• Scenario 1: Abdominal Pain
• Scenario 2: Annual
Physical Exam
• Scenario 3: Earache
• Scenario 4: Anemia
• Scenario: COPD with Acute
Pneumonia Example
• Scenario: Cervical
Disc Disease
• Scenario: Abdominal Pain
• Scenario: Diabetes
• Scenario: ER Follow Up
Clinical Scenarios
Table Of Contents
Common Codes
Clinical Documentation Tips
• Abdominal Pain
• Acute Respiratory Infections
• Back and Neck
Pain (Selected)
• Chest Pain
• Diabetes Mellitus w/o
Complications Type 2
• General Medical Examination
• Headache
• Hypertension
• Pain in Joint
• Pain in Limb
• Other Forms of
Heart Disease
• Urinary Tract
Infection, Cystitis
• Hypertension
• Asthma
• Underdosing
• Abdominal Pain Tenderness
• Diabetes Mellitus,
Hypoglyemia and
Hyperglycemia
• Injuries
3
Common Codes
ICD-10 Compliance Date: October 1, 2015
R10.0 Acute abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.13 Epigastric pain
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.84 Generalized abdominal pain
R10.9* Unspecified abdominal pain
Abdominal Pain (ICD-9-CM 789.00 to 789.09 range)
*Codes with a greater degree of specicity should be considered rst.
4
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M54.89 Other dorsalgia
M54.9* Dorsalgia, unspecified
Back and Neck Pain (Selected) (ICD-9-CM 723.1, 724.1, 724.2, 724.5)
*Codes with a greater degree of specicity should be considered rst.
J02.8 Acute pharyngitis due to other specified organisms
J02.9* Acute pharyngitis, unspecified
J06.9* Acute upper respiratory infection, unspecified
J20.0 Acute bronchitis due to Mycoplasma pneumoniae
J20.1 Acute bronchitis due to Hemophilus influenzae
J20.2 Acute bronchitis due to streptococcus
J20.3 Acute bronchitis due to coxsackievirus
J20.4 Acute bronchitis due to parainfluenza virus
J20.5 Acute bronchitis due to respiratory syncytial virus
J20.6 Acute bronchitis due to rhinovirus
J20.7 Acute bronchitis due to echovirus
J20.8 Acute bronchitis due to other specified organisms
J20.9* Acute bronchitis, unspecified
Acute Respiratory Infections (ICD-9-CM 462, 465.9, 466.0)
[Note: Organisms should be specified where possible]
*Codes with a greater degree of specicity should be considered rst.
4
5
R07.1 Chest pain on breathing
R07.2 Precordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
R07.9* Chest pain, unspecified
E11.9 Type 2 diabetes mellitus without complications
R51 Headache
I10 Essential (primary) hypertension
Z00.00 Encounter for general adult medical exam without abnormal findings
Z00.01 Encounter for general adult medical exam with abnormal findings
Chest Pain (ICD-9-CM 786.50 to 786.59 range)
Diabetes Mellitus w/o Complications Type 2 (ICD-9-CM 250.00)
Headache (ICD-9-CM 784.0)
Hypertension (ICD-9-CM 401.9)
General Medical Examination (ICD-9-CM V70.0)
*Codes with a greater degree of specicity should be considered rst.
6
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.519* Pain in unspecified shoulder
M25.521 Pain in right elbow
M25.522 Pain in left elbow
M25.529* Pain in unspecified elbow
M25.531 Pain in right wrist
M25.532 Pain in left wrist
M25.539* Pain in unspecified wrist
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.559* Pain in unspecified hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M25.569* Pain in unspecified knee
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M25.579* Pain in unspecified ankle and joints of unspecified foot
M25.50* Pain in unspecified joint
Pain in Joint (ICD-9-CM 719.40 to 719.49 range)
*Codes with a greater degree of specicity should be considered rst.
7
M79.601 Pain in right arm
M79.602 Pain in left arm
M79.603* Pain in arm, unspecified
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.606* Pain in leg, unspecified
M79.609 Pain in unspecified limb
M79.621 Pain in right upper arm
M79.622 Pain in left upper arm
M79.629* Pain in unspecified upper arm
M79.631 Pain in right forearm
M79.632 Pain in left forearm
M79.639* Pain in unspecified forearm
M79.641 Pain in right hand
M79.642 Pain in left hand
M79.643* Pain in unspecified hand
M79.644 Pain in right finger(s)
M79.645 Pain in left finger(s)
M79.646* Pain in unspecified finger(s)
M79.651 Pain in right thigh
M79.652 Pain in left thigh
M79.659* Pain in unspecified thigh
M79.661 Pain in right lower leg
M79.662 Pain in left lower leg
M79.669* Pain in unspecified lower leg
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.673* Pain in unspecified foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
M79.676* Pain in unspecified toe(s)
Pain in Limb (ICD-9-CM 729.5)
*Codes with a greater degree of specicity should be considered rst.
8
I48.0 Paroxysmal atrial fibrillation
I48.2 Chronic atrial fibrillation
I48.91* Unspecified atrial fibrillation
N30.00 Acute cystitis without hematuria
N30.01 Acute cystitis with hematuria
N30.10 Interstitial cystitis (chronic) without hematuria
N30.11 Interstitial cystitis (chronic) with hematuria
N30.20 Other chronic cystitis without hematuria
N30.21 Other chronic cystitis with hematuria
N30.30 Trigonitis without hematuria
N30.31 Trigonitis with hematuria
N30.40 Irradiation cystitis without hematuria
N30.41 Irradiation cystitis with hematuria
N30.80 Other cystitis without hematuria
N30.81 Other cystitis with hematuria
N30.90 Cystitis, unspecified without hematuria
N30.91 Cystitis, unspecified with hematuria
N39.0* Urinary tract infection, site not specified
Other Forms Of Heart Disease (ICD-9-CM 427.31)
URINARY TRACT INFECTION, CYSTITIS (ICD-9-CM 595.0 TO 595.4
RANGE, 595.81, 595.82, 595.89, 595.9, 599.0)
*Codes with a greater degree of specicity should be considered rst.
*Codes with a greater degree of specicity should be considered rst.
9
Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how
physicians and clinicians communicate and to what they pay attention - it is a matter of ensuring the information is
captured in your documentation.
In ICD-10-CM, there are three main categories of changes:
Denition Changes
Terminology Dierences
Increased Specicity
Over 1/3 of the expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other
clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).
HYPERTENSION
Denition Change
In ICD-10, hypertension is defined as essential (primary). The concept of “benign or malignant” as it relates to
hypertension no longer exists.
When documenting hypertension, include the following:
1. Type e.g. essential, secondary, etc.
2. Causal relationship e.g. Renal, pulmonary, etc.
Primer for Family Practice Clinical
Documentation Changes
ICD-10 Compliance Date: October 1, 2015
I10 Essential (primary) hypertension
I11.9 Hypertensive heart disease without heart failure
I15.0 Renovascular hypertension
ICD-10 Code Examples
10
ASTHMA
Terminology Dierence
ICD-10 terminology used to describe asthma has been updated to reflect the current clinical classification system.
When documenting asthma, include the following:
1. Cause Exercise induced, cough variant, related to smoking, chemical or
particulate cause, occupational
2. Severity Choose one of the three options below for persistent asthma patients
1. Mild persistent
2. Moderate persistent
3. Severe persistent
3. Temporal Factors Acute, chronic, intermittent, persistent, status asthmaticus,
acute exacerbation
UNDERDOSING
Terminology Dierence
Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less
of a medication than is prescribed.
When documenting underdosing, include the following:
1. Intentional, Unintentional,Non-compliance Is the underdosing deliberate? (e.g., patient refusal)
2. Reason Why is the patient not taking the medication?
(e.g.financial hardship, age-related debility)
J45.30 Mild persistent asthma, uncomplicated
J45.991 Cough variant asthma
Z91.120 Patient’s intentional underdosing of medication regimen due to
financial hardship
T36.4x6A Underdosing of tetracyclines, initial encounter
T45.526D Underdosing of antithrombotic drugs, subsequent encounter
ICD-10 Code Examples
ICD-10 Code Examples
11
ABDOMINAL PAIN AND TENDERNESS
Increased Specicity
When documenting abdominal pain, include the following:
1. Location e.g. Generalized, Right upper quadrant, periumbilical, etc.
2. Pain or tenderness type e.g. Colic, tenderness, rebound
DIABETES MELLITUS, HYPOGLYCEMIA AND HYPERGLYCEMIA
Increased Specicity
The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system
affected, and the complications affecting that body system.
When documenting diabetes, include the following:
1. Type e.g. Type 1 or Type 2 disease, drug or chemical induced, due to underlying
condition, gestational
2. Complications What (if any) other body systems are affected by the diabetes condition? e.g. Foot
ulcer related to diabetes mellitus
3. Treatment Is the patient on insulin?
A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document
and code for these conditions without using “diabetes mellitus.” You can also specify if the condition is due to a
procedure or other cause.
The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are
specific secondary options.
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
E09.01 Drug or chemical induced diabetes mellitus with
hyperosmolarity with coma
R73.9 Transient post-procedural hyperglycemia
R79.9 Hyperglycemia, unspecified
ICD-10 Code Examples
ICD-10 Code Examples
12
INJURIES
Increased Specicity
ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and
expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care e.g. Initial, subsequent, sequelae
2. Injury site Be as specific as possible
3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian,
slip and fall, environmental exposure, etc.)?
4. Place of Occurrence e.g. School, work, etc.
Initial encounters may also require, where appropriate:
1. Intent e.g. Unintentional or accidental, self-harm, etc.
2. Status e.g. Civilian, military, etc.
Example 1:
A left knee strain injury that occurred on a private recreational playground when a child landed
incorrectly from a trampoline:
• Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level,
left leg, initial encounter
• External cause: W09.8xxA, Fall on or from other playground equipment,
initial encounter
• Place of occurrence: Y92.838, Other recreation area as the place of occurrence
of the external cause
• Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping
Example 2:
On October 31st, Kelly was seen in the ER for shoulder pain and X-rays indicated there was
a fracture of the right clavicle, shaft. She returned three months later with complaints of
continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle
fracture is coded as S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for
fracture with nonunion.
ICD-10 Code Examples
13
Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity,
and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused
scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.
The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will
vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and
coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant
codes are presented.
Family Practice Clinical Scenarios
ICD-10 Compliance Date: October 1, 2015
Scenario Details
Chief Complaint
• “My stomach hurts and I feel full of gas.”
History
• 47 year old male with mid-abdominal epigastric pain
1
, associated with severe nausea &
vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
• Has had an estimated 13 pound weight loss over the past month.
• Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he
believes initiated his symptoms.
• Patient admits to a history of alcohol dependence
2
. Consuming 5 – 6 beers per day now, down
from 10 – 12 per day 6 months ago. States that he has nausea and sweating with “the shakes”
when he does not drink.
Exam
• VS: T 99.8°F, otherwise normal.
• Mild jaundice noted.
• Abdomen distended and tender across upper abdomen
3
. Guarding is present. Bowel sounds
diminished in all four quadrants.
• Oral mucosa dry, chapped lips, decreased skin turgor
Scenario 1: Abdominal Pain
14
Assessment and Plan
• Dehydration and suspected acute pancreatitis.
• Admit to the hospital. Orders written and sent to on-call hospitalist.
• 1L IV NS started in office. Blood drawn for labs.
• Recommend behavioral health counseling for substance abuse assessment and
possible treatment.
• Patient’s wife notified of plan; she will transport to hospital by private vehicle.
Summary of ICD-10-CM Impacts
Clinical Documentation
1. Describe the pain as specifically as possible based on location.
2. When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse,
and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for
coding substance abuse disorders. In this encounter note, as the acute pancreatitis is
suspected, and the patient’s alcohol intake status is stated, the associated alcoholism
code is listed.
3. Abdominal tenderness may be coded. Ideally the documentation should include right or left
upper quadrant and indicate if there is rebound in order to identify a more specific code.
Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the
documentation is insufficient in laterality and specificity.
Coding
Other Impacts
No specific impacts noted.
Scenario 1: Abdominal Pain (continued)
ICD-9-CM Diagnosis Codes
789.06 Abdominal pain, epigastric
789.60 Abdominal tenderness,
unspecified site
782.4 Jaundice NOS
276.51 Dehydration
303.90 Other and unspecified
alcohol dependence,
unspecified
ICD-9-CM Diagnosis Codes
R10.13 Epigastric pain
R10.819 Abdominal tenderness,
unspecified site
R17 Unspecified jaundice
E86.0 Dehydration
F10.20 Alcohol dependence,
uncomplicated
15
Scenario Details
Chief Complaint
• “I’m here for my annual check-up.
1
”
History
• 73 year old male with history of coronary artery disease, stent placement, hyperlipidemia,
HTN and GERD.
• Recent admission to hospital following a hypertensive crisis. Discharged home on olmesartan
medoxomil 20 mg daily.
• Patient stopped taking olmesartan medoxomil due to side effects
2
, including a headache that
began after starting the medication and still exists, and tiredness.
• Regular activity includes walking, golfing. Active social life. No complaints of chest pain, or
dyspnea on exertion.
• Last colonoscopy was 9 months ago. No significant pathology found; some
diverticular disease.
• Medications were reviewed.
Exam
• Chest clear. Heart sounds normal. Mental status exam intact.
• EKG shows no changes from prior EKG.
• Vitals: BP is 159/95, otherwise normal. Per patient, he had good control of BP on meds,
but it has risen without medication.
• BUN/creatinine normal limits.
Assessment and Plan
• HTN noted on exam today. Change from olmesartan medoxomil to metoprolol tartrate 50 mg
once daily, will titrate dosage every two weeks until BP normalizes.
• Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP
medication as prescribed; he verbalizes understanding.
• Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy,
and repeat BUN/creatinine.
Scenario 2: Annual Physical Exam
16
Summary of ICD-10-CM Impacts
Clinical Documentation
1. Documenting why the encounter is taking place is important, as the coder may assign a
different code based on the type of visit (e.g., screening, with no complaint or suspected
diagnosis, for administrative purposes). In this situation, the patient is requesting an encounter
without a complaint, suspected or reported diagnosis.
2. Document that the patient is noncompliant with his medication. This “underdosing” concept
can often be coded, along with the patient’s reason for not taking the prescribed medications.
Document if there is a medical condition linked to the underdosing that is relevant to the
encounter, and ensure the connection is clearly made. The ICD-10-CM terms provide new
detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case
there was no noted history of noncompliance. In this note the side effects of stopping the
medication include headache, which remains as a patient complaint for this encounter. When
documenting headache do differentiate if intractable versus non-intractable.
Coding
Other Impacts
• Assess if the new patient-centric preventative health incentives for annual exams are relevant
to your practice.
• For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans,
certain diagnosis codes are used as to determine severity of illness, risk, and resource
utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The
physician should examine the patient each year and compliantly document the status of all
chronic and acute conditions. HCC codes are payment multipliers.
Scenario 2: Annual Physical Exam (continued)
ICD-9-CM Diagnosis Codes
V70.0 Routine medical exam
401.9 Unspecified essential
hypertension
339.3 Drug-induced headache,
not elsewhere classified
N/A
N/A
ICD-10-CM Diagnosis Codes
Z00.01 Encounter for general adult medical
examination with abnormal findings
I10 Essential (primary) hypertension
G44.40 Drug-induced headache, not els
where classified, not intractable
T46.5X6A Underdosing of other
antihypertensive drugs,
initial encounter
Z91.128 Patient’s intentional underdosing of
medication regimen for other reason
17
Scenario Details
Chief Complaint
• Right earache and ear pain.
History
• This 20 year old male is an established patient and well known to me. He is a full-time college
student, and presents with a right sided ear pain, noted 8/10. The symptoms started yesterday
and continue to worsen with no pain relief using acetaminophen. Denies discharge, hearing
loss, or ringing/roaring. He denies trauma or recent barotrauma to ear. He denies fever, sore
throat, and cough today. He reports recently having an URI that resolved with OTC medications.
• He is up to date on his influenza, HPV, Tdap, and meningococcal immunizations.
• Patient does not use tobacco, alcohol, or illicit drugs. He denies exposure to second
hand smoke.
• Medical history includes major depressive disorder with recurrent episodes of mild severity, and
bipolar II disorder. His current medications include aripiprazole, and duloxetine.
• No known allergies.
• 16 point review of systems negative except for notations above.
Exam
• Healthy appearing male. A&Ox3. He appears calm and is cooperative.
• Vital signs: BP: 130/78 HR: 70 bpm T: 99.8 °F Wt: 235 lbs Ht: 5’ 10”.
• ENT: auricle and external canals normal bilaterally. Right ear: erythematous membrane,
bulging, with loss of landmarks. Pharynx, teeth, and nose exam normal. No cervical
adenopathy bilaterally.
• Integumentary: Skin is flushed, warm, and dry with no edema. Mucous membranes are moist.
• Respiratory: Lungs clear CTA with normal respiratory effort.
• Abdomen: non-tender, no organomegely.
Assessment and Plan
• New onset AOM AD, suppurative, with pain unrelieved by acetaminophen.
• Prescriptions: amoxicillin for AOM; ibuprofen for pain.
• Return in one week if symptoms persist.
Scenario 3: Earache
18
Summary of ICD-10-CM Impacts
Clinical Documentation
1. In diagnosing otitis media using ICD-9-CM you should document items such as acute,
chronic, not specified as acute or chronic, nonsuppurative or suppurative, and with or
without spontaneous rupture of the eardrum. In ICD-10-CM, you will need to document these
characteristics plus left, right or bilateral that are affected and is the problem initial or recurrent
to assign a correct code.
2. In this fictional test case we gave this young male a diagnosis of bipolar II disorder. You would
not report the bipolar disorder unless it affects treatment at today’s encounter. Conditions that
are not treated or that do not affect patient treatment nor are treated should not be reported.
Coding
Other Impacts
No specific impact noted.
Scenario 3: Earache (continued)
ICD-9-CM Diagnosis Codes
382.00 Acute suppurative otitis
media without spontaneous
rupture of eardrum
ICD-10-CM Diagnosis Codes
H66.001 Acute suppurative otitis media
without spontaneous rupture of
ear drum, right ear
19
Scenario Details
Chief Complaint
• Discuss laboratory results.
History
• 38 year old established female seen by me over one week ago for decreased exercise
tolerance and general malaise over the past four weeks when doing her daily aerobics class.
Labs were ordered on that visit. She presents today with pale skin, weakness, and epigastric
pain; symptoms are unchanged since previous visit. Laboratory studies reviewed today are
as follows: HGB 8.5 gm/dL, HCT 27%, platelets 300,000/mm3, reticulocytes 0.24%, MCV 75,
serum iron 41 mcg/dL, serum ferritin 9 ng/ml, TIBC 457 mcg/dL; Fecal occult blood test
is positive.
• She takes Esomeprazole daily for GERD with esophagitis and reports taking OTC antacids at
bedtime for epigastric pain for the past three months. She also uses ibuprofen as needed
for headaches.
• Current pain is 0/10.
• Medical history significant for GERD, peptic ulcer, pre-eclampsia with last pregnancy.
• LMP: two weeks ago, normal flow, unchanged in last three months.
• Married; three children ages 15, 12, and 1 year old.
• Patient does not use tobacco, alcohol, or illicit drugs.
• No known allergies.
• No changes in interval history and review of systems noted from encounter 8 days ago.
Exam
• Well-nourished, well groomed, pleasant female who shows good judgment and insight.
Oriented X 3. Good recent and remote memory. Appropriate mood and affect.
• Vital signs: T 98.7, RR 18, BP: 118/75, standing 120/60, HR: 90.
• HEENT: PERRLA.
• Neck: Supple. No thyromegaly.
• Lungs: clear to auscultation with normal respiratory effort.
• Cardiovascular: Regular rate and rhythm. No pedal edema.
• Integumentary: Pale, clear of rashes and lesions, no ulcers. Early cheilosis noted.
• Rectal: No gross blood on exam one week ago; stool sample results noted above.
• Lymphatics: No lymphadenopathy.
• Musculoskeletal: The patient had good, stable gait.
Scenario 4: Anemia
20
Assessment and Plan
• Iron-deficiency anemia secondary to blood loss.
• Continue esomeprazole as prescribed.
• Replace ibuprofen use with acetaminophen extra strength for headaches, dosage as per label.
• Prescribed iron sulfate supplements for three month trial. Counseled patient on appropriate use
of iron supplementation and side effects.
• Patient to return in one week for repeat laboratory studies.
Summary of ICD-10-CM Impacts
Clinical Documentation
1. In ICD-10-CM, gastro-esophageal reflux disease is differentiated by noting “with esophagitis”
versus “without esophagitis.” “With esophagitis” must be documented in the record.
Coding
Other Impacts
• 530.11 Reflux esophagitis is not coded when GERD is coded in ICD-9-CM because 530.11
is an “excluded code” from 530.81 in ICD-9-CM but it is a combination code in ICD-10-CM.
Scenario 4: Anemia (continued)
ICD-9-CM Diagnosis Codes
280.0 Iron deficiency anemia
secondary to blood loss
(chronic)
530.81 Disease, Gastroesophageal
reflux (GERD)
ICD-10-CM Diagnosis Codes
D50.0 Iron deficiency anemia
secondary to blood loss
(chronic)
K21.0 Gastro-esophageal reflux
disease with esophagitis
21
Scenario Details
Chief Complaint
• “I just got out of the hospital 2 days ago. I’m a little better, but still can barely breathe.”
History
• 67-year-old male with 40 pack/year history of cigarette use (still smoking) and severe oxygen
dependent COPD developed cough with increased production of green/gray sputum 2 weeks
prior to office visit. Admitted to hospital through Emergency Department with diagnosis of
presumed pneumonia superimposed on severe COPD. Hospital exam confirmed acute RLL
pneumococcal pneumonia. Patient treated with an IV cephalosporin as he has known penicillin
allergy, and was discharge from hospital to home 2 days prior to office visit.
• PMH shows severe O2 dependent COPD, with type II diabetes mellitus secondary to chronic
prednisone therapy, which is treated with oral hypoglycemics. Patient also has known
hypertension, on ACE inhibitor therapy.
Review of Systems, Physical Exam, Laboratory Tests
• T 99, BP 145/105, P 92 and irregular, RR 28
• Chest exam shows decreased lung sounds throughout all lung fields except in RLL where there
were mild rhonchi and wheezes noted
• ABG’s on 2L O2 by nasal cannula show PO2 62, PCO2 47, pH 7.40
• CXR shows hyperinflation of lungs with small RLL alveolar infiltration. Comparison to CXR from
hospitalization shows approximately 75% resolution of pneumonia.
• ECG reveals persistent atrial fibrillation which was not present on previous ECG of 6 months
earlier, but had been found at time of recent hospitalization. Labs show finger stick glucose
of 195mg%.
Assessment and Plan
• Acute Community Acquired Pneumococcal Pneumonia: continue oral cephalosporin. Schedule
office follow up visit in 1 week with repeat CXR.
• Severe COPD: continue O2, low dose Prednisone, and inhaled bronchodilator.
• Chronic Hypoxemic, Hypercarbic Respiratory Failure
• Persistent Atrial Fibrillation: continue digoxin initiated during recent hospitalization
• Hypertension: continue ACE inhibitor therapy
• Diabetes Mellitus, Type II, secondary to prednisone therapy; continue oral
hypoglycemic therapy
• Penicillin Allergy
• Tobacco Dependence
Scenario: COPD with Acute Pneumonia Example
22
Summary of ICD-10-CM Impacts
Clinical Documentation
• ICD-10-CM separates pneumonia by infectious agent. Document the infectious agent of pneu-
monia, as there are discrete ICD-10-CM codes for each type.
• ICD-10-CM separates by acuity of respiratory failure, and hypoxia or hypercapnia, if present.
• Document drug allergies with ICD-10-CM status” Z” codes from Chapter 21 to identify these.
• Document the type of cardiac arrhythmia. Atrial fibrillation in ICD-10-CM separates into par-
oxysmal, persistent, chronic, typical, atypical, unspecified. Acute atrial fibrillation defaults to
unspecified in ICD-10-CM.
• The Table of Drugs & Chemicals has a code assignment for Adverse effect of the drug that
would be followed by the secondary diabetes code. Go to the Volume 3 Index to Table of Drugs
and Chemicals. Along the left hand side proceed alphabetically to “Glucocorticoids” and then
move horizontally across to the column for Adverse Effect”. In Volume 1 (Tabular List) the in-
struction at the beginning of the code category T38 are the instructions for the 7th character.
• Note: Drug-induced Diabetes Mellitus is a secondary type of diabetes due to the use of gluco-
corticoids. This code can only be coded as an “additional code” and would never be first-listed
The code categories for secondary diabetes are :
• Due to underlying disease (E08)
• Due to drug (E09)
• Due to other specified condition such as post pancreatectomy. (E13)
These three categories can never be rst-listed per ICD-10-CM guidelines. The underlying cause
would be rst-listed diagnosis.
Scenario: COPD with Acute Pneumonia Example (continued)
ICD-9-CM Diagnosis Codes
481 Pneumonia, Pneumococcal
496 COPD
V46.2 Oxygen dependence
427.31 Atrial fibrillation
249.00 Diabetes, secondary, drug induced
E932.0 Therapeutic use of Prednisone
401.9 HTN
V14.0 Allergy, Penicillin
305.1 Tobacco dependence
ICD-10-CM Diagnosis Codes
J13 Pneumonia due to
Streptococcus pneumoniae
J44.0 Chronic obstructive pulmonary
disease with acute lower
respiratory infection
Z99.81 Dependence on supplemental
oxygen
I48.1 Persistent atrial fibrillation
E09.9 Drug or chemical induced
diabetes mellitus without
complications
T38.0x5A Adverse effect of glucocorticoids
and synthetic analogues, initial
encounter
I10 Essential (primary) hypertension
Z88.0 Allergy status to penicillin
F17.210 Nicotine dependence, cigarettes,
uncomplicated
Coding
23
Scenario Details
Chief Complaint
• “My neck hurts and I have a tingling pain sensation going down my right arm.”
History
• Patient is a 68 year-old male with history of neck pain that has been worsening over the last two
years. Recently, he has experienced some numbness and a painful tingling sensation in his right
arm going down to his thumb. No other symptoms or pertinent medical history.
Review of Systems, Physical Exam, Laboratory Tests
• Review of systems is negative except for the neck pain and sensations in his right arm de-
scribed above. No history of acute injury to neck or arm.
• Physical exam is normal except for neurological exam of the right upper extremity, which
reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6
nerve root distribution. No evidence of weakness in the muscles of the arm or hand.
• MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of
disc material. No other abnormalities noted.
Assessment and Plan
• Cervical transforaminal injection at C5-6
Scenario: Cervical Disc Disease
Other Impacts
• Management of chronic conditions such as COPD, Diabetes Mellitus, Hypertension, and Atrial
Fibrillation should be described in the record.
Scenario: COPD with Acute Pneumonia Example (continued)
24
Summary of ICD-10-CM Impacts
Clinical Documentation
• Subcategory M50.1 describes cervical disc disorders. M50.12 Cervical disc disease that
includes degeneration of the disc as a combination code. The 5th character differentiates
various regions of the cervical spine (high cervical C2-3 and C3-4; mid-cervical C4-5, C5-6,
and C6-7; cervicothoracic C7-T1 and the associated radiculopathies at each level). This is a
combination code that includes the disc degeneration and radiculopathy
Coding
Scenario: Cervical Disc Disease (continued)
ICD-9-CM Diagnosis Codes
722.0 Cervical disc displacement
without myelopathy
722.4 Degeneration of cervical
intervertebral disc
ICD-10-CM Diagnosis Codes
M50.12 Cervical disc disorder with
radiculopathy, mid-cervical region
25
Scenario Details
Chief Complaint
• “My stomach hurts.”
History
• Patient is a 65-year-old male admitted to the hospital with abdominal pain. He has a history
of Crohn’s disease of the large intestine. He also has a history of coronary artery disease, had
a heart attack 5 years ago, but has had no problems since then. He smoked cigarettes for
45 years, but quit after his myocardial infarction. He also has a history of allergic reactions to
Penicillins and Cephalosporins.
Review of Systems, Physical Exam, Laboratory Tests
• 99.8
• Abdomen: diffuse tenderness over entire abdomen
• CT scan of abdomen: abscess secondary to Crohn’s disease of descending colon
Assessment and Plan
• Crohn’s disease, large intestine with abscess.
• Awaiting GI consultation
Scenario: Abdominal Pain
26
Summary of ICD-10-CM Impacts
Clinical Documentation
• Crohn’s disease in ICD-10-CM is separated by small, large intestine or both (small and large
intestine), with or without complications of rectal bleeding, obstruction, fistula, or abscess
(combination codes).
Coding
Other Impacts
• Coding allergies to specific medications allows the providers who share a common EHR to be
notified of these allergies. They can be placed into the ongoing problem list therefore becoming
available whenever relevant for coding on the claim.
• At the beginning of Chapter 10 Respiratory conditions this instruction is found:
Use additional code, where applicable, to identify:
• exposure to environmental tobacco smoke (Z77.22)
• exposure to tobacco smoke in the perinatal period (P96.81)
• history of tobacco use (Z87.891)
• occupational exposure to environmental tobacco smoke (Z57.31)
• tobacco dependence (F17.-)
• tobacco use (Z72.0)
• These tobacco-related codes should also be coded into the ongoing problem list for future
coding situations as indicated in ICD-10-CM.
Scenario: Abdominal Pain (continued)
ICD-9-CM Diagnosis Codes
555.1 Regional enteritis, large
intestine
567.22 Abscess, abdominal
412 Old myocardial infarction
V15.82 History of tobacco use
V14.0 History of allergy to Penicillin
V14.1 History of allergy to other
antibiotic (cephalosporins)
ICD-10-CM Diagnosis Codes
K50.114 Crohn’s disease of the large
intestine with abscess
I25.2 Old myocardial infarction
Z87.891 Personal history of nicotine
dependence or personal history
of tobacco use.
Z88.0 Allergy status to Penicillin
Z88.1 Allergy status to other
antibiotic agent
27
Scenario Details
Chief Complaint
• “I am here for my quarterly evaluation of my diabetes.”
History
• Patient is a 50-year-old woman with Type 1 diabetes since childhood. She has been on insulin
since age 13. As a result of her diabetes she has chronic kidney disease and is currently on
dialysis for ESRD. She also has diabetic neuropathy affecting both lower extremities.
Review of Systems, Physical Exam, Laboratory Tests
• No changes in underlying condition during the last 3 months. She continues to perform self-
testing of her blood sugar levels on a daily basis, is on dialysis every other day, most recently
24 hours ago, and has not noticed any changes in the numbness in her legs.
• BP 140/75, P 80, R 16 and T 98.8
• Dialysis fistula without any signs of infection
• Decreased sensation over lower extremities below the knees
• Lab: BUN/Cr nl, K+ 3.5, glu 105, Hgb A1c 7.9
Assessment and Plan
• Continue BS checks daily with sliding scale as previously prescribed
• Start Capsaicin topically and defer to nephrologist for any Rx at this time. She has an
appointment 10 am tomorrow.
Scenario: Diabetes
28
Summary of ICD-10-CM Impacts
Coding
Other Impacts
E10.22 is a combination code in ICD-10-CM incorporating both the type of diabetes (type 1 is E10) and
the manifestation chronic kidney disease (after decimal point.22). Instructions from Volume 1 under the
code E10.22 is to “use additional code to identify stage of chronic kidney disease N18.1 –N18.6”. In
this documentation the ESRD is documented.
Code the type of diabetes and each associated complication (diabetes with renal disease and diabetic
neuropathy) in ICD-10-CM.
Code the stage of the patient’s chronic kidney disease per instruction under the diabetic code E10.22
Code the dialysis and AV graft by the use of “status codes” (Z codes). The key word to find this status
code in the Index to Diseases from Volume 3 is “Dependence” and then sub indent to the word “on”
and then to the words renal dialysis Z99.2
Scenario: Diabetes (continued)
ICD-9-CM Diagnosis Codes
250.41 Diabetes with renal
manifestations, type 1, not
stated as uncontrolled
585.6 End stage renal disease
250.61 Diabetes with neurological
manifestations, type 1, not
stated as uncontrolled
357.2 Polyneuropathy in diabetes
V45.11 Renal dialysis status
ICD-10-CM Diagnosis Codes
E10.22 Type 1 diabetes mellitus with
diabetic chronic kidney disease
N18.6 End-stage renal disease
Z99.2 Dependence on renal dialysis
Presence of AV shunt for dialysis
E10.42 Type 1 diabetes mellitus with
polyneuropathy
29
Scenario Details
Chief Complaint
• “Seen in the ER over the weekend.”
History
• Mrs. Jones is a 64-year-old female, with a history of morbid obesity, type 2 diabetes with
nephropathy, and asthma, presents here for follow-up ER visit two days ago for shortness of
breath. Patient was discharged with a diagnosis of bronchitis, an Albuterol and Beclomethasone
inhaler prescription, along with five day course of Z pack and a six-day steroid dose pack.
Patient is improving on the regimen. She is no longer wheezing and her phlegm is now scant.
Her sugars however, have been poorly controlled with the Prednisone with fasting sugars
greater than 200.
• Patient has long-standing asthma with 2-3 exacerbations per week and daily need for rescue
inhalers. Patient is still smoking half a pack a day. She is compliant with her inhalers when she
is not feeling well.
• Patient has diabetes with overt proteinuria with her last creatinine of 1.3
• Hypertension
• Morbid Obesity
Review of Systems, Physical Exam, Laboratory Tests
• BMI 44; central adiposity; no respiratory distress; able to speak in full sentences
• BP 142/64 HR94 RR 12 Sats: 98% on RA
• HEENT: TM clear; conjunctiva clear; no sinus tenderness; mallampati 3 airway
• Neck: thick; no adenopathy
• Lungs: scattered wheezing; no consolidation prolonged expiratory phase
• Ext: thin no edema
Assessment and Plan
• Asthma: moderate persistent, with acute exacerbation
• Bronchitis
• Current Smoker
• Diabetes Type 2 with nephropathy and poorly controlled hyperglycemia secondary to prescribed
use of steroid medication
Scenario: ER Follow Up
30
Summary of ICD-10-CM Impacts
Clinical Documentation
• Choosing the first-listed diagnosis in this scenario is determined by the Section IV Guidelines of
ICD-10-CM found in Volume 2 of ICD-10-CM
• Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
• Selection of first-listed condition
• In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
• ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
• List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encoun-
ter/visit shown in the medical record to be chiefly responsible for the services provided. List ad-
ditional codes that describe any coexisting conditions. In some cases the first-listed diagnosis
may be a symptom when a diagnosis has not been established (confirmed) by the physician.
• Asthma was chosen as first-listed in this scenario.
• Asthma is classified as mild, moderate and severe with additional detail as intermittent, persis-
tent and severe; include if there is acute exacerbation or status asthmaticus. Bronchitis was not
specified as “acute” so the assignment is made to not specify as acute or chronic. In ICD-10-
CM both bronchitis and asthma are reported separately.
• Bronchitis is reported separately from asthma per ICD-10-CM guidelines. Bronchitis was not
specified as acute or chronic and the default code would be J40. Conditions involving infec-
tious processes will have “acute” versus “chronic” choice. Providers should document when-
ever possible “acute” or “chronic”.
• Guidelines require reporting of tobacco use or exposure for respiratory, vascular and some
other chronic illnesses such as oral and esophageal cancer codes. The guideline message for
using these codes is found at the beginning of the respiratory Chapter 10 in this scenario.
• Diabetic manifestations are incorporated into the primary code for Diabetes Mellitus (combina-
tion codes). In this case diabetes with nephropathy is a combination code.
• “Uncontrolled” diabetes is no longer a concept in ICD-10. Diabetes that is poorly controlled
should include whether hyperglycemia or hypoglycemia is present; whenever either is present
it should be coded accordingly. This patient would also have hyperglycemia reported as the
recorded Blood sugars show hyperglycemia.
• Adverse effects of prescribed medications are reported from the Table of Drugs & Chemicals
and then a final code assignment from Tabular List for the 7th character. Identify which medi-
cations are causing adverse reactions and go to The Table of Drugs and Chemicals found in
Volume 3 of ICD-10-CM. Along the left side of that table find the drug or (drug class if individual
drug is not found.)
Then the 7th characters are found at the beginning of the T38 category in Volume 1 (Tabular
List) of ICD-10-CM. The choices for 7th character for this Table are:
A= initial encounter
D= subsequent encounter
S= Sequela
Scenario: ER Follow Up (continued)
31
Official CMS Industry Resources for the ICD-10 Transition
www.cms.gov/ICD10
ICD-10 Compliance Date: October 1, 2015
Clinical Documentation (continued)
• In this scenario it would be an initial encounter as this is the first time this provider is evaluating
the patient for this adverse effect.
• Hypertension and Obesity are documented as co-morbid conditions and reported when treat-
ment is given for affected by these conditions. Instructions found at the obesity code instruct to
also report the BMI if documented.
• Note: In ICD-10-CM “Nephritis” is not referenced in the diabetes complication codes with ne-
phropathy
Coding
Scenario: ER Follow Up (continued)
ICD-9-CM Diagnosis Codes
493.92 Asthma, unspecified with
(acute) exacerbation
N/A
305.1 Tobacco use disorder
250.42 Diabetes with renal
manifestations, Type II or
unspecified type, uncontrolled
583.81 Nephritis and nephropathy,
not specified as acute or
chronic, in diseases classified
elsewhere
N/A
995.20 Effect, adverse to medication
properly administered
401.9 Hypertension, unspecified
278.01 Morbid obesity
V85.41 BMI 40.0 – 44.9
ICD-10-CM Diagnosis Codes
J45.41 Moderate persistent asthma with
(acute) exacerbation
J40 Bronchitis, not specified as acute
or chronic
F17.210 Nicotine dependence, cigarettes,
uncomplicated
E11.21 Type 2 Diabetes Mellitus with
diabetic nephropathy
N/A
E11.65 Type 2 diabetes mellitus with
hyperglycemia
T38.0x5A Adverse effect of glucocorticoids
and synthetic analogues, initial
encounter
I10 Essential (primary) hypertension.
E66.01 Morbid (severe) obesity due to
excess calories
Z68.41 Body mass index (BMI) 40.0-44.9,
adult
