. pre-pregnancy
Condition: gestational vs. preexisting (if gestational
diabetes is controlled)
Others
Multiples: Fetuses, fetus identication Metabolic Disease: Hyper- & Hypo- dont document ^ or v
(one with complication) Skin: Disease linkage with cause or infectious agent

17
 Clinical Scenario
Chief Complaint
Vaginal discharge accompanied by odor since one week.
History
32 year old female, mother, complains of a watery, whitish-gray vaginal discharge, accompanied by a
bitter-shy smell and an itchy vulva. Symptoms were observed about 8 days back. She afrms that symptoms
have never appeared before, and that she tried self-treatment using an OTC (over the counter) yeast mix
ture about 5 days ago. Method was ineffective.
LMP: two-weeks ago: normal. Mammograms: none, previously. Previous PAP examination 7 months ago:
normal.
Social history: Physically and sexually active. Patient is in a sexually active relationship with protection with
new male partner since 6 weeks (one partner). Denies history or presence of STIs. Informs of regular bubble
baths & douching.
She does not take alcohol, tobacco, or other drugs.
Patient is not immunized for Human papillomavirus (HPV).

Exam
Vitals: T 98.7, BP 126/62, Weight: 115 lbs.
Well groomed, A&O x3.
Pelvic: External exam-vulvar redness, negative for vulvar edema, and negative for adherent
white clumps.
Bimanual exam: patient has no pelvic tenderness, the uterus (smooth) & adnexa are both sized
normal, and ovaries arent palpable.
Speculum exam: pink vaginal-walls, cervix is intact, os is closed, thin gray-white & sharp, foul
smelling discharge observed in vaginal canal. Swab specimen has been obtained for her
microscopy exam.
In-ofce lab tests: Urine hCG - Negative; Yeast - negative; Wet Prep - Positive whiff test,
leukocytes and clue cells present; Vaginal-pH - elevated.

Assessment and Plan

Patient has bacterial vaginosis.
She has been prescribed metronidazole (7 days).
HPV vaccine administered today after discussion in ofce.
Vaginal hygiene leaet handed to her. 18
 Clinical Scenario

Summary of ICD-10-CM-Impacts
Clinical Documentation
1. In ICD-10-CM, there are 4 choices in contrast to ICD-9s single code for Vaginitis and vulvovaginitis, unspecied, 616.10. The alternatives are N76.0 for
acute vaginitis, N76.1 subacute & chronic vaginitis; N76.2 acute vulvitis; & N76.3 subacute & chronic vulvitis. As the patient shows no trends or history of
ongoing care or previous episodes, we have selected Acute vaginitis.
2. Moreover, as bacterial vaginosis is not frequently connected to itching, irritation or soreness, it will be assigned a separate code.
3. Although bacterial vaginosis is not an STI. The physician has recommended refraining from intercourse.
4. In ICD-9, there are several vaccination codes while ICD-10 contains only one general code for immunization.
5. The note intentionally does not include a discussion of STI or reproductive planning as it is expected to be commonly denoted in the evaluation & counselling
of females of this age.

ICD-9 CM Diagnosis ICD-10 CM Diagnosis

Codes Codes

616.10 Vaginitis and vulvovaginitis, unspecied N76. Acute Vaginitis

698.1 Pruritis, vulvar L29.2 Vulvar, pruritis

V04.89 Need for prophylactic vaccination and inoculation Z23 Encounter for Immunization
against other viral diseases

19
 Common Codes
List of the most common ICD-10 codes for an Obstetrics & Gynecology practice.
*Always utilize more specic codes rst.
ABNORMAL FEMALE GENITAL CYTOLOGY ICD-9-CM Codes: 622.10, 622.11, 622.12,792.9, 795.01 - 795.19, 795.4
(excluding neoplasia and malignancy codes)
ICD-10-CM Codes Diagnosis

R87.610 Atypical squamous cells of undetermined signicance on cytologic smear of cervix (ASC-US)

R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)

R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)

R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)

R87.615 Unsatisfactory cytologic smear of cervix

R87.616 Satisfactory cervical smear but lacking transformation zone

R87.618 Other abnormal cytological ndings on specimens from cervix uteri

R87.619* Unspecied abnormal cytological ndings in specimens from cervix uteri

R87.620 Atypical squamous cells of undetermined signicance on cytologic smear of vagina (ASC-US)

R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)

R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)

R87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)

R87.625 Unsatisfactory cytologic smear of vagina

R87.628 Other abnormal cytological ndings on specimens from vagina

R87.629* Unspecied abnormal cytological ndings in specimens from vagina

R87.69 Abnormal cytological ndings in specimens from other female genital organs

N87.0 Mild cervical dysplasia

N87.1 Moderate cervical dysplasia

N87.9 Dysplasia of cervix uteri, unspecied

R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive

R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive

R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive

R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive
20
 Common Codes

EXCESSIVE, FREQUENT, GENERAL MEDICAL AND ICD-9-CM Codes: V70.0, V72.31, V72.32
AND IRREGULAR MENSTRUATION ICD-9-CM Codes: 626.2 - 626.6, 627.0 GYNECOLOGICAL EXAMINATIONS (excluding contraceptive and procreative encounter codes)

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

N92.0 Excessive & frequent menstruation with regular cycle Z00.00 Encounter for general adult medical exam without a ab

N92.1 Excessive & frequent menstruation with irregular cycle Z00.01 Encounter for general adult medical exam with ab

N92.2 Excessive menstruation at puberty Z01.411 Encounter for gynecological examination (general) (routine) w ab

N92.3 Ovulation bleeding Z01.419 Encounter for gynecological examination (general) (routine) w/o ab

N92.4 Excessive bleeding in the premenopausal period Z01.42 Encounter for cervical smear to conrm ndings of recent normal
smear following initial abnormal smear
N92.5 Other specied irregular menstruation
N92.6* Irregular menstruation, unspecied *abnormal ndings=ab

View the complete list of codes here

21
 Dermatology

Documentation Clinical Most Common

Analysis Scenario Codes
 Documentation Analysis

Specialty: Dermatology
The clinical staff at a Dermatology practice must adequately document these elds in order to fulll the ICD-10 coding requirements:

Laterality Diabetes
Bilateral Type I, Type II, or due to other cause (disease/ drug)
Right Linkage with complications
Left
Skin
Multiple locations
Disease linkage with cause or infectious agent
Infections Pressure ulcer: laterality, stage (I to IV), & site
Linkage between disease process & infective organism Non pressure ulcer (chronic): laterality, site, skin breakdown,
muscle necrosis, bone necrosis, fat-layer exposed
Disease Status
Primary General Injuries
Secondary Location: head, proximal, shaft, etc
Acute Care episode: initial / subsequent/ sequela
Intermittent Document reason for contact dermatitis
Transient
Injury Cause
Chronic
Reason: e.g. fell from stairs
Recurrent
Location: e.g. stadium
Musculoskeletal Activity: e.g. collecting tickets
Previous trauma, infection, other disease courses External cause: civil, military, leisure, work related
Disease linkage with cause or infectious agent Neoplasms
Primary, secondary, or post-traumatic disease Malignant vs. benign, in situ, primary, secondary
Cause: pathological fracture due to osteoporosis, Location details
neoplastic disease, or other Overlapping vs. distinct locations
Arthritis: osteoarthritis vs. rheumatoid

23
 Clinical Scenario
Subjective
A 78-year-old returning female patient came in today on Dr. Andrews request. Patient recovering from a fall (from stairs) while walking in her home. Patient
complaining of pain in lower back; just above her hips.
Following up last week on an ulcer, the nurse requested Dr. Andrew to inspect the patients nose which contains a multicolored lesion with unusual borders.
It is usually covered using makeup. Patient said a beauty mark was always present there, but that it grew recently (over several months), and
changed color.
We conducted a biopsy last week, which is being returned to the patient along with its results. The complete lesion wasnt taken last week; because of its size.
All other systems came out as negative.

Objective
Vitals: BP 120/80, temperature 98.9, and BMI 20.1.
Exam
GEN: Patient is alert but appears somewhat uncomfortable.
CV: No murmur reported.
RESP: No crackles, wheezing, or rales.
ABD: Abdomen not tender to palpitation. Though, pressure on ulcer center on sacrum was present
(specify). Fat layer was exposed (specify detailed stage) because patients skin was vulnerable to
breakdown and very thin. There was not any exposure, nor was there necrosis of muscle or bone.
EXT: No bruising or edema.
FACE: Lesion observed on her nose on the right side of the nasal bridge. It was above the supratip
break on the other side of the nose to the tear trough of the patients right side (location in detail).
About 2.6 cm across, and having a reddish appearance lacking clear borders.

Assessment & Plan

Patient has stage-2 pressure ulcer on sacrum. Skin lesion on nose conrmed malignant melanoma.
Malignant melanoma: on the nasal bridge continuing to the right tear. Performed lesions removal with complex
closure. A total length of 3 cm was present.
Sacral pressure ulcer stage 2.

24
 Common Codes
List of the most common ICD-10 codes for Dermatology.
*Always utilize more specic codes rst.

ATOPIC DERMATITIS AND

PSORIASIS ICD-9-CM Code: 696.1 RELATED CONDITIONS, OTHER ICD-9-CM Code: 691.8

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

L40.0 Psoriasis vulgaris L20.0 Besnier's prurigo

L40.1 Generalized pustular psoriasis L20.8 Other atopic dermatitis
L40.2 Acrodermatitis continua L20.81 Atopic neurodermatitis
L40.3 Pustulosis palmaris er plantaris L20.82 Flexural eczema
L40.4 Guttate psoriasis L20.83 Infantile (acute) (chronic) eczema
L40.5 Psoriasis, other L20.84 Intrinsic (allergic) eczema
L40.50 Arthropathic psoriasis, unspecied L20.89 Other atopic dermatitis
L40.51 Distal interphalangeal psoriatic arthropathy L20.9 Atopic dermatitis, unspecied
L40.52 Psoriatic arthritis mutilans
L40.53 Psoriatic spondylitis
L40.54 Psoriatic juvenile arthropathy
L40.59 Other psoriatic arthropathy
L40.8 Other psoriasis

View the complete list of codes here

25
 Pediatrics

Documentation Clinical Most Common

Analysis Scenario Codes
 Documentation Analysis
Specialty: Pediatrics
The clinical staff at a Pediatrics practice must adequately document these elds in order to fulll the ICD-10 coding requirements:

Laterality Neoplasms
Bilateral Type: in situ, malignant vs. benign, primary, & secondary
Right Locations: overlapping & distinct
Left Leukemia: in relapse or in remission
Multiple Locations
Nervous System
Infections Primary vs. secondary: cause & disease
Linkage: disease process & infective organism Epilepsy type: seizure is a single event (or yet to be diagnosed),
seizure disorder is epilepsy
Disease Status Drug-induced disorders: drug name / type
Acute Migraine type & aura presence
Recurrent Hydrocephalus type
Intermittent Intractable disease presence
Chronic Paralysis: type & level
Transient
Digestive System
Newborns Linkage of complications with disease: bleeding, stula,
Newborn-conditions codes differ from 28 day (and perforation, obstruction, abscess, and gangrene
older) babies Hernia: unilateral vs. bilateral
Specify maternal conditions: affected & suspected Constipation: slow transit / outlet dysfunction

Anomalies, Congenital Respiratory System

For syndromes, anomalies (additional) must be Chronic disease exacerbation
documented Asthma: intermittent vs. persistent & mild, severe or moderate

27
 Documentation Analysis

Circulatory System
Rheumatic vs. nonrheumatic disease

Eye & Ear

Upper vs. lower eyelid
Cataract: age, drug-related, or traumatic
Disease: primary vs. secondary
Tobacco usage/ exposure impact on ear

Musculoskeletal
Previous trauma, infection, other disease courses
Disease linkage with cause or infectious agent
Primary, secondary, or post-traumatic disease
Arthritis: osteoarthritis vs. rheumatoid

Diabetes
Type I, Type II, or due to other cause (disease/ drug)
Linkage with complications

Skin
Disease linkage with cause or infectious agent

General Injuries
Location: head, proximal, shaft, etc
Care episode: initial / subsequent/ sequela

Genitourinary
Disease: primary vs. secondary
Disease linkage with cause or infectious agent

28
 Clinical Scenario
Chief Complaint
Watery (thin) diarrhea accompanied by vomiting and fever since 1 day.

History
31 month-old female came in with dehydration after 2 days of vomiting, watery diarrhea, & fever. She did not show nauseous symp-
toms, but she kept crying without any tears. According to her father, she is unimmunized for all vaccines. Her parents also reported
that she was urinating lesser than before. The father is of the view that symptoms began after a swimming pool outing with her siblings
where she could have swallowed water from the swimming pool.

Exam
She is in evident acute distress, appears dehydrated, and is continuously holding her stomach.
Vitals: T 100.0, BP 90/55, P 135, R 36. BS hyperactive times all 4 quadrants. Abdomen appears swollen and diffusely tender to
palpation. Rebound tenderness, organomegaly or masses not present.
Both mouth and tongue are dry, and her membranes are mildly pale. Her capillary rell is less than 3 seconds. Skin is dry and skin
turgor poor.

Assessment and Plan

After resolution of current episode, parents will be addressed of her unvaccinated status, which is a concern.
The patient needs IV hydration. IV uids & observation at hospital, for which admission orders have been ordered.
Rotavirus seems likely. Order rotavirus with EIA & RT-PCR, electrolyte panel.

29
 Clinical Scenario

ICD-10-CM Impacts
Clinical Documentation
1. The symptoms of dehydration, diarrhea, dry mouth, vomiting, and fever must be coded. After the determination of nausea (if the patient feels nauseous), the
appropriate codes will be entered. Nausea & vomiting differ in codes, as does vomiting unaccompanied by nausea.

2. Establishing why the patient remains unimmunized is necessary for documentation. It is important to determine why the patient was unimmunized & to
document it here as this is a signicant public health issue. ICD-10-CM has multiple codes to explain why a child has not been immunized.

ICD-9 CM Diagnosis Name ICD-10 CM Diagnosis Name

Codes Codes

787.91 Diarrhea R19.7 Diarrhea, unspecied

780.60 Fever, unspecied R50.9 Fever, unspecied

787.03 Vomiting alone R11.11 Vomiting without nausea

276.51 Dehydration E86.0 Dehydration

789.67 Abdominal tenderness, generalized R10.817 Generalized abdominal tenderness

V64. No vaccination, not otherwise specied Z28.3 Under-immunization status

Other Impacts
None.

30
 Common Codes
List of the most common ICD-10 codes for a Pediatrics practice.
*Always utilize more specic codes rst.

ABDOMINAL PAIN ICD-9-CM Codes: 789.00 - 789.09 ACUTE BRONCHITIS ICD-9-CM Codes: 466.0, 466.11, 466.19

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

R10.0 Acute abdomen J20.0 Acute bronchitis due to Mycoplasma pneumoniae

R10.10 Upper abdominal pain, unspecied J20.1 Acute bronchitis due to Hemophilus inuenzae
R10.11 Right upper quadrant pain J20.2 Acute bronchitis due to streptococcus
R10.12 Left upper quadrant pain J20.3 Acute bronchitis due to coxsackievirus
R10.13 Epigastric pain J20.4 Acute bronchitis due to parainuenza virus
R10.2 Pelvic and perineal pain J20.5 Acute bronchitis due to respiratory syncytial virus
R10.30 Lower abdominal pain J20.6 Acute bronchitis due to rhinovirus
R10.31 Right lower quadrant pain J20.7 Acute bronchitis due to echovirus
R10.32 Left lower quadrant pain J20.8 Acute bronchitis due to other specied organisms
R10.33 Periumbilical pain J20.9* Acute bronchitis, unspecied
R10.84 Generalized abdominal pain
R10.9* Unspecied abdominal pain

CHEST PAIN ICD-9-CM Codes: 786.50 - 786.59 CHEST PAIN ICD-9-CM Codes: 786.50 - 786.59

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

R07.1 Chest pain on breathing R07.82 Intercostal pain

R07.2 Precordial pain R07.89 Other chest pain
R07.81 Pleurodynia R07.9* Chest pain, unspecied

31
 Common Codes
ASTHMA ICD-9-CM Codes: 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.81, 493.82 , 493.90, 493.91, 493.92

ICD-10-CM Codes Diagnosis

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.901* Unspecied asthma with (acute) exacerbation

J45.902* Unspecied asthma with status asthmaticus

J45.909* Unspecied asthma, uncomplicated

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma

HEADACHE ICD-9-CM Code: 784.0

ICD-10-CM Codes Diagnosis

R51 Headache
without complications
32
 Common Codes
CHRONIC TUBOTYMPANIC CHRONIC ATTICOANTRAL SUPPURATIVE
SUPPURATIVE OTITIS MEDIA ICD-9-CM Code: 382.01 OTITIS MEDIA ICD-9-CM Code: 382.2

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

H66.10* Chronic tubotympanic suppurative otitis media, unspecied H66.20* Chronic atticoantral suppurative otitis media, unspecied ear
H66.11 Chronic tubotympanic suppurative otitis media, right ear H66.21 Chronic atticoantral suppurative otitis media, right ear
H66.12 Chronic tubotympanic suppurative otitis media, left ear H66.22 Chronic atticoantral suppurative otitis media, left ear
H66.13 Chronic tubotympanic suppurative otitis media, bilateral H66.23 Chronic atticoantral suppurative otitis media, bilateral

View the complete list of codes here

33
 Cardiovascular

Documentation Clinical Most Common

Analysis Scenario Codes
 Documentation Analysis

Specialty: Cardiovascular
The clinical staff at a cardiovascular practice must adequately document these elds in order to fulll the ICD-10 coding requirements:

Laterality Circulatory System

Bilateral Heart failure: Systolic vs. diastolic, right vs. left
Right Acute myocardial infarction (time period = 4 weeks)
Left Disease: rheumatic vs. nonrheumatic
Multiple locations Linkage of complications with hypertension
Cerebral hemorrhage: traumatic vs. nontraumatic, cause
Infections of hemorrhage/infarction, artery rupture/ block
Linkage between disease process & infective organism
Respiratory System
Status of Disease Chronic disease exacerbation
Primary Effects of tobacco
Secondary
Acute Nervous System
Intermittent Primary vs. secondary: disease & cause
Transient Intractable disease
Chronic Paralysis: Type & level
Recurrent
Genitourinary
Diabetes Primary vs. secondary
Type I, Type II, other drug/disease related Stage: chronic kidney disease
Linkage with complications Disease linkage with cause or infectious agent

35
 Clinical Scenario
Chief Complaint
Dr. Andrews said that you need to check my hypertension before my surgery.
History
77-year-old male patient scheduled for a Transurethral resection of the prostate (TURP) in 6 days. Dr. Andrews asked
for the patient to be evaluated for hypertension & cardiac clearance assessment before surgery.
Inferior wall MI, about one year and two months ago, received thrombolytic therapy which resolved his symptoms
completely. The most recent EF, last month, was 50%.
Patient partakes in swimming, golng, and walking regularly; denies shortness of breath (SOB) with exertion.
Patient has no prior history of cerebrovascular disease, and is also negative for CHF,DM, agina, or renal failure.
Patient does have a history of essential hypertension for which he had been prescribed one daily dose of metoprolol
succinate by his primary care physician; however, he has not been taking it citing expense related issues.

Exam
Patient is in no acute distress.
Vitals: BP at 157/92 is elevated. Weight & height are ne for age.
EKG: non-specic t-wave changes.
PE is normal, chest clear, and no pedal edema.
Labs: creatinine is at 1.5, slightly increased from his baseline, and could be a possible indicator of early renal
insufciency.

Assessment and Plan

A PCP will monitor Creatinine & BUN for renal function, and nephrology referral if needed.
HTN probably from patients failure to adhere to his daily metoprolol succinate requirements. Will
talk to Dr. Andrews to determine if he knew of the patients nancial situation. Change to 2 tab PO
daily of propranolol 20 mg, rst tab administered in ofce. Provided 30-day free sample supply of
proprano lol.
Reevaluation of HTN after 3 days; if improved, then give go-ahead for surgery.

36
Summary of ICD-10-CM Impacts
Clinical Documentation
1. Documenting the need of the clinical encounter is essential, because the coders assign different codes for initial vs. routine vs. surgery clearance visits.
2. According to the lab results, there is a slight enhancement in the patients baseline, and could be an indicator of early renal insufciency. This allows the
physician to report additional diagnoses that add validity to the abnormal test result.
3. If recognized, it is essential to document the patients compliance with their prescribed medications. ICD-10-CM introduces a relatively new concept of
underdosing, which can be captured in alongside diagnoses; in this case that is of metoprolol succinate. Also with underdosing, the physician must document if
the undedosing is recurrent or new.
4. ICD-10 also allows coders to Use Additional Code notes beneath the Hypertensive diseases (I10-I15). If recognized, you can document if patients have:
exposure to environmental tobacco smoke, occupational exposure to environmental tobacco smoke, history of tobacco use, tobacco use, and/or dependence.

ICD-9 CM Diagnosis Name ICD-10 CM Diagnosis Name

Codes Codes

401.9 Unspecied essential hypertension I10 Essential (primary) hypertension

794.31 Nonspecic abnormal Electrocardiogram (ECG)(EKG) R94.31 Abnormal electrocardiogram [ECG] [EKG]

794.4 Nonspecic abnormal results of function study of kidney R94.4 Abnormal results of kidney function studies

412 Old myocardial infarctions I25.2 Old myocardial infarction

Underdosing of other antihypertensive

N/A T46.5X6A drugs, [initial encounter]
Patients intentional underdosing of medication
N/A Z91.120 regimen due to nancial hardship
Encounter for pre-procedural cardiovascular
V72.81 Pre-operative cardiovascular examination Z01.810 examination

Other Impacts
In Medicare Advantage Risk Adjustment plans, specically hierarchical condition categories (HCC), some diagnosis codes are considered to determine severity
of risk, illness, and resource utilization. These HCC effects are unnoticed by many in the ICD-9 to ICD-10 conversion. For this, physicians need to examine
patients each year and subsequently document the latters chronic and acute condition statuses accordingly. These HCC codes are considered payment
multipliers.
37
 Common Codes
List of the most common ICD-10 codes for the Cardiovascular specialty.
*Always utilize more specic codes rst.

NONRHEUMATIC VALVE DISORDERS

ICD-10-CM Codes Diagnosis

Aortic Valve Disorders ICD-9-CM Code: 424.1

I35.0 Nonrheumatic aortic (valve) stenosis

I35.1 Nonrheumatic aortic (valve) insufciency

I35.2 Nonrheumatic aortic (valve) stenosis with insufciency

I35.8 Other nonrheumatic aortic valve disorders

I35.9* Nonrheumatic aortic valve disorder, unspecied

Mitral Valve Disorders ICD-9-CM Code: 424.0

I34.0 Nonrheumatic mitral (valve) insufciency

134.0 Nonrheumatic mitral (valve) prolapse

134.1 Nonrheumatic mitral (valve) stenosis

134.2 Other nonrheumatic mitral valve disorders

134.8 Nonrheumatic mitral valve disorder, unspecied

134.9 Subsequent non-ST elevation (NSTEMI) myocardial infarction

38
 Common Codes
CARDIAC ARRHYTHMIAS ICD-9-CM Codes: 427.41, 427.42, 427.60, CHEST PAIN ICD-9-CM Codes: 411.1, 413.1, 413.9, 786.50 - 786.59
(OTHER) 427.61, 427.69, 427.81, 427.89, 427.9

ICD-10-CM Codes Diagnosis ICD-10-CM Codes Diagnosis

I49.01 Ventricular brillation I20.0 Unstable angina

I49.02 Ventricular utter I20.1 Angina pectoris with documented spasm
I49.1 Atrial premature depolarization I20.8 Other forms of angina pectoris
I49.2 Junctional premature depolarization I20.9 Angina pectoris, unspecied
I49.3 Ventricular premature depolarization R07.1 Chest pain on breathing
I49.40 Unspecied premature depolarization R07.2 Precordial pain
I49.49 Other premature depolarization R07.81 Pleurodynia
I49.5 Sick sinus syndrome R07.82 Intercostal pain
I49.8 Other specied cardiac arrhythmias R07.89 Other chest pain
I49.9* Cardiac arrhythmia, unspecied R07.9* Chest pain, unspecied

View the complete list of codes here

39
 Need Help?

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References
Getting Specific: ICD-10 for Dermatology, Nextech, 2015 Retrieved from: http://www.nextech.com/blog/getting-specific-icd-10-for-dermatology
ICD-10: Interactive Training Guide, Pulse, 2014. Retrieved from: http://www.pulseinc.com/wp-content/uploads/2014/10/eBook_ICD-10_10232014.pdf
Road to 10: The Small Physician Practice's Route to ICD-10. Retrieved from: http://www.roadto10.org/

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