Home Health Care ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Home Health Care and Top 20 codes
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1 Home Health Care ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Home Health Care and Top 20 codes Chapter 4: Endocrine, Nutritional and Metabolic Diseases (E00-E99) ICD-10-CM diabetes mellitus codes are now combination codes that include the type of diabetes (1 or 2), the body system affected and complications affecting the body system. Use as many codes within a particular category as necessary to describe all of the complications of the disease. Diabetes mellitus (E08-E13) is no longer classified as controlled or uncontrolled in ICD-10- CM. With ICD-10-CM,there are five category codes for diabetes mellitus: - E08 Diabetes mellitus due to underlying conditions - E09 Drug or chemical-induced diabetes mellitus - E10 Type 1 diabetes mellitus - E11 Type 2 diabetes mellitus - E13 Other specified diabetes mellitus Overweight and obesity codes: - The classification for overweight and obesity has been expanded in ICD-10-CM to include: Obesity due to excess calories Morbid (severe) obesity due to excess calories Drug-induced obesity Morbid (severe) obesity due to alveolar hypoventilation-overweight Additional code (Z68 category) is used to identify the body mass index, if known. Chapter 9 Diseases of the Circulatory System (I00-I99) A new category has been added for coding a subsequent acute myocardial infarction, which is an MI that occurs within 28 days of a previous acute MI. The time frame for assigning the acute MI code is 28 days in ICD-10-CM. Terminology used to describe several cardiovascular conditions has been revised to reflect more current medical practice. A major change is the classification of hypertension, which in ICD-9-CM was classified by type: - Benign, malignant or unspecified - That classification is not required in ICD-10-CM because there is only one code for hypertension in ICD-10; the code is I10- essential (primary) hypertension. Chapter 12 Diseases of the Skin and Subcutaneous Tissue (L00-L99) This chapter has been restructured to bring together groups of diseases that are related to one another. Pressure ulcer codes are combination codes that identify the site and stage of the ulcer. Procedural complications of the skin and subcutaneous tissue are included in Chapter 12. 1
2 Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00-M99 ICD-10-CM identifies 3 different causes for pathologic fractures: - Neoplastic disease - Osteoporosis - Other specified disease Some codes in this chapter require: - The 7th character that describes type of encounter or the stage of the fracture s healing process, and any residual effects or sequela from the fracture. Chapter 19 Injury, Poisoning and certain other Consequences of External Causes (S00- T88) Injuries are grouped by body part rather than category of injury as they were in ICD-9-CM. Laterality is specified in this chapter. ICD-10-CM introduces a seventh character requirement that describes the type of encounter. Most categories in this chapter use the seventh character requirement. Most categories in this chapter (see below for fractures) have three seventh character values of: - A Initial encounter - D Subsequent encounter - S Sequela - For traumatic fractures, there are additional seventh character requirements depending upon the type of fracture and complication. Some of these character descriptions are based on the Gustilo open fracture classification. Code for underdosing are new in ICD-10-CM. Underdosing refers to taking less of a medication than is prescribed by a provider or less than the manufacturer s instructions. Codes for underdosing should not be assigned as principal or first-listed codes. Chapter 21 Factors influencing Health Status and contact with Health Services (Z00-Z99) These codes are used in any healthcare setting. Z codes may be used as either first listed (principal diagnosis code in the inpatient setting), or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis in certain conditions-refer to Official Coding Guidelines for details. Aftercare code note: - In ICD-10-CM Aftercare Z codes are not used for aftercare of fractures. - For aftercare of a fracture, assign the acute fracture code with the 7 th character extension of D for subsequent encounter. (Source: 2014 Draft ICD-10-CM Official Guidelines for Coding and Reporting) Examples of Coding Laterality M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M Pain in right knee M Pain in left knee M Pain in unspecified knee The top 20 Home Health Care ICD-9 codes based on volume are mapped to ICD-10 codes in the following Chart. 2
3 1 V54.81 Aftercare following joint replacement Z47.1 Aftercare following joint replacement surgery(use additional code to identify joint) 2 V57.1 Care involving other physical therapy Z51.89 Encounter for other specified aftercare 3 V58.73 Aftercare following surgery of the circulatory system, NEC Z Encounter for surgical aftercare following surgery on the circulatory system Congestive heart failure unspecified I50.20 Unspecified systolic(congestive) heart failure I50.21 Acute systolic(congestive) heart failure I50.22 Chronic systolic(congestive) heart failure Acute on chronic systolic(congestive) heart I50.23 failure I50.30 Unspecified diastolic(congestive) heart failure I50.31 Acute diastolic(congestive) heart failure I50.32 Chronic diastolic(congestive) heart failure Acute on chronic diastolic(congestive) heart I50.33 failure Unspecified combined systolic(congestive) and I50.40 diastolic(congestive) heart failure Acute combined systolic(congestive) and I50.41 diastolic(congestive) heart failure Chronic combined systolic(congestive) and I50.42 diastolic(congestive) heart failure Acute on chronic combined systolic(congestive) I50.43 and diastolic(congestive) heart failure I50.9 Heart failure, unspecified 5 V57.89 Care involving other specified rehabilitation procedure Z51.89 Encounter for other specified aftercare Intracranial injury of other/unspecified nature w/o open cranial wound, unspecified state of consciousness S06.890A Other specified intracranial injury w/o loss of consciousness, initial encounter Non-healing surgical wound T81.89XA Other complications of procedures, NEC, initial encounter 8 V58.42 Aftercare following surgery for neoplasm Z48.3 Aftercare following surgery for neoplasm(use additional code for neoplasm) Diabetes w/ other specified manifestations, type II or unspecified type, not stated as uncontrolled E Type 2 diabetes mellitus w/other diabetic arthropathy E Type 2 diabetes mellitus w/diabetic dermatitis E Type 2 diabetes mellitus w/foot ulcer E Type 2 diabetes mellitus w/other skin ulcer Type 2 diabetes mellitus w/other skin E complications E Type 2 diabetes mellitus w/periodontal disease Type 2 diabetes mellitus w/other oral E complications Type 2 diabetes mellitus w/hypoglycemia w/o E coma
4 E11.65 Type 2 diabetes mellitus w/hyperglycemia Type 2 diabetes mellitus w/other specified E11.69 complication(use additional code for comp.) Other specified diabetes mellitus w/other E diabetic arthropathy Other specified diabetes mellitus w/diabetic E dermatitis E Other specified diabetes mellitus w/foot ulcer Other specified diabetes mellitus w/other skin E ulcer Other specified diabetes mellitus w/other skin E complications Other specified diabetes mellitus w/periodontal E disease Other specified diabetes mellitus w/other oral E complications Other specified diabetes mellitus E w/hypoglycemia w/o coma Other specified diabetes mellitus E13.65 w/hyperglycemia Other specified diabetes mellitus w/other E13.69 specified complication Other postoperative infection K68.11 Postprocedural retroperitoneal abscess 11 V V T81.4XXA Infection following a procedure, initial encounter Aftercare following surgery on the musculoskeletal system, NEC Z48.89 Encounter for other specified surgical aftercare Obstructive chronic bronchitis Chronic obstructive pulmonary disease w/acute w/acute exacerbation J44.1 exacerbation Aftercare following surgery of the teeth, oral cavity and digestive Encounter for surgical aftercare following system Z surgery on the teeth or oral cavity Encounter for surgical aftercare following Z surgery on the digestive system Late effects of cerebrovascular disease, hemiplegia affecting nontraumatic subarachnoid hemorrhage nondominant side I affecting right nondominant side nontraumatic subarachnoid hemorrhage I affecting left nondominant side nontraumatic intracerebral hemorrhage affecting I right nondominant side nontraumatic intracerebral hemorrhage affecting I left nondominant side other nontraumatic intracranial hemorrhage affecting I right nondominant side other nontraumatic intracranial hemorrhage affecting I left nondominant side cerebral I infarction affecting right nondominant side Hemiplegia & hemiparesis following cerebral I infarction affecting left nondominant side 4
5 I other cerebral vascular disease affecting right nondominant side I other cerebral vascular disease affecting left nondominant side I unspecified cerebral vascular disease affecting right nondominant side I unspecified cerebral vascular disease affecting left nondominant side Diabetes mellitus w/o mention of complication, Type II or unspecified type, not stated as uncontrolled E11.9 Type 2 diabetes mellitus w/o complications E13.9 Other specified diabetes mellitus w/o complications Osteoarthrosis unspecified whether generalized or localized involving lower leg M17.9 Osteoarthritis of knee, unspecified Disruption of external operation(surgical) wound T81.31XA Disruption of external operation(surgical) wound, not elsewhere classified, initial encounter 18 V54.9 Unspecified orthopedic aftercare Z51.89 Encounter for other specified aftercare Cellulitis and abscess of leg except foot L Cutaneous abscess of right lower limb L Cutaneous abscess of left lower limb Open wound of abdominal wall, anterior, w/o mention of complication L Cutaneous abscess of limb, unspecified L Cellulitis of right lower limb L Cellulitis of left lower limb L Cellulitis of unspecified part of limb L Acute lymphangitis of right lower limb L Acute lymphangitis of left lower limb L Acute lymphangitis of unspecified part of limb Unspecified open wound of abdominal wall, epigastric region w/o penetration into peritoneal S31.102A cavity, initial encounter Unspecified open wound of abdominal wall, periumbilical region w/o penetration into S31.105A peritoneal cavity, initial encounter Laceration w/o foreign body of abdominal wall, epigastric region w/o penetration into peritoneal S31.112A cavity, initial encounter Laceration w/o foreign body of abdominal wall, periumbilical region w/o penetration into S31.115A peritoneal cavity, initial encounter Puncture wound of abdominal wall w/o foreign body, epigastric region w/o penetration into S31.132A peritoneal cavity, initial encounter Puncture wound of abdominal wall w/o foreign body, periumbilical region w/o penetration into peritoneal S31.135A cavity, initial encounter 5
6 S31.152A Open bite of abdominal wall, epigastric region w/o penetration into peritoneal cavity, initial encounter S31.155A Open bite of abdominal wall, periumbilical region w/o penetration into peritoneal cavity, initial encounter The codes highlighted in orange indicate the individual ICD-9 code that is being mapped to one or many ICD-10 codes (Source of ICD-9-CM to ICD-10-CM mappings: CMS.org General Equivalence Mappings (GEMs), 2015) The information in this document is not intended to impart legal advice. This overview is intended as an educational tool only and should not be relied upon as legal or compliance advice. If you have any legal questions about the information contained herein, you should consult your attorney or other professional legal services provider. 6
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