Scottish Clinical Coding Standards ICD-10

1 NationalServicesScotlandConsolidationSco ttish Clinical Coding Standards ICD-10 June 2017 ICD-10 Consolidation, June 2017 page 2 ICD-10 ConsolidationHow to use this documentThis document has been compiled to enable coders to quickly identify Coding Standards for ICD-10 . All discharges from 1st April 2017 should adhere to the guidance given in this document and subsequent publications of the Scottish Clinical Coding Standards . Standards are indexed in order of the ICD-10 chapter to which they mostly apply. Some may be repeated in more than one chapter. They appear alphabetically within the chapters. General Standards those which are not chapter specific are at the start of the document. This document is not intended to be printed out, but to be easily accessed by pinning to a PC menu or Coding staff should ensure that their ICD-10 Fifth Edition 2016 books are updated to reflect ALL valid Standards .

2 If you require this document in an accessible format, please contact the Terminology Services Helpdesk on 0131- 275 -7283 or can navigate using the following keyboard shortcuts:This will allow you to jump back to the exact page you came will allow you to move between the next page and the previous will allow you to zoom out of the will allow you to zoom into the Consolidation, June 2017 page 3 ICD-10 ConsolidationConsolidationGeneral StandardsAccidental cuts/perforations during proceduresSCCS5 Mar 14 Acute on Chronic Conditions CG2 Jan 99 AllergiesCG13 Jan 03 Cause of deathSCCS2 July 13 Comorbidities Coding ( Other conditions Coding on SMR01)CG21 Nov 07 Dagger and asterisk codingSCCS2 July 13 Diseases/diagnoses with other conditionsSCCS2 July 13 Errata ICD10 Version 5 SCCS11 Sep 16 SCCS13 Sep 16 Last Coding position ICD-10 SCCS14 Apr 17 Past history in a recurrence of the same conditionCG13 Jan 03 Presumptive DiagnosesCG25 Apr 10 Sequelae codesSCCS2 July 13 Test Results and their use in SMR01 codingCG20 June 07 CHI Certain infectious and parasitic diseasesCarrier of viral hepatitis SCCS13 Sep 16 Conditions caused by an infectious agentSCCS14 Apr 17E Coli 0157CQ2 Feb 97 Helicobacter infectionSCCS2 July 13 Helicobacter positiveCQ3 May 97 HIV disease, Coding in ICD10CQ1 Nov 96CQ2 Feb 97 Human Papillomavirus (HPV)

3 SCCS2 July 13 Infections (or carrier status)SCCS13 Sep 16 Measles with febrile convulsionCG17 Jan 06 MRSA (Methicillin resistant staphylococcus aureus)SCCS14 Apr 17 Neutropenic sepsisCG31 Sep 12 Viral associated wheezeCG25 Apr 10 Zika Virus Infection Coding on SMR01 and SMR02 SCCS12 May 16 ICD-10 Consolidation, June 2017 page 4 ICD-10 ConsolidationCHII NeoplasmsAnal Intraepithelial Neoplasia (AINIII)CG20 June 07 History of TCC bladderSCCS2 July 13 Intramucosal carcinoma (of the gastrointestinal tract)CG07 Nov 00 Malignant pleural effusionCG20 June 07 Multiple primary neoplasmsSCCS2 July 13 Paraneoplastic syndromeCG8 Feb 01 Pancreatic intraepithelial neoplasia (PanIN)CG26 Oct 10 Prostatic intraepithelial neoplasia, Grade III (PIN III)/High grade glandular intraepithelial neoplasia of the prostate (HGIN)SCCS2 July 13 Recurrent cancer breast, colorectal, melanoma of skin (5th digits)SCCS10 Sep 15 Secondary neoplasm or metastases from haematological malignanciesSCCS10 Sep 15 Transitional cell carcinoma (papillary)

4 Of urinary tractSCCS13 Sep 16 CHIII Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanismAnaemia due to neoplasm or lymphomasCG9 July 01 Factor V LeidenSCCS3 Sep 13 Raised INRCG16 Aug 05 CHIV Endocrine, nutritional and metabolic diseasesCystic fibrosis with manifestationsSCCS10 Sep 15 Hyperglycaemic hyperosmolar state (HHS)/Hyperosmolar nonketotic state (HONK) in diabetes mellitusSCCS14 Apr 17 MCAD deficiencyCG17 Jan 06 Patient with Type 2 diabetes treated with InsulinSCCS14 Apr 17 Uncontrolled diabetesCG2 Jan 99 CHV Mental and behavioural disordersAlcohol excessCG28 Mar 11 Alcohol-related conditionsCG1 May 96 Chronic schizophreniaCG12 Sep 02 Current smoker/current heavy smoker - advised to give upCG23 Sep 08E-CigarettesSCCS11 Mar 16Ex-smokerCG23 Sep Multiple identified psychoactive substancesCG16 Aug 05 Heavy drinkersCG6 June 00 Learning DisabilityCG6 Jun 00 Low MoodSCCS14 Apr 17 Methadone ProgrammeCG19 Sep 06 Mixed dementia or mixed vascular and Alzheimer dementiaSCCS14 Apr 17 Overdose.

5 Patient transferred to psychiatric hospitalCQ3 May 97 Seasonal Affective Disorder (SAD)CG6 June 00 Suicidal Ideation (SMR04)SCCS14 Apr 17 Toxic Confusional StateCG2 Jan 99 CHVI Diseases of the nervous systemPineal cystCG14 Jan 04 ICD-10 Consolidation, June 2017 page 5 ICD-10 ConsolidationCHVII Diseases of the eye and adnexaJuvenile/senile cataractsCG12 Sep 02 Posterior capsular opacification (after-cataract)CG31 Sep 12 CHIX Diseases of the circulatory systemAngina with ischaemic heart diseaseCG13 Jan 03 Arterial diseaseCQ2 Feb 97 Cardiac arrestCG12 Sep 02 Chronic ischaemic heart disease and triple vessel diseaseCG16 Aug 05 DVT ( Deep vein thrombosis) caused by travelCG9 July 01 Heart Failure Coding fifth digits and Clinical outcomesSCCS3 Sep 13 Lymphoedema following a lumpectomy or quadrantectomyCG11 Apr 02 Mixed Arterial and Venous Ulcer of Lower LegCG8 Feb 01 Myocardial Infarction and Unstable Angina STEMI & NSTEMI 5th DigitsSCCS14 Apr 17 Old myocardial infarctionSCCS2 July 13 Old StrokeCG17 Jan 06 Recording of NSTEMI do not use new v5 trailsSCCS11 Mar 16 Small vessel disease and lacunar infarctsCG19 Sep 06 Stroke with hemiplegia.

6 Dysphagia and dysplasiaSCCS10 Sep 15 Triple vessel diseaseCG13 Jan 03 Type 2 Myocardial InfarctionSCCS14 Apr 17 CHX Diseases of the respiratory systemAcute asthmaCG13 Jan 03 COAD/COPD + pneumoniaSCCS2 July 13 COAD/COPD and associated conditions, Coding ofSCCS2 July 13 Influenza A (H1N1) [Swine Flu]SCCS11 Mar 16 Recurrent tonsillitisCQ2 Feb 97 Respiratory failureSCCS11 Mar 16 CHXI Diseases of the digestive systemBarrett s oesophagus/ulcerSCCS2 July 13 Bile reflux into the Stomach and Biliary Gastritis SCCS14 Apr 17 Eosinophilic colitisSCCS2 July 13 Haemorrhoids and perianal venous thrombosis (K64)SCCS11 Mar 16 Haemorrhoids with bleedingSCCS11 Mar 16 Inflammatory bowel disease (IBD)SCCS2 July 13 Oesophageal webSCCS2 July 13 Rectal versus per rectal haemorrhageCG30 Mar 12 CHXII Diseases of the skin and subcutaneous tissueCellulitis following a wound injurySCCS2 July 13 Leg ulcer with infection SCCS14 Apr 17 ICD-10 Consolidation, June 2017 page 6 ICD-10 ConsolidationCHXIII Diseases of the musculoskeletal system and connective tissueArthrosisSCCS2 July 13 Juvenile ArthritisSCCS14 Apr 17 Mandatory 5th characters in Chapter XIIISCCS2 July 13 Musculoskeletal chest painCG13 Jan 03 Rectus Sheath Haematoma (RSH)

7 SCCS3 Sep 13 Repetitive Strain InjuryCG17 Jan 06 Site of musculoskeletal involvementSCCS2 July 13 CHXIV Diseases of the genitourinary systemAcute Kidney InjuryCG31 Sep 12 Cellulitis of breastSCCS11 Mar 16 CHXV Pregnancy, childbirth and the puerperiumAbortion codes on SMR02CQ2 Feb 97 AnaemiaSMR02 Review 00 Anaemia complicating pregnancy, childbirth & the puerperium Review 10 Ante-partum haemorrhageCQ5 Jan 98 Conditions in pregnancyCG1 May 96 Foetal/fetal distressSMR02 Review 10 Habitual abortion/Recurrent miscarriageReprinted SCCS4 Feb 14CG22 Mar 08 Haemorrhage and Stage of GestationSMR02 review 00 Haemorrhage, Intrapartum vs. PostpartumSMR02 Review 10 Hard Coded Diagnostic and Procedure Fields on SMR02 SMR02 Review 10 Hypertension and raised BP in pregnancy.

8 SMR02 Review 10 Hypertension in pregnancySMR02 Review 00 MeconiumSMR02 Review 00 Meconium stainingCQ4 Sep 97 Multiple gestation O30 SMR02 Review 10 OedemaSMR02 Review 00 Post-dates and post-termSMR02 Review 00 Precipitate labour Review 10 Pre-eclampsiaSMR02 Review 00 Premature Rupture of Membrane (PROM) Review 10 Reason for Operative Delivery Recording SMR02 SCCS9 Mar 15 Retained placentaSMR02 Review 10 Spontaneous Rupture of Membranes CQ1 Nov 96 Termination of pregnancy resulting in livebornSCCS4 Feb 14 Termination (abortion)/miscarriage Coding SCCS4 Feb 14 Vaginal thrush in pregnancyCG23 Sep 08CH XVI Certain conditions originating in the perinatal periodDisorders related to length of gestation and fetal growth (P05-P08)

9 SCCS11 Mar 16 Perinatal conditionsCG23 Sep 08CG26 Oct 10 Perinatal Period definition ofSCCS2 July 13 ICD-10 Consolidation, June 2017 page 7 ICD-10 ConsolidationCH XVII Congenital malformations, deformations and chromosomal abnormalitiesDevelopmental dysplasia of hipSCCS8 Sep 14 Pfeiffer s disease/ syndromeCG3 June 99CH XVIII Symptoms, signs and abnormal Clinical and laboratory findings not elsewhere classifiedBowel ScreeningSCCS2 July 13 Clicking hipCQ1 Nov 96 FrailtyCG14 Jan 04 Frailty, immobility and geriatric fallsSCCS2 July 13 GangreneCG14 Jan 04 High cholesterolCG19 Sep 06 Jittery babyCG17 Jan 06 Multi-organ failureSCCS2 July 13 Raised PSACG17 Jan 06 CHXIX Injury, poisoning and certain other consequences of external causesAlcohol involvement when noted with an overdose of drugsCG16 Aug 05 Bilateral InjuriesCG15 Nov 04 Burns classified according to percentage of body areaCG4 Sep 99 Compound drugs.

10 Multiple drug and alcohol involvement SCCS14 Apr 17 Drugs and alcohol poisoningSCCS2 Jul 13 Periprosthetic fracture and dislocated joint prosthesisCG28 Mar 11 External cause codesCQ3 May 97 External cause codes in poisoningsCG14 Jan 04 External Orthopaedic fixatorsCG6 June 00 Head InjuriesCG3 June 99 Impulsive overdoseCG11 Apr 02 Injury with tendon involvementCQ1 Nov 96 MephedroneCG28 Mar 11 Open wound to artery or veinCG10 Dec 01 Open wound with infectionSCCS2 July 13 Poisoning - intentional self-harm or accidental?CG1 May 96 Poisonings with the drug ecstasyCQ1 Nov 96 Postprocedural disordersCG1 May 96 Prosthetic device at the end of its natural lifeCQ3 May 97 RhabdomyolysisSCCS2 July 13 Soft Tissue InjuryCG9 July 01 Undetermined intent.