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About This Book
Updated for 2018 ICD-10 CM (International Classification of Diseases, Clinical Modification) guidelines, this 6 page laminated guide covers core essentials of coding clearly and succinctly. Author Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer used her knowledge and experience to provide the largest number of valuable facts you can find in 6 pages, designed for you to find answers fast with color coded sections, and bulleted lists. A must for students seeking coding certification and a great desktop refresher for professionals for classifying and coding diagnoses, symptoms and procedures recorded in conjunction with hospital care.
6-page laminated guide includes:
- General Coding Conventions & Official Guidelines
- Instructional Notations
- Chapter-Specific Official Guidelines
- Selection of Principal Diagnosis
- Reporting Additional Diagnoses
- Diagnostic Coding & Reporting Guidelines for Outpatient Services
- Steps to Coding Diagnoses
- Using the ICD-10-CM Manual
- Documentation of Complications of Care
- Rules of Compliance
- External Cause Codes
- Sequencing Multiple Codes Correctly
- What to Code & What Not to Code
- The Process of Abstracting
- Medical Coding ICD-10-PCS
- Selection of Principal Procedure
- ICD-10-PCS Coding Conventions
- ICD-10-PCS Sections & Subsections
- Medical & Surgical Section: Guidelines
- Obstetrics Section: Guidelines
- New Technology Section: Guidelines
- ICD-10-PCS Terms
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Information
Topic
MedicineChapter-Specific Official Guidelines
SECTION I
1. Certain Infectious & Parasitic Diseases (A00âB99)
- Human immunodeficiency virus (HIV) infections Infectious agents as the cause of diseases classified to other chapters
- Infections resistant to antibiotics
- Sepsis, severe sepsis, and septic shock
- Methicillin-resistant Staphylococcus aureus (MRSA) conditions f. Zika virus infections
- INCLUDES: Diseases generally recognized as communiÂcable or transmissible
- Use additional code to identify resistance to antimicrobial drugs (Z16.â)
- EXCLUDES1: Certain localized infections (see body system-related chapters)
- EXCLUDES2: Carrier or suspected carrier of infectious disease (Z22.â); infectious and parasitic diseases comÂplicating pregnancy, childbirth, and the puerperium (O98.â); infectious and parasitic diseases specific to the perinatal period (P35âP39); and influenza and other acute respiratory infections (J00âJ22)
A00âA09 Intestinal infectious diseases
A15âA19 Tuberculosis
A20âA28 Certain zoonotic bacterial diseases
A30âA49 Other bacterial diseases
A50âA64 Infections with a predominantly sexual mode of transmission
A65âA69 Other spirochetal diseases
A70âA74 Other diseases caused by chlamydiae characterized by skin and mucous membrane lesions
A75âA79 Rickettsioses
A80âA89 Viral and prion infections of the central nervous system
A90âA99 Arthropod-borne viral fevers and viral hemorrhagic fevers
B00âB09 Viral infections characterized by skin and mucous membrane lesions
B10 Other human herpes viruses
B15âB19 Viral hepatitis
B20 Human immunodeficiency virus [HIV] disease
B25âB34 Other viral diseases
B35âB49 Mycoses
B50âB64 Protozoal diseases
B65âB83 Helminthiases
B85âB89 Pediculosis, acariasis, and other infestations
B90âB94 Sequelae of infectious and parasitic diseases
B95âB97 Bacterial and viral infectious agents
B99 Other infectious diseases
2. Neoplasms (C00âD49)
Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm, it is necessary to determine from the record if the neoplasm is benign, in-situ, maligÂnant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.
- Primary malignant neoplasms overlapping site boundaries: A primary malignant neoplasm that overÂlaps two or more contiguous (next to each other) sites should be coded with a fourth character of .8 (âoverÂlapping lesionâ), unless the combination is specifically indexed elsewhere.
Notes: Functional activity, morphology (histology), primary malignant neoplasms with overlapping site boundaries, and malignant neoplasms of ectopic tissue
Guidelines Treatment directed at the malignancy
Treatment of secondary site
Coding and sequencing of complications
Primary malignancy previously excised
Admissions/Encounters involving chemotherapy, immunotherapy, and radiation therapy
Admission/Encounter to determine extent of malignancy
Symptoms, signs, and abnormal findings listed in chapter 18 associated with neoplasms
Admission/Encounter for pain control/management
Malignancy in two or more noncontiguous sites
Disseminated malignant neoplasm, unspecified
Malignant neoplasm without specification of site
Sequencing of neoplasm codes
Current malignancy vs. personal history of malignancy
Leukemia, multiple myeloma, and malignant plasma cell neoplasms in remission versus personal history
Aftercare following surgery for neoplasm
Follow-up care for completed treatment for neoplasm
Prophylactic organ removal for prevention of malignancy
Malignant neoplasm associated with transplanted organ
Tabular List Chapter Notations - Functional activity: All neoplasms are classified in this chapter, whether they are functionally active or not. An additional code from chapter 4 may be used to identify functional activity associated with any neoplasm.
- Morphology [Histology]: Chapter 2 classifies neoÂplasms primarily by site (topography), with broad groupings for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should be used to identify the correct topography code. In a few cases, such as for malignant melanoma and certain neuroendocrine tumors, the morphology (histologic type) is included in the category and codes.
- Primary malignant neoplasms overlapping site boundaries: A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 (âoverlapping lesionâ) unless the combination is speÂcifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.
- Malignant neoplasm of ectopic tissue: Malignant neoplasms of ectopic tissue are to be coded to the site mentioned (e.g., ectopic pancreatic malignant neoÂplasms are coded to pancreas, unspecified (C25.9)).
C00âC14 Malignant neoplasms of lip, oral cavity, and pharynx
C15âC26 Malignant neoplasms of digestive organs
C30âC39 Malignant neoplasms of respiratory and intrathoracic organs
C40âC41 Malignant neoplasms of bone and articular cartilage
C43âC44 Melanoma and other malignant neoplasms of skin
C45âC49 Malignant neoplasms of mesothelial and soft tissue
C50 Malignant neoplasms of breast
C51âC58 Malignant neoplasms of female genital organs
C60âC63 Malignant neoplasms of male genital organs
C64âC68 Malignant neoplasms of urinary tract
C69âC72 Malignant neoplasms of eye, brain, and other parts of central nervous system
C73âC75 Malignant neoplasms of thyroid and other endocrine glands
C7A Malignant neuroendocrine tumors
C7B Secondary neuroendocrine tumors
C76âC80 Malignant neoplasms of ill defined, other secondary, and unspecified sites
C81âC96 Malignant neoplasms of lymphoid, hemaÂtopoietic, and related tissue
D00âD09 In-situ neoplasms
D10âD36 Benign neoplasms, except benign neuroenÂdocrine tumors
D3A Benign neuroendocrine tumors
D37âD48 Neoplasms of uncertain behavior, polycytheÂmia vera, and myelodysplastic syndromes
D49 Neoplasms of unspecified behavior
3. Diseases of the Blood & Blood-Forming Organs & Certain Disorders Involving the Immune Mechanism (D50âD89)
Guidelines Reserved for future expansion
Tabular List Chapter Notations - EXCLUDES2: Autoimmune disease (systemic) NOS (M35...
Table of contents
- General Coding Conventions & Official Guidelines
- Instructional Notations
- Chapter-Specific Official Guidelines
- SECTION II: Selection of Principal Diagnosis
- SECTION III: Reporting Additional Diagnoses
- SECTION IV: Diagnostic Coding & Reporting Guidelines for Outpatient Services
- STEPS TO CODING DIAGNOSES
- Using the ICD-10-CM Manual
- Documentation of Complications of Care
- Rules of Compliance
- External Cause Codes
- Sequencing Multiple Codes Correctly
- What to Code & What Not to Code
- The Process of Abstracting