ICD-10 CM (International Classification of Disease 10th

Revision clinical Modification)

www.icd10data.com (To search code online)

ICD 10 CM managed by CMS- Center for Medicare- (Federal Govt Insurance) and Medicaid
(State govt Insurance) Services). Changes happen every year on the First of October each
Year. Some codes deleted and some codes added.

There are 3 index and Two Tables

1. Alphabetic Index- Always search all diseases first in the alphabetic Index. It can be
used like a dictionary.
2. Neoplasm Table
3. Drug and Chemicals Table
4. External Factor Index: External Cause of injuries
5. Tabular Index- Contain ICD codes, always use it to confirm whether codes are valid
or invalid.

Always refer to the Alphabetic Index first then refer to the tabular index to confirm
whether code is valid or not valid. We always need to code Valid Codes

ICD codes are 3-7 seven digit alphanumeric codes. 3 digit code can be valid if no
extension required and 6 digit code can be invalid if further extension is required.
How to Identify Valid or InValid Codes:- Always use Valid Code, never use invalid
code.
3 Digit Valid Code Example:
I.e, B20 is a valid code as no further extension required

3 Digit Invalid Code Example

B25 is a three digit code but it is invalid as further extension is required. Below
mention codes will be valid for B25

Note: In the alphabetic index there will be a right mark, or x mark or any other
symbol mentioned against code which describes invalid code. Always refer to the
tabular index to get valid code.
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Example of Invalid code:

First letter of ICD 10 always starts with the Alphabet.

Description of First Letter.
A- Infection- (Virus, Bacteria, Fungus), sepsis, microorganism
B- Infection- (Virus, Bacteria, Fungus), microorganism
C- Cancer, Metastasis
D- Tumor, Benign Neoplasm, Anemia and other blood disorder
E- Endocrine Disorder (Diabetes, Thyroid, all hyper/hypo condition)
F- Psychiatric disorder
G- Nervous system
H- Eye and Ear
I- Cardiovascular disorder
J- Respiratory disorder
K- Digestive
L- Skin (Integumentary)
M- Musculoskeletal
N- Urinary System/Reproductive system- Male and Female
O- Complication during pregnancy
P- Neonatal (patient up-to one month age)
Q- Congenital Disorder ( By birth disorder)
R- Sign and Symptoms
S- Fracture, Injury, Trauma, Open wound
T- Poisoning, Burn, Mechanical complication, post operative
complication
U- Covid-19
V, W, X, Y- External Factor
Z- Vaccination, History, status post, and many more
How to search ICD code.

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 1. First Identify Disease (Always check from disease started in alphabet index
never start search with Continued term)
2. Once disease identified check Organ system or Organ
3. Anatomic location (Upper, Lower, Right, Left)
4. Severity- (Acute, Chronic, subacute etc)

Example 1: Acute Liver Failure- K72.00

Failure (First search failure in alphabetic index)

Liver

Once we reach Liver no code available but index is guiding to search hepatic under
main entry of failure to get liver failure code

Acute- Once hepatic located under failure codes are available but in this example
physician mentioned severity of liver failure as acute so correct code for this scenario
will be K72.00

Example 2: Coronary Artery Disease- I25.10

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Disease- First Locate Disease in Alphabetic Index

Artery- Under disease search Artery

Coronary: Under artery search subterm Coronary

Search ICD codes for

Liver Abscess- K75.0
Acute Renal Failure - N17.9
Acute Respiratory Failure- J96.00
Acute upper respiratory tract infection - J06.9
Right Knee Pain- M25.561
Chronic Diastolic Heart Failure - I50.32
Acute on Chronic heart failure I50.9

Basic Guidelines:

NOS- (Not Otherwise Specified): (Unspecified) If a physician mentions a disease

and there are multiple specific codes available for that but the physician did not
specify either anatomy or severity in that case we need to take an unspecified code.

Knee Pain (Physician mention in Medical Record)

Codes Available
1. Right Knee pain
2. Left knee pain
3. Unspecified knee pain

In this particular case we need to take unspecified code as physician did not
mentioned left or right knee
Note: Most of the time insurance companies denied unspecified codes especially
when laterality codes are available

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NEC Not elsewhere classified: (Other specified) If a physician mentions a disease
and there are multiple specific codes available for that but no code available for
specification which is mentioned by the physician in that case we need to take
another specified code.

Example:
Lower Abdominal Pain-

Codes Available for

Right upper quadrant pain
Left upper quadrant pain
Right lower quadrant pain
Left lower quadrant pain
Periumbilical pain
Epigastric pain
Other specified site Abdominal pain pain
Unspecified abdominal Pain pain

In this example physician specified site but no specific code available for that site in
that case we need to take other specified code.

Parenthesis: Small Bracket ()

Parentheses are used in ICD-10-CM to enclose supplementary words that may be
present or absent in the statement of diagnosis without affecting code to which it is
assigned. Such terms are considered to be “nonessential modifiers” and are used to
suggest that the terms in parentheses are included in the code but need not be
stated in the diagnosis. This is a significant factor in correct code assignment. Terms
enclosed in parentheses in either the Tabular List or the Alphabetic Index do not
affect the code assignment in any way; they serve only as reassurance that the
correct code has been located.

If Something is mentioned in the medical record and the same thing is mentioned in
parenthesis in the alphabetic index we will take that code.

If something is not mentioned in the medical record but mentioned in parenthesis in

the alphabetic index still we will still take that code. In that, whatever written in
Parenthesis has zero value and there will be no impact on code selection.

Liver Abscess-K75.0
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Abscess
liver (cholangitic) (hematogenic) (lymphogenic) (pylephlebitis) (pyogenic) K75.0

Liver Abscess- K75.0

Hematogenic Liver Abscess- K75.0
Pyogenic Liver Abscess- K75.0
Cholangitic Liver Abscess- K75.0

Whether physician mentioned only liver abscess or also mentioned supplementary

terms code will remain same for Liver abscess

Square Bracket:
Square brackets are often used in the Tabular List to enclose synonyms, alternative
wordings, abbreviations, and explanatory phrases that provide additional information

And:
The word “and” should be interpreted to mean either “and” or “or” when it appears in
a code title. For example, cases of “tuberculosis of bones,” “tuberculosis of joints,”
and “tuberculosis of bones and joints” are classified to subcategory A18.0,
Tuberculosis of bones and joints.

With and In

The words with and in should be interpreted to mean “associated with” or “due to”
when they appear in a code title, the Alphabetic Index (either under a main term or
subterm), or an instructional note in the Tabular List. The classification presumes a
causal relationship between the two conditions linked by these terms in the
Alphabetic Index or the Tabular List.

Placeholder: Always use (X) for missing numbers in ICD. In that process we
always have the initial digit of icd codes and Last digit of ICD codes. Whenever a
placeholder is required there will be an indication for the same and the missing digit
will always be X. X can be placed only after 3 digit of ICD

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7th Digit code with Placeholder symbol

S43.50XA
T20.12XA

Normally S and T series code required Placeholder as maximum of these codes are
7th digit.

Include: If physician mention 2 disease and when we search ICD code in Tabular
index under the description of icd code other disease is include in that case we need
to only use one code

Example:
Kidney Stone
Renal Colic

N20.0- Kidney stone

Includes: Renal Colic (XYZ)

In that case only Kidney stone code will be coded as Renal Colic is included in
Kidney stone.

Exclude1:

Excludes1 (Not coded here) note instructs that the code excluded should never be
used at the same time as the code above the “excludes1” note. This instruction is
used when two conditions cannot occur together and therefore both codes cannot be
used together.
Example:

N20.0- Kidney stone

Exclude 1: Renal Colic (XYZ)
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Final coding: N20.0

In brief: In case of exclude 1 if Physician mention 2 disease and under one icd code
other disease is mentioned as Exclude 1 in that case we will not use Exclude 1
condition.

Exclude 2: (Not Included here) instructs that the condition excluded is not part of the
condition represented by the code. However, a patient may have both conditions at
the same time. When an “excludes2” note appears under a code, it is acceptable to
use both the code and the excluded code together.

In case of exclude 2 if Physician mention 2 disease and under the icd code of one
disease other disease is mentioned as Exclude 2 in that case we will use both
disease codes.

N20.0- Kidney stone

Exclude 2: Renal Colic (XYZ)

Final Coding:
ICD 1- N20.0
ICD 2- XYZ

Code First and Use Additional Code: Certain conditions have both an underlying
etiology and multiple body system manifestations due to the underlying etiology. In
the Tabular List, “code first” and “use additional code” instructional notes indicate the
proper sequencing order of these conditions—etiology (underlying condition)
followed by manifestation. The “use additional code” note is found at the etiology
code as a clue to identify the manifestations commonly associated with the disease.
The “code first” note is found at the manifestation code to provide instructions that
the underlying condition, if present, should be sequenced first.

Manifestation: if a patient gets another disease Due to the first disease we call it
manifestation of the first disease. In that case if combination code is available we
need to use combination code if combination code is not available we will use two
codes one for disease and another for Manifestation. Underlying Disease (Main

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Disease) code will be Principal Diagnosis and Manifestation code will be secondary
diagnosis.

I,e- Diabetic Retinopathy- E11.319- retinopathy manifestation of diabetes yes

Diabetic nephropathy - E11.21- yes
Diabetic Neuropathy -E11.40- yes

Retinopathy due to diabetes. - retinopathy manifestation of diabetes yes

Retinopathy secondary to diabetes - retinopathy manifestation of diabetes yes

But if physician mention only diabetes and retinopathy we will not consider
retinopathy as manifestation of diabetes
1. Diabetes
2. Retinopathy
See and See also: We will search code in alphabetic index till the time we will not
get desired ICD code. Sometimes there is no direct code available, in that case an
alphabetic index guide to see or see conditions where we need to search ICD code.

Example: GallBladder Stone - K80.20

In the Gallbladder stone example there is no code available under stone for
Gallbladder. Stone guide to search Gall bladder stone under term Calculus which
lead to ICD K80.20
Sign and Symptoms:

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If sign and Symptoms are part of Disease process in that case no need to code sign
and symptoms

Example: 1
I.e. Leg Fracture
Leg Pain
In that case we will only code Leg Fracture.

Example 2
Abdominal Pain
Kidney Stone
Use code for only Kidney stone

If Sign and Symptoms are not part of disease process in that case we need to code
both disease as well as sign and symptoms
Example:
Leg Fracture
Abdominal Pain

In that case we need to code both Leg Fracture as well as Abdominal Pain.

Code one ICD code only once per medical record no matter how many times
that disease mention in medical record

Acute and Chronic Condition:

If a patient has both acute and chronic conditions for the same disease and there is
a combination code available in that case we need to use combination code. If
combination code is not available and separate code available for both acute and
chronic conditions in that case we need to code Acute as Principal Diagnosis and
Chronic as secondary diagnosis. To search acute and chronic combination code
check words i.e. in, with, on.

Kidney Failure - N19

Acute Kidney Failure - N17.9
Chronic Kidney Failure

Example 1:
Acute kidney Failure- N17.9
Chronic kidney disease/Failure - N18.9
Coding:
1. Acute kidney disease -N17.9
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 2. Chronic Kidney disease- N18.9

Example 2:
Acute Diastolic heart Failure- I50.31
Chronic diastolic heart Failure- I50.32

ICD 10: I50.33- Acute on chronic diastolic heart failure

Code Also: Sometimes when we cross check Tabular index there is a note
mentioning code also. In that case we need to use an additional code according to
documentation provided by the physician.
Example: BPH with urinary retention

Late Effect (Sequela)- Late effect also known as residual effect, There is no time
duration when a late effect can occur. Late effects can occur immediately or one
month later or one year later or even 5 years later.

Impending or Threatened Condition:

Patient admitted with impending Myocardial infarction. Final Diagnosis rules out
Myocardial Infarction.

If condition not occurred check subterm impending or threatened in alphabetic index

if code available for that code use that code. If impending or threatened condition not
found in alphabetic index in that case no need to code for threatened or impending
condition

Searching Criteria:
If code is available for Impeding or Threatened condition

Infarction Myocardial Impending/Threatened If ICD

10 code available code it

If code is not available for impending or threatened Condtion

Infarction Myocardial No ICD 10 Code available No

need to code it as an impending or threatened term not mentioned in the Alphabetic
index.

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Patient admitted with impending Myocardial infarction. Final Diagnosis rules out
Myocardial Infarction.

What not need to code:

Rule out, suspected, Questionable, Likely, Probable, Consistent with, Possible,
Differential Diagnosis. In that case do not provide code for diagnosis mentioned in
the Medical Record.

Example1: Rule out Gall bladder stone- No Code

Suspected Liver Cancer- No code

Example2: Differential diagnosis are MI, CKD, HTN, DM- no code

Example3: Indication: Gall bladder Stone.

Final Dx: Ultrasound shows there is no evidence of Gall Bladder stone

Laterality: If a physician mentioned Left or Right in a medical record we need to use

code for left or right and if physicians mention both in that case we need to check
bilateral code available or not. If bilateral code is available use only one code for
bilateral. If Bilateral code is not available we need to code for both left and right

Example1:
Right knee pain- M25.561
Left knee pain - M25.562
Unspecified Knee pain. M25.569
Code: M25.561 and M25.562 if bilateral knee pain is mention

Example2: Right Carotid Artery disease I65.21

Left Carotid Artery disease I65.22
Bilateral Carotid artery disease I65.23
Code: use only I65.23 as bilateral code will cover both left and right

If laterality is not mentioned in the medical record but code is available in that case
we need to raise a query to the physician. (Practically).

Borderline Dx: If a physician mentions a borderline word before or after diagnosis in

that case we need to search for the same in the Alphabetic index. If borderline is not
mentioned we will take actual code.

Borderline Hypertension will be coded as Hypertension (I10)

Practice Exercise:
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 1. Urinary Tract infection-N39.0
2. Renal Cyst- N28.1
3. Right upper quadrant abdominal pain-R10.11
4. Cirrhosis - K74.60
5. Kidney stone -N20.0
6. Cardiac Arrest- I46.9
7. Cholecystitis-K81.9
8. Acute Pyelonephritis -N10
9. Right Knee Pain- M25.561
10. Colon Polyp- K63.5

Basic Rule of ICD Coding: Always code diagnosis for which patient is admitted to
the hospital or reason for the visit as principal Dx. If a patient came with symptoms
and final diagnosis related to symptoms in that case we only code Final Diagnosis as
symptoms will be part of disease. If there is no confirmed disease in that case we will
code symptoms for which patient went for treatment.

I.e. Patient came to hospital with abdominal pain final Dx is Gall Bladder Stone

PDX (Principal Diagnosis) Gall Bladder stone

There are some Exception for which their are Chapter specific Guidelines:

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HIV: (Human Immunodeficiency Virus)- B20

Always code HIV as principal Diagnosis except in case of Fracture, Burn,

Poisoning and Pregnancy or injury.

In all above cases HIV will be a secondary Diagnosis.

Rule 1: If a Patient Underwent HIV test in that case there are 4 results
possible

Result 1: Patient May have Confirmed HIV disease in that case we need
to take ICD-10 CM- B20

Result 2: Patient HIV result may come positive but patient do not have
any symptoms in that case we need to use Z21 code rather than B20 code

Result 3: Patient HIV test result can be Abnormal but neither it fall in
confirmed Category nor it fall in Positive HIV test category in that case we
need to take ICD 10-CM code R75

Result 4: Patient HIV screening test came Negative in that case we need
to use ICD 10-CM code Z11.4

Rule 2: If a patient is admitted to the hospital for HIV related illness for
example tuberculosis, cardiomyopathy etc and treatment done for these
conditions in that case we will code HIV as principal Dx even if the reason
for the visit is Tuberculosis, Cardiomyopathy or any HIV related illness.

Rule 3: If a patient has an HIV positive but does not have any sign or
symptoms of disease in that case we will not use ICD 10 CM code B20 in
this particular scenario we need to code Z21.

Rule 4: If a patient has been assigned B20 code in previous visit or

hospitalization or physician mentions AIDS (Acquired Immunodeficiency
Syndrome) in the patient's medical record in that case always assigned
ICD 10 CM code B20 even in the report it mentions HIV positive. We
cannot use ICD 10 CM Z21 and B20 together in a Single report.

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Hypertension:

There are 5 series which we can use to code Hypertension.

I10
I11
I12
I13
I16

When to use ICD 10 CM I10: We need to use the I10 code for Hypertension If a
patient has hypertension he may have some other diseases also but none of the
disease should be correlated with hypertension especially Heart disease and
Chronic Kidney disease. In this scenario we need to use ICD code I10 for
hypertension.

Example:
A patient have HIV disease, Hypertension and Diabetes in this case we need to
provide ICD code as follow

For HIV use ICD code - B20

For Hypertension use ICD code- I10
For Diabetes use ICD code- E11.9

When to Use ICD 10 Code I11:

If patient has hypertension and he also have heart disease due to hypertension
or
Physician mentioned hypertensive heart disease for example hypertensive
cardiomyopathy, hypertensive cardiomegaly etc
or
Physician mentioned hypertension and heart failure in medical Record

As a Medical coder we need to use I11 series code in this type of cases

In I11 we need to be very careful to check whether patients also have heart failure or
not. Heart failure can be CHF, Systolic Heart Failure, Diastolic Heart Failure or even
Acute Heart Failure

If patient have Heart failure in that case we need to use I11.0 ICD code and if patient
do not have heart failure in medical Record we need to use I11.9 ICD code
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Patient have Heart dx Patient have hypertensive heart disease without Heart
HTN with heart Failure Failure
I11.0 I11.9

Whenever ICD code I11 series is used for hypertension in that case no need to
provide ICD Code for cardiomegaly or cardiomyopathy. But always provide type of
heart failure mentioned in medical record and ICD codes for other diagnosis also
need to provided as per medical record

If physicians clearly indicate both hypertension and heart disease are unrelated then
code both conditions separately.

Example 1- A patient have Hypertension, Diabetes Mellitus, HIV disease and

Congestive heart failure in that we need to code

Hypertension with ICD I11.0

Diabetes with ICD E11.9
HIV with ICD B20
CHF (Congestive Heart Failure) with ICD I50.9

Example 2: A Patient have hypertensive cardiomyopathy along with other diagnosis

of Diabetes and HIV

ICD 10 Code for Hypertensive cardiomyopathy- I11.9

ICD 10 Code for Diabetes- E11.9
ICD 10 Code for HIV - B20
Please note that there is no need to provide additional code for Cardiomyopathy in
this scenario.

When to use ICD 10 CM code I12- If a patient has Hypertension and also has CKD
(Chronic Kidney disease) in that case we always need to code ICD 10 CM code from
I12 series for hypertension and A secondary code also needs to be provided for CKD
stage.

There is no need to check correlation between CKD and hypertension made by

physician or not

Use I12.0 ICD code if physician mentioned CKD stage 5 or ESRD

Use I12.9 ICD code if physician mentioned CKD stage 1-4 or he did not mentioned
stage of CKD
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Patient Have CKD Stage 5 or ESRD If patient have CKD stage 1-4 or unspecified
with HTN stage with HTN
I12.0 I12.9

Try to remember CKD stages ICD codes

CKD of Unspecified stage- N18.9
CKD Stage 1- N18.1
CKD Stage 2- N18.2
CKD Stage 3- N18.30, N18.31 (use for stage 3A) and N18.32 (use for stage 3B)
CKD Stage 4- N18.4
CKD Stage 5- N18.5
ESRD End Stage Renal Disease- N18.6

Example 1: Patient has Hypertension and CKD stage 4

ICD for HTN= I12.9
ICD for CKD4 N18.4

Example 2: Patient has Hypertension and ESRD (End stage renal Disease)
ICD for HTN=I12.0
ICD for ESRD N18.6

Example 3: A Patient have HIV, hypertension, Diabetes Mellitus, and Chronic

Kidney disease
ICD for HIV B20
ICD for HTN I12.9
ICD for DM E11.9
ICD for CKD N18.9

Never correlated Hypertension with Acute kidney disease. If a patient does not have
CKD (Chronic Kidney Disease) but has acute kidney disease with hypertension in
that case, never use the I12 series code for hypertension. A Code from either
category I10 or I11 need to be used as per documentation

If Physicians have mentioned multiple stages of CKD in medical records, in that case
only need to provide one code for the higher available stage.

If a physician mentions CKD stage 4 or 5 or even three but the patient is on Dialysis
in that always consider it as ESRD patient Once Patient is on dialysis patient need to
be considered as ESRD patient
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When to use ICD code I13: If patient has hypertension and also has heart disease
due to hypertension or physician mentions hypertensive heart disease or physician
mentions hypertension and heart failure and also has Chronic Kidney disease in that
we need to code I13 series rather than I11 and I12 together.

Below mentioned table will give clear Idea how to use I13 series code in correct way

Patient has hypertension and also heart disease due to hypertension

Without Heart Failure With Heart Failure
Patient also have CKD Patient also have CKD
CKD 1-4 or
unspecified CKD 5 or ESRD CKD 1-4 or unspecified CKD 5 or ESRD
I13.10 I13.11 I13.0 I13.2

Apart from I13 code we also need to use additional code for Stage of CKD and type
of Heart Failure.

If patients do not have CKD but have acute kidney disease do not use I13.

No need to use additional code for Cardiomyopathy or cardiomegaly with I13.

When to use ICD I16- We need to use I16 as an additional code along with I10-I13 if
physician mention hypertensive Urgency or Emergency in medical record

I16.0- Hypertensive Urgency

I16.1- Hypertensive Emergency

If a patient has high blood pressure but does not have hypertensive disease in that
case do not use the I10-I13 code, we need to use the R03.0 (Elevated blood
pressure or high blood =-pressure) code.

White Coat Hypertension that is also high blood pressure or elevated blood
pressure: R03.0

Example-1
CHF
HTN-I13.0

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CKD Stage 2

Example-2
CKD Kidney Disease
HTN-I13.0
Heart failure

Example-3.
ESRD
DM
CHF
HIV
HTN-I13.2

Example-4
Hypertensive Cardiomyopathy - I13.0
CHF-I50.9
CKD 3- N18.3

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Neoplasm: Neoplasm is abnormal growth; it can be tissue, organ or even bone.

Organ
Name Malignant
Carcinom Uncertain Unspecified
Primary Secondary a in Situ Benign Behavior Behavior
Brain
Lung
Liver

We will consider Neoplasm as Malignant if Cancer, Sarcoma, Carcinoma or positive

margins mentioned in Medical Record. We will consider Malignant as Primary by
default until the alphabetic index guides us for Secondary malignant Neoplasm or
Carcinoma in Situ.

If physicians mention Metastatic or Metastasis Cancer we will consider it as

Secondary Malignant Neoplasm. Or if medical record indicate cancer has been
spread from one organ to another organ still we will consider it as Secondary
Malignant Neoplasm

Liver cancer to lung

Liver cancer from lung

To Report Secondary Malignant Neoplasm We Need Primary Site Cancer. If primary

site cancer is not mentioned and physicians only mention Metastatic Cancer in that
case we have two methods to code it.

Either we need to code it as Primary site cancer

or
we need to code Secondary site cancer with unknown primary site.

Example: Metastatic Liver Cancer

Method 1:
C78.7
C80.1- Primary Of unspecified site

Method 2:
C22.9
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How to Search Neoplasm Code: Never Search Neoplasm code directly in the
Neoplasm table. First identify the Histopathological term and then search this
histopathological term in the Alphabetic index. Then under histopathological term
check the organ system or organ.

Histopathological Term in Alphabetic index

Organ found Organ not found
Check sentence mention in front of histopathological
term and search
it in the Neoplasm table by following the guideline
mentioned in the sentence. Sentences mentioned in
front of histopathological term will guide which category
If Code Available take that code we need to take out of six categories mentioned in
code the neoplasm table.

Example1:
Meningioma Brain

For Benign, Uncertain Behavior of Unspecified Behavior Alphabetical index guide us.
D32.0

Example2:
Brain Tumor- D49.6
See Neoplasm , Unspecified Behavior by Site (Organ)

Example3:
Brain Cancer- C71.9
See Neoplasm , by Site (Organ), Malignant

Organ
Name Malignant
Carcinom Uncertain Unspecified
Primary Secondary a in Situ Benign Behavior Behavior
Brain C71.9 D49.6

Meninges
- Brain D32.0

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Neoplasm Guidelines:

If a patient has cancer of one site (Primary Malignant Neoplasm) and it spreads to
Another Site (Secondary Malignant Neoplasm or Metastatic). In that case we will
code Principal Dx for the reason the patient visits or is admitted to the hospital.

Example1:
Brain Cancer ( Primary Malignant Neoplasm)- Reason for the visit- C71.9
Right Lung Cancer (Secondary Malignant Neoplasm)- C78.01

Principal DX- Brain - C71.9

Secondary Dx- Right Lung Cancer- C78.01

Organ
Name Malignant
Carcinom Uncertain Unspecified
Primary Secondary a in Situ Benign Behaviour Nature
Brain C71.9 D49.6

Lung C78.01 D49.6

Example 2
Brain Cancer ( Primary Malignant Neoplasm)- C71.9
Lung Cancer (Secondary Malignant Neoplasm) Reason for the visit- C78.01

Principal DX- Lung - C78.01

Secondary Dx- Brain- C71.9

Rule1: If a patient has Neoplasm and due to Neoplasm patient’s get Anemia now
admitted to the hospital for the treatment of anemia in that case we need to code
Neoplasm as Principal Dx and Anemia due to Neoplasm as Secondary Dx.

If due to mention in medical records check it either in Due to or in.

We will code
Principle Dx- Neoplasm
Secondary Dx- Anemia due neoplasm - D63

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Rule2: If patient have Neoplasm and due to Antineoplastic Treatment patient get
Anemia or Dehydration and now admitted to the hospital for the treatment of anemia
or dehydration due to antineoplastic Treatment in that case we will code Dehydration
or Anemia due to Antineoplastic treatment as Principal Diagnosis and Neoplasm as
Secondary Dx. We also need to use an additional code for adverse reactions to
Antineoplastic treatment.

Code1: Anemia or dehydration due to antineoplastic treatment - D64.81

Code 2: Neoplasm
Code 3: Adverse Reaction of Antineoplastic treatment

Rule3: If patient has Cancer and now admitted to the hospital for the administration
of Chemotherapy (Z51.11), Radiation Therapy (Z51.0) or Immunoglobulin therapy
(Z51.12) in that case we need to code reason for the visit ( Z51.0 or Z51.11 or
Z51.12) as Principal Diagnosis and Cancer as Secondary Diagnosis.

Code1:
Z51.0- Encounter for Radiation Therapy
Z51.11 Encounter for Chemotherapy
Z51.12 Encounter for Immunoglobulin Therapy

Code2- Cancer
Please: note that Z51 is always principal dx or never coded if not primary. If a patient
is admitted to the hospital for removal of organs and also receives radiation, chemo
or immunoglobulin therapy in that case never use Z51. If a patient is admitted to
hospital for excision of cancer in that case cancer will be always principal Diagnosis
no matter whether he received chemotherapy or radiation or any other therapy
always use cancer as PDX in that case.
Rule 4: If a patient has Transplanted organ in the past and now gets cancer in a
transplanted organ. In That case we need to use 3 codes.

Code1: Complication---------Transplant-----------Organ

Code 2: C80.2 (it will be fix code) - Transplanted organ cancer

Code 3: Cancer of that organ

Example: Transplanted Liver cancer -

Code1: T86.49 Complication Transplant Liver

Code2: C80.2 Fix code for Transplanted organ cancer
Code3: C22.9- Liver Cancer
Adverse Reaction/Poisoning/Toxic Effect/Underdosing
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 Drugs and Chemical Table
Poisoning Poisoning
Accidental Intentional- Poisoning Poisoning Adverse
Drug/chemical (Unintentional) Self Harm Assault Undetermined Effect Underdosing
Albutonin
Amidone

Adverse Reaction:

Patient Problem Physician Physician Give Medicine

A 1 Tab -Patient take Medicine A 1 Tab Patient Get Reaction
(Nausea, Vomiting, unconsciousness, Dizziness) Now again came to
physician

Code-1 Reaction (Nausea, Vomiting, dizziness or any symptoms)

Code-2 Adverse Reaction of Medicine A

Example: Albutoin prescribed and patient Vomited after taking correct

dose
Code 1: Vomiting - R11.10
Code 2: Adverse Reaction of Albutonin - T42.0X5A

Poisoning:
Scenario A- Correct dose with Alcohol

Patient Problem Physician Physician Give Medicine

A 1 Tab Patient take Medicine A 1 Tab Patient also consume
Alcohol -Patient Get Reaction (Nausea, Vomiting, Consciousness,
Dizziness) Now again came to physician

Code1: Poisoning of Medicine A (Type of Poisoning depend on context of Medical

Record)
Code 2: Reaction code i.e. nausea, Vomiting, dizziness etc

Example: Albutoin prescribed and patient Vomited after taking correct dose but also
consumed alcohol
Code1: Poisoning undetermined- T42.0X4A

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Code 2: Vomiting - R11.10
Scenario B- Overdose
Patient Problem Physician Physician Give Medicine
A 1 Tab Patient take Medicine A more then 1 Tab Patient Get
Reaction (Nausea, Vomiting, Consciousness, Dizziness Now again came
to physician

Code1: Poisoning of Medicine A (Type of Poisoning depend on context of Medical

Record)
Code 2: Reaction code i.e. nausea, Vomiting, dizziness etc

Scenario C- Prescribed Medicine taken with Unprescribed Medicine

Patient Problem Physician Physician Give Medicine
A 1 Tab Patient take Medicine A 1 Tab Patient also take
Medicine Bl which is not prescribed Patient Get Reaction (Nausea,
Vomiting, Consciousness, Dizziness) Now again came to physician

Code1: Poisoning of Medicine A (Type of Poisoning depend on context of Medical

Record)
Code 2: Poisoning of Medicine B (Type of Poisoning depend on context of Medical
Record)
Code 3: Reaction

OR

Code 1: Poisoning of Medicine B (Type of Poisoning depend on context of Medical

Record)
Code2: Poisoning of Medicine A (Type of Poisoning depend on context of Medical
Record)
Code 3: Reaction
Toxic Effect:
Patient Inhale Toxic Substance and get Reaction germicide, homicide, Phenol
Code1: Poisoning of Toxic substance (Type of Poisoning depend on context of
Medical Record)
Code 2: Reaction

Underdosing:
Patient did not complete prescribed dose of medicine and condition worsened
Code1: Disease
Code 2: Underdosing of Medicine
Code 3: Non compliance medicine/drug

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Diabetes/Diabetes Mellitus:

There are two category of Diabetes

1. Diabetes Mellitus type 1 or Juvenile Type (Insulin Dependent- Patient cannot

survive without Insulin)
2. Diabetes Mellitus Type 2 or Unspecified type or Diabetes Mellitus- (Patient
can take insulin or not)

If a physician only mentions Diabetes mellitus in Medical Record but did not mention
type in that case we need to code Unspecified or Type 2 diabetes mellitus Code.

E08- Secondary Diabetes Mellitus - If patient get diabetes after surgery or accident
or due to any other disease
E09- Diabetes due to drug or Chemicals
E10- Diabetes Mellitus Type 1 or Juvenile Type
E11- Diabetes Mellitus Type 2 or unspecified Type
E13- Other Specified

If a patient is on long term or current use of Insulin in that case we need to code an
additional code Z79.4 which represents long term or current use of insulin.

Never use Z79.4 with E10 Series code, as Type 1 diabetic patients can not survive
without insulin.

Always provide ICD codes for all manifestations due to diabetes i.e. diabetic
retinopathy, Nephropathy, neuropathy etc. Never use normal diabetes in that case.

Always correlate diabetes with Neuropathy, Nephropathy, angiopathy, Peripheral

vascular disease, Gangrene, Foot ulcer in that case always use combination code.

If patient have diabetes and also have diabetes manifestation in this case do not use
unspecified diabetes codes i.e. E10.9, E11.9

Example 1: A 35 year old patient who has Diabetes Mellitus and is on long term use
of insulin
ICD 10 Codes:
E11.9
Z79.4
Example 2: A 35 year old patient who has Diabetes Mellitus type 1 and is on long
term use of insulin
ICD 10 Codes:
E10.9
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Example 3: A 35 year old patient who have diabetic Retinopathy and Nephropathy is
on long term use of insulin
Codes:
E11.319
E11.21
Z79.4

If a patient has diabetes and also has CKD, Peripheral vascular disease,
Angiopathy, Foot Ulcer, Gangrene in all these cases we correlate these conditions
as Diabetic manifestation.

Malfunctioning of Insulin pump:

Overdose of Insulin:
Code 1- T85.6----- (Complication------Insulin Pump)
Code 2- T38.3X1A (Poisoning Insulin Accidental)
Code 3- Diabetes mellitus

Underdosing of Insulin pump:

Code 1- T85.6----- (Complication------Insulin Pump)
Code 2- T38.3X6A- Underdosing
Code 3- Diabetes mellitus

If the patient is on oral hypoglycemic and also taking insulin in that case we use both
oral hypoglycemic and Insulin code Z79.4.

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 Sepsis/Severe Sepsis/Septic Shock

Sepsis:

Sepsis is a life-threatening condition. Sepsis occurs when an infection triggers a

chain reaction throughout the patient body. Infections that lead to sepsis most often
start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment,
sepsis can rapidly lead to organ failure and death.

If physicians mention Multiple Microorganisms which cause sepsis in that case we

need to use sepsis of all microorganisms.

If a physician mentions sepsis but culture report is negative in that case we cannot
code sepsis.

Most of the time A Series codes lead to Sepsis Code, sometimes B Series codes
also fall in Sepsis category.

Never use A series code for sepsis in Pregnancy. Always use B series codes for
Sepsis in Pregnancy to represent microorganisms.

Urosepsis is not a sepsis, Never consider it as Sepsis it will consider UTI-

Urinary Tract Infection

Example:
MRSA Sepsis (methicillin resistant staphylococcus aureus) - A41.02
E Coli Sepsis- A41.5-
Enterococcus Sepsi- A41.81

Severe Sepsis:
Severe sepsis (R65.2-) refers to sepsis with associated acute or multiple organ
failure. ICD 10 code R65.2- is further subdivided to identify whether the severe
sepsis is associated with septic shock (R65.21) or without septic shock (R65.20).
Septic shock refers to circulatory failure associated with severe sepsis and therefore
represents a type of acute organ dysfunction. The physician must specifically record
“septic shock” in the diagnostic statement in order for it to be coded as septic shock.
Septic shock indicates the presence of severe sepsis, and code R65.21, Severe
sepsis with septic shock, must be assigned, even if the term “severe sepsis” is not
documented. R65.2- Category code cannot used as Principal Diagnosis and always
assigned after Sepsis ICD code.

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If a patient has Sepsis and due to sepsis Patient gets Organ Failure. In that case we
will consider it as Severe Sepsis. If a patient has sepsis and also has organ failure
and that organ failure is not due to Sepsis in that case we will not consider it as
Severe sepsis.

Or physician mention Severe Sepsis word

And Codes will be as below

Code1: Sepsis (Try to put specific microorganism code)
Code 2: R65.20- Severe Sepsis without septic shock
Code 3: Organ Failure

Example: Acute Liver failure due to MRSA Sepsis

Code-1 A41.02
Code 2: R65.20
Code 3- K72.00

Septic Shock: in that case we need to use

Code1: Sepsis
Code 2: R65.21- Severe Sepsis with septic shock
Code 3: Organ Failure

Example: Acute Liver failure due to MRSA Septic Shock

Code-1 A41.02
Code 2- K72.00
Code 3: R65.21

Always code Sepsis as Principal Diagnosis except in pregnancy. In case of

pregnancy sepsis due to pregnancy from O series will be principal Diagnosis.

A 35 year old patient who has Acute liver failure due sepsis. His culture came
positive for MRSA sepsis, E.Coli Sepsis, and Enterococcus Sepsis.
Example: MRSA Sepsis - A41.02
E Coli Sepsis- A41.51
Enterococcus Sepsis- A41.81
Acute Liver Failure- K72.00
Severe Sepsis-R65.20
If patients do not have Sepsis but physicians mention Microorganisms with or without
disease in that case we need to code microorganisms from B95- B96 Series.

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Example:
MRSA - B95.62
E Coli - B96.20
Enterococcus - B95.2

All Bacteria are Either Gram Positive or Gram Negative. If their is no specific
code available for particular bacteria in that we need to check whether bacteria
is gram positive or Negative.

For Gram Negative- A49.9

For Gram Positive-A48.8
Use these code only when no specific code available for particular microorganism

Coding Tip:
If Physicians Mention microorganism and Disease together i,e, Cryptococcus Cystitis
and there is no combination code available for Cryptococcus Cystitis in that we need
to only code Cryptococcus no need to code cystitis.

Example: Cryptococcus Cystitis - B45.9

Coding Tip:
If a physician mentions Disease due to Microorganism in that case we need to first
search for a combination code and if the combination code is not available we need
to use two codes one for Disease and another for microorganism. In that case we
need to use Disease code as principal diagnosis and Microorganism as secondary
diagnosis,
Example1:
UTI due to E. Coli
N39.0- UTI
B96.20- E.coli
Example 2:
Klebsiella Pneumoniae pneumonia
MRSA/MSSA Colonization:
If physicians only Mention MRSA colonization in that case we only need to code
MRSA colonization. If physicians mention both Current Infection and Colonization in
that we will use both Current MRSA code and Colonization code.
Colonization
MRSA Z22.322 (Methicillin resistant Staphylococcus aureus)
MSSA Z22.321 (Methicillin susceptible Staphylococcus aureus)
Sepsis due to a Postprocedural Infection:
Sepsis due to a postprocedural infection is based on the provider’s documentation of
the relationship between the infection and the procedure. For such cases, the
postprocedural infection code—such as a code from T81.40- to T81.43-, Infection
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following a procedure, or a code from O86.00 to O86.03, Infection of obstetric
surgical wound, that identifies the site of the infection, should be coded first,
followed by the code to identify the infectious agent.

Sepsis and Severe Sepsis with a Localized Infection

If the reason for admission is both sepsis or severe sepsis and a localized infection
(e.g., pneumonia or cellulitis), Sepsis code will be assigned first and the code for the
localized infection should be assigned as a secondary diagnosis.

If the patient is admitted with a localized infection, such as pneumonia, and the
sepsis/severe sepsis developed after admission to the hospital the code for the
localized infection should be assigned first, followed by sepsis/severe sepsis codes.

Bacteremia: Assign code R78.81

Coding Tip:
Rule1: MRSA sepsis or MSSA Sepsis :Assign code A41.01 or A41.02
Rule2: Severe Sepsis: Assigned Sepsis code followed by R65.2- and organ failure
Rule 3: Septic Shock: Assigned Sepsis code followed by R65.21 and organ failure
Rule 4: Patient Admitted Due to both pneumonia and sepsis :Assign codesA41.9 as
PDX and J18.9 as SDX.
Rule 5: Patient Admitted Due to both pneumonia and developed sepsis in hospital:
Assign codesA41.9 as SDX and J18.9 as PDX.

Fracture:
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There are Two Types of Fracture Displaced or Nondisplaced until unless the
physician did not mention nondisplaced by default we will take displaced Fracture.

Closed Fracture and Open Fracture:

In closed Fracture bone remains inside the skin and in Open Fracture bone came out
of skin and is clearly visible from outside. We always consider fracture as Closed
fracture until unless the physician mentions open fracture or used any term which
indicates open fracture.

Sometime Physicians mention that they performed Open Reduction internal fixation
of a Fracture which is an open Procedure. Even though the physician performed the
Open procedure still we take ICD of Closed Fracture until unless the physician
mentions Open fracture or used any word which indicates open fracture.

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In addition to the specific anatomical site (location) and type of fracture, a coder needs to
look for specific documentation as to whether the fracture is displaced or not, the laterality, if
the fracture treatment is routine versus delayed healing, nonunion, or malunions and, finally,
the type of encounter (initial, subsequent, sequela) has to be understood in order to assign
the appropriate code. Like injuries, the 7th character for fractures describes the type of
encounter and include:
Always take fracture code from S series which is from Traumatic fracture. If physicians
mention compression fracture or Pathological fracture code will be from M series.

7th character Required in Fracture Coding.

A - Initial encounter for closed fracture
B - Initial encounter for open fracture
D - Subsequent encounter for fracture with routine healing
G - Subsequent encounter f-or fracture with delayed healing
K - Subsequent encounter for fracture with nonunion
P - Subsequent encounter for fracture with malunion
S -Sequela

By Default We will consider Fracture as Traumatic Fracture until physician

Mention Pathological Fracture. Fracture code needs to be from S series.
Examples:
1. Right Distal Radial Fracture -S52.501A
2. Right Femur mid shaft Fracture - S72.301A
3. Right Femur mid shaft fracture Open-S72.301B
4. Malunion of Right Femoral Shaft Fracture - S72.301P
5. Open fracture of Right Femoral Shaft- S72.301B
6. Left Tibial Bone Fracture- S82.202A
7. Left Ulnar fracture - S52.202A
8. 2nd Left Rib Fracture -S22.32XA
9. Open fracture of right femur S72.91XB

Physicians mention Pathological fracture (M Series code) or Compression Fracture

in that case we will take Pathological fracture and it came from M series code.
Common pathological fractures are Spine.

Burn: (T20-T31)

There are three Category of Burn

First Degree- Erythema

Second Degree- Blisters
Third Degree- Loss of Skin

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We need to always code highest Degree Burn First followed by Lower degree burn if
burn is at a different location.

If a patient gets multiple degree burns at the same anatomical site in that case we
need to code for the highest degree of burn. I.e. Third and Second degree burn on
Right upper arm, in that case we need to use only third degree burn. If anatomical
sites are different we need to take the ICD code of all burn sites. Ie. Third degree
burn on right upper arm and Second degree burn on Left upper arm. In that we will
code both second degree as well as third degree as the anatomical site is different.

Area fall in Trunk: Chest, Abdomen, upper back and lower back

Example:
Second Degree Burn of Right index finger - T23.221A
First Degree burn Right Forearm Subsequent Encounter - T22.111D
Third degree Burn of left upper arm-T22.332A
Third Degree burn of face-T20.30XA
Second degree burn of Chest- T21.21XA

Rule of Nine: Use to calculate TBSA- Total body surface Area

When we need to use Rule of 9: If a patient has Third Degree burn in Medical Record in
That case we need to use an additional code to represent 3rd Degree Percentage in
comparison with Total body surface area. In that case we need to code all sites and degree
codes and to represent third degree burn we need to use an additional code T31.XY.

X= Percentage of TBSA and

Y = percentage of third degree

Calculation of Total Body Surface Area- 100%

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Head & Neck- 9%
Chest- 9
Abdomen- 9
Upper Back 9
Lower Back 9
Right Arm 9
Left Arm 9
Right Leg 18 (Anterior leg 9% and Posterior leg 9%)
Left Leg 18 (Anterior leg 9% and Posterior leg 9%)
Genital Organ 1

7th Character in Burn ICD codes:

A Initial encounter
D Subsequent encounter
S Sequela
Seventh Digit “A” (initial encounter) is used for each encounter in which the patient is
receiving active treatment for the injury. Examples of active treatment are surgical treatment,
emergency department encounter, and evaluation and management of acute injuries. A will
always be used each time when active treatment is going on —not on whether the provider
is seeing the patient for the first time.

Seventh Digit as “D” (subsequent encounter) is used for encounters after the patient has
completed active treatment of the injury and is receiving routine care for the injury during the
healing or recovery phase. Examples of subsequent care are medication adjustment, other
aftercare, and follow-up visits following injury treatment. The aftercare Z codes should not be
used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the
seventh character “D”

Seventh Digit as “S” (sequela) is used for complications or conditions that arise as a direct
result of an injury, such as scar formation after a burn; the scars are sequelae of the burn.
When using value “S,” it is necessary to use both the code for the sequela itself and the
injury code that precipitated the sequela. The specific type of sequela (e.g., scar) is
sequenced first, followed by the injury code. The “S” value identifies the injury responsible
for the sequela and is added only to the burn or corrosion code, not the sequela code.

Example 1:
9% Second Degree Burn of Right index finger - T23.221A
First Degree burn Right Forearm - T22.111A
9% Third degree Burn of left Wrist-T23.372A
9% Third Degree burn of lower Back- T21.34XA
9% Second degree burn of Chest- T21.21XA
9% Third Degree burn of upper back- T21.33XA
18% Second degree burn of Right thigh - T24.211A

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TBSA= 63
Third Degree= 27

T31.62
If TBSA or Third degree area fall in single digit put 0 before single digit
TBSA- 9 will 09
Third degree 9 will be 09

Code will be: T31.00 in this case

Practice Exercise
1. Right upper Lobe lung Cancer-
2. Nausea with Vomiting-
3. Cholelithiasis with Acute Cholecystitis -
4. Acute otitis Media Right ear-
5. HTN with Acute Kidney disease and Congestive Heart failure-
6. Metastatic Liver Cancer-
7. Right Kidney cyst-
8. Left ankle and Right Shoulder pain -
9. Epigastric pain -

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10. Atrial Septal Defect-
11. Atelectasis -
12. Pleural Effusion -
13. Colon Polyp-
14. GERD-
15. Lung Tumor left lower lobe -
16. Anemia due to antineoplastic Treatment for Liver Cancer -
17. Transplanted Right Kidney Cancer-
18. Brain cancer due to Liver Cancer-
19. Right shoulder rotator cuff tear, -
20. Chronic frontal sinusitis.-
21. Deviated nasal septum.-
22. Bilateral inferior turbinate hypertrophy.-
23. Conductive hearing loss-
24. Morton Neuroma-
25. Hemoptysis-
26. Laceration digital nerve, right index-
27. Primary osteoarthritis of the ankle-
28. Crohn's Disease-
29. Right shoulder impingement-
30. Acute and Chronic Systolic heart Failure-

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Myocardial Infarction: Heart Attack

An MI described as acute or with a duration of four weeks or less is classified in

category I21, ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial
infarction, with a fourth character indicating the wall involved (such as anterolateral
wall or inferior wall).

Example:

Past Medical Hx: Myocardial Infarction in 2018, PTCA- 2019, CABG- 2018

I25.2

Z95.5

Z95.1

Example: Patient had a myocardial infarction of Lateral wall 2 weeks ago.

I21.29

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ST Elevated Myocardial Infarction Rule: Until unless physicians mention NSTEMI
(non ST elevated Myocardial Infarction) we will consider all Myocardial Infarction as
ST Elevated.

If a patient is admitted to the hospital with NSTEMI and later NSTEMI converted into
STEMI in that case we will code it as STEMI.

If a patient is admitted to the hospital with STEMI and later STEMI converted in to
NSTEMI in that case again we will code it as STEMI.

AMI documented as nontransmural or subendocardial but site provided it is

still considered as subendocardial AMI:

Risk factor Code in MI:

Z77.22 Exposure to environmental tobacco smoke

Z87.891 History Of Nicotine Dependence

Z57.31 Occupational exposure to environmental tobacco smoke

F17.- Nicotine dependence

Z72.0 Tobacco use

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CVA Cerebrovascular Accident also known as stroke-

A stroke, sometimes called a brain attack, occurs when something blocks blood
supply to part of the brain or when a blood vessel in the brain bursts.

In either case, parts of the brain become damaged or die. A stroke can cause lasting
brain damage, long-term disability, or even death.

Use I63.9- Code when there is an active Infarction mentioned in the medical record.
Never code it for Old CVA.

For Old CVA use ICD code Z86.73

When patients have CVA in the past there are chances he will get Late effects later.
If patient have late effect in that case code late effect diagnosis

Common Late Effect of CVA are

Hemiplegia ( a condition caused by brain damage or spinal cord injury that leads to
paralysis on one side of the body ) due to CVA

Never code old CVA (Z86.73) along with Active CVA or Late effects of CVA.
Active CVA and Late effects of CVA can be coded together both condition exist

If there are multiple late effects of CVA code, all of them.

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Pressure Ulcer:

Pressure ulcer also known as Decubitus ulcer. In pressure ulcer we check two things

1. Site of pressure ulcer

2. Stage of Pressure ulcer

If a patient has multiple stage pressure ulcers on one site in that case code only the
highest stage pressure ulcer. If physicians mention different stages and different
sites we need to code all site pressure ulcers.

If stage of pressure ulcer not mention in Medical Record code it as unspecified

pressure ulcer

Never code Healed Pressure ulcer.

If the stage of pressure ulcer changes during admission in that code stage
according to disease present.

Example: Right ankle stage 2 and right ankle stage 3 Pressure ulcer

Example: Right ankle stage 2 and left ankle stage 3 Pressure ulcer

Code: Left ankle stage 3 pressure ulcer - L89.523

Right ankle stage 2 pressure ulcer - L89.512

Respiratory System: Common Respiratory system Disease

Asthma-J45.909

COPD-J44.9

Chronic Bronchitis-J42

Acute Respiratory failure- J96.00

Acute Bronchitis - J20.9

COPD exacerbation -J44.1

Patient have COPD and Asthma

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Psychoactive Substance: Use, Abuse and dependence

If use and Abuse both are mention then only use Abuse code

If Abuse and Dependence both are mention in medical record only Dependance
code.

If use, abuse and dependence are mention in medical record in that case we will
only code Dependance

USE- ABUSe- DEPENDANCE

Pain Management ICD Guidelines:

When pain management or control is the reason for admission for example insertion
of neurostimulator in that case we will use Pain ICD code as Principal Dx.

If a patient is admitted for surgical procedure for pain in that case the cause of the
pain will be principal dx (Disc displacement, Back pain, nerve impingement) and site
specific pain will be secondary Dx.

Assigning of G89 code with Specific Pain codes:

If a physician mentions Pain and also mentions acute and chronic pain. If there is no
combined code for Acute or Chronic pain of that particular site in that we will code
site specific code along with Acute or chronic pain.

Acute or chronic pain codes are mentioned in the alphabetic index and series will be
G series for these ICD codes.

G89 series code as PDX:

If a patient is admitted to hospital for pain management in that case use G89 series
as Principal Diagnosis followed by Site specific Pain.

If encounter or reason for admission is other than pain and related Dx is not
mentioned in that case we will code Site specific pain as PDX and G89 code as
Secondary.

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Postoperative Pain:

If a patient has post operative pain without surgical complication or you can say
patient has postoperative pain not due to complications of surgery in that case we
need to use postoperative pain from G89 category.

If patient have pain due to complication of surgery in that case we will code
Complication of that particular procedure as Principal Dx and postoperative pain as
secondary dx

Neoplasm Related Pain (G89.3): If a patient has pain due to cancer or neoplasm and
the reason for the visit is pain management use G89.3 as Principal Diagnosis. If the
reason for the visit is excision of neoplasm in that case use neoplasm as Principal
Dx and Pain due to neoplasm as secondary Dx.

If physicians mention Central Pain Syndrome (G89.0) or Chronic Pain syndrome

(G89.4) use these codes as required.

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Pregnancy (Obstetrician) (OB):
General Rules for Obstetric Cases

If a patient is Pregnant whether she has any complication or does not have any
complication, Pregnancy Related ICD 10 code will be always principal Dx.

There can be 3 Categories in Pregnancy

1. Pregnant do not have complication- Use Z34 or Z36 series code

2. Pregnant do not have complication but have complication in previous pregnancy-
O09 high risk pregnancy Code need to be coded - Check all codes mentioned in
O09 series for better understanding
3. Patient is pregnant and have complication of pregnancy or other disease during
pregnancy use O series codes

Last Digit in Pregnancy Related ICD Codes based on Trimester so we need to have
good idea about trimester

Trimester in Pregnancy will as as per below criteria

First Trimester Gestation Week- 0 days to less than 14 Weeks (3 months)

Second Trimester Gestation Week: 14 weeks to less than 28 weeks (7 months)
Third Trimester Gestation Week- 28 Weeks till delivery
Sometimes physicians did not mention Gestation weeks but he mentioned LMP (Last
menstrual Period) . In that case we need to count gestation week from LMP date till
the date on which service was provided.

Selection of trimester for inpatient admissions that encompass more than one
trimesters
In instances when a patient is admitted to a hospital for complications of pregnancy
during one trimester and remains in the hospital into a subsequent trimester, the
trimester character for the antepartum complication code should be assigned on the
basis of the trimester when the complication developed, not the trimester of the
discharge. If the condition developed prior to the current admission/encounter or
represents a pre-existing condition, the trimester character for the trimester at the
time of the admission/encounter should be assigned.

Example:
Patient Admitted on 10th January Second trimester
Physician saw patient on 13th January - Code will be based on Second Trimester
Third Trimester starts on 15th January
Physician Saw Patient on 18th Jan- Code will be based on Third Trimester
PAtient Discharge on 25th January after Delivery- Based on Delivery
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Unspecified trimester (Do not use this and if Trimester is not mentioned in that
case we need to raise a query to the physician. If we code unspecified Trimester
there are chances claim will deny but in exam you can use unspecified code as we
code according to guidelines if trimester not mention)

Each category that includes codes for trimester has a code for “unspecified
trimester.” The “unspecified trimester” code should rarely be used, such as when the
documentation in the record is insufficient to determine the trimester and it is not
possible to obtain clarification.

Selection of OB principal or first-listed diagnosis

1) Routine outpatient prenatal visits- If the patient is Pregnant and does not have
any complications in that case we need to use Z34 or Z36 Series code.

For routine outpatient prenatal visits when no complications are present, a code from
category Z34, Encounter for supervision of normal pregnancy, should be used as the
first-listed diagnosis. These codes should not be used in conjunction with chapter 15
series codes which start from O.

2) Prenatal outpatient visits for high-risk patients- Patient is Pregnant do not

have any complication at present but due to past Pregnancy she is on high risk- (i.e.
Patients get abortion during the last pregnancy or get any other complication during
previous pregnancy) in That case we need to use O09 Series code.

3) Episodes when no delivery occurs

In episodes when no delivery occurs, the principal diagnosis should correspond to

the principal complication of the pregnancy which necessitated the encounter.
Should more than one complication exist, all of which are treated or monitored, any
of the complications codes may be sequenced first.

4) When a delivery occurs

When a delivery occurs, the principal diagnosis should correspond to the main
circumstances or complication of the delivery. In cases of cesarean delivery, the
selection of the principal diagnosis should be the condition established after study
that was responsible for the patient’s admission. If the patient was admitted with a
condition that resulted in the performance of a cesarean procedure, that condition
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should be selected as the principal diagnosis. If the reason for the
admission/encounter was unrelated to the condition resulting in the cesarean
delivery, the condition related to the reason for the admission/encounter should be
selected as the principal diagnosis.

Patient is pregnant and also have complication:

We need to provide all ICD codes for complications of pregnancy mentioned in the
Medical Record. Most of the time every one disease mentioned in Medical Record of
pregnant females leads to 2 codes.

Which normally searches

Pregnancy complicated by Disease if Disease found in Alphabetic index, no
additional code required we will take that code. If disease is not found in that case
we need to first check Pregnancy complicated by Organ if organ also not mentioned
in that case we need to Check pregnancy complicated by organ systems. In this
Scenario we need to use additional code for Particular disease along with Pregnancy
complication

We also need to use an additional code Z3A.XY along with O series code where XY
represents no of weeks the patient is pregnant. Some codes have exceptions not to
use Z3A.XY specially Abortion.

i.e 25 weeks pregnant - Z3A.25

32 Weeks pregnant- Z3A.32

If patient Pregnant at older age 35+ use additional code Elderly Gravida
If a patient is pregnant in Early age before 16 years - young Primarily Gravida.

You need to check high risk category O09 for these codes.

Example: A 45 Year Old patient who is 22 weeks pregnant went to the physician
office with a complaint of Thyroid nodule.
ICD:
O99.282- Pregnancy complicated endocrine disorder
O09.512- Elderly gravida
E04.1- Thyroid nodule
Z3A.22- 22 weeks gestation

Example 2: A 45 Year Old patient who went to the physician office with a complaint
of Thyroid nodule.
E04.1
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5) Outcome of delivery
A code from category Z37, Outcome of delivery, should be included on every
maternal record when a delivery has occurred. These codes are not to be used on
subsequent records or on the newborn record.

Pre-existing conditions versus conditions due to the pregnancy

Pre-existing hypertension in pregnancy

Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the

puerperium, includes codes for hypertensive heart and hypertensive chronic kidney
disease. When assigning one of the O10 codes that includes hypertensive heart
disease or hypertensive chronic kidney disease, it is necessary to add a secondary
code from the appropriate hypertension category to specify the type of heart failure
or chronic kidney disease.

Example: A 45 Year Old patient who is 22 weeks pregnant went to the physician
office with a complaint of Thyroid nodule. Patient has CKD and HTN
ICD:
O99.282- Pregnancy complicated endocrine disorder
O09.512- Elderly gravida
O10.212
I12.9
N18.9
E04.1- Thyroid nodule
Z3A.22- 22 weeks gestation

Example: A 25 Year Old patient who is 22 weeks pregnant went to the physician
office with a complaint of Thyroid nodule. Patient also have HTN
ICD:

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O99.282- Pregnancy complicated endocrine disorder
O10.012
E04.1- Thyroid nodule
Z3A.22- 22 weeks gestation

Example 2: A 45 Year Old patient who went to physician office with complaint of
Thyroid nodule and HTN
E04.1
I10
Use all HTN guidelines along with O10 code.

Fetal conditions affecting the management of the mother

1) Codes from categories O35 and O36

Codes from categories O35, Maternal care for known or suspected fetal abnormality
and damage, and O36, Maternal care for other fetal problems, are assigned only
when the fetal condition is actually responsible for modifying the management of the
mother, i.e., by requiring diagnostic studies, additional observation, special care, or
termination of pregnancy. The fact that the fetal condition exists does not justify
assigning a code from this series to the mother’s record.

Commen: Large for dates and small for dates

HIV Infection in pregnancy, childbirth and the puerperium

If patient is Pregnant and have Second code HIV disease B20 or HIV positive without
symptoms Z21 all guidelines will be same HIV except we need to use Principal Dx code of
first code O98.7-
Third code Z3A.XY
During pregnancy, childbirth or the puerperium, a patient admitted because of an HIV-related
illness should receive a principal diagnosis from subcategory O98.7-, Human
immunodeficiency [HIV] disease complicating pregnancy, childbirth and the puerperium,
followed by the code(s) for the HIV-related illness(es).

Patients with asymptomatic HIV infection status admitted during pregnancy, childbirth, or the
puerperium should receive codes of O98.7- and Z21, Asymptomatic human
immunodeficiency virus [HIV] infection status.

Example1: A 45 Year Old patient who is 22 weeks pregnant who has HIV Disease
went to the physician office. Patient also has a thyroid nodule.

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ICD:
O98.712- Pregnancy complicated by HIV disease
O09.512
O99.282
B20- HIV
E04.1
Z3A.22

Example2: A 45 Year Old patient who is 22 weeks pregnant who is HIV Positive
without any symptoms went to the physician office.

O98.712- Pregnancy complicated by HIV disease

O09.512
Z21
Z3A.22

Diabetes mellitus in pregnancy (Patient is Diabetic then gets pregnant- Pre Existing
diabetes)- Use additional code from (E08-E13) to show type of Diabetes.

Long term use of insulin

Code Z79.4, Long-term (current) use of insulin, should also be assigned if the diabetes
mellitus is being treated with insulin. Never use this code for Type 1 Diabetes patient or E10
Series code
Pregnancy- Complicated by - Diabetes

Gestational (pregnancy induced) diabetes: Patient is Pregnant and then get

diabetes) in case Gestational Diabetes never use ICD code of Diabetes from (E08-
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E13). Code Z79.4, Long-term (current) use of insulin, should also be assigned if the
diabetes mellitus is being treated with insulin

Sepsis and septic shock complicating abortion, pregnancy, childbirth and the
puerperium- Never use A41 Series code if patient is pregnant and also have sepsis.
We need to use O85 Series code and represent microorganism we will use B95-96
series code

Code O85, Puerperal sepsis, should be assigned with a secondary code to identify
the causal organism (e.g., for a bacterial infection, assign a code from category B95-
B96, Bacterial infections in conditions classified elsewhere). A code from category
A40, Streptococcal sepsis, or A41, Other sepsis, should not be used for puerperal
sepsis. If applicable, use additional codes to identify severe sepsis (R65.2-) and any
associated acute organ dysfunction.

Example:

Example: A 45 Year Old patient who is 22 weeks pregnant admitted to the hospital
for MRSA Sepsis.
ICD:
O85
O09.512
B95.62
Z3A.22

Example: A 45 Year Old patient admitted to the hospital for MRSA Sepsis.

ICD:
A41.02

l. Alcohol and tobacco use during pregnancy, childbirth and the puerperium

1) Alcohol use during pregnancy, childbirth and the puerperium

Codes under subcategory O99.31, Alcohol use complicating pregnancy,
childbirth, and the puerperium, should be assigned for any pregnancy case when a
mother uses alcohol during the pregnancy or postpartum. A secondary code from
category F10, Alcohol related disorders, should also be assigned to identify
manifestations of the alcohol use.

2) Tobacco use during pregnancy, childbirth and the puerperium

Codes under subcategory O99.33, Smoking (tobacco) complicating pregnancy,

childbirth, and the puerperium, should be assigned for any pregnancy case when a
mother uses any type of tobacco product during the pregnancy or postpartum. A
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secondary code from category F17, Nicotine dependence, or code Z72.0, Tobacco
use, should also be assigned to identify the type of nicotine dependence.

Poisoning,toxic effects,adverse effects and underdosing in pregnant patient

A code from subcategory O9A.2, Injury, poisoning and certain other consequences
of external causes complicating pregnancy, childbirth, and the puerperium, should be
sequenced first, followed by the appropriate injury, poisoning, toxic effect, adverse
effect or underdosing code, and then the additional code(s) that specifies the
condition caused by the poisoning, toxic effect, adverse effect or underdosing

Normal delivery, code O80

1) Encounter for full term uncomplicated delivery

Code O80 should be assigned when a woman is admitted for a full-term normal
delivery and delivers a single, healthy infant without any complications antepartum,
during the delivery, or postpartum during the delivery episode. The delivery should
be Vaginal.

Outcome of normal delivery for O80 will be always Single Live born Z37.0

We will not consider delivery as normal if outcome is single live born as it can be
from C-Sec delivery or single born can happen with complication also

The postpartum period begins immediately after delivery and continues for six weeks
following delivery. The peripartum period is defined as the last month of pregnancy
to five months postpartum.

2) Peripartum and postpartum complication

A postpartum complication is any complication occurring within the six-week period.

3) Pregnancy-related complications after 6 week period
`
Chapter 15 codes may also be used to describe pregnancy-related complications
after the peripartum or postpartum period if the provider documents that a condition
is pregnancy related.

4) Admission for routine postpartum care following delivery outside hospital

When the mother delivers outside the hospital prior to admission and is admitted for
routine postpartum care and no complications are noted, code Z39.0, Encounter for
care and examination of mother immediately after delivery, should be assigned as

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the principal diagnosis.

5) Pregnancy associated cardiomyopathy

Pregnancy associated cardiomyopathy, code O90.3, is unique in that it may
be diagnosed in the third trimester of pregnancy but may continue to progress
months after delivery. For this reason, it is referred to as peripartum cardiomyopathy.
Code O90.3 is only for use when the cardiomyopathy develops as a result of
pregnancy in a woman who did not have pre-existing heart disease.

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Z Codes:

Z codes Never used for active disease.

Z code can be used in any healthcare setting (Hospital, Office, Nursing Home etc).
Z codes can be a principal Dx as well as secondary Diagnosis. Some Z codes are
only used as Principal Dx.

Categories of Z Codes

1) Contact/Exposure
There is a Tuberculosis patient in Hospital or at home and somebody came in
contact with him and now that person went to the physician's office for this reason. In
that we need to search ICD code either in Contact or in exposure. Z20.1

2) Inoculations and vaccinations

If a patient went to the physician office for vaccination in this scenario Vaccination
CPT codes (Drugs and Administration) always use Z23 ICD code no matter which
physician administered which vaccine.

3) Status
Status codes we used for the condition which can impact in future.
Z21 Asymptomatic HIV infection status

Z28.3 Under immunization status

Z33.1 Pregnant state, incidental- Patient is not aware that she is pregnant and went
to the physician office for check then physician told the patient that she is pregnant in
that we will use Z33.1 incidental Pregnancy.

Z68 Body mass index (BMI)- Use BMI specially in case of of Obese/Obesity/Over
weight Patient

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Z79 Long-term (current) drug therapy-
Insulin- Z79.4
Anticoagulant - Coumadin and Warfarin (Blood Thinners) - Z79.01
NSAID- Z79.1
Route to search code Long Term use of therapy

Z89 Acquired absence of limb

Route to search code

Absence---- Leg---Above the knee below the knee

BKA (Below Knee Amputation)- Z89.5--

AKA (Above Knee Amputation) - Z89.6--

Z93 Artificial opening status- use these codes only when artificial opening is present.
Once the Doctor removes these tubes no need to code.
Tracheostomy - Z93.0
Gastrostomy- Z93.1
Ileostomy- Z93.2
Colostomy - Z93.3

Z94 Transplanted organ and tissue status

Transplant-------organ
Kidney-Z94.0
Liver-Z94.4
*Never use codes for Transplant status if patient have complication in
Transplanted organ

I.e. Patient has failed liver transplant

T86.49 - do not use Z94.4 for Liver transplant status

Z95 Presence of cardiac and vascular implants and grafts

PTCA- Percutaneous Transluminal Coronary Angioplasty -Z95.5
CABG- Coronary artery Bypass Graft - Z95.1
Cardiac Pacemaker -Z95.0
AICD- Automatic Implantable Cardioverter Defibrillator - Z95.810
Valve Replacement - Z95.4

Z96 Presence of other functional implants

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Status ------ organ replacement--------prosthesis (artificial)

Joint Replacement
Knee- Z96.65-
Hip- Z96.64-
Shoulder- Z96.61-
Ankle - Z96.66-

Z99- Dependence on Machine

Dialysis -Z99.2
Ventilator - Z99.11

4.) History-

Never use history code for condition which are non treatable but can be managed in
that case we need to used actual ICD code rather than z code
I.e. History of Diabetes, History of Hypertension, Hypercholesterolemia etc.

Never use history code for Acute condition if acute condition mention in Past Medical
History as acute condition can be treated in 3-6 weeks
I.e. History or Pneumonia, History fracture etc. In that we aren't required to use code
for acute conditions as these conditions occurred in the past and there will be no
impact in future.

We need to use history code for

Cancer- if cancer was treated in the past and currently there is no active treatment
going on.

Organ removed due to cancer in past but patient is still receiving chemotherapy or
radiation therapy or immunoglobulin therapy we need to use Active cancer code
rather then history of cancer

Example 1

Patient had right Kidney cancer and right kidney removed in 2017.

ICD: History of Right Kidney Cancer

Example 2:

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Patient had right Kidney cancer and right kidney removed in 2017 patient is still
taking Chemotherapy regularly

ICD: Right Kidney Cancer

Family history
Family history of Chronic condition(use family history for parents and sibling only if
mention in medical record) - Diabetes, Thyroid, Hypercholesterolemia, Hypertension,
Heart Disease

Smoking history
CVA history - Cerebrovascular Accident (Z86.73) - If there is no current CVA or Late
effect of CVA. If current CVA or Late effect of CVA is mentioned in that case we
need to take CVA or Late effect of CVA code rather than Hx of CVA.

MI history - Myocardial Infarction - I25.2

5.) Screening

Always use Screening as principal Diagnosis if the reason for the

visit is specifically the screening exam. Even patients diagnosed with Cancer during
screening still will use Screening as principal Diagnosis and Cancer as secondary
DX. It may also be used as an additional code if the screening is done during an
office visit for other health problems. A screening code is not necessary if the
screening is inherent to a routine examination, such as a pap smear done during a
routine pelvic examination. Should a condition be discovered during the screening
then the code for the condition may be assigned as an additional
diagnosis.

The Z code indicates that a screening exam is planned. A

Procedure code is required to confirm that the screening was
performed.
The screening Z codes/categories:
Z11 Encounter for screening for infectious and parasitic
diseases
Z12 Encounter for screening for malignant neoplasms
Z13 Encounter for screening for other diseases and disorders
Except: Z13.9, Encounter for screening,0 unspecified
Z36 Encounter for antenatal screening for mother

Example:
Screening Mammography - Z12.31- always use this as Principal DX

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Screening DEXA Scan: Z13.820. If osteoporosis or Osteopenia found during DEXA
use Osteoporosis or osteopenia code.

Observation- Observation normally done for suspected condition when there is no

diagnosis found Z03, Z04

Reason for Visiting Gall Bladder Stone.

Final DX: Their no Evidence of Gall Bladder stone

Z03 or Z04

Aftercare- When patient already received initial treatment and now visit Physician
office in healing Phase

Follow up - When treatment has been completed and physician asked for follow up
at later stage

Donor- Person who donate organ

kidney Z52.4
liver Z52.6

Counseling- Smoking. Alcohol, Illicit drug used

Routine and Administrative Exam: - Pre-Employment, Pre-School, Well Baby

Exam, Annual Health Check up.

Z00 Encounter for general examination without complaint,

suspected or reported diagnosis
Z01 Encounter for other special examination without
complaint, suspected or reported diagnosis
Z02 Encounter for administrative examination
Except: Z02.9, Encounter for administrative
examinations, unspecified
Z32.0- Encounter for pregnancy test

Z codes that may only be principal/first-listed diagnosis

The following Z codes/categories may only be reported as the
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principal/first-listed diagnosis, except when there are multiple
encounters on the same day and the medical records for the
encounters are combined:
Z00 Encounter for general examination without complaint,
suspected or reported diagnosis
Except: Z00.6
Z01 Encounter for other special examination without
complaint, suspected or reported diagnosis
Z02 Encounter for administrative examination
Z03 Encounter for medical observation for suspected
diseases and conditions ruled out
Z04 Encounter for examination and observation for other
reasons
Z33.2 Encounter for elective termination of pregnancy
Z31.81 Encounter for male factor infertility in female patient
Z31.82 Encounter for Rh incompatibility status
Z31.83 Encounter for assisted reproductive fertility procedure
cycle
Z31.84 Encounter for fertility preservation procedure
Z34 Encounter for supervision of normal pregnancy
Z39 Encounter for maternal postpartum care and
examination
Z38 Liveborn infants according to place of birth and type of
delivery
Z42 Encounter for plastic and reconstructive surgery
following medical procedure or healed injury
Z51.0 Encounter for antineoplastic radiation therapy
Z51.1- Encounter for antineoplastic chemotherapy and
immunotherapy
Z52 Donors of organs and tissues
Except: Z52.9, Donor of unspecified organ or tissue
Z76.1 Encounter for health supervision and care of foundling
Z76.2 Encounter for health supervision and care of other
healthy infant and child
Z99.12 Encounter for respirator [ventilator] dependence during
power failure

Neonatal/newborn - 28 days
Infant- 29 days till One year
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Child- 1+ years till 16 years
Adult- 16+

External Factor:

Cause

Intent

Place

Activity

Person Status

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