ICD Coding Scenario
ICD Coding Guideline with explanation
Chronic atrial fibrillation with rapid ventricular response |
ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2018 Page: 6 Effective with discharges: September 24, 2018
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Question:
A patient is admitted for treatment of chronic atrial fibrillation (AF) with rapid ventricular response (RVR). The classification provides codes that describe paroxysmal, chronic, and persistent atrial fibrillation, but not atrial fibrillation with rapid ventricular response. A diagnosis of chronic AF with RVR seems to indicate severity. Would it be appropriate to assign code I48.0, Paroxysmal atrial fibrillation, for AF with RVR? If not, what code should be assigned to reflect chronic atrial fibrillation with RVR?
Answer:
Note fromSolventum:
As of October 1, 2019, codes in category I48, Atrial fibrillation and flutter, were expanded to describe the different types of atrial fibrillation. See advice published in Coding Clinic, 4th Quarter 2019, pages 7-8.
No, code I48.0 is not appropriate since the patient does not have paroxysmal atrial fibrillation. Assign code I48.2, Chronic atrial fibrillation, for chronic AF with RVR. The RVR is not coded separately. Chronic atrial fibrillation with rapid ventricular response (RVR) indicates problems with rate control, not paroxysmal atrial fibrillation.
Anemia due to Acute Blood Loss
It is important to distinguish between anemia due to chronic blood loss and anemia due to acute blood loss, as the two conditions have entirely different codes in ICD-10-CM. Acute blood-loss anemia results from a sudden, significant loss of blood over a brief period of time. It may occur due to trauma, such as laceration, or a rupture of the spleen or other injury of abdominal viscera, where no external blood loss is noted. A diagnosis of acute blood-loss anemia should be supported by documented evidence of the condition, such as a sustained, significant lowering of the hemoglobin and/or hematocrit level. However, these abnormal findings are not coded and reported unless the physician indicates their clinical significance. If findings are outside the normal range, and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.
Acute blood-loss anemia may occur following surgery, but it is not necessarily a complication of the procedure and should not be coded as a postoperative complication unless the physician identifies it as such. Many surgical procedures, such as hip replacement, routinely involve a considerable amount of bleeding as an expected part of the operation. This may or may not result in anemia; a code for anemia should be assigned only when the anemia is documented by the physician. If, in the physician's clinical judgment, surgery results in an expected amount of blood loss and the physician does not describe the patient as having anemia or a complication of surgery, do not assign a code for the blood loss. If a postoperative blood count is low enough to suggest anemia, it is appropriate to ask the physician whether a diagnosis of anemia should be added. It should not be assumed, however, that mention of blood loss and/or transfusion during surgery is an indication that anemia is present. Blood replacement is sometimes carried out as a preventive measure. When postoperative anemia is documented without specification of acute blood loss, code D64.9, Anemia, unspecified, is the default. Code D62, Acute posthemorrhagic anemia, should be assigned when postoperative anemia is due to acute blood loss. When neither the diagnostic statement nor review of the medical record indicates whether a blood-loss anemia is acute or chronic, code D50.0, Iron deficiency anemia secondary to blood loss (chronic), should be assigned.
Asthma with COPD |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2024 Page: 3 Effective with discharges: June 1, 2024
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Question:
What are the appropriate code assignments for asthma in a patient with chronic obstructive pulmonary disease (COPD)? The Alphabetic Index and Tabular List appear to conflict in code assignment. When referencing "Asthma, with, chronic obstructive pulmonary disease" in the Index, code J44.89, Other specified chronic obstructive pulmonary disease, is provided. However, when referencing "Disease, lung, obstructive (chronic), with asthma," code J44.9, Chronic obstructive pulmonary disease, unspecified, is listed.
Should a separate code be reported to identify asthma in COPD patients?
Answer:
Assign code J44.89, Other specified chronic obstructive pulmonary disease, for a patient with asthma and COPD. A separate code for asthma should not be assigned unless the type of asthma is specified, or the asthma is exacerbated.
The instructional note under category J44, Other chronic obstructive pulmonary disease, states "code also type of asthma, if applicable (J45-)." Therefore, it would be appropriate to separately report a code for the specific type of asthma and/or asthma exacerbation when documented.
Although asthma exacerbation does not specify a type of asthma, it does provide additional specificity (acuity) regarding the asthma. Do not assign code J45.909, Unspecified asthma, uncomplicated, when the type of asthma is not further specified. "Unspecified" is not considered a type of asthma.
Emphysema/bronchiectasis and COPD |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2024 Pages: 4-5 Effective with discharges: June 1, 2024
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Question:
In previous issues of Coding Clinic (Fourth Quarter 2017 and First Quarter 2019), it was advised to report only code J43.9, Emphysema, unspecified, for a patient with both chronic obstructive pulmonary disease (COPD) and emphysema because emphysema is a specific form of COPD. This Coding Clinic advice further stated that it was not appropriate to report codes from both categories J43, Emphysema, and J44, Other chronic obstructive pulmonary disease, because of the Excludes1 notes at both categories.
Effective with the October 1, 2023, updates, the Excludes1 notes found at categories J43 and J44 were changed to Excludes2 notes, which now appears to allow the reporting of codes from both categories, when appropriate. However, when referencing "Disease, lung, obstructive (chronic), with emphysema," only code J43.9 is provided. Do these Excludes note changes allow the reporting of COPD separately in a patient with emphysema? Please clarify the proper code assignment for COPD in a patient with emphysema.
Answer:
Assign only code J43.9, Emphysema, unspecified, for a patient with COPD and emphysema. No additional code for COPD is assigned unless it is further specified (i.e., with infection or with acute exacerbation). As stated in previous Coding Clinic guidance, emphysema is a form of COPD; therefore, it is not appropriate to assign code J44.9, Chronic obstructive pulmonary disease, unspecified, in addition to code J43.9.
Code J43.9 can be referenced in the Alphabetic Index as follows:
Disease, diseased
-lung
--obstructive (chronic)
---with
----emphysema J43.9
Chronic non-pressure ulcer of heel with subcutaneous tissue exposure |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2020 Page: 19 Effective with discharges: May 29, 2020
Question:
A patient with Type 2 diabetes mellitus presents to outpatient wound care for debridement of a chronic non-pressure ulcer of the right heel. The provider documented that the ulcer was necrotic with exposed subcutaneous tissue. For the purposes of code assignment, should documentation of "subcutaneous tissue exposure" be interpreted to mean fat level exposure?
Answer:
Yes. The subcutaneous tissue includes the fat layer. Assign codes E11.621, Type 2 diabetes mellitus with foot ulcer, and L97.412, Nonpressure chronic ulcer of right heel and midfoot with fat layer exposed, for the right heel nonpressure ulcer.
Diabetic manifestations following weight loss surgery |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2020 Page: 12 Effective with discharges: March 5, 2020
Question:
A patient with a long-standing history of type 2 diabetic polyneuropathy underwent bariatric surgery. The patient no longer requires medication for the diabetes secondary to the significant weight loss, and in fact, the physician documents that the diabetes has resolved. The patient has now developed an ulceration of the right foot with acute osteomyelitis secondary to diabetic polyneuropathy. Would these conditions still be coded as diabetic complications?
Answer:
Assign codes E11.42, Type 2 diabetes mellitus with diabetic polyneuropathy; E11.69, Type 2 diabetes mellitus with other specified complication; E11.621, Type 2 diabetes mellitus with foot ulcer; M86.171, Other acute osteomyelitis, right ankle and foot; and L97.511, Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin. Assign also code Z98.84, Bariatric surgery status, for the post status weight loss surgery.
The patient still has complications associated with the diabetes, even though glucose levels have normalized. Codes from category E11, Type 2 diabetes mellitus are required to capture the diabetic manifestations.
Use of electronic cigarettes |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2017 Page: 29 Effective with discharges: May 17, 2017
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Question:
The same patient as above is currently using e-cigarettes and has stopped smoking regular cigarettes. What codes should be assigned?
Answer:
Assign code F17.290, Nicotine dependence, other tobacco product, uncomplicated, to capture the use of e-cigarettes.
In this case, code F17.210 would not be assigned, since the patient is no longer smoking regular cigarettes.
Kidney Disease with Diabetes Mellitus
Diabetic kidney complications are coded to E08-E13 with .21 for diabetic nephropathy, .22 for chronic kidney disease, and .29 for other kidney complication. Kidney disease sometimes results from both hypertension and diabetes mellitus. In this situation, the combination code from category I12 or category I13 and a code from subcategory E08-E13 with .2- are assigned. A code from category N18 is assigned to specify the stage of chronic kidney disease.
Examples of appropriate codes for kidney disease due to diabetes include the following:
| E11.21 | Diabetic nephrosis |
| I12.9 + E10.22 + N18.4 | Chronic kidney disease stage 4 due to hypertension and type 1 diabetes mellitus |
| E10.22 | Chronic kidney disease, unspecified, due to type 1 diabetes |
Decompensated systolic heart failure |
ICD-10-CM/PCS Coding Clinic, Second Quarter 2013 Page: 33 Effective with discharges: July 8, 2013
Question:
Coding Clinic, Third Quarter 2008, p. 12, states "decompensated indicates that there has been a flare-up (acute phase) of a chronic condition." Should this general definition of decompensated be applied when assigning ICD-10-CM codes as well? For example, what is the appropriate ICD-10-CM code assignment for a diagnosis of chronic systolic heart failure, currently decompensated?
Answer:
Assign code I50.23, Acute on chronic systolic heart failure, for decompensated systolic heart failure. As previously stated, "decompensated" indicates that there has been a flare-up (acute phase) of a chronic condition.
Hypertension with congestive heart failure |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 47 Effective with discharges: March 13, 2017
Question:
In the guideline for hypertension with heart disease, category I50, Heart failure, is included in the list of heart conditions that are classified as hypertensive heart disease, but it is not included in the Alphabetic Index nor Tabular List. Is congestive heart failure (CHF) in a patient with hypertension coded as hypertensive heart disease with failure, when the provider's documentation has not explicitly linked the two conditions?
Answer:
Assign code I11.0, Hypertensive heart disease, with failure, along with the appropriate code from category I50, Heart failure, for CHF in a patient with hypertension. The classification presumes a causal relationship between hypertension and heart involvement unless the provider documents that the conditions are unrelated.
Although heart failure is not in the list of heart conditions in the inclusion note, in ICD-10-CM, there is a note instructing "Use additional code to identify type of heart failure" in the Tabular List. The code range under category I11, Hypertensive heart failure, is not intended to be an all-inclusive list. The range of heart conditions in the Alphabetic Index and Tabular List will be considered for future modification through the Coordination and Maintenance Committee.
Residual right-sided weakness due to previous cerebral infarction |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2015 Page: 25 Effective with discharges: March 16, 2015
Question:
The patient is a 72-year-old male admitted to the hospital, because of gastrointestinal bleeding. The provider documented that the patient had a history of acute cerebral infarction with residual rightsided weakness (dominant side), and ordered an evaluation by physical and occupational therapy. What is the appropriate code assignment for residual right-sided weakness, resulting from an old CVA without mention of hemiplegia/hemiparesis?
Answer:
Assign code I69.351, Hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, for the residual right-sided weakness due to cerebral infarction. When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia. Unilateral weakness outside of this clear association cannot be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.
National Institutes of Health Stroke Scale (NIHSS) scores |
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Page: 61-62 Effective with discharges: October 1, 2016
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A new subcategory (R29.7-) has been created to report the National Institutes of Health Stroke Scale (NIHSS) scores. The NIHSS scale is a clinical assessment tool to evaluate and document neurological status in acute stroke patients. The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
Codes from R29.7- are intended to be used as secondary codes as the acute cerebral infarction (I63-) should be coded first. The codes discretely identify NIHSS scores from 0 to 42. At a minimum, report the initial score documented. If desired, a facility may choose to capture multiple stroke scale scores.
Code assignment for the NIHSS may be based on medical record documentation from clinicians who are not the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis), since this information is typically documented by other clinicians involved in the care of the patient. However, the associated diagnosis (such as stroke) must be documented by the patient's provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.
Question:
A 70-year-old male patient was admitted with acute stroke. The physician documented an NIHSS score of 30. How should this be coded?
Answer:
Assign code I63.9, Cerebral infarction, unspecified as the principal diagnosis. Code R29.730, NIHSS score 30, is assigned as an additional diagnosis.
Diagnostic colonoscopy due to positive Cologuard® test |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Page: 33 Effective with discharges: March 20, 2019
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Question:
A patient is referred for a colonoscopy due to the positive results of a Cologuard® test. During colonoscopy, a cecal polyp was found and removed. The preoperative diagnosis is screening colonoscopy and abnormal Cologuard®. What is the ICD-10-CM code for the colonoscopy encounter?
Answer:
Based on the documentation submitted, assign code K63.5, Polyp of colon, as the first-listed diagnosis for the colonoscopy. When a colonoscopy is performed due to a positive finding on a Cologuard® test, the colonoscopy would be considered a diagnostic examination, not a screening.
The Official Guidelines for Coding and Reporting, outpatient services state, "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis (es) documented in the interpretation." Code to the highest degree of certainty.
Hyperlipidemia not specified with hypercholesterolemia |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2022 Pages: 6-7 Effective with discharges: June 3, 2022
Question:
What is the appropriate ICD-10-CM code(s) for a diagnosis of unspecified hyperlipidemia and hypercholesterolemia?
Answer:
Assign code E78.00, Pure hypercholesterolemia, unspecified, for a diagnosis of unspecified hyperlipidemia and hypercholesterolemia. Do not assign code E78.5, Hyperlipidemia, unspecified, as the hypercholesterolemia identifies the specific blood lipid elevated.
Hypercholesterolemia is a high blood cholesterol level. Hyperlipidemia is high or elevated lipids/fats levels in the blood. Providers may use the terms hyperlipidemia and hypercholesterolemia interchangeably, as high blood cholesterol is a lipid disorde
End-stage renal disease or fluid overload |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2023 Pages: 19-20 Effective with discharges: March 3, 2023
Question:
A patient with hypertension and end-stage renal disease presents for emergent dialysis due to fluid overload. The patient has been compliant with dialysis. Which condition is sequenced as the principal diagnosis, end-stage renal disease or fluid overload?
Answer:
Assign code E87.70, Fluid overload, unspecified, as the principal diagnosis. Fluid overload is not inherent to end stage renal disease (ESRD); it is a distinct problem and a complication of the kidney disease. Typically, patients in fluid overload who have ESRD are treated with dialysis. Code E87.70 is assigned as the principal diagnosis since this is the specific condition that required admission to the hospital. The circumstances of inpatient admission always govern selection of the principal diagnosis.
Asthma
Asthma is a bronchial hypersensitivity characterized by mucosal edema, constriction of bronchial musculature, and excessive viscid edema. Manifestations of asthma are wheezing, dyspnea out of proportion to exertion, and cough.
A diagnosis of wheezing alone is not classified as asthma; code R06.2 is assigned in such a case.
Medycoding Notes
1. What does the first paragraph mean?
Asthma is a disease of the airways (bronchi) in which the airways become overly sensitive and can narrow.
The description mentions three major changes:
Mucosal edema → swelling of the airway lining
Constriction of bronchial musculature → the muscles around the airways tighten, narrowing the airway
Excessive viscid mucus → thick/sticky mucus is produced
These changes can produce symptoms such as:
Wheezing
Dyspnea (difficulty breathing)
Cough
So, conceptually:
Asthma = underlying diseaseWheezing/dyspnea/cough = manifestations or symptoms
2. The key coding rule
The important sentence is:
“A diagnosis of wheezing alone is not classified as asthma.”
This means:
Provider documents:
Wheezing
but does not diagnose asthma.
You cannot assume asthma just because wheezing is commonly associated with asthma.
Instead, code the documented symptom:
R06.2 — Wheezing
3. Why can't the coder assume asthma?
Because wheezing has many possible causes.
For example:
Asthma
COPD
Respiratory infection
Allergic reaction
Airway obstruction
Other respiratory conditions
Therefore:
Wheezing ≠ automatically asthma
The provider must establish the diagnosis of asthma.
4. Compare these two scenarios
Scenario A — Only symptom documented
Documentation:
"Patient presents with wheezing and shortness of breath."
No diagnosis of asthma is documented.
Coding:
R06.2 — Wheezing
You should not code J45.- (asthma) simply because the patient is wheezing.
Scenario B — Asthma is diagnosed
Documentation:
"Patient has asthma with wheezing."
Now asthma is established as the diagnosis.
You would determine the appropriate J45.- asthma code based on the provider's documentation, including the type/severity and whether there is acute exacerbation or status asthmaticus.
You would not automatically code R06.2 separately merely because wheezing is mentioned as a manifestation of the asthma.
Asthma is classified into category J45, with a fourth character indicating the severity (mild intermittent, mild persistent, moderate persistent, severe persistent, other, and unspecified) and a final character indicating whether the condition is uncomplicated or whether status asthmaticus or exacerbation is present.
Status asthmaticus is defined in slightly different ways by different authorities, but, in general, it represents a patient who continues to have extreme wheezing in spite of conventional therapy or who has suffered from an acute asthmatic attack in which the degree of obstruction is not relieved by the usual therapeutic measures. Early status asthmaticus represents patients who are refractory to treatment or who fail to respond to the usual therapies; advanced status asthmaticus represents patients who show full development of an asthma attack that could result in respiratory failure, with signs and symptoms of hypercapnia (excess carbon dioxide in the blood). The final character 2 is assigned for both types of status asthmaticus. Use of this final character usually indicates a medical emergency for treatment of acute, severe asthma.
Other terms used to describe status asthmaticus include the following:
Intractable asthma attack
Refractory asthma
Severe, intractable wheezing
Airway obstruction not relieved by bronchodilators
Severe, prolonged asthmatic attack
Medycoding Notes
1. Asthma codes start with J45
ICD-10-CM places asthma in category J45.
The code structure essentially works like this:
J45 + asthma type/severity + clinical status
The asthma type/severity is identified in the characters before the final character.
Common asthma categories
Asthma type | Example code family |
Mild intermittent | J45.2- |
Mild persistent | J45.3- |
Moderate persistent | J45.4- |
Severe persistent | J45.5- |
Other asthma | J45.8- |
Unspecified asthma | J45.9- |
Then the final character tells you the current status:
Final character | Meaning |
0 | Uncomplicated |
1 | With acute exacerbation |
2 | With status asthmaticus |
Example
J45.40→ Moderate persistent asthma, uncomplicated
J45.41→ Moderate persistent asthma with acute exacerbation
J45.42→ Moderate persistent asthma with status asthmaticus
So you can think:
J45.4 + 0/1/2
2. What exactly is status asthmaticus?
This is the most important part.
Status asthmaticus is not simply “bad asthma.”
It refers to an acute, severe asthma attack that does not respond adequately to the usual/conventional treatment.
In simple terms:
Asthma attack + persistent severe airway obstruction + inadequate response to usual treatment = status asthmaticus
For example:
A patient has severe wheezing and difficulty breathing.
The patient receives usual bronchodilator treatment.
But the airway obstruction/wheezing continues despite treatment.
That is the type of clinical situation being described by status asthmaticus.
3. Early vs. advanced status asthmaticus
The paragraph divides it conceptually into two stages.
Early status asthmaticus
The patient:
Has an acute asthma attack
Is refractory to treatment
Doesn't respond adequately to usual therapy
Think:
“Treatment is not working as expected.”
Advanced status asthmaticus
The asthma attack has progressed significantly and may lead to:
Severe airway obstruction
Respiratory failure
Hypercapnia (elevated CO₂ in the blood)
Think:
“Severe attack progressing toward respiratory failure.”
But an important coding point is:
Both early and advanced status asthmaticus use final character 2.
You don't have separate ICD-10-CM codes for early vs. advanced status asthmaticus.
4. Very important: Don't require respiratory failure to code status asthmaticus
This is a common misunderstanding.
The text says advanced status asthmaticus could result in respiratory failure and may have hypercapnia.
It does not mean:
"Respiratory failure must be documented before I can code status asthmaticus."
That's incorrect.
If the provider documents status asthmaticus, the asthma code uses the final character 2, even if respiratory failure is not documented.
If respiratory failure is separately documented and clinically reportable, that is a separate coding consideration.
5. What do the alternative terms mean?
The list gives terminology that may be used by providers to describe this condition.
Intractable asthma attack
Intractable essentially means the attack is difficult to control or does not respond adequately to treatment.
Refractory asthma
Refractory means the asthma is not responding adequately to usual treatment.
Severe, intractable wheezing
Severe wheezing that persists despite treatment may indicate status asthmaticus when the provider establishes that diagnosis/clinical relationship.
Airway obstruction not relieved by bronchodilators
This is describing an important characteristic:
Bronchodilator given → expected improvement does not occur.
Severe, prolonged asthmatic attack
A severe attack that persists and does not respond adequately to conventional therapy can be described as status asthmaticus.
6. But here's the important coding caution
Do not independently convert every one of these terms into status asthmaticus without considering the applicable coding guidance and provider documentation.
For example:
"Patient has severe wheezing."
That alone does not automatically mean status asthmaticus.
Similarly:
"Patient has refractory asthma."
The coder should evaluate the documentation and applicable ICD-10-CM Index/Tabular instructions rather than simply deciding clinically that it must be status asthmaticus.
The key distinction is:
Symptom
Wheezing → R06.2
Asthma diagnosis
Asthma → J45.-
Asthma with acute exacerbation
J45.xxx1
Asthma with status asthmaticus
J45.xxx2
7. Status asthmaticus vs. acute exacerbation
This is the connection with your previous question.
Acute exacerbation
The asthma has become worse.
Example:
"Moderate persistent asthma with acute exacerbation."
→ J45.41
Status asthmaticus
The asthma attack is severe/persistent and not responding adequately to conventional therapy.
Example:
"Moderate persistent asthma with status asthmaticus."
→ J45.42
If both are documented:
"Moderate persistent asthma with acute exacerbation and status asthmaticus."
You do not assign J45.41 + J45.42.
You assign:
J45.42 only
Because the classification directs that the status asthmaticus code takes precedence.
It should never be assumed that status asthmaticus is present without a specific statement from the provider. However, asthma described as acute, characterized by prolonged or severe intractable wheezing, or asthma being treated by the administration of adrenal corticosteroids should alert the coding professional that status asthmaticus may exist and that the provider should be asked whether the diagnosis is to be added.
Exacerbations of asthma are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness—or some combination of these symptoms. The final character 1 is used for asthma referred to as "exacerbated" or in "acute exacerbation." An asthma code with a final character 1, with acute exacerbation, may not be assigned with an asthma code with a final character 2, with status asthmaticus. When there is documentation of both acute exacerbation and status asthmaticus, only the code with the final character 2 should be assigned.
Medycoding Notes
1. What is an asthma exacerbation?
An exacerbation means the patient's asthma has suddenly or progressively become worse.
Typical symptoms include:
Increasing shortness of breath
Increasing cough
Wheezing
Chest tightness
Any combination of these
Think of it as:
Asthma + worsening symptoms = acute exacerbation
2. What does the final character mean?
Many asthma codes are distinguished by the last character:
Final character | Meaning |
0 | Uncomplicated asthma |
1 | With acute exacerbation |
2 | With status asthmaticus |
For example, depending on the type/severity of asthma:
J45.xxx1 → asthma with acute exacerbation
J45.xxx2 → asthma with status asthmaticus
The exact middle characters (xxx) depend on the documented asthma type/severity.
3. The important part: Exacerbation vs. Status asthmaticus
The key rule is:
You cannot assign both the “1” and “2” asthma codes for the same episode.
Why?
Because status asthmaticus represents a severe, prolonged asthma attack and is considered the more severe condition.
So:
Example 1 — Acute exacerbation only
Provider documents:
"Moderate persistent asthma with acute exacerbation."
Code:
J45.41Moderate persistent asthma with (acute) exacerbation.
There is no status asthmaticus, so the final character is 1.
Example 2 — Status asthmaticus only
Provider documents:
"Moderate persistent asthma with status asthmaticus."
Code:
J45.42Moderate persistent asthma with status asthmaticus.
Here, final character is 2.
4. What if BOTH are documented?
This is the most important exam/coding point.
Suppose the provider documents:
"Patient has moderate persistent asthma with acute exacerbation and status asthmaticus."
You might initially think:
J45.41 → acute exacerbation
J45.42 → status asthmaticus
But you do NOT code both.
Instead:
Assign only:
J45.42 — Moderate persistent asthma with status asthmaticus
The final character 2 takes precedence.
Why?
Think of it this way:
Acute exacerbation⬇️Asthma has worsened
Status asthmaticus⬇️A more severe/prolonged asthma attack
Therefore:
Status asthmaticus includes the acute worsening, so you don't separately code the exacerbation code.
Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified to category J44, Other chronic obstructive pulmonary disease. Code also the type of asthma (J45.-) only when the specific type of asthma is documented by the provider. If the documentation does not specify the type of asthma, do not assign code J45.909, Unspecified asthma, uncomplicated. "Unspecified" is not a type of asthma.
A diagnosis of asthmatic bronchitis without further specification is coded as J45.9-. If the diagnosis is stated as exacerbated or acute chronic asthmatic bronchitis, code J44.1 is assigned. A diagnosis of asthmatic bronchitis with COPD or chronic asthmatic bronchitis is coded to J44.89. Examples of coding for asthma include the following:
| J45.902 | Asthmatic bronchitis with status asthmaticus |
| J45.909 | Childhood asthma |
| J44.89 + J45.40 | Moderate persistent asthma with COPD |
| J44.1 + J45.901 | Chronic asthmatic bronchitis with acute exacerbation |
| J45.909 + F54 | Psychogenic asthma |
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) is a general term used to describe a variety of conditions that result in obstruction of the airway. ICD-10-CM classifies these conditions to category J44, Other chronic obstructive pulmonary disease. Category J44 includes the following conditions:
Asthma with chronic obstructive pulmonary disease
Chronic asthmatic (obstructive) bronchitis
Chronic bronchitis with airways obstruction
Chronic bronchitis with emphysema
Chronic emphysematous bronchitis
Chronic obstructive asthma
Chronic obstructive bronchitis
Chronic obstructive tracheobronchitis
Category J44 is further subdivided to specify whether there is an acute lower respiratory infection (J44.0) and whether there is an exacerbation of the condition (J44.1). If applicable, a code from category J45 is assigned to specify the type of asthma. In the case of code J44.0, Chronic obstructive pulmonary disease with (acute) lower respiratory infection, a code should also be assigned to identify the infection. Code J44.0 is assigned for COPD with acute bronchitis or pneumonia, but not for COPD with influenza, because influenza involves both upper and lower respiratory infections. Category J44 also includes a code for COPD with acute exacerbation (J44.1). An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, although an exacerbation may be triggered by an infection. For example, COPD with acute bronchitis should be coded to J44.0, rather than J44.1. Examples of the terms classified to J44.1, Chronic obstructive pulmonary disease with (acute) exacerbation, are "exacerbation," "in exacerbation," "decompensated," "acute exacerbation," "exacerbated," or "uncompensated." When the diagnosis is stated only as COPD, review the medical record to determine whether a more definitive diagnosis is documented. Bronchiolitis obliterans (a condition in which bronchioles become inflamed, damaged, and then scarred) that occurs following lung transplantation is known as bronchiolitis obliterans syndrome (BOS). BOS is assigned to code J44.81. Obstructive bronchitis that includes chronic asthmatic bronchitis and chronic emphysematous bronchitis is coded to J44.89, Other specified chronic obstructive pulmonary disease. Code J44.9, Chronic obstructive pulmonary disease, unspecified, is assigned only when a more specific code cannot be assigned.
Note that emphysema without chronic bronchitis is coded to J43.-, and chronic bronchitis not otherwise specified is classified to code J42.
Bronchospasm
Bronchospasm is an integral part of asthma or any other type of chronic airway obstruction; therefore, no additional code is assigned to indicate its presence when an asthma or other chronic airway obstruction is diagnosed. Code J98.01, Acute bronchospasm, is assigned only when the underlying cause has not been identified.
Z72.0 — Tobacco use: Used when tobacco use is documented without a diagnosis of tobacco dependence.
F17.- — Nicotine dependence: Used when nicotine dependence is documented.
Alzheimer's disease and dementia |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Pages: 43-44 Effective with discharges: March 13, 2017
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Question:
What is the correct code assignment for a diagnosis of Alzheimer's disease without provider documentation of dementia? When referencing the Alphabetic Index, the coding professional is directed to codes G30.9, Alzheimer's disease, unspecified, and [F02.80], Dementia in other diseases classified elsewhere without behavioral disturbance. Based on this index entry, are two codes required, or must the provider specifically document Alzheimer's disease with dementia?
Answer:
Note fromSolventum:
As of October 1, 2022, new codes have been added to recognize the stages of severity and to identify the behavioral and psychological symptoms of dementia (BPSD). See advice published in Coding Clinic, 4th Quarter 2022, pages 14-15.
Dementia is an inherent part of Alzheimer's disease; therefore, the provider does not need to separately document it. Assign code G30.9, Alzheimer's disease, unspecified, followed by code F02.80, Dementia in other diseases classified elsewhere, without behavioral disturbance. In the Alphabetic Index, code G30.9 is listed first, followed by code F02.80 or F02.81 in brackets. Code G30.9 represents the underlying etiology, Alzheimer's disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance.
The Official Guidelines for Coding and Reporting pertaining to the etiology/manifestation convention (1.A.13), states "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation."
Hyperplastic rectal polyp with adenomatous changes |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Pages: 6-7 Effective with discharges: February 18, 2018
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Question:
The patient presented for colon cancer screening due to increased risk secondary to family history of colon cancer. During the screening colonoscopy, a rectal polyp was found and removed via hot snare. The pathological findings revealed "hyperplastic polyp with focal adenomatous changes." Should code K62.1, Rectal polyp or code D12.8, Benign neoplasm of rectum, be assigned for a hyperplastic rectal polyp with focal adenomatous changes?
Answer:
Assign code Z12.11, Encounter for screening for malignant neoplasm of colon, as the first-listed diagnosis. Assign code D12.8, Benign neoplasm of rectum, as an additional diagnosis for the hyperplastic polyp with focal adenomatous changes. Code Z80.0, Family history of malignant neoplasm of digestive organs, should also be assigned. This is a definitive finding of an adenomatous polyp. A mixed polyp would be treated clinically as an adenoma, which requires stricter surveillance and follow-up.
Surveillance colonoscopy |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 9 Effective with discharges: March 13, 2017
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Question:
A patient, who is status post removal of adenomatous colon polyps five years ago, presents to the GI lab for surveillance colonoscopy. The colonoscopy is completely normal and the provider recommends surveillance colonoscopy in ten years. What is the correct diagnosis code assignment?
Answer:
Assign code Z12.11, Encounter for screening for malignant neoplasm of colon, as the first-listed diagnosis for the surveillance colonoscopy. Code Z86.010, Personal history of colonic polyps, should be assigned as an additional diagnosis. A surveillance colonoscopy is still a screening, and patients are being screened for malignancy; however, it is considered a high-risk screening exam due to the history of previous polyps.
Gastric intestinal metaplasia |
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2021 Pages: 15-16 Effective with discharges: October 1, 2021
Gastric Intestinal Metaplasia
Subcategory K31.A, Gastric intestinal metaplasia, has been created for gastric intestinal metaplasia of the stomach with and without dysplasia and unspecified gastric intestinal metaplasia.
K31.A0, Gastric intestinal metaplasia, unspecified
K31.A11, Gastric intestinal metaplasia without dysplasia, involving the antrum
K31.A12, Gastric intestinal metaplasia without dysplasia, involving the body (corpus)
K31.A13, Gastric intestinal metaplasia without dysplasia, involving the fundus
K31.A14, Gastric intestinal metaplasia without dysplasia, involving the cardia
K31.A15, Gastric intestinal metaplasia without dysplasia, involving multiple sites
K31.A19, Gastric intestinal metaplasia without dysplasia, unspecified site
K31.A21, Gastric intestinal metaplasia with low grade dysplasia
K31.A22, Gastric intestinal metaplasia with high grade dysplasia
K31.A29, Gastric intestinal metaplasia with dysplasia, unspecified
Gastric intestinal metaplasia (GIM) occurs when the normal gastric epithelium that lines the stomach is replaced with goblet cells from the intestines. Risk factors associated with GIM are H. pylori infection, chronic bile reflux, cigarette smoking, family history of gastric cancer, and high salt intake. GIM is a precancerous lesion. Typically, there are no noticeable symptoms and GIM may be demonstrated on diagnostic endoscopy. The pathway to gastric adenocarcinoma is believed to be a progression from chronic gastritis, atrophic gastritis, GIM, dysplasia, and finally, abnormal cancerous cells. Metaplastic changes in the antrum and body of the stomach, indicating diffuse GIM, are associated with a higher risk for cancer versus involvement of the antrum alone. The presence of dysplasia, a benign unequivocal neoplastic epithelial lesion, adds an even greater risk for malignant transformation, with the location of the lesion being less important.
Medycoding Notes :
The key difference is whether the documentation identifies the site of gastric intestinal metaplasia and whether dysplasia is present
Depression and anxiety |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages: 10-11 Effective with discharges: March 10, 2021
Question:
When the provider's documentation indicates a patient has both depression and anxiety by using terminology such as depression and anxiety or depression with anxiety, are these diagnoses coded separately? Does the classification assume a linkage between the two conditions? There are no Excludes 1 notes that prohibit coding depression and anxiety together. What is the appropriate code assignment for a patient with depression and anxiety?
Answer:
The classification does not assume a linkage between depression and anxiety; therefore, documentation of the two conditions is not sufficient to link them together. Assign codes F32.9, Major depressive disorder, single episode, unspecified, and F41.9, Anxiety disorder, unspecified, when the documentation has not established a linkage between the depression and the anxiety.
If, however, the provider does indicate a relationship between the two conditions, it would be appropriate to assign code F41.8, Other specified anxiety disorders. This code assignment includes anxiety depression and mixed anxiety and depressive disorder.
Mixed anxiety and depressive disorder, also known as MADD, is a distinct clinical diagnosis. In ICD-10-CM, it is not classified the same as unspecified anxiety and depression. Unless there is a linkage in the documentation to indicate a single disorder, these conditions should be coded separately.
Medications used on an as-needed basis |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages: 12-13 Effective with discharges: March 10, 2021
Question:
A patient diagnosed with asthma is currently on prescribed inhaled albuterol, "as needed" for control of symptoms. Since the medication is prescribed for long-term treatment of asthma, would it be appropriate to assign a code from category Z79, Long-term (current) drug therapy, even though the medication is taken pro re nata (PRN) to control symptoms of asthma?
Answer:
Medications that are prescribed on an as needed (PRN) basis would not be assigned codes from category Z79, Long-term (current) drug therapy. For example, rescue medications used to relieve asthma symptoms are not classified as long-term drug therapy.
Newly prescribed hypoglycemic medication intended for long-term use |
ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2024 Pages: 26-27 Effective with discharges: June 1, 2024
Question:
A patient is admitted to our facility for further evaluation of a possible stroke. The provider documented the probable etiology as small vessel disease due to uncontrolled hypertension and new onset of diabetes mellitus. The patient was discharged to a rehab facility with oral metformin and sodium-glucose cotransporter-2 (SGLT2) inhibitor. Would it be appropriate to assign a code from category Z79, Long-term (current) drug therapy, for newly prescribed hypoglycemic (anti-diabetic) medication based on the intended long-term use to manage a chronic condition?
Answer:
It would be appropriate to assign a code from category Z79, Long-term (current) drug therapy, when a patient is prescribed a medication that is intended to be taken on a long-term basis to control a chronic condition such as diabetes mellitus. Code assignment is not based on whether the medication is new for the patient, but rather the intended use of the medication for long-term drug therapy. However, if there is an indication that the medication is to be used for a brief period and not on a long-term basis, a code for long-term drug therapy would not be reported.
This is consistent with the Official Guidelines for Coding and Reporting, which state "Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis)."
Acute congestive heart failure with diastolic or systolic dysfunction |
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 46 Effective with discharges: March 13, 2017
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Question:
How should acutely decompensated congestive heart failure with diastolic or systolic dysfunction be coded in ICD-10-CM? There is no longer an index entry for diastolic/systolic dysfunction. For example, a patient is admitted for treatment of acute congestive heart failure. The provider documents, "Acutely decompensated congestive heart failure with diastolic dysfunction." Can this be coded as acute diastolic congestive heart failure?
Answer:
If the provider links acute congestive heart failure with diastolic dysfunction, assign code I50.31, Acute diastolic (congestive) heart failure, as the principal diagnosis. When the provider has linked either diastolic or systolic dysfunction with acute or chronic heart failure, it should be coded as "acute/chronic diastolic or systolic heart failure." If there is no provider documentation linking the two conditions, assign code I50.9, Heart failure, unspecified.
Long term care coding issues for ICD-10-CM |
ICD-10-CM/PCS Coding Clinic, Fourth Quarter 2012 Pages: 90-98 Effective with discharges: October 1, 2012
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Long Term Care Coding Issues for ICD-10-CM
Coding guidelines and examples were provided in Coding Clinic for ICD-9- CM, Fourth Quarter 1999 with regards to the application of coding guidelines for long term care (LTC). Similarly, inquiries have been received regarding how coders should sequence the principal diagnosis when coding in the long term care (LTC) setting. The following have been developed and approved by the Cooperating Parties in conjunction with the Editorial Advisory Board of Coding Clinic, to standardize the process of data collection for LTC and to assist the coder in coding and reporting these cases using ICD-10-CM.
The diagnostic listing in long term care (LTC) is dynamic and dependent on many factors and has a longer time frame than an acute care stay. ICD-10- CM codes are assigned upon admission, concurrently as diagnoses arise, at the time of discharge, transfer, or expiration of the resident. The UHDDS definition of principal diagnosis (that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care) has been expanded since its initial development and now includes all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). Other diagnoses present (e.g., chronic conditions) which affect the resident's continued care should also be coded. The listing of diagnoses in the long-term care setting, may vary depending on the point in time when coding is being done.
The "first listed diagnosis" is the diagnosis which is chiefly responsible for the admission to, or continued residence in the nursing facility and should be sequenced first. For example, when coding an admission to the facility, the "first listed diagnosis" is the condition chiefly responsible for the admission to the facility. If coding diagnoses during the resident's stay, it is the condition chiefly responsible for the continued stay in the facility.
Question:
A patient is discharged from the hospital and admitted to a long-term care facility (LTC) with a diagnosis of acute cerebral infarction with left-sided hemiparesis and dysphasia. The diagnosis on admission to the LTC is documented as acute CVA. What is the appropriate code assignment to describe this patient's condition?
Answer:
Assign code I69.354, Hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, and code I69.321, Dysphasia following cerebral infarction, to completely describe the patient's condition. The hemiparesis and dysphasia are considered sequelae of the acute CVA for this LTC admission. Coding guidelines state that these "late effects" include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. Codes from I60- I67 are reserved for the initial (first) episode of care for the acute cerebrovascular disease. Please refer to the 2013 edition of the coding guidelines for guidance as to the use of dominant/nondominant side for codes from category I69.
Question:
Does the medical documentation have to state "old CVA" in order to use the sequelae (I69) codes for the LTC admission?
Answer:
No, there is no time limit on when a late effect code may be used since the neurologic deficit caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to I60-I67. When the patient is admitted to long term care (LTC) following treatment of an acute CVA, a code from subcategory I69.3, Sequelae of cerebral infarction, is assigned for the LTC admission.
Question:
A patient is admitted to the LTC facility following treatment of an acute CVA. The patient made a complete recovery from the CVA. She was diagnosed with progressive senile dementia, coronary artery disease and congestive heart failure. Because of her deteriorating physical status and chronic medical conditions, she was admitted into a long-term care facility. How would you code and sequence these diagnoses?
Answer:
Any of the chronic medical conditions may be sequenced as the first-listed diagnosis. Therefore, assign codes F03.90, Unspecified dementia without behavioral disturbance, I50.9, Heart failure, unspecified, and I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris. A code from category I69, Sequelae of cerebrovascular disease, is inappropriate, because there are no residuals from the CVA. Code Z86.73, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, may be assigned as an additional diagnosis, toidentify the history of CVA.
Question:
The patient is transferred to LTC for physical therapy following a hospitalization for treatment of an acute pelvic and clavicular fracture. How should the LTC stay be coded?
Answer:
When a patient is admitted to the LTC specifically for rehabilitative physical therapy following an injury, assign the acute injury code with the appropriate 7th character (for subsequent encounter), as the first-listed diagnosis. In this example, assign code S32.9XXD, Fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, or S42.009D, Fracture of unspecified part of unspecified clavicle, subsequent encounter for fracture with routine healing, as the reason for the admission. Assign the appropriate procedure code to show that the physical therapy was provided. It is inappropriate to assign aftercare Z codes for aftercare for traumatic fractures in ICD-10-CM. Refer to Section I.C.19.c., of the Official Guidelines for coding and Reporting for the Application of 7th characters for Chapter 19.
Question:
A patient is admitted to LTC following hospital treatment of a fracture of the right femur. The reason for the LTC admission is to allow the patient to regain strength and the fracture to heal. What code is used to describe the LTC admission?
Answer:
Assign code S72.90XD, Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, as the principal diagnosis. The 7th character "D" is used for encounters after the patient has received active treatment for the condition and is now receiving routine care during the healing or recovery phase. Code any other coexistent conditions that require treatment. Do not assign an aftercare Z code.
Question:
A resident in LTC facility develops a urinary tract infection (UTI), which is treated and resolved during the LTC stay. Should the UTI be coded?
Answer:
Assign code N39.0, Urinary tract infection, site not specified. The diagnosis would be part of the resident's active problem list until the infection is resolved, at which time it would no longer be coded and reported.
Question:
A resident returns to the LTC facility following hospital care for pneumonia. The physician's orders state, "continue IV antibiotics for 3 days," after which time the resident is to have a repeat x-ray to determine status of the pneumonia. Would you code the pneumonia?
Answer:
Yes, the pneumonia should be coded. If the physician does not identify a causal organism (e.g., staph, strep, pseudomonas, etc.), assign code J18.9, Pneumonia, unspecified organism, until the condition is resolved, after which time it would no longer be coded and reported.
Question:
A nursing home resident is transferred to the hospital for treatment of pneumonia. She returns to the nursing home and is still receiving antibiotics for the pneumonia. However, the main reason she is returning to the nursing home is because this has been her residence since developing a CVA with residuals several years ago. Which diagnosis should be listed first at the nursing home, the pneumonia or late effects of the CVA? Would it make any difference if the pneumonia was no longer receiving any treatment upon the resident's return to the nursing home?
Answer:
Assign the appropriate code from subcategory I69.3, Sequelae of cerebral infarction, as the principal diagnosis to identify the neurologic deficits, which resulted from the acute CVA. Assign the appropriate code for the pneumonia as a secondary diagnosis, for as long as the patient receives treatment for the condition.
Question:
A nursing home resident fell and was transferred to the hospital for treatment of a left wrist fracture. After inpatient surgical treatment of the fracture, he is returned to the nursing home where he has resided for several years due to Alzheimer's disease. The patient will receive occupational therapy at the nursing home, but the therapy is not the primary reason for the nursing home admission. How should this be coded?
Answer:
Code G30.9, Alzheimer's disease, unspecified, should be the principal diagnosis. Assign code S62.102D, Fracture of unspecified carpal bone, left wrist, subsequent encounter for fracture with routine healing, as a secondary diagnosis, for the healing wrist fracture, and code W19.XXXD, Unspecified fall, subsequent encounter. Assign the procedure code to show that the patient received occupational therapy.
Question:
When patients are admitted to a nursing home for convalescence following an acute illness or injury, is code Z51.89, Encounter for other specified aftercare, appropriate? How would the condition that now requires convalescence be reported by the LTC? For reporting purposes, "status post" or "history of" data is often necessary.
Answer:
Code assignment is based upon the condition being treated as documented in the medical record. It would be appropriate to assign codes for any late effects, residual conditions, signs, or symptoms that are present. When the reason for the admission is strictly for convalescence and there is no other definitive diagnosis, assign code Z51.89, Encounter for other specified aftercare, as the first-listed diagnosis.
Question:
When a patient is transferred to a nursing home for convalescence and strengthening following coronary artery bypass surgery, which diagnosis is first listed for the LTC? The aftercare codes seem to relate to post surgical wound care and generally, wound care can be provided at home. The main reason for admission to the LTC is the patient's debility and inability to care for himself at home. Would code Z51.89, Encounter for other specified aftercare, be appropriate, or should symptom codes (e.g., weakness, debility, etc.) be assigned?
Answer:
In this case, assign code Z48.812, Encounter for surgical aftercare following surgery on the circulatory system, as the principal diagnosis. The condition that was treated surgically if still present would be coded. Assign also codes for any symptoms such as weakness, gait disturbance, pain, etc., as additional diagnoses.
Question:
When a patient is transferred from a hospital to a nursing home for continued recovery following an acute inferior wall myocardial infarction, what is the principal diagnosis at the nursing home? Would this be considered a "subsequent episode of care?"
Answer:
In this case, if the patient is in the recovery phase equal to, or less than, the four-week time frame for the acute myocardial infarction (AMI), continue to use code I21.19, ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall. Please note that for encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute setting or a postacute setting, and the patient requires continued care for the myocardial infarction, codes from category I21 may continue to be reported. However, if the AMI occurred more than four weeks before, assign code Z51.89, Encounter for other specified aftercare.
It is inappropriate to assign code I22.1, Subsequent ST elevation (STEMI) myocardial infarction of inferior wall, for the LTC admission, since codes in category I22 are reserved for when a patient who has suffered an AMI has a new AMI within the four week time frame of the initial AMI, and not for subsequent episodes of care.
Question:
When a patient is admitted to a nursing home for "deconditioning," how should this be coded?
Answer:
Code the symptoms of the deconditioning, such as gait disturbance, weakness, etc.
Question:
A resident in a long-term care facility has a diagnosis of "mental status changes." How should this be coded?
Answer:
Assign code R41.82, Altered mental status, unspecified, for the diagnosis of mental status changes. This code assignment may be located in the ICD-10-CM Index by referencing, Change(s), mental status.
Question:
A patient is admitted to a long-term care facility for nonspecific reasons such as generalized weakness, debility, or deterioration (or "old age"), rather than for a specific diagnosis. What is the appropriate principal diagnosis when the patient is admitted for these nonspecific complaints?
Answer:
It would be appropriate to assign codes for the symptoms (i.e., generalized weakness, gait disturbance, debility, etc.)
GASTROINTESTINAL HEMORRHAGE
Gastrointestinal (GI) bleeding manifests itself in several ways:
Hematemesis (vomiting of blood), which indicates acute upper GI hemorrhage
Melena (presence of dark-colored blood in stool), which indicates upper or lower GI hemorrhage
Occult bleeding (presence of blood in stool that can be seen only on laboratory examination), which indicates upper or lower GI bleeding
Hematochezia (presence of bright-colored blood in stool), which indicates lower GI bleeding
The most common causes of GI bleeding are gastric and intestinal ulcers and diverticular disease of the intestine. A diverticular hemorrhage stops spontaneously in approximately 80 percent of cases, with the other 20 percent experiencing a second or third bleeding episode. ICD-10-CM provides specific codes for GI tract ulcers, gastritis, angiodysplasia, duodenitis, gastroduodenitis, Crohn's disease, ulcerative colitis, diverticulosis, and diverticulitis to indicate whether there is associated hemorrhage or bleeding. Examples include the following:
| K29.01 | Acute gastritis with hemorrhage |
| K57.13 | Diverticulitis of small intestine with hemorrhage |
| K31.811 | Angiodysplasia of duodenum with hemorrhage |
As stated in section I. A. 15 of the Official Coding Guidelines, the classification presumes a causal relationship between the two conditions linked by the terms "with" or "in" in the Alphabetic Index or Tabular List. ICD-10-CM provides such a linkage for bleeding with certain GI conditions such as ulcers, gastritis, duodenitis, ulcerative esophagitis, and diverticulosis. Unless the provider documents a different cause of the bleeding or states that the conditions are unrelated, it is appropriate to report the combination code for these conditions. When codes for bleeding of any of the conditions mentioned above are available, do not assign codes K92.0, Hematemesis; K92.1, Melena; or K92.2, Gastrointestinal hemorrhage, unspecified. These codes are acceptable only when the classification does not presume a linkage between bleeding and the condition, or when the physician's diagnostic statement clearly indicates that the bleeding is due to another condition.
Patients with a recent history of GI bleeding are sometimes seen for an endoscopy to determine the site of the bleeding but do not demonstrate any bleeding during the examination. If the physician documents a clinical diagnosis based on the history or other evidence, the fact that no bleeding occurs during the episode of care does not preclude the assignment of a code that includes mention of hemorrhage, or a code from K92.0 through K92.2 when the cause of bleeding could not be determined.
Patients may present for a colonoscopy because of rectal bleeding. If the findings include internal and external hemorrhoids with no statement as to whether the rectal bleeding is due to the hemorrhoids, the physician should be queried to determine whether the rectal bleeding is secondary to the hemorrhoids or the hemorrhoids are an incidental finding. If the hemorrhoids are incidental findings and unrelated to the rectal bleeding, code K62.5, Hemorrhage of anus and rectum, should be assigned, followed by codes for the hemorrhoids without mention of complication. If, however, the physician establishes a causal relationship between the bleeding and the internal and external hemorrhoids, assign codes K64.8, Other hemorrhoids, and K64.4, Residual hemorrhoidal skin tags. "Bleeding" is a nonessential modifier under "hemorrhoids" in the Alphabetic Index and in the inclusion terms for codes K64.0-K64.3; therefore, bleeding is included in the code assignment for the hemorrhoids and should not be coded separately.
Bilateral inguinal hernia with unilateral complication |
ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2021 Page: 31 Effective with discharges: September 20, 2021
Question:
The patient presents for robotic bilateral inguinal hernia repair. The surgeon listed the postoperative diagnosis as bilateral inguinal hernia, without obstruction or gangrene, right-sided hernia is recurrent. What is the appropriate ICD-10-CM code assignment for this case?
Answer:
Assign code K40.91, Unilateral inguinal hernia, without obstruction or gangrene, recurrent, and code K40.90, Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent, for bilateral inguinal hernias with one side recurrent.
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