Workbook
Even though there is still time for excitement and planning as with any new change there is a certain
amount of anxiety that is expected with such a major overhaul such as the ICD-10 system will bring with
it. So, the best way to alleviate the “fear of change or the fear of the unknown” is to meet it head on.
The best way to do this is by learning and preparing earlier than later for what is to come.
In this workbook you will find information in regards to ICD-10-CM and ICD-10-PCS. You will find great
detail in regards to the ICD-10 PCS characters including definitions, guidelines and examples.
Why is ICD-10 important to our ever evolving healthcare system at this juncture? It is important to note
the World Health Organization developed and released the ICD-10 coding system a decade ago and it is
currently used worldwide for classification of diseases and signs, symptoms, abnormal findings,
complaints, social circumstances and external causes of injury or diseases. The United States is the last
industrialized country in the world to implement ICD-10. The International Classification of Diseases
(ICD) 10th revision, allows enhancement for the efficiency of clinical data collection and the quality of
administrative data. ICD-9-CM is outdated without room for expansion to meet the needs of new
disease processes and utilizes antiquated terminology. The increased specificity related to the
classification of diseases allows for improved quality measures, research capability, value based
purchasing initiatives and cost efficiency.
There has been much controversy and anxiety related to the transition to ICD-10 due to costs required
to update systems and the exchange of healthcare information necessary for payment. In addition, the
necessary education for all involved in the coding and classification of disease processes is also costly
and time consuming. In many cases, anatomy and physiology, medical terminology, pathophysiology,
and pharmacology will have to be learned or require refreshing knowledge bases for these subjects
because coder knowledge of these topics haven’t been updated since their primary education. Needless
to say, it will be a “team effort” between providers, physicians and payers to make this transition as
smooth as possible.
One of the key areas we can influence during the next year is physician documentation. Understanding
the key differences in the classification system and how it impacts physician documentation of diseases
will help you communicate with the physician and prepare him/her for the increased specificity required
for ICD-10-CM. These sessions along with this workbook will be helpful in education of providers and
other service providers with documentation privileges in the patient record.
Source; AHIMA Special E-ALERT February 22, 2012, CEO Lynne Thomas Gordon
Benefits of ICD-10-CM
ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and
disease classification have been updated to be consistent with current clinical practice. The modern
classification system will provide much better data needed for:
Non-specific codes still exist for use when the medical record documentation does not support a more
specific code.
The 7th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal,
and External Cause chapters). It has a different meaning depending on the section where it is being used
(e.g., in the Injury and External Cause sections, the 7th character classifies an initial encounter,
subsequent encounter, or sequelae (late effect)). Primarily, changes in ICD-10-CM are in its organization
and structure, code composition, and level of detail.
Laterality
Combination Codes (for conditions with common manifestations, e.g., Crohn’s disease with
rectal bleeding, obstruction, etc.)
Excludes Notes
Excludes 1
Excludes 2
Expanded Codes (e.g., Non-pressure ulcer codes now delineate depth of ulcer (e.g., with fat layer
exposed, with necrosis of muscle, etc.)
Injuries are grouped by anatomical site rather than by type of injury
Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters,
resulting in the classification of certain diseases and disorders that are different from ICD-9-CM
Certain diseases have been reclassified to different chapters or sections in order to reflect current
medical knowledge
New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8
weeks)
The codes corresponding to ICD-9-CM V codes (Factors Influencing Health Status and Contact with
Health Services) and E codes (External Causes of Injury and Poisoning) are incorporated into the main
classification rather than separated into supplementary classifications as they were in ICD-9-CM
Placeholder character; The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a
placeholder at certain codes to allow for future expansion. An example of this is at the poisoning,
adverse effect and underdosing codes, categories T36-T50. Where a placeholder exists, the X must be
used in order for the code to be considered a valid code.
7th Characters; Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th
character is required for all codes within the category, or as the notes in the Tabular List instruct. The
7th character must always be the 7th character in the data field. If a code that requires a 7th
character is not 6 characters, a placeholder X must be used to fill in the empty characters.
Episode of care for most injuries is incorporated into the injury codes
Diagnosis codes are to be used and reported at their highest number of characters available. ICD-10-
CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three
characters are included in ICD-10-CM as the heading of a category of codes that may be further
subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater
detail. A three-character code is to be used only if it is not further subdivided. A code is invalid if it
has not been coded to the full number of characters required for that code, including the 7th
character, if applicable.
Laterality
The Laterality guideline states “For bilateral sites, the final character of the codes in the ICD-10-CM
indicates laterality. An unspecified side code is also provided should the side not be identified in the
medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes
for both the left and right side
[ ] 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 Disease 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 ICD-10-CM Alphabetic Index under the main term Enteritis, “acute”
is a nonessential modifier and “chronic” is a subentry. In this case, the nonessential modifier “acute”
does not apply to the subentry “chronic”.
Excludes 1 note is a pure excludes note. It means “NOT CODED HERE!” An Excludes 1 note indicates
the code excluded should never be used when two conditions cannot occur together, such as a
congenital form versus an acquired form of the same condition.
Excludes 2 note means “Not included here.” This type of excludes 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 Excludes 2 note appears under a code, it is acceptable to use
both the code and the excluded code together if the patient has both conditions.
Chapter 2.c.1 and 2.c.2 (Anemia and malignancy) significant change in ICD-10-CM
Guideline – 2.c.1 states 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 first-listed diagnosis followed by
the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).
Guideline – 2.c.2 states 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).
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
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 T36-T50. The poisoning codes have an associated intent as their 5th or 6th character
accidental, intentional self-harm, assault and undetermined. Use additional code(s) for all
manifestations of poisonings.
Underdosing
Certain diseases have also been rearranged in Chapter 1 of ICD-10-CM. For example, a separate
subchapter, or block, has been created and appropriate conditions grouped together for Infections with
a predominantly sexual mode of transmission (A50-A64). Two additional examples of separate blocks
being created with the appropriate conditions grouped together are viral hepatitis (B15-B19) and other
viral diseases (B25-B34).
Some terminology changes and revisions to the classification of specific infectious and parasitic disease
in ICD-10-CM have occurred as well. For instance, the term sepsis has replaced septicemia throughout
Chapter 1. Additionally, streptococcal sore throat and its inclusion terms found in the Infectious and
Parasitic Disease chapter of ICD-9-CM are reclassified in ICD-10-CM to Chapter 10: Diseases of the
respiratory system.
Many of the codes in Chapter 1 of ICD-10-CM have been expanded to reflect manifestations of the
disease with the use of fourth or fifth characters allowing the infectious disease and manifestation to be
captured in one code instead of two.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
This patient is a 36-year-old HIV positive male who comes in with fever and cough. Final diagnosis was
Pneumocystis pneumonia due to AIDS.
____________________________________________________________________________________________
C00-C75 Malignant neoplasms stated or presumed to be primary (of specific sites) and certain
specified histologies, except neuroendocrine, and of lymphoid, hematopoietic and related
tissues
C00-C14 Malignant neoplasms of lip, oral cavity and pharynx
C15-C26 Malignant neoplasms of digestive organs
C30-C39 Malignant neoplasms of respiratory and intrathoracic organs
C40-C41 Malignant neoplasms of bone and articular cartilage
C43-C44 Melanoma and other malignant neoplasms of skin
C45-C49 Malignant neoplasms mesothelial and soft tissue
C50 Malignant neoplasms of breast
C51-C58 Malignant neoplasms of female genital organs
C60-C63 Malignant neoplasms of male genital organs
C64-C68 Malignant neoplasms of urinary tract
C69-C72 Malignant neoplasms of eye, brain and other parts of central nervous system
C73-C75 Malignant neoplasms of thyroid and other endocrine glands
C7A Malignant neuroendocrine tumors
C7B Secondary neuroendocrine tumors
C76-C80 Malignant neoplasms of ill-defined, other secondary and unspecified sites
C81-C96 Malignant neoplasm of lymphoid, hematopoietic and related tissue
D00-D09 In situ neoplasms
D10-D36 Benign neoplasms except benign neuroendocrine tumors
Neoplasm Guidelines
A new guideline under category D3A, Benign neuroendocrine tumor instructs the coding professional to
code additional disorders.
Another new guideline is found under many of the categories for malignant neoplasms. This guideline
instructs coding professionals to use an additional code to identify such conditions as alcohol abuse and
dependence, alcohol dependence in remission, tobacco dependence, and history of tobacco use.
The NCHS has published chapter-specific guidelines for Chapter 2 of ICD-10-CM. Some of these
guidelines are:
Neoplasm Scenarios
Scenario 4 (Coding):
56-year-old male is being seen today for chemotherapy treatment. Patient has a diagnosis of carcinoma
of the small intestines, in the area where the duodenum and jejunum join. This carcinoma was totally
removed three months ago.
_________________________________________________________________________________ ___________
____________________________________________________________________________________________
Scenario 6 (Coding):
A patient received scheduled chemotherapy treatment for lung cancer today in the hospital outpatient
department. The patient underwent removal of malignant nodule in the upper lobe of the right lung 4
weeks ago.
____________________________________________________________________________________________
Coding professionals will find the organizational structure of ICD-10-CM’s Chapter 3 an improvement
over ICD-9-CM’s Chapter 4: Diseases of the Blood and Blood-forming Organs. Diseases and disorders
have been grouped into subchapters or blocks making it easier to identify the type of conditions
classified to Chapter 3. Modifications have also been made to specific categories that bring the
terminology up-to-date with current medical practice. Other enhancements to Chapter 3 include
classification changes that provide greater specificity than found in ICD-9-CM.
The last block in this chapter (D80-D89) groups disorders involving the immune mechanism. The
immunodeficiency disorders have been reclassified from Chapter 4: Endocrine, Nutritional and
Metabolic Diseases, and Immunity Disorders in ICD-9-CM to Chapter 3 in ICD-10-CM.
Blood and Blood Forming Organs and Certain Disorders Involving the Immune
Mechanism Scenarios
Scenario 7 (Coding):
This 48-year-old female is seen for sickle-cell crisis with acute chest syndrome
____________________________________________________________________________________________
Scenario 8 (Coding):
This is an elderly woman being seen in the ER with complaints of nausea and not “feeling like eating.”
During the gastrointestinal work-up, mild gastritis was revealed. Lab work also indicated anemia,
probably due to the lack of nutrition. Admitted to inpatient stay.
____________________________________________________________________________________________
Scenario 9 (Coding):
This 25-year-old male was admitted to the hospital with pain symptoms related to sickle cell/HB-SS
disease. Chest x-ray was performed and revealed evidence of acute chest syndrome.
____________________________________________________________________________________________
A number of new subchapters have been added to the chapter for endocrine, nutritional, and metabolic
diseases. For example, diabetes mellitus and malnutrition have their own subchapter while these
conditions were grouped with diseases of other endocrine glands and nutritional deficiencies
respectively. Code titles have been revised in a number of places in Chapter 4.
A significant change to ICD-10-CM is the classification of diabetes mellitus. Instead of a single category
(250) as in ICD-9-CM, there are five categories for diabetes mellitus in ICD-10-CM. Additionally, diabetes
mellitus codes have been expanded to reflect manifestations and complications of the disease by using
fourth or fifth characters rather than by using an additional code to identify the manifestation. ICD-10-
CM classifies inadequately controlled, out of control, and poorly controlled diabetes mellitus to diabetes
mellitus, by type with hyperglycemia.
____________________________________________________________________________________________
____________________________________________________________________________________________
Changes were necessary in many parts of Chapter 5 because of outdated terminology. For example,
given what has been discovered in the past 20 years about the effects of nicotine, ICD-10-CM contains a
separate category F17 for nicotine dependence with subcategories to identify the specific tobacco
product and nicotine-induced disorders. ICD-9-CM has a single code, 305.1, for tobacco use disorder or
tobacco dependence.
The identification of the stage of the substance use, namely continuous or episodic, is not a part of ICD-
10-CM. A single ICD-10-CM code identifies not only the substance but also the disorder the substance
use induced. There continues to be codes for substance dependence “in remission.”
____________________________________________________________________________________________
Scenario 13 (Coding):
This is a 27-year-old female patient who was brought in to the emergency department by police after
becoming disorderly and aggressive at a restaurant. She admits to a history of paranoid schizophrenia.
Diagnoses: Schizophrenia, paranoid type, chronic with acute exacerbation. Borderline personality
disorder.
____________________________________________________________________________________________
Scenario 14 (Coding):
This is a 33-year-old male brought to the emergency room following a seizure. Family member states
that he is a heavy drinker. Final Diagnosis: Alcohol Withdrawal.
________________________________________________________________________ ____________________
The organization of Chapter 6 in ICD-10-CM is comparable to that in ICD-9-CM. One change to note is
that only diseases of the nervous system are contained in Chapter 6 of ICD-10-CM. Diseases of the sense
organs, namely eye/adnexa and ear/mastoid processes, each have their own chapter in ICD-10-CM while
they are combined into a single chapter in ICD-9-CM. A few categories in Chapter 6 have rephrased titles
and in some cases encompass a combination of conditions. Additionally, a number of codes for diseases
of the nervous system have been expanded in ICD-10-CM.
____________________________________________________________________________________________
Scenario 16 (Coding):
Patient is seen today for hemiparesis of the right side. She has had this status for over a year.
____________________________________________________________________________________________
Scenario 17 (Coding):
This is a 72-year-old female patient who has been experiencing episodes of memory loss and loss of time
and place and sometimes does not recognize family. The patient has been experiencing these episodes
gradually over the past year, but in the past two months, her condition has worsened. In the past few
weeks, the patient has been getting aggressive and abusive with family. Patient was diagnosed with
Alzheimer’s Dementia.
____________________________________________________________________________________________
Chapter 7 is an entirely new chapter in ICD-10-CM. In ICD-9-CM, the conditions classified in this chapter
are located in Chapter 6: Diseases of the Nervous System and Sense Organs. Chapter 7 in ICD-10-CM also
has a different organization than what is found in ICD-9-CM. While the structure is still by “site” for
diseases of the eye and adnexa, the order differs.
Some categories in Chapter 7 have undergone title changes to reflect the terminology used today. For
example, ICD-9-CM uses senile cataract while ICD-10-CM utilizes the descriptor age-related cataract.
Many of the classification changes in Chapter 7 have to do with the expansion of characters to provide
for laterality. ICD-10-CM contains codes for right side, left side, and in some instances bilateral sides for
diseases of the eye and adnexa.
____________________________________________________________________________________________
Scenario 19 (Coding):
This is a 56-year-old female patient with long-standing, primary open-angle glaucoma and age-related
bilateral macular degeneration. Patient is admitted because of abnormally high intraocular pressure.
____________________________________________________________________________________________
Chapter 8 is an entirely new chapter in ICD-10-CM. In ICD-9-CM, the conditions classified in this chapter
are located in Chapter 6: Diseases of the Nervous System and Sense Organs. Diseases of the ear and
mastoid process have been arranged into blocks making it easier to identify the types of conditions t hat
would occur in the external ear (block 1), middle ear and mastoid (block 2), and inner ear (block 3). Block
4 is used for other disorders of the ear. Block 5 contains the codes for intraoperative and postprocedural
complications. The intraoperative and postprocedural complications are grouped at the end of the
chapter rather than scattered throughout different categories. Category and subcategory titles have
been revised in a number of locations in Chapter 8.
Although Chapter 8 in ICD-10-CM basically parallels the corresponding section in Chapter 6 of ICD-9-CM,
there are quite a few changes. These changes include greater specificity added at the fourth-, fifth- and
sixth-character levels; the delineation of laterality and the addition of many more “code first underlying
disease” notes.
One last noted classification change in this chapter is that the ICD-9-CM category 381, Nonsuppurative
otitis media and Eustachian tube disorders, has been split into two categories in ICD -10-CM; H65,
Nonsuppurative otitis media and H68, Eustachian salpingitis and obstruction.
Another new guideline is found under the category for suppurative and unspecified otitis media (H66).
The note instructs coding professionals to use an additional code to identify: exposure to environmental
tobacco smoke (Z77.22), exposure to tobacco smoke in the perinatal period (P96.81), history of tobacco
use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence
(F17.-), or tobacco use (Z72.0).
At this time, there are no chapter-specific guidelines related to Chapter 8: Diseases of the ears and
mastoid process.
____________________________________________________________________________________________
Scenario 21(Coding):
The 42-year-old male has bilateral conductive hearing loss due to nonobliterative conductive hearing loss
due to nonobliterative otosclerosis of the staples at the oval window. He is unable to hear with hearing
aids and has decided to undergo left stapedectomy. During surgery an inadvertent laceration was made
to the tympanic meatal flap which was repaired.
____________________________________________________________________________________________
The organization of Chapter 9 in ICD-10-CM is comparable to Chapter 7 in ICD-9-CM. One change to note
is the order of conditions within the block for ischemic heart disease.
One last noted change is with the classification of hypertension. In ICD-9-CM, hypertension codes
classify the type of hypertension (benign, malignant, unspecified). In ICD-10-CM, hypertension codes no
longer classify the type.
New guidelines that clarify code usage are also found under specific codes. Under code I05, rheumatic
mitral valve diseases, is a note that states this category includes conditions classifiable to both I05.0 and
I05.2-I05.9, whether specified as rheumatic or not.
The NCHS has published chapter-specific guidelines for Chapter 9 of ICD-10-CM:
____________________________________________________________________________________________
Scenario 23 (Coding):
Pulmonary Endarteritis
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 25 (Coding):
Acute Cerebrovascular infarction-embolism of the left cerebral artery with dysphagia and right
hemiplegia, dominant side. What diagnosis codes are assigned?
_________________________________________________________________ ___________________________
Scenario 26 (Coding):
Patient presented to the emergency department two weeks after being admitted for a previous MI and
was diagnosed with an acute inferior wall myocardial infarction. She is still being monitored following
her initial heart attack three weeks earlier and continues to have atrial fibrillation. She will be transferred
to a larger facility for a cardiac catheterization and possible further intervention. Please assign diagnosis
codes.
_______________________________________________________________________________ _____________
Scenario 27 (Coding):
This 54-year-old female is being treated for an acute non-ST anterior wall myocardial infarction which
she suffered 5 days ago. She also has atrial fibrillation.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 29 (Coding):
Chronic Obstructive Bronchitis
____________________________________________________________________________________________
Scenario 30 (Coding):
Acute Respiratory Failure
____________________________________________________________________________________________
Scenario 31 (Coding):
Discharge diagnosis: Moderate persistent asthma with status asthmaticus, Acute exacerbation of chronic
obstructive pulmonary disease. Hospital Course: The patient presented with gradual increase in
shortness of breath, which was unresponsive to home nebulizer treatments. In the emergency room, he
received more respiratory treatments; however, he failed to improve. Therefore, the patient was
admitted to the hospital. At the time of admission, the theophylline level was 5.9. Chest x-ray showed no
evidence of active infiltrates. The patient was bolused with intravenous steroids and started on frequent
respiratory therapy treatments. IV aminophylline boluses and drip were used to increase his theophylline
level to therapeutic range. The patient gradually cleared and by the next day was much better. His IV
aminophylline was changed to p.o. The Ventolin treatments were decreased to q 4 hr. and his steroids
were rapidly tapered back to 10 mg. of Prednisone. What diagnosis codes are assigned?
____________________________________________________________________________________________
A number of new subchapters have been added to the chapter for diseases of the digestive system. For
instance, in ICD-10-CM diseases of the liver have their own subchapter or block while these conditions
were grouped with other diseases of the digestive system in ICD-9-CM. Some terminology changes and
revisions to the classification of specific digestive conditions have occurred in ICD-10-CM as well.
ICD-10-CM category K50, Crohn’s disease, has been expanded to the fourth, fifth, and sixth character in
contrast to ICD-9-CM category 555, Regional enteritis. The expansion at the fourth character level
specifies the site of the Crohn’s disease, the fifth character indicates whether a complication was
present and the sixth character further classifies the specific complication.
In ICD-9-CM, the presence or absence of obstruction is used as an axis for classifying ulcers. In ICD -10-
CM a fairly substantial classification change was made and the identification of obstruction is no longer a
part of the ICD-10-CM ulcer code structure.
At this time, there are no chapter-specific guidelines related to Chapter 11: Diseases of the digestive
system.
_______________________________________________________________ _____________________________
Scenario 33 (Coding):
Acute cholecystitis w/ stone in Gallbladder.
____________________________________________________________________________________________
Scenario 34 (Coding):
Acute suppurative peritonitis due to E Coli.
____________________________________________________________________________________________
Scenario 35 (Coding):
A 68-year-old man was admitted to the hospital for bilateral inguinal hernia repair that could not be
done on an outpatient basis because of anticipated extended recovery time required due to his COPD,
chronic low back pain, and hypertension. After being prepared for surgery, the patient complained of
precordial chest pain. The surgery was cancelled and the patient was returned to his room. Cardiac
studies failed to find a reason for the chest pain which resolved later that day. What are the correct
diagnosis codes?
____________________________________________________________________________________________
ICD-10-CM Chapter 12 represents a complete restructuring to bring together groups of diseases that are
related to one another in some way. Additionally, greater specificity has been added to many of the
codes at either the fourth-, fifth- and even sixth-character level. ICD-9-CM Chapter 12 has only three
subchapters which have been expanded in ICD-10-CM to create the nine blocks listed above.
One example of an organizational change to Chapter 12 of ICD-10-CM is a subchapter or block for ICD-
10-CM codes for radiation-related disorders of the skin and subcutaneous tissue. The conditions found
in this block are not located together in ICD-9-CM.
Some categories in Chapter 12 have undergone title changes to reflect terminology in use today. For
instance, ICD-10-CM uses androgenic alopecia while this term is not used at all in ICD-9-CM.
An example of a classification improvement is the addition of characters in ICD-10-CM to represent the
site and severity of the decubitus ulcer.
With the formation of new categories for allergic (L23) and irritant (L24) contact dermatitis, new
instructions on which condition to code first, that is, the drug or substance, have also been created.
This instruction is different from the one found under ICD-9-CM code 692.3, dermatitis due to drugs and
medicines in contact with the skin, which states to use an additional E code to identify the drug.
The NCHS has published chapter-specific guidelines for Chapter 12 of ICD-10-CM:
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 38 (Coding):
Stage IV Decubitus Ulcer, Left Hip
____________________________________________________________________________________________
Scenario 39 (Coding):
This 35-year-old male patient presents with edema, redness, and pain of the left big toe. He did not seek
treatment because he thought it would improve on its own. He does not remember any injury, but the
pain has gotten progressively worse for the past week. Diagnosis: Gangrenous abscess of the entire left
big toe. What diagnosis codes are assigned?
____________________________________________________________________________________________
Almost every code in Chapter 13 of ICD-10-CM has been expanded in some way with the expansion
including very specific sites as well as laterality. Numerous codes have been moved from various
chapters in ICD-9-CM to Chapter 13 in ICD-10-CM.
Category M80 in ICD-10-CM classifies the type of osteoporosis in addition to the site of a current
pathological fracture into one combination code.
Additionally, some categories and subcategories in Chapter 13 require the use of seventh character
extensions.
The seventh character extensions are:
Instructional notes have also been added to different categories or subcategories to explain how codes
should be assigned.
Notes have also been used to define terms.
The NCHS has published chapter-specific guidelines for Chapter 13 of ICD-10-CM:
____________________________________________________________________________________________
Scenario 41 (Coding):
Old Bucket Handle Tear, Lateral Meniscus, Right Knee
____________________________________________________________________________________________
Scenario 42 (Coding):
Nonunion Pathological Distal Right Humerus
____________________________________________________________________________________________
Scenario 43 (Coding):
This young man is being treated for his ongoing juvenile rheumatoid arthritis. This condition is found only
in both ankles and feet. What diagnosis codes are assigned?
____________________________________________________________________________________________
For the most part, those genitourinary disorders in diseases classified elsewhere have been placed in
their own category at the end of each block of Chapter 14. This differs from ICD-9-CM in that these
conditions were classified within different subcategories.
Changes were necessary in some sections of Chapter 14 because of outdated terminology. For example,
given what has been discovered since the last revision of ICD about male erectile dysfunction, ICD-10-
CM includes category N52 for this condition with subcategories to identify the different causes of the
dysfunction. ICD-9-CM has a single code, 607.84, for impotence of organic origin.
____________________________________________________________________________________________
_____________________________________________________________________________ _______________
Scenario 46 (Coding):
Chronic Interstitial Cystitis with Hematuria
____________________________________________________________________________________________
Scenario 47 (Coding):
This 45-year-old female is currently being treated for chronic kidney disease, stage 3. She has previously
undergone a kidney transplant but still continues to suffer from chronic kidney disease. This patient is
also treated for hypothyroidism following removal of the thyroid for thyroid carcinoma. At this time,
there is no longer evidence of an existing thyroid malignancy. What diagnosis codes are assigned?
____________________________________________________________________________________________
With respect to classification changes, episode of care is no longer a secondary axis of classification for
most conditions classified in Chapter 15. Instead ICD-10-CM identifies the trimester in which the
condition occurred at the fifth- and sixth-character level.
Code titles have been revised in a number of locations in Chapter 15. For instance, ICD -9-CM’s
terminology states the indication for care such as inlet contractions of pelvis (653.2). I CD-10-CM
terminology is much more descriptive of what the code represents, that is, maternal care for
disproportion due to inlet contractions of pelvis (O33.2).
Codes for elective (legal or therapeutic) abortion are classified with the abortion codes in ICD-9-CM. In
contrast, the elective abortion (without complication) code has been moved to code Z33.2, Encounter
for elective termination of pregnancy, in Chapter 21 of ICD-10-CM. Complications of induced
termination of pregnancy are found in category O04.
ICD-10-CM requires the use of a seventh character extension to identify the fetus to which certain
complication codes apply.
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 Z3A, weeks of gestation, may be assigned to provide additional information about the
pregnancy. The date of the admission should be used to determine weeks of gestation for impatient
admission that encompasses more than one gestational week.
____________________________________________________________________________________________
Scenario 49 (Coding):
The patient, G2P1, in her 12th week of pregnancy developed severe cramping and vaginal bleeding. The
patient was subsequently taken to the emergency department and was admitted to the hospital. After
examination, the physician documented that the patient had an incomplete early spontaneous abortion.
During this pregnancy the patient had been treated for gestational hypertension of pregnancy, for which
she was monitored during this hospital stay. The patient was taken to surgery where a dilation and
curettage was performed. There were no complications following surgery. Code the diagnoses codes
only.
____________________________________________________________________________________________
Scenario 50 (Coding)
Code the following diagnosis code(s): 20-week pregnancy with low weight gain and pre-existing essential
hypertension complicating the pregnancy.
____________________________________________________________________________________________
P00-P04 Newborn affected by maternal factors and by complications of pregnancy, labor and
delivery
P05-P08 Disorders related to length of gestation and fetal growth
P09 Abnormal findings on neonatal screening
P10-P15 Birth trauma
P19-P29 Respiratory and cardiovascular disorders specific to the perinatal period
P35-P39 Infections specific to the perinatal period
P50-P61 Hemorrhagic and hematological disorders of newborn
P70-P74 Transitory endocrine and metabolic disorders specific to newborn
P76-P78 Digestive system disorders of newborn
P80-P83 Conditions involving the integument and temperature regulation of newborn
P84 Other problems with newborn
P90-P96 Other disorders originating in the perinatal period
A number of new subchapters have been added to Chapter 16 for certain conditions originating in the
perinatal period.
Chapter 16 of ICD-10-CM also contains terminology updates. The terms “fetus” and “newborn” used in
many ICD-9-CM code titles have been removed from ICD-10-CM code titles. Additionally, in the first
block in ICD-10-CM, newborns affected by maternal factors and by complications of pregnancy, labor,
and delivery, the phrase “suspected to be” is included in the code title as a nonessential modifier to
indicate that the codes are for use when the listed maternal condition is specified as the cause of
confirmed or suspected newborn morbidity or potential morbidity.
Some revisions to the classification have occurred as well. For instance, the subclassification for 2,500 g
and over for birth weight is no longer an option for category P05.
Codes from this chapter are only for use on the newborn or infant record, never on the maternal record
as indicated by a note that appears at the beginning of Chapter 16. Codes from this chapter are also only
applicable for liveborn infants. Further, should a condition originate in the perinatal period and continue
____________________________________________________________________________________________
Scenario 52 (Coding):
Assign the code(s) for the following diagnosis: 20-day-old infant was admitted with Staphylococcus
aureus sepsis.
____________________________________________________________________________________________
The arrangement of ICD-10-CM’s Chapter 17 is an improvement over ICD-9-CM’s Chapter 14. Congenital
malformations, deformations, and chromosomal abnormalities have been grouped into subchapters or
blocks making it easier to identify the type of conditions classified to Chapter 17.
____________________________________________________________________________________________
Scenario 54 (Coding):
Assign the code(s) for the following diagnosis: Penoscrotal hypospadias.
____________________________________________________________________________________________
R00-R09 Symptoms and signs involving the circulatory and respiratory systems
R10-R19 Symptoms and signs involving the digestive system and abdomen
R20-R23 Symptoms and signs involving the skin and subcutaneous tissue
R25-R29 Symptoms and signs involving the nervous and musculoskeletal systems
R30-R39 Symptoms and signs involving the genitourinary system
R40-R46 Symptoms and signs involving cognition, perception, emotional state and behavior
R47-R49 Symptoms and signs involving speech and voice
R50-R69 General symptoms and signs
R70-R79 Abnormal findings on examination of blood, without diagnosis
R80-R82 Abnormal findings on examination of urine, without diagnosis
R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without
diagnosis
R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
R97 Abnormal tumor markers
R99 Ill-defined and unknown cause of mortality
Chapter 18 of ICD-10-CM has undergone some organizational changes. For example, in ICD-10-CM codes
for general symptoms and signs follow those related specifically to a body system or other relevant
grouping. In the comparison of Chapter 18 of ICD-10-CM to Chapter 16 of ICD-9-CM it is evident that
some codes have been moved from one chapter to another. A fairly substantial classification change
was made to hematuria. Various types of hematuria are coded in Chapter 18 unless included with the
underlying condition such as acute cystitis with hematuria. In those cases, the code is found in Chapter
14, Diseases of the genitourinary system.
New guidelines that clarify code usage are also found under specific codes. Code R52, pain unspecified,
includes inclusive terms and Excludes1 notes.
____________________________________________________________________________________________
Scenario 56 (Coding):
Assign the code(s) for the following diagnosis: Sinoatrial bradycardia.
____________________________________________________________________________________________
Superficial injury
Open wound
Fracture
Dislocation and sprain
Injury of nerves
Injury of blood vessels
Injury of muscle and tendon
Crushing injury
Traumatic amputation
Other and unspecified injuries
Some categories in Chapter 19 have undergone title changes to reflect terminology in use today. In ICD-
10-CM, codes from blocks T20-T32 classify burns and corrosions. The addition of the term corrosion is
7th character “D” subsequent encounter is used for encounters after the patient has received active
treatment of the condition and is receiving routine care for the condition during the healing or recovery
phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation
device, medication adjustment, other aftercare and follow up visits following treatment of the injury or
condition.
The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings,
where 7th characters are provided to 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.
Instructions for coding open wounds have changed in ICD-10-CM. The note in ICD-9-CM defined
“complicated” used in the fourth-digit subdivisions to mean those open wounds with infection. ICD-10-
CM contains a note under the different categories for open wounds and directs the coding professional
to code also any associated wound infection.
A similar change has occurred to the instruction for complications of surgical and medical care, not
elsewhere classified (T80-T88). In ICD-9-CM, there is no guideline under this subchapter. However, ICD-
10-CM includes a note stating to use additional code (Y62-Y82) to identify devices involved and details of
circumstances.
Most categories in Chapter 19 have seventh character extensions that identify the encounter:
A initial encounter
D subsequent encounter
S sequela
Additional extensions are available to identify specific encounters for fracture coding. Fracture
extensions are unique to each type of bone and type of fracture.
The NCHS has published chapter-specific guidelines for Chapter 19 of ICD-10-CM:
____________________________________________________________________________________________
Scenario 58 (Coding):
This 85-year old patient is seen in the hospital with a diagnosis of congestive heart failure due to
hypertensive heart disease. Patient also has stage 5 chronic kidney failure. The patient had been
prescribed Lasix previously but admits that he forgets to take his medication every day. This is due to
his advanced age. What are the correct diagnosis codes? (Do not assign external codes.)
____________________________________________________________________________________________
Scenario 59 (Coding):
This patient is seen in follow-up his traumatic displaced lateral epicondyle fracture of the right elbow.
This is healing normally. What is the correct diagnosis code? (Do not assign external cause codes.)
____________________________________________________________________________________________
Scenario 60 (Coding):
This patient is seen emergently for a frontal skull fracture with a subsequent subdural hemorrhage.
There was a 45-minute loss of consciousness at the time of the accident. What is the correct diagnosis
code(s)? (Do not assign the external cause codes.)
____________________________________________________________________________________________
V00-X58 Accidents
V00-V99 Transport accidents
V00-V09 Pedestrian injured in transport accident
V10-V19 Pedal cycle rider injured in transport accident
V20-V29 Motorcycle rider injured in transport accident
V30-V39 Occupant of three-wheeled motor vehicle injured in transport accident
V40-V49 Car occupant injured in transport accident
As previously noted, codes for external causes are no longer found in a supplemental classification in
ICD-10-CM. The causes currently located in the ICD-9-CM E code chapter have been disseminated to
Chapter 19: Injury, poisoning and certain other consequences of external causes, or Chapter 20: External
causes of morbidity. Codes in Chapter 20 capture the cause of the injury or health condition, the intent
(unintentional or accidental; or intentional, such as suicide or assault), the place where the event
Changes in terminology were also necessary due to the revisions made overall to this chapter. In
numerous instances, conditions included as subcategory codes in ICD-9-CM have been given a specific
category code in ICD-10-CM allowing expansion of the codes at the fourth-, fifth-, or sixth-character
level.
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 ICD-10-CM external cause code reporting. Unless a
provider is subject to a state-based external cause code reporting mandate or there codes are required
by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not
required. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily
report external cause codes, as they provide valuable data for injury research and evaluation of injury
prevention strategies.
____________________________________________________________________________________________
Scenario 62 (Coding):
This patient is a 20 year old male who is brought to the emergency department by ambulance, found to
be the victim of a random beating. This patient was walking in his neighborhood park when he was
pulled down and then beaten during a fight. The patient was comatose when found by the paramedics
but did open his eyes in response to pain; however, has no verbal or motor response. The patient was in a
coma upon admission but regained consciousness within 40 minutes of arriving in the ED, less than an
hour after being found. The MRI is negative for fractures or internal bleeding. The physician describes the
injury as a closed head injury with loss of consciousness of less than 1 hour. What diagnosis codes are
assigned?
____________________________________________________________________________________________
Chapter 21: Factors influencing health status and contact with health
services (Z00-Z99)
Coding professionals will find the listing of codes for factors influenci ng health status and contact with
health services a bit different in ICD-10-CM than what is currently found in ICD-9-CM. The following
blocks represent the ICD-10-CM arrangement:
Factors Influencing Health Status and Contact with Health Services Guidelines
The note at the beginning of this chapter has been modified from what it states in ICD -9-CM. All codes in
Chapter 21 are affected by these revised guidelines.
Instructional notes also have been added to different categories to explain how codes should be
assigned.
The NCHS has published chapter-specific guidelines for Chapter 21 of ICD-10-CM:
Factors Influencing Health Status and Contact with Health Services Scenarios
Scenario 63 (Coding):
Assign the code(s) for the following diagnosis: Medical examination of four-year-old child prior to
admission to preschool.
____________________________________________________________________________________________
____________________________________________________________________________________________
CHF classification is a combination code enabling diastolic/systolic heart failure to only require
one (1) code
STEMI AMI codes in ICD-10-CM now classify specific artery involvement for appropriate
classification
Classification now exists for subsequent AMIs within 4 weeks of the initial AMI
Subsequent AMIs require both a code from I21 and I22 category to appropriately classify disease
process
When the patient requires continued care for the myocardial infarction, codes from category I21
may continue to be reported for the duration of 4 weeks (28 days) or less from onset, regardless
of the healthcare setting, including when a patient is transferred from the acute care setting to
the post-acute care setting if the patient is still within the four weeks time frame in ICD-10-CM,
this coding guideline is different from coding guidelines in ICD-9-CM
Respiratory
“Acute” Respiratory Failure – documentation must reflect “acute” – whereas in ICD-9-CM,
unspecified respiratory failure defaulted to “acute respiratory failure”, in ICD-10-CM, it does not
default, therefore documentation of “acute” is required when diagnosing respiratory failure if
appropriate.
COPD and bronchiectasis are further classified to “with lower respiratory infection” and “acute
exacerbation”
Pneumoconiosis due to other inorganic dusts category greatly expanded to classify specific
inorganic dusts
H1N1 influenza and avian influenza are expanded to delineate gastrointestinal manifestations
as well as myocarditis, otitis media, encephalopathy and other manifestations
Instructional notes are more numerous in ICD-10-CM for this chapter than in ICD-9-CM. Coders
will need to pay close attention to instructions for accurate classification of respiratory diseases
Nervous System
Alzheimer’s disease is further classified to early and late onsets
Hereditary ataxia (G11) further sub-divided to delineate Congenital nonprogressive ataxia, Early
onset cerebellar ataxia, Late onset cerebellar ataxia, and Cerebellar ataxia with defective DNA
repair and other/unspecified
Disorders of autonomic nervous system (G90) delineates new category for Complex regional
pain syndrome I (CRPS I) further classifying upper/lower limb and laterality
Cluster, vascular, tension, drug-induced headaches and other trigeminal autonomic cephalgias
(TAC) (G44.0) further classify with/without intractable headache
Hemiplegia and Hemiparesis (G81) as well as monoplegia are further classified to laterality and
dominant/non-dominant sides
Other specified paralytic syndromes (G83) are further subclassified to: Brown-Sequard,
anterior/posterior cord and Todd’s paralysis (postepileptic)
Migraines (G43) are further classified to delineate: Cycling vomiting, Opthalmoplegic migraine,
Periodic headache syndromes in child or adult and Menstrual migraine
Other and unspecified myopathies (G72) are further classified to Drug induced and Alcoholic
Other and unspecified polyneuropathies (G62) are further subdivided to delineate if due to
Critical illness or is Radiation-induced
Endocrine System
Iodine-deficiency thyroid disorders are new classifications in ICD-10-CM and are delineated as
congenital, related thyroid disorders (goiters) and subclinical hypothyroidism due to iodine
deficiency
Poorly controlled, inadequately controlled and out of control diabetes mellitus are classified to
Diabetes, by type, with hyperglycemia – this is a new classification to ICD-10-CM
Gestational diabetes is classified to insulin controlled or diet controlled and puerperal in the OB
chapter
Auto-immune and non-autoimmune anemias (D59) are further subclassified to specify drug-
induced and paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) types as well as other
nonautoimmune hemolytic anemias
Aplastic anemia (D61) is further subclassified to drug-induced, due to other external agents,
idiopathic and other
Other coagulation defects (D68) is expanded to include Hemorrhagic disorder due to extrinsic
circulating anticoagulants (intrinsic already classified in ICD-9-CM) as well as Primary and other
thrombophilia
Diseases of the spleen (D73) are further subdivided to include Hyposplenism, abscess, cyst and
infarction
Sarcoidosis (D86) is significantly expanded to include specific organ systems rather than
requiring an additional code to signify “in diseases classified elsewhere” in each chapter.
Combination codes for sarcoidosis include: Lung, lymph nodes, lung with lymph nodes,
iridocyclitis, pyelonephritis, myocarditis, arthropathy, myositis and other sites)
Infectious Diseases
A second code from subcategory R65.2, Severe sepsis, should not be assigned unless severe
sepsis or an associated acute organ dysfunction is documented
The acute organ dysfunction must be documented by the physician as “due to” the sepsis to be
considered a manifestation of the sepsis thereby qualifying as a “severe” sepsis with organ
dysfunction
Only one code is required to classify sepsis alone with no organ dysfunction or documentation
of severe sepsis
R65.21, Severe sepsis with septic shock, must be assigned if septic shock is documented in the
medical record, even if the term severe sepsis is not documented. Severe sepsis is assumed
when shock is present.
The term “urosepsis” is nonspecific and is not synonymous with sepsis. There is not a default
code in the Alphabetic Index in ICD-10-CM. Should a provider use the term “urosepsis”, he/she
must be queried for clarification of specific disease process.
Disease continuum for sepsis is: bacteremia, septicemia, sepsis, severe sepsis, sepsis with septic
shock and MODS (Multiple Organ Dysfunction Syndrome)
Two (2) common clinical laboratory findings indicating severe sepsis are Hyperlactatemia and
lactic acidosis
Many infectious diseases are further subdivided to specify body system or specific disease
process (i.e., meningitis, peritonitis, etc.) (see Typhoid fever (A01) for an example)
Tuberculosis no longer has a 5th digit subclassification for bacterial or histological findings
Listeriosis is greatly expanded in ICD-10-CM delineating specific body sites for infection. ICD-9-
CM only had 1 code classification for this disease
OB-GYN
Fistulae involving female genital tract classification (N82) is expanded to include Vesicovaginal,
Other urinary-genital tract fistulae, Vagina to small intestine, Vagina to large intestine and Other
intestinal-genital fistulae
Intraoperative and postprocedural complications and disorders of OB-GYN system, are classified
including residual ovary syndrome and post-procedural adhesions of vagina and peritoneum
OB conditions are classified by trimester – 1st trimester (< 14 weeks 0 days), 2nd trimester (14
weeks 0 days to < 28 weeks 0 days) and 3rd trimester (28 weeks 0 days until delivery)
Complications of labor affecting fetus must specify which fetus is affected in those instances
with multiple gestation (i.e., fetus 1,2,3,4,5 or other fetus (when number of fetuses exceeds
quintuplets))
Abortion and ectopic/molar pregnancies with complications are further classified to with cardiac
arrest, sepsis, and UTI
Genitourinary infections affecting pregnancy are classified by specific site, i.e., kidney, bladder,
urethra, cervix, salpingo-oophoritis and other/unspecified sites
Underlying causes of cephalo-pelvic disproportion and other obstructed labor have been
expanded to include both fetal and maternal abnormalities. Documentation of specific
underlying causes is necessary for appropriate classification of these conditions and for accurate
reflection of patient acuity and outcome
Physical, sexual and psychological abuse are classified complicating pregnancy, childbirth and
puerperium with further expansion to delineate trimester of occurrence
Urinary System
Acute and chronic glomerulonephritis/nephrotic/nephritic syndrome categories (N00-N08) have
been significantly revised and expanded in ICD-10-CM to include greater specificity related to
glomerular lesions and glomerulonephritis
Recurrent and persistent hematuria (N02) is now classified in ICD-10-CM with expansion to
include many different types of glomerulonephritis; ICD-9-CM only classified hematuria to
“gross”, “microscopic” or “unspecified”. If hematuria is unspecified it is classified to the Signs
and Symptoms chapter in ICD-10-CM
New classifications for “Hereditary nephropathy” and “Isolated proteinuria with specified
morphological lesion” (N06-N07) are included in ICD-10-CM
Neuromuscular dysfunction of bladder, NEC is created to include Uninhibited, Reflex and Flaccid
neuropathic bladder disorders
NOTE: Please code ONLY the diagnosis codes in the Case Studies
listed below.
Respiratory Disease
Scenario 1 (Coding):
Diagnosis and Procedures: Patient is a 70 year old male admitted to ER short of breath and
dusky appearance. He reports coughing almost non-stop for the last 3 days and is
experiencing severe chest pain. He has a history of COPD. Copious sputum is produced and
cultured. Patient is admitted to the hospital for treatment of bronchitis and respiratory
treatments for severe shortness of breath with a RR 30, PCO2 60, pH 7.29 and hypoxemia.
Patient is placed on a ventilator 6 hours later for 72 hours. Sputum cultures return positive
for Mycoplasma pneumoniae and patient is prescribed azithromycin. With appropriate
documentation of Acute Respiratory Failure, Acute Mycoplasma Bronchitis and ventilator
how would this case be coded?
____________________________________________________________________________________________
___________________________________________________________________________________________
Scenario 2 (Coding):
Diagnosis and Procedures: Patient undergoes a total sigmoidectomy for CA of sigmoid colon
and liver/lymph node biopsies. Patient develops acute pneumothorax 1 day after the
procedure. A chest tube is inserted in the right upper lobe of lung. Pathology report also notes
metastasis to the liver and intestinal lymph nodes. The physician documents CA colon with a
removal of the sigmoid colon and lymph nodes and biopsy of the liver. With appropriate
documentation of diagnoses (CA sigmoid colon, mets to liver/lymph nodes and postprocedura l
pneumothorax) what codes would be utilized?
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: Patient is admitted with cough, sore throat, fever and extreme fatigue with
inability to take a deep breath and shortness of breath. He has a history of rheumatoid
arthritis in both hands for which he has been treated with methotrexate after a flare of the
arthritis. CXR demonstrates an infiltrate in the right middle lobe and diffuse linear opacities.
Patient is admitted to the hospital for treatment. Patient is diagnosed with Interstitial Lung
Pneumonia with no further specifics. With appropriate documentation, how is RA as the
underlying cause of the interstitial pneumonia coded? How would you code the condition if
the medication treatment [Methotrexate] was the underlying cause and it was documented by
the physician as acute drug-induced interstitial pneumonia?
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 4 (Coding):
Diagnosis: Patient is admitted with cough, sore throat, fever and extreme fatigue with
difficulty breathing and shortness of breath. Patient is also extremely nauseous with vomiting
and diarrhea the last 12 hours. Patient appears to be dehydrated with dry mouth and poor
skin turgor. CXR demonstrates an infiltrate in the right middle lobe. Patient is admitted to the
hospital for treatment with IV fluids, antiemetic and antibiotics and antivirals for infiltrate.
Patient is diagnosed with Influenza with no further specifics. With appropriate
documentation of influenza related N&V&D as well as confirmation of infiltrate on CXR as
being influenza pneumonia what codes would be assigned? Patient is also diagnosed with
dehydration.
____________________________________________________________________________________________
Circulatory Disease
Scenario 1 (Coding):
Diagnosis and Procedure: The patient is a 62-year old female who was admitted to another
hospital on 1/8/XX after experiencing tachycardia. There she underwent a cardiac
catheterization, showing the presence of severe two-vessel coronary artery disease. The
patient does not have any history of a CABG in the past. The patient has a history of sick sinus
syndrome, hypertensive heart disease, and CHF. She was transferred to our hospital to
undergo a percutaneous transluminal angioplasty.
Hospital Course: To manage the patient’s sick sinus syndrome, a permanent dual chamber
pacemaker was implanted on 1/9/XX with leads inserted in right atrium and right ventricle.
On 1/10/XX the patient underwent a PTCA of both the left anterior descending artery and the
right coronary artery (with DES) without complications and good results obtained.
Postoperatively, the patient was stable and was subsequently discharged. The patient’s
hypertensive heart disease and CHF were managed and monitored during the hospital stay
and the patient continued taking her normal medications for these conditions.
____________________________________________________________________________________________
____________________________________________________________________________________________
A patient was admitted through the emergency room complaining of chest pain with
radiation down the left arm increasing in severity over the past three hours. Initial impression
was impending myocardial infarction, and the patient was taken dire ctly to the surgical suite,
where percutaneous transluminal angioplasty with insertion of coronary stent was carried
out on the right coronary artery. Infarction was aborted, and the diagnosis was listed as acute
coronary insufficiency.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: A patient was admitted with systolic heart failure, acute on chronic, congestive
heart failure, and unstable angina. The unstable angina was treated with nitrates, and IV
Lasix was administered to manage the heart failure. Both conditions improved, and the
patient was discharged to be followed on an outpatient basis.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 4 (Coding):
Diagnosis and Procedure: The reason for this woman’s admission was for a repair of a 4.7
centimeter infrarenal abdominal aortic aneurysm. She also had arterial hypertension.
Because of her strong family history of aneurysms she wished to have her aneurysm removed
on an elective basis rather than waiting for it to follow its natural course. An infrarenal
excision of the aortic aneurysm, open approach, was performed using a 16 millimeter Dacron
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 5 (Coding):
Diagnosis and Procedure: This patient was admitted for repair of a left common carotid
stenosis. Four months earlier she had suffered a cerebral hemorrhage that resulted in apraxia
which required additional nursing assistance. The open left endarterectomy was successfully
accomplished and the patient was discharged on the fourth hospital day.
____________________________________________________________________________________________
____________________________________________________________________________________________
Endocrine Disease
Scenario 1 (Coding):
Diagnosis: The patient is being seen because of increasingly irritating symptomatology,
including nervousness, irritability, increased perspiration, shakiness and increased appetite
with unexplained weight loss, increased heart rate, palpitations, and sleeping difficulties. A
thyroid stimulating hormone test revealed elevated levels and a thyroid nuclear medicine
scan revealed hyperactivity of the entire thyroid gland. Based on the diagnostic findings the
patient was diagnosed with hyperthyroidism with multinodular goiter. The patient was
started on oral anti-thyroid medication. Arrangements were also made for patient to see a
cardiologist due to the fact her palpitations were more pronounced than seen in other
patients with hyperthyroidism. What diagnosis codes are assigned?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: A 35 year old woman was having flushing and sleeplessness due to premature
menopause.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 4 (Coding):
Diagnosis: Patient with type 2 diabetes mellitus participated in a strenuous game of
racquetball without adjusting his insulin dosage; he is admitted with blood sugar of 35 and is
diagnosed as being hypoglycemic.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 5 (Coding):
Diagnosis: The patient was seen with severe abdominal cramping, nausea and vomiting, and
diarrhea. She stated she ate turkey salad several hours before these symptoms developed. The
patient was treated with IV therapy. Diagnosis: Dehydration and Salmonella gastroenteritis.
____________________________________________________________________________________________
__________________________________________________________________________ __________________
A. ____ Anemia ____ A deficiency in platelets, the cells that are important in
B. ____ Thrombocytopenia blood clotting
C. ____ Sickle-Cell Anemia
D. ____ Aplastic Anemia
____ A condition in which there is a deficiency of red blood
E. ____ Sickle Cell Trait
F. ____ Pancytopenia cells because the bone marrow is failing to produce them
Diagnosis and Procedure: A patient six months pregnant was diagnosed as having an iron-
deficiency anemia and was admitted for transfusion of nonautologous packed red blood cells,
via peripheral vein.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: A patient with sickle-cell anemia presents to the emergency department with a two
to three day history of severe right leg and arm pain. After she was admitted parenteral
narcotics were administered and the pain improved. The blood counts returned to a stable
level within 24 hours. The patient was diagnosed with Sickle-cell pain crisis.
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 4 (Coding):
Diagnosis: The patient was diagnosed with Coombs’ negative hemolytic anemia four years
earlier. Since the diagnosis her disease course waxed and waned. During some bouts she had
15 to 20 blood transfusions of two to three units of packed red blood cells each. This
admission was for splenectomy for hypersplenism. . A total open splenectomy was performed
without incident. Her postoperative recovery was without incident. The patients discharge
diagnosis was Hypersplenism secondary to acquired hemolytic anemia.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 2 (Coding):
Diagnosis: Patient is admitted with a history of hypertension and Type 2 diabetes with
generalized fatigue, swelling of legs, decreased appetite, infrequent urination and nausea and
vomiting. Patient has been diagnosed with chronic kidney disease (CKD) in the past. G FR is 20.
He is treated with IV Furosemide 60 mg per day X 2 days and placed on a maintenance dose
upon discharge. He is advised to follow a reduced sodium diet and decrease protein intake.
With the appropriate documentation of CKD related to DM and the stage 4 of the CKD, what
codes would be required?
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis and procedures: Patient is admitted with severe flank pain, painful urination, fever
and gross hematuria. Patient is also extremely nauseous with vomiting the last 12 hours. IVP
____________________________________________________________________________________________
____________________________________________________________________________________________
Nervous System
Scenario 1 (Coding):
Diagnosis: Patient is a 70 year old male admitted to ER after being found by police wandering
the street, mentally confused and combative. Police reported the patient was verbally abusive
and had tried to assault a passerby on the street. Police also reported the patient had been
reported missing from a nursing home that morning. ED physician documents diagnosis of
Alzheimer’s disease with no further specificity. What is required for accurate classification of
Alzheimer’s disease? With appropriate documentation of late onset Alzheimer’s with
dementia and behavioral disturbances what codes would be assigned?
____________________________________________________________________________________________
____________________________________________________________________________________ ________
Scenario 2 (Coding):
Diagnosis: Patient is admitted with upper limb tremors after being placed on perphenazine
for mood disorder. His medication was changed to quetiapine, but tremor was unabated.
Motor, sensory, and cerebellar testing were normal. Other findings included mild stoop with
normal gait and reflexes. He demonstrated a mild chin tremor and moderately irregular
finger tapping bilaterally. A diagnosis of Parkinsonism is documented by the attending
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: A 75 year old male is admitted with a cerebral infarction. He is demonstrating
expressive aphasia and apraxia. Physician documents cerebral infarction as the final
diagnosis. Patient is discharged to a rehab facility. With appropriate documentation of
cerebral infarction (thrombosis) on the left side with middle cerebral artery involvement
what would be the code(s) assigned to this case?
____________________________________________________________________________________________
____________________________________________________________________________________________
OB/GYN
Scenario 1 (Coding):
Diagnosis and Procedure: Physician documents diagnosis of vaginal fistula with repair with
no further specificity. A repair is performed with a resection of a portion of the small intestine
with anastomosis of small to small intestine and a repair of the vaginal wall with mesh. Path
report reveals a fistula involving vagina to small intestine. With appropriate documentation
of vaginal fistula involving small intestine with repair, what codes would be applied?
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis and Procedure: Patient with a history of total abdominal hysterectomy 12 months
ago is now admitted for repair of vaginal vault prolapse via vaginal approach with removal of
some of the vaginal tissue and inserting mesh to reinforce it. With appropriate documentation
of hysterectomy related vaginal vault prolapsed, what code(s) would applied for both the
diagnosis and procedure?
____________________________________________________________________________________________
____________________________________________________________________________________________
Infection Disease
Scenario 1 (Coding):
Diagnosis: Patient is admitted to the hospital and taken to the ICU with a T 102, Pulse 120, RR
25, altered mental status, BP 85/62, confusion and WBCs 25.2. He is treated with IV
antibiotics. Physician documents Urosepsis as the principal diagnosis. Can this case be coded
as it is documented? Why?
____________________________________________________________________________________________
Scenario 2 (Coding):
Diagnosis: A patient is admitted to the hospital and taken to the ICU with a T 102, Pulse 120,
RR 25, altered mental status, BP 85/62, confusion and WBCs 25.2. He is treated with IV
antibiotics. The day following admission, patient has decreased urine output with a rise in
BUN/Creatinine. Patient is diagnosed with Acute Renal Failure. With appropriate
documentation of Severe Sepsis with Acute Renal Failure what are the codes to assign?
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 3 (Coding):
Diagnosis: Patient is a 70 year old male admitted from a nursing home to ER with fever, WBC
25.4, shaking, chills, confusion and low BP 90/50. Patient’s blood cultures are positive for
streptococcus A and chest x-ray is positive for infiltrate. The patient also has a Stage 3
decubitus ulcer of the left hip demonstrating inflammation and has a serous discharge. With
appropriate documentation of Streptococcus A sepsis with pneumonia and Stage 3 decubitus
ulcer of left hip, what codes would be assigned?
____________________________________________________________________________________________
____________________________________________________________________________________________
Scenario 20 Scenario 31
H65.04 J45.42, J44.1
Scenario 24 Scenario 35
I21.02 K40.20, R07.2, J44.9, M54.5, I10, Z53.09
Scenario 27 Scenario 37
I21.4, I48.91 L03.115
Scenario 44 Scenario 54
N73.9 Q54.2
Scenario 48 Scenario 57
O63.1, Z3A.39, Z37.0 S22.41XA, S62.101A
Scenario 1
Answer: G30.1, F02.81, Z91.83
Scenario 2
Answer: G21.11, T43.3x5A
Scenario 3
Answer: I63.312, I69.320, I69.390
OB/GYN
Scenario 1
Answer: N82.2, 0DB80ZZ, 0UUG0JZ
Scenario 2
Answer: N98.0, N71.0
Scenario 3
Answer: N99.3, 0UBGXZZ, 0UUGXJZ
Infectious Disease
Scenario 1
Answer: No, there is no classification for
urosepsis. Patient has clinical signs of
sepsis, would require retrospective query.
Scenario 2
Answer: A41.9, R65.20, N17.9
Scenario 3
Answer: A40.0, J15.4, L89.22
Pocket Guide of ICD-10-CM and ICD-10-PCS. Ann M. Zeisset, RHIT, CCS, CCS-P and Sue E. Bowman, RHIA,
CCS.
ICD-10-CM/PCS Coder Training Manual. Ann Barta, MSA. RHIA, Kathryn DeVault, RHIA, CCS; and Ann
Zeisset, RHIT, CCS, CCS-P
ICD-10-CM/PCS Coder Training Manual Instructor’s Edition. Ann Barta, MSA, RHIA; Kathryn DeVault,
RHIA, CCS; and Ann Zeisset, RHIT, CCS, CCS-P. AHIMA. 2009.
http://www.cms.hhs.gov/ICD10
http://training.seer.cancer.gov/lymphoma/anatomy/chains/index.html
http://www.ahima.org/ICD10/
http://msjensen.cehd.umn.edu/webanatomy/
http://msjensen.cehd.umn.edu/1135/med_term_activites/roots_list.html
http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-PCS.html
Instructional Notations
2013 and 2014 Official Guidelines for Coding and Reporting
2013 and 2014 Table of Drugs and Chemicals
2013 and 2014 Neoplasm Table
2013 and 2014 Index to External Causes
2013 and 2014 Mapping ICD-9 to ICD-10