FY 2017
(October 1, 2016 - September 30, 2017)
Narrative changes appear in bold text
Items underlined have been moved within the guidelines since the FY 2016 version
Italics are used to indicate revisions to heading changes
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government's Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the
These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the
The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and
outpatient coding and reporting. It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.
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13.Etiology/manifestation convention ("code first", "use additional code" and "in diseases
14.Documentation for BMI, Depth of
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g.Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms . 30
n.Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus
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3.Chapter 3: Disease of the blood and
j.Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium 59
17.Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-
18.Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere
19.Chapter 19: Injury, poisoning, and certain other consequences of external causes
B.Two or more interrelated conditions, each potentially meeting the definition for principal
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Section I. Conventions, general coding guidelines and chapter specific guidelines
The conventions, general guidelines and
A. Conventions for the
The conventions for the
1.The Alphabetic Index and Tabular List
The
See Section I.C2. General guidelines
See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects
2.Format and Structure:
The
The
3.Use of codes for reporting purposes
For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.
4.Placeholder character
The
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Where a placeholder exists, the X must be used in order for the code to be considered a valid code.
5.7th Characters
Certain
6.Abbreviations
a. Alphabetic Index abbreviations
NEC |
"Not elsewhere classifiable" |
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This abbreviation in the Alphabetic Index represents "other |
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specified." When a specific code is not available for a |
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condition, the Alphabetic Index directs the coder to the "other |
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specified" code in the Tabular List. |
NOS |
"Not otherwise specified" |
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This abbreviation is the equivalent of unspecified. |
b. Tabular List abbreviations |
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NEC |
"Not elsewhere classifiable" |
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This abbreviation in the Tabular List represents "other |
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specified". When a specific code is not available for a condition, |
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the Tabular List includes an NEC entry under a code to identify |
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the code as the "other specified" code. |
NOS |
"Not otherwise specified" |
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This abbreviation is the equivalent of unspecified. |
7.Punctuation
[ ] Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic Index to identify manifestation codes.
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. The nonessential modifiers in the Alphabetic Index to Diseases apply to subterms following a main term except when a nonessential modifier and a subentry are mutually exclusive, the subentry takes precedence. For example, in the
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"chronic" is a subentry. In this case, the nonessential modifier "acute" does not apply to the subentry "chronic".
:Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.
8.Use of "and".
See Section I.A.14. Use of the term "And"
9.Other and Unspecified codes
a. "Other" codes
Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. Alphabetic Index entries with NEC in the line designate "other" codes in the Tabular List. These Alphabetic Index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code.
b. "Unspecified" codes
Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the "other specified" code may represent both other and unspecified.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
10.Includes Notes
This note appears immediately under a three character code title to further define, or give examples of, the content of the category.
11.Inclusion terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
12.Excludes Notes
The
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a. Excludes1
A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes1 note for "sleep related teeth grinding (G47.63)," because "teeth grinding" is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.
b. Excludes2
A type 2 Excludes note represents "Not included here." An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
13.Etiology/manifestation convention ("code first", "use additional code" and "in diseases classified elsewhere" notes)
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-
In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/ manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as
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underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention.
There are manifestation codes that do not have "in diseases classified elsewhere" in the title. For such codes, there is a "use additional code" note at the etiology code and a "code first" note at the manifestation code, and the rules for sequencing apply.
In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.
An example of the etiology/manifestation convention is dementia in Parkinson's disease. In the Alphabetic Index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiology, Parkinson's disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance.
"Code first" and "Use additional code" notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination.
See Section I.B.7. Multiple coding for a single condition.
14."And"
The word "and" should be interpreted to mean either "and" or "or" when it appears in a title.
For example, cases of "tuberculosis of bones", "tuberculosis of joints" and "tuberculosis of bones and joints" are classified to subcategory A18.0, Tuberculosis of bones and joints.
15."With"
The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.
These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related.
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The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.
16."See" and "See Also"
The "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the "see" note to locate the correct code.
A "see also" instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the "see also" note when the original main term provides the necessary code.
17."Code also" note
A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.
18.Default codes
A code listed next to a main term in the
19.Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
B. General Coding Guidelines
1.Locating a code in the
To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List.
It is essential to use both the Alphabetic Index and Tabular List when locating and assigning a code. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. A dash
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if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.
2.Level of Detail in Coding
Diagnosis codes are to be used and reported at their highest number of characters available.
A
3.Code or codes from A00.0 through T88.9,
The appropriate code or codes from A00.0 through T88.9,
4.Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5.Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
6.Conditions that are not an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
7.Multiple coding for a single condition
In addition to the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. "Use additional code" notes are found in the Tabular List at codes that are not part of an
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etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair, "use additional code" indicates that a secondary code should be added.
For example, for bacterial infections that are not included in chapter 1, a secondary code from category B95, Streptococcus, Staphylococcus, and Enterococcus, as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, may be required to identify the bacterial organism causing the infection. A "use additional code" note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code.
"Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first.
"Code, if applicable, any causal condition first" notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or
Multiple codes may be needed for sequela, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction.
8.Acute and Chronic Conditions
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.
9.Combination Code
A combination code is a single code used to classify: Two diagnoses, or
A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List.
Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements documented in the diagnosis. When the combination code lacks necessary specificity in
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describing the manifestation or complication, an additional code should be used as a secondary code.
10.Sequela (Late Effects)
A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury.
Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.
See Section I.C.9. Sequelae of cerebrovascular disease
See Section I.C.15. Sequelae of complication of pregnancy, childbirth and the puerperium
See Section I.C.19. Application of 7th characters for Chapter 19
11.Impending or Threatened Condition
Code any condition described at the time of discharge as "impending" or "threatened" as follows:
If it did occur, code as confirmed diagnosis.
If it did not occur, reference the Alphabetic Index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for "Threatened."
If the subterms are listed, assign the given code.
If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.
12.Reporting Same Diagnosis Code More than Once
Each unique
13.Laterality
Some
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condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.
When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the
14.Documentation for BMI, Depth of
For the Body Mass Index (BMI), depth of
The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.
15.Syndromes
Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations that are not an integral part of the disease process may also be assigned when the condition does not have a unique code.
16.Documentation of Complications of Care
Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care,
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regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a
17.Borderline Diagnosis
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in
18.Use of Sign/Symptom/Unspecified Codes
Sign/symptom and "unspecified" codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.
If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate "unspecified" code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.
C.
In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Please refer to Section II for guidelines on the selection of principal diagnosis.
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1.Chapter 1: Certain Infectious and Parasitic Diseases
1)Code only confirmed cases
Code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H.
In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the provider's diagnostic statement that the patient is HIV positive, or has an
2)Selection and sequencing of HIV codes
(a)Patient admitted for
If a patient is admitted for an
(b)Patient with HIV disease admitted for unrelated condition
If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be B20 followed by additional diagnosis codes for all reported
(c)Whether the patient is newly diagnosed
Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision.
(d)Asymptomatic human immunodeficiency virus
Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology. Do not use this code if the term "AIDS" is used or if the patient is treated for any
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(e)Patients with inconclusive HIV serology
Patients with inconclusive HIV serology, but no definitive diagnosis or manifestations of the illness, may be assigned code R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV].
(f)Previously diagnosed
Patients with any known prior diagnosis of an
(g)HIV Infection in Pregnancy, Childbirth and the Puerperium
During pregnancy, childbirth or the puerperium, a patient admitted (or presenting for a health care encounter) because of an
Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth, or the puerperium should receive codes of O98.7- and Z21.
(h)Encounters for testing for HIV
If a patient is being seen to determine his/her HIV status, use code Z11.4, Encounter for screening for human immunodeficiency virus [HIV]. Use additional codes for any associated high risk behavior.
If a patient with signs or symptoms is being seen for HIV testing, code the signs and symptoms. An additional counseling code Z71.7, Human immunodeficiency virus [HIV] counseling, may be used if counseling is provided during the encounter for the test.
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When a patient returns to be informed of his/her HIV test results and the test result is negative, use code Z71.7, Human immunodeficiency virus [HIV] counseling.
If the results are positive, see previous guidelines and assign codes as appropriate.
b.Infectious agents as the cause of diseases classified to other chapters
Certain infections are classified in chapters other than Chapter 1 and no organism is identified as part of the infection code. In these instances, it is necessary to use an additional code from Chapter 1 to identify the organism. A code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified to other chapters, B96, Other bacterial agents as the cause of diseases classified to other chapters, or B97, Viral agents as the cause of diseases classified to other chapters, is to be used as an additional code to identify the organism. An instructional note will be found at the infection code advising that an additional organism code is required.
c. Infections resistant to antibiotics
Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.
d.Sepsis, Severe Sepsis, and Septic Shock
1)Coding of Sepsis and Severe Sepsis
(a)Sepsis
For a diagnosis of sepsis, assign the appropriate code for the underlying systemic infection. If the type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified organism.
A code from subcategory R65.2, Severe sepsis, should not be assigned unless severe sepsis or an associated acute organ dysfunction is documented.
(i)Negative or inconclusive blood cultures and sepsis
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Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition; however, the provider should be queried.
(ii)Urosepsis
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.
(iii)Sepsis with organ dysfunction
If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis.
(iv)Acute organ dysfunction that is not clearly associated with the sepsis
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign a code from subcategory R65.2, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.
(b)Severe sepsis
The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required.
Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes.
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2)Septic shock
(a)Septic shock generally refers to circulatory failure associated with severe sepsis, and therefore, it represents a type of acute organ dysfunction.
For cases of septic shock, the code for the systemic infection should be sequenced first, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Postprocedural septic shock. Any additional codes for the other acute organ dysfunctions should also be assigned. As noted in the sequencing instructions in the Tabular List, the code for septic shock cannot be assigned as a principal diagnosis.
3)Sequencing of severe sepsis
If severe sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2 as required by the sequencing rules in the Tabular List. A code from subcategory R65.2 can never be assigned as a principal diagnosis.
When severe sepsis develops during an encounter (it was not present on admission), the underlying systemic infection and the appropriate code from subcategory R65.2 should be assigned as secondary diagnoses.
Severe sepsis may be present on admission, but the diagnosis may not be confirmed until sometime after admission. If the documentation is not clear whether severe sepsis was present on admission, the provider should be queried.
4)Sepsis and severe sepsis with a localized infection
If the reason for admission is both sepsis or severe sepsis and a localized infection, such as pneumonia or cellulitis, a code(s) for the underlying systemic infection should be assigned first and the code for the localized infection should be assigned as a secondary diagnosis. If the patient has severe sepsis, a code from subcategory R65.2 should also be assigned as a secondary diagnosis. If the patient is admitted with a localized infection, such as pneumonia, and sepsis/severe sepsis doesn't develop until after admission, the localized infection should be assigned first, followed by the appropriate sepsis/severe sepsis codes.
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5)Sepsis due to a postprocedural infection
(a)Documentation of causal relationship
As with all postprocedural complications, code assignment is based on the provider's documentation of the relationship between the infection and the procedure.
(b)Sepsis due to a postprocedural infection
For such cases, the postprocedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. If the patient has severe sepsis, the appropriate code from subcategory R65.2 should also be assigned with the additional code(s) for any acute organ dysfunction.
(c)Postprocedural infection and postprocedural septic shock
In cases where a postprocedural infection has occurred and has resulted in severe sepsis the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded first followed by code R65.20, Severe sepsis without septic shock. A code for the systemic infection should also be assigned.
If a postprocedural infection has resulted in postprocedural septic shock, the code for the precipitating complication such as code T81.4, Infection following a procedure, or O86.0, Infection of obstetrical surgical wound should be coded first followed by code
6)Sepsis and severe sepsis associated with a noninfectious process (condition)
In some cases a noninfectious process (condition), such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection. If severe sepsis is present, a code from subcategory
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R65.2 should also be assigned with any associated organ dysfunction(s) codes. It is not necessary to assign a code from subcategory R65.1, Systemic inflammatory response syndrome (SIRS) of
If the infection meets the definition of principal diagnosis, it should be sequenced before the
Only one code from category R65, Symptoms and signs specifically associated with systemic inflammation and infection, should be assigned. Therefore, when a
See Section I.C.18. SIRS due to
7)Sepsis and septic shock complicating abortion, pregnancy, childbirth, and the puerperium
See Section I.C.15. Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium
8)Newborn sepsis
See Section I.C.16. f. Bacterial sepsis of Newborn
e.Methicillin Resistant Staphylococcus aureus (MRSA) Conditions
1)Selection and sequencing of MRSA codes
(a)Combination codes for MRSA infection
When a patient is diagnosed with an infection that is due to methicillin resistant Staphylococcus aureus (MRSA), and that infection has a combination code that includes the causal organism (e.g., sepsis, pneumonia) assign the appropriate combination code for the condition (e.g., code A41.02, Sepsis due to Methicillin resistant Staphylococcus aureus or code J15.212, Pneumonia due to Methicillin resistant Staphylococcus aureus). Do not assign code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere, as an additional code, because the combination code includes the type of infection
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and the MRSA organism. Do not assign a code from subcategory Z16.11, Resistance to penicillins, as an additional diagnosis.
See Section C.1. for instructions on coding and sequencing of sepsis and severe sepsis.
(b)Other codes for MRSA infection
When there is documentation of a current infection (e.g., wound infection, stitch abscess, urinary tract infection) due to MRSA, and that infection does not have a combination code that includes the causal organism, assign the appropriate code to identify the condition along with code B95.62, Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere for the MRSA infection. Do not assign a code from subcategory Z16.11, Resistance to penicillins.
(c)Methicillin susceptible Staphylococcus aureus (MSSA) and MRSA colonization
The condition or state of being colonized or carrying MSSA or MRSA is called colonization or carriage, while an individual person is described as being colonized or being a carrier. Colonization means that MSSA or MSRA is present on or in the body without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as "MRSA screen positive" or "MRSA nasal swab positive".
Assign code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, for patients documented as having MRSA colonization. Assign code Z22.321, Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus, for patient documented as having MSSA colonization. Colonization is not necessarily indicative of a disease process or as the cause of a specific condition the patient may have unless documented as such by the provider.
(d)MRSA colonization and infection
If a patient is documented as having both MRSA colonization and infection during a hospital admission, code Z22.322, Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus, and a code for the MRSA infection may both be assigned.
f.Zika virus infections
1)Code only confirmed cases
Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guideline Section II, H.
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In this context, "confirmation" does not require documentation of the type of test performed; the physician's diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.
If the provider documents "suspected", "possible" or "probable" Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and (suspected) exposure to other viral communicable diseases.
2.Chapter 2: Neoplasms
General guidelines
Chapter 2 of the
Primary malignant neoplasms overlapping site boundaries
A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous such as tumors in different quadrants of the same breast, codes for each site should be assigned.
Malignant neoplasm of ectopic tissue
Malignant neoplasms of ectopic tissue are to be coded to the site of origin mentioned, e.g., ectopic pancreatic malignant neoplasms involving the stomach are coded to pancreas, unspecified (C25.9).
The neoplasm table in the Alphabetic Index should be referenced first. However, if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates "adenoma," refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to "see also neoplasm, by site, benign." The table provides the proper code based on the type of neoplasm and the site. It is important to select the
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proper column in the table that corresponds to the type of neoplasm. The Tabular List should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.
See Section I.C.21. Factors influencing health status and contact with health services, Status, for information regarding Z15.0, codes for genetic susceptibility to cancer.
a. Treatment directed at the malignancy
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate
b. Treatment of secondary site
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
c. Coding and sequencing of complications
Coding and sequencing of complications associated with the malignancies or with the therapy thereof are subject to the following guidelines:
1)Anemia associated with malignancy
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or
2)Anemia associated with chemotherapy, immunotherapy and radiation therapy
When the admission/encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect (T45.1X5, Adverse effect of antineoplastic and immunosuppressive drugs).
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When the admission/encounter is for management of an anemia associated with an adverse effect of radiotherapy, the anemia code should be sequenced first, followed by the appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure.
3)Management of dehydration due to the malignancy
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
4)Treatment of a complication resulting from a surgical procedure
When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or
d.Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or
e.Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy
1)Episode of care involves surgical removal of neoplasm
When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or
2)Patient admission/encounter solely for administration of chemotherapy, immunotherapy and radiation therapy
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If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the
The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis.
3)Patient admitted for radiation therapy, chemotherapy or immunotherapy and develops complications
When a patient is admitted for the purpose of radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or
f.Admission/encounter to determine extent of malignancy
When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or
g.Symptoms, signs, and abnormal findings listed in Chapter 18 associated with neoplasms
Symptoms, signs, and
See section I.C.21. Factors influencing health status and contact with health services, Encounter for prophylactic organ removal.
h. Admission/encounter for pain control/management
See Section I.C.6. for information on coding admission/encounter for pain control/management.
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i. Malignancy in two or more noncontiguous sites
A patient may have more than one malignant tumor in the same organ. These tumors may represent different primaries or metastatic disease, depending on the site. Should the documentation be unclear, the provider should be queried as to the status of each tumor so that the correct codes can be assigned.
j. Disseminated malignant neoplasm, unspecified
Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.
k. Malignant neoplasm without specification of site
Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.
l.Sequencing of neoplasm codes
1)Encounter for treatment of primary malignancy
If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the
2)Encounter for treatment of secondary malignancy
When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the
3)Malignant neoplasm in a pregnant patient
When a pregnant woman has a malignant neoplasm, a code from subcategory
4)Encounter for complication associated with a neoplasm
When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the
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treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.
The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or
5)Complication from surgical procedure for treatment of a neoplasm
When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the
6)Pathologic fracture due to a neoplasm
When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.
If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.
m.Current malignancy versus personal history of malignancy
When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.
When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.
See Section I.C.21. Factors influencing health status and contact with health services, History (of)
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n.Leukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplasms in remission versus personal history
The categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes Z85.6, Personal history of leukemia, and Z85.79, Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues. If the documentation is unclear as to whether the leukemia has achieved remission, the provider should be queried.
See Section I.C.21. Factors influencing health status and contact with health services, History (of)
o. Aftercare following surgery for neoplasm
See Section I.C.21. Factors influencing health status and contact with health services, Aftercare
p.
See Section I.C.21. Factors influencing health status and contact with health services,
q. Prophylactic organ removal for prevention of malignancy
See Section I.C. 21, Factors influencing health status and contact with health services, Prophylactic organ removal
r. Malignant neoplasm associated with transplanted organ
A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category
3.Chapter 3: Disease of the blood and
Reserved for future guideline expansion
4.Chapter 4: Endocrine, Nutritional, and Metabolic Diseases
a. Diabetes mellitus
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. As many codes within a particular category
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as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08 - E13 as needed to identify all of the associated conditions that the patient has.
1)Type of diabetes
The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reaching puberty. For this reason type 1 diabetes mellitus is also referred to as juvenile diabetes.
2)Type of diabetes mellitus not documented
If the type of diabetes mellitus is not documented in the medical record the default is
3)Diabetes mellitus and the use of insulin and oral hypoglycemics
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, code E11, Type 2 diabetes mellitus, should be assigned. Code Z79.4,
4)Diabetes mellitus in pregnancy and gestational diabetes
See Section I.C.15. Diabetes mellitus in pregnancy.
See Section I.C.15. Gestational (pregnancy induced) diabetes
5)Complications due to insulin pump malfunction
(a)Underdose of insulin due to insulin pump failure
An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants and grafts, that specifies the type of pump malfunction, as the principal or
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(b)Overdose of insulin due to insulin pump failure
The principal or
,Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional).
6)Secondary diabetes mellitus
Codes under categories E08, Diabetes mellitus due to underlying condition, E09, Drug or chemical induced diabetes mellitus, and E13, Other specified diabetes mellitus, identify complications/manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning).
(a)Secondary diabetes mellitus and the use of insulin or hypoglycemic drugs
For patients who routinely use insulin or hypoglycemic drugs, code Z79.4,
(b)Assigning and sequencing secondary diabetes codes and its causes
The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08, E09 and E13.
(i)Secondary diabetes mellitus due to pancreatectomy
For postpancreatectomy diabetes mellitus (lack of insulin due to the surgical removal of all or part of the pancreas), assign code E89.1, Postprocedural hypoinsulinemia. Assign a code from category E13 and a code from subcategory
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(ii)Secondary diabetes due to drugs
Secondary diabetes may be caused by an adverse effect of correctly administered medications, poisoning or sequela of poisoning.
See section I.C.19.e for coding of adverse effects and poisoning, and section I.C.20 for external cause code reporting.
5.Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 - F99)
a.Pain disorders related to psychological factors
Assign code F45.41, for pain that is exclusively related to psychological disorders. As indicated by the Excludes 1 note under category G89, a code from category G89 should not be assigned with code F45.41.
Code F45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified, if there is documentation of a psychological component for a patient with acute or chronic pain.
See Section I.C.6. Pain
b.Mental and behavioral disorders due to psychoactive substance use
1)In Remission
Selection of codes for "in remission" for categories
2)Psychoactive Substance Use, 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:
â¢If both use and abuse are documented, assign only the code for abuse
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â¢If both abuse and dependence are documented, assign only the code for dependence
â¢If use, abuse and dependence are all documented, assign only the code for dependence
â¢If both use and dependence are documented, assign only the code for dependence.
3)Psychoactive Substance Use
As with all other diagnoses, the codes for psychoactive substance use
6.Chapter 6: Diseases of the Nervous System
Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
â¢For ambidextrous patients, the default should be dominant.
â¢If the left side is affected, the default is
â¢If the right side is affected, the default is dominant.
b.Pain - Category G89
1)General coding information
Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and
If the pain is not specified as acute or chronic, post- thoracotomy, postprocedural, or
A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for
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the encounter is pain control/ management and not management of the underlying condition.
When an admission or encounter is for a procedure aimed at treating the underlying condition (e.g., spinal fusion, kyphoplasty), a code for the underlying condition (e.g., vertebral fracture, spinal stenosis) should be assigned as the principal diagnosis. No code from category G89 should be assigned.
(a)Category G89 Codes as Principal or
Category G89 codes are acceptable as principal diagnosis or the
â¢When pain control or pain management is the reason for the admission/encounter (e.g., a patient with displaced intervertebral disc, nerve impingement and severe back pain presents for injection of steroid into the spinal canal). The underlying cause of the pain should be reported as an additional diagnosis, if known.
â¢When a patient is admitted for the insertion of a neurostimulator for pain control, assign the appropriate pain code as the principal or
(b)Use of Category G89 Codes in Conjunction with Site Specific Pain Codes
(i)Assigning Category G89 and
Codes from category G89 may be used in conjunction with codes that identify the site of pain (including codes from chapter 18) if the category G89 code provides additional information. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes should be assigned.
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(ii)Sequencing of Category G89 Codes with Site- Specific Pain Codes
The sequencing of category G89 codes with site- specific pain codes (including chapter 18 codes), is dependent on the circumstances of the encounter/admission as follows:
â¢If the encounter is for pain control or pain management, assign the code from category G89 followed by the code identifying the specific site of pain (e.g., encounter for pain management for acute neck pain from trauma is assigned code G89.11, Acute pain due to trauma, followed by code M54.2, Cervicalgia, to identify the site of pain).
â¢If the encounter is for any other reason except pain control or pain management, and a related definitive diagnosis has not been established (confirmed) by the provider, assign the code for the specific site of pain first, followed by the appropriate code from category G89.
2)Pain due to devices, implants and grafts
See Section I.C.19. Pain due to medical devices
3)Postoperative Pain
The provider's documentation should be used to guide the coding of postoperative pain, as well as Section III. Reporting Additional Diagnoses and Section IV.
Diagnostic Coding and Reporting in the Outpatient
Setting.
The default for
Routine or expected postoperative pain immediately after surgery should not be coded.
(a)Postoperative pain not associated with specific postoperative complication
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Postoperative pain not associated with a specific postoperative complication is assigned to the appropriate postoperative pain code in category G89.
(b)Postoperative pain associated with specific postoperative complication
Postoperative pain associated with a specific postoperative complication (such as painful wire sutures) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. If appropriate, use additional code(s) from category G89 to identify acute or chronic pain (G89.18 or G89.28).
4)Chronic pain
Chronic pain is classified to subcategory G89.2. There is no time frame defining when pain becomes chronic pain. The provider's documentation should be used to guide use of these codes.
5)Neoplasm Related Pain
Code G89.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic.
This code may be assigned as the principal or
When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain.
See Section I.C.2 for instructions on the sequencing of neoplasms for all other stated reasons for the admission/encounter (except for pain control/pain management).
6)Chronic pain syndrome
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Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term "chronic pain," and therefore codes should only be used when the provider has specifically documented this condition.
See Section I.C.5. Pain disorders related to psychological factors
7.Chapter 7: Diseases of the Eye and Adnexa
1)Assigning Glaucoma Codes
Assign as many codes from category H40, Glaucoma, as needed to identify the type of glaucoma, the affected eye, and the glaucoma stage.
2)Bilateral glaucoma with same type and stage
When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and there is a code for bilateral glaucoma, report only the code for the type of glaucoma, bilateral, with the seventh character for the stage.
When a patient has bilateral glaucoma and both eyes are documented as being the same type and stage, and the classification does not provide a code for bilateral glaucoma (i.e. subcategories H40.10, H40.11 and H40.20) report only one code for the type of glaucoma with the appropriate seventh character for the stage.
3)Bilateral glaucoma stage with different types or stages
When a patient has bilateral glaucoma and each eye is documented as having a different type or stage, and the classification distinguishes laterality, assign the appropriate code for each eye rather than the code for bilateral glaucoma.
When a patient has bilateral glaucoma and each eye is documented as having a different type, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign one code for each type of glaucoma with the appropriate seventh character for the stage.
When a patient has bilateral glaucoma and each eye is documented as having the same type, but different stage, and the classification does not distinguish laterality (i.e. subcategories H40.10, H40.11 and H40.20), assign a code for
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the type of glaucoma for each eye with the seventh character for the specific glaucoma stage documented for each eye.
4)Patient admitted with glaucoma and stage evolves during the admission
If a patient is admitted with glaucoma and the stage progresses during the admission, assign the code for highest stage documented.
5)Indeterminate stage glaucoma
Assignment of the seventh character "4" for "indeterminate stage" should be based on the clinical documentation. The seventh character "4" is used for glaucomas whose stage cannot be clinically determined. This seventh character should not be confused with the seventh character "0", unspecified, which should be assigned when there is no documentation regarding the stage of the glaucoma.
8.Chapter 8: Diseases of the Ear and Mastoid Process
Reserved for future guideline expansion
9.Chapter 9: Diseases of the Circulatory System
The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.
For hypertension and conditions not specifically linked by relational terms such as "with," "associated with" or "due to" in the classification, provider documentation must link the conditions in order to code them
as related.
1)Hypertension with Heart Disease
Hypertension with heart conditions classified to I50.- or I51.4- I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use an additional code from category I50, Heart failure, to identify the type of heart failure in those patients with heart failure.
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The same heart conditions
2)Hypertensive Chronic Kidney Disease
Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD
should not be coded as hypertensive if the physician has specifically documented a different cause.
The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of chronic kidney disease.
See Section I.C.14. Chronic kidney disease.
If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.
3)Hypertensive Heart and Chronic Kidney Disease
Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when there is hypertension with both heart and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.
The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the stage of chronic kidney disease.
See Section I.C.14. Chronic kidney disease.
The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13. If a patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for hypertension, heart disease and chronic kidney disease, or codes from I11 or I12.
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For patients with both acute renal failure and chronic kidney disease, an additional code for acute renal failure is required.
4)Hypertensive Cerebrovascular Disease
For hypertensive cerebrovascular disease, first assign the appropriate code from categories
5)Hypertensive Retinopathy
Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category I10
- I15, Hypertensive disease to include the systemic hypertension. The sequencing is based on the reason for the encounter.
6)Hypertension, Secondary
Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter.
7)Hypertension, Transient
Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an established diagnosis of hypertension. Assign code
8)Hypertension, Controlled
This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the appropriate code from categories
9)Hypertension, Uncontrolled
Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories I10- I15, Hypertensive diseases.
10)Hypertensive Crisis
Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease
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b. Atherosclerotic Coronary Artery Disease and Angina
When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease.
See Section I.C.9. Acute myocardial infarction (AMI)
c. Intraoperative and Postprocedural Cerebrovascular Accident
Medical record documentation should clearly specify the cause- and- effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for intraoperative or postprocedural cerebrovascular accident.
Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.
d.Sequelae of Cerebrovascular Disease
1)Category I69, Sequelae of Cerebrovascular disease
Category I69 is used to indicate conditions classifiable to categories
Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify
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whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:
â¢For ambidextrous patients, the default should be dominant.
â¢If the left side is affected, the default is
â¢If the right side is affected, the default is dominant.
2)Codes from category I69 with codes from
Codes from category I69 may be assigned on a health care record with codes from
3)Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)
Codes from category I69 should not be assigned if the patient does not have neurologic deficits.
See Section I.C.21. 4. History (of) for use of personal history codes
e.Acute myocardial infarction (AMI)
1)ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI)
The
If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the myocardial infarction meets the definition for "other diagnoses" (see Section III, Reporting Additional Diagnoses), codes from category I21 may continue to be reported. For encounters after
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the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21. For old or healed myocardial infarctions not requiring further care, code I25.2, Old myocardial infarction, may be assigned.
2)Acute myocardial infarction, unspecified
Code I21.3, ST elevation (STEMI) myocardial infarction of unspecified site, is the default for unspecified acute myocardial infarction. If only STEMI or transmural MI without the site is documented, assign code I21.3.
3)AMI documented as nontransmural or subendocardial but site provided
If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.
See Section I.C.21.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.
4)Subsequent acute myocardial infarction
A code from category I22, Subsequent ST elevation (STEMI) and non ST elevation (NSTEMI) myocardial infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
10.Chapter 10: Diseases of the Respiratory System
a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma
1)Acute exacerbation of chronic obstructive bronchitis and asthma
The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.
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b.Acute Respiratory Failure
1)Acute respiratory failure as principal diagnosis
A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter- specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.
2)Acute respiratory failure as secondary diagnosis
Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.
3)Sequencing of acute respiratory failure and another acute condition
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no
If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.
c.Influenza due to certain identified influenza viruses
Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and due to other identified influenza virus (category J10). This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis).
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In this context, "confirmation" does not require documentation of positive laboratory testing specific for avian or other novel influenza A or other identified influenza virus. However, coding should be based on the provider's diagnostic statement that the patient has avian influenza, or other novel influenza A, for category J09, or has another particular identified strain of influenza, such as H1N1 or H3N2, but not identified as novel or variant, for category J10.
If the provider records "suspected" or "possible" or "probable" avian influenza, or novel influenza, or other identified influenza, then the appropriate influenza code from category J11, Influenza due to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to certain identified influenza viruses, should not be assigned nor should a code from category J10, Influenza due to other identified influenza virus.
d.Ventilator associated Pneumonia
1)Documentation of Ventilator associated Pneumonia
As with all procedural or postprocedural complications, code assignment is based on the provider's documentation of the relationship between the condition and the procedure.
Code J95.851, Ventilator associated pneumonia, should be assigned only when the provider has documented ventilator associated pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not assign an additional code from categories
Code J95.851 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator and the provider has not specifically stated that the pneumonia is
2)Ventilator associated Pneumonia Develops after Admission
A patient may be admitted with one type of pneumonia (e.g., code J13, Pneumonia due to Streptococcus pneumonia) and subsequently develop VAP. In this instance, the principal diagnosis would be the appropriate code from categories J12-
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J18 for the pneumonia diagnosed at the time of admission. Code J95.851, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the presence of ventilator associated pneumonia.
11.Chapter 11: Diseases of the Digestive System
Reserved for future guideline expansion
12.Chapter 12: Diseases of the Skin and Subcutaneous Tissue
a.Pressure ulcer stage codes
1)Pressure ulcer stages
Codes from category L89, Pressure ulcer, identify the site of the pressure ulcer as well as the stage of the ulcer.
The
Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.
2)Unstageable pressure ulcers
Assignment of the code for unstageable pressure ulcer
3)Documented pressure ulcer stage
Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index. For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried.
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4)Patients admitted with pressure ulcers documented as healed
No code is assigned if the documentation states that the pressure ulcer is completely healed.
5)Patients admitted with pressure ulcers documented as healing
Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.
For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.
6)Patient admitted with pressure ulcer evolving into another stage during the admission
If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.
13.Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue
a.Site and laterality
Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a "multiple sites" code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.
1)Bone versus joint
For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis,
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M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
b.Acute traumatic versus chronic or recurrent musculoskeletal conditions
Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are usually found in chapter 13. Recurrent bone, joint or muscle conditions are also usually found in chapter 13. Any current, acute injury should be coded to the appropriate injury code from chapter 19. Chronic or recurrent conditions should generally be coded with a code from chapter 13. If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.
c. Coding of Pathologic Fractures
7th character A is for use as long as the patient is receiving active treatment for the fracture. While the patient may be seen by a new or different provider over the course of treatment for a pathological fracture, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.
7th character D is to be used for encounters after the patient has completed active treatment. The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for routine care of fractures during the healing and recovery phase as well as treatment of problems associated with the healing, such as malunions, nonunions, and sequelae.
Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
See Section I.C.19. Coding of traumatic fractures.
d. Osteoporosis
Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. The site codes under category M80, Osteoporosis with current pathological fracture, identify the site of the fracture, not the osteoporosis.
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1)Osteoporosis without pathological fracture
Category M81, Osteoporosis without current pathological fracture, is for use for patients with osteoporosis who do not currently have a pathologic fracture due to the osteoporosis, even if they have had a fracture in the past. For patients with a history of osteoporosis fractures, status code Z87.310, Personal history of (healed) osteoporosis fracture, should follow the code from M81.
2)Osteoporosis with current pathological fracture
Category M80, Osteoporosis with current pathological fracture, is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.
14.Chapter 14: Diseases of Genitourinary System
1)Stages of chronic kidney disease (CKD)
The
If both a stage of CKD and ESRD are documented, assign code N18.6 only.
2)Chronic kidney disease and kidney transplant status
Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient's stage of CKD and code Z94.0, Kidney transplant status. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C.19.g for information on coding complications of a kidney transplant. If
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the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
3)Chronic kidney disease with other conditions
Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the Tabular List.
See I.C.9. Hypertensive chronic kidney disease.
See I.C.19. Chronic kidney disease and kidney transplant complications.
15.Chapter 15: Pregnancy, Childbirth, and the Puerperium
a.General Rules for Obstetric Cases
1)Codes from chapter 15 and sequencing priority
Obstetric cases require codes from chapter 15, codes in the range
2)Chapter 15 codes used only on the maternal record
Chapter 15 codes are to be used only on the maternal record, never on the record of the newborn.
3)Final character for trimester
The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter. If trimester is not a component of a code, it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one.
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Assignment of the final character for trimester should be based on the provider's documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for
Whenever delivery occurs during the current admission, and there is an "in childbirth" option for the obstetric complication being coded, the "in childbirth" code should be assigned.
4)Selection of trimester for inpatient admissions that encompass more than one trimester
In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the discharge. If the condition developed prior to the current admission/encounter or represents a
5)Unspecified trimester
Each category that includes codes for trimester has a code for "unspecified trimester." The "unspecified trimester" code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification.
6)7th character for Fetus Identification
Where applicable, a 7th character is to be assigned for certain categories (O31, O32, O33.3 - O33.6, O35, O36, O40, O41, O60.1, O60.2, O64, and O69) to identify the fetus for which the complication code applies.
Assign 7th character "0":
â¢For single gestations
â¢When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification.
â¢When it is not possible to clinically determine which fetus is affected.
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b.Selection of OB Principal or
1)Routine outpatient prenatal visits
For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the
These codes should not be used in conjunction with chapter 15 codes.
2)Supervision of
Codes from category O09, Supervision of
For routine prenatal outpatient visits for patients with
3)Episodes when no delivery occurs
In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy which necessitated the encounter. Should more than one complication exist, all of which are treated or monitored, any of the complications codes may be sequenced first.
4)When a delivery occurs
When an obstetric patient is admitted and delivers during that admission, the condition that prompted the admission should be sequenced as the principal diagnosis. If multiple conditions prompted the admission, sequence the one most related to the delivery as the principal diagnosis. A code for any complication of the delivery should be assigned as an additional diagnosis. In cases of cesarean delivery, if the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission should be selected as the principal diagnosis.
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5)Outcome of delivery
A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.
c.
Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy
Categories that do not distinguish between
d.
Category O10,
See Section I.C.9. Hypertension.
e.Fetal Conditions Affecting the Management of the Mother
1)Codes from categories O35 and O36
Codes from categories O35, Maternal care for known or suspected fetal abnormality and damage, and O36, Maternal care for other fetal problems, are assigned only when the fetal condition is actually responsible for modifying the management of the mother, i.e., by requiring diagnostic studies, additional observation, special care, or termination of pregnancy. The fact that the fetal condition exists does not justify assigning a code from this series to the mother's record.
2)In utero surgery
In cases when surgery is performed on the fetus, a diagnosis code from category O35, Maternal care for known or suspected
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fetal abnormality and damage, should be assigned identifying the fetal condition. Assign the appropriate procedure code for the procedure performed.
No code from Chapter 16, the perinatal codes, should be used on the mother's record to identify fetal conditions. Surgery performed in utero on a fetus is still to be coded as an obstetric encounter.
f. HIV Infection in Pregnancy, Childbirth and the Puerperium
During pregnancy, childbirth or the puerperium, a patient admitted because of an
Patients with asymptomatic HIV infection status admitted during pregnancy, childbirth, or the puerperium should receive codes of
O98.7- and Z21, Asymptomatic human immunodeficiency virus [HIV] infection status.
g. Diabetes mellitus in pregnancy
Diabetes mellitus is a significant complicating factor in pregnancy. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth, and the puerperium, first, followed by the appropriate diabetes code(s) (E08- E13) from Chapter 4.
h. Long term use of insulin and oral hypoglycemics
Code Z79.4,
term (current) use of oral hypoglycemic drugs, should also be assigned if the diabetes mellitus is being treated with insulin or oral medications. If the patient is treated with both oral medications and insulin, only the code for
i. Gestational (pregnancy induced) diabetes
Gestational (pregnancy induced) diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of
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The codes under subcategory O24.4 include diet controlled, insulin controlled, and controlled by oral hypoglycemic drugs. If a patient with gestational diabetes is treated with both diet and insulin, only the code for
An abnormal glucose tolerance in pregnancy is assigned a code from subcategory O99.81, Abnormal glucose complicating pregnancy, childbirth, and the puerperium.
j.Sepsis and septic shock complicating abortion, pregnancy, childbirth and the puerperium
When assigning a chapter 15 code for sepsis complicating abortion, pregnancy, childbirth, and the puerperium, a code for the specific type of infection should be assigned as an additional diagnosis. If severe sepsis is present, a code from subcategory R65.2, Severe sepsis, and code(s) for associated organ dysfunction(s) should also be assigned as additional diagnoses.
k. Puerperal sepsis
Code O85, Puerperal sepsis, should be assigned with a secondary code to identify the causal organism (e.g., for a bacterial infection, assign a code from category
l.Alcohol and tobacco use during pregnancy, childbirth and the puerperium
1)Alcohol use during pregnancy, childbirth and the puerperium
Codes under subcategory O99.31, Alcohol use complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses alcohol during the pregnancy or postpartum. A secondary code from category F10, Alcohol related disorders, should also be assigned to identify manifestations of the alcohol use.
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2)Tobacco use during pregnancy, childbirth and the puerperium
Codes under subcategory O99.33, Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium, should be assigned for any pregnancy case when a mother uses any type of tobacco product during the pregnancy or postpartum. A secondary code from category F17, Nicotine dependence, should also be assigned to identify the type of nicotine dependence.
m.Poisoning, toxic effects, adverse effects and underdosing in a pregnant patient
A code from subcategory O9A.2, Injury, poisoning and certain other consequences of external causes complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate injury, poisoning, toxic effect, adverse effect or underdosing code, and then the additional code(s) that specifies the condition caused by the poisoning, toxic effect, adverse effect or underdosing.
See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects.
n.Normal Delivery, Code O80
1)Encounter for full term uncomplicated delivery
Code O80 should be assigned when a woman is admitted for a
2)Uncomplicated delivery with resolved antepartum complication
Code O80 may be used if the patient had a complication at some point during the pregnancy, but the complication is not present at the time of the admission for delivery.
3)Outcome of delivery for O80
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Z37.0, Single live birth, is the only outcome of delivery code appropriate for use with O80.
o.The Peripartum and Postpartum Periods
1)Peripartum and Postpartum periods
The postpartum period begins immediately after delivery and continues for six weeks following delivery. The peripartum period is defined as the last month of pregnancy to five months postpartum.
2)Peripartum and postpartum complication
A postpartum complication is any complication occurring within the
3)
Chapter 15 codes may also be used to describe
4)Admission for routine postpartum care following delivery outside hospital
When the mother delivers outside the hospital prior to admission and is admitted for routine postpartum care and no complications are noted, code Z39.0, Encounter for care and examination of mother immediately after delivery, should be assigned as the principal diagnosis.
5)Pregnancy associated cardiomyopathy
Pregnancy associated cardiomyopathy, code O90.3, is unique in that it may be diagnosed in the third trimester of pregnancy but may continue to progress months after delivery. For this reason, it is referred to as peripartum cardiomyopathy. Code O90.3 is only for use when the cardiomyopathy develops as a result of pregnancy in a woman who did not have
p.Code O94, Sequelae of complication of pregnancy, childbirth, and the puerperium
1)Code O94
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Code O94, Sequelae of complication of pregnancy, childbirth, and the puerperium, is for use in those cases when an initial complication of a pregnancy develops a sequelae requiring care or treatment at a future date.
2)After the initial postpartum period
This code may be used at any time after the initial postpartum period.
3)Sequencing of Code O94
This code, like all sequela codes, is to be sequenced following the code describing the sequelae of the complication.
q.Termination of Pregnancy and Spontaneous abortions
1)Abortion with Liveborn Fetus
When an attempted termination of pregnancy results in a liveborn fetus, assign code Z33.2, Encounter for elective termination of pregnancy and a code from category Z37, Outcome of Delivery.
2)Retained Products of Conception following an abortion
Subsequent encounters for retained products of conception following a spontaneous abortion or elective termination of pregnancy are assigned the appropriate code from category O03, Spontaneous abortion, or codes O07.4, Failed attempted termination of pregnancy without complication and Z33.2, Encounter for elective termination of pregnancy. This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.
3)Complications leading to abortion
Codes from Chapter 15 may be used as additional codes to identify any documented complications of the pregnancy in conjunction with codes in categories in O07 and O08.
r.Abuse in a pregnant patient
For suspected or confirmed cases of abuse of a pregnant patient, a code(s) from subcategories O9A.3, Physical abuse complicating pregnancy, childbirth, and the puerperium, O9A.4, Sexual abuse complicating pregnancy, childbirth, and the puerperium, and O9A.5, Psychological abuse complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate codes (if applicable) to identify any associated current injury due to physical abuse, sexual abuse, and the perpetrator of abuse.
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See Section I.C.19. Adult and child abuse, neglect and other maltreatment.
16.Chapter 16: Certain Conditions Originating in the Perinatal Period
For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth. The following guidelines are provided for reporting purposes.
a.General Perinatal Rules
1)Use of Chapter 16 Codes
Codes in this chapter are never for use on the maternal record. Codes from Chapter 15, the obstetric chapter, are never permitted on the newborn record. Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
2)Principal Diagnosis for Birth Record
When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. A code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital.
A code from category Z38 is used only on the newborn record, not on the mother's record.
3)Use of Codes from other Chapters with Codes from
Chapter 16
Codes from other chapters may be used with codes from chapter 16 if the codes from the other chapters provide more specific detail. Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established. If the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first.
4)Use of Chapter 16 Codes after the Perinatal Period
Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should continue to be used regardless of the patient's age.
5)Birth process or community acquired conditions
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If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 16 should be used. If the condition is
6)Code all clinically significant conditions
All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:
*clinical evaluation; or
*therapeutic treatment; or
*diagnostic procedures; or
*extended length of hospital stay; or
*increased nursing care and/or monitoring; or
*has implications for future health care needs
Note: The perinatal guidelines listed above are the same as the general coding guidelines for "additional diagnoses", except for the final point regarding implications for future health care needs. Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs.
b.Observation and Evaluation of Newborns for Suspected Conditions not Found
1)Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom.
2)A code from category Z05 may also be assigned as a principal or
3)Z05 on a birth record
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A code from category Z05 is to be used as a secondary code after the code from category Z38, Liveborn infants according to place of birth and type of delivery.
c.Coding Additional Perinatal Diagnoses
1)Assigning codes for conditions that require treatment
Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization.
2)Codes for conditions specified as having implications for future health care needs
Assign codes for conditions that have been specified by the provider as having implications for future health care needs.
Note: This guideline should not be used for adult patients.
d.Prematurity and Fetal Growth Retardation
Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05, Disorders of newborn related to slow fetal growth and fetal malnutrition, and P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age. Codes from category P05 should not be assigned with codes from category P07.
When both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age.
e. Low birth weight and immaturity status
Codes from category P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had a low birth weight as a newborn and this is affecting the patient's current health status.
See Section I.C.21. Factors influencing health status and contact with health services, Status.
f. Bacterial Sepsis of Newborn
Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code
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from category P36 should be assigned. If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should not be assigned. If the P36 code does not include the causal organism, assign an additional code from category B96. If applicable, use additional codes to identify severe sepsis
g. Stillbirth
Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirths. No other code should be used with P95. Code P95 should not be used on the mother's record.
17.Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities
Assign an appropriate code(s) from categories
When a malformation/deformation or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any manifestations that may be present.
When the code assignment specifically identifies the malformation/deformation or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are not an inherent component.
Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the physician, it is appropriate to assign a code from codes Q00- Q99.For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00- Q99.
18.Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
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Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and
a. Use of symptom codes
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
b. Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
c.Combination codes that include symptoms
d. Repeated falls
Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.
Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.
e. Coma scale
The coma scale codes
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regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
f.Functional quadriplegia
Functional quadriplegia (code R53.2) is the lack of ability to use one's limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.
g. SIRS due to
The systemic inflammatory response syndrome (SIRS) can develop as a result of certain
h. Death NOS
Code R99,
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is pronounced dead upon arrival. It does not represent the discharge disposition of death.
i. NIHSS Stroke Scale
The NIH stroke scale (NIHSS) codes (R29.7-
At a minimum, report the initial score documented. If desired, a facility may choose to capture multiple stroke scale scores.
See Section I.B.14. for information concerning the medical record documentation that may be used for assignment of the NIHSS codes.
19.Chapter 19: Injury, poisoning, and certain other consequences of external causes
a. Application of 7th Characters in Chapter 19
Most categories in chapter 19 have a 7th character requirement for each applicable code. Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7th character values. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.
For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter.
7th character "A", initial encounter is used for each encounter where the patient is receiving active treatment for the condition.
7th character "D" subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to
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identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character "D" (subsequent encounter).
7th character "S", sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character "S", it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The "S" is added only to the injury code, not the sequela code. The 7th character "S" identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.
See Section I.B.10 Sequelae, (Late Effects)
b. Coding of Injuries
When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes
The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.
1)Superficial injuries
Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.
2)Primary injury with damage to nerves/blood vessels
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
c.Coding of Traumatic Fractures
The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the level of detail furnished by medical record content.
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A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.
More specific guidelines are as follows:
1)Initial vs. Subsequent Encounter for Fractures
Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the
patient is receiving active treatment for the fracture. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.
Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.
Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).
Malunion/nonunion: The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.
The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q).
A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.
See Section I.C.13. Osteoporosis.
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The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character.
2)Multiple fractures sequencing
Multiple fractures are sequenced in accordance with the severity of the fracture.
d.Coding of Burns and Corrosions
The
Current burns
Burns of the eye and internal organs
1)Sequencing of burn and related condition codes
Sequence first the code that reflects the highest degree of burn when more than one burn is present.
a.When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree.
b.When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or
c.When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or
2)Burns of the same local site
Classify burns of the same local site
3)
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Necrosis of burned skin should be coded as a
4)Infected Burn
For any documented infected burn site, use an additional code for the infection.
5)Assign separate codes for each burn site
When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.
6)Burns and Corrosions Classified According to Extent of Body Surface Involved
Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a
Categories T31 and T32 are based on the classic "rule of nines" in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent. Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.
7)Encounters for treatment of sequela of burns
Encounters for the treatment of the late effects of burns or
corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character "S" for sequela.
8)Sequelae with a late effect code and current burn
When appropriate, both a code for a current burn or corrosion with 7th character "A" or "D" and a burn or corrosion code with 7th character "S" may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Burns and corrosions do not heal at the same rate and a current healing
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wound may still exist with sequela of a healed burn or corrosion.
See Section I.B.10 Sequela (Late Effects)
9)Use of an external cause code with burns and corrosions
An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.
e.Adverse Effects, Poisoning, Underdosing and Toxic Effects
Codes in categories
1)Do not code directly from the Table of Drugs
Do not code directly from the Table of Drugs and Chemicals. Always refer back to the Tabular List.
2)Use as many codes as necessary to describe
Use as many codes as necessary to describe completely all drugs, medicinal or biological substances.
3)If the same code would describe the causative agent
If the same code would describe the causative agent for more than one adverse reaction, poisoning, toxic effect or underdosing, assign the code only once.
4)If two or more drugs, medicinal or biological substances
If two or more drugs, medicinal or biological substances are reported, code each individually unless a combination code is listed in the Table of Drugs and Chemicals.
5)The occurrence of drug toxicity is classified in
(a)Adverse Effect
When coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug
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have a 5th or 6th character "5" (for example
(b)Poisoning
When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories
If there is also a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code.
Examples of poisoning include:
(i)Error was made in drug prescription
Errors made in drug prescription or in the administration of the drug by provider, nurse, patient, or other person.
(ii)Overdose of a drug intentionally taken
If an overdose of a drug was intentionally taken or administered and resulted in drug toxicity, it would be coded as a poisoning.
(iii)Nonprescribed drug taken with correctly prescribed and properly administered drug
If a nonprescribed drug or medicinal agent was taken in combination with a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning.
(iv)Interaction of drug(s) and alcohol
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When a reaction results from the interaction of a drug(s) and alcohol, this would be classified as poisoning.
See Section I.C.4. if poisoning is the result of insulin pump malfunctions.
(c)Underdosing
Underdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer's instruction. For underdosing, assign the code from categories T36- T50 (fifth or sixth character "6").
Codes for underdosing should never be assigned as principal or
Noncompliance
(d)Toxic Effects
When a harmful substance is ingested or comes in contact with a person, this is classified as a toxic effect. The toxic effect codes are in categories
Toxic effect codes have an associated intent: accidental, intentional
f. Adult and child abuse, neglect and other maltreatment
Sequence first the appropriate code from categories T74.- (Adult and child abuse, neglect and other maltreatment, confirmed) or T76.- (Adult and child abuse, neglect and other maltreatment, suspected) for abuse, neglect and other maltreatment, followed by any accompanying mental health or injury code(s).
If the documentation in the medical record states abuse or neglect it is coded as confirmed
For cases of confirmed abuse or neglect an external cause code from the assault section
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when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code.
If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76.
If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged adult rape or code Z04.42, Encounter for examination and observation following alleged child rape, should be used, not a code from T76.
See Section I.C.15. Abuse in a pregnant patient.
g.Complications of care
1)General guidelines for complications of care
(a)Documentation of complications of care
See Section I.B.16. for information on documentation of complications of care.
2)Pain due to medical devices
Pain associated with devices, implants or grafts left in a surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 19, Injury, poisoning, and certain other consequences of external causes. Specific codes for pain due to medical devices are found in the T code section of the
3)Transplant complications
(a)Transplant complications other than kidney
Codes under category T86, Complications of transplanted organs and tissues, are for use for both complications and rejection of transplanted organs. A transplant complication code is only assigned if the complication affects the function of the transplanted organ. Two codes are required to fully describe a transplant complication: the appropriate code from category T86 and a secondary code that identifies the complication.
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See I.C.21. for transplant organ removal status See I.C.2. for malignant neoplasm associated with transplanted organ.
(b)Kidney transplant complications
Patients who have undergone kidney transplant may still have some form of chronic kidney disease (CKD) because the kidney transplant may not fully restore kidney function. Code T86.1- should be assigned for documented complications of a kidney transplant, such as transplant failure or rejection or other transplant complication. Code T86.1- should not be assigned for post kidney transplant patients who have chronic kidney (CKD) unless a transplant complication such as transplant failure or rejection is documented. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.
Conditions that affect the function of the transplanted kidney, other than CKD, should be assigned a code from subcategory T86.1, Complications of transplanted organ, Kidney, and a secondary code that identifies the complication.
For patients with CKD following a kidney transplant, but who do not have a complication such as failure or rejection, see section I.C.14. Chronic kidney disease and kidney transplant status.
4)Complication codes that include the external cause
As with certain other T codes, some of the complications of care codes have the external cause included in the code. The code includes the nature of the complication as well as the type of procedure that caused the complication. No external cause code indicating the type of procedure is necessary for these codes.
5)Complications of care codes within the body system chapters
Intraoperative and postprocedural complication codes are found within the body system chapters with codes specific to the organs and structures of that body system. These codes should
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be sequenced first, followed by a code(s) for the specific complication, if applicable.
20.Chapter 20: External Causes of Morbidity
The external causes of morbidity codes should never be sequenced as the first- listed or principal diagnosis.
External cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred the activity of the patient at the time of the event, and the person's status (e.g., civilian, military).
There is no national requirement for mandatory
a.General External Cause Coding Guidelines
1)Used with any code in the range of
An external cause code may be used with any code in the range of
2)External cause code used for length of treatment
Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequela) for each encounter for which the injury or condition is being treated.
Most categories in chapter 20 have a 7th character requirement
for each applicable code. Most categories in this chapter have three 7th character values: A, initial encounter, D, subsequent encounter and S, sequela. While the patient may be seen by a new or different provider over the course of treatment for an
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injury or condition, assignment of the 7th character for external cause should match the 7th character of the code assigned for the associated injury or condition for the encounter.
3)Use the full range of external cause codes
Use the full range of external cause codes to completely describe the cause, the intent, the place of occurrence, and if applicable, the activity of the patient at the time of the event, and the patient's status, for all injuries, and other health conditions due to an external cause.
4)Assign as many external cause codes as necessary
Assign as many external cause codes as necessary to fully explain each cause. If only one external code can be recorded, assign the code most related to the principal diagnosis.
5)The selection of the appropriate external cause code
The selection of the appropriate external cause code is guided by the Alphabetic Index of External Causes and by Inclusion and Exclusion notes in the Tabular List.
6)External cause code can never be a principal diagnosis
An external cause code can never be a principal
7)Combination external cause codes
Certain of the external cause codes are combination codes that identify sequential events that result in an injury, such as a fall which results in striking against an object. The injury may be due to either event or both. The combination external cause code used should correspond to the sequence of events regardless of which caused the most serious injury.
8)No external cause code needed in certain circumstances
No external cause code from Chapter 20 is needed if the external cause and intent are included in a code from another chapter (e.g. T36.0X1- Poisoning by penicillins, accidental (unintentional)).
b.Place of Occurrence Guideline
Codes from category Y92, Place of occurrence of the external cause, are secondary codes for use after other external cause codes to identify the location of the patient at the time of injury or other condition.
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Generally, a place of occurrence code is assigned only once, at the initial encounter for treatment. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned. No 7th characters are used for Y92.
Do not use place of occurrence code Y92.9 if the place is not stated or is not applicable.
c. Activity Code
Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred.
An activity code is used only once, at the initial encounter for treatment. Only one code from Y93 should be recorded on a medical record.
The activity codes are not applicable to poisonings, adverse effects, misadventures or sequela.
Do not assign Y93.9, Unspecified activity, if the activity is not stated.
A code from category Y93 is appropriate for use with external cause and intent codes if identifying the activity provides additional information about the event.
d.Place of Occurrence, Activity, and Status Codes Used with other External Cause Code
When applicable, place of occurrence, activity, and external cause status codes are sequenced after the main external cause code(s). Regardless of the number of external cause codes assigned, generally there should be only one place of occurrence code, one activity code, and one external cause status code assigned to an encounter. However, in the rare instance that a new injury occurs during hospitalization, an additional place of occurrence code may be assigned.
e.If the Reporting Format Limits the Number of External Cause Codes
If the reporting format limits the number of external cause codes that can be used in reporting clinical data, report the code for the cause/intent most related to the principal diagnosis. If the format permits capture of additional external cause codes, the cause/intent, including medical misadventures, of the additional events should be reported rather than the codes for place, activity, or external status.
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f. Multiple External Cause Coding Guidelines
More than one external cause code is required to fully describe the external cause of an illness or injury. The assignment of external cause codes should be sequenced in the following priority:
If two or more events cause separate injuries, an external cause code should be assigned for each cause. The
External codes for child and adult abuse take priority over all other external cause codes.
See Section I.C.19., Child and Adult abuse guidelines.
External cause codes for terrorism events take priority over all other external cause codes except child and adult abuse.
External cause codes for cataclysmic events take priority over all other external cause codes except child and adult abuse and terrorism.
External cause codes for transport accidents take priority over all other external cause codes except cataclysmic events, child and adult abuse and terrorism.
Activity and external cause status codes are assigned following all causal (intent) external cause codes.
The
g. Child and Adult Abuse Guideline
Adult and child abuse, neglect and maltreatment are classified as assault. Any of the assault codes may be used to indicate the external cause of any injury resulting from the confirmed abuse.
For confirmed cases of abuse, neglect and maltreatment, when the perpetrator is known, a code from Y07, Perpetrator of maltreatment and neglect, should accompany any other assault codes.
See Section I.C.19. Adult and child abuse, neglect and other maltreatment
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h. Unknown or Undetermined Intent Guideline
If the intent (accident,
1)Use of undetermined intent
External cause codes for events of undetermined intent are only for use if the documentation in the record specifies that the intent cannot be determined.
i.Sequelae (Late Effects) of External Cause Guidelines
1)Sequelae external cause codes
Sequela are reported using the external cause code with the 7th character "S" for sequela. These codes should be used with any report of a late effect or sequela resulting from a previous injury.
See Section I.B.10 Sequela (Late Effects)
2)Sequela external cause code with a related current injury
A sequela external cause code should never be used with a related current nature of injury code.
3)Use of sequela external cause codes for subsequent visits
Use a late effect external cause code for subsequent visits when a late effect of the initial injury is being treated. Do not use a late effect external cause code for subsequent visits for follow- up care (e.g., to assess healing, to receive rehabilitative therapy) of the injury when no late effect of the injury has been documented.
j.Terrorism Guidelines
1)Cause of injury identified by the Federal Government (FBI) as terrorism
When the cause of an injury is identified by the Federal Government (FBI) as terrorism, the
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may be assigned if the injury is the result of more than one mechanism of terrorism.
2)Cause of an injury is suspected to be the result of terrorism
When the cause of an injury is suspected to be the result of terrorism a code from category Y38 should not be assigned. Suspected cases should be classified as assault.
3)Code Y38.9, Terrorism, secondary effects
Assign code Y38.9, Terrorism, secondary effects, for conditions occurring subsequent to the terrorist event. This code should not be assigned for conditions that are due to the initial terrorist act.
It is acceptable to assign code Y38.9 with another code from Y38 if there is an injury due to the initial terrorist event and an injury that is a subsequent result of the terrorist event.
k.External cause status
A code from category Y99, External cause status, should be assigned whenever any other external cause code is assigned for an encounter, including an Activity code, except for the events noted below. Assign a code from category Y99, External cause status, to indicate the work status of the person at the time the event occurred. The status code indicates whether the event occurred during military activity, whether a
A code from Y99, External cause status, should be assigned, when applicable, with other external cause codes, such as transport accidents and falls. The external cause status codes are not applicable to poisonings, adverse effects, misadventures or late effects.
Do not assign a code from category Y99 if no other external cause codes (cause, activity) are applicable for the encounter.
An external cause status code is used only once, at the initial encounter for treatment. Only one code from Y99 should be recorded on a medical record.
Do not assign code Y99.9, Unspecified external cause status, if the status is not stated.
21.Chapter 21: Factors influencing health status and contact with health services
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Note: The chapter specific guidelines provide additional information about the use of Z codes for specified encounters.
a. Use of Z codes in any healthcare setting
Z codes are for use in any healthcare setting. Z codes may be used as either a
Certain Z codes may only be used as
b. Z Codes indicate a reason for an encounter
Z codes are not procedure codes. A corresponding procedure code must accompany a Z code to describe any procedure performed.
c.Categories of Z Codes
1)Contact/Exposure
Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who do not show any sign or symptom of a disease but are suspected to have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic.
Category Z77, Other contact with and (suspected) exposures hazardous to health, indicates contact with and suspected exposures hazardous to health.
Contact/exposure codes may be used as a
2)Inoculations and vaccinations
Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a
3)Status
Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a
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history code. The history code indicates that the patient no longer has the condition.
A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient.
For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, Chronic respiratory failure, followed by code Z99.11, Dependence on respirator [ventilator] status.
The status Z codes/categories are:
Z14 Genetic carrier
Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease.
Z15 Genetic susceptibility to disease
Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease.
Codes from category Z15 should not be used as principal or
Z16 Resistance to antimicrobial drugs
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|
This code indicates that a patient has a condition that |
|
is resistant to antimicrobial drug treatment. Sequence |
|
the infection code first. |
Z17 |
Estrogen receptor status |
Z18 |
Retained foreign body fragments |
Z19 |
Hormone sensitivity malignancy status |
Z21 |
Asymptomatic HIV infection status |
|
This code indicates that a patient has tested positive |
|
for HIV but has manifested no signs or symptoms of |
|
the disease. |
Z22 |
Carrier of infectious disease |
|
Carrier status indicates that a person harbors the |
|
specific organisms of a disease without manifest |
|
symptoms and is capable of transmitting the |
|
infection. |
Z28.3 |
Underimmunization status |
Z33.1 |
Pregnant state, incidental |
|
This code is a secondary code only for use when the |
|
pregnancy is in no way complicating the reason for |
|
visit. Otherwise, a code from the obstetric chapter is |
|
required. |
Z66 |
Do not resuscitate |
|
This code may be used when it is documented by the |
|
provider that a patient is on do not resuscitate status |
|
at any time during the stay. |
Z67 |
Blood type |
Z68 |
Body mass index (BMI) |
|
As with all other secondary diagnosis codes, the |
|
BMI codes should only be assigned when they meet |
|
the definition of a reportable diagnosis (see Section |
|
III, Reporting Additional Diagnoses). |
Z74.01 |
Bed confinement status |
Z76.82 |
Awaiting organ transplant status |
Z78 |
Other specified health status |
|
Code Z78.1, Physical restraint status, may be used |
|
when it is documented by the provider that a patient |
|
has been put in restraints during the current |
|
encounter. Please note that this code should not be |
|
reported when it is documented by the provider that |
|
a patient is temporarily restrained during a |
|
procedure. |
Z79 |
|
|
Codes from this category indicate a patient's |
continuous use of a prescribed drug (including such things as aspirin therapy) for the
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subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.
Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis).
Z88 Allergy status to drugs, medicaments and biological substances
Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status
Z89 Acquired absence of limb
Z90 Acquired absence of organs, not elsewhere classified
Z91.0- Allergy status, other than to drugs and biological substances
Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility
Assign code Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility.
This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility.
The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first.
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Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record.
Z93 Artificial opening status
Z94 Transplanted organ and tissue status
Z95 Presence of cardiac and vascular implants and grafts
Z96 Presence of other functional implants
Z97 Presence of other devices
Z98 Other postprocedural states
Assign code Z98.85, Transplanted organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter.
See section I.C19. for information on the coding of organ transplant complications.
Z99 Dependence on enabling machines and devices, not elsewhere classified
Note: Categories
4)History (of)
There are two types of history Z codes, personal and family. Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.
Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.
Personal history codes may be used in conjunction with follow- up codes and family history codes may be used in conjunction with screening codes to explain the need for a test or procedure. History codes are also acceptable on any medical record regardless of the reason for visit. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
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The history Z code categories are:
Z80 Family history of primary malignant neoplasm
Z81 Family history of mental and behavioral disorders
Z82 Family history of certain disabilities and chronic diseases (leading to disablement)
Z83 Family history of other specific disorders
Z84 Family history of other conditions
Z85 Personal history of malignant neoplasm
Z86 Personal history of certain other diseases
Z87 Personal history of other diseases and conditions
Z91.4- Personal history of psychological trauma, not elsewhere classified
Z91.5 Personal history of
Z91.8- Other specified personal risk factors, not elsewhere classified
Exception:
Z91.83, Wandering in diseases classified elsewhere
Z92 Personal history of medical treatment Except: Z92.0, Personal history of contraception Except: Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility
5)Screening
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram).
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.
A screening code may be a
Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.
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The Z code indicates that a screening exam is planned. A procedure code is required to confirm that the screening was performed.
The screening Z codes/categories:
Z11 Encounter for screening for infectious and parasitic diseases
Z12 Encounter for screening for malignant neoplasms
Z13 Encounter for screening for other diseases and disorders
Except: Z13.9, Encounter for screening, unspecified
Z36 Encounter for antenatal screening for mother
6)Observation
There are three observation Z code categories. They are for use in very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or symptoms related to the suspected condition are present. In such cases the diagnosis/symptom code is used with the corresponding external cause code.
The observation codes are to be used as principal diagnosis only. The only exception to this is when the principal diagnosis is required to be a code from category Z38, Liveborn infants according to place of birth and type of delivery. Then a code from category Z05, Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out, is sequenced after the Z38 code. Additional codes may be used in addition to the observation code, but only if they are unrelated to the suspected condition being observed.
Codes from subcategory Z03.7, Encounter for suspected maternal and fetal conditions ruled out, may either be used as a
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Additional codes may be used in addition to the code from subcategory Z03.7, but only if they are unrelated to the suspected condition being evaluated.
Codes from subcategory Z03.7 may not be used for encounters for antenatal screening of mother. See Section I.C.21. Screening.
For encounters for suspected fetal condition that are inconclusive following testing and evaluation, assign the appropriate code from category O35, O36, O40 or O41.
The observation Z code categories:
Z03 Encounter for medical observation for suspected diseases and conditions ruled out
Z04 Encounter for examination and observation for other reasons
Except: Z04.9, Encounter for examination and observation for unspecified reason
Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out
7)Aftercare
Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the
The aftercare Z codes should also not be used for aftercare for
injuries. For aftercare of an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter).
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The aftercare codes are generally
Aftercare codes should be used in conjunction with other aftercare codes or diagnosis codes to provide better detail on the specifics of an aftercare encounter visit, unless otherwise directed by the classification. Should a patient receive multiple types of antineoplastic therapy during the same encounter, code Z51.0, Encounter for antineoplastic radiation therapy, and codes from subcategory Z51.1, Encounter for antineoplastic chemotherapy and immunotherapy, may be used together on a record. The sequencing of multiple aftercare codes depends on the circumstances of the encounter.
Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title.
Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings.
Status Z codes may be used with aftercare Z codes to indicate the nature of the aftercare. For example code Z95.1, Presence of aortocoronary bypass graft, may be used with code Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, to indicate the surgery for which the aftercare is being performed. A status code should not be used when the aftercare code indicates the type of status, such as using Z43.0, Encounter for attention to tracheostomy, with Z93.0, Tracheostomy status.
The aftercare Z category/codes:
Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury
Z43 Encounter for attention to artificial openings
Z44 Encounter for fitting and adjustment of external prosthetic device
Z45 Encounter for adjustment and management of implanted device
Z46 Encounter for fitting and adjustment of other devices
Z47 Orthopedic aftercare
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Z48 Encounter for other postprocedural aftercare
Z49 Encounter for care involving renal dialysis
Z51 Encounter for other aftercare and medical care
8)
The
longer exists. They should not be confused with aftercare codes, or injury codes with a 7th character for subsequent encounter, that explain ongoing care of a healing condition or its sequelae.
A
The
Z08 Encounter for
Z09 Encounter for
Z39 Encounter for maternal postpartum care and examination
9)Donor
Codes in category Z52, Donors of organs and tissues, are used for living individuals who are donating blood or other body tissue. These codes are only for individuals donating for others, not for
10)Counseling
Counseling Z codes are used when a patient or family member receives assistance in the aftermath of an illness or injury, or when support is required in coping with family or social problems. They are not used in conjunction with a diagnosis code when the counseling component of care is considered integral to standard treatment.
The counseling Z codes/categories:
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Z30.0- Encounter for general counseling and advice on contraception
Z31.5 Encounter for genetic counseling
Z31.6- Encounter for general counseling and advice on procreation
Z32.2 Encounter for childbirth instruction
Z32.3 Encounter for childcare instruction
Z69 Encounter for mental health services for victim and perpetrator of abuse
Z70 Counseling related to sexual attitude, behavior and orientation
Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified
Z76.81 Expectant mother prebirth pediatrician visit
11)Encounters for Obstetrical and Reproductive Services
See Section I.C.15. Pregnancy, Childbirth, and the Puerperium, for further instruction on the use of these codes.
Z codes for pregnancy are for use in those circumstances when none of the problems or complications included in the codes from the Obstetrics chapter exist (a routine prenatal visit or postpartum care). Codes in category Z34, Encounter for supervision of normal pregnancy, are always
Codes in category Z3A, Weeks of gestation, may be assigned to provide additional information about the pregnancy. Category
Z3A codes should not be assigned for pregnancies with abortive outcomes (categories
The outcome of delivery, category Z37, should be included on all maternal delivery records. It is always a secondary code. Codes in category Z37 should not be used on the newborn record.
Z codes for family planning (contraceptive) or procreative management and counseling should be included on an obstetric record either during the pregnancy or the postpartum stage, if applicable.
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Z codes/categories for obstetrical and reproductive services:
Z30 Encounter for contraceptive management
Z31 Encounter for procreative management
Z32.2 Encounter for childbirth instruction
Z32.3 Encounter for childcare instruction
Z33 Pregnant state
Z34 Encounter for supervision of normal pregnancy
Z36 Encounter for antenatal screening of mother
Z3A Weeks of gestation
Z37 Outcome of delivery
Z39 Encounter for maternal postpartum care and examination
Z76.81 Expectant mother prebirth pediatrician visit
12)Newborns and Infants
See Section I.C.16. Newborn (Perinatal) Guidelines, for further instruction on the use of these codes.
Newborn Z codes/categories:
Z76.1 Encounter for health supervision and care of foundling
Z00.1- Encounter for routine child health examination
Z38 Liveborn infants according to place of birth and type of delivery
13)Routine and administrative examinations
The Z codes allow for the description of encounters for routine examinations, such as, a general
The codes are not to be used if the examination is for diagnosis of a suspected condition or for treatment purposes. In such cases the diagnosis code is used. During a routine exam, should a diagnosis or condition be discovered, it should be coded as an additional code.
Some of the codes for routine health examinations distinguish between "with" and "without" abnormal findings. Code assignment depends on the information that is known at the time the encounter is being coded. For example, if no abnormal findings were found during the examination, but the encounter is being coded before test results are back, it is acceptable to assign the code for "without abnormal findings." When assigning a code for "with abnormal findings," additional
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code(s) should be assigned to identify the specific abnormal finding(s).
The Z codes/categories for routine and administrative examinations:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis
Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
Z02 Encounter for administrative examination Except: Z02.9, Encounter for administrative examinations, unspecified
Z32.0- Encounter for pregnancy test
14)Miscellaneous Z codes
The miscellaneous Z codes capture a number of other health care encounters that do not fall into one of the other categories. Certain of these codes identify the reason for the encounter; others are for use as additional codes that provide useful information on circumstances that may affect a patient's care and treatment.
Prophylactic Organ Removal
For encounters specifically for prophylactic removal of an organ (such as prophylactic removal of breasts due to a genetic susceptibility to cancer or a family history of cancer), the principal or
If the patient has a malignancy of one site and is having prophylactic removal at another site to prevent either a new primary malignancy or metastatic disease, a code for the malignancy should also be assigned in addition to a code from subcategory Z40.0, Encounter for prophylactic surgery for risk factors related to malignant neoplasms. A Z40.0 code should not be assigned if the patient is having organ removal for treatment of a malignancy, such as the removal of the testes for the treatment of prostate cancer.
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Miscellaneous Z codes/categories:
Z28 Immunization not carried out
Except: Z28.3, Underimmunization status
Z29 Encounter for other prophylactic measures
Z40 Encounter for prophylactic surgery
Z41 Encounter for procedures for purposes other than remedying health state
Except: Z41.9, Encounter for procedure for purposes other than remedying health state, unspecified
Z53 Persons encountering health services for specific procedures and treatment, not carried out
Z55 Problems related to education and literacy
Z56 Problems related to employment and unemployment
Z57 Occupational exposure to risk factors
Z58 Problems related to physical environment
Z59 Problems related to housing and economic circumstances
Z60 Problems related to social environment
Z62 Problems related to upbringing
Z63 Other problems related to primary support group, including family circumstances
Z64 Problems related to certain psychosocial circumstances
Z65 Problems related to other psychosocial circumstances
Z72 Problems related to lifestyle
Note: These codes should be assigned only when the documentation specifies that the patient has an associated problem
Z73 Problems related to life management difficulty
Z74 Problems related to care provider dependency Except: Z74.01, Bed confinement status
Z75 Problems related to medical facilities and other health care
Z76.0 Encounter for issue of repeat prescription
Z76.3 Healthy person accompanying sick person
Z76.4 Other boarder to healthcare facility
Z76.5 Malingerer [conscious simulation]
Z91.1- Patient's noncompliance with medical treatment and regimen
Z91.83 Wandering in diseases classified elsewhere
Z91.89 Other specified personal risk factors, not elsewhere classified
15)Nonspecific Z codes
Certain Z codes are so
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justification for their use in the inpatient setting. Their use in the outpatient setting should be limited to those instances when there is no further documentation to permit more precise coding. Otherwise, any sign or symptom or any other reason for visit that is captured in another code should be used.
Nonspecific Z codes/categories:
Z02.9 Encounter for administrative examinations, unspecified
Z04.9 Encounter for examination and observation for unspecified reason
Z13.9 Encounter for screening, unspecified
Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified
Z52.9 Donor of unspecified organ or tissue
Z86.59 Personal history of other mental and behavioral disorders
Z88.9 Allergy status to unspecified drugs, medicaments and biological substances status
Z92.0 Personal history of contraception
16)Z Codes That May Only be
The following Z codes/categories may only be reported as the
Z00 Encounter for general examination without complaint, suspected or reported diagnosis Except: Z00.6
Z01 Encounter for other special examination without complaint, suspected or reported diagnosis
Z02 Encounter for administrative examination
Z03 Encounter for medical observation for suspected diseases and conditions ruled out
Z04 Encounter for examination and observation for other reasons
Z33.2 Encounter for elective termination of pregnancy
Z31.81 Encounter for male factor infertility in female patient
Z31.83 Encounter for assisted reproductive fertility procedure cycle
Z31.84 Encounter for fertility preservation procedure
Z34 Encounter for supervision of normal pregnancy
Z39 Encounter for maternal postpartum care and examination
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Z38 Liveborn infants according to place of birth and type of delivery
Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury
Z51.0 Encounter for antineoplastic radiation therapy
Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy
Z52 Donors of organs and tissues
Except: Z52.9, Donor of unspecified organ or tissue
Z76.1 Encounter for health supervision and care of foundling
Z76.2 Encounter for health supervision and care of other healthy infant and child
Z99.12 Encounter for respirator [ventilator] dependence during power failure
Section II. Selection of Principal Diagnosis
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp.
Since that time the application of the UHDDS definitions has been expanded to include all non- outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care).
In determining principal diagnosis, coding conventions in the
(See Section I.A., Conventions for the
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.
A. Codes for symptoms, signs, and
Codes for symptoms, signs, and
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B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.
When there are two or more interrelated conditions (such as diseases in the same ICD-
C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
D. Two or more comparative or contrasting conditions
In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.
E. A symptom(s) followed by contrasting/comparative diagnoses
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014
F. Original treatment plan not carried out
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.
G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the
H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements
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for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to
I.Admission from Observation Unit
1.Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.
2.Admission Following
When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
J. Admission from Outpatient Surgery
When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:
â¢If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
â¢If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
â¢If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.
K.Admissions/Encounters for Rehabilitation
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. For example, for an admission/encounter for rehabilitation for
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If the condition for which the rehabilitation service is no longer present, report the appropriate aftercare code as the
See Section I.C.21.c.7, Factors influencing health states and contact with health services, Aftercare.
Section III. Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.
The UHDDS item
Since that time the application of the UHDDS definitions has been expanded to include all non- outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care).
The following guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in
A. Previous conditions
If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and
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procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (categories
B. Abnormal findings
Abnormal findings (laboratory,
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
C. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to
Section IV.Diagnostic Coding and Reporting Guidelines for Outpatient Services
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting
Information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the
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The terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis does not apply to
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
A. Selection of
In the outpatient setting, the term
In determining the
Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.
The most critical rule involves beginning the search for the correct code assignment through the Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding errors.
1.Outpatient Surgery
When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the
2.Observation Stay
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the
When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
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B. Codes from A00.0 through T88.9,
The appropriate code(s) from A00.0 through T88.9,
C. Accurate reporting of
For accurate reporting of
D. Codes that describe symptoms and signs
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of
E. Encounters for circumstances other than a disease or injury
See Section I.C.21. Factors influencing health status and contact with health services.
F. Level of Detail in Coding
1.
2.Use of full number of characters required for a code
A
G.
List first the
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some cases the
H. Uncertain diagnosis
Do not code diagnoses documented as "probable", "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Please note: This differs from the coding practices used by
I. Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)
J. Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80- Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
K. Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
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L. Patients receiving therapeutic services only
For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
M. Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for
N. Ambulatory surgery
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
O. Routine outpatient prenatal visits
See Section I.C.15. Routine outpatient prenatal visits.
P. Encounters for general medical examinations with abnormal findings
The subcategories for encounters for general medical examinations,
Q. Encounters for routine health screenings
See Section I.C.21. Factors influencing health status and contact with health services, Screening
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Appendix I
Present on Admission Reporting Guidelines
Introduction
These guidelines are to be used as a supplement to the
These guidelines are not intended to replace any guidelines in the main body of the
As stated in the Introduction to the
These guidelines are not a substitute for the provider's clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings.
Please see the CDC website for the detailed list of
General Reporting Requirements
All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.
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Present on admission is defined as present at the time the order for inpatient admission occurs
POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.
If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.
Reporting Options
Y - Yes
N - No
U - Unknown
W - Clinically undetermined
Unreported/Not used - (Exempt from POA reporting)
Reporting Definitions
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition is present on admission W = provider is unable to clinically determine whether condition was present on admission or not
Timeframe for POA Identification and Documentation
There is no required timeframe as to when a provider (per the definition of "provider" used in these guidelines) must identify or document a condition to be present on admission. In some clinical situations, it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider's best clinical judgment.
If at the time of code assignment the documentation is unclear as to whether a condition was present on admission or not, it is appropriate to query the provider for clarification.
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Assigning the POA Indicator
Condition is on the "Exempt from Reporting" list
Leave the "present on admission" field blank if the condition is on the list of
POA Explicitly Documented
Assign Y for any condition the provider explicitly documents as being present on admission.
Assign N for any condition the provider explicitly documents as not present at the time of admission.
Conditions diagnosed prior to inpatient admission
Assign "Y" for conditions that were diagnosed prior to admission (example: hypertension, diabetes mellitus, asthma)
Conditions diagnosed during the admission but clearly present before admission Assign "Y" for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.
Diagnoses subsequently confirmed after admission are considered present on admission if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis, or constitute an underlying cause of a symptom that is present at the time of admission.
Condition develops during outpatient encounter prior to inpatient admission
Assign Y for any condition that develops during an outpatient encounter prior to a written order for inpatient admission.
Documentation does not indicate whether condition was present on admission Assign "U" when the medical record documentation is unclear as to whether the condition was present on admission. "U" should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.
Documentation states that it cannot be determined whether the condition was or was not present on admission
Assign "W" when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission.
Chronic condition with acute exacerbation during the admission
If a single code identifies both the chronic condition and the acute exacerbation, see POA guidelines pertaining to codes that contain multiple clinical concepts.
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If a single code only identifies the chronic condition and not the acute exacerbation (e.g., acute exacerbation of chronic leukemia), assign "Y."
Conditions documented as possible, probable, suspected, or rule out at the time of discharge
If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings suspected at the time of inpatient admission, assign "Y."
If the final diagnosis contains a possible, probable, suspected, or rule out diagnosis, and this diagnosis was based on signs, symptoms or clinical findings that were not present on admission, assign "N".
Conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were present on admission, assign "Y".
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were not present on admission, assign "N".
Acute and Chronic Conditions
Assign "Y" for acute conditions that are present at time of admission and N for acute conditions that are not present at time of admission.
Assign "Y" for chronic conditions, even though the condition may not be diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the POA guidelines for codes that contain multiple clinical concepts.
Codes That Contain Multiple Clinical Concepts
Assign "N" if at least one of the clinical concepts included in the code was not present on admission (e.g., COPD with acute exacerbation and the exacerbation was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission).
Assign "Y" if all of the clinical concepts included in the code were present on admission (e.g., duodenal ulcer that perforates prior to admission).
For infection codes that include the causal organism, assign "Y" if the infection (or signs of the infection) were present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with pneumonia and the provider documents Pseudomonas as the causal organism a few days later).
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Same Diagnosis Code for Two or More Conditions
When the same
Assign "Y" if all conditions represented by the single
Assign "N" if any of the conditions represented by the single
Obstetrical conditions
Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not.
If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign "Y".
If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2nd degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign "N".
If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign "N".
(e.g., Category O11,
Perinatal conditions
Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned "Y". This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal).
Congenital conditions and anomalies
Assign "Y" for congenital conditions and anomalies except for categories Q00- Q99, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission.
External cause of injury codes
Assign "Y" for any external cause code representing an external cause of morbidity that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission)
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Assign "N" for any external cause code representing an external cause of morbidity that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission)
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