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.

3 + 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. 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.

4 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.

5 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.

6 + 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.+ Note: Assume a causal relationship between seropositive rheumatoid arthritis and one of the above inflammatory conditions unless the medical record states otherwise.

7 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.

8 (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.

9 ++ 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.+ Burn Face, Head, Neck T20.+ Trunk T21.+ Upper Limb T22.+ Wrist, Hand T23.+ Lower Limb (except ankle/foot) T24.

10 + 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.))