Chapter 16, 17, 18, 19, 20, 21

M80.08xA
Patient with senile osteoporosis is seen for complaints of severe back pain with no history of trauma. X-rays revealed pathological compression fractures of several lumbar vertebrae.

M08.071, M08.072
Juvenile rheumatoid arthritis, only occurring in both ankles

M84.551A, C79.51, Z85.118, Z92.3
Patient has left upper lobe carcinoma, diagnosed over five years ago, but is seen now for a fracture of the shaft of the right femur. During this admission, the patient was diagnosed with metastatic bone cancer (from the lung) and this fracture is a result of the metastatic disease. This patient’s lung cancer was treated with radiation and ther is no longer eveidence of an existing primary malignancy.

M00.861
Bacterial septic arthritis, right knee

M84.361D
Stress fracture, right tibia, seen in the clinic for a subsequent encounter with routine healing

M41.116
Juvenile idiopathic scoliosis, lumbar region

M23.212
Tear of medial meniscus, anterior horn, due to old injury, left knee

M22.41, M22.42
Chondromalacia, patellae, bilateral knees

M25.521, M25.421
Pain in right elbow with joint effusion in right elbow, cause unknown; both symptoms being investigated.

M45.4
Ankylosing spondylitis, thoracic spinal region

Malunion of a fracture
Fracture was reduced but the bone ends did not align properly during the healing process
Often requires surgical treatment

Nonunion of a fracture
The failure of the fracture fragments to unite or align and heal
Often more difficult to treat than malunion
May require internal fixation or other surgical treatment

Stress Fractures
Usually not traumatic; rather, break is due to repetitive force on the site
Coder should use an additional external cause code(s) to identify the cause of the stress fracture
X-rays often negative when pain first develops
Occurs most commonly in athletes, such as runners

Category M80 in ICD-10-CM classifies
classifies the type of osteoporosis in addition to the site of a current pathological fracture into one combination code

Distinction is made between the types of etiological relationships
Direct infection of joint
Indirect infection of joint

Instructional notes are included to explain how codes should be assigned, for example:
Code M21.7, Unequal limb length
Note: The site used should correspond to the shorter limb
Code M50, Cervical disc disorders
Note: Code to the most superior level of disorder

Notes have been used to define terms, for example:
M41.11 Juvenile idiopathic scoliosis
Note: Juvenile is defined as 5 through 10 years of age
M66 Spontaneous rupture of synovium and tendon
Note: A spontaneous rupture is one that occurs when a normal force is applied to tissues that are inferred to have less than normal strength

There are chapter-specific guidelines for chapter 13 of ICD-10-CM concerning:
Site and laterality
Acute traumatic vs. chronic vs. recurrent conditions
Coding of pathologic fractures
Osteoporosis with current pathological fracture

A note appears at the beginning of chapter 13:
Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition

Most of the codes in chapter 13
include site and laterality

Some current musculoskeletal conditions in chapter 13 are
the result of a previous injury or trauma to a site and others are recurrent conditions

Any acute injury is coded to a different chapter in ICD-10-CM,
however, some fractures included in chapter 13 are current events and include a 7th character to indicate episode of care

ICD-10-CM has different categories and subcategories for pathologic fractures:
M80 Osteoporosis with current pathological fracture
M84.4 Pathological fracture NEC
M84.5 Pathological fracture in neoplastic disease
M84.6 Pathological fracture in other disease

Intraoperative and postprocedural complications included in chapter 13 include codes for
Hemorrhage, hematoma, accidental laceration
Codes specific to musculoskeletal complications such as fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate

found in chapter 13
Bone, joint or muscle conditions that are the result of a healed injury and recurrent bone, joint or muscle conditions are

are generally coded with a code from chapter 13
Chronic or recurrent conditions

The following 7th character extensions are required for codes in chapter 13 that represent pathological or stress fractures with codes M84.3-M84.6:
A—Initial encounter for fracture
D—Subsequent encounter for fracture with routine healing
G—Subsequent encounter for fracture with delayed healing
K—Subsequent encounter for fracture with nonunion
P—Subsequent encounter for fracture with malunion
S—Sequela

Seventh character A is for use when the patient is receiving active treatment for the fracture. Active treatment is
Surgical treatment, emergency department encounter, and evaluation and treatment by a new physician

Seventh character D is used when the patient is being seen in an encounter after the patient has completed active treatment. Subsequent encounter for routine healing includes
Cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits

M15, Polyosteoarthritis
Includes arthritis of multiple sites

M30-M36, Systemic connective tissue disorders
Includes autoimmune disease, collagen (vascular) disease, systemic autoimmune disease and systemic collagen (vascular) disease

M41, Scoliosis
Includes kyphoscoliosis

M50, Cervical disc disorders
Includes cervicothoracic disc disorders with or without cervialgia

M66, Spontaneous rupture of synovium and tendon
Defined as one that occurs when a normal force is applied to tissues that are inferred to have less than normal strength

M70, Soft tissue disorders related to use, overuse and pressure
Includes soft tissue disorders of occupational origin

M87, Osteonecrosis
Includes the condition known as avascular necrosis of bone

Conditions coded in chapter 16 of ICD-10-CM include
Newborn affected by maternal factors
Disorders of newborn related to length of gestation and fetal growth
Abnormal findings on neonatal screening
Birth trauma
And other conditions occurring in the newborn

In ICD-10-CM category P00-P04
, newborns affected by maternal factors and by complications of pregnancy, labor and delivery

The phrase “suspected to be” is included in the code title as a nonessential modifier to indicate that the codes are for use:
when the listed maternal condition is specified as the cause of the confirmed or suspected newborn morbidity or potential morbidity

New notes help to clarify how codes are used. For example the following note appears under P07:
When both birth weight and gestational age of the newborn are available, both should be coded with the birth weight sequenced before the gestational age.

Note appears under P08.21 defines it as:
Newborn with gestation period over 40 completed weeks to 42 completed weeks

Codes from chapter 16 are only for use
on the newborn or infant record, never on the maternal record

If a condition originate in the perinatal period and continue through the life of the child,
the perinatal code should continue to be used regardless of the age of the patient

Chapter 16 has chapter-specific guidelines that address:
General perinatal rules
Observation and evaluation of newborns for suspected conditions not found
Coding additional perinatal diagnoses
Prematurity and fetal growth retardation
Low birth weight and immaturity status
Bacterial sepsis of newborn
Stillbirth

Codes in this chapter describe conditions
that occur before birth and through the 28th day following birth

The same birthweights are used in ICD-9-CM and ICD-10-CM to identify
An extremely low birth weight newborn (999 grams or less) and
Other low birth weight newborns (1000-2499 grams)

In ICD-10-CM the codes for weeks of gestation are divided into two subcategories
P07.2 includes subcategory code for extreme immaturity of newborn with specific codes for less than 24 completed weeks, 24-26 completed weeks and 27 completed weeks

In ICD-10-CM the codes for weeks of gestation are divided into two subcategories
P07.3 is used for other preterm newborns defined as 28 completed weeks or more but less than 37 completed weeks with specific codes for 28-31 completed weeks and 32-36 completed weeks

The principal diagnosis for coding the birth episode of a newborn is not
included in chapter 16

Instead a code from category Z38
Liveborn infants according to place of birth and type of delivery is used

Codes from category Z38
identify the number of liveborn infants, where they are born (in hospital, outside hospital) and how they were delivered (vaginally or by cesarean)

Other ICD-10-CM codes exist
for twin, triplet, quadruplet, quintuplet and other multiple liveborn infants

Chapter 16 codes are for use on
on newborn records, never on material records

Conditions in chapter 16 have their origin
in the fetal or perinatal period, before birth through the first 28 days after birth, even if morbidity occurs later

Codes in chapter 16 may
be used throughout the life of the patient

A code for prematurity should not
be assigned unless it is documented

These codes should be based
on the recorded birth weight and estimated gestational age

The birth weight code should
be sequenced before the code for gestational age

When coding the birth episode in a newborn record,
a code from category Z38, Liveborn infants according to place of birth and type of delivery should be the principal diagnosis

If a newborn is transferred to another institution,
a code from category Z38 should not be used at the receiving hospital

Category P36
Bacterial sepsis of newborn, includes congenital sepsis

If a perinate is documented as having sepsis without documentation of congenital or community acquired,
the default is congenital sepsis and a code from category P36 is assigned

If the P36 code does not include the causal organism,
assign an additional code from category B96, other bacterial agents

Congenital anomalies or syndrome may occur
as a set of symptoms or multiple malformations

If there is no specific code
a code should be assigned for each manifestation of the syndrome, from any chapter in the classification

For syndromes with specific codes
additional codes may be assigned to identify manifestations not included in the specific code

Chapter 17 codes in the range of Q00-Q99
may be used throughout the life of the patient as long as the condition is present; the condition is not only coded at birth or when it is first diagnosed

If a congenital malformation or deformity has been corrected,
, a personal history code should be used to identify the history of the malformation or deformity

Conditions included in Chapter 17
are organized by body system and include laterality for limbs and bones

More specific codes are included in ICD-10-CM
to further describe the congenital condition

There are expanded codes for
congenital conditions and chromosomal abnormalities

Chapter 17 codes are assigned
when a malformation, deformation or chromosomal abnormality is documented

The code may be
the principal or first listed diagnosis on a record or a secondary diagnosis

When the code identifies the condition
manifestations that are an inherent component of the anomaly should not be coded separately

Additional codes should be assigned
for manifestations that are not an inherent component of the condition

A malformation, deformation or chromosomal abnormality may
be present at birth but not identified until later in late

When the condition is diagnosed by the physician,
it may be coded at any time during the life of the patient

If the condition is diagnosed during the birth admission
the appropriate code from category Z38, Liveborn infant, should be sequenced first followed by code from chapter 17

ICD-10-CM Chapter 18 includes
symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded

In ICD-10-CM, codes for
for general symptoms and signs follow those related specifically to a body system or other relevant grouping

Symptom codes
have been moved from one chapter to another in ICD-10-CM

Signs and symptoms that point rather definitely
to a given diagnosis have been assigned to a category in other chapters of the classification

Categories in this chapter include
the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point equally to two or more diseases or to two or more systems of the body

All categories could be designated
“not otherwise specified”

Conditions included in this chapter are
Cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated

Conditions included in this chapter are
Signs and symptoms existing at the time of the initial encounter that proved to be transient and whose cases could not be determined

Conditions included in this chapter are
Provisional diagnosis in a patient who failed to return for further investigation of care

Conditions included in this chapter are
Cases referred elsewhere for investigation or treatment before the diagnosis was made

Conditions included in this chapter are
Cases in which a more precise diagnosis was not available for any other reason

Conditions included in this chapter are
Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right

ICD-10-CM Chapter 18 guidelines address:
Use of a symptom code
Use of a symptom code with a definitive diagnosis code
Combination codes that include symptoms
Repeated falls
Coma scale
Functional quadriplegia
SIRS due to non-infectious process
Death MOS

Codes from R00-R49
that describe symptoms and signs involving certain body systems, such as circulatory, respiratory and digestive

General symptoms and signs (R50-R69)
include symptoms and signs that could be explained by various body systems

Codes for systemic inflammatory response syndrome (SIRS) of noninfectious codes (R65.10-R65.11) and a code for severe sepsis (R65.2)
include a code first note appear with these codes to code first the underlying condition and to use an additional code to identify specific acute organ dysfunction when it exists

Codes in the range of R70-R79,
Abnormal findings on examination of blood, without diagnosis, contain such findings as impaired or elevated fasting glucose

Other abnormal test results on examination of urine and other body fluids are contain in the
codes in the range of R80-R89

Categories R90-R94
identify abnormal findings on diagnostic imaging and in function studies, without diagnosis

Example of a code in this area is
mammographic calcification found on diagnostic imaging of breast

Alphabetic Index entries used to locate the symptoms and sign codes include
Abnormal, abnormalities
Elevated, elevation
Findings, abnormal, inconclusive, without diagnosis
Positive

Glasgow Coma Scale
Subcategory R40.2, Coma, incorporates the Glasgow Coma Scale (R40.211-R40.236) codes
These codes are used in conjunction with traumatic brain injury or sequelae of cerebrovascular disease codes
These codes are sequenced after the diagnosis codes

Glasgow Coma Scale
One code from each subcategory (R40.21, R40.22, and R40.23) is needed to complete the scale
The seventh character extension indicates when the scale was recorded and it should match for all three codes
0—unspecified time
1—in the field (EMT or ambulance)
2—at arrival to emergency department
3—at hospital admission
4—with 24 hours or more after hospital admission

Glasgow Coma Scale
Coma score may be documented by emergency medical personnel prior to arrival at the hospital and non-physician emergency medical personnel

Glasgow Coma Scale
It would be appropriate to use the prehospital documentation or non-physician documentation to determine the Glasgow coma scale

Glasgow Coma Scale
Subcategory R40.24, Glasgow coma scale, total score, is used only when the total score is documented instead of the individual measures for the eyes open, verbal response, and motor response

Most categories in chapter 19 have 7th character extensions that identify the encounter
A = Initial Encounter
D = Subsequent Encounter
S = Sequela

Fracture extensions are unique
to the type of bone and the type of fracture

ICD-10-CM contains a note under the different categories of open wounds
to direct the coder to code also any associated wound infection

For coding of complications of surgical and medical care,
ICD-10-CM includes a note stating to use additional code (Y62-Y82) to identify devices involved and details of circumstances

Chapter-specific guidelines of ICD-10-CM address:
Application of 7th characters in chapter 19
Coding of injuries
Coding of traumatic fractures
Coding of burns and corrosions

Chapter 19 use two alphabetic letters as the first character of the code: S and T
The S section provides codes for various types of injuries related to single body system
The T section covers injuries to unspecified body regions as well as poisonings and certain other consequences of external causes

Fracture codes include:
Type of fracture
Specific anatomical site
Whether the fracture is displaced or not
Laterality
Routine vs. delayed healing
Nonunions
Malunions

Fracture codes include 7th characters:
A—Initial encounter for closed fracture
B—Initial encounter for open fracture
D—Subsequent encounter for fracture with routine healing
G—Subsequent encounter for fracture with delayed healing
K—Subsequent encounter for fracture with nonunion
P—Subsequent encounter for fracture with malunion
S—Sequelae

Open fracture codes include 7th characters such as :
B—Initial encounter for open fracture type I or II
C—Initial encounter for open fracture type IIIA, IIIB, or IIIC
E—Subsequent encounter for open fracture type I or II
F—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with routine healing
H—Subsequent encounter for open fracture type I or II with delayed healing

Open fracture codes include 7th characters such as :
J—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with delayed healing
M—Subsequent encounter for open fracture type I or II with nonunion
N—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with nonunion
Q—Subsequent encounter for open fracture type I or II with malunion
R—Subsequent encounter for open fracture type IIIA, IIIB, IIIC with malunion

According to ICD-10-CM Coding Guidelines for fracture coding
When a fracture is not indicated as displaced or nondisplaced, it should be coded as displaced
When a fracture not indicated as open or closed, it should be coded as closed

Initial encounter in ICD-10-CM means
the patient is receiving active treatment for the injury, for example, surgical treatment, emergency department encounter, and evaluation and treatment by a new physician

Subsequent encounter in ICD-10-CM means
the patient has received active treatment. It means the patient is receiving routine care for the injury during the healing or recovery phrase. For example to change or remove a cast, remove fixation device, other aftercare, medication adjustments, and follow up visits following injury treatment

Seventh character S for sequela is used for
complications and conditions that arise as a direct result of an injury, such as a scar formation after a burn

When coding for a sequela,
it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself.

The 7th character of S
is added only to the injury code

This identifies
the injury responsible for the sequela.

The specific type of sequela
is sequenced first

The injury code is sequenced
second with the 7th character of S

The aftercare Z codes
should not be used for aftercare for injuries according to the ICD-10-CM Official Guidelines for Coding and Reporting

For aftercare of an injury
the coder should assign the acute injury code with the appropriate seventh character for “subsequent encounter”

categories T36-T50 are combination codes. The codes identify whether the condition was a:
Poisoning
Adverse effect or
Underdosing of drug or biological substance
The code also includes the external cause

Underdosing
It is defined as taking less of a medication than is prescribed by a provider or the manufacturer’s instructions with a resulting negative health consequence

Sequencing issues are eliminated because
poisoning, adverse effects and underdosings are combination codes

Codes in categories T36-T65 are combination codes
that include the substances related to adverse effects, poisonings, toxic effects, and underdosing, as well as the external cause
No additional external cause code is required

Code from categories T36-T65 is sequenced first,
followed by the code(s) that specify the nature of the adverse effect, poisoning, or toxic effect. This does not apply to the underdosing codes.

For underdosing
assign the code from categories T36-T50 (fifth or sixth character 6) as an additional code

Codes for underdosing
should never be assigned as principal or first-listed codes

If the patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose
then the medical condition itself should be coded

Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.61, Y63.8-Y63.9) codes
are to be used with an underdosing code to indicate intent, if known

Other chapter specific guidelines address
Adult and child abuse, neglect, and other maltreatment
Complications of care

The S section provides codes
for the various types of injuries related to single body regions

The T section covers
injuries to unspecified body regions as well as poisonings and certain other consequences of external causes

Includes note with codes T36-T50
define poisoning, adverse effect and underdosing

Combination codes for poisonings
include the associated external cause (accidental, intentional self harm, assault, undetermined)

When no intent of poisoning is indicated
, the coder should code to “accidental”

Undetermined intent
is only used when there is specific documentation that the intent of the poisoning cannot be determined

The seventh character for Chapter 19 codes indicate whether the episode of care is the:
Initial encounter (A)
Subsequent encounter (D)
Sequela (S)

Example of combination code
T36.0x1A
Poisoning by penicillins, accidental (unintentional) initial encounter

ICD-10-CM Table of Drugs and Chemicals is
organized into seven columns with rows for the substances involved

The first, left-most column
column contains the name of the drug, chemical or biological substance

The next six columns contain
Poisoning, accidental (nonintentional)
Poisoning, intentional self-harm
Poisoning, assault
Poisoning, undetermined
Adverse effect
Underdosing

When a code is less than six characters long
, a placeholder character of “x” is used to fill the missing sixth character so that the seventh character can be applied.

The Table of Drugs and Chemicals include codes
that require a seventh character.

In ICD-10-CM, the external cause codes
codes start with characters V, W, X, and Y

These are used as additional codes
to follow a code from another chapter that indicates the nature of the injury or condition

Codes capture the
cause of injury or health condition, the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (namely, civilian, military)

New notes have been added to show which categories require the 7th character extensions
to indicate whether the episode of care being identified was the initial, subsequent, or the condition is a result of an event or sequelae

The 7th character to be added are:
A—Initial encounter
D—Subsequent encounter
S—Sequela

Category Y92,
Place of occurrence of the external cause, is used in conjunction with activity code

The activity code from category Y93
indicates the activity of the person seeking healthcare for an injury or health condition

Chapter-specific guidelines were published for Chapter 20 addressing
General external cause coding guidelines
Place of occurrence guideline
Activity code
Place of occurrence, activity, and status codes used with other external cause code
If the reporting format limits the number of external cause codes

Chapter-specific guidelines were published for Chapter 20 addressing
Multiple external cause coding guidelines
Child and adult abuse guideline
Unknown or undetermined intent guideline
Late effects of external cause guidelines
Terrorism guidelines
External cause status

External cause codes are intended
to be used as a secondary code with another code from other chapters in ICD-10-CM

For syndromes with specific codes
, additional codes may be assigned to identify manifestations not included in the specific code

Instead a code from category Z38
Liveborn infants according to place of birth and type of delivery is used

Most often, the condition will be coded from Chapter 19,
Injury, poisoning and certain other consequences of external causes (S00-T88)

The Chapter 20 codes
provide additional information as to the cause of the condition

External cause codes contain
the 1st character of V, W, X, and Y

A review of the Tabular List helps the coder
gain an understanding of all of the possible codes available

ICD-10-CM contain an Index to External Causes with main terms identify the event
Such entries are accident, drowning, exposure, forces of nature, falling, slipping, and other events that can cause an injury

Other entries exist for assignment of
the activity of the person
place of occurrence and
status of external cause, such as civilian, leisure, or student activity

Many, but not all, of the V00-Y99 codes
require a 7th character to indicate whether the healthcare encounter was the initial encounter (A), subsequent encounter (D), or sequela (S)

Late effects of external causes of morbidity in ICD-10-CM are reported
reported using the external cause code with the 7th character of S for sequela. These codes are used with any report of a later effect or sequela resulting from a previous injury

The transport accident section V00-V99
is structure in 12 groups

Land transport accidents
reflect the victim’s mode of transport, and are subdivided to identify the victim’s counterpart or the type of event

The vehicle of which the injured person is an occupant is identified
by the first two characters since it is seen as the most important factor to identify for prevention purposes

A transport accident is one in which the vehicle involved
must be moving or running or in use for transport purposes at the time of the accident

The definitions of transport vehicles are
provided in the ICD-10-CM book and should be reviewed

Examples of the Chapter 20 blocks include
V00-V99, Transport accidents
W00-W19, Slipping, tripping, stumbling and falls
W20-W49, Exposure to inanimate mechanical forces
W50-W64, Exposure to animate mechanical forces
X00-X08, Exposure to smoke, fire and flames
X10-X19, Contact with heat and hot substances
X71-X83, Intentional self harm
X92-Y08, Assault
Plus numerous other blocks of codes

Certain external cause codes are only used once at the initial encounter:
The place of occurrence
The activity code(s)

Category Y92 codes
codes identify the place of occurrence of the external event

Only one code from Y92 is used
at the time of the initial encounter for treatment

Do not use an unspecified code Y92.9
if the place of occurrence is not stated

Appropriate for use
with injury codes and for conditions that are due to the long-term cumulative effects of an activity, such as those from Chapter 13 of ICD-10-CM

Category Y93 codes
should be used in conjunction with codes for cause and intent if identifying the activity provides additional information on the event

These codes are used
with code for external cause status (Y99) and place of occurrence (Y92)

The activity code
is only used at initial encounter

Only one code
from Y93 should be reported

Examples of Y93 codes broad categories are activities involving, among other activities:
Walking and running
Ice and snow
Other sports and athletics played as a team or group
Computer technology and electronic devices
Caregiving
Food preparation, cooking and grilling
Playing musical instruments

Category Y99,
external cause status codes should be assigned whenever any other external cause code is assign for an encounter, including an activity code, except for the certain events

External cause status indicates
the work status of the person at the time the event occurred

These codes are not applicable
to poisonings, adverse effects, misadventures, or late effects

A code from category Y99
is not assigned if no other external cause codes (cause, activity) are assigned

External cause status code
is used only once at the initial encounter

Only one code from Y99
should be reported

The 7th character of an external cause code
must always be the 7th character in the data field

If a code that requires a 7th character
is not six characters long, a placeholder X must be used to fill in the empty characters

Z38.01, Q20.3
Newborn was delivered by cesarean section. Congenital condition diagnosed was complete transposition of the great vessels with cyanosis.

P59.9
Full-term newborn was delivered four days ago and discharged home. The infant was readmitted to the hospital and diagnosed with hyperbilirubinemia. Phototherapy was initiated and the baby will continue to have phototherapy provided at home after discharge.

Z38.00, Q86.0
Full-term female infant was born in this hospital by vaginal delivery. Her mother has been an alcoholic for many years and would not stop drinking during her pregnancy. Th baby was born with fetal alcohol syndrome and was placed in the NICU.

Z38.01, P04.41, P07.14, P07.34, P74.1
Premature “crack” baby born in the hospital by cesarean section to a mother dependent on cocaine. The newborn did not show signs of withdrawal. Birth weight of 1,247 g, 31 completed weeks of gestation. Dehydration was also diagnosed and treated.

Q01.0
Frontal encephalocele with hydroencephalocele

P36.2
20-day-old infant was admitted with Staphylococcus sepsis

Q54.2
Penoscrotal hypospadias

Q37.4
Cleft palate involving both the soft and hard palate, with bilateral cleft lip.

P04.3
Newborn suspected to be affected by maternal use of alcohol during pregnancy but not found to have fetal alcohol syndrome. Newborn transferred to NICU at another hospital, code for the hospital receiving the infant.

P29.3
Newborn transferred to Children’s hospital for delayed closure of the ductus arteriosus of the heart (code for the Children’s hospital)

R10.821
Right upper quadrant rebound abdominal tenderness

R10.11, R11.2, R03.0
The patient is seen complaining of right upper quadrant abdominal pain. In addition, the patient is having nausea and vomiting several times. The patient also has elevated blood pressure readings but a diagnosis of hypertension is not made at this visit

R92.0
Microcalcification found on breast mammography

R00.1
Sinoatrial bradycardia

J18.9
Pneumonia with cough

R50.9
The patient who has experienced a fever of 101 degrees Fahrenheit with chills was brought to the emergency department. Laboratory tests, including a complete blood count and urinalysis, were performed with normal results. Th ED physician wrote the final diagnosis as “Fever with chills, possible viral syndrome.”

R07.89, I20.9, K21.9
The attending physician concluded the patient had “atypical chest pain due to either angina or GERD.”

I46.9
Cardiorespiraratory arrest

R73.09
Abnormal glucose tolerance test (GTT)

R59.0
Swollen lymph glands in the neck

S91.322A
Two (2) cm laceration of the left heel with foreign body. This is a current injury.

S82.852K
The patient is seen for increased pain in her ankle. She has a previous trimalleolar fracture of the left ankle. After evaluation she was found to have a nonunion of her left trimalleolar fracture.

S52.351B
Displaced, compound comminuted fracture of the right radial shaft. It is a type II open fracture.

T74.4xxA
The 6-month-old is seen for increased fussiness and vomiting. After significant study, the patient is diagnosed with shaken baby syndrome.

S02.65xG
Delayed healing of his traumatic mandible fracture. The fracture was at the angle of the jaw.

S02.0xxA, S06.5x2A
Frontal skull fracture with a subsequent subdural hemorrhage. There was a 45-minute loss of consciousness at the time of the accident.

G82.21, S32.029S
The patient is a complete paraplegic due to a traumatic L2 vertebral fracture 5 years ago. At this time, she is experiencing no new problems.

S42.431D
Follow-up of patient’s traumatic lateral epicondyle fracture of the right elbow. This is healing normally.

S22.41xA, S62.101A
Patient had a right-sided fracture of 3 ribs, a right chest contusion and a fractured right wrist. None of his injuries required surgical intervention.

S01.01xD
Patient is seen in the physician’s office for removal of sutures placed for a laceration of the scalp. The wound has healed and the sutures are removed during this visit.

T39.1x1A
Child is seen emergently for an accidental overdose of acetaminophen. He inadvertently ate several of these when he found an open bottle at home.

T40.7x2A, T40.5X2A, S01.412A, S01.01xA
The woman is admitted for an intentional overdose of marijuana and cocaine. She sustained a fall which resulted in a left cheek and scalp laceration. After she is stabilized medically, she will be transferred to a psychiatric unit.

W00.0XXA
Patient slipped on an icy sidewalk

V43.52XA, Y92.411
Driver of an auto in collision with another vehicle on the expressway

V81.7XXA
Passenger injured in an accidental train derailment

X06.2XXA, Y92.010
Patient’s clothes caught fire in kitchen accident at a single family home

W10.9XXA
Patient fell down stairs

V28.0XXA, Y92.410
Motorcyclist fell off her motorcycle on a city street without having a collision with another vehicle

V97.22Xa
Parachutist killed upon landing while skydiving

W54.0XXA, Y92.830
Child bitten by neighbor’s dog at the neighborhood park

W67.XXXA, Y92.016
Accidental drowning in a swimming pool at a private single family home

X00.0XXA, Y92.039
Firefighter burned by flames in an uncontrolled apartment building fire

Using the ICD-10-CM, complete the following. The correct reporting for acute cholecystitis with cholelithiasis with obstruction: K80.01 Using the ICD-10-CM, complete the following. The correct reporting for stage IV chronic kidney disease associated with diabetes mellitus, type 2: E11.22, N18.4 …

O what letter do codes begin with? MATERNAL what record do we use O codes in? WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample 1st trimester up to less …

Disorders of Thyroid Gland E00 – E07 Diabetes Mellitus E08 – E13 WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample Other disorders of glucose regulation & pancreatic internal secretion …

List two of the four cooperating parties that agree on coding principles AMA, CMS, AHA, AHIMA Identify the main______ in the diagnostic statement term WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE …

Objective evidence of disease observed through physician examination defines: Sign Subjective observation reported by the patient Symptom WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample Select the block that …

For example, Tracheobronchitis is classified to bronchitis in J40, Bronchitis, not specified as acute or chronic When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the …

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