Medical Coding ICD-10-CM

a QuickStudy Laminated Reference Guide

Shelley C Safian

• Publisher: QuickStudy Reference Guides
• Year: 2018
• Print ISBN: 9781423236542
• eBook ISBN: 9781423240709
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

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
  

Chapter-Specific Official Guidelines

SECTION I

1. Certain Infectious & Parasitic Diseases (A00–B99)

• 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

Tabular List Chapter Notations

• INCLUDES: Diseases generally recognized as communi­cable or transmissible
• Use additional code to identify resistance to antimicrobial drugs (Z16.–)
• EXCLUDES1: Certain localized infections (see body system-related chapters)
• EXCLUDES2: Carrier or suspected carrier of infectious disease (Z22.–); infectious and parasitic diseases com­plicating pregnancy, childbirth, and the puerperium (O98.–); infectious and parasitic diseases specific to the perinatal period (P35–P39); and influenza and other acute respiratory infections (J00–J22)

Chapter Blocks

A00–A09 Intestinal infectious diseases

A15–A19 Tuberculosis

A20–A28 Certain zoonotic bacterial diseases

A30–A49 Other bacterial diseases

A50–A64 Infections with a predominantly sexual mode of transmission

A65–A69 Other spirochetal diseases

A70–A74 Other diseases caused by chlamydiae characterized by skin and mucous membrane lesions

A75–A79 Rickettsioses

A80–A89 Viral and prion infections of the central nervous system

A90–A99 Arthropod-borne viral fevers and viral hemorrhagic fevers

B00–B09 Viral infections characterized by skin and mucous membrane lesions

B10 Other human herpes viruses

B15–B19 Viral hepatitis

B20 Human immunodeficiency virus [HIV] disease

B25–B34 Other viral diseases

B35–B49 Mycoses

B50–B64 Protozoal diseases

B65–B83 Helminthiases

B85–B89 Pediculosis, acariasis, and other infestations

B90–B94 Sequelae of infectious and parasitic diseases

B95–B97 Bacterial and viral infectious agents

B99 Other infectious diseases

2. Neoplasms (C00–D49)

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, malig­nant, 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 over­laps two or more contiguous (next to each other) sites should be coded with a fourth character of .8 (“over­lapping lesion”), 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 neo­plasms 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 (“overlapping lesion”) unless the combination is spe­cifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.
• Malignant neoplasm of ectopic tissue: Malignant neoplasms of ectopic tissue are to be coded to the site mentioned (e.g., ectopic pancreatic malignant neo­plasms are coded to pancreas, unspecified (C25.9)).

Chapter Blocks

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 of 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 neoplasms of lymphoid, hema­topoietic, and related tissue

D00–D09 In-situ neoplasms

D10–D36 Benign neoplasms, except benign neuroen­docrine tumors

D3A Benign neuroendocrine tumors

D37–D48 Neoplasms of uncertain behavior, polycythe­mia vera, and myelodysplastic syndromes

D49 Neoplasms of unspecified behavior

3. Diseases of the Blood & Blood-Forming Organs & Certain Disorders Involving the Immune Mechanism (D50–D89)

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