Icd 10 Cm and Icd 10 Pcs Coding Handbook 2018 Review
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-ten-CM/PCS Trainer
In 2019, HIA reviewed over 725,600 ICD-ten-CM codes from many different facilities including reviews on our own coders. Yesterday nosotros looked at the ICD-x-CM Chapter 9 and today we volition focus on the fifth area with the most coding opportunities constitute during HIA reviews.
- Z00-Z99—Factors influencing health status and contact with wellness services
- A00-B99—Certain Infectious and Parasitic Diseases
- I00-I99—Disease of the Circulatory Organisation
- J00-J99—Diseases of the Respiratory System
- E00-E89—Endocrine, Nutritional, and Metabolic Diseases
For Office 5 of this 5-role series, we will expect at Chapter iv within ICD-ten-CM—E00-E89—Endocrine, Nutritional, and Metabolic Diseases. At that place is no possible way to include every guideline or coding reference for this chapter, but hither are some of the most common issues.
Chapter ten: E00-E89—Endocrine, Nutritional, and Metabolic Diseases:
Affiliate 4 in ICD-x-CM has 10 sections. In looking through the recommendations made, information technology looks like revisions and add-on of the diagnoses are the most common recommendations. The "with" guideline is kickoff to sink in with most coders but we withal find recommendations due to this guideline. This chapter covers malnutrition, obesity and diabetes equally well as other endocrine, nutritional and metabolic diseases. Below are a few areas where coding opportunities were identified during HIA client and internal quality reviews.
- Coders not using the "with" guideline when diabetes is documented with some other condition that is presumed associated in ICD-10-CM (such as retinopathy, nephropathy, etc.).
- Sequencing of the appropriate diabetes lawmaking with manifestations when multiple manifestations are nowadays
- Coding diabetes with unspecified complications or without complications in addition to a specified lawmaking for diabetes with a specific complication
- Just reporting dehydration when patient has hypernatremia or hyponatremia in improver. In ICD-10-CM, both may exist reported
- Reporting unspecified obesity when documentation supported morbid obesity
- Reporting malnutrition without clinical indicators to support the diagnosis
- Missed query opportunities to clarify the specific malnutrition state
- Missed hyperlipidemia when patient is on long term medications
- Missed hypercholesterolemia when patient is on long term medications
- Missed further specificity on diagnoses that is available in the record
- Coding hypothyroidism in a patient s/p thyroidectomy to unspecified instead of postsurgical
In addition to the Official Coding Guidelines for ICD-x-CM for FY 2020, Pages 36-38 that accost specific chapter guidelines to follow for reporting diseases of the respiratory organisation, there are multiple AHA Coding Clinics that talk over some of these in particular. Here are a few of these:
- ICD-10-CM/PCS Coding Dispensary, Fourth Quarter 2016 Pages: nine-14
- ICD-x-CM/PCS Coding Clinic, Fourth Quarter 2013 Pages: 114-115
- ICD-ten-CM/PCS Coding Clinic, 3rd Quarter 2013 Page: 20
- ICD-10-CM/PCS Coding Dispensary, First Quarter 2016 Pages: 12-13
- ICD-ten-CM/PCS Coding Clinic, 3rd Quarter 2018 Pages: three-5
- ICD-10-CM/PCS Coding Clinic, Second Quarter 2016 Pages: 36-37
- ICD-ten-CM/PCS Coding Clinic, 4th Quarter 2017 Pages: 7, 102, 108-109
- ICD-x-CM/PCS Coding Clinic, 3rd Quarter 2016 Page: 42
- ICD-ten-CM/PCS Coding Clinic, Third Quarter 2017 Pages: 24-26
- ICD-ten-CM/PCS Coding Dispensary, Fourth Quarter 2018 Pages: 5-6, 79-80
Coding Tips for Chapter four: E00-E89-Endocrine, Nutritional and Metabolic Diseases:
- Follow all instructional notes within ICD-10-CM for sequencing and to determine if boosted codes would be reported
- Per coding guidelines, obesity is ever considered to be clinically significant
- Per ICD-x-CM Official Guidelines for Coding and Reporting FY 2020 Pages 12 & 13, "The word "with" or "in" should exist interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index (either nether a master term or subterm), or an instructional note in the Tabular List. The classification presumes a causal relationship between the 2 conditions linked by these terms in the Alphabetic Index or Tabular Listing. These conditions should be coded as related fifty-fifty in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between ii conditions (e.k., sepsis guideline for "acute organ dysfunction that is not conspicuously associated with the sepsis")…The word "with" in the Alphabetic Alphabetize is sequenced immediately following the main term or subterm, not in alphabetical gild."
- Diabetes is a meaning complicating factor in pregnancy. A lawmaking from Chapter 15 (O00-O9A)—Pregnancy, Childbirth, and the Puerperium should be sequenced first followed by a lawmaking from Affiliate 4 for the specific type of diabetes documented
- Review the entire medical record to expect for specificity of any diagnoses
- Remember to lawmaking BMI when in that location is an associated condition documented by the provider
- Remember to study any long term use of medications the patient may be taking
Most of the tips in a higher place are for diabetes but there are many more diagnosis in this chapter of ICD-10-CM. Diabetes is merely the most common reported code then there are more chances for errors. Following the instructional notes within ICD-ten-CM is a must in this chapter.
Give thanks you for taking the time to read this 5 Part series on the codes/chapters with the nearly recommendations for reviews in 2019.
References listed higher up.
Happy Coding!
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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Source: https://www.hiacode.com/education/part-5-top-5-icd-10-cm-chapters-2019/