specialty code set training anesthesia

ICD-10-CMSpecialty Code Set Training

Anesthesia201

Module 2

ii ICD-10-CM Specialty Code Set Training — Anesthesia © 2013 AAPC. All rights reserved.082813

DisclaimerThis course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course.

AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within.

Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members.

To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

©2013 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, www.aapc.com

Printed 082813. All rights reserved.

CPC®, CPC-H®, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

© 2013 AAPC. All rights reserved. www.aapc.com iii082813

ICD-10 ExpertsRhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education

Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training

Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training

Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training

Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and Training

Contents

Commonly Coded. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Dorsopathies (M40-M54) Deforming dorsopathies . . . . . . . . . . . . . . . . . . . . . . . 9

Soft Tissue Disorders (M60-M79) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00–R99) . . . . . . . . . . . . . 13

Symptoms and Signs Involving the Circulatory and Respiratory Systems (R00-R09) . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 11: Diseases of Digestive System (K00–K95) . . . . . . . . . . . . . . . . . . . . 14

Diseases of the Appendix (K35-K38) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

© 2013 AAPC. All rights reserved. www.aapc.com 9082813

Commonly CodedAnesthesiologists treat patients with a wide variety of conditions and diseases. Some of the most commonly coded conditions for anesthesia have already been covered including neoplasms; fractures, headaches, sinusitis, otitis media. These will not be repeated here. Instead, other commonly coded conditions will be addressed: dorsopathies; soft tissue disorders; signs and symptoms; diseases of the digestive systems and fractures.

Dorsopathies (M40-M54) Deforming dorsopathiesDorsopathies is a term used to describe various diseases of the back and or spine. Dorsopathies includes diseases such as kyphosis, lordosis, and scolosis.

In ICD-10-CM, the codes for dorsopathies are broken down by the site, as listed below.

� Cervical region � Cervicothoracic region � Thoracic region � Thoracolumbar region � Lumbar region � Lumbosacral region � Sacral and sacroccygeal region

Kyphosis is a common condition of an abnormal curvature of the upper back and is called hunchback. It can be either the result of degenerative diseases, developmental problems, or trauma.

In ICD-10-CM, the codes for kyphosis are broken down by site as listed above as well as by type as listed below.

� Congenital � Postural � Secondary

Lordosis is an inward curvature of a portion of the vertebral column. Two segments of the vertebral column—namely cervical and lumbar— are set in a curve that has its convexity anteriorly and posteriorly. Excessive or hyperlordosis is commonly referred to as swayback or saddle back.

Scoliosis is when a person’s spine is curved from side to side. The spine may look like an “S” or a “C” rather than a straight line. Scoliosis is typically classified as congenital, idiopathic, and neuromuscular (secondary symptoms of another condition).

In ICD-10-CM, the codes for scoliosis are broken down by site as listed above as well as by type as listed below.

� Infantile idiopathic � Juvenile idiopathic � Adolescent

10 ICD-10-CM Specialty Code Set Training — Anesthesia © 2013 AAPC. All rights reserved.082813

Commonly Coded

� Other idiopathic � Thoracogenic � Neuromuscular � Other secondary � Other

Spondylolysis is a defect of a vertebra. The majority of cases occur in the lowest of the lumbar vertebrae but may also occur in the other lumbar and thoracic vertebrae. It is typically caused by a stress fracture of the bone. Spondylolysis is especially common in adolescents who overtrain in activities.

Spondylolisthesis is the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. These “slips” occur most often in the lumbar spine.

SpondylopathiesSpondylopathies is any disease of the vertebrae. Associated with compression of peripheral nerve roots and spinal cord which causes pain and stiffness of the part. Some of these diseases include spondylitis, spinal enthesopathy, spondylosis, spinal stenosis, and fatigue fracture.

In ICD-10-CM, the codes for spondylopathies are broken down by the site, as listed below.

� Cervical region � Cervicothoracic region � Thoracic region � Thoracolumbar region � Lumbar region � Lumbosacral region � Sacral and sacroccygeal region

Ankylosing Spondylitis is rheumatoid arthritis of the spine predominately affecting young people with pain and stiffness as a result of inflammation of the sacroiliac, intervetebral, and costoverteral joints. This may progress to cause complete spinal and thoracic rigidity.

Spinal Enthesopathy is an arthritic condition affecting the tendons and ligaments rather than joint membranes.

EXAMPLE:Todd presents to the office limping complaining of pain in his buttocks. After examination the physician diagnoses the patient with sacroiliitis. M46.1 Sacroiliitis, not elsewhere classified

Spondylosis is a condition of the spine characterized by fixation or stiffness of a vertebral joint.

In ICD-10-CM, the codes for spondylosis are broken down by site as listed above as well as by type as listed below.

� With/without myelopathy � With/without radiculopathy


Commonly Coded

EXAMPLE:Susan comes into the office for a follow up and her MRI results. The MRI confirms spondylosis at the L3-4 level without myelopathy or radiculopathy. M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

Spinal stenosis is a narrowing of the spinal canal that causes compression of the spinal nerve cord. This causes pain and may cause loss of some body functions.

Fatigue fracture is a stress fracture of the vertebra. In ICD-10-CM, the codes for fatigue fractures are broken down by site. When coding for fatigue fractures of the vertebrae and/or collapse vertebra a seventh character extender will be required. The seventh character extensions that are required for these codes are: A, initial encounter, D, subsequent encounter for fracture with routine healing, G subsequent encounter for fracture of delayed healing, and S sequela.

Soft Tissue Disorders (M60-M79)This subcategory covers disorders of the muscle, tendons, fat, fibrous tissue, blood vessels and other supporting tissue matrix. Soft tissue means all body tissue except bone, teeth, nails, hair, and cartilage. Some examples of soft tissue disorders are myositis, myalgia, fibromyalgia, and rotator cuff impingement syndrome.

MyositisMyositis means inflammation of the muscle and is also a symptom. The causes of myositis are from injuries or a side effect from a condition. The most common cause of myositis is an autoimmune condition.

In ICD-10-CM there are more specific code choices for myositis. Documentation will require the following.

� Location � Laterality � Type

� Infective � Interstitial � Progressiva � Traumatica

EXAMPLE:A patient comes in for interstitial myositis of the right thigh. M60.151 Interstitial myositis, right thigh

Myalgia Myalgia means muscle pain, which is a symptom of different diseases or injuries. Myalgia broadly means “muscle pain” and is a symptom of many different diseases and injuries. Myalgia can also be caused by illnesses and conditions such as chronic fatigue syndrome or viral infection.


Commonly Coded

Fibromyalgia Fibromyalgia is a disorder characterized by widespread musculoskeletal pain. Widespread means the pain occurs on both sides of your body and above and below your waist. This pain can be accompanied by fatigue, memory and mood issues.

The cause of fibromyalgia is unknown but most likely involves a variety of factors working together. Fibromyalgia affects women much more than men and tends to run in families. Fibromyalgia is triggered by some illness as well as physical or emotional trauma.

EXAMPLE:The patient returns for a follow up visit for fibromyalgia. In the interval since the last office visit, she has been doing fairly well, with respect to symptom control. M79.7 Fibromyalgia

Rotator CuffThe rotator cuff is a group of four muscles and tendons that hold the bones of the shoulder together. The rotator cuff allows the arms to lift and reach overhead. Rotator cuff injuries are caused by repetitive motion and overuse as well as trauma.

Rotator cuff impingement syndrome is divided into three stages of severity. Stage I is an overuse injury where the patient has swelling and/or bleeding. Stage II has inflammation of the tendon and development of scar tissue. Stage III involves tendon rupture or muscle tear.

In ICD-10-CM coding there are more specific code choices for rotator cuff diagnoses. Documentation requires the following.

� Type � Adhesive capsulitis � Rotator cuff tear

» Incomplete or complete » Traumatic or nontraumatic

� Bicipital tendinitis � Calcific tendinitis � Impingement syndrome � Bursitis � Other shoulder lesion

� Laterality

EXAMPLE:A 67-year-old patient comes in with left shoulder pain. Radiographic findings show an incomplete left-sided rotator cuff tear. M75.112 Incomplete rotator cuff tear or rupture of left shoulder not specified as traumatic.


Commonly Coded

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00–R99)Use of Symptom CodesCodes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

Symptoms and Signs Involving the Digestive System and Abdomen (R10-R19)ICD-10-CM offers greater specificity in this subcategory. When coding for the abdomen the choices include:

� Type � Pain � Tenderness � Rebound tenderness � Swelling � Mass and lump � Rigidity

� Laterality � Site

� Right upper quadrant � Left upper quadrant � Right lower quadrant � Left lower quadrant � Epigastric � Periumbilic � Generalized

EXAMPLE:A patient visited his general surgeon with complaints of epigastric pain. The physician documents epigastric rebound abdominal tenderness and orders testing. R10.826 Epigastric rebound abdominal tenderness

Symptoms and Signs Involving the Circulatory and Respiratory Systems (R00-R09)ICD-10-CM offers greater specificity in this subcategory. When coding for the chest pain the choices include:

� Type � Chest pain on breathing � Precordial


Commonly Coded

� Pleurodynia � Intercostal � Other chest pain

Chapter 11: Diseases of Digestive System (K00–K95)

Diseases of the Appendix (K35-K38)AppendixThe appendix is a finger-shaped pouch that projects out from your colon on the lower right side of the abdomen. This small structure has no known essential purpose.

Appendicitis is a condition in which the appendix becomes inflamed and fills with rapidly growing bacteria and pus. This causes pain which typically begins around the navel and then shifts to the lower right abdomen. Typically the pain increases over a period of 12 to 18 hours and eventually becomes very severe. Appendicitis most often occurs in people between the ages of 10 and 30 but can affect anyone. The standard treatment is surgical removal of the appendix.

ICD-10-CM offers greater specificity in this subcategory. When coding for the diseases of the appendix the choices include:

� Type � Acute appendicitis

» With generalized peritonitis » With localized peritonitis

� Chronic � Other

» Hyperplasia » Appendicular concretions » Diverticulum » Fistula » Other

EXAMPLE:Lisa is a 17-year-old female who came into the ED for cramp-like pains above and around the umbilicus which has moved to the lower right quadrant. She has an elevated temp of 100.8. CT scan confirms acute appendicitis. K35.80 Unspecified acute appendicitis

Hernia (K40-K46)A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity.


Subcategory K40 is for inguinal hernias. This includes codes for direct inguinal, double inguinal, indirect, oblique inguinal and scrotal hernias. In order to assign a code, not only do you need to know location but also laterality, with or without obstruction, whether or not the hernia is recurrent and if there is gangrene or not.

Inguinal (groin) hernias make up 75 percent of all abdominal-wall hernias and occur up to 25 times more often in men than women. These hernias are divided into two different types—direct and indirect. Both types occur in the groin area where the skin of the thigh joins the torso, but they have slightly different origins.

An indirect inguinal hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may actually occur at any age.

The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age.

EXAMPLE: Jennifer has been diagnosed with a unilateral inguinal hernia with obstruction and gangrene that has been recurrent. K40.41 Unilateral inguinal hernia, with gangrene, recurrent

Femoral hernias are coded from category K41 and include the same coding components as described above.

The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated.

Umbilical hernias are common hernias (10 percent–30 percent) often noted at birth as a protrusion at the bellybutton. This is caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth. Umbilical hernias are coded from category K42 and require knowledge of obstruction and with or without gangrene for proper code assignment.

Ventral hernias are a type of abdominal hernia that commonly occurs along the midline of the abdominal wall, although they can occur at any location on the abdominal wall. Umbilical hernias are those that occur beneath or near the navel. Ventral hernias that occur at the site of a previous


Commonly Coded

abdominal surgery are called incisional hernias, and incisional hernias are fairly common. Coding for ventral hernias remains consistent with the other categories.

EXAMPLE:Tina noticed a bulge in her abdominal wall. She indicates the bulge appears to expand under increased abdominal pressure, such as when she coughs or lifts a heavy object. The physician diagnosed her with ventral hernia. K43.9 Ventral hernia, unspecified, without obstruction or gangrene

A diaphragmatic hernia is a birth defect in which there is an abnormal opening in the diaphragm, the muscle that helps you breathe. The opening allows part of the organs from the belly (stomach, spleen, liver, and intestines) to go up into the chest cavity near the lungs. Diaphragmatic hernias are coded to K44.

ICD-10-CM offers greater specificity in this subcategory. When coding for hernia, the choices include:

� Type � Inguinal � Femoral � Umbilical � Ventral

» Incisional » Parastomal

� Diaphragmatic � Other

� Localization � Bilateral � Unilateral

� Symptoms/Findings/Manifestations � With/without obstruction � With/without gangrene

� Severity � Recurrent

Gallbladder (K80-K87)The gallbladder is a small, pear-shaped organ on the right side of the abdomen, just beneath the liver that holds digestive fluid called bile that’s released into your small intestine.

Inflammation of the gallbladder is called cholecystitis. Cholecystitis is caused by gallstones that block the tube leading out of the gallbladder. The bile builds up and can cause inflammation, bile duct problems and tumors. Cholecystitis can lead to serious complications if left untreated such as:

� Gallstones (cholelithiasis) can block the cystic duct and result in inflammation. Gallstones are hardened deposits of digestive fluid that can form in the gallbladder. Gallstones can range in size from as small as a grain of sand to as large as a golf ball. People can develop just one gallstone to many at the same time.


Commonly Coded

� Tumor which may prevent bile from draining out of the gallbladder properly. � Death of gallbladder tissue which can happen when cholecystitis is left untreated. When the

gallbladder tissue dies it can tear or may cause the gallbladder to burst.

When coding for cholelithiasis the documentation needed to state with or without obstruction.

EXAMPLE:John has been having difficulty with his gallbladder off and on for several years. Today he came into the ED with severe right upper quandrant pain. Ultrasound confirms the patient has cholecystitis. The surgeon diagnoses the patient with acute and chronic cholecystitis. K81.2 Acute cholecystitis with chronic cholecystitis

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