IPES Prelim n.fm Page i W ednesday,June 20,2012 10:30 A M

ICD-9-CM for Physicians – Volumes 1 & 2 2014 Expert International Classification of Diseases 9th Revision Clinical Modification Sixth Edition Edited by: Anita C. Hart, RHIA, CCS, CCS-P Melinda S. Stegman, MBA, CCS Beth Ford, RHIT, CCS Optum is committed to providing you with the ICD-9-CM code update information you need to code accurately and to be in compliance with HIPAA regulations. In case of adoption of additional ICD-9-CM code changes effective April 1, 2014, Optum will provide these code changes to you at no additional cost! Just check back at www.optumcoding.com/productalerts to review the latest information concerning any new code changes.

Codes Valid October 1, 2013, through September 30, 2014

ICD 9-P-V 1.book Page 129 M onday,June 18,2012 2:06 PM

Tabular List

Diseases of the Circulatory System

421–424.0 Cardiac Tamponade

DEF: Bacterial inflammation of the endocardium (intracardiac area); major symptoms include fever, fatigue, heart murmurs, splenomegaly, embolic episodes and areas of infarction.

421.0 Acute and subacute bacterial endocarditis Endocarditis (acute)(chronic) (subacute): bacterial infective NOS lenta malignant purulent septic ulcerative vegetative Infective aneurysm Subacute bacterial endocarditis [SBE] Use additional code to identify infectious organism [e.g., Streptococcus 041.0, Staphylococcus 041.1] AHA: 4Q, ‘08, 73; 1Q, ‘99, 12; 1Q, ‘91, 15 I33.0 Acute and subacute infective endocarditis

Normal

Serous pericardium (visceral layer)

Pericardial space (potential)

422.99 Other

b 423 Other diseases of pericardium

2

422.0 Acute myocarditis in diseases classified elsewhere Code first underlying disease, as: myocarditis (acute): influenzal (487.8, 488.09, 488.19) tuberculous (017.9) 2 myocarditis (acute) (due to): aseptic, of newborn (074.23) Coxsackie (virus) (074.23) diphtheritic (032.82) meningococcal infection (036.43) syphilitic (093.82) toxoplasmosis (130.3)

c 422.9 Other and unspecified acute myocarditis 422.90 Acute myocarditis, unspecified Acute or subacute (interstitial) myocarditis 422.91 Idiopathic myocarditis Myocarditis (acute or subacute): Fiedler's giant cell isolated (diffuse) (granulomatous) nonspecific granulomatous 422.92 Septic myocarditis Myocarditis, acute or subacute: pneumococcal staphylococcal Use additional code to identify infectious organism [e.g., Staphylococcus 041.1] 2 myocarditis, acute or subacute: in bacterial diseases classified elsewhere (422.0) streptococcal (391.2)

that specified as rheumatic (393)

423.0 Hemopericardium DEF: Blood in the pericardial sac (pericardium).

423.1 Adhesive pericarditis Adherent pericardium Fibrosis of pericardium Milk spots

Pericarditis: adhesive obliterative Soldiers' patches

DEF: Two layers of serous pericardium adhere to each other by fibrous adhesions.

423.2 Constrictive pericarditis Concato's disease Pick's disease of heart (and liver) DEF: Inflammation identified by a rigid, thickened and sometimes calcified pericardium; ventricles of the heart not adequately filled; congestive heart failure may result.

423.3 Cardiac tamponade Code first the underlying cause DEF: Life-threatening condition in which fluid or blood accumulates between the muscle of the heart (myocardium) and the outer sac (pericardium), resulting in compression of the heart, which decreases cardiac output. AHA: 4Q, ’07, 86, 87

423.8 Other specified diseases of pericardium Calcification of pericardium Fistula AHA: 2Q, ‘89, 12

423.9 Unspecified disease of pericardium AHA: 1Q, ’07, 11

b 424 Other diseases of endocardium

2

bacterial endocarditis (421.0-421.9) rheumatic endocarditis (391.1, 394.0-397.9) syphilitic endocarditis (093.20-093.24)

424.0 Mitral valve disorders Mitral (valve): incompetence NOS of specified cause, insufficiency except rheumatic regurgitation 2 mitral (valve): disease (394.9) failure (394.9) stenosis (394.0) the listed conditions: specified as rheumatic (394.1) unspecified as to cause but with mention of: diseases of aortic valve (396.0-396.9) mitral stenosis or obstruction (394.2) AHA: 3Q, ’06, 7; 2Q, ‘00, 16; 3Q, ‘98, 11; N-D, ‘87, 8; N-D, ‘84, 8 I34.8 Other nonrheumatic mitral valve disorders

Manifestation Code

wx Revised Text

l

New Code

I-10

s Revised Code Title

Volume 1 – 129

421–424.0

acute rheumatic myocarditis (391.2)

Other Specified Code

-- constricted areas

DEF: Inflammation of the heart muscle due to an adverse reaction to certain drugs or chemicals reaching the heart through the bloodstream.

I-10

DEF: Acute inflammation of the muscular walls of the heart (myocardium).

Unspecified Code

Serous pericardium (parietal layer)

422.93 Toxic myocarditis

b 422 Acute myocarditis

b Additional Digit Required c 2013 ICD-9-CM

Excessive fluid in pericardial space

Fibrous pericardium

421.1 Acute and subacute infective endocarditis in diseases classified elsewhere Code first underlying disease, as: blastomycosis (116.0) Q fever (083.0) typhoid (fever) (002.0) 2 endocarditis (in): Coxsackie (virus) (074.22) gonococcal (098.84) histoplasmosis (115.0-115.9 with fifth-digit 4) meningococcal infection (036.42) monilial (112.81) 421.9 Acute endocarditis, unspecified Endocarditis Myoendocarditis acute or subacute Periendocarditis 2 acute rheumatic endocarditis (391.1)

2

Cardiac Tamponade

Diseases of the Circulatory System

b 421 Acute and subacute endocarditis

ICD 9-P-V 1.book Page 134 M onday,June 18,2012 2:06 PM

Diseases of the Circulatory System

432–437.4

Diseases of the Circulatory System §

Cerebrovascular Arteries Posterior parietal Parietal-occipital Calcarine

1

Middle cerebral Ophthalmic

Anterior inferior cerebellar

2

Posterior communicating External carotid

Posterior inferior cerebellar Basilar

DEF: Temporary restriction of blood flow to arteries branching into brain.

435.1 Vertebral artery syndrome 435.2 Subclavian steal syndrome

Aorta

DEF: Cerebrovascular insufficiency, due to occluded subclavian artery; symptoms include pain in mastoid and posterior head regions, flaccid paralysis of arm and diminished or absent radial pulse on affected side.

b 432 Other and unspecified intracranial hemorrhage AHA: 4Q, ’04, 7

432.0 Nontraumatic extradural hemorrhage Nontraumatic epidural hemorrhage

435.3 Vertebrobasilar artery syndrome DEF: Transient ischemic attack; due to brainstem dysfunction; symptoms include confusion, vertigo, binocular blindness, diplopia, unilateral or bilateral weakness and paresthesis of extremities. AHA: 4Q, ‘95, 60

DEF: Bleeding, nontraumatic, between skull and brain lining.

432.1 Subdural hemorrhage Subdural hematoma, nontraumatic DEF: Bleeding, between outermost and other layers of brain lining.

b 433 Occlusion and stenosis of precerebral arteries

1

embolism narrowing of basilar, carotid, and vertebral obstruction arteries thrombosis Use additional code, if applicable, to identify status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (V45.88) 2 insufficiency NOS of precerebral arteries (435.0-435.9)

432–437.4

The following fifth-digit subclassification is for use with category 433: 0 without mention of cerebral infarction 1 with cerebral infarction DEF: Blockage, stricture, arteries branching into brain. AHA: 2Q, ‘95, 14; 3Q, ‘90, 16

c 433.0 Basilar artery [0-1]

c 433.1 Carotid artery [0-1]

§

AHA: 1Q, ‘00, 16; For code 433.10: 1Q, ’06, 17; 1Q, ‘02, 7, 10 I65.29 Occlusion and stenosis of unspec carotid artery I63.239 Cerbral infarct d/t usp occ/stenosis of uns carotid art I63.449 Cerbral infarct d/t embo of uns cerebellar art

I-10 I-10 I-10

[0-1]

c 433.3 Multiple and bilateral

§

c 433.8 Other specified precerebral artery

[0-1]

AHA: 2Q, ‘02, 19

The following fifth-digit subclassification is for use with category 434: 0 without mention of cerebral infarction 1 with cerebral infarction

c 434.0 Cerebral thrombosis Thrombosis of cerebral arteries

§

437.2 Hypertensive encephalopathy DEF: Cerebral manifestations (such as visual disturbances and headache) due to high blood pressure. AHA: J-A, ‘84, 14

AHA: 2Q, ’09, 12

AHA: For code 434.01: 4Q, ’04, 77

437.4 Cerebral arteritis

c 434.1 Cerebral embolism [0-1]

I-10

437.3 Cerebral aneurysm, nonruptured Internal carotid artery, intracranial portion Internal carotid artery NOS 2 congenital cerebral aneurysm, nonruptured (747.81) internal carotid artery, extracranial portion (442.81)

AHA: 2Q, ‘95, 14

§

y

AHA: 1Q, ’09, 8

Use additional code, if applicable, to identify status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (V45.88)

[0-1]

AHA: 4Q, ’04, 77; 4Q, ‘99, 3 TIP: Do not assign when documentation indicates “CVA, stroke, or cerebral infarction.” See instead default code 434.91.

437.1 Other generalized ischemic cerebrovascular disease Acute cerebrovascular insufficiency NOS Cerebral ischemia (chronic)

Precerebral artery NOS

b 434 Occlusion of cerebral arteries

§

436 Acute, but ill-defined, cerebrovascular disease Apoplexy, apoplectic: Apoplexy, apoplectic: NOS seizure attack Cerebral seizure cerebral 2 any condition classifiable to categories 430-435 cerebrovascular accident (434.91) CVA (ischemic) (434.91) embolic (434.11) hemorrhagic (430, 431, 432.0-432.9) thrombotic (434.01) postoperative cerebrovascular accident (997.02) stroke (ischemic) (434.91) embolic (434.11) hemorrhagic (430, 431, 432.0-432.9) thrombotic (434.01)

AHA: 3Q, ’10, 15 I67.2 Cerebral atherosclerosis

c 433.9 Unspecified precerebral artery [0-1]

I-10

437.0 Cerebral atherosclerosis Atheroma of cerebral arteries Cerebral arteriosclerosis

[0-1] §

AHA: N-D, ‘85, 12 G45.9 Transient cerebral ischemic attack unspecified

b 437 Other and ill-defined cerebrovascular disease

c 433.2 Vertebral artery

§

435.8 Other specified transient cerebral ischemias 435.9 Unspecified transient cerebral ischemia Impending cerebrovascular accident Intermittent cerebral ischemia Transient ischemic attack [TIA]

432.9 Unspecified intracranial hemorrhage Intracranial hemorrhage NOS

§

cerebrovascular insufficiency (acute) with transient focal neurological signs and symptoms insufficiency of basilar, carotid, and vertebral arteries spasm of cerebral arteries acute cerebrovascular insufficiency NOS (437.1) that due to any condition classifiable to 433 (433.0-433.9)

435.0 Basilar artery syndrome

Internal carotid

Vertebral

§

AHA: For code 434.91: 3Q, ’10, 5-6; 4Q, ‘08, 108; 3Q, ‘07, 9; 1Q, ‘07, 23; 4Q, ’04, 77-78; 4Q, ‘98, 87

b 435 Transient cerebral ischemia

Anterior communicating

Posterior cerebral

c 434.9 Cerebral artery occlusion, unspecified [0-1]

Callosal-marginal Pericallosal Anterior cerebral

Tabular List

AHA: For code 434.11: 4Q, ’04, 77; 3Q, ‘97, 11 I63.449 Cerbral infarct d/t embo of uns cerebellar art

I-10

DEF: Inflammation of a cerebral artery or arteries. AHA: 4Q, ‘99, 21

Requires fifth digit. Valid digits are in [brackets] under each code. See appropriate category for codes and definitions.

8 Newborn Age: 0 134 – Volume 1

9 Pediatric Age: 0-17

x Maternity Age: 12-55

y Adult Age: 15-124 2013 ICD-9-CM

ICD 9-P-V 1.book Page 328 M onday,June 18,2012 2:06 PM

V Codes

V28.6–V42.83

V Codes

V28.6 Screening for Streptococcus B

Tabular List

x;

Persons with a Condition Influencing their Health Status (V40-V49)

AHA: 4Q, ‘97, 46

c V28.8 Other specified antenatal screening

NOTE

AHA: 4Q, ‘08, 159; 3Q, ‘99, 16

V28.81 Encounter for fetal anatomic survey

x; x;

V28.82 Encounter for screening for risk of pre-term labor V28.89 Other specified antenatal screening Chorionic villus sampling Genomic screening Nuchal translucency testing Proteomic screening

TIP: Includes patients with a carrier status or who have sequelae or residual of a past condition or disease, which may affect current or future treatment.

b V40 Mental and behavioral problems V40.0 Problems with learning

x;

V40.1 Problems with communication [including speech] V40.2 Other mental problems

c V40.3 Other behavioral problems

V28.9 Unspecified antenatal screening

;

AHA: 4Q, ’11, 158

V40.31 Wandering in diseases classified elsewhere Code first underlying disorder such as: Alzheimer’s disease (331.0) autism or pervasive developmental disorder (299.0-299.9) dementia, unspecified, with behavioral disturbance (294.21) intellectual disabilities (317-319) V40.39 Other specified behavioral problem V40.9 Unspecified mental or behavioral problem

b V29 Observation and evaluation of newborns and infants for suspected condition not found NOTE This category is to be used for newborns, within the neonatal period, (the first 28 days of life) who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and, which after examination and observation, is found not to exist. 2 suspected fetal conditions not found (V89.01-V89.09) 1

AHA: 1Q, ‘00, 25; 4Q, ‘94, 47; 1Q, ‘94, 9; 4Q, ‘92, 21 TIP: Do not assign if the infant shows any signs or symptoms.

V29.0 Observation for suspected infectious condition

8

AHA: 1Q, ‘01, 10

1

V29.1 Observation for suspected neurological condition 1 V29.2 Observation for suspected respiratory condition 1 V29.3 Observation for suspected genetic or metabolic condition 1

1

b V41 Problems with special senses and other special functions V41.0 Problems with sight

8 8 8

V41.1 Other eye problems V41.2 Problems with hearing V41.3 Other ear problems

AHA: 2Q, ’05, 21; 4Q, ‘98, 59, 68

V29.8 Observation for other specified suspected condition

V41.4 Problems with voice production

8

V41.5 Problems with smell and taste V41.6 Problems with swallowing and mastication

AHA: 2Q, ‘03, 15

V29.9 Observation for unspecified suspected condition

8

V41.7 Problems with sexual function 2 marital problems (V61.10) psychosexual disorders (302.0-302.9)

V28.6–V42.83

AHA: 1Q, ‘02, 6

V41.8 Other problems with special functions

Liveborn Infants According to Type of Birth (V30-V39) NOTE

These categories are intended for the coding of liveborn infants who are consuming health care [e.g., crib or bassinet occupancy].

V41.9 Unspecified problem with special functions

b V42 Organ or tissue replaced by transplant

1

The following fourth-digit subdivisions are for use with categories V30-V39: 0 Born in hospital 8 1 Born before admission to hospital 8 2 Born outside hospital and not hospitalized The following two fifth-digits are for use with the fourth-digit .0, Born in hospital: 0 delivered without mention of cesarean delivery 1 delivered by cesarean delivery

V42.0 Kidney AHA: 1Q, ‘08, 10; 1Q, ‘03, 10; 3Q, ‘01, 12 Z94.0 Kidney transplant status

I-10

V42.1 Heart AHA: 3Q, ‘03, 16; 3Q, ‘01, 13

AHA: 1Q, ‘01, 10

V42.2 Heart valve

u

b V30 Single liveborn

V42.3 Skin

AHA: 2Q, ‘03, 9; 4Q, ‘98, 46, 59; 1Q, ‘94, 9; For code V30.00: 1Q, ‘04, 8, 16; 4Q, ’03, 68; For code V30.01: 4Q, ’09, 101; 4Q, ’05, 88; For code V30.10: 3Q, ’06, 10 I-10 Z38.00 Single liveborn infant delivered vaginally §

homologous or heterologous (animal) (human) transplant organ status

AHA: 3Q, ’11, 5; 3Q, ‘98, 3, 4 TIP: Do not assign if the patient has a complication of the transplanted organ; the code from subcategory 996.8 provides the information.

c

§

These categories are intended for use when these conditions are recorded as “diagnoses” or “problems.”

V42.4 Bone V42.5 Cornea

u

b V31 Twin, mate liveborn AHA: 3Q, ‘92, 10 Z38.31 Twin liveborn infant delivered by cesarean

§

b V32 Twin, mate stillborn

§

b V33 Twin, unspecified

§

b V34 Other multiple, mates all liveborn

§

b V35 Other multiple, mates all stillborn

§

b V36 Other multiple, mates live and stillborn

§

b V37 Other multiple, unspecified

§

b V39 Unspecified

V42.6 Lung V42.7 Liver

I-10

u u u u u u u

AHA: 3Q, ’11, 5 Z94.4 Liver transplant status

I-10

c V42.8 Other specified organ or tissue AHA: 4Q, ‘98, 64; 4Q, ‘97, 49

V42.81 Bone marrow

AHA: w1Q, ’12, 13x

V42.82 Peripheral stem cells V42.83 Pancreas AHA: 1Q, ‘03, 10; 2Q, ‘01, 16

1 A code from the V30–V39 series may be sequenced before the V29 on the newborn medical record. §

Require fourth and fifth digits. See beginning of section V30-V39 for codes and definitions.

8 Newborn Age: 0 328 – Volume 1 • October 2012

9 Pediatric Age: 0-17

x Maternity Age: 12-55

y Adult Age: 15-124

u Primary Diagnosis 2013 ICD-9-CM

IPEU Resources.fm Page 12 Tuesday,June 19,2012 4:19 PM

Diabetes

Coding Tables

Coding Tables Diabetes (brittle) (congenital) (familial) (mellitus) (severe) (slight)

ICD-9-CM

Controlled or not stated as uncontrolled

Without complication or manifestation With complication or manifestation coma (ketoacidosis) hyperosmolar (nonketotic) complication NOS specified NEC gangrene hyperosmolarity ketosis, ketoacidosis osteomyelitis specified manifestations NEC Abnormal glucose NOS NOS non-fasting fasting tolerance test Abnormal glucose tolerance test (GTT), elevated glucose tolerance test Acetonemia Acidosis Amyotrophy Angiopathia, angiopathy (peripheral) retinalis (juvenilis) Arthritis, arthropathy Charcôt's neuropathic (Charcôt's) Asymptomatic elevated (abnormal glucose) Ataxia, ataxy, ataxic, locomotor (progressive) Autonomic neuropathy (peripheral) Bone change Bronze, bronzed Cataract diabetic senile (non diabetic) snowflake Charcôt's joint (disease) Chemical Coma (with ketoacidosis) hyperglycemic hyperosmolar (nonketotic) hypoglycemic nondiabetic insulin nondiabetic Kussmaul's prediabetic Complication NOS specified NEC Dermopathy Dietary supervision Ebstein’s disease Edema (macula) (retina) Family History Gangrene Gastroparalysis/Gastroparesis Gestational diabetes antepartum delivered w/o antepartum condition postpartum unspecified. episode. of care with antepartum condition with long term (current) insulin use Glaucoma Glomerulohyalinosis — diabetic syndrome 12 – Resources

TYPE II or unspecified type. The codes found in these columns are for use even if the patient requires insulin.

TYPE I Uncontrolled

Controlled or not stated as uncontrolled

Uncontrolled

250.01

250.03

250.00

250.02

250.31 250.21 250.91 250.81 250.71 250.21 250.11 250.81 250.81

250.33 250.23 250.93 250.83 250.73 250.23 250.13 250.83 250.83

250.30 250.20 250.90 250.80 250.70 250.20 250.10 250.80 250.80

250.32 250.22 250.92 250.82 250.72 250.22 250.12 250.82 250.82

Additional Code Required Other metabolic disorders or conditions

List these codes after the diabetes code

785.4

731.8

790.29 790.29 790.21 790.22 790.22 250.11 250.11 250.61 250.71 250.51 250.61 250.61 250.61

250.13 250.13 250.63 250.73 250.53 250.63 250.63 250.63

250.10 250.10 250.60 250.70 250.50 250.60 250.60 250.60

250.12 250.12 250.62 250.72 250.52 250.62 250.62 250.62

250.61 250.61 250.81

250.63 250.63 250.83

250.60 250.60 250.80

250.62 250.62 250.82

250.51 250.01 250.51 250.61

250.53 250.03 250.53 250.63

250.50 250.00 250.50 250.60

250.52 250.02 250.52 250.62

250.31 250.31 250.21 250.31

250.33 250.33 250.23 250.33

250.30 250.30 250.20 250.30

250.32 250.32 250.22 250.32

250.31

250.33

250.30

250.32

250.31 250.21 250.91 250.81 250.81

250.33 250.23 250.93 250.83 250.83

250.30 250.20 250.90 250.80 250.80

250.32 250.22 250.92 250.82 250.82

353.1 443.81 362.01 713.5 713.5 713.5 790.29 337.1 337.1 731.8 275.01 366.41 366.17 366.41 713.5 790.29

251.0 251.0

709.8 V65.3

250.41 250.51

250.43 250.53

250.40 250.50

250.42 250.52

250.71 250.61

250.73 250.63

250.70 250.60

250.72 250.62

581.81 362.01 V18.0 785.4 536.3 648.83 648.81 648.84 648.80 648.82

250.51 250.41

250.53 250.43

250.50 250.40

250.52 250.42

V58.67 365.44 581.81 2013 ICD-9-CM

Physician 8.5x11 FM .fm Page xii W ednesday,June 20,2012 10:29 A M

ICD-10-CM Coding and Documentation Proficiency Self-Assessment Introduction This self-assessment covers ICD-10-CM coding guidance and the required level of detail for clinical documentation of heart disease, diabetes, and pneumonia. These high-volume diagnoses have numerous coding guidelines and documentation requirements. The assessment also covers ICD-10-CM conventions that are new or problematic. Use this self-assessment to identify the areas that may require additional coding training or documentation improvement before ICD-10-CM is implemented on October 1, 2014.

Instructions Code assignments are based upon the 2012 ICD-10-CM diagnosis code set for all reportable diagnoses, including external causes of morbidity (V00–Y99), as appropriate, according to the instructions in ICD-10-CM conventions and the 2012 ICD-10-CM Draft Official Guidelines for Coding and Reporting. Answer each question based on the information provided. Note that for some questions, the codes in the answer are not based upon the information provided, requiring that the provider be queried for specific information because the documentation is insufficient to assign codes correctly.

6. Assign the appropriate code(s) for a patient diagnosed by the provider with community-acquired pneumonia who presented with hemoptysis, productive cough, fever, and an increased respiratory rate with sputum culture stain showing gram-negative bacilli. Code assignment:___________________________ 7. Discharge summary: 1. VAP, with sputum stain identifying Klebsiella pneumoniae, sensitivity performed and Keflex administered. 2. Vent-dependent patient. A

Assign J95.851 Ventilator associated pneumonia, B96.1 Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere, and Z99.11 Dependence on respirator [ventilator] status.

B

Documentation does not follow guidelines and/or the physician must be queried to determine the following: • Clinical significance of the sputum results • Pneumonia: present on admission or post admission

Self-Assessment Questions 1. In ICD-10-CM what are the two anatomical classifications of pneumonia and the sites of the lung affected by each? 2. The attending physician’s final diagnosis on the progress note on the day of discharge: atypical pneumonia. Sputum results: normal flora. Chest x-ray: bilateral lower lobe consolidation. A

Assign J18.9 Pneumonia, unspecified organism.

B

Documentation does not follow guidelines and/or the physician must be queried to determine the following:

8. Assign the appropriate diagnosis code(s) for diabetes II with Charcôt joint, left hallux with ulcer, with dry gangrene and with chronic osteomyelitis. The patient is admitted for amputation due to osteomyelitis documented in the surgeon’s admission note. Code assignment:___________________________ 9. What is the appropriate code assignment for a diagnosis of ischemic cardiomyopathy and coronary artery disease, as documented by the provider? Code assignment:___________________________

• Clinical significance of the sputum results • Clinical significance of the chest x-ray 3. What is the appropriate diagnosis code assignment(s) for ESRD due to type I diabetes on chronic dialysis via right arm AV shunt and hypertension as documented by the provider? Code assignment:___________________________ 4. Attending admission note: Patient is a 42-year-old female who presents with diabetes with hypoglycemia. A

Assign E11.649 Type II diabetes mellitus with hypoglycemia without coma.

B

Documentation does not follow guidelines and/or the physician must be queried to determine the following:

10. Discharge summary: Patient was admitted from the ED for work-up of precordial chest pain, elevated troponin; history of CABG, congestive heart failure, hypertension. Final diagnosis: ASCAD with USA, s/p CABG, CHF. Most recent diagnostic left heart catheterization showed clean vein and mammary grafts with 90% atherosclerotic stenosis of the native LAD portion. Plans are for future coronary angioplasty as an outpatient. Continue Lasix, Norvasc, and Nitrolingual. A

Assign I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina, I11.9 Hypertensive heart disease without heart failure, I50.9 Heart failure, unspecified, Z95.1 Presence of aortocoronary bypass graft.

B

Documentation does not follow guidelines and/or the physician must be queried to determine the following:

• Type of diabetes mellitus

• Description of relationship between the hypertension and congestive heart failure

• Cause of the hypoglycemia

• Type of congestive heart failure

5. Assign the appropriate code(s) for a diagnosis by the provider of ischemic heart disease and coronary artery disease without history of coronary bypass and current smoker. Code assignment:___________________________

11. What is the appropriate diagnosis code assignment for the postobstructive pneumonia, right middle lobe, due to hilar lung cancer right lobe when the treatment is directed only toward the pneumonia as documented in the admission note by the resident? Code assignment:___________________________

xii

2013 ICD-9-CM