ICD-10 Coding Help Sheet - ehhi.com

1 ICD-10 Coding help Sheet 1 Abnormal Breathing Signs Acute Respiratory Distress Apnea Dyspnea Cheyne-Stoke (Periodic) Hyperventilation Orthopnea Shortness of Breath Stridor Tachypnea Wheezing Abnormality of Gait Ataxic (staggering) Gait Paralytic (spastic) Gait Difficulty Walking (chronic limp) Unsteadiness on feet Musculoskeletal/Other Unspecified Abnormal Weight Loss Abrasion See Superficial Skin Injury Absence of: Arm, Above Elbow + Arm, Below Elbow) + Breast + Foot Hand Joint Hip + Knee + Shoulder Leg, Above Knee + Leg, Below Knee + Toe, Great Toe(s), Other Abscess Abdominal Wall Buttocks Face Foot + Hand + Limb + Neck Peritoneal (Abdominal Cavity) Trunk + Note: Use additional code B95-B97 to identify infectious agent Aftercare: Amputation Note: Use additional code to identify limb amputated Z89.

2 +++ Note: If due to DM ulcer add code for the history of DM ulcer Breast Reconstruction, Post-Mastectomy Fracture Code the fracture Joint Explanation (staged procedure, including a subsequent joint replacement) - + Note: If removed and not replaced code the acquired absence of a joint Hip + Knee + Shoulder + Joint Replacement - Note: Use additional code to identify the joint ++ Neoplasm Removal Note: Use additional code to identify the neoplasm (continued treatment) or history of neoplasm (eradicated/no further treatment) Ortho NEC Note: Used for other orthopedic surgeries, spinal surgery Ostomies Z43.+ Post-procedural Wound Closure Specified Body System Sensory Neurological - Circulatory - Respiratory - Digestive - Genitourinary - Integumentary - Transplant + Note: Aftercare is not coded if due to trauma, injury or if a complication is present.

3 Note: Use other aftercare codes if applicable, surgical dressing change AIDS B20 Note: It may not be coded as primary in some states per State Law ICD-10 Coding help Sheet 2 Allergies, Seasonal ALS Alteration of Cognitive Functions Signs Age-Related Cognitive Decline Altered Mental Status Confusion/Delirium/Disoriented Memory Loss/Amnesia Alteration of Consciousness Signs Altered Awareness, Transient Coma, Unspecified Somnolence Stupor (Semi-coma) Vegetative State, Persistent Alzheimer s Disease Early onset (before age 65) Late onset (age 65 or >) Unspecified Note: Use additional Dementia manifestation code and identify the presence or absence of behavioral disturbance(s) + Note: Use additional code for delirium (includes Sun-downing) F05 Note: Use additional code for wandering Amputation (due to surgery) See Absence of Anemia (due to): B12 Deficiency NOS Blood Loss D62 (acute) (chronic) Chemotherapy Note: Use additional code, + Chronic Kidney Disease Note: Code first the CKD code Iron Deficiency NOS Macrocytic NOS Microcytic NOS Normocytic Neoplastic Disease Note.

4 Code first the neoplasm Pernicious Unspecified Aneurysm (no rupture) Abdominal aortic Thoracic Thoraco-abdominal Angina (Not for Coronary Artery Disease) Unstable Anxiety Disorder Generalized Disorder Panic Disorder Unspecified Anxiety/Depression (Combined) Anorexia (loss of appetite) Anoxic Brain Injury Aphasia (non CVA) Arrhythmia, Unspecified (Cardiac) Atrial Fibrillation NOS Bradycardia Tachycardia Arthritis (Non-Rheumatoid) Crystal M11.+++ Gouty See Gout M10.+ Juvenile M08. ++ Kaschin-Beck M12.+++ Monoarthritis ++ Palindromic Rheumatism ++ Polyarthritis Pyogenic M00.++ Unspecified Note: Degenerative joint disease is coded under Osteoarthritis (Osteoarthrosis) Arthritis, Rheumatoid Seronegative (Default) ++ Seropositive No Organ Involvement + With Organ Involvement Carditis + Lung + Myopathy + Other + Polyneuropathy + Vasculitis + spinal (Ankylosing Spondylitis) M45.

5 + Note: Assume a causal relationship between seropositive rheumatoid arthritis and one of the above inflammatory conditions unless the medical record states otherwise. Arteriosclerosis, (CAD) Coronary Artery CAD, Native Artery (Default) no Angina CAD, Native Artery (Default) with Angina + Note: Use additional Tobacco code ICD-10 Coding help Sheet 3 Arteriosclerosis, (PAD) Lower Extremity Native Artery ++ Ascites Malignant Note: Code first the malignancy NOS Asthma Mild, Intermittent + Mild, Persistent + Moderate, Persistent + Severe, Persistent + Unspecified Note: Use additional Tobacco code Ataxia NOS (non CVA) Cerebellar (Hereditary) - G11.+ Atrial Fibrillation Paroxysmal - Persistent Chronic NOS Atrial Flutter NOS Attention to: ( nursing action) Foley (includes straight cath) Vascular (IV) Non-vascular catheter (SQ infusions, intrathecal infusions, epidural infusions) Dressings: (not coded with complications) Non-surgical Surgical Suture/Staple Removal Drain Removal Nasogastric Tube Ostomy.

6 (also used for care to ostomy that is reversed/closed, not coded when ostomy complication is present) Colostomy Cystostomy Gastrostomy (PEG) Ileostomy Nephrostomy/Ureterostomy Pleurx Catheter Tracheostomy Bacteremia (Positive Blood Culture) Barrett s Esophagus NOS Bell s Palsy Bipolar, Unspecified (Type I) In Remission NOS Type II Note: Excludes a Diagnosis of Clinical Depression, Single or Recurrent Episode Bleed, GI Unspecified Blindness, Legal Note: Code first any underlying condition Blood Pressure, Elevated (no dx of HTN) BMI Z68.++ Boil, Infected Furuncle (one) or Carbuncle (group) L02.+ Note: Use additional code to identify organism B95-B96 BPH (Hypertrophy and Hyperplasia) Without LUTS With LUTS Note: Use additional code for symptoms Bradycardia, Unspecified Breathing Abnormality See Abnormal Breathing Signs Bronchitis Acute Chronic NOS J42 NOS J40 Note: Excludes patients with chronic obstructive bronchitis (COPD) - J44.

7 + Burn Face, Head, Neck T20.+ Trunk T21.+ Upper Limb T22.+ Wrist, Hand T23.+ Lower Limb (except ankle/foot) T24.+ Ankle/Foot T25.+ Eye/Adnexa T26.+ Note: Use additional code to code the external cause of the burn, review sequencing and classifying guidelines under T20-T32 header in the book Note: A non-healing or necrosis burn is coded as an acute burn Note: Use additional code to identify infection if present Cachexia (Inanition) R64 ICD-10 Coding help Sheet 4 CAD (includes with or without CABG unless CAD is in the graft vessel) NOS/No Angina (Native Artery, Default With Angina (Native Artery, Default + Note: Use additional Tobacco code Cardiomegaly Note: Do not code with I11.+ or I13.+ Cancer See Neoplasm Cardiomyopathy Ischemic Note: Use additional Tobacco code Non-ischemic I42.))

8 + Carrier (or colonization) MRSA MSSA Cataract Senile Unspecified Catheter Management See Attention To Cauda Equina Syndrome C-Diff (Colitis) Recurrent Cellulitis Face Finger + Limb + Toe + Trunk + Note: If the cellulitis is associated with a wound or ostomy, code the wound or ostomy complication first Cerebral Palsy G80.+ Cervicalgia (neck pain) (not coded if due to disc disorder) Charcot s Joint Note: If diabetic, defer to diabetes with neuropathic arthropathy Cholecystitis K81.+ Chronic Ischemic Heart Disease NOS With Angina Stable Unstable Note: Use additional Tobacco code Chronic Kidney Disease Stage I/GFR: 90+ Stage II/GFR: 60-89 (mild) Stage III/GFR: 30-59 (moderate) Stage IV/GFR: 15-29 (severe) Stage V/GFR:<15 Stage VI (end-stage) Note: Use additional code for dialysis status Unspecified Note: Code first associated Diabetic CKD and/or Hypertensive CKD Note: Use additional code for kidney transplant status if applicable Note: GFR = glomerular filtration rate (ml/min) Cirrhosis, Liver NOS Note: Code also Hepatitis if applicable Alcoholic + Note.

9 Use additional code for alcohol abuse and dependence Cognitive Issues See Alterations of Cognitive Function Signs Colitis, Ulcerative Unspecified No complications With complications + Complications: Amputation Site Infection + Dehiscence Note: if dehiscence and infection are both present sequence dehiscence, followed by infection Necrosis + Neuroma + Non-healing Bariatric Gastric Band Procedure Infection Other Complications Other Bariatric Procedures Infection Other Complications ICD-10 Coding help Sheet 5 Complications, Continued: Cesarean Wound Disruption - Infection Dialysis AV Fistula/Shunt Mechanical ++D Infection + Catheter: Peritoneal Dialysis Mechanical ++D Infection + Catheter.

10 Vascular Dialysis Mechanical ++D Infection + Electronic stimulator Device Implanted Bone Mechanical ++D Infection +++ Cardiac Mechanical ++D Infection Nervous System (Brain, Peripheral Nerve or spinal cord ) Mechanical ++D Infection + Genitourinary Infection due to Indwelling Urethral Catheter + Infection due to Cystostomy Catheter + Pessary Infection Infusion Catheter ( spinal Canal) Epidural/Subdural Mechanical ++D Infection + Insulin Pump Mechanical ++D Infection + Internal Fixation Device Mechanical Arm/Leg ++D Mechanical Other Bones ++D Infection +++ Internal Joint Prosthesis Mechanical ++D Infection +X+ Intravenous Catheter Mechanical ++D Peripheral IV Infection +++ Central Venous Cath Infection (Hickman, PICC, Port-a-Cath, Triple Lumen) Bloodstream + Local + Unspecified + Extravasation of vesicant ++ Mesh Complication ++D Infection ++ Muscle Flap Over Pressure Ulcer Mechanical Postprocedural Hematoma, Hemorrhage or Seroma Note: Search under Complication , then one of the above terms, then search by body system involved.