Layout and Organization. To review: the first digit of an ICD-10-CM code is always an alpha, the second digit is always numeric, and digits three through seven may be alpha or numeric. Here’s a simplified look at ICD-10-CM’s format.
Extensions are only found in the seventh character of an ICD-10-CM code. If a coder has to include an extension for an initial encounter on a code that does not have six characters, they must add placeholder characters.
Each code begins with a letter, and that letter is followed by two numbers. The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease.
ICD-10-CM is a seven-character, alphanumeric code. Each code begins with a letter, and that letter is followed by two numbers. The first three characters of ICD-10-CM are the “category.”. The category describes the general type of the injury or disease. The category is followed by a decimal point and the subcategory.
81.
Top 10 most common injuries related to non-venomous animalsICD-10 CodeICD-9 CodeICD-10 DescriptionW540XXAE9060Bitten by dog, initial encounterW5501XAE9063Bitten by cat, initial encounterW540XXDE9060Bitten by dog, subsequent encounterW5503XAE9068Scratched by cat, initial encounter6 more rows
ICD-10 code Z51. 81 for Encounter for therapeutic drug level monitoring is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
ICD-10 Code for Other long term (current) drug therapy- Z79. 899- Codify by AAPC.
W54.0XXAICD-10-CM Code for Bitten by dog, initial encounter W54. 0XXA.
ICD-Code W54. 0XXA is a billable ICD-10 code used for healthcare diagnosis reimbursement of Bitten by Dog, Initial Encounter.
The patient's primary diagnostic code is the most important. Assuming the patient's primary diagnostic code is Z76. 89, look in the list below to see which MDC's "Assignment of Diagnosis Codes" is first. That is the MDC that the patient will be grouped into.
ICD-10 Codes for Long-term TherapiesCodeLong-term (current) use ofZ79.84oral hypoglycemic drugsZ79.891opiate analgesicZ79.899other drug therapy21 more rows•Aug 15, 2017
ICD-10 code Z76. 89 for Persons encountering health services in other specified circumstances is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
ICD-10 Code for Encounter for issue of repeat prescription- Z76. 0- Codify by AAPC.
Code R53. 83 is the diagnosis code used for Other Fatigue. It is a condition marked by drowsiness and an unusual lack of energy and mental alertness. It can be caused by many things, including illness, injury, or drugs.
ICD-10-CM Diagnosis Code Z79 Z79.
Therapeutic drug monitoring (TDM) is testing that measures the amount of certain medicines in your blood. It is done to make sure the amount of medicine you are taking is both safe and effective. Most medicines can be dosed correctly without special testing.
F90. 1, Attention-deficit hyperactivity disorder, predominantly hyperactive type.
ICD-10-CM Codes that Support Medical Necessity For monitoring of patient compliance in a drug treatment program, use diagnosis code Z03. 89 as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.
Quantitation of detected drugs is not reimbursable. Code 82205 is for therapeutic monitoring only.
We’d select the one that best describes the condition diagnosed by the physician, which in this case would be L21.9, “Seborrheic dermatitis, unspecified.” We use “unspecified” here because the other codes for seborrheic dermatitis pertain either to infants or describe an “other” seborrheic dermatitis. In this case, “unspecified” is our best option.
The coder could look this up in the alphabetic index, or turn to the section in the tabular index for diseases of the skin or subcutaneous tissue: L00-L99. From there the coder would look for dermatitis and eczema and find L21: “seborrheic dermatitis.”
ICD-10-CM’s Excludes notes have been divided into two ‘levels.’ Excludes1 informs coders that the codes listed in the note may not, in any circumstance, be listed with the code that contains the Excludes1 note. For example, you might find something that looks like this:
The coding process begins with the analysis and abstraction of a medical report. Using their notes from the report, the coder may go straight to the tabular section or may refer to the alphabetic section to find the correct code, and then confirm it in the tabular.
Remember, extensions typically provide information what encounter this is for the healthcare provider with the patient. These are not always included, but in the case that they are, they cannot simply be appended to the end of whatever code is attached. Extensions are only found in the seventh character of an ICD-10-CM code.
ICD-10-CM is a seven-character, alphanumeric code. Each code begins with a letter, and that letter is followed by two numbers. The first three characters of ICD-10-CM are the “category.” The category describes the general type of the injury or disease. The category is followed by a decimal point and the subcategory. This is followed by up to two subclassifications, which further explain the cause, manifestation, location, severity, and type of injury or disease. The last character is the extension.
We’d select the code for our Type II Le Fort fracture: S02.412. Since this is the doctor’s first encounter with this injury, we’d use the initial encounter extension ‘A,’ and would end up with: S02.412A, “Le Fort type II fracture, closed, initial encounter.”
The ICD-10-PCS code assignment for this example is: 1 0UT90ZZ, Resection of uterus, open approach (for the hysterectomy) 2 0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix) 3 0UJD4ZZ, Inspection of uterus and cervix, percutaneous endoscopic approach (for the attempted laparoscopic hysterectomy) 4 8E0W4CZ, Robotic assisted procedure of trunk region, percutaneous endoscopic approach (for the attempted robotic-assisted surgery)
The American Hospital Association’s (AHA’s) Coding Clinic indicates when the provider’s operative note documentation does not specify the end placement of the infusion device, the imaging report may be used to identify the required body part for the ICD-10-PCS code assignment. This scenario illustrates how the use of two procedure document types provide all the required documentation necessary for the accurate ICD-10-PCS code assignment and emphasizes the need for facilities to define all the appropriate procedure document types for ICD-10-PCS coding.
Although no federal requirements define the specific health record document types that must be present at the time of coding, the Office of Inspector General’s (OIG) Compliance Program Guidance for Hospitals indicates that “the documentation necessary for accurate code assignment should be available to coding staff.” 1.
It is important to note that the UHDDS is a minimum common core of data on individual hospital discharges and is not intended to serve the entire facility-specific inpatient procedural coded data requirement needs. Any additional ICD-10-PCS procedure coding requirements beyond the hospital inpatient UHDDS requirements are to be defined within facility health information management (HIM) coding compliance programs and facility-specific inpatient procedure coding policies.
In ICD-10-PCS, procedure codes consist of a seven character code structure, with each character code including specific values. ICD-10-PCS coding is applied at the procedure document type level where a code is assigned based on specific values for each of the seven characters (see Figure 1 above).
0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix)
ICD-10-PCS codes 0UT90ZZ and 0UTC0ZZ are assigned based on the following Character 3 root operation coding guidelines and advice for this procedure: Medical and Surgical Section of the 2015 ICD-10-PCS Official Guidelines for Coding and Reporting:
Billable codes are sufficient justification for admission to an acute care hospital when used a principal diagnosis.
Digoxin toxicity may occur in individuals who take excessive amounts of the drug digoxin in a short period of time or in individuals who accumulate high levels of digoxin during an ongoing chronic treatment. Digoxin (derived from foxglove plants of the genus Digitalis) is a medication prescribed to individuals with heart failure and/or atrial ...
Example. If the diagnosis is primary open-angle glaucoma, severe stage, in the right eye, submit H40.11X3. While some glaucoma codes require you to indicate laterality (using the sixth character), that’s not the case with H40.11. But you are required to indicate staging, which is done with the seventh character, so you need to use X as a placeholder.
When you look up a code in the Tabular List, you may see one or more other codes listed in an Excludes note. There are two types—Excludes1 and Excludes2— and the two serve very different purposes.
In the Tabular List, you will see the dash used for cross-referencing.
The Alphabetical Index of diagnostic terms (plus their corresponding ICD-10 codes) lists thousands of “main terms” alphabetically. Under each of those main terms, there is often a sublist of more-detailed terms—for instance, “Cataract” has a sublist of 84 terms. However, the Alphabetical Index doesn’t include coding instructions, which are in the Tabular List.
If you looked only at the Alphabetical Index, you wouldn’t know that some glaucoma diagnosis codes require a sixth character to represent laterality—1 for the right eye, 2 for the left eye, and 3 for both eyes—or a seventh character to represent staging (see “ Step 5 ”). Step 3: Read the code’s instructions.
Example. The ICD-10 code H40.2232 represents bilateral chronic angle-closure glaucoma, moderate stage. Breaking that down, H40.22 represents chronic angle-closure glaucoma, the 3 in the sixth position indicates that it is bilateral, and the 2 in the seventh position represents that it is moderate stage.
Example. A patient presents with a complaint of pain in the right eye for two hours. A corneal abrasion is diagnosed. The code is S05.01 Injury of conjunctiva and corneal abrasion without foreign body, right eye. That code’s entry in the Tabular List instructs you to add a seventh character—A, D, or S. Since S05.01 is only five characters long, use X as a placeholder in the sixth position. In the seventh position, add A to indicate an initial encounter—S05.01XA. When the patient is seen in follow-up, use code S05.01XD. If the patient develops a recurrent erosion as a result of the abrasion, use code S05.01XS.
All codes require a decimal after the third (3rd) character. 6. Laterality (side of the body affected) is required for certain codes. If a code requires laterality, it must be included in order for the code to be valid. The number 1 is used to indicate right side. The number 2 is used to indicate left side.
In the above example, S52 is the category. The fourth and fifth characters of "5" and "2" provide additional clinical detail and anatomic site. The sixth character (1) indicates laterality, i.e., right radius. The seventh character, "A", is an extension which, in this example, means "initial encounter".
One significant difference between ICD-9 and ICD-10 is the need to assign a 7th character, also called a 7th character extension, to codes in certain ICD-10-CM categories.
Addition of 7th character - required for certain codes, including 'S' codes (injuries and external causes), to provide information about the characteristic of the encounter. When required, one of the following alpha digits must be used in the 7th position for the code to be considered valid.
1. Codes are alphanumeric and may be up to 7 characters in length. 2. 1st character is always alpha; alpha characters may appear elsewhere in the code as well. (Alpha characters are NOT case sensitive.) 3. 2nd character is always numeric. 4. The remaining 5 digits may be any combination of alpha/numeric. 5.
"S" (Sequela) - Complications that arise as a direct result of a condition.
The number 1 is used to indicate right side.