Appendix A
DOCUMENTATION CODING CHECKLISTS
Introduction
Appendix A provides checklists for common diagnoses and other conditions which are designed to be used for review of current records to help identify any documentation deficiencies. The checklists begin with the applicable ICD-10-CM categories, subcategories, and/or codes being covered. ICD-10-CM definitions and other information pertinent to coding the condition are then provided. This is followed by a checklist that identifies each element needed for assignment of the most specific code. If one or more of the required elements are not documented, this information should be shared with the physician and a corrective action plan initiated to ensure that the necessary information is captured in the future.
Similar documentation and coding checklists for conditions not addressed in this book can be created using the checklists provided as a template. There are a few different formats and styles of checklists so users can determine which style works best for their practice and then create additional checklists using that format and style.
Angina Pectoris
ICD-10-CM Categories/Subcategories
Angina is classified based on whether it occurs alone or with documented atherosclerosis as follows:
I20
Angina pectoris
I25.11
Atherosclerotic heart disease with angina
I25.7
Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris
I23.7
Postinfarction angina
ICD-10-CM Definitions
Angina – Pain or discomfort, pressure or squeezing, usually centered in the chest, or other atypical symptoms that result from diseased coronary arteries with restricted blood flow to the heart muscle. Also called angina pectoris. Angina is classified in ICD-10-CM by the types described below.
Angina equivalent – Instead of decreased blood flow to the heart causing classic angina symptoms such as chest pain or discomfort, pressure or squeezing, atypical symptoms occur, such as indigestion, shortness of breath, weakness, or malaise. These symptoms are the patient’s angina equivalent, that is the symptoms that the patient gets instead of classic angina symptoms. Use the ICD-10-CM code for other forms of angina pectoris (I20.8).
Angina of effort – Angina that occurs as a result of exertion. Use the ICD-10-CM code for other forms of angina pectoris (I20.8).
Coronary slow flow syndrome – Angina that occurs in the absence of angiographic evidence indicating atherosclerotic disease or narrowing of the coronary arteries. The cause is believed to be due to disease or narrowing in the microvasculature of the heart. Use the code for other forms of angina pectoris (I20.8).
Prinzmetal angina – Rare type of angina caused by spasm of the coronary arteries that temporarily restricts blood flow to the heart muscle. Pain usually occurs at rest, is often severe, and is typically relieved by angina medication. Also called angiospastic angina, spasm-induced angina, and variant angina. Use the ICD-10-CM code for angina with documented spasm (I20.1).
Stable angina – The most common form of angina. Typically occurs with exertion and subsides with rest. The type and severity of pain is usually predictable; pain is of short duration, usually 5 minutes or less and responds to angina medication. Use the ICD-10-CM code for unspecified angina (I20.8).
Unstable angina – A medical emergency that may signal an impending myocardial infarction, characterized by chest pain or discomfort that is unexpected in that it may occur at rest, increase in severity, last longer than is typical (30 minutes or more), and may not respond to angina medications. Also called accelerated angina, crescendo angina, de novo effort angina, intermediate coronary syndrome, preinfarction syndrome, or worsening effort angina. Use the ICD-10-CM code for unstable angina (I20.0).
Checklist
1.Identify angina pectoris as with/without atherosclerotic disease:
□With coronary atherosclerosis – See Coronary Atherosclerosis Check List
□Without coronary atherosclerosis
2.For angina without a diagnosis of coronary atherosclerosis, identify type of angina pectoris:
□Unstable angina, which includes:
□Accelerated angina
□Crescendo angina
□De novo effort angina
□Intermediate coronary syndrome
□Preinfarction syndrome
□Worsening effort angina
□Angina with documented spasm, which includes:
□Angiospastic angina
□Prinzmetal angina
□Spasm-induced angina
□Variant angina
□Other forms of angina pectoris, which include:
□Angina equivalent
□Angina of effort
□Coronary slow flow syndrome
□Stenocardia
□Stable angina
□Unspecified angina pectoris, which includes:
□Angina NOS
□Anginal syndrome
□Cardiac angina
□Ischemic chest pain
□Postinfarction angina
Asthma
ICD-10-CM Categories
In ICD-10-CM, asthma is classified by cause, such as exercise induced; by symptoms, such as cough variant; and by severity in the following categories:
J44
Other chronic obstructive pulmonary disease – Note: use a code from category J44 in conjunction with a code from category J45 for the following documented conditions:
•asthma and chronic obstructive pulmonary disease
•chronic asthmatic bronchitis
•chronic obstructive asthma
J45
Asthma
ICD-10-CM Definitions
Definitions of asthma severity:
Mild intermittent asthma – Asthma symptoms that come and go. Daytime symptoms occur 2 days or less per week, nighttime symptoms 2 days per month or less, use of rescue inhaler 2 times or less per week. Asthma does not interfere with daily activities, and FEV1 (forced expiratory volume in 1 second) is normal.
Mild persistent asthma – Asthma symptoms that occur almost weekly, but can be controlled with a single medication. Daytime symptoms occur more than 2 days per week but not daily, nighttime symptoms 3-4 nights per month, rescue inhaler more than 2 days per week but not daily. There is minor interference with daily activities, and FEV1 > 80% of predicted or normal most of the time.
Moderate persistent asthma – Asthma symptoms that occur almost daily, but can be controlled with two medications. Daily daytime asthma symptoms, nighttime symptoms more than 1 night per week but not every night, rescue inhaler use daily. Asthma moderately interferes with daily activities, and FEV1 > 60% but < 80% of predicted.
Severe persistent asthma – Daily asthma symptoms despite the use of more than two medications. Symptoms throughout the day, nightly asthma, use of rescue inhaler multiple times per day, extreme interference with daily activities, and FEV1 < 60% of predicted.
Definitions of other types of asthma:
Cough variant asthma – Asthma in which a cough is the only symptom
Exercise induced bronchospasm – Asthma that occurs during or after exercise
Asthma complications:
Acute exacerbation – Episode of progressively worsening shortness of breath, coughing, wheezing, and chest tightness or any combination of these; also called an asthma attack.
Status asthmaticus – Acute, severe, life-threatening asthma attack that does not respond to inhaled bronchodilators and is accompanied by symptoms of potential respiratory failure.
Checklist
1.Identify severity/type of asthma:
□Mild
□Intermittent
□Persistent
□Moderate persistent
□Severe persistent
□Other specified type
□Cough variant asthma
□Exercise induced bronchospasm
□Other asthma
□Unspecified asthma
2.Identify complications:
□With acute exacerbation
□With status asthmaticus
□Uncomplicated
Note: Complications do not apply to other specified types of asthma (cough variant, exercise induced bronchospasm, other specified type)
3.For chronic obstructive asthma, assign a code from category J44 Other chronic obstructive pulmonary disease and a code from category J45 Asthma
4.Use additional code to identify:
□Exposure to environmental tobacco smoke (Z77.22)
□Exposure to tobacco smoke in the perinatal period (P96.81)
□History of tobacco dependence (Z87.891)
□Occupational exposure to environmental tobacco smoke (Z57.31)
□Tobacco dependence (F17.-)
□Tobacco use (Z72.0)
Bronchitis/Bronchiolitis, Acute Infection
ICD-10-CM Categories
Acute bronchitis and bronchiolitis are classified in the following categories:
J20
Acute bronchitis
J21
Acute bronchiolitis
ICD-10-CM Definitions
Bronchiolitis, acute infection – Inflammation and swelling of the mucous membranes lining the bronchioles, the smallest airways in the lungs, most often caused by a viral infection/illness. Primarily affects infants and children under the age of 2 years. Symptoms can include productive cough, wheezing, tachypnea (fast breathing), nasal flaring, and intercostal retractions.
Bronchitis, acute infection – Inflammation of the mucous membranes lining the bronchi caused by a viral or bacterial infection/illness with symptoms that include cough with production of mucus. Bronchi are the large to medium-size airways that branch from the trachea carrying air to distal portions of the lungs.
Checklist
1.Identify site of infection:
□Bronchitis (bronchi)
□Bronchiolitis (bronchioles)
2.For bronchitis, identify organism:
□Coxsackievirus
□Echovirus
□Haemophilus influenzae
□Mycoplasma pneumoniae
□Parainfluenza virus
□Respiratory syncytial virus (RSV)
□Rhinovirus
□Streptococcus
□Other specified organism – Specify _________________
□Unspecified
3.For bronchiolitis, identify organism:
□Human metapneumovirus
□Respiratory syncytial virus (RSV)
□Other specified organism – Specify _________________
□Unspecified
Burns, Corrosions, and Frostbite
ICD-10-CM Categories
Burns and corrosions are classified in the following ICD-10-CM categories:
T20
Burn and corrosion of head, face and neck
T21
Burn and corrosion of trunk
T22
Burn and corrosion of shoulder and upper limb, except wrist and hand
T23
Burn and corrosion of wrist and hand
T24
Burn and corrosion of lower limb, except ankle and foot
T25
Burn and corrosion of ankle and foot
T26
Burn and corrosion confined to eye and adnexa
T27
Burn and corrosion of respiratory tract
T28
Burn and corrosion of internal organ
T30
Burn and corrosion, body region unspecified
T31
Burns classified according to extent of body surface involved
T33
Superficial frostbite
ICD-10-CM Definitions
Burn – A thermal injury due to a heat source such as fire, a hot appliance, friction, hot objects, hot air, hot water, electricity, lightning, and radiation. Burns due to exposure to the sun are not considered burns in ICD-10-CM.
Corrosion – A thermal injury due to chemicals.
Episode of Care – There are three (3) possible 7th character values for burns and corrosions. The 7th character defines the stage of treatment and residual effects related to the initial injury.
AInitial encounter. The period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An ‘A’ may be assigned on more than one claim.
DSubsequent encounter. Encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery.
SSequela. Encounter for complications or conditions that arise as a direct result of an injury.
Extent of body surface – The amount of body surface burned is governed by the rule of nines. These percentages may be modified for infants and children or adults with large buttocks, thighs, and abdomens when those regions are burned.
Head and neck – 9%
Each arm – 9%
Each leg – 18%
Anterior trunk – 18%
Posterior trunk – 18%
Genitalia – 1%
Levels of Burns:
First Degree – Affects only the epidermis causing pain, redness, and swelling.
Second Degree – Affects both the dermis and epidermis causing pain, redness, white or blotchy skin, and swelling. Blistering may occur and pain can be intense. Scarring can develop.
Third Degree – Affects the fat or subcutaneous layer of the skin. The skin will appear white or charred black or may look leathery. Third degree burns can destroy nerves resulting in numbness.
Note: Burns noted as non-healing are coded as acute burns and necrosis of burned skin should be coded as a non-healing burn.
Checklist
1.Identify the type of thermal injury:
□Burn
□Corrosion
□Frostbite (Proceed to #9)
2.Identify the body region:
□Eye
□Internal organs
□Skin (external body surface)
□Multiple areas
□Unspecified body region
Note: Codes from category T30 Burn and corrosion, body region unspecified, is extremely vague and should rarely be used.
3.Identify the body area
□Eye and adnexa
□Eyelid and periocular area
□Cornea and conjunctival sac
□With resulting rupture and destruction of eyeball
□Unspecified site – review medical record/query physician
□External body surface
□Head, face and neck
□Scalp
□Forehead and cheek
□Ear
□Nose
□Lips
□Chin
□Neck
□Multiple sites of head, face, and neck
□Unspecified site – review medical record/query physician
□Trunk
□Chest wall
□Abdominal wall
□Upper back
□Lower back
□Buttocks
□Genital region
□Female
□Male
□Other site
□Unspecified site – review medical record/query physician
□Shoulder and upper limb (excluding wrist and hand)
□Scapula
□Shoulder
□Axilla
□Upper arm
□Elbow
□Forearm
□Multiple sites shoulder and upper limb (excluding wrist and hand)
□Unspecified site – review medical record/query physician
□Wrist and hand
□Wrist
□Hand
□Back of hand
□Palm
□Finger
□Multiple fingers not including thumb
□Multiple fingers including thumb
□Single except thumb
□Thumb
□Unspecified site hand – review medical record/query physician
□Multiple sites of wrist and hand
□Lower limb except ankle and foot
□Thigh
□Knee
□Lower leg
□Multiple sites of lower limb
□Unspecified site lower limb – review medical record/query physician
□Ankle and foot
□Ankle
□Foot
□Toe(s)
□Multiple sites of ankle and foot
□Unspecified site ankle or foot – review medical record/query physician
□Internal Organs
□Ear drum
□Esophagus
□Genitourinary organs, internal
□Mouth and pharynx
□Other parts of alimentary tract
□Respiratory tract
□Larynx and trachea
□Larynx and trachea with lung
□Other parts of respiratory tract (thoracic cavity)
□Unspecified site respiratory tract- review medical record/query physician
□Other internal organ
□Unspecified internal organ
4.Identify degree of burn:
□First degree
□Second degree
□Third degree
□Unspecified degree – review medical record/query physician
5.Identify laterality:
□Left
□Right
□Unspecified – review medical record/query physician
Note: Laterality only applies to burns and corrosions involving the extremities, ears, and eyes.
6.Identify episode of care/stage of healing/complication
□A Initial encounter
□D Subsequent encounter
□S Sequela
7.Identify extent of body surface involved and percent of third degree burns, if over 10% of body surface:
□Less than 10% of body surface
□10-19% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of third degree burns
□60-69% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of third degree burns
□60-69% of third degree burns
□70-79% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of third degree burns
□60-69% of third degree burns
□70-79% of third degree burns
□80-89% of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of third degree burns
□60-69% of third degree burns
□70-79% of third degree burns
□80-89% of third degree burns 90% or more of body surface
□0% to 9% of third degree burns
□10-19% of third degree burns
□20-29% of third degree burns
□30-39% of third degree burns
□40-49% of third degree burns
□50-59% of third degree burns
□60-69% of third degree burns
□70-79% third degree burns
□80-89% third degree burns
□90% or more third degree burns
Note: Extent of body surface is to be coded as a supplementary code for burns of an external body surface when the site is specified. It should only be used as the primary code when the site of the burn is unspecified.
8.Identify the external cause source/chemical agent, intent and place:
□If burn, identify the source and intent X00-X19, X75-X77, X96-X98
□If corrosion, code first the chemical agent and intent (T51-T65)
□Place Y92
9.For frostbite, identify extent of tissue involvement:
□Superficial
□With tissue necrosis
10.For frostbite, identify body area:
□Head
□Ear
□Nose
□Other part of head
□Neck
□Thorax
□Abdominal wall, lower back and pelvis
□Arm
□Wrist, hand, and fingers
□Wrist
□Hand
□Finger(s)
□Hip and thigh
□Knee and lower leg
□Ankle, foot, and toes
□Ankle
□Foot
□Toe(s)
□Other sites
□Unspecified site
11.Identify laterality (excluding nose, neck, thorax, abdominal wall, lower back and pelvis):
□Left
□Right
□Unspecified – review medical record/query physician
12.For sequencing of multiple burns and/or burns with related conditions:
•Multiple external burns only. When more than one external burn is present, the first listed diagnosis code is the code that reflects the highest degree burn
•Internal and external burns. The circumstances of the admission or encounter govern the selection of the principle or first-listed diagnosis
•Burn injuries and other related conditions such as smoke inhalation or respiratory failure. The circumstances of the admission or encounter govern the selection of the principal or first-listed diagnosis.
•Assign separate codes for each burn site
•Classify burns of the same local site (three-digit category level) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.
Cataract
ICD-10-CM Categories/Codes
Cataracts are classified in Chapter 7 Diseases of the Eye and Adnexa based on whether they are age related or due to other underlying conditions. There is also a code for congenital cataract classified in Chapter 17 Congenital Malformations, Deformations, and Chromosomal Abnormalities. The codes are as follows:
For Diabetic Cataracts, see:
E08.36
Diabetes mellitus due to underlying condition with diabetic cataract
E09.36
Drug or chemical induced diabetes mellitus with diabetic cataract
E10.36
Type I diabetes mellitus with diabetic cataract
E11.36
Type II diabetes mellitus with diabetic cataract
E13.36
Other specified diabetes mellitus with diabetic cataract
H25
Age-related cataract
H26
Other cataract
H28
Cataract in diseases classified elsewhere
Q12.0
Congenital cataract
ICD-10-CM Definitions
Cataract – Opacity or clouding of the lens of the eye that can cause blurring, haziness of vision, and blindness.
Age-related cataract – Cataract that occurs as a result of aging. Also called a senile cataract.
Congenital cataract – Cataract that is present at birth.
Incipient – Initial stage, beginning to happen or develop
Presenile cataract – Cataract that is not a result of aging, trauma, drug toxicity, or another condition or disease process. In the Alphabetic Index, a See note for Cataract, presenile is provided when the terms Cataract, infantile or Cataract, juvenile are referenced. Cataract, presenile lists codes in subcategory H26.0 Infantile and juvenile cataract.
Checklist
1.Identify cataract as age-related, congenital, or other type:
□Age-related – Proceed to #2
□Congenital – Use code Q12.0
□Other type – Proceed to #3
□In diseases classified elsewhere – Proceed to #4
2.Age-Related Cataract
a.Identify type:
□Combined forms
□Incipient
□Anterior subcapsular polar
□Cortical
□Posterior subcapsular polar
□Other incipient type
□Morgagnian type
□Nuclear
□Other specified type
□Unspecified age-related cataract
b.Specify laterality:
□Right
□Left
□Bilateral
□Unspecified eye
3.Cataract – Other Type
Excludes age-related types and congenital cataract.
a.Identify type:
□Infantile and juvenile
□Combined forms
□Cortical/lamellar/zonular
□Nuclear
□Subcapsular polar
□Anterior
□Posterior
□Other specified infantile/juvenile
□Unspecified
□Traumatic – Use additional code from Chapter 20 to identify external cause
□Localized
□Partially resolved
□Total
□Unspecified traumatic cataract
□Complicated
□Glaucomatous – Specify and code first glaucoma type (see category H40-H42) _______________
□Secondary to ocular disorder – Specify associated ocular disorder _______________
□With neovascularization – Specify associated condition ___________________
□Unspecified complication
□Toxic – Use additional code for adverse effect T36-T50
□Secondary
□Soemmering’s ring
□Other specified type secondary cataract
□Unspecified secondary cataract
□Other specified type
□Unspecified cataract
b.Specify laterality:
□Right
□Left
□Bilateral
□Unspecified eye
4.Cataract in Diseases Classified Elsewhere
a.Code first underlying disease
□Hypoparathyroidism E20.-
□Myxedema E03.-
□Myotonia G71.1-
Cholecystitis, Cholelithiasis, Choledocholithiasis and Cholangitis
ICD-10-CM Categories/Codes
K80
Cholelithiasis
K81
Cholecystitis
K82.A1
Gangrene of gallbladder in cholecystitis
K82.A2
Perforation of gallbladder in cholecystitis
K83.0
Cholangitis
ICD-10-CM Definitions
Cholangitis – Inflammation of the bile ducts most often caused by the presence of stones or calculi in the bile ducts.
Cholecystitis – Inflammation of the gallbladder most often caused by the presence of calculi or sludge that blocks the flow of bile. Cholecystitis may be acute or chronic and chronic cases may be complicated by an acute inflammation.
Choledocholithiasis – Calculi in the bile ducts that may also cause inflammation of the bile ducts, referred to as cholangitis. A complication of calculi in the bile ducts is obstruction of the flow of bile.
Cholelithiasis – The presence of stones or calculi in the gallbladder. Cholelithiasis may occur alone or with cholecystitis. A complication of calculi in the gallbladder is obstruction of the flow of bile.
Checklist
1.Cholecystitis
□With cholelithiasis or choledocholithiasis – Proceed to 3
□Without cholelithiasis or choledocholithiasis
□Acute (K81.0)
□Acute with chronic (K81.2)
□Chronic (K81.1)
□Unspecified (K81.9) – review medical record/query physician
□Gallbladder gangrene (K82.A1)
□Gallbladder perforation (K82.A2)
2.Cholangitis
□With choledocholithiasis – Proceed to 3
□Without choledocholithiasis (K83.0)
3.Cholelithiasis – Identify site of calculus:
□Bile duct only – Proceed to 5
□Gallbladder only – Proceed to 4
□Gallbladder and bile duct – Proceed to 6
□Other
□With obstruction (K80.81)
□Without obstruction (K80.80)
4.Calculus of gallbladder only
□With cholecystitis
□Acute
□With obstruction (K80.01)
□Without obstruction (K80.00)
□Acute and chronic
□With obstruction (K80.13)
□Without obstruction (K80.12)
□Chronic
□With obstruction (K80.11)
□Without obstruction (K80.10)
□Other
□With obstruction (K80.19)
□Without obstruction (K80.18)
□Without cholecystitis
□With obstruction (K80.21)
□Without obstruction (K80.20)
5.Calculus of bile duct only
□With cholangitis
□Acute
□With obstruction (K80.33)
□Without obstruction (K80.32)
□Acute and chronic
□With obstruction (K80.37)
□Without obstruction (K80.36)
□Chronic
□With obstruction (K80.35)
□Without obstruction (K80.34)
□Unspecified
□With obstruction (K80.31) – review medical record/query physician
□Without obstruction (K80.30) – review medical record/query physician
□With cholecystitis (includes cholangitis if present)
□Acute
□With obstruction (K80.43)
□Without obstruction (K80.42)
□Acute and chronic
□With obstruction (K80.47)
□Without obstruction (K80.46)
□Chronic
□With obstruction (K80.45)
□Without obstruction (K80.44)
□Unspecified
□With obstruction (K80.41) – review medical record/query physician
□Without obstruction (K80.40) – review medical record/query physician
□Without cholangitis or cholecystitis
□With obstruction (K80.51)
□Without obstruction (K80.50)
6.For calculus of gallbladder and bile duct, identify:
□With cholecystitis
□Acute
□With obstruction (K80.63)
□Without obstruction (K80.62)
□Acute and chronic
□With obstruction (K80.67)
□Without obstruction (K80.66)
□Chronic
□With obstruction (K80.65)
□Without obstruction (K80.64)
□Unspecified
□With obstruction (K80.61) – review medical record/query physician
□Without obstruction (K80.60) – review medical record/query physician
□Without cholecystitis
□With obstruction (K80.71)
□Without obstruction (K80.70)
Conjunctivitis
ICD-10-CM Categories/Subcategories
B30
Viral conjunctivitis
H10.0
Mucopurulent conjunctivitis
H10.1
Acute atopic conjunctivitis
H10.2
Other acute conjunctivitis
H10.3
Unspecified acute conjunctivitis
H10.4
Chronic conjunctivitis
H10.5
Blepharoconjunctivitis
H10.8
Other conjunctivitis
H10.9
Unspecified conjunctivitis
Refer to ICD-10-CM Alphabetic Index for newborn conjunctivitis, conjunctivitis due to other specific organisms, and other less common types of conjunctivitis.
ICD-10-CM Definitions
Conjunctivitis – Inflammation of the conjunctiva, the clear membrane lining the inner surface of the eyelid and outer surface of the eye. Inflammation may be caused by bacteria, viruses, allergens, or chemicals. Symptoms include redness, swelling, drainage, and discomfort, but visual acuity and pupil response should be normal.
Checklist
1.Identify type of conjunctivitis:
□Acute conjunctivitis
□Atopic
□Pseudomembranous
□Serous
□Toxic (chemical) – Code first chemical and intent (T51-T65)
□Unspecified acute conjunctivitis
□Blepharoconjunctivitis
□Angular
□Contact
□Ligneous
□Unspecified blepharoconjunctivitis
□Chronic conjunctivitis
□Follicular
□Giant papillary
□Simple
□Vernal
□Other chronic allergic
□Unspecified chronic conjunctivitis
□Mucopurulent conjunctivitis
□Acute follicular
□Other mucopurulent type
□Pingueculitis
□Viral
□Acute epidemic hemorrhagic (enteroviral)
□Due to adenovirus
□Conjunctivitis
□Keratoconjunctivitis
□Pharyngoconjunctivitis
□Other viral conjunctivitis – Specify ______________
□Unspecified viral conjunctivitis
□Other conjunctivitis – Specify _______________
□Unspecified
2.Specify laterality (excluding viral conjunctivitis):
□Right
□Left
□Bilateral
□Unspecified eye
Coronary Atherosclerosis With/Without Angina
ICD-10-CM Subcategories
Atherosclerotic heart disease is classified as with or without angina pectoris in the following subcategories:
I25.1Atherosclerotic heart disease of native coronary artery
I25.7Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris
I25.81Atherosclerosis of other coronary vessels without angina pectoris
ICD-10-CM Definitions
A combination code is used to identify coronary atherosclerosis as with or without angina in ICD-10-CM. Use codes from subcategories I25.1, I25.7, and I25.8 to capture both the coronary atherosclerosis, the presence/absence of angina, and when angina is present, the type of angina. For angina without documented coronary atherosclerosis, see category I20.
Angina – Pain or discomfort, pressure or squeezing, usually centered in the chest, or other atypical symptoms that result from diseased coronary arteries with restriction of blood flow to the heart muscle. Also called angina pectoris. Angina is classified in ICD-10-CM by the type of angina, which includes: unstable, angina with documented spasm, other forms of angina, and unspecified angina. For detailed definitions of each type, see the Angina check list.
Coronary Atherosclerosis – Condition affecting arterial blood vessels in the heart and characterized by inflammation and accumulation of macrophage white blood cells and low-density lipoproteins along the arterial walls leading to narrowing of the vessels and decreased blood flow to the heart muscle. Synonymous terms include:
•Atherosclerotic cardiovascular disease
•Atherosclerotic heart disease
•Coronary (artery) atheroma
•Coronary (artery) disease
•Coronary (artery) sclerosis
•Chronic ischemic heart disease
Checklist
1.Identify site of coronary atherosclerosis:
□Native coronary artery
□Graft
□Autologous artery bypass graft
□Autologous vein bypass graft
□Nonautologous biological bypass graft
□Other specified type of bypass graft
□Unspecified type of bypass graft
□Transplanted heart
□Native coronary artery of transplanted heart
□Bypass graft (artery/vein) of transplanted heart
2.Identify presence/absence and type of angina pectoris:
□With angina pectoris
□Unstable
□With documented spasm
□With other documented form of angina pectoris
□Unspecified angina pectoris
□Without angina pectoris
3.Identify and assign additional code for any:
□Chronic total occlusion of coronary artery (I25.82)
□Coronary atherosclerosis due to
□Calcified coronary lesion (I25.84)
□Lipid rich plaque (I25.83)
4.Use additional code to identify exposure to tobacco smoke or history of, current use of, or dependence on tobacco:
□Exposure to environmental tobacco smoke (Z77.22)
□History of tobacco use (Z87.891)
□Occupational exposure to environmental tobacco smoke (Z57.31)
□Tobacco dependence (F17.-)
□Tobacco use (Z72.0)
Dermatitis, Contact
ICD-10-CM Categories
Contact dermatitis is classified in the following categories:
L23
Allergic contact dermatitis
L24
Irritant contact dermatitis
L25
Unspecified contact dermatitis
ICD-10-CM Definitions
In ICD-10-CM, the terms dermatitis and eczema are used synonymously and interchangeably in the classification.
Contact dermatitis (eczema) – Inflammation of the skin resulting from direct contact with a substance which causes the inflammatory skin reaction. Skin inflammation may be due to an allergy to the substance or due to irritants in the substance.
Allergic contact dermatitis (eczema) – Inflammation of the skin resulting from an allergy to a substance that has come in direct contact with the skin.
Irritant contact dermatitis (eczema) – Inflammation of the skin resulting from irritation by a chemical or other substance that has come in direct contact with the skin.
Checklist
1.Identify type of contact dermatitis:
□Allergic – Proceed to #2
□Irritant – Proceed to #3
□Unspecified – Proceed to #4
2.Allergic Contact Dermatitis
a.Specify cause:
□Animal (cat) (dog) dander
□Adhesives
□Cosmetics
□Drugs in contact with skin – Specify drug ___________
□Dyes
□Food in contact with skin
□Metals
□Plants (except food)
□Other chemical products
□Other specified agents – Specify agent ______________
□Unspecified cause
3.Irritant Contact Dermatitis
a.Specify cause:
□Cosmetics
□Detergents
□Drugs in contact with skin – Specify drug ___________
□Food in contact with skin
□Metals
□Plants (except food)
□Oils and greases
□Solvents
□Other chemical products
□Other specified agents – Specify agent ______________
□Unspecified cause
4.Unspecified Contact Dermatitis
a.Specify cause:
□Cosmetics
□Drugs in contact with skin – Specify drug ___________
□Dyes
□Food in contact with skin
□Other chemical products
□Plants (except food)
□Other specified agents – Specify agent ______________
□Unspecified cause
For contact dermatitis caused by drugs, use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth character 5)
Diabetes Mellitus
ICD-10-CM Categories
E08
Diabetes mellitus due to underlying condition
E09
Drug or chemical induced diabetes mellitus
E10
Type 1 diabetes mellitus
E11
Type 2 diabetes mellitus
E13
Other specified diabetes mellitus
ICD-10-CM Definitions
Codes for diabetes mellitus are combination codes that reflect the type of diabetes, the body system affected, and any specific complications/manifestations affecting that body system.
Other specified diabetes (E13) includes secondary diabetes specified as:
•Due to genetic defects of beta-cell function
•Due to genetic defects in insulin action
•Postpancreatectomy
•Postprocedural
•Secondary diabetes not elsewhere classified
Checklist
1.Identify the type of diabetes mellitus:
□Type 1
□Type 2 (includes unspecified)
□Secondary diabetes
□Drug or chemical induced
□Due to underlying condition
□Other specified diabetes mellitus
2.Identify the body system affected and any manifestations/complications:
□No complications
□Arthropathy
□Neuropathic
□Other arthropathy
□Circulatory complications
□Peripheral angiopathy
□With gangrene
□Without gangrene
□Other circulatory complication
□Hyperglycemia
□Hyperosmolarity (except type 1)
□With coma
□Without coma
□Hypoglycemia
□With coma
□Without coma
□Ketoacidosis
□With coma
□Without coma
□Kidney complications
□Nephropathy
□Chronic kidney disease – Use additional code (N18.1-N18.6) for stage of CKD
□Other diabetic kidney complication
□Neurological complications
□Amyotrophy
□Autonomic (poly)neuropathy
□Mononeuropathy
□Polyneuropathy
□Other diabetic neurological complication
□Unspecified diabetic neuropathy
□Ophthalmic complications
□Diabetic retinopathy
□Mild nonproliferative
□With macular edema
□Without macular edema
□Moderate nonproliferative
□With macular edema
□Without macular edema
□Severe nonproliferative
□With macular edema
□Without macular edema
□Proliferative
□With traction retinal detachment involving the macula
□With traction retinal detachment not involving the macula
□With combined traction retinal detachment and rhegmatogenous retinal detachment
□With macular edema
□Without macular edema
□Unspecified
□With macular edema
□Without macular edema
□Identify laterality (except with diabetic cataract, unspecified diabetic retinopathy, and other diabetic ophthalmic complication)
□Right eye
□Left eye
□Bilateral
□Unspecified eye
□Diabetic cataract
□Diabetic macular edema, resolved following treatment
□Other diabetic ophthalmic complication
□Oral complications
□Periodontal disease
□Other oral complications
□Skin complications
□Dermatitis
□Foot ulcer, chronic, non-pressure – Use additional code (L97.4-, L97.5-) to identify site and severity of ulcer
□Other chronic, non-pressure skin ulcer – Use additional code (L97.1-, L97.2-, L97.3-, L97.8-, L98.41-, L98.49-) to identify site and severity of ulcer
□Other skin complication
□Other specified complication – Use additional code to identify complication
□Unspecified complication
For Type II (E11) and secondary diabetes types (E08, E09, E13), use additional code to identify any long-term insulin use (Z79.4).
For diabetes due to underlying disease (E08), code first the underlying condition.
For diabetes due to drugs or chemicals (E09):
•Code first poisoning due to drug or toxin (T36-T65 with 5th or 6th character 1-4 or 6) – OR-
•Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with 5th or 6th character 5)
For other specified diabetes mellitus (E13) documented as due to pancreatectomy:
•Assign first code E89.1 Postprocedural hypoinsulinemia
•Assign the applicable codes from category E13
•Assign a code from Z90.41- Acquired absence of pancreas
•Use additional code (Z79.4, Z79.84) to identify type of control
Examination, Administrative
ICD-10-CM Categories
Codes for encounters for examination are found in categories Z00-Z13.
Administrative examinations are listed in category Z02 Encounter for administrative examination.
ICD-10-CM Definitions
Administrative examination – Examinations that are performed for specific administrative purposes such as pre-employment, school, sports, and insurance.
Checklist
Identify reason for administrative examination:
□Admission to
□Educational institution
□Residential institution
□Adoption services
□Alcohol/drug test
□Armed forces recruitment
□Certificate for
□Disability
□Other medical certificate
□Driver’s license
□Insurance
□Paternity testing
□Pre-employment
□Sports participation
□Other administrative purposes
□Unspecified administrative purposes
Examination, General Medical
ICD-10-CM Categories
Codes for encounters for examination are found in categories Z00-Z13. Categories for encounter for general examinations and special examinations include:
Z00
Encounter for general examination without complaint, suspected or reported diagnosis
Z01
Encounter for other special examination without complaint, suspected or reported diagnosis
While gynecological examinations are reported with codes in category Z01, examinations related to pregnancy and reproduction are not – see categories Z30-Z36 and Z39.
ICD-10-CM Definitions
General examination – Codes for encounters for general examinations are reported for patients who are seen without a medical complaint or a suspected or reported diagnosis, such as an annual examination for an adult or a well-child examination. Codes for adults and infants/children are specific as to whether the examination was with or without abnormal findings. Codes identifying any abnormal findings are reported additionally.
Special examination – Special examinations include: eyes/vision, ears/hearing, dental exam/cleaning, blood pressure, gynecological, preprocedural, allergy testing, blood typing, and antibody response.
Checklist
1.Identify purpose of examination:
□General examination – Proceed to #2
□Special examination – Proceed to #3
2.For general examination identify:
□Adult
□With abnormal findings
□Without abnormal findings
□Child (Over 28 days old)
□Adolescent development state
□Period of delayed growth
□With abnormal findings
□Without abnormal findings
□Period of rapid growth
□Routine
□With abnormal findings
□Without abnormal findings
□Newborn (Under 29 days old)
□Under 8 days old
□8-28 days old
□Other reason
□Normal comparison and control in clinical research program
□Other general examination
□Potential organ/tissue donor
3.For special examination, identify type/reason:
□Allergy testing
□Antibody response examination
□Blood pressure
□With abnormal findings
□Without abnormal findings
□Blood typing
□Dental exam and cleaning
□With abnormal findings
□Without abnormal findings
□Ears/Hearing
□Hearing conservation treatment
□Evaluation
□With abnormal findings
□Following failed hearing screening
□With other abnormal findings
□Without abnormal findings
□Eyes/Vision
□With abnormal findings
□Without abnormal findings
□Gynecological
□Cervical smear to confirm findings of normal smear following initial abnormal smear
□Examination (routine)
□With abnormal findings
□Without abnormal findings
□Preprocedural
□Cardiovascular examination
□Laboratory examination
□Other preprocedural examination
□Respiratory examination
□Other specified special examination
Use additional code(s) to identify any abnormal findings.
Examination, Gynecological/Contraception
ICD-10-CM Categories/Subcategories
Z01.4
Encounter for gynecological examination
Z08
Encounter for gynecological exam status post hysterectomy for malignant condition
Z12.4
Encounter for screening for malignant neoplasm of cervix
Z30
Encounter for contraceptive management
ICD-10-CM Definitions
Contraceptive Management – General counseling and advice on contraception; prescribing and surveillance of contraceptive pills, injectable contraceptives, and emergency contraception; insertion, removal, and replacement of intrauterine device; and other contraceptive advice and services such as natural family planning and sterilization.
Gynecological Examination – An annual or periodic pelvic examination that may or may not include a cervical pap smear.
Screening for malignant neoplasm of cervix – A screening pap smear of the cervix to evaluate and detect any cytological abnormalities that might be indicative of malignant neoplasm.
Checklist
1.Identify purpose of examination:
□Gynecological – Proceed to #2
□Cervical pap smear only (not performed as part of general gynecological examination) – Use code Z12.4
□Contraceptive management – Proceed to #3
2.Gynecological Examination
a.Identify reason for visit:
□Cervical smear to confirm findings of recent normal smear following initial abnormal smear
□Gynecological exam status post hysterectomy for malignancy
□Routine gynecological examination with or without cervical smear
□With abnormal findings
□Without abnormal findings
b.Use additional code(s) to identify any abnormal findings
c.Use additional code to identify:
□Screening for human papillomavirus, if applicable, (Z11.51)
□Screening vaginal pap smear, if applicable (Z12.72)
□Acquired absence of uterus, if applicable (Z90.71-)
3.Contraceptive Management
a.Identify type of encounter for contraceptive management:
□Contraceptive pills
□Initial prescription
□Surveillance
□Emergency contraception
□General counseling and advice on contraception
□Implantable subdermal contraceptive
□Initial prescription
□Surveillance
□Injectable contraceptive
□Initial prescription
□Surveillance
□Intrauterine contraceptive device
□Initial prescription
□Insertion (without removal of previously placed IUD)
□Routine checking of device
□Removal
□Removal with reinsertion (replacement)
□Natural family planning instruction to avoid pregnancy
□Other contraception (barrier/diaphragm)
□Initial prescription
□Surveillance
□Transdermal patch hormonal contraceptive
□Initial prescription
□Surveillance
□Sterilization
□Other contraceptive management
□Vaginal ring hormonal contraceptive
□Initial prescription
□Surveillance
□Unspecified contraceptive management
Examination, Obstetric/Reproductive
ICD-10-CM Categories
Z31
Encounter for procreative management
Z32
Encounter for pregnancy test and childbirth and childcare instruction
Z33
Pregnant state
Z34
Encounter for supervision of normal pregnancy
Z36
Encounter for antenatal screening of mother
Z39
Encounter for maternal postpartum care and examination
Note: For contraceptive management, see Examination, Gynecological/Contraceptive checklist.
ICD-10-CM Definitions
Pregnancy Z-codes – Z-codes for pregnancy are used when none of the problems or complications included in the Obstetrics chapter exist. Z-codes are used to report antenatal screening, procreative management, routine prenatal visits, and postpartum care.
Checklist
Identify purpose of visit:
□Assisted reproductive fertility procedure cycle (Z31.83)
□Antenatal screening of mother (Z36)
□Procreative management
□Fertility
□Male factor infertility in female patient (Z31.81)
□Preservation
□Counseling (Z31.62)
□Procedure (Z31.84)
□Testing (Z31.41)
□Genetic counseling (Z31.5)
□Genetic testing, female/mother
□Disease carrier status (Z31.430)
□Other genetic testing (Z31.438)
□Genetic testing, male/father
□Disease carrier status (Z31.440)
□Recurrent pregnancy loss in partner (Z34.441)
□Other genetic testing (Z31.448)
□General procreative counseling/advice, other (Z31.69)
□Gestation carrier counseling/management (Z31.7)
□Investigation and testing, other procreative (Z31.49)
□Natural family planning (Z31.61)
□Sterilization reversal
□Reversal services (Z31.0)
□Aftercare (Z31.42)
□Rh incompatibility status (Z31.82)
□Other procreative management services (Z31.89)
□Pregnancy – other services
□Childbirth instruction (Z32.2)
□Childcare instruction (Z32.3)
□Elective termination (Z33.2)
□State
□Gestational carrier (Z33.3)
□Incidental (Z33.1)
□Test
□Positive (Z32.01)
□Negative (Z32.02)
□Result unknown (Z32.00)
□Supervision of normal pregnancy
□First pregnancy
□First trimester (Z34.01)
□Second trimester (Z34.02)
□Third trimester (Z34.03)
□Unspecified trimester (Z34.00)
□Other normal pregnancy
□First trimester (Z34.81)
□Second trimester (Z34.82)
□Third trimester (Z34.83)
□Unspecified trimester (Z34.80)
□Unspecified normal pregnancy
□First trimester (Z34.91)
□Second trimester (Z34.92)
□Third trimester (Z34.93)
□Unspecified trimester (Z34.90)
□Postpartum care/examination
□Immediately after delivery (Z39.0)
□Lactation supervision (Z39.1)
□Routine follow-up examination (Z39.2)
Feeding Problems, Newborn
ICD-10-CM Categories
P92
Feeding problems of newborn
ICD-10-CM Definitions
Codes in category P92 are used for feeding problems in a newborn which is defined as 28 days old or younger. For feeding problems in a child over 28 days old, see R63.3.
Failure to thrive in a newborn is reported with code P92.6. For failure to thrive in a child over 28 days old, see R62.51.
Vomiting of a newborn is reported with codes in subcategory P92.0. For vomiting of a child over 28 days old, see subcategory R11.1-
Checklist
Specify condition:
□Difficulty feeding at breast
□Failure to thrive
□Overfeeding
□Regurgitation/rumination
□Slow feeding
□Underfeeding
□Vomiting
□Bilious
□Other vomiting
□Other feeding problem – Specify __________________
□Unspecified feeding problem
Fractures
ICD-10-CM Categories
Fractures are classified according to whether the fracture is a result of trauma or due to overuse or an underlying disease process (nontraumatic).
Nontraumatic fractures are classified in the following ICD-10-CM categories:
M48.4
Fatigue fracture of vertebra
M48.5
Collapsed vertebra, not elsewhere classified
M80
Osteoporosis with current pathological fracture
M84.3
Stress fracture
M84.4
Pathological fracture, not elsewhere classified
M84.5
Pathological fracture in neoplastic disease
M84.6
Pathological fracture in other disease
M84.75
Atypical femoral fracture
Traumatic fractures are classified in the following ICD-10-CM categories:
S02
Fracture of skull and facial bones
S12
Fracture of cervical vertebra and other parts of neck
S22
Fracture of ribs, sternum and thoracic spine
S32
Fracture of lumbar spine and pelvis
S42
Fracture of shoulder and upper arm
S49.0
Physeal fracture of upper end of humerus
S49.1
Physeal fracture of lower end of humerus
S52
Fracture of forearm
S59.0
Physeal fracture of lower end of ulna
S59.1
Physeal fracture of upper end of radius
S59.2
Physeal fracture of lower end of radius
S62
Fracture at wrist and hand level
S72
Fracture of femur
S79.0
Fracture of upper end of femur
S79.1
Fracture of lower end of femur
S82
Fracture of lower leg, including ankle
S89.0
Physeal fracture of upper end of tibia
S89.1
Physeal fracture of lower end of tibia
S89.2
Physeal fracture of upper end of fibula
S89.3
Physeal fracture of lower end of fibula
S92
Fracture of foot and toe, except ankle
S99.0
Physeal fracture of calcaneus
S99.1
Physeal fracture of metatarsal
S99.2
Physeal fracture of phalanx of toe
ICD-10-CM Definitions
Closed – A fracture that does not have contact with the outside environment.
Comminuted – A fracture that has more than two pieces.
Displaced – Bone breaks in two or more parts that are not in normal alignment.
Episode of Care – There are sixteen (16) possible 7th character values to select from for fractures depending upon the fracture category. The 7th character defines the stage of treatment, fracture condition for traumatic fractures (open vs. closed), status of healing and residual effects related to the initial fracture.
A.Initial encounter. The period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An ‘A’ may be assigned on more than one claim.
B.Initial encounter for open fracture or (Gustilo) type I or II.
C.Initial encounter for open fracture (Gustilo) type IIIA, IIIB or IIIC.
D.Subsequent encounter for (closed) fracture with routine healing. Encounter after the active phase of treatment and when the patient is receiving routine care for the fracture during the period of healing or recovery.
E.Subsequent encounter for open fracture (Gustilo) type I or II. Encounter after the active phase of treatment and when the patient is receiving routine care for the fracture during the period of healing or recovery.
F.Subsequent encounter for open fracture (Gustilo) type IIIA, IIIB, IIIC with routine healing. Encounter after the active phase of treatment when the patient is receiving routine care for the fracture during the period of healing or recovery.
G.Subsequent encounter for (closed) fracture with delayed healing.
H.Subsequent encounter for open fracture (Gustilo) type I or II with delayed healing.
J.Subsequent encounter for open fracture (Gustilo) type IIIA, IIIB, IIIC with delayed healing.
K.Subsequent encounter for (closed) fracture with nonunion.
M.Subsequent encounter for open fracture (Gustilo) type I or II with nonunion.
N.Subsequent encounter for open fracture (Gustilo) type IIIA, IIIB, IIIC with nonunion.
P.Subsequent encounter for (closed) fracture with malunion.
Q.Subsequent encounter for open fracture (Gustilo) type I or II with malunion.
R.Subsequent encounter for open fracture (Gustilo) type IIIA, IIIB, IIIC with malunion.
S.Sequela. Encounter for complications or conditions that arise as a direct result of a fracture.
Fracture – A disruption or break of the continuity of a bone, epiphyseal plate or cartilaginous surface.
Greenstick – Incomplete fracture in children where one side of the bone breaks, the other side bends. Tends to occur in the shaft of a long bone.
Oblique – A diagonal fracture of a long bone.
Open fracture – An open wound at the site of the fracture resulting in communication with the outside environment. The open may be produced by the bone or the opening can produce the fracture.
Gustilo classification – Classification of open fractures of the forearm (S52), femur (S72) and lower leg (S82) based upon the size of the open wound and the amount of soft tissue injury.
Osteochondral – A break of tear of the articular cartilage along with a fracture of the bone.
Pathologic – Fracture that involves an underlying disease process. It may involve an injury but of the type that would not typically result in a fracture.
Physeal – Fracture in growing children that involves the growth plate.
Spiral – Twisting fracture usually of a long bone resulting in a spiral-shaped fracture line.
Stress – Fracture due to repetitive activity or overexertion without trauma.
Torus – Incomplete fracture of a long bone in children where one side buckles and the other side bulges. Occurs towards the ends of the shaft of the bone.
Transverse – A fracture line that goes across the shaft of a long bone.
Checklist
1.Identify whether the fracture is due to trauma or non-traumatic:
□Nontraumatic fracture
□Atypical femoral fracture
□Pathological fracture
□Due to osteoporosis
□Age-related
□Other
□Due to neoplastic disease
□Define neoplasm
□Due to other disease
□Define underlying disease
□Not otherwise specified
□Stress fracture
□Traumatic fracture
2.If non-traumatic, identify nature and anatomic site of fracture:
□Due to osteoporosis
□Shoulder
□Humerus
□Forearm
□Hand
□Femur
□Lower leg
□Ankle and foot
□Vertebra
□Pathological, other disease process
□Shoulder
□Humerus
□Radius
□Ulna
□Hand
□Finger(s)
□Pelvis
□Femur
□Hip, unspecified
□Tibia
□Fibula
□Ankle
□Foot
□Toe(s)
□Other site (includes vertebra)
□Stress
□Shoulder
□Humerus
□Radius
□Ulna
□Hand
□Finger(s)
□Pelvis
□Femur
□Hip, unspecified
□Tibia
□Fibula
□Ankle
□Foot
□Toe(s)
□Vertebra
a.Identify type:
□Collapsed/Compression/Wedging
□Fatigue
b.Identify spinal region:
□Occipito-atlanto-axial region
□Cervical region
□Cervicothoracic region
□Thoracic region
□Thoracolumbar region
□Lumbar region
□Lumbosacral region
□Sacral/sacrococcygeal region
□Other site
3.If traumatic, identify location and specific anatomic site (bone):
□Skull
□Vault (frontal bone, parietal bone)
□Base of skull
□Occiput
□Occipital condyle
□Type I
□Type II
□Type III
□Other bone base of skull
□Facial bones
□Malar
□Mandible
□Alveolus of mandible
□Angle
□Condylar process
□Coronoid process
□Ramus
□Subcondylar process
□Maxillary
□Maxilla
□Le Fort
□Le Fort I
□Le Fort II
□Le Fort III
□Alveolus of maxilla
□Nasal bones
□Orbital floor
□Zygomatic
□Other skull and facial bones
□Vertebra
□Cervical
□C1
□Posterior arch
□Lateral mass
□Other
□Unspecified – review medical record/query physician
□C2/Dens
□Type II dens
□Other dens
□Other fracture 2nd cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□C3
□Other fracture 3rd cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□Unspecified – review medical record/query physician
□C4
□Other fracture 4th cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□Unspecified – review medical record/query physician
□C5
□Other fracture 5th cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□Unspecified – review medical record/query physician
□C6
□Other fracture 6th cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□Unspecified – review medical record/query physician
□C7
□Other fracture 7th cervical
□Spondylolisthesis, traumatic
□Type III
□Other
□Unspecified – review medical record/query physician
□Unspecified – review medical record/query physician
□Thoracic
□T1
□T2
□T3
□T4
□T5-T6
□T7-T8
□T9-T10
□T11-T12
□Unspecified – review medical record/query physician
□Lumbar
□L1
□L2
□L3
□L4
□L5
□Sacrum
□Type 1
□Type 2
□Type 3
□Zone 1
□Zone 2
□Zone3
□Other
□Unspecified – review medical record/query physician
□Coccyx
□Clavicle
□Sternal end
□Shaft
□Lateral/acromial end
□Unspecified – review medical record/query physician
□Scapula
□Acromial end
□Body
□Coracoid process
□Glenoid cavity
□Neck
□Other
□Unspecified – review medical record/query physician
□Humerus
□Upper end
□Greater tuberosity
□Lesser tuberosity
□Physeal
□Surgical neck
□Other upper/proximal end
□Unspecified – review medical record/query physician
□Shaft
□Lower end
□Condyle
□Lateral condyle/capitellum
□Medial condyle/trochlea
□Supracondylar
□Transcondylar
□Epicondyle
□Lateral
□Medial
□Physeal
□Other lower/distal end
□Unspecified – review medical record/query physician
□Shoulder girdle, part unspecified – review medical record/query physician
□Radius
□Upper end
□Head
□Neck
□Physeal
□Other upper/proximal end
□Unspecified – review medical record/query physician
□Shaft
□Lower end
□Physeal
□Radial styloid
□Other lower/distal end
□Unspecified – review medical record/query physician
□Ulna
□Upper end
□Coronoid process
□Olecranon process
□Other upper/proximal end
□Unspecified – review medical record/query physician
□Shaft
□Lower end
□Ulnar styloid
□Physeal
□Other lower/distal end
□Unspecified – review medical record/query physician
□Carpal
□Navicula (scaphoid)
□Proximal third (pole)
□Middle third (waist)
□Distal third (pole)
□Unspecified – review medical record/query physician
□Lunate
□Triquetrum
□Pisiform
□Trapezium
□Trapezoid
□Capitate
□Hamate
□Body
□Hook
□Metacarpal
□First
□Base
□Shaft
□Neck
□Unspecified – review medical record/query physician
□Second
□Base
□Shaft
□Neck
□Other
□Unspecified – review medical record/query physician
□Third
□Base
□Shaft
□Neck
□Other
□Unspecified – review medical record/query physician
□Fourth
□Base
□Shaft
□Neck
□Other
□Unspecified – review medical record/query physician
□Fifth
□Base
□Shaft
□Neck
□Other
□Unspecified – review medical record/query physician
□Phalanx
□Thumb
□Proximal phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Index finger
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Middle finger
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Ring finger
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Little finger
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Other finger
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Unspecified – review medical record/query physician
□Unspecified fracture of wrist and hand – review medical record/query physician
□Pelvis
□Ilium
□Ischium
□Pubis
□Superior rim
□Other specified
□Unspecified – review medical record/query physician
□Acetabulum
□Anterior column
□Anterior wall
□Dome
□Medial wall
□Posterior column
□Posterior wall
□Transverse
□Transverse-posterior
□Other specified
□Unspecified fracture of acetabulum – review medical record/query physician
□Multiple fractures of pelvis
□Other parts of pelvis
□Unspecified part of lumbosacral spine and pelvis – review medical record/query physician
□Femur
□Upper end
□Apophyseal
□Base of neck
□Epiphysis (separation)
□Greater trochanter
□Head (articular)
□Intracapsular unspecified/subcapital
□Intertrochanteric
□Lesser trochanter
□Midcervical
□Pertrochanteric
□Physeal
□Subtrochanteric
□Other fracture of head and neck
□Unspecified fracture head of femur – review medical record/query physician
□Unspecified part of neck of femur – review medical record/query physician
□Unspecified trochanteric fracture – review medical record/query physician
□Shaft
□Lower end
□Condyle
□Lateral
□Medial
□Supracondylar
□with intracondylar extension
□without intracondylar extension
□Epiphysis (separation)
□Physeal
□Other lower/distal end
□Other fracture of femur
□Unspecified fracture of femur – review medical record/query physician
□Patella
□Tibia
□Upper end
□Condyle
□Bicondylar
□Lateral
□Medial
□Physeal
□Tibial spine
□Tibial tuberosity
□Other upper/proximal end
□Unspecified upper end of tibia – review medical record/query physician
□Shaft
□Lower end
□Physeal
□Other lower/distal end
□Unspecified lower end of tibia – review medical record/query physician
□Fibula
□Physeal
□Upper end
□Lower end
□Shaft
□Upper end
□Lower end
□Other fracture upper and lower end of fibula
□Unspecified fracture of lower leg – review medical record/query physician
□Ankle
□Bimalleolar
□Medial malleolus
□Lateral malleolus
□Pilon/plafond
□Trimalleolar
□Foot
□Talus
□Body
□Dome
□Neck
□Posterior process
□Other fracture of talus
□Unspecified fracture of talus – review medical record/query physician
□Calcaneus
□Anterior process
□Body
□Extraarticular, other
□Intraarticular
□Physeal
□Tuberosity
□Unspecified fracture of calcaneus – review medical record/query physician
□Tarsal, other
□Navicula
□Cuneiform
□Medial
□Intermediate
□Lateral
□Cuboid
□Unspecified tarsal – review medical record/query physician
□Metatarsal
□First
□Second
□Third
□Fourth
□Fifth
□Physeal
□Unspecified metatarsal fracture – review medical record/query physician
□Toe
□Great toe/hallux
□Proximal phalanx
□Distal phalanx
□Other
□Unspecified fracture great toe– review medical record/query physician
□Lesser toe(s)
□Proximal phalanx
□Middle phalanx
□Distal phalanx
□Other
□Unspecified fracture lesser toe– review medical record/query physician
□Physeal
□Other fracture of foot
□Sesamoid
□Unspecified fracture of foot– review medical record/query physician
□Unspecified fracture of toe– review medical record/query physician
□Other fractures
□Neck (includes hyoid, larynx, thyroid cartilage, trachea)
□Rib (s)
□One
□Multiple
□Flail chest
□Sternum
□Body
□Manubrium
□Manubrium dissociation
□Xiphoid process
4.For atypical femoral fractures and traumatic fractures, identify fracture configuration/type, where appropriate:
□Atypical femoral fracture
□Complete oblique
□Complete transverse
□Incomplete
□Vertebral fractures
□C1
□Stable burst
□Unstable burst
□Thoracic and Lumbar
□Wedge
□Stable burst
□Unstable burst
□Other
□Humerus
□Surgical neck
□2-part
□3-part
□4-part
□Upper or lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Torus
□Shaft
□Comminuted
□Greenstick
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Supracondylar without intercondylar fracture
□Comminuted
□Simple
□Ulna
□Olecranon process
□with intercondylar extension
□without intercondylar extension
□Upper or lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Torus
□Shaft
□Bent bone
□Comminuted
□Greenstick
□Monteggia
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Radius
□Upper or lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Torus
□Shaft
□Bent bone
□Comminuted
□Galeazzi’s
□Greenstick
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Lower end
□Extraarticular
□Colles’
□Smith’s
□Other
□Intraarticular
□Barton’s
□Other
□Torus
□Pelvis
□Ilium
□Avulsion
□Other
□Ischium
□Avulsion
□Other
□Multiple fractures of pelvis
□with stable disruption of pelvic ring
□with unstable disruption of pelvic ring
□without disruption of pelvic ring
□Femur
□Physeal upper end
□Salter-Harris Type I
□Other
□Unspecified
□Shaft
□Comminuted
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Torus
□Other
□Patella
□Comminuted
□Longitudinal
□Osteochondral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Tibia
□Upper or lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Torus
□Other
□Shaft
□Comminuted
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Fibula
□Upper or lower end
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Other
□Unspecified – review medical record/query physician
□Torus
□Other
□Shaft
□Comminuted
□Oblique
□Segmental
□Spiral
□Transverse
□Other
□Unspecified – review medical record/query physician
□Talus
□Avulsion
□Calcaneus
□Avulsion
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Metatarsal
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
□Phalanx
□Physeal
□Salter-Harris Type I
□Salter-Harris Type II
□Salter-Harris Type III
□Salter-Harris Type IV
□Other
□Unspecified – review medical record/query physician
5.For traumatic fractures excluding torus and greenstick, identify displacement unless inherent to fracture configuration:
□Displaced
□Nondisplaced
Note: Fractures not documented as displaced or nondisplaced, default to displaced.
6.Identify laterality, excluding vertebral fractures:
□Left
□Right
□Unspecified – review medical record/query physician
7.For traumatic fractures, identify status:
□Closed
□Open
□If S52, S72, S82
□Gustilo Type I
□Gustilo Type II
□Gustilo Type IIIA
□Gustilo Type IIIB
Note: Fractures not identified as open or closed, default to closed.
8.Identify episode of care/stage of healing/complication:
□Pathologic fracture
□A Initial encounter
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□K Subsequent encounter with nonunion
□P Subsequent encounter with malunion
□S Sequela
□Stress fracture (excluding vertebra)
□A Initial encounter
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□K Subsequent encounter with nonunion
□P Subsequent encounter with malunion
□S Sequela
□Stress fracture vertebra (fatigue, collapsed vertebra)
□A Initial encounter
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□S Sequela
□Traumatic fracture vertebra
□A Initial encounter for closed fracture
□B Initial encounter for open fracture
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□K Subsequent encounter with nonunion
□S Sequela
□Traumatic (excluding torus and greenstick and S52, S62, S72, S82)
□A Initial encounter for closed fracture
□B Initial encounter for open fracture
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□K Subsequent encounter with nonunion
□P Subsequent encounter with malunion
□S Sequela
□Traumatic torus and greenstick
□A Initial encounter
□D Subsequent encounter with routine healing
□G Subsequent encounter with delayed healing
□K Subsequent encounter with nonunion
□P Subsequent encounter with malunion
□S Sequela
□Traumatic (S52 forearm, S72 femur, S82 lower leg)
□A Initial encounter for closed fracture
□B Initial encounter for Gustilo type I or II
□C Initial encounter for Gustilo type III A or IIIB
□D Subsequent encounter closed fracture with routine healing
□E Subsequent encounter Gustilo type I or II with routine healing
□F Subsequent encounter Gustilo type IIIA or IIIB with routine healing
□G Subsequent encounter closed fracture with delayed healing
□H Subsequent encounter Gustilo type I or II with delayed healing
□J Subsequent encounter Gustilo type IIIA or IIIB with delayed healing
□K Subsequent encounter closed fracture with nonunion
□M Subsequent encounter Gustilo type I or II with nonunion
□N Subsequent encounter Gustilo type IIIA or IIIB with nonunion
□P Subsequent encounter closed fracture with malunion
□Subsequent encounter Gustilo type I or II with malunion
□R Subsequent encounter Gustilo type IIIA or IIIB with malunion
□S Sequela
9.Identify any associated injuries:
□Fracture of skull and facial bones any associated intracranial injuries S06.-
□Fracture of cervical vertebra any associated spinal cord injury S14.0, S14.1-
□Fracture of thoracic vertebra any associated spinal cord injury S24.0, S24.1-
□Fracture of lumbar vertebra any associated spinal cord/nerve injury S34.0-, S34.1-
□Fracture of rib(s) and sternum any associated injury intrathoracic organ S27.-
10.Identify the external cause, intent, activity, place, and status where applicable
Gestational Diabetes/Abnormal Glucose Tolerance
ICD-10-CM Code Subcategories
O24.4
Gestational diabetes mellitus
O99.81
Abnormal glucose complicating pregnancy, childbirth and the puerperium
ICD-10-CM Definitions
Abnormal glucose – An abnormal glucose tolerance test without specific documentation of gestational diabetes mellitus.
Gestational diabetes mellitus – Glucose intolerance during pregnancy with specific documentation of gestational diabetes mellitus.
ICD-10-CM Guidelines
Gestational diabetes can occur during the second and third trimesters in women without a pre-pregnancy diagnosis of diabetes mellitus. Gestational diabetes may cause complications similar to those in patients with pre-existing diabetes mellitus. Coding guidelines for reporting gestational diabetes are as follows:
•Assign a code from subcategory O24.4 Gestational diabetes mellitus
•Do not assign any other codes in category O24 Diabetes mellitus in pregnancy, childbirth and the puerperium, in conjunction with codes in subcategory O24.4
•The provider must document whether the gestational diabetes is being controlled by diet, insulin, or oral hypoglycemic drugs
•If documentation indicates the gestational diabetes is being controlled with both diet and insulin, report only the code for insulin-controlled
•Do not assign code Z79.4, Long-term use of insulin, with codes in subcategory O24.4.
•Do not assign a code in subcategory O24.4 for documentation of an abnormal glucose tolerance test in pregnancy without specific documentation by the provider that the patient has gestational diabetes. Use a code from subcategory O99.81 Abnormal glucose complicating pregnancy, childbirth, and the puerperium
Checklist
1.Identify condition:
□Abnormal glucose
□Gestational diabetes
2.Identify maternal episode of care:
□Pregnancy
□Childbirth
□Puerperium
3.For gestational diabetes, specify method of control:
□Controlled by oral hypoglycemics
□Diet controlled
□Insulin controlled
□Unspecified control
Glaucoma
ICD-10-CM Categories/Subcategories
H40
Glaucoma
H42
Glaucoma in diseases classified elsewhere
Q15.0
Congenital glaucoma
ICD-10-CM Definitions
Glaucoma – Group of eye disorders characterized by elevated intraocular pressure that can cause optic nerve damage.
Checklist
1.Identify type:
□Glaucoma in diseases classified elsewhere – Specify underlying condition _________________
□Glaucoma suspect
□Anatomical narrow angle (primary angle closure suspect)
□Open angle with borderline findings
□High risk
□Low risk
□Ocular hypertension
□Preglaucoma
□Primary angle closure without glaucoma damage
□Steroid responder
□Open-angle glaucoma
□Capsular glaucoma with pseudoexfoliation of lens
□Low-tension glaucoma
□Pigmentary glaucoma
□Primary open-angle glaucoma
□Residual stage of open-angle glaucoma
□Unspecified open angle glaucoma
□Primary angle-closure glaucoma
□Acute angle-closure glaucoma (attack) (crisis)
□Chronic angle-closure glaucoma
□Intermittent angle-closure glaucoma
□Residual stage of angle-closure glaucoma
□Unspecified primary angle-closure glaucoma
□Secondary glaucoma (due to)
□Drugs – Specify drug _____________________
□Eye inflammation – Specify underlying condition ________________
□Eye trauma – Specify underlying condition ________________
□Other eye disorders – Specify underlying condition ________________\
□Other specified type of glaucoma
□Aqueous misdirection (malignant glaucoma)
□Glaucoma with increased episcleral venous pressure
□Hypersecretion glaucoma
□Other specified type – Specify _________________
□Unspecified type
2.Specify laterality:
□Right eye
□Left eye
□Bilateral
□Unspecified eye
3.Specify stage using the appropriate 7th character:
□0 – Stage unspecified
□1 – Mild stage
□2 – Moderate stage
□3 – Severe stage
□4 – Indeterminate stage
Note: Stage is not required for conditions listed under the following:
•Angle-closure glaucoma
•Acute
•Intermittent
•Residual stage
•Glaucoma suspect
•Open-angle
•Residual stage
•Other specified type of glaucoma
•Aqueous misdirection
•Hypersecretion
•With increased episcleral venous pressure
•Other specified glaucoma
•Unspecified glaucoma
4.Use additional code for adverse effect, if applicable, to identify the drug (T36-T50 with 5th or 6th character 5) for glaucoma secondary to drugs
5.Code also the underlying condition for:
•Glaucoma secondary to eye trauma
•Glaucoma secondary to eye inflammation
•Glaucoma secondary to other eye disorders
6.For glaucoma in diseases classified elsewhere, code underlying condition first
Gout
ICD-10-CM Categories
Gout is classified in two categories in Chapter 13 as a disease of the musculoskeletal system and connective tissue:
M1A
Chronic gout
M10
Gout
ICD-10-CM Definitions
Chronic gout – Long term gout that develops in cases where uric acid levels remain consistently high over a number of years, resulting in more frequent attacks and pain that may remain constant.
Gout – A complex type of arthritis characterized by the accumulation of uric acid crystals within the joints, causing severe pain, redness, swelling, and stiffness, particularly in the big toe. The needle-like crystal deposits in a joint cause sudden attacks or flares of severe pain and inflammation that intensify before subsiding.
Uric acid – A chemical compound of ions and salts formed by the metabolic breakdown of purines, found in foods such as meats and shellfish, and in cells of the body.
Checklist
1.Identify type of gout:
□Acute (attack) (flare)
□Chronic
□Unspecified
2.Identify cause:
□Drug-induced
□Use additional code to identify drug and adverse effect, if applicable
□Due to renal impairment
□Code first causative renal disease
□Idiopathic (primary)
□Lead-induced
□Code first toxic effects of lead and lead compounds
□Secondary
□Code first associated condition
□Unspecified
3.Identify site:
□Lower extremity
□Ankle/foot
□Hip
□Knee
□Upper extremity
□Elbow
□Hand
□Shoulder
□Wrist
□Vertebrae
□Multiple sites
□Unspecified site
4.Identify laterality for extremities:
□Left
□Right
□Unspecified
5.For chronic gout, identify presence/absence of tophi:
□With tophi
□Without tophi
6.For all types of gout, identify any accompanying conditions with the underlying gout:
□Autonomic neuropathy
□Cardiomyopathy
□Disorders of external ear, iris, or ciliary body
□Glomerular disorders
□Urinary calculus
Headache Syndromes
ICD-10-CM Subcategories
G44.0
Cluster headaches and other trigeminal autonomic cephalgias (TAC)
G44.1
Vascular headache, not elsewhere classified
G44.2
Tension-type headache
G44.3
Post-traumatic headache
G44.4
Drug-induced headache, not elsewhere classified
G44.5
Complicated headache syndromes
G44.8
Other specified headache syndromes
R51.0
Headache with orthostatic component, not elsewhere classified
R51.9
Headache NOS
ICD-10-CM Definitions
Headache NOS – Headache not further documented as a migraine or other specific headache syndrome is reported with the sign/symptom code R51.9 in Chapter 18 of ICD-10-CM.
Intractable headache – A headache that is not responding to treatment. Synonymous terms include: pharmacoresistant (pharmacologically resistant) headache, treatment resistant headache, refractory headache, and poorly controlled headache.
Not intractable headache – Headache that is responding to treatment.
Tension headache – Tension headache is synonymous with tension-type headache in ICD-10-CM. Use codes in subcategory G44.2 for headache documented as tension headache.
Checklist
1.Identify the specific type of headache or syndrome:
□Cluster headaches and trigeminal autonomic cephalgias
□Cluster headache
□Chronic
□Episodic
□Unspecified
□Paroxysmal hemicranias
□Chronic
□Episodic
□Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)
□Other trigeminal autonomic cephalgias (TAC)
□Vascular headache, not elsewhere classified
□Tension-type headache
□Chronic
□Episodic
□Unspecified
□Post-traumatic headache
□Acute
□Chronic
□Unspecified
□Drug-induced headache, not elsewhere classified – Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with 5th or 6th character 5)
□Complicated headache syndromes
□Hemicrania continua
□New daily persistent headache (NDPH)
□Primary thunderclap headache
□Other complicated headache syndrome
□Other specified headache syndromes
□Hypnic headache
□Headache associated with sexual activity
□Primary cough headache
□Primary exertional headache
□Primary stabbing headache
□Other specified type headache syndrome – Specify ____________________
2.Identify response to treatment for the following types: cluster, paroxysmal hemicranias, SUNCT, other TAC, tension-type, post-traumatic, and drug-induced
□Intractable
□Not intractable