CODING CLINIC FOR ICD-10-CM:

WHAT YOU NEED TO KNOW

Sheri Poe Bernard, CPC, COC, CDEO, CCS-P
 Goals
• Understand what Coding Clinic for ICD-10-CM is, why it is important,
and how to access it

• Review pertinent Coding Clinic entries from 2012 Through Q1 2017

so that we can code compliantly

• Due to the amount of materials to be covered, we won’t be able to go

over associated A&P

• All ICD-10-CM references from ICD-10 Coding Clinic onset are

included here for reference, but we won’t have time to discuss them
all. Those not discussed have in the upper left corner.
 What’s Coding Clinic?
• Cooperative effort between American Hospital Association, National
Center for Health Statistics, AHIMA, and Centers for Medicare and
Medicaid Services

• Includes rules not addressed in Official Guidelines for Coding and

Reporting in ICD-10-CM

• Enforced for all CMS claims, provider, hospital, risk adjustment, etc.

• Sometimes lead to new Guidelines. Sometimes, not

 What’s Coding Clinic?
• Provides data on new ICD-10-CM codes, much like Insider’s View provides data
on new CPT codes. Example:

Q4 2016 “Irritable bowel syndrome

Codes K58.1, Irritable bowel syndrome with constipation, K58.2, Mixed irritable bowel syndrome, and K58.8
Other irritable bowel syndrome, have been created to distinguish types of irritable bowel syndrome.
Irritable bowel syndrome (IBS) is characterized by abdominal pain and discomfort, bloating and changes in
bowel movement. There are four types of IBS that are based on the predominant alteration in stool consistency:
IBS-C, with constipation; IBS-D, with diarrhea; IBS-M, mixed IBS; and IBS-U, unsubtyped IBS (diarrhea and
constipation less than 25% of the time).
IBS is a functional gastrointestinal disorder that affects 10% to 15% of the adult population. A thorough history
and examination are important in obtaining the diagnosis. Colonoscopy and imaging are necessary to rule out
other conditions.
The type of IBS and symptoms determines the treatment. Medication may reduce constipation and diarrhea.
Medications that affect serotonin levels or serotonin receptions have been noted to improve symptoms by
working on the nerves of the bowel.”
 What’s Coding Clinic?
• Often embedded into software, for example, Encoder
Pro, for an added fee, and linked to codes
• Available through AHA for $375 a year (single user)
• Essential to: inpatient and risk adjustment coding
• Very useful in all other coding environments – will
become increasingly important for compliance
• Published quarterly
 What’s Coding Clinic?
• Contents of Coding Clinic are copyrighted, so all
slides today contain the references in my own
language.

• Coding Clinic entries are referenced by year and

quarter, for easy access.

• Lots to cover so let’s get started!

General Advice
 Probable diagnoses
• The Official Guidelines for Coding and Reporting, Section IV.I. state,
‘Do not code diagnoses documented as “probable,” “suspected,”
“questionable,” “rule out,” or “working diagnosis” or other similar
terms indicating uncertainty. Rather, code the condition(s) to the
highest degree of certainty for that encounter/visit, such as
symptoms, signs, abnormal test results, or other reason for the visit.
This is a definitive diagnosis: CODE IT This is a probable diagnosis: CODE
SYMPTOMS INSTEAD
“Evidence of” in a radiology report “Appears to be” in a radiology report

Coding Clinic for ICD-10-CM, Q1 2014

 Coding from Path/Lab reports
• Consistency with the provider diagnosis is key to using more granular
diagnoses found in pathology or laboratory reports:
USE THE LAB/RAD REPORT TO CODE USE THE PROVIDER DIAGNOSIS TO CODE
Radiology provides a DX that is more granular Radiology provides a DX that is different from the
than the provider (ie, “displaced fracture of neck provider (ie, “displaced fracture of neck of right
of right scapula” vs provider’s “scapula fracture” scapula” vs provider’s “scapular sprain”
Lab provides a DX that is more granular than the Lab provides a DX that is different from the
provider (ie, “pneumococcal pneumonia” vs provider (ie, “:pneumococcal pneumonia “vs
provider’s “pneumonia” provider’s “bronchitis
Radiology provides the exact site of a cerebral
infarct or hemorrhagic stroke; provider only
documents “cerebral infarct” or “hemorrhagic
stroke”
Coding Clinic for ICD-10-CM, Q3 2016; Q3 2014
 Code number instead of diagnosis
• Issue exists because of EHRs
• Documentation must support code assignment
• Codes alone are not sufficient documentation
IF THE PROVIDER CODER REPORTS THIS BECAUSE
DOCUMENTS THIS
E10.9 nothing there is no documentation
E10.9 Diabetes E11.9 Type 2 Diabetes, the default for “diabetes” is type 2,
uncomplicated uncomplicated
E10.9 Type 1 diabetes E10.9 Type 1 diabetes, We have enough information in the
uncomplicated code description to select
uncomplicated diabetes

Coding Clinic for ICD-10-CM, Q4 2015

 Using prior encounters
• Code only the current encounter

• Each date of service or inpatient admission must stand alone

• Past conditions may not be clinically relevant (can’t code from PMH)

• Coders need to educate their providers on this point.

Coding Clinic for ICD-10-CM, Q3 2013

 Arrows in documentation
• Up and down arrows cannot be the basis for a diagnosis

• May indicate a change, not necessarily an abnormal condition

Coding Clinic for ICD-10-CM, Q1 2014

 “Code first”
• “Code first” refers to the pairing of codes, not necessarily the final
order of all codes on a claim

• For example, a patient with sepsis and hypertensive heart failure,

being treated for sepsis:

• A note under I50 Heart failure says to “code first” the

hypertension.

• Coders should sequence the sepsis, then HTN (I11.0), then

heart failure
Coding Clinic for ICD-10-CM, Q1 2016
 Guideline clarification
"The assignment of a diagnosis code is based on the provider's diagnostic
statement that the condition exists. The provider's statement that the patient
has a particular condition is sufficient. Code assignment is not based on
clinical criteria used by the provider to establish the diagnosis."
• Has nothing to do with clinical documentation improvement efforts
• Simply means a coder’s responsibility is, for example, to code sepsis if sepsis is
documented, regardless of whether the provider is using new clinical criteria, old
clinical criteria, the ICD-10-CM definition, or his or her own judgment.
• Coders are not to disregard documentation after making a clinical assessment. It
is not their role.

Coding Clinic for ICD-10-CM, Q4 2016

 “With”
• A causal relationship is assumed between two disorders linked by
“with” in the Index

• It is not required that the two disorders linked by “with” in the Index
be listed together in the medical documentation, ie, in A&P or even
on the same page

• Causal relationships between two disorders that are not linked by the
word “with” in the Index must be documented as etiology and
manifestation in the medical record in order for them to be linked in
the coding
Coding Clinic for ICD-10-CM, Q1 2016
 “With”
• Requires study!
• Abuse Dementia
alcohol with
with Parkinsonism
anxiety disorder Parkinson’s disease
mood disorder
psychosis Hematuria
sexual dysfunction with glomerular lesion
sleep disorder
Coding Clinic for ICD-10-CM, Q1 2016
 “With”
• Requires study!
• Diabetes
with
….
dermatitis E11.620
foot ulcer E11.621
gangrene E11.52
….

Coding Clinic for ICD-10-CM, Q1 2016

Infectious disease
 Viral Sepsis
• Use code A41.89 Other specified sepsis to report viral sepsis
(even though A30-A49 classified as bacterial disorders)
• Report a code from B97 Viral agents as the cause of diseases
classified elsewhere
(to identify virus)
Coders cannot assign sepsis codes based on clinical criteria
(provider must diagnose sepsis)

Coding Clinic for ICD-10-CM, Q4 2016

Neoplasms
 Neobladder cancer coding
A neobladder created from small intestine develops carcinoma. Is this
reported as cancer of the bladder or cancer of the small intestine?

• Code bladder cancer, as the intestine is acting as bladder in this

case.

C67.9 Malignant neoplasm of bladder, unspecified

Coding Clinic for ICD-10-CM, Q1 2016

Blood and blood-forming organs
Q3 2015 Immunocompromised state
Immunosuppressants can help patients with autoimmune disorders like
lupus, Crohn’s, RA, or myasthenia gravis, or for patients with transplants. An
immunocompromised state due to medication is a therapeutic state and
therefore is not reported. The long term use of immunosuppressants is
reported with:
• Z79.899 Other long-term (current) drug therapy

If the immunocompromised state exists without immunosuppressants or a

documumented underlying cause (ie, AIDS, etc), report:
• D89.9 Disorder involving the immune mechanism, unspecified
Coding Clinic for ICD-10-CM, Q3 2015
 Trapped temporal horn
• Woman with enlarging right temporal horn and right cavity near the lateral
ventricle had been previously diagnosed with pilocytic astrocytoma is
status post intraventricular tumor resection, endoscopic membrane lysis,
and ventricular peritoneal shunt placement. The patient was admitted for
trapped right temporal horn and was also diagnosed with recurrent
astrocytoma, hydrocephalus, and encephalopathy.

AC71.9 Malignant neoplasm of brain, unspecified

G91.4 Hydrocephalus in diseases classified elsewhere

Entrapment of the temporal horn is a form of focal hydrocephalus caused in

this case by the brain tumor, and is therefore represented by the code for the
astrocytoma.
Coding Clinic for ICD-10-CM, Q3 2014
Endocrine and nutrition
 Diabetic cataracts
• Although we have all been trained otherwise, it is now believed there
IS a link between cataracts and diabetes.

• The causal relationship between diabetes and cataracts is

established, along with many other manifestations, in the Index under
Diabetes/with

Coding Clinic for ICD-10-CM, Q4 2016

 Diabetic gastroparesis
• Be specific when coding autonomic (poly)neuropathy in diabetes.
Use a second code, for example K31.84 Gastroparesis, to identify
the type of autonomic (poly)neuropathy, with a diabetes code ending
in .43

• This may help reduce queries from payers and provides granularity
to the codes reported in the claim.

Coding Clinic for ICD-10-CM, Q4, 2013

 Diabetes with hyperglycemia
• A patient with diabetes mellitus and hyperglycemia is experiencing a
complication of diabetes, and the hyperglycemia is reported with .65,
for example:

E11.65 Type 2 diabetes with hyperglycemia

• The hyperglycemia must be documented by the provider

• “Uncontrolled” is not the same as hyperglycemia.

Coding Clinic for ICD-10-CM, Q3 2013; Q1, 2017

 Diabetic ketoacidosis
• Hypergylcemia is inherent in DKA. Do not code in addition to DKA

• The default for DKA, unspecified type is Type 1. Nearly all DKA is
type 1. This is different from guidelines regarding unspecified type.

• ICD-10-CM does not allow Type 2 diabetes with DKA to be reported.

If a patient is documented as having Type 2 diabetes with DKA, use:
E13.10 Other specified DM with DKA without coma, or
E13.11 Other specified DM with DKA with coma
• Watch for change
Coding Clinic for ICD-10-CM, Q1, 2013; Q3 2013; Q2 2016
 DM and metabolic encephalopathy
• Acute metabolic encephalopathy secondary to hypoglycemia is
reported with a diabetic code ending in .641 or .649, for
hypoglycemia with or without coma; and G93.41 Metabolic
encephalopathy

• Never report E16.2, Hypoglycemia, unspecified, found in the Index

under "encephalopathy, hypoglycemic," as this code is not for
diabetics.

• Any note in the record indicating adverse effect, underdosing, and/or

poisoning would lead to additional codes
Coding Clinic for ICD-10-CM, Q3 2016
Mental and Behavioral
 Nicotine induced disorders
• Do not report F17.218 Nicotine dependence, with other nicotine-
induced disorders, for a current smoker with COPD unless a causal
link is documented by the provider.

• The provider must document whether nicotine dependence is in

remission, or is a past history.

• In Index: Smoker – see Dependence, drug, nicotine

Coding Clinic for ICD-10-CM, Q4, 2013

 Prolonged remission
• If the provider documents “prolonged remission” for substance
dependence, report it as a personal history since there are no
remission codes in substance dependence

Coding Clinic for ICD-10-CM, Q1, 2013

 Alcohol abuse and withdrawal
• Alcohol withdrawal in ICD-10-CM can only be reported with
dependence, not with abuse.

• By definition, withdrawal would mean dependence, but there is no

guidance from Coding Clinic to assume dependence. Instead, if the
provider documents alcohol abuse and withdrawal, query the
provider.

Coding Clinic for ICD-10-CM, Q2 2015

 Chronic depression
• Documented “chronic depression” or “depression” is reported as:

F32.9 Major depressive disorder, single episode, unspecified.

Coding Clinic for ICD-10-CM, Q1, 2013

 Speech therapy
• For a patient undergoing speech therapy for echolalia and other
speech disorders due to the patient’s autism, sequence the codes as
follows:

F80.89 Other developmental disorders of speech and language

R48.8 Other symbolic dysfunctions
F84.0 Autism disorder

Autism would not be sequence first because of the range of

manifestations of autism. The guideline about signs and symptoms
therefore does not apply to autism.
Coding Clinic for ICD-10-CM, Q1, 2017
 Complicated bereavement
• “Complicated bereavement” should be reported with F43.21
Adjustment disorder with depressed mood. This can be used for any
bereavement, family or otherwise.

• “Bereavement” should be reported with Z63.4, Disappearance and

death of family member, and can only be used for a family member.

Coding Clinic for ICD-10-CM, Q1, 2014

Nervous System
 Alzheimer’s disease
Dementia is inherent in Alzheimer’s disease. If the provider does not
document dementia, but documents Alzheimer’s disease, report:

G30.9 Alzheimer’s disease, unspecified

F02.80 Dementia in other diseases classified elsewhere without

behavioral disturbance

• This is based on the Index entry requiring two codes, one bracketed.

• Sheri’s note: This convention also affects Lewy body and Pick’s
disease when dementia is not noted
Coding Clinic for ICD-10-CM, Q1, 2017
 Neurological deficits due to stroke
• Hemiplegia is not inherent to stroke or acute cerebrovascular
accident (CVA) and should be reported separately

• If the hemiplegia resolves, with or without treatment, before the

conclusion of the episode of care (ie, discharge) the hemiplegia shold
be reported. The hemiplegia affects the care that the patient
receives.

• This rule applies to any neurological deficit(s) caused by a CVA

Coding Clinic for ICD-10-CM, Q1, 2014

Acute cerebral infarct with left-sided weakness
• If “right-sided weakness” or “left-sided weakness” is linked in
documentation to a cerebral infarct or cerebral hemorrhage, it should
be reported as hemiplegia. For example an acute infarct:
I63.9 Cerebral infarction, unspecified.
G81.94 Hemiplegia, unspecified affecting left nondominant side

• The linkage cannot be assumed

• If the weakness is described, as “residual right arm weakness” or
lower limb weakness, choose the appropriate monoplegia code from
I69.34-.
Coding Clinic for ICD-10-CM, Q1 2015; Q1 2017
 Q4 2014 Dural tear
A dural tear existing from a previous epidural injection is reported with:
G96.11 Dural tear
In ICD-10-CM, “Non-traumatic dural tear” is indexed to G96.11. Also
report:
Y84.8 Other medical procedures as the cause of abnormal reaction
of the patient, or of later complication, without mention of
misadventure at the time of the procedure
The tear happened before the procedure and is not related to the
procedure.
G97.41 is assigned if the durotomy occurs during a current procedure.
Coding Clinic for ICD-10-CM, Q4, 2014
 Acute inflammatory demyelinating polyneuropathy
• Report acute inflammatory demyelinating polyneuropathy with:

G61.0 Guillain-Barre syndrome

Coding Clinic for ICD-10-CM, Q3, 2014

 Anti-MAG peripheral neuropathy
• Anti-myelin-associated glycoprotein (anti-MAG) peripheral
neuropathy is reported with:

G62.89 Other specified polyneuropathies

Coding Clinic for ICD-10-CM, Q2 2016

Eye and Ear
 Bilateral cataracts
• When a patient has bilateral cataracts, and comes in for surgery on
the first one, the diagnosis could should reflect the bilateral condition.

• CPT reporting will capture laterality.

• For the second cataract surgery, a unilateral condition is reported,

since the first eye no longer has a cataract.

Coding Clinic for ICD-10-CM, Q1, 2016

Circulatory system
 Q1 2013 Default for MI
• Report I21.3 ST elevation (STEMI) myocardial infarction of
unspecified site, for unspecified myocardial infarct, even though this
specifies STEMI

• If the MI is documented by vessel without reporting STEMI/NSTEMI,

report the STEMI code for that vessel

• If the MI is documented by vessel and as NSTEMI, report the

NSTEMI code, I21.4 Non-ST elevation (NSTEMI) myocardial
infarction

Coding Clinic for ICD-10-CM, Q1, 2013

 Atrial appendage thrombus
An atrial appendage thrombus is reported with:

I51.3 Intracardiac thrombosis, not elsewhere classified

Coding Clinic for ICD-10-CM, Q1, 2013

 Stage A heart failure
The American College of Cardiology and American Heart Association
has designated “Stage A heart failure” as a risk of heart failure.

Stage A heart failure is NOT heart failure, and should not be reported
with I50.9.

Instead, report:

Z91.89 Other specified personal risk factions, not elsewhere classified

Coding Clinic for ICD-10-CM, Q1, 2017

Heart failure with pleural effusion
• Pleural effusion is often seen in CHF, and should be reported
secondarily to CHF only if the pleural effusion is the subject of
therapeutic intervention or diagnostic testing. Report the pleural
effusion with:

J91.8 Pleural effusion in other conditions classified elsewhere

Coding Clinic for ICD-10-CM, Q2, 2015

 Heart failure
The coder may interpret documentation as diastolic or systolic heart
failure based on this nomenclature:
Alternative nomenclature for Alternative nomenclature for
DIASTOLIC HEART FAILURE SYSTOLIC HEART FAILURE

HFpEF HFrEF

Heart failure with preserved ejection fraction Heart failure with reduced systolic function

Heart failure with low ejection fraction

Heart failure with reduced ejection fraction

Coding Clinic for ICD-10-CM, Q1, 2016

 Decompensated heart failure
• Decompensated heart failure indicates an acute on chronic condition,
and should be reported as such.

Coding Clinic for ICD-10-CM, Q2, 2013

 Linkage in CHF
If the provider documents congestive heart failure and also documents
either systolic or diastolic dysfunction, but does not link the dysfunction
to the CHF, report:

I50.9 Heart failure, unspecified

Report a linkage between CHF and hypertension even when it is not

documented.

Coding Clinic for ICD-10-CM, Q1, 2017

 CPVT
• For catecholaminergic polymorphic ventricular tachycardia (CPVT),
report:
I47.2 Ventricular tachycardia
• Catecholaminergic identifies arrhythmias initiated during emotional
stress or physical exertion, when the nervous system uses natural
adrenaline to stimulate physical performance.. Polymorphic means
that the arrhythmia is coming from multiple locations in the heart’s
conduction system. In most cases, normal rhythm is reestablished
when the VT stops spontaneously. In some cases, the VT can
degenerate into ventricular fibrillation, causing sudden death.
Coding Clinic for ICD-10-CM, Q3 2013
Respiratory system
 Acute respiratory failure
For a patient who presents with smoke inhalation and acute respiratory
failure, report:
J96.00 Acute respiratory failure, unspecified whether with hypoxia
or hypercapnia
T59.811A Toxic effect of smoke, accidental (unintentional), Initial
encounter
J70.5 Respiratory conditions due to smoke inhalation

Coding Clinic for ICD-10-CM, Q4, 2013

 Respiratory failure
• For documentation stating “respiratory distress” in a child or adult,
code
R06.00 Dyspnea

Coding Clinic for ICD-10-CM, Q1, 2017

 Acute exacerbation of COPD
For documented acute exacerbation of COPD due to acute bronchitis, report:

J44.0 Chronic obstructive pulmonary disease with acute lower

respiratory infection

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

J20.9 Acute bronchitis, unspecified

Influenza is excluded from “acute lower respiratory infection” in J44.0,

because influenza involves upper and lower respiratory infections. Report the
infections separately.
Coding Clinic for ICD-10-CM, Q3, 2016
 Acute exacerbation of COPD
For documented acute exacerbation of COPD with acute exacerbation
of moderate persistent asthma, report:

J44.1 Chronic obstructive pulmonary disease with (acute)

exacerbation

J45.41 Moderate persistent asthma with (acute) exacerbation

Coding Clinic for ICD-10-CM, Q1, 2017

 Pneumonia and COPD
• Aspiration pneumonia with COPD is NOT reported with

J44.0 Chronic obstructive pulmonary disease with acute lower

respiratory infection

• Instead, assign codes

J44.9 COPD, unspecified

J69.0 Pneumonitis due to inhalation of food and vomit

Coding Clinic for ICD-10-CM, Q1, 2017

 Pneumonia and hemoptysis
• Because “hemorrhagic” is no longer a nonessential modifier in the
Index for pneumonia, it should be reported separately when it occurs,
with:
• J18.9 Pneumonia, unspecified organism
• R04.2 Hemoptysis

Coding Clinic for ICD-10-CM, Q4, 2013

 Acute cor pulmonale
A patient with pulmonary hypertension, COPD and cor pulmonale is diagnosed with “right
heart failure, decompensated cor pulmonale secondary to severe pulmonary hypertension”
in this encounter.

• Unfortunately the Index under “pulmonary hypertension with acute cor pulmonale” leads
to:
• I26.09 Other pulmonary embolus with acute cor pulmonale.
• I26.09 is not appropriate since the patient does not have a pulmonary embolism.
Correct coding is:
• I50.9 Heart failure, unspecified
• I27.81 Cor pulmonale (chronic)
• I27.2 Other secondary pulmonary hypertension
• J44.9 Chronic obstructive pulmonary disease, unspecified, as additional diagnoses.

NCHS will consider modifying the codes describing pulmonary embolism with cor pulmonale.
Coding Clinic for ICD-10-CM, Q4, 2014
Digestive system
 Q4 2012 Crohn’s disease
When a patient presents with Crohn’s disease of the small intestine
with a rectal abscess, report:

K50.014 Crohn’s disease of small intestine with abscess

K61.1 Rectal abscess

Codes in category K50 describe intestinal abscess only, and rectum is

not part of intestine.
Coding Clinic for ICD-10-CM, Q4, 2012
 Shock liver
Report “shock liver” with either:
K72.00 Acute and subacute hepatic failure, without coma
K72.01 Acute and subacute hepatic failure, with coma

Coding Clinic for ICD-10-CM, Q2, 2014

 Nontraumatic acute liver injury
• Sometimes, the liver is documented as having an injury with no sign
of trauma. Acute nontraumatic liver injury is reported as the exact
nature of the liver problem, for example, liver failure.

Coding Clinic for ICD-10-CM, Q2, 2015

 Hyperplastic polyp in descending colon
Report hyperplastic polyp in the descending colon with:

K63.5 Polyp of colon

Typically hyperplastic polyps of the colon are slow-growing and not pre-
cancerous – they are not neoplastic in nature.

For encounters following removal of the hyperplastic polyp, report

Z87.19 Personal history of other diseases of the digestive system

Do not report Z806.01- because a hyperplastic polyp is not neoplastic in

nature.
Also report a history of rectal polyps with Z87.19.
Coding Clinic for ICD-10-CM, Q2, 2015, Q1 2017
 Foreign body in esophagus
A foreign body in the esophagus may present with no inflammation,
tissue damage, or signs of injury. When this occurs, report:

T18.198- Other foreign object in the esophagus causing other

injury

An esophageal FB is a medical emergency, due to the potential of

serious complications to the airway, esophagus, and digestive tract.

Coding Clinic for ICD-10-CM, Q1, 2015

 Follow-up after polyp removal
A patient has ad adenomatous polyps removed from his colon, and is
being seen six months later for a follow-up exam. This is reported as:

Z09 Encounter for follow up examination after completed treatment

for conditions other than malignant neoplasm
Z86.010Personal history of colonic polyps

Coding Clinic for ICD-10-CM, Q1, 2017

 Hepatic encephalopathy
• Hepatic encephalopathy is not synonymous with hepatic failure with
hepatic coma. The default is:

K72.90 Hepatic failure, unspecified without coma

• A patient with hepatic encephalopathy of chronic Hep C would be

reported as:

B18.2 Chronic viral hepatitis

K72.10 Chronic hepatic failure without coma

Coding Clinic for ICD-10-CM, Q2, 2016 and Q1, 2017

 Cyclical vomiting syndrome
• For documented cyclical vomited syndrome, report

K31.89 Other diseases of the stomach and duodenum

And a code from R11 Nausea and vomited to identify the symptoms.

It is appropriate to capture an additional code to describe symptoms

when reporting a nonspecific code.

Coding Clinic for ICD-10-CM, and Q1, 2017

Skin and subcutaneous
 Pressure injury
• A pressure injury is reported as a pressure ulcer and is coded to the
site and stage. This is just new terminology from the National
Pressure Ulcer Advisory Panel.

Coding Clinic for ICD-10-CM, Q3, 2016

 Subcutaneous radionecrosis
• There is no code specific to soft tissue radionecrosis.

• Do not report codes for skin necrosis.

• Instead, report

• L59.8 Other specified disorders of skin and subcutaneous tissue

Y84.2 Radiological procedure and radiotherapy as the cause of
abnormal reaction of the patient or later complication without
mention of misadventure at the time

Coding Clinic for ICD-10-CM, Q1, 2017

Musculoskeletal system
 Cervical disc disorders
• The instructional note at category M50, Cervical disc disorders reads,
"Code to the most superior level of disorder."
• This direction is to code to the most superior level (e.g., the lowest
disc number) only for each fourth digit subcategory describing a
unique disorder. For example, if C3-C4 and C7-C8 have
radiculopathy, report:
M50.11 Cervical disc disorder with radiculopathy, high cervical region
• M50.11 includes C2-C-4
• Do not also report M50.13 (radiculopathy of C7-T1)
Coding Clinic for ICD-10-CM, Q1, 2016
 Primary osteoarthritis as default
• When the type of osteoarthritis is not documented, primary is the
default

• It is the most common form of osteoarthritis

Coding Clinic for ICD-10-CM, Q4, 2016

 Comminuted fracture of distal tibia and fibula
• For comminuted fracture of the left distal tibia and fibula, report:
S82.392- Other fracture of lower end of left tibia
• for comminuted fracture of distal tibia
S82.832- Other fracture of upper and lower end of left fibula
• for comminuted fracture of distal fibula

Coding Clinic for ICD-10-CM, Q1, 2015

Genitourinary system
 ESRD in polycystic kidney disease
• The Official Coding Guidelines Section I.C.9.a.2., states that ICD-10-CM
presumes a cause-and-effect relationship and classifies hypertension with
chronic kidney disease (CKD) as hypertensive chronic kidney disease.

• How to report a patient’s HTN due to ESRD with ESRD due to congenital
polycystic kidney disease:

N18.6 End stage renal disease

Q61.3 Polycystic kidney, unspecified

I15.1 Hypertension secondary to other renal disorders

Coding Clinic for ICD-10-CM, Q3, 2016
Ureteral stone migrating into bladder
• If a calculus migrates from the ureter to the bladder, report the
diagnoses as ureteral stones, but the procedure (at least, for PCS)
as bladder stones. It is not necessary that the diagnosis and
procedure codes match when reporting about calculi, since they
often move

..good luck with this one.

Coding Clinic for ICD-10-CM, Q3, 2016
 Prostate cancer and hematuria
• In ICD-9-CM, we were instructed to sequence hematuria first for the
patient with prostate cancer and hematuria who was being admitted
to the hospital with a significant drop in hemoglobin.

• In ICD-10-CM, we are to report the prostate cancer as the first-listed

diagnosis, with the hematuria reported secondarily.

Coding Clinic for ICD-10-CM, Q1, 2017

 Transplant failure with CKD
• Kidney transplant failure with chronic kidney disease, stage IV is
reported as:

T86.12 Kidney transplant failure

N18.4 Chronic kidney disease, stage 4 (severe), for the CKD

Coding Clinic for ICD-10-CM, Q1, 2013

 Default for Gustilo-Anderson
• When abstracting a chart in which a patient is being seen for a
subsequent encounter for an open fracture, and there is no known
information regarding the original Gustilo-Anderson classification,
report a seventh character for open fracture Type 1 or II (E, H, M Q).

Coding Clinic for ICD-10-CM, Q1, 2016

Pregnancy and childbirth
 7 th character fetal ID
If the physician documents twins as fetus A and B, it is appropriate to
convert those A and B designations to 1 and 2, according to the 7 th

character fetal identification system in ICD-10-CM.

• Just be consistent.

Coding Clinic for ICD-10-CM, Q4, 2012

 Meconium staining
The presence of meconium indicates fetal stress and fetal stress does
not need to be so documented in order to use the meconium code in
category 077 Other fetal stress complicating labor and delivery.

O77.0 Labor and delivery complicated by meconium in amniotic

fluid

Coding Clinic for ICD-10-CM, Q4, 2013

 42 weeks gestation
• Greater than 42 weeks gestation, for the purposes of Z3A.49, means
at least 43 weeks and 0 days gestation. Z3A.42 would be reported
for pregnancies from 42 weeks, 0 days to 42 weeks, 6 days.

Z3A.42 42 weeks gestation of pregnancy

Z3A.49 greater than 42 weeks gestation of pregnancy

Coding Clinic for ICD-10-CM, Q4, 2014

 2 nd degree perineal laceration
• Documentation of degree of perineal laceration is sufficient for code
selection for obstetrical laceration. It is not necessary that the
provider describe the type of tissue (for second degree, the perineum
muscle).

Coding Clinic for ICD-10-CM, Q4, 2014

 Elderly mother, normal delivery
• Do not assign supervision codes in category O09 during an episode of care that
includes delivery. If an elderly gravida has a normal delivery, report:

O80 Encounter for full-term uncomplicated delivery

• Effective October 1, 2016, Guideline 15.b.2 of the ICD-10-CM Official Guidelines

for Coding and Reporting states, in part:

• "Codes from category O09, Supervision of high-risk pregnancy, are intended for
use only during the prenatal period. For complications during the labor or delivery
episode as a result of a high-risk pregnancy, assign the applicable complication
codes from Chapter 15. If there are no complications during the labor or delivery
episode, assign code O80, Encounter for full-term uncomplicated delivery."
Coding Clinic for ICD-10-CM, Q1, 2016
 Weeks gestation
• Report the weeks of gestation in pregnancy at the time of admission
and not at the time of discharge, if they differ.

Coding Clinic for ICD-10-CM, Q2, 2013

 Chemotherapy in the postpartum
• A patient diagnosed with cancer during pregnancy is undergoing
chemotherapy two weeks postpartum. This is reported with:

Z51.11 Encounter for antineoplastic chemotherapy

O9A.13 Malignant neoplasm complicating the puerperium

• And the specific neoplasm code

• It is the provider's responsibility to document that a condition being

treated is not affecting a pregnancy.
Coding Clinic for ICD-10-CM, Q3, 2015
 Rh incompatibility status
• An Rh negative mother delivers at term without complication, and is
administered Rhogam prophylactically during the admission. This is
reported with:

O26.893 Other specified pregnancy related conditions, third trimester

Z67.91 Unspecified blood type, Rh negative (or more specific code)

• Codes in category O36 Maternal care for Rh isoimmunization, are not

appropriate since the patient does not have isoimmunization. Prophylaxis
is being given to prevent isoimmunization. Z31.82 Encounter for Rh
incompatibility status, is not appropriate either, as this code may only be
reported as the principal or first-listed diagnosis
Coding Clinic for ICD-10-CM, Q3, 2015
 Triamniotic Trichorionic Triplets
• There is no specific code addressing number of placenta and
chorion in a triamniotic trichorionic pregnancy (three fetuses each
with their own amniotic sac and placenta). Until a unique code is
created for this situation, report:

O30.10- Triplet pregnancy, unspecified number of placenta and

unspecified number of amniotic sacs

Coding Clinic for ICD-10-CM, Q2, 2016

Perinatal
 Perinatal period
• The Official ICD-10-CM Guidelines for Coding and Reporting in the
chapter on the perinatal period state, “For coding and reporting
purposes the perinatal period is defined as before birth through the
28th day following birth.”

• The World Health Organization considers the patient’s date of birth

as day zero

Coding Clinic for ICD-10-CM, Q1, 2014

 Gestational age discrepancy
• Use the gestational age provided by the pediatrician if it differs from
the gestational age provided by the obstetrician, when reporting for
the newborn

• Gestational abnormalities (pre- or post-) should only be reported on

the baby’s chart when documented by the baby’s provider. Notation
of a post term pregnancy on the mother’s chart is not sufficient
documentation to report post-term infant

Coding Clinic for ICD-10-CM, Q1, 2014

 Infant feeding problems
If infant feeding problems extend beyond the 28 days associated with
perinatal problems in the newborn, report the perinatal code, for
example:

P92.5 Neonatal difficulty in feeding at breast

Guidelines state, "Should a condition originate in the perinatal period,

and continue throughout the life of the patient, the perinatal code
should continue to be used regardless of the patient's age."

Coding Clinic for ICD-10-CM, Q3, 2016

 Newborn coding
• For physician coding and reporting, category Z38 codes are not
limited to only the day the baby was born. A physician may report a
code from category Z38 for each visit during the birth admission

Coding Clinic for ICD-10-CM, Q2, 2015

 Newborn ABO incompatibility
• Report ABO incompatibility on the newborn record if the baby’s
provider documents ABO incompatibility, regardless of whether a
positive Coombs test is charted.

P55.1 ABO isoimmunization of newborn

Coding Clinic for ICD-10-CM, Q3, 2015

Signs and symptoms
 Finding of dense breasts
• If a patient is discovered to have dense breasts, requiring further
investigation, during a screening mammogram, report:

Z12.31 Encounter for screening mammogram for malignant

neoplasm

• For the follow-up encounter, report

R92.2 Inconclusive mammogram

Coding Clinic for ICD-10-CM, Q1, 2015

 Glasgow coma scales
• Guidelines have been revised so that the coma scale codes may also
be used to assess the status of the central nervous system for other
non-trauma conditions, for example monitoring patients in the
intensive care unit regardless of the medical condition

• Provider documentation of numeric values is sufficient for coding

specific components of the coma scale, but not tallying a total score.
For total score, the total score itself must be documented.

• EMT and other non-physician documentation can be used for these

scores
Coding Clinic for ICD-10-CM, Q4, 2016; Q2 2015
Injuries
 Q4 2012 Malunion
• When the first medical encounter reveals an old fracture with
malunion, report initial encounter for closed fracture

Coding Clinic for ICD-10-CM, Q4, 2012

 Q4 2012 Open dislocation
• Report an open dislocation of the elbow by reporting the dislocation
first, then reporting an unspecified open wound of the elbow

Coding Clinic for ICD-10-CM, Q4, 2012

 7 th character in injuries
• Choice of the 7th character is based on whether the patient is
undergoing active treatment, for example, surgery, ER care,
evaluation of the injury, or consultation of the injury. Choice is not
based on whether the provider is seeing the patient for the first time

• For complication codes, “active treatment” may refer to antibiotic

therapy for an infection

Coding Clinic for ICD-10-CM, Q1, 2015

 7 th character in injuries
• A patient coming in for a wound check or suture removal would be
reported as undergoing a subsequent visit

• Do not use aftercare Z codes for injuries or poisonings

• Injuries discovered following initial treatment are reported as initial

encounters (example: slow brain bleed discovered days after
forehead laceration has been treated)

• Subsequent encounters are appropriate for new patients, if the

treatment phase of the injury is complete
Coding Clinic for ICD-10-CM, Q1, 2015
 7 th character in injuries
• A sequela is a direct result of a condition, so stated in
documentation.

Coding Clinic for ICD-10-CM, Q1, 2015

 Femoroacetabular impingement
• For a patient with a symptomatic labral tear of the left hip and
femoroacetabular impingement, report:

S73.192A Other sprain of left hip, initial encounter

M25.852 Other specified joint disorders, left hip

• Sprains can include tears, and a tear is equivalent to a third degree sprain,
which is a complete disruption.

• ICD-10-CM does not provide a specific code for femoroacetabular

impingement. Code M25.85- can be referenced in the Index under
Disorder, joint specified type NEC, hip.
Coding Clinic for ICD-10-CM, Q1, 2014
External causes
 Activity codes in subsequent encounters
• The 7th character for initial encounter in injuries is assigned while the
patient is receiving active treatment for the condition, regardless how
many visits or how much time passes

• Activity codes can only be used once, the first encounter, and it
does not need to correlate to the assignment of the 7th character for
"initial encounter" in the injury code.

Coding Clinic for ICD-10-CM, Q3, 2015

 Warfarin induced skin necrosis
• Warfarin induced skin necrosis is reported:

I96 Gangrene, not elsewhere classified

T45.515A Adverse effect of anticoagulants, initial encounter

Coding Clinic for ICD-10-CM, Q2, 2013

Health status and contact
 Second-hand smoke from eCigs
• Report adverse effects of second-smoke from electronic cigarettes
with:

Z77.29 Contact with and (suspected) exposure to other hazardous

substances

• Symptoms as appropriate

• Electronic cigarettes don’t produce tobacco smoke. However,

electronic cigarette vapors and exhaled gases may contain certain
fine particulate matter and substances that can constitute hazards.
Coding Clinic for ICD-10-CM, Q2, 2016
 Adult physical exam
• A patient with known comorbidities who undergoes a physical with no new
findings. Report:
Z00.00 Encounter for general adult medical examination without
abnormal findings
• Also report existing comorbidities addressed during the physical

• A patient with known comorbidities has worsening symptoms for those

comorbidities, or with new disorder found during his physical exam, report:
Z00.01 Encounter for general adult medical examination with abnormal
findings
• Also report existing comorbidities addressed during the physical
Coding Clinic for ICD-10-CM, Q1, 2016
 BMI
• An adult BMI of 19.5 is reported with

Z68.1 BMI, 19 or less, adult

Coding Clinic for ICD-10-CM, Q1, 2017

 Newborn hearing exam
• For newborn hearing exam with normal results, report:

Z13.5 Encounter for screening for eye and ear disorders

• For newborn hearing exam with abnormal results, report:

Z01.118 Encounter for examination of ears and hearing with other

abnormal findings

R94.120 Abnormal auditory function study

Coding Clinic for ICD-10-CM, Q3, 2016

 D50C
Thank you!
Sheri Poe Bernard, CPC, COC, CDEO, CCS-P
[email protected]