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ICD-10-CM General Guidelines
Locating a code in ICD-10-CM
◦ Locate the main term in the alphabetic index
◦ Verify the code in the tabular list
◦ Read and be guided by instructional notations
in the index AND tabular
◦ Selection of a full code including laterality and
7th digits can only be done in the tabular list
◦ A dash “-” at the end of an index entry means
additional digits are required
ICD-10-CM General Guidelines
Placeholder
◦ X is used as a placeholder when required,
without it, code is considered invalid
7th Characters
◦ When instructed to use a 7th character it is
required for all codes in that category or as
notes instruct
◦ If the code is not 6 characters use the
placeholder X to “fill-in” the empty spaces
ICD-10-CM General Guidelines
Excludes Notes
◦ Excludes1
“Not coded here”
Indicates code excluded should never be used at the same time as the code above
The two conditions cannot occur together
◦ Excludes2
“Not included here”
Indicates condition excluded is not part of the condition above HOWEVER the patient may have both conditions and therefore both can be coded
ICD-10-CM General Guidelines
“Code also note”
◦ This instruction means that two codes may be required to fully describe a condition but this note DOES NOT provide sequencing direction
Default Codes
◦ The alphabetic index has a code listed next to the main term considered a default code
This represents a condition that is most associated with the main term or is the unspecified code for the condition
ICD-10-CM General Guidelines
Sequela (Late Effects)
◦ The residual effect after the acute phase of an illness or injury has terminated
◦ There is no time limit on when a sequela code can be used
◦ Sequence first the condition or nature of the sequela followed by the sequela code second
◦ Exceptions:
Sequela is followed by a manifestation code
Sequela code has been expanded to include the manifestation
ICD-10-CM General Guidelines
Laterality ◦ If no bilateral code is provided and the condition
is bilateral assign separate codes for both the left and right sides
Documentation of BMI and Ulcer Stage ◦ BMI, non-pressure ulcers and pressure ulcers may
be coded from clinician documentation
◦ The associated diagnosis must come from the physician
◦ If the documentation is conflicting between clinicians the physician should be queried
◦ BMI is only acceptable as a secondary diagnosis
ICD-10-CM General Guidelines
Documentation of Complications of Care
◦ This guideline extends to any complications of
care, regardless of the chapter the code is
located in.
◦ Must be a cause-and-effect relationship
between the care provided and the condition
Borderline Diagnosis
◦ A “borderline” diagnosis listed at the time of
discharge is coded as confirmed unless there
is a specific index entry for “borderline”
ICD-10-CM Cardiovascular
Guidelines Hypertension
◦ Hypertension with Heart Disease
Heart conditions (I50, I51.4-I51.9) are assigned a
code from I11 hypertensive heart disease when a
causal relationship is stated if not they are coded
separately
◦ Hypertension with Chronic Kidney Disease
Assign codes from I12 hypertensive chronic kidney
disease when both hypertension and a condition in
category N18 are present. N18 category is
sequenced second
ICD-10-CM Cardiovascular
Guidelines ◦ Hypertension with Heart and Chronic Kidney
Disease
Assign combination code from I13 if both heart and
kidney are stated as hypertensive if they are not
code kidney disease and hypertension together
with a code from N18 as secondary
If heart failure is present use an additional code
from I50
If a patient has acute renal failure and chronic
kidney disease both conditions are coded
ICD-10-CM Cardiovascular
Guidelines ◦ Hypertensive Cerebrovascular Disease
First assign code from I60-I69(cerebrovascular
diseases) followed by hypertension code
◦ Hypertensive Retinopathy
H35.0 retinopathy should be used with I10-I15
hypertension code. Sequencing depends on reason
for encounter
◦ Hypertension, Secondary
Secondary hypertension is due to an underlying
condition therefore two codes are required
ICD-10-CM Cardiovascular
Guidelines ◦ Hypertension, Transient
Assign code R03.0 elevated blood pressure
For OB code O13.-gestational [pregnancy induced] hypertension without significant proteinuria or O14 pre-eclampsia for transient hypertension of pregnancy
◦ Hypertension, Controlled
Refers to hypertension under control by therapy assign code from I10-I15 hypertension category
◦ Hypertension, Uncontrolled
Refers to untreated or hypertension not responding to therapy assign code from I10-I15
ICD-10-CM Cardiovascular
Guidelines Atherosclerotic Coronary Artery Disease
and Angina
◦ Category I25.11 atherosclerotic heart disease
of native coronary artery with angina pectoris
◦ Category I25.7 atherosclerosis of coronary
artery bypass graft(s) and coronary artery of
transplanted heart with angina pectoris
◦ Assume causal relationship between
atherosclerosis and angina pectoris unless
stated otherwise
ICD-10-CM Cardiovascular
Guidelines Acute Myocardial Infarction
◦ ST elevation MI (STEMI) and non ST elevation
MI (NSTEMI)
STEMI I21.0-I21.2, I21.3 ; NSTEMI I21.4
Code by site identified
If NSTEMI evolves to STEMI code to STEMI code
If STEMI converts to NSTEMI due to thrombolytic
therapy code to STEMI
◦ Acute MI, Unspecified
Assign code I21.3
ICD-10-CM Cardiovascular
Guidelines ◦ AMI documented as nontransmural or
subendocardial but site provided
Nontransmural and subendocardial AMI’s are coded
to subendocardial even if site is provided
◦ Subsequent acute MI
Assign a code from category I22 when a patient
who has suffered an AMI has a new AMI within the
4 week time frame of the initial AMI
Sequencing depends on circumstances of encounter
ICD-10-PCS General Guidelines
Valid Code is 7 Digits
Valid Code includes all combinations
within the row of the table
“And” means and/or
Coder’s responsibility to determine what
the documentation equates to in PCS
Definitions
ICD-10-PCS General Guidelines
Body System
◦ Anatomical region system
Use when procedure is performed on region rather
than a specific body part
Use when no information available to support a
specific body part
Upper and Lower specifies body parts located
above or below the diaphragm
ICD-10-PCS General Guidelines
Root Operation
◦ Procedural steps necessary to reach the
operative site and close the operative site
including anastomosis of a tubular body part
are not code separately
◦ Multiple Procedures
Same root operation is performed on different
body parts with distinct values
Same root operation is repeated at different body
sites within the same body part
ICD-10-PCS General Guidelines
◦ Multiple Procedures continued…
Multiple root operations with distinct objectives
done on same body part
Intended root operation is attempted using one
approach but then converted to another approach
◦ Discontinued Procedures
Code to the root operation performed if
procedure is discontinued before any root
operation is performed code to inspection of body
part or anatomical region
ICD-10-PCS General Guidelines
◦ Biopsy followed by more definitive treatment
If a diagnostic excision, extraction, or drainage is followed by a more definitive procedure both procedures are coded
◦ Overlapping body layers
Roots – Excision, Repair or Inspection of Musculoskeletal system is code to deepest layer
◦ Bypass Procedures
Coded by body part bypassed “from” and then the body part bypassed “to” 4th character is “from”
7th character is “to”
ICD-10-PCS General Guidelines
◦ Bypass Procedures Continued…. Coronary Arteries
Classified by number of distinct artery
Body part character identifies number of coronary arteries bypassed to
Qualifier identifies the vessel bypassed from
Multiple coronary artery sites are coded separately for each site that uses a different device and/or qualifier
◦ Control vs. more definitive root operations If control of postprocedural bleeding is unsuccessful and a
definitive root operation is done to control the bleeding then the definitive root operation is used rather than “control”
◦ Excision vs. Resection PCS subdivides some body parts such as lobes of lung and
liver and regions of the intestine – code resection of the subdivsion
ICD-10-PCS General Guidelines
◦ Excision for Graft
Code separately the autograft taken from a different body part in order to complete the objective of a procedure
◦ Fusion procedures of the spine
There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level
For each vertebral joint that uses a different device and/or qualifier is coded separately
Combinations of devices – 1st interbody fusion device, 2nd autologous, 3rd nonautologous bone graft
ICD-10-PCS General Guidelines
◦ Inspection procedures Not coded when inspection is done in order to achieve
the objective of a procedure
Multiple tubular parts code to most distal
Multiple non-tubular parts code to entire area
When an inspection procedure is done with another procedure on the same body part code separately ONLY if different approaches
◦ Occlusion vs. Restriction for vessel embolization procedures Embolization done to completely close a vessel use root
“occlusion”
Embolization done to narrow a vessel use root “restriction”
ICD-10-PCS General Guidelines
◦ Release Procedures The body part value is assigned to the body part being freed
not the part being cut
◦ Release vs. Division Objective is to free a body part without cutting use root
“release”
Objective is separating or transecting use root “division”
◦ Reposition for fracture treatment Reduction of displaced fx use root “reposition”
Cast is not coded separately
Non-displaced fx code to procedure performed
◦ Transplantation vs. Administration Putting in autologous or nonautologous cells go to
administrative section
Putting in living body part use root “transplantation”
ICD-10-PCS General Guidelines
Body Part
◦ General Procedures performed on a portion of a body part that
does not have a specific value code to the whole body part
When “peri” is combined with a body part code to the whole body part
◦ Branches of body parts
If a specific branch of a body part does not a specific value code to closest proximal branch with a value
◦ Bilateral body parts values
If no bilateral body part value exists, each procedure is coded separately
Lateral plantar artery Use: Foot Artery, Right Foot
Artery, Left
Lateral plantar nerve Use: Tibial Nerve
Lateral rectus muscle Use: Extraocular Muscle, Right
Extraocular Muscle, Left
Lateral sacral artery Use: Internal Iliac Artery, Right
Internal Iliac Artery, Left
Lateral sacral vein Use: Hypogastric Vein, Right
Hypogastric Vein, Left
Lateral sural cutaneous nerve Use: Peroneal Nerve
Lateral tarsal artery Use: Foot Artery, Right Foot
Artery, Left
ICD-10-PCS General Guidelines
◦ Coronary Arteries
Classified as single body part then number of sites
treated NOT by name or number of arteries
◦ Tendons, Ligaments, Bursae and Fascia near a
joint
Procedures done on supporting joint structures are
coded to the respective body system that is the
focus of the procedure
Procedures done on the joint itself are coded to
the joint body system
ICD-10-PCS General Guidelines
◦ Skin, subcutaneous tissue and fascia overlying
a joint
Procedure done on skin, subcutaneous tissue or
fascia overlying a joint code to the following body
part:
Shoulder > upper arm
Elbow > lower arm
Wrist > lower arm
Hip > upper leg
Knee > lower leg
Ankle > lower leg
ICD-10-PCS General Guidelines
◦ Fingers and toes
Procedures without fingers listed as a body part
value code to hand
Procedure without toes listed as a body part value
code to foot
◦ Upper and Lower Intestinal Tract
Roots – Change, Inspection, Removal and Revision
Upper intestinal tract is from esophagus down to and
including the duodenum
Lower intestinal tract is from the jejunum down to and
including the rectum and anus
ICD-10-PCS General Guidelines
Approach ◦ Open approach with percutaneous endoscopic
assistance Open procedures done with the assistance of
percutaneous endoscopy are coded to “open”
◦ External approach Procedures done on structures that are visible without
the aid of instrumentation are coded to “external”
Application of external force through the intervening body layers are coded to “external”
◦ Percutaneous procedure via device Procedures performed percutaneously through a device
placed for the procedure are coded to “percutaneous”
ICD-10-PCS General Guidelines
Device
◦ General Code device only when device is left in after the
procedure
Sutures, ligatures, radiological markers, and temporary postoperative wound drains are not considered devices
Use Root Operations change, irrigation, removal, and revision for procedures done on devices and not a body part
◦ Drainage Device When a separate procedure is done to place a drainage
device code to root “drainage” with device value drainage device
References
www.cms.gov
www.nchs.gov
www.ahima.org
www.ohima.org
Dee Mandley, RHIT, CCS, CCS-P
◦ 330-677-5630