Objectives

• Learn structure, organization & unique features of ICD-

10-CM
• Understand basic coding guidelines
• Demonstrate ability to look up and code basic diagnosis
• Understand how coding guidelines to all types of care
• Relate coding guidelines to all types of care
• Know basic disease classification and how to use
resource books
• Be able to determine primary diagnosis

ICD-10-CM
Coding Essentials for LTC
3
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Agenda ICD-9 vs ICD-10

• Introduction • ICD-10 offers:

• Objectives – Increased precision with diagnoses
– Full diagnostic titles for each code
• ICD-9 vs ICD-10
– More flexibility in incorporating
• Official Coding Guidelines advances in medicine & technology
• Terms & Conventions – Uses more current & up to date med
terms
• Chapters of ICD-10-CM
– Laterality Added (left and right, both)
• Q&A – Room for expansion

2 4
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Examples of Structure Official Coding Guidelines

• S52 – Fx of Forearm • Set of rules that have been developed to

accompany and complement the official
• S52.5 – Fx lower end of radius conventions and instructions provided
within the ICD-10-CM coding manual itself
• S52.52 – Torus Fx of lower end of
radius
• S52.521 – Torus Fx of lower end of R
radius
• S52.521D – Torus Fx of lower end of R
radius, subsequent care

7
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Conventions

• General rules for use of the classification

independent of the guidelines
• Incorporated within the Alphabetic Index
and Tabular List as instructional notes
Conventions & General
Guidelines

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Use of Codes for Reporting Purposes Punctuation

• In order for code to be correct we must • [] Brackets

ensure that every digit possible is
– Used in Alphabetic Index to identify
recorded
manifestation codes
• For reimbursement
– Used in Tabular List to enclose
• For statistical reporting
• Synonyms
• For clinical accuracy • Alternative wording
• Explanatory phrases

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Placeholder Character “X” Punctuation

• “X” is used as a placeholder in certain • () Parentheses

codes to allow for future expansion – Used in both volumes to enclose
– Example: T49.8X5D Adverse affect to a supplementary words that may be present or
cosmetic absent in the statement of a disease or
procedure without affecting the code number
• Some categories have applicable 7th to which it is assigned
characters, use the “X” placeholder to – Referred to as nonessential modifiers
ensure the 7th character is in the right
place – Example:

– Example: T75.4XXD Electrocution

• Hypertension, hypertensive (accelerated)
(benign) (essential) (idiopathic)
(malignant) (systemic)
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Punctuation Other & Unspecified Codes

• Other or Other Specified

• : Colons
– Use when information in the medical
– Colons in the record provides detail for which a
tabular list
specific code does not exist
highlight an
incomplete term • Unspecified
– Use when the information in the medical
record is insufficient to assign a more
specific code

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Abbreviations Includes Notes

• NEC – Not elsewhere classifiable • A note that appears immediately under a

three character code title to further define
– Represents “other specified”
or give examples of the content of the
– Used when a specific code is not category
available for a condition
• NOS – Not otherwise specified
– Equivalent of unspecified

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Inclusion Terms Excludes 1 Notes

• List of terms included under some codes

• Conditions for which the code is to be
used

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Excludes Notes Excludes 2 Notes

• Excludes 1
– Pure excludes note
– NOT CODED HERE!
– Indicates that the code excluded should never be
used at the same time as the code above the note
• Excludes 2
– Not included here
– Indicates that the condition excluded is not a part
of the condition represented by the code but a
patient may have both conditions at the same time
– Acceptable to use both the code and the excluded
code together when appropriate
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“And” “See” and “See Also”

• Should be interpreted to mean either • See

“and” or “or” – Indicates another term should be
referenced
• Example:
– Necessary to go to the main term
– Cases of “tuberculosis of bones”,
referenced with the “see” note to locate the
“tuberculosis of joints” and “tuberculosis correct code
of bones and joints” are classified to
subcategory A18.0, Tuberculosis of • See Also
bones and joints – Instructs that there is another main term
that may also be referenced that may
provide additional Alphabetic Index entries
that may be useful
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“With” “See” and “See Also”

• Interpreted to mean “associated with” or

“due to”
• Sequenced in Alphabetic Index right after
main term

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Signs & Symptoms Combination Code

• Are acceptable for reporting purposes • A single code used to classify:

when a related definitive diagnosis has not
– Two diagnoses OR
been established (or confirmed) by the
provider – A diagnosis with an associated secondary
process (manifestation)
• Signs and symptoms that are an integral
– A diagnosis with an associated complication
part of the disease process should not be
assigned as additional codes unless • Identified by referring to sub-term entries in the
otherwise instructed by the classification Alpha Index and by reading the inclusion and
exclusion notes in the Tabular List
• Multiple coding should not be used when there is
a combination code that clearly identifies all of
the elements documented by the diagnosis
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“Code Also” Note Acute and Chronic Conditions

• Instructs that two codes may be required • If the same condition is described as both
to fully describe a condition acute (sub-acute) and chronic, and
separate subentries exist in the Alphabetic
• Note does not provide sequencing Index at the same indentation level, code
direction both
• (acute code is sequenced first)

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Sequela (Late Effects) Code First

• A residual effect after the acute phase of

an illness or injury

• No time limit on when it can be used

• May require two codes

– Chemical burn of cornea

– Poisoning by cleaning chemical

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Etiology/Manifestation Reporting Code More Than Once

• Code First • Each unique ICD-10-CM diagnosis code

may be reported only once for an
• Use additional code encounter
• In diseases classified elsewhere • Applies to bilateral conditions when there
• Underlying condition first then are no distinct codes identifying laterality
manifestation • Applies when two different conditions are
• Example: classified to the same code

– Diabetes is underlying condition

– Neuropathy is manifestation

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Laterality Main Term

• If no bilateral code is provided and the • A term that must be used to locate a
condition is bilateral, assign separate possible code in the tabular index
codes for both left and right sides • Bold
• If side is not identified in medical record, • Left justified
assign the code for the unspecified side
• It’s how you find the code!
• Represent conditions, diseases, nouns,
adjectives, but not usually anatomical
sites

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BMI and Pressure Ulcer Subterms

• BMI, depth of non-pressure chronic ulcers • Indented from Main term

and pressure ulcer stage codes • Describe differences in condition,
– Clinician can assign anatomical site, cause, clinical type

– Associated diagnosis (overweight,

obesity, pressure ulcer) must be
documented by patient’s provider

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Locating a Code

1. Always locate the main term first in the • Includes diseases generally recognized as
Alphabetic Index
communicable or transmissible
2. Then verify the code in the Tabular List
• Use additional code to identify resistance
3. Read and be guided by the instructional to antimicrobial drugs (Z16.-)
notations that appear in both the Alphabetic
Index and the Tabular List – Unless infection code specifically identifies
drug resistance
4. Alpha Index does not always provide the full
code • Pay close attention to Chapter 1
– Laterality and 7th characters can only be assigned from Guidelines and category notes for HIV and
the Tabular List sepsis coding
– A dash at the end of an Alphabetic Index code may
indicate additional characters are required
39
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CHAPTER 1
Sequela – Infections/Parasitic

• Codes B90-B94
– used to indicate conditions in categories
A00-B89 as the cause of sequela, which are
themselves classified elsewhere
Certain Infectious and Parasitic
Diseases (A00-B99) – include residuals of diseases classifiable to
the above categories if the disease itself is
no longer present
– Code first the condition (or “sequela”)
resulting from the infectious or parasitic
disease

38 40
©Pathway Health 2013
1.1 Sequela Case Study Sepsis

A patient is seen for right lower leg muscle • Requires one code from category A41 if no
atrophy that is the result of a previous bout documentation of severe sepsis or an
of polio. What is the correct diagnosis code? associated organ dysfunction
− M62.561 Atrophy, muscle, lower leg • Assign appropriate code for underlying
systemic infection
− B91 Late effect(s) – See Sequelae,
Sequelae (of), poliomyelitis (acute) • If the type of infection or causal organism
is not further specified, assign code A41.9,
Sepsis, unspecified organism.

41
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Bacterial/Viral B95-B97 Severe Sepsis

• Supplementary or additional codes to • Requires a minimum of two codes:

identify the infectious agent(s) in diseases – first a code for the underlying systemic
classified elsewhere infection,
– followed by a code from subcategory
R65.2, Severe sepsis.
– Additional code(s) for the associated
organ dysfunction are also required
(i.e., respiratory failure)

42 44
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CHAPTER 2

• Contains codes for most benign and all

malignant neoplasms
• First step is to determine from medical record
if neoplasm is benign, in-situ, malignant or of
Neoplasms C00-D49 uncertain histologic behavior
• If malignant, any secondary (metastatic) sites
should be determined
• The Neoplasm Table in the Alphabetic Index
should be referenced first
– Example: Adenoma
47
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Neoplasm Table

• Neoplasms grouped by behavior and then • A primary malignant neoplasm

subgroups by site overlapping two or more contiguous (next
• Neoplasm table found in the index to each other) sites should be classified to
the subcategory/code .8 (overlapping
− Identifies the behavior (columns) and site
(rows)
lesion), unless the combination is
specifically indexed elsewhere
• Important terms
• Multiple noncontiguous neoplasms of the
− Neoplasm
same site, such as tumors in different
− Tumor quadrants of the same breast, codes for
each site should be assigned
− Dysplasia
− Mass
48
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 Chapter 3

• Z85-, Personal history of malignant

neoplasm
– History with no further treatment
directed to the site and no evidence of
existing primary malignancy Diseases of the Blood
– Any mention of extension, invasion or and Blood-Forming Organs
met to another site is coded as a and Certain Disorders Involving the
secondary malignant neoplasm to that Immune Mechanism
site
(D50-D89)

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2.1 Neoplasm Case Study

Small cell carcinoma of right lower • Same basic coding rules

lobe of lung with metastasis to the • No specific Coding Guidelines at this time
intrathoracic lymph nodes, brain and
right rib

-C34.31 lung, malignant, primary, lower lobe

-C77.1 lymph gland, malignant, intrathoracic,
secondary site
-C79.31 brain, malignant, secondary site
-C79.51 bone, malignant, rib, secondary site

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3.1 Anemia Case Study Diabetes Mellitus

Congenital red cell aplastic anemia • Combination codes that include:

– Type of DM
– D61.01 Anemia (essential) (general) – Body system affected
(hemoglobin deficiency) (infantile)
– Complications affecting that body system
(primary) (profound), aplastic, red cell
(pure), congenital • Not classified as controlled or uncontrolled
– Code by type with hyperglycemia

©Pathway Health 2013

Chapter 4
Diabetes Mellitus

• Use as many codes as necessary to

describe all complications
• If type of DM is not documented in the
medical record, the default is E11.- Type
Endocrine, Nutritional and
2 diabetes mellitus
Metabolic Diseases (E00-E89)
• If the record does not indicate the type of
DM, but does indicate the use of insulin,
code also Z79.4 Long-term (current) use
of insulin

54 56
 Chapter 5
4.1 Diabetes Case Study

62-year-old male with mild nonproliferative diabetic

retinopathy with macular edema. He has type 2 DM
and takes insulin on a daily basis. He also has a
diabetic cataract in his right eye. What is the
correct code assignment?
•combo code for Diabetic retinopathy with macular edema Mental and Behavioral
•E11.321 Diabetes, diabetic (mellitus) (sugar), type 2, with,
retinopathy, nonproliferative, mild, with macular edema
Disorders (F01-F99)
•E11.36 Diabetes, diabetic (mellitus) (sugar), type 2, with,
cataract
•Z79.4 Long-term (current) (prophylactic) drug therapy (use
of), insulin

57 59

Secondary Diabetes In Remission

• DM due to underlying condition, drug or • History of drug or alcohol dependence is

chemical induced or other specified coded “in remission”
• Always caused by another condition or • The appropriate codes for “in remission”
event are assigned only on the basis of provider
documentation
• Z79.4 should only be assigned for patients
who routinely use insulin – not if only
given to temporarily control blood sugar
• E09, Drug or chemical induced DM – use
additional code from Drug and Chemical
Table to identify drug causing adverse
effect 58 60
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 CHAPTER 6
Substance, Abuse and Dependence

When the provider documentation refers to

use, abuse and dependence of the same
substance (e.g. alcohol, opioid, cannabis,
etc.) only one code should be assigned to
identify the pattern of use based on the
following hierarchy: Diseases of the Nervous
System (G00-G99)
1. Dependence
2. Abuse
3. Use

61 63
©Pathway Health 2013

5.2 Dementia Case Study Dominant/Nondominant Side

A 52-year-old with dementia and • If affected side is documented but not

forgetfulness has been wandering from specified as dominant or nondominant:
home and getting lost. The diagnosis is
– For ambidextrous patients, the default should
dementia due to early-onset of Alzheimer’s be dominant
disease.
– If the left side is affected the default is
G30.0 Alzheimer’s Disease, early onset with nondominant
behaviors
– If the right side is affected the default is
F02.81 Dementia, in Alzheimer’s dominant
Z91.83 Wandering in diseases classified
elsewhere

62 64
G89, Pain, Not Elsewhere Classified Epilepsy and Migraine

• May be used with codes from other categories • The following terms are considered to be
and chapters to provide more detail about pain equivalent to intractable
• Must be documented as:
– Pharmacoresistant (or
− Acute or chronic
pharmacologically resistant)
− Post thoracotomy, postprocedural or neoplasm-related
• Do not use if underlying diagnosis is known – Treatment resistant
• Chronic pain must be documented by the – Refractory (medically)
provider
– Poorly controlled
• Central pain syndrome and chronic pain
syndrome are different than the term “chronic
pain”
− Only used when specifically documented by provider
65 67

Postoperative Pain Coding Examples (6.2-6.4)

• Provider documentation guides coding • Left-sided hemiplegia

• Routine or expected postop pain should – G81.94 Hemiplegia
not be coded • Seizure disorder
• Postop pain associated with a specific – G40.909 Epilepsy, unspecified, not
complication is coded in Chapter 19 with intractable, without status epilepticus
an additional G89 code for acute or • Includes Recurrent Seizures and Seizure
chronic Disorder NOS
• (Seizure = R56.9 Unspecified convulsions)
• Parkinson’s Disease
– G20
66 68
Chapter 7
Coding Exercise 7.1

A patient with moderate primary open-angle

glaucoma of the left eye.
What is the correct diagnosis code?
Diseases of the Eye – H40.11X2 Glaucoma, open angle,
and Adnexa (H00-H59) primary.

69 71

CHAPTER 8
Glaucoma Guidelines

• Assign as many codes from category H40,

Glaucoma, as needed to identify the type
of glaucoma, the affected eye and the
glaucoma stage
• Check for a bilateral code when both eyes DISEASES OF THE EAR AND
are documented as same type and stage MASTOID PROCESS (H60-H95)
• Code glaucoma to the highest stage
documented

70 72
 CHAPTER 9
Chapter Specific Note:

• Use an external cause code, if applicable,

following the code for the ear condition
– Exposure to environmental tobacco smoke
(Z77.22)
– Exposure to tobacco smoke in the perinatal DISEASES OF THE
period (P96.81)
CIRCULATORY SYSTEM
– History of tobacco use (Z87.891)
(I00-I99)
– Occupational exposure to environmental
tobacco smoke (Z57.31)
– Tobacco dependence (F17.-)
– Tobacco use (Z72.0) 73 75

Ear Case Studies 8.2-8.4 Hypertension with Heart Disease

• Bilateral conductive hearing loss • You may not assume a causal relationship
between hypertension and heart disease
– H90.0

• Meniere’s vertigo of left ear • The documentation must state:

– H81.02 – Hypertensive
– Due to Hypertension
• Benign paroxysmal vertigo

– H81.10

74 76
Hypertensive CKD Combination Codes…

• Assign codes from category I12, • Hypertension and heart disease?

Hypertensive CKD when both hypertension – No – do not assume a causal relationship
and a condition classifiable to category • Hypertensive heart disease?
N18, chronic kidney disease, are present – Yes – relationship must be stated to use the
I11 code
• You may assume a causal relationship
between these two conditions • Chronic kidney disease and hypertension
– Yes – you may assume a causal relationship-
• Also code from category N18 to identify code to I12
the stage of CKD • Chronic kidney disease and hypertensive heart
disease
– Yes – assume the relationship between the
CKD and HTN – code to I13
77 79

HTN and Chronic Kidney Disease Transient HTN

• Assume a causal relationship between the • Comes and goes, not permanent “white
hypertension and the CKD whether or not coat syndrome” just an elevated BP
the condition is so designated
• Transient HTN
• Assign additional codes for the stage of
– Assign code R03.0, Elevated blood
CKD and heart failure, if present
pressure reading without diagnosis of
hypertension (unless pt. has established
HTN diagnosis)

78 80
9.1 HTN Case Study Acute Myocardial Infarction

Stage 3 chronic kidney disease with • Code category I21 for initial MI less
congestive heart failure due to hypertension than or equal to 4 weeks old
• Code category I22 for subsequent MI
• I13.0 Hypertension w/heart failure, with
Stage 1-4 CKD – Use when a patient who has suffered an
AMI has a new AMI within the 4 week
• I50.9 CHF time frame of the initial AMI
• N18.3 CKD Stage 3
– Must be used in conjunction with a code
from category I21-never alone

81 83

CAD and ANGINA Acute Myocardial Infarction

• Combo codes • I21.3, ST elevation (STEMI) myocardial

infarction of unspecified site is default for
• Additional code is not necessary to “unspecified MI”
capture angina pectoris
• If an AMI is documented as nontransmural
• Causal relationship is assumed when or subendocardial, but the site is provided,
patient has both atherosclerosis and it is still coded as a subendocardial AMI
angina unless documentation indicates
otherwise • Old or healed MI not requiring further care
is I25.2

82 84
CHAPTER 10
Acute Exacerbation

• COPD and Asthma

– acute exacerbation
• Worsening or decompensation of a
DISEASES OF THE chronic condition
RESPIRATORY SYSTEM
• Not equivalent to an infection
(J00-J99) superimposed on a chronic condition
• May be triggered by an infection

85 87

Chapter Notes Influenza

• Respiratory condition described as occurring • Code only confirmed cases due to certain
in more than one site that is not specifically identified viruses (J09 and J10)
indexed, classify to the lower anatomic site
(e.g. tracheobronchitis to bronchitis in J40) • Suspected, possible or probable should be
coded to J11, Influenza due to unidentified
• Additional codes required for some
influenza virus
categories:
– To identify infectious agent or virus
– Associated lung abscess
– Underlying disease
– Tobacco use or exposure
86 88
 CHAPTER 11
Ventilator Associated Pneumonia

• Only code based on provider

documentation
• Additional code required to identify
organism
DISEASES OF THE
• Do not use an additional code from DIGESTIVE SYSTEM (K00-K95)
categories J12-J18 to identify type of
pneumonia
– UNLESS: Patient was admitted to
hospital with one type of pneumonia
and subsequently developed VAP (which
would become a secondary diagnosis) 89 91

10.1 COPD Case Study 11.1 Hernia Case Study

COPD with emphysema Patient with recurrent right inguinal hernia

with gangrene and obstruction
J43.9 Emphysema (remember that
emphysema IS COPD) read the notes in the K40.41 Hernia, inguinal, with gangrene (and
book – more specific – COPD is a generic obstruction) recurrent
code • Category note:
*Pay attention to includes and excludes – Hernia with both gangrene and obstruction is
notes classified to hernia with gangrene

90 92
CHAPTER 12
12.1 Pressure Ulcer Case Study

Patient with gangrenous pressure ulcer of

right hip with cellulitis and pressure ulcer of
sacrum documented by physician. Nursing
assessment indicated stage 2 sacral ulcer
and stage 3 decubitus ulcer of right hip
Diseases of the Skin and
Subcutaneous Tissue (L00-L95) • I96 – Ulcer, gangrenous, gangrene
• L89.213 – Ulcer, pressure, Stage 3, hip
• L89.152 – Ulcer, Stage 2, sacral
• L03.115 – Cellulitis, lower limb

93 95
©Pathway Health 2013

CHAPTER 13
Pressure Ulcer Stage Codes

• Combination codes that identify site and

stage
• Severity designated by stages 1-4,
unstageable and unspecified based on Diseases of the Musculoskeletal
clinical documentation
System and Connective Tissue
• Any associated gangrene should be (M00-M99)
sequenced first
• Unspecified vs. unstageable
• No code is assigned for healed pressure
ulcer
94 96
©Pathway Health 2013
Musculoskeletal System Aftercare

• Most codes have site and laterality • Aftercare for broken bones will now be
designations coded to fracture with 7th character D
• Site represents bone, joint or muscle • Pathological and stress fractures are
involved found in this chapter
• “Multiple sites” codes

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Seventh Characters Osteoporosis

• A – initial encounter • Use category M81, Osteoporosis without

pathologic fx, for patients with
• D – subsequent encounter osteoporosis who do not current have a
• G – subsequent encounter – delayed pathologic fracture due to osteoporosis.
healing – patients with a history of osteoporosis
• K – subsequent encounter – nonunion fractures, status code Z87.310, Personal
history of (healed) osteoporosis
• P – subsequent encounter – malunion fracture, should follow code M81
• S - sequela

©Pathway Health 2013 ©Pathway Health 2013

 CHAPTER 14
Pathological Fracture

• Use category M80, Osteoporosis with

current pathological fracture, for patients
who have a current pathologic fracture at
the time of an encounter.
– DO NOT USE traumatic fracture code
Diseases of the Genitourinary
here System (N00-N99)
– this must be determined and
documented by the physician.

103
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13.1 Path Fracture Case Study Stages of Chronic Kidney Disease

An 80-year-old female with senile • CKD classification based on severity

osteoporosis complaining of severe back designated by stages 1-5
pain with no history of trauma. Provider
• End stage renal disease (ESRD) is
documentation reveals pathological
assigned when it has been documented by
compression fractures of several lumbar
the provider (Stage 5 requiring chronic
vertebrae.
dialysis)
• If both a stage of CKD and ESRD have
-M80.08XD been documented, assign the code for
ESRD only

104
©Pathway Health 2013 ©Pathway Health 2013
 CHAPTER 17
14.1 Kidney Failure Case Study

An 83-year-old man with complaints of

lower abdominal pain and the inability to
urinate over the past 24 hours, diagnosed
as acute kidney failure due to acute tubular
necrosis, caused by a urinary obstruction. Congenital Malformations,
The urinary obstruction was a result of the Deformations and Chromosomal
patient’s benign prostatic hypertrophy. Abnormalities (Q00-Q99)

105 107
©Pathway Health 2013

Kidney Failure Answer Congenital Malformations

N17.0 – Failure, kidney, acute w/tubular • Assigned any time in a patient’s life if
being diagnosed or treated
necrosis
N40.1 – Hypertrophy, prostate – see • May be present at birth but not diagnosed
enlargement, prostate with luts until later in life
N13.8 – Obstruction, urinary • If previously treated and resolved, code
personal history code

108
©Pathway Health 2013
 CHAPTER 18
Manifestations

• DO NOT code manifestations if they are

inherent to the
malformation/deformation/abnormality
• DO code manifestations that are not
inherent Symptoms, Signs and Abnormal
Clinical and Laboratory Findings
• EX: Down Syndrome – Use F70-79 to (R00-R99)
further identify the intellectual disability

111
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17.1 Down Syndrome Case Study Signs & Symptoms

Down Syndrome • Symptoms, signs, abnormal results and

ill-defined conditions without a classifiable
-Q90.9 diagnosis
• Only use if definitive diagnosis has not
been established
• May be used in addition to a definitive
diagnosis as long as the sign or symptom
is not routinely associated with that
diagnosis

112
©Pathway Health 2013
 CHAPTER 19
Signs & Symptoms

• R29.6, Repeated falls

– when patient has recently fallen and the
reason is being investigated
• Z91.81, History of falling Injury, Poisoning, and Certain Other
Consequences of External Causes
– when a patient has fallen in the past (S00-T88)
and is at risk for future falls
• May be assigned together

113 115

18.1 Fever Case Study 7TH CHARACTERS

• A – initial encounter
Patient with fever of 101 degrees with chills.
Lab tests and urinalysis are within normal – Active treatment (surgical treatment, ED
limits. Physician gives final diagnosis as encounter, eval & tx by new physician)
fever with chills, possible viral syndrome. • D – subsequent encounter
– Routine care during healing or recovery phase
– Aftercare Z codes are not used for aftercare for
• R50.9 Fever (inanition) (of unknown injuries or poisonings where 7th characters are
origin) (persistent)(with chills) (with rigor) provided to identify subsequent care
• S – sequelae
– Complications or conditions arising as direct
result of condition
114 116
Injuries Traumatic Fractures

• Assign separate codes for each injury • A fracture not indicated as open or closed
unless a combo code is provided should be coded to closed
• Superficial injuries are not coded when • A fracture not designated as displaced or
associated with more severe injuries of non-displaced should be coded to
same site displaced
• Do not assign traumatic injury codes for • 7th characters
normal, healing surgical wounds or
complications of these – Some fractures have expanded 7th
characters to identify open fractures
• Compound fracture = open fracture
117 119

Aftercare Fracture Specificity

• Aftercare for broken bones will now be • Greater specificity for fractures
coded to Fracture with 7th character D
– Type
• Traumatic fractures are found in this
chapter – Specific site
– Displaced vs non-displaced
– Routine vs delayed healing
– Mal-union
– Type of encounter

120
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19.1 Elbow FX Case Study 19.3 Digoxin Case Study

A patient admitted for aftercare following A patient taking Digoxin is experiencing

traumatic lateral epicondyle fracture of the nausea, vomiting and profound fatigue. The
right elbow, which is healing normally. patient indicates that she has been taking
the drug as prescribed. Evaluation and
treatment focused on adjustment of
medication only.
– S42.431D Fracture, traumatic (abduction)
(adduction) (separation), humerus, lower – R11.2 Nausea, with vomiting
end, epicondyle, lateral (displaced) – R53.83 Fatigue
– T46.0X5D Table of Drugs and Chemicals,
Digoxin, adverse effect

121 123
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Adverse Effects Poisoning

• Drug correctly prescribed and properly • Error made in drug prescription

administered
• Overdose of drug intentionally taken
• Code nature of adverse effect followed by
• Non-prescribed drug taken with correctly
the code for the cause in the Table of
prescribed and properly administered
Drugs and Chemicals
drug
– Tachycardia, delirium, vomiting, renal
• Interaction of drugs and alcohol
failure, etc.
• 5th or 6th character shows intent
• DO NOT code directly from the Table!
• Use additional code for manifestations of
poisoning
122 124
Under-dosing

• Taking less than is prescribed by provider

or manufacturers instruction inadvertently
or deliberately
• Noncompliance (Z91.12-, Z91.13-) or External Causes Morbidity
complication of care (Y63.61, Y63.8-
Y63.9) codes are to be used in addition to (V00-Y99)
indicate intent, if known

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Toxic Effects External Causes of Morbidity

• Harmful substance is ingested or comes in • Not used in LTC

contact with a person
• Never sequenced as first listed diagnosis
• Associated intent:
• Example: Fall from stairs, car accident
– Accidental
• These were “E Codes” in ICD-9
– Intentional self-harm
– Assault
– Undetermined

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 Coding Examples

• Resistance to penicillin, Z16.11

• Body mass index, adult, (33.0), Z68.33
• Long term (current) use of antibiotics,
Factors Influencing Health Z79.2
Status and contact with health
• Personal history of malignant neoplasm,
services (Z00-Z99) bladder Z85.51
• Presence of automatic implantable cardiac
defibrillator Z95.810

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Z CODES 21.1 Aftercare Case Study

• Previously V Codes A 75-year-old woman was admitted for

• For use in any health care setting
occupational therapy (OT) following
cardiac bypass surgery. She continues to
• Aftercare (except for fractures & rehab) have significant acute post-thoracotomy
• personal history codes pain. Assign the correct diagnostic
code(s).
• noncompliance • Z48.812 Aftercare, following surgery (for)(on),
circulatory system
• acquired absence of limb
• Z95.1 Status (post), aortocoronary bypass
• devices • G89.12 Pain(s) (see also Painful), acute, post-
thoracotomy

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21.2 LTC Case Study Question & Answer

• This 81-year-old female is a resident of

the nursing facility due to CHF and
atrial fibrillation. She fell from the bed
at the nursing facility and was
transferred to the hospital. She was
readmitted to the nursing facility to
resume care and to add physical
therapy following open reduction and
pinning of left comminuted subcapital
femoral neck fracture.

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21.2 LTC Case Study Cont. Pathway Health, Inc.

• I50.9 Failure, heart, congestive

• I48.91 Fibrillation, atrial or auricular
(established) www.pathwayhealth.com
• S72.012D Fracture, traumatic, femoral
neck, see Fracture, femur, upper end,
subcapital (displaced)
• R29.6 Falls (repeated)

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