specialty code set training internal...

ICD-10-CMSpecialty Code Set Training

Internal Medicine2014

Module 1

ii ICD-10-CM Specialty Code Set Training — Internal Medicine © 2013 AAPC. All rights reserved.083013

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.

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

© 2013 AAPC. All rights reserved. www.aapc.com iii083013

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

Combination Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Stage I 6

Stage II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Stage III . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Stage IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Non-Pressure Chronic Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Strep throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Influenza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Mental, Behavioral and Neurodevelopmental Disorders (F01–F99) . . . . . . . . . . . . 13Mental and Behavioral Disorders Due to Psychoactive Substance Use . . . . . . . 13

Alcohol Use, Abuse, and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Nicotine Use and Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

iv ICD-10-CM Specialty Code Set Training — Internal Medicine © 2013 AAPC. All rights reserved.083013

Contents

Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Vascular Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Other Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Anxiety and Stress-related Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

© 2013 AAPC. All rights reserved. www.aapc.com 1083013

Combination CodesICD-10-CM not only includes more combination codes than in ICD-9-CM, but they often provide more specific information. They have the potential to reveal more about the quality of patient care by helping make it clear when complications or manifestations exist and helps to better track the outcomes of care. Combination codes are identified by referring to the subterm entries in the Alphabetic Index and by reading the Inclusion and Exclusion notes in the Tabular List. Combination codes should only be applied when the code fully identifies the diagnostic conditions involved and when the Alphabetic Index directs the user to do so. If the combination code lacks necessary specificity in describing the manifestation or complication, additional code(s) may still be necessary to report to fully describe the patient’s condition.

It is important that internists understand this expansion to ensure that the documentation supports use of the codes. An understanding of the changes to the code set as it applies to the additional combination codes found in ICD-10-CM is imperative to assign codes to the highest level of specificity. The conditions that will be discussed here are diabetes mellitus, hypertension, pressure ulcers, non-pressure chronic ulcers, and Crohn’s disease.

Diabetes Mellitus Diabetes mellitus is a condition that occurs when the body can’t use glucose normally. Glucose is the main source of energy for the body’s cells. The levels of glucose in the blood are controlled by a hormone called insulin, which is made by the pancreas. Insulin helps glucose enter the cells. Type 1 diabetes develops when the pancreas does not make enough insulin. Type 2 diabetes develops when the body is unable to respond normally to the insulin that is made. The inability of the body to process insulin causes glucose levels to rise in the blood leading to symptoms such as increased urination, extreme thirst, and unexplained weight loss. Diabetes mellitus is a chronic disease that causes serious health complications including renal failure, heart disease, stroke, and blindness.

According to the American Diabetes Association, the latest data released from the National Diabetes Fact Sheet (released Jan. 26, 2011), there are 25.8 million Americans living with diabetes. That is 8.3 percent of the population. This figure includes 18.8 million people diagnosed with diabetes, and 7 million people that are undiagnosed. There are 79 million people estimated to have prediabetes.

The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, the complications affecting that body system, and if the patient is on long term insulin if a non-type 1 diabetic patient. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08–E13 as needed to identify all of the associated conditions that the patient has.

For internists, diabetes will be a common condition seen in the practice. The way diabetes is coded is different than in ICD-9-CM with all of the combination codes. A thorough understanding of what to look for in the documentation and how it fits together for coding purposes is necessary to assign codes properly in ICD-10-CM.

2 ICD-10-CM Specialty Code Set Training — Internal Medicine © 2013 AAPC. All rights reserved.083013

Combination Codes

There are five diabetes mellitus categories in the ICD-10-CM. They are:

� E08 Diabetes mellitus due to an underlying condition � E09 Drug or chemical induced diabetes mellitus � E10 Type 1 diabetes mellitus � E11 Type 2 diabetes mellitus � E13 Other specified diabetes mellitus

Definitions for the types of diabetes mellitus are included in the “Includes notes” under each DM category. Internists should be instructed to document the type of diabetes as type 1 or type 2, when appropriate, and not insulin and non-insulin dependent as these terms are no longer used in the coding schema.

The subcategories for the complications with the body systems affected by diabetes mellitus are as follows:

� Ketoacidosis � Without coma � With coma

� Kidney complications � Diabetic nephropathy � Diabetic chronic kidney disease � Other diabetic kidney complications

� Ophthalmic complications � Diabetic retinopathy

» Mild nonproliferative with/without macular edema » Moderate nonproliferative with/without macular edema » Severe nonproliferative with/without macular edema » Proliferative with/without macular edema

� Diabetic cataract � Other diabetic ophthalmic complications

� Neurological complications � Diabetic neuropathy

» Diabetic mononeuropathy » Diabetic polyneuropathy » Diabetic autonomic (poly)neuropathy

� Diabetic amyotrophy � Other diabetic neurological complications

� Circulatory complications � Diabetic peripheral angiopathy with/without gangrene � Other circulatory complications


Combination Codes

� Other specified complications � Diabetic arthropathy

» Diabetic neuropathic arthropathy » Other diabetic arthropathy

� Skin complications » Diabetic dermatitis » Foot ulcer » Other skin ulcer » Other skin complication

� Oral complications » Periodontal disease » Other oral complications

� Hypoglycemia » With coma » Without coma

� Hyperglycemia � Other specified complication

All the categories above with the exception of E10 include a note directing users to use an additional code to identify any insulin use, which is Z79.4. The concept of insulin and non-insulin requiring are not a component of the diabetes mellitus (DM) categories in ICD-10-CM. Code Z79.4 Long-term current use of insulin is added to identify the use of insulin for diabetic management even if the patient is not insulin dependent in code categories E08–E09 and E11–E13.

EXAMPLEPatient is a 34-year-old male with significant type 1 diabetic polyneuropathy. Exam is significant for lower extremity numbness throughout. Monofiliament test shows more than 3 regions without sensation bilaterally. Bottoms of feet appear calloused and dry. Skin is intact. E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy

Sequencing of diabetes codes from categories E08–E09 have a “Code first” note indicating that diabetes is to be sequenced after the underlying condition, drug or chemical that is responsible for the diabetes. Codes from categories E10–E13 (diabetes mellitus) are sequenced first, followed by codes for any additional complications outside of these categories if applicable.

EXAMPLE70-year-old female with type 2 diabetic CKD, stage 4. Patient’s current and regular medications include NovoLog 20 units with each meal, Lantus 30 units at bedtime. E11.22 Type 2 diabetic mellitus with diabetic chronic kidney disease N18.4 Chronic kidney disease, stage 4 (severe) Z79.4 Long term (current) use of insulin


Combination Codes

EXAMPLEJanet presents for cystic fibrosis-related diabetes check. She is doing well on her insulin and continues to consume the correct protein (15 percent) and fat levels (35 percent) daily. Eating a lot of fish and chicken and consuming extra salt when hot outside. Diagnosis: CFRD. Doing well. Labs before next visit. See back in 2 months. E84.8 Cystic fibrosis with other manifestations E08.9 Diabetes mellitus due to underlying condition without complications

HypertensionAccording to the Centers for Disease Control (CDC), hypertension affects one in three adults in the United States, approximately 68 million people. It contributes to one out of every seven deaths in the United States and to nearly half of all cardiovascular disease–related deaths, including stroke.

From a coding perspective, hypertension is another area where combination codes come in to play. Unlike diabetes, the codes are similar in nature to the way hypertension is coded in ICD-9-CM. The basic code for hypertension (without complications) is actually easier in ICD-10-CM. There is no longer the “benign” or “malignant” issue—there is just essential hypertension, indicated by code I10.

If there is a body system affected, then combination codes kick in. The code set addresses hypertensive heart disease with category I11, hypertensive chronic kidney disease with category I12, and hypertensive heart and chronic kidney disease with category I13.

Hypertensive heart disease is the number one cause of death associated with high blood pressure. It refers to a group of disorders that includes heart failure, ischemic heart disease, hypertensive heart disease, and left ventricular hypertrophy. If the patient has hypertensive heart disease, the internist must make the connection with the conditions in order for the combination code to be assigned. Documentation must state (heart failure due to hypertension) or imply (hypertensive heart failure) a causal relationship to assign a code from category I11, Hypertensive heart disease.

With hypertensive chronic kidney disease, though, the guidelines state that there is a presumption that a cause-and-effect relationship exists between the two conditions.

If a patient has all three conditions present, hypertension, heart disease, and chronic kidney disease, the guidelines state that the connection must still be made for the heart disease and hypertension, but not for the CKD and hypertension.

EXAMPLE 1Assessment: 1. Hypertension

2. Chronic diastolic congestive heart failure. I10 Essential (primary) hypertension I50.32 Chronic diastolic (congestive) heart failure

Since there is no causal relationship indicated, the two conditions would have to be coded separately,


Combination Codes

EXAMPLE 2 Assessment: Hypertension with hypertensive chronic diastolic congestive heart failure I11.0 Hypertensive heart disease with heart failure I50.32 Chronic diastolic (congestive) heart failure

The causal relationship is indicated, so the first-listed code is now different. The instructional note under code I11.0 states that the second code is still necessary to identify the type of heart failure.

EXAMPLEThe patient is a 68-year-old gentleman with hypertension and stage 3 CKD with a creatinine of 1.8. I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney

disease, or unspecified chronic kidney disease N18.3 Chronic kidney disease, stage 3 (moderate)

EXAMPLEPatient presents with hypertensive heart disease and stage 2 CKD. I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1

through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.2 Chronic kidney disease, stage2 (mild)

Pressure UlcersPressure ulcers are injuries to skin and underlying tissues that result from prolonged pressure on the skin. The codes are located in category L89 in ICD-10-CM. Pressure ulcers most often develop on skin that covers bony areas of the body, such as the heel, ankles, hips or buttocks. In ICD-10-CM, pressure ulcers are now combination codes that integrate site, laterality, and stage. There is also an instructional note that states to code first any associated gangrene.

The subcategories for the specific sites are listed below.

� L89.0- Elbow (right and left) � L89.1- Back, upper and lower (right and left)

Includes sacral region (L89.15-) � L89.2- Hip (right and left) � L89.3- Buttock (right and left) � L89.4- Back, buttock, and hip � L89.5- Ankle (right and left) � L89.6- Heel (right and left) � L89.8- Other sites


Combination Codes

Severity is the final piece of the coding puzzle for pressure ulcers in ICD-10-CM. The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, has defined each stage as follows:

Stage IThe beginning stage of a pressure sore has the following characteristics:

� The skin is intact. � The skin appears red on people with lighter skin color, and the skin doesn’t briefly

lighten (blanch) when touched. � On people with darker skin, there may be no change in the color of the skin, and the

skin doesn’t blanch when touched. Or the skin may appear ashen, bluish or purple. � The site may be painful, firm, soft, warmer or cooler compared with the surrounding skin.

Source: AAPC

Stage IIThe stage II ulcer is an open wound:

� The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.

� The pressure ulcer may appear as a shallow, pinkish-red, basin-like wound. � It may also appear as an intact or ruptured fluid-filled blister.

Source: AAPC


Combination Codes

Stage IIIAt this stage, the ulcer is a deep wound:

� The loss of skin usually exposes some amount of fat. � The ulcer has a crater-like appearance. � The bottom of the wound may have some yellowish dead tissue (slough). � The damage may extend beyond the primary wound below layers of healthy skin.

Source: AAPC

Stage IVA stage IV ulcer exhibits large-scale loss of tissue:

� The wound may expose muscle, bone and tendons. � The bottom of the wound likely contains slough or dark, crusty dead tissue (eschar). � The damage often extends beyond the primary wound below layers of healthy skin.

Source: AAPC

There are separate codes for stage 1-4 and one for unstageable. Unstageable is not the same as unspecified. The guidelines state that assignment of the code for unstageable pressure ulcer should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (eg, the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage. When


Combination Codes

there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage.

A coder needs to be able to pull this information from the medical record and understand how it correlates to the correct ICD-10-CM code or codes.

EXAMPLEA wheelchair-bound patient presents for a check up. He complains of buttock pain and is moved to the exam table for a more thorough exam. A 3 X 3.25 cm stage 2 pressure ulcer is found over the right ischial tuberosity. L89.312 Pressure ulcer of right buttock, stage 2

EXAMPLEPatient is 72 and has recently been discharged from the hospital. She complains of pain in her left buttock. It hurts when she sits down, so she has been shifting her weight to her right side to stop the pain, but this is causing stiffness. On examination, there is an oval area of broken skin, with dermal and epidermal skin loss, about 1 cm in diameter, indicating a Stage 2 pressure ulcer. L89.322 Pressure ulcer of left buttock, stage 2

Non-Pressure Chronic UlcersA bigger change from a coding perspective will be seen with non-pressure ulcers, located in categories L97 and L98 in ICD-10-CM. In ICD-9-CM, the non-pressure ulcers are only broken down by site. But in ICD-10-CM, they are now similar to pressure ulcers, including site, laterality and severity in the code classification. There are also instructional notes for the codes that state to code first and associated underlying conditions, such as:

any associated gangrene (I96)

atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-, I70.34-, I70.43-, I70.44-, I70.53-, I70.54-, I70.63-, I70.64-, I70.73-, I70.74-)

chronic venous hypertension (I87.31-, I87.33-)

diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622)

postphlebitic syndrome (I87.01-, I87.03-)

postthrombotic syndrome (I87.01-, I87.03-)

varicose ulcer (I83.0-, I83.2-)

The subcategories for the specific sites are listed below.

� L97.1- Thigh (right and left) � L97.2- Calf (right and left) � L97.3- Ankle (right and left)


Combination Codes

� L97.4- Heel and midfoot (right and left) � L97.5- Other part of foot (right and left) � L97.8- Other part of lower leg (right and left) � L98.41- Buttock � L98.42- Back � L98.49- Skin of other sites

Severity is the final component to look for in the documentation of non-pressure ulcers. From a coding perspective, the codes are broken down in the following manner:

� Limited to breakdown of skin � With fat layer exposed � With necrosis of muscle � With necrosis of bone

It will be necessary to work with internists on the new coding parameters to ensure that the documentation meets the ICD-10-CM standards. If not, unspecified codes will have to be assigned, which may pose reimbursement issues.

EXAMPLEPatient is a type 2 diabetic who presents with a type 2 diabetic left midfoot ulcer open into the dermis, but not full-thickness. E11.621 Type 2 diabetes mellitus with foot ulcer L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin

EXAMPLEPatient seen for venous stasis ulcer of right calf with the fat layer exposed. I83.012 Varicose veins of right lower extremity with ulcer of calf L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed

Crohn’s DiseaseThe exact cause of Crohn’s disease is unknown. It is a condition that occurs when the body’s immune system mistakenly attacks and destroys healthy body tissue, so it is an autoimmune disorder. Crohn’s most often affects the ileum, but it may affect any part of the gastrointestinal tract. The inflammation of the intestine can “skip” areas, leaving normal areas in between patches of diseased intestine.

This condition differs from ulcerative colitis in the fact that ulcerative colitis only affects the colon and it does not skip areas, like Crohn’s.

The code set for Crohn’s has expanded in ICD-10-CM to include both site and complications. There is also an instructional note that states to use an additional code to identify manifestations. The small intestine would include the duodenum, the jejunum, and the ileum. It may also be


Combination Codes

documented as regional ileitis or terminal ileitis. The large intestine would include terminology of the colon, large bowel, rectum, granulomatous colitis, or regional colitis.

The second factor for coding Crohn’s is the complications. If documentation does not indicate any, there are codes in each subcategory for “without complications”. These new criteria need to be discussed with the providers. If they are not informed of what is in the codes, the documentation will not adjust for specific verbiage necessary in ICD-10-CM. These complications will help indicate the severity of the patient’s conditions to a payer. Payers may allow for certain testing or certain amount of visits for conditions, so it is important to code these things when they are present.

EXAMPLEPatient presents for check up on his Crohn’s disease of the ileum. He is stable with no complications on 100 mg Imuran daily. K50.00 Crohn’s disease of small intestine without complications

InfectionsThere are many combination codes in ICD-10-CM that relate to infections. These can be found throughout the ICD-10-CM manual. From an Internal Medicine standpoint, many are found in the Respiratory section of codes, and include strep throat, influenza, and bacterial and viral pneumonias.

Strep throat Strep throat, ICD-10-CM code J02.0, is a bacterial infection in the throat and tonsils caused by streptococci bacteria. There are many different types of strep bacteria, with some causing more serious infection than others. Common symptoms of strep throat are a sudden, severe sore throat; pain when swallowing; fever over 101̊ F; swollen tonsils and lymph nodes, and white or yellow spots on the back of a reddened throat. Some patients may not have all of the symptoms. Strep throat is usually diagnosed by a rapid strep test. If the rapid strep is negative, but the patient is symptomatic, a throat culture may be performed. Strep throat is treated with antibiotics.

InfluenzaInfluenza, or the flu, is a highly contagious viral infection. It is unknown why the flu is more prevalent in the winter months, but it is believed that the virus survives and is transmitted better in cold temperatures. Because there are many different strains of influenza, a person my get the flu more than once. There are 3 influenza virus families: Type A, B, or C.

In ICD-10-CM, the codes for influenza are located in categories J09, J10, and J11. They are broken down by type of virus and bundle in manifestations.

Category J09 includes codes for novel influenza A virus, including bird flu, avian flu, swine flu, H5N1, and other animal origins than bird or swine. The codes are broken down by associated manifestations:

� J09.X1 Influenza due to identified novel influenza A virus with pneumonia � J09.X2 Influenza due to identified novel influenza A virus with other respiratory

manifestations


Combination Codes

� J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations

� J09.X9 Influenza due to identified novel influenza A virus with other manifestations.

Category J10 includes codes for other identified influenza virus, but states an additional code should be reported to identify the virus from category B97. The codes are similar to the J09 category as they combine the manifestations:

� J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia

� J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia

� J10.08 Influenza due to other identified influenza virus with other specified pneumonia � J10.1 Influenza due to other identified influenza virus with other respiratory

manifestations � J10.2 Influenza due to other identified influenza virus with gastrointestinal

manifestations � J10.81 Influenza due to other identified influenza virus with encephalopathy � J10.82 Influenza due to other identified influenza virus with myocarditis � J10.83 Influenza due to other identified influenza virus with otitis media � J10.89 Influenza due to other identified influenza virus with other manifestations

Category J11 includes codes for unidentified influenza virus:

� J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia � J11.08 Influenza due to unidentified influenza virus with specified pneumonia � J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations � J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations � J11.81 Influenza due to unidentified influenza virus with encephalopathy � J11.82 Influenza due to unidentified influenza virus with myocarditis � J11.83 Influenza due to unidentified influenza virus with otitis media � J11.89 Influenza due to unidentified influenza virus with other manifestations

Although these are combination codes, it does not necessarily mean no other codes are needed. The above codes may also need additional codes to be assigned in some cases to further specify conditions. For example, under J09.X1, it states to code also associated lung abscess or other specified type of pneumonia, if applicable. All instructional notes should be read surrounding the codes you are using before making final code assignment to ensure complete reporting.

EXAMPLEA 21-year-old man presents to the clinic with symptoms of cough, sore throat, fever of 102 ,̊ and runny nose. A rapid antigen test was positive for influenza A. J09.X2 Influenza due to identified novel influenza A virus with other respiratory

manifestations


Combination Codes

PneumoniaPneumonia is an infection of the lungs, most commonly caused by bacteria or viruses. According to the CDC, pneumonia causes more deaths globally than any other infectious disease. The codes for pneumonia in ICD-10-CM are combination code that include causal organism, and are located in categories J12 through J17.

In the United States the most common bacterial cause of pneumonia are:

� Streptococcus pneumoniae (J13), and � Staphylococcus aureus (J15.211 due to MSSA; J15.212 due to MRSA).

The most common viral causes of pneumonia in the U.S. are:

� Influenza (bundled with the Influenza codes discussed earlier), � Parainfluenza (J12.2), � Respiratory syncytial virus (J12.1), and � Adenovirus (J12.0).

EXAMPLEPatient admitted yesterday for Streptococcus pneumoniae pneumonia. On the day of admission, patient presented with a four day history of progressive, productive cough and two days of spiking fevers. He had a respiratory rate of 40/minutes, pulse was 120 bpm. He was alert in mild respiratory distress. Chest exam was notable for decreased breath sounds and dullness to percussion. Chest X-ray indicated pneumonia and he had a positive blood culture. Today, he is doing a little better on Cipro. Continue breathing treatments and medication at same dosage. J13 Pneumonia due to Streptococcus pneumoniae

EXAMPLEGina, a 52-year-old woman, is being seen for recheck of her parainfluenzal pneumonia. She was originally seen for cough, wheezing, and shortness of breath that did not seem to be improving. Chest X-ray confirmed pneumonia and antigen detection test indicated parainfluenza as the agent. She is doing well and breathing better, feeling more like herself. Continue present management. The patient was told to return if she has difficulty breathing or has any other respiratory issues. J12.2 Parainfluenza virus pneumonia


Combination Codes

Mental, Behavioral and Neurodevelopmental Disorders (F01–F99) Mental and Behavioral Disorders Due to Psychoactive Substance UseThe expansion of mental and behavioral disorders due to psychoactive substance use in the block F10–F19 has created more complete clinical pictures. The third character in the codes indicates the substance used, the fourth and fifth characters the psychopathological syndrome, eg, from acute intoxication and residual states; this allows the reporting of all disorders related to a substance even when only three-character categories are used.

EXAMPLES: F10.23- Alcohol dependence with withdrawal F12.12- Cannabis abuse with intoxication

In the first example, subcategory F10.23-, the 3rd character 0 indicates the substance as alcohol. The 4th character 2 indicates dependence and the 5th character 3 indicates with withdrawal.

In the second example, subcategory F12.12-, the 3rd character 2 indicates the substance as cannabis. The 4th character 1 indicates abuse and the 5th character 2 indicates with intoxication.

When the provider documentation refers to use, abuse and dependence of the same substance (eg, alcohol, opioid, cannabis, etc), only one code should be assigned to identify the pattern based on hierarchy:

� If both use and abuse are documented, assign only the code for abuse � If both abuse and dependence are documented, assign only the code for dependence � If both use and dependence are documented, assign only the code for dependence � If use, abuse and dependence are all documented, assign only the code for dependence

EXAMPLE Patient presents to the office and the internist documents alcohol use and abuse in the assessment. F10.10 Alcohol abuse, uncomplicated

EXAMPLEPatient presents to the office with uncomplicated alcohol dependence and cocaine abuse with cocaine-induced anxiety disorder. F10.20 Alcohol dependence, uncomplicated F14.180 Cocaine abuse with cocaine-induced anxiety disorder

In the first example above, the internist documents alcohol use and abuse. According to the hierarchy rules, only the abuse is coded because it is the same substance.


Combination Codes

In the second example, there is abuse and dependence, but of two different substances, so each substance is coded with its associated psychopathological syndrome.

Alcohol Use, Abuse, and DependenceAlcohol use, abuse, and dependence codes are located in the following subcategories: F10.1- Alcohol abuse, F10.2- Alcohol dependence, and F10.9- Alcohol use, unspecified.

Alcohol use is nonabusive, nondependent use of alcohol. The DSM-V manual provides clinical definitions for alcohol abuse and dependence. It is important to ensure that the internist is aware of these definitions so that the documentation indicates the correct condition for proper code assignment. Below are the definitions from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-V) relating to alcohol abuse and dependence.

Alcohol Abuse (DSM-V Criteria):

1. A maladaptive pattern of alcohol abuse leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:

� Recurrent alcohol use resulting in failure to fulfill major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; or neglect of chil-dren or household).

� Recurrent alcohol use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine).

� Recurrent alcohol-related legal problems (eg, arrests for alcohol-related disorderly conduct).

� Continued alcohol use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (eg, arguments with spouse about consequences of intoxication or physical fights).

2. These symptoms must never have met the criteria for alcohol dependence.

Alcohol Dependence (DSM-V Criteria)

A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period:

1. Tolerance, as defined by either of the following: � A need for markedly increased amounts of alcohol to achieve intoxication or desired

effect. � Markedly diminished effect with continued use of the same amount of alcohol.

2. Withdrawal, as defined by either of the following: � The characteristic withdrawal syndrome for alcohol (refer to DSM-V for further details). � Alcohol is taken to relieve or avoid withdrawal symptoms.

3. Alcohol is often taken in larger amounts or over a longer period than was intended.


Combination Codes

4. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use.

5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects.

6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (eg, continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

ICD-10-CM breaks down the code subcategories as follows: uncomplicated, with intoxication, with withdrawal, with alcohol-induced mood disorder, with alcohol-induced psychotic disorder, with alcohol-induced persisting amnestic disorder, with alcohol-induced persisting dementia, with other alcohol-induced disorder, and with unspecified alcohol-induced disorder. To assign the appropriate ICD-10-CM code, the provider must be specific in the documentation as to the severity of the condition.

EXAMPLEPatient presents for visit stating he is having issues with alcohol. He says that in the past 6 months, his drinking has increased markedly. He states that he needs to drink twice as much to get “buzzed”. He states that he thinks about drinking more often and desires alcohol most times of the day. He has missed family gatherings and a few appointments due to being inebriated. He has come for help as he has tried to quit on his own and has not been successful. F10.20 Alcohol dependence, uncomplicated

Nicotine Use and DependenceNicotine dependence is an addiction to tobacco products caused by the drug nicotine. The term nicotine dependence indicates that the person cannot stop using the substance. Nicotine is the chemical in tobacco that keeps a person smoking. Nicotine is very addictive. It increases the release of brain chemicals called neurotransmitters, which help regulate mood and behavior. One of these neurotransmitters is dopamine, which makes the smoker feel good. Getting that dopamine boost is part of the addiction process.

Signs of dependence include:

� The patient can’t stop smoking. � The patient experiences withdrawal symptoms when they try to stop. � The patient continues to smoke despite health problems. � The patient gives up social or recreational activities to smoke.

While the nicotine in tobacco causes the dependence, the toxic effects come mainly from other substances in tobacco. Smokers have much higher rates of heart disease, stroke and cancer than do nonsmokers. Nicotine produces physical and mood-altering effects in the brain that are temporarily pleasing. These effects create the desire to use tobacco, which leads to dependence.


Combination Codes

At the same time, stopping tobacco use causes withdrawal symptoms, including irritability and anxiety.

Nicotine dependence codes are located in category F17. ICD-10-CM breaks down the category by tobacco product, and whether the condition is uncomplicated, in remission, with withdrawal, with other nicotine-induced disorder, or with unspecified nicotine-induced disorder. Additional codes relating to nicotine in ICD-10-CM include:

� Z72.0 Tobacco use � Z87.891 History of tobacco dependence � Z77.22 Exposure to environmental tobacco smoke � Z57.31 Occupational exposure to environmental tobacco smoke � P96.81 Exposure to tobacco smoke in the perinatal period � O99.33- Tobacco use (smoking) during pregnancy, childbirth, and the puerperium

EXAMPLEPatient presents requesting a nicotine patch to assist her to stop smoking. She has been smoking for 12 years with a pack and half of cigarettes per day habit. She quit a week ago and is experiencing withdrawal symptoms of agitation, sleeplessness, and nervousness. F17.213 Nicotine dependence, cigarettes, with withdrawal

EXAMPLEPatient comes in for asthma check-up. She has mild persistent asthma and a history of cigarette smoking. She quit smoking 5 years ago. J45.30 Mild persistent asthma, uncomplicated Z87.891 History of tobacco dependence

DepressionThe Centers for Disease Prevention and Control (CDC) estimates that five percent of Americans older than age 11 may have depression. Depression is a disorder of the brain. There are a variety of causes, including genetic, environmental, psychological, and biochemical factors. Depression usually starts between the ages of 15 and 30, and is much more common in women.1 Depression can also be referred to clinically as Clinical depression, Dysthymic disorder, Major depressive disorder or Unipolar depression. Internists play a key role in the identification and treatment of depression.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), classifies a depressive episode as a 2-week period in which the patient experiences either a depressed mood or a marked decrease in interest or pleasure gained from most activities. The patient must also complain of at least four of the following symptoms: change in appetite or weight; insomnia or hypersomnia; change in psychomotor activity; feelings of guilt or worthlessness; fatigue or loss of energy; indecisiveness or diminished ability to concentrate; and suicidal ideation or recurrent thoughts of death. To warrant a diagnosis of depression, symptoms must also cause impairment or marked distress in important areas of functioning. Depending on the number and severity of the symptoms, a depressive episode may be specified as mild, moderate, or severe. ________________________1 www.nlm.nih.gov/medlineplus/depression.html


Combination Codes

A recurrent depressive disorder is characterized by repeated episodes of depression without any history of independent episodes of mood elevation and increased energy or mania. There has been at least one previous episode lasting a minimum of two weeks and separated by the current episode of at least two months. At no time in the past have there been any hypomanic or manic episodes.

For a classification of in remission the patient has had two or more depressive episodes in the past but has been free from depressive symptoms for several months. This category can still be used if the patient is receiving treatment to reduce the risk of further episodes.

Understanding the condition is necessary in ICD-10-CM to assign the most appropriate codes. In ICD-10-CM, the codes for depression are located in categories F32 and F33 and are classified by the following parameters:

� Episode—Single (F32) or Recurrent (F33) � Type—Mild (F32.0, F33.0), Moderate (F32.1, F33.1), Severe (F32.2, F32.3, F33.2, F33.3) � With psychotic features (F32.3, F33.3) or without psychotic features (F32.2, F33.2) � Remission status—Partial (F32.4, F33.41) Full (F32.5, F33.42), and unspecified (F33.40)

EXAMPLEVera, a 38-year-old single woman presents to her internal medicine physician with symptoms of depression for the past year. These include feelings of sadness, anhedonia, significant loss of energy, psychomotor retardation, and difficulty sleeping. She denies any significant medical issues and states her symptoms began when her relationship of 8 years ended. Patient scored a 24 on the Beck Depression Inventory (BDI), supporting a diagnosis of major depressive disorder, single episode, moderate. F32.1 Major depressive disorder, single episode, moderate

Bipolar DisorderBipolar disorder is a serious mental illness. It is most commonly diagnosed in persons between 18 and 24 years of age. People who have it experience dramatic mood swings. They may go from overly energetic, “high” and/or irritable, to sad and hopeless, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.

A hypomanic episode is characterized by a persistent mild elevation of mood, increased energy and activity, and usually marked by feelings of well being and both physical and mental efficiency. Increased sociability, talkativeness, overfamiliarity and increased sexual energy and a decreased need for sleep are often present.

A manic episode is characterized by mood that is elevated out of keeping with the patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement. Elation is accompanied by increased energy, resulting in over-activity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained and there is often distractibility. Loss of social inhibitions may result in behavior that is reckless, foolhardy or inappropriate to the circumstances and out of character for the patient. In some manic episodes the mood is one of irritability or suspiciousness rather than elation.

Bipolar II (F31.81) is similar to bipolar I disorder, with moods cycling between high and low over time.


Combination Codes

However, in bipolar II disorder, the “up” moods never reach full-on mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.

A person affected by bipolar II disorder has had at least one hypomanic episode in life. Most people with bipolar II disorder also suffer from episodes of depression. This is where the term “manic depression” comes from. In between episodes of hypomania and depression, many people with bipolar II disorder live normal lives.

The onset of bipolar disorder is usually diagnosed by the internist as the “first line” treatment provider. The internal medicine physician may seek psychiatric consultation for differential diagnosis and treatment recommendations. Often, the psychiatrist assumes responsibility for initial management until the patient’s clinical pattern is determined. During follow-up, both physicians will usually monitor the patient for signs of psychosis, mood swings, violence and self-harmful behaviors. As the patient’s illness stabilizes and management becomes routine, the internist oftentimes resumes responsibility for ongoing care.

In ICD-10-CM, codes for bipolar disorder are in category F31 and are classified by the following parameters:

� Type—Type I or Type II � Current episode—Hypomanic (F31.0), Manic (F31.1-, F31.2), Depressed (F31.3-, F31.4,

F31.5), Mixed (F31.6-) � Severity—Mild (F31.11, F31.31, F31.61), Moderate (F31.12, F31.32, F31.62), Severe (F31.13,

F31.2, F31.4, F31.5, F31.63, F31.64) � With psychotic features (F31.2, F31.5, F31.64) or Without psychotic features (F31.13,

F31.4, F31.63) � Remission status—Partial (F31.71, F31.73, F31.75, F31.77), Full (F31.72, F31.74, F31.76,

F31.78), or unspecified (F31.70)

EXAMPLEJulie presents today for a check-up on her bipolar disorder. She states that she has recently begun feeling depressed, not wanting to get out of bed, not showering, etc. She says she wanted to come in to “nip it in the bud.” Patient admits to being noncompliant with taking her medication recently, which may have set off this mild depression. She states that she does not like to be dependent on it. Discussed the importance of taking medications properly and on time. We will increase her Seroquel for a short period and have the patient return in 1 week. Patient informed to contact our office immediately or present to the ED if she has thoughts of harming herself. Plan reviewed with her sister who will ensure patient takes her medication. F31.31 Bipolar disorder, current episode depressed, mild Z91.128 Patient’s intentional underdosing of medication regimen for other reason

Cyclothymia is a persistent instability of mood involving numerous periods of depression and mild elation, none of which is sufficiently severe or prolonged to justify a diagnosis of bipolar or recurrent depressive disorders. This disorder is often found in the relatives of patients with bipolar disorder, some eventually develop bipolar disorders themselves.

Dysthymia is a chronic depression of mood, lasting at least several years, it is not severe and episodes are not prolonged enough to justify a diagnosis of severe, moderate or mild recurrent depressive disorders.


Combination Codes

EXAMPLECindy comes in today for a check-up. She was diagnosed with dysthymic disorder 3 years ago. She states her sessions with the LCSW have been very helpful in changing her feelings of low self-esteem and with restructuring her negative thought patterns. She states she still has some sleep issues and fatigue when stressed. Continue same dose of Paxil® and have her return in 2 months. F34.1 Dysthymic disorder

DementiaDementia is a term used for a group of cognitive disorders usually characterized by memory impairment, marked difficulty with language, motor skills, object recognition, and disturbance of executive function (ability to plan, organize, and abstract). From an ICD-10-CM perspective, there are three types of dementia, vascular dementia, dementia in diseases classified elsewhere, and unspecified dementia. This accounts for only six codes in the codebook. It is not the codes themselves, but the codes that are reported along with them, that add complexity to reporting.

Vascular DementiaVascular dementia is caused by brain damage from impaired blood flow to the brain, which damages the brain’s blood vessels. Cerebral infarction (stroke), stenosis, and chronic damage to cerebral blood vessels are the most common causes of vascular dementia. It is the second most common form of dementia.

There are two codes in ICD-10-CM for vascular dementia:

� F01.50 Vascular dementia without behavioral disturbance � F01.51 Vascular dementia with behavioral disturbance

Examples of behavioral disturbances listed under code F01.51 are: aggressive behavior, combative behavior, and violent behavior.

There are some important instructional notes for category F01. The first is under the category, which gives a sequencing guideline. It states to code first the underlying physiological condition or sequelae of cerebrovascular disease.

EXAMPLEA 71-year-old female is brought in for evaluation by her son for cognitive decline. She has short-term memory issues that have been progressive for the past few months after the patient suffered a stroke. She has lost interest in day-to-day activities and has to be reminded to take her medications. She has been complaining of dizziness and balance problems. She is diagnosed with vascular dementia due to the stroke. I69.31 Cognitive deficits following cerebral infarction F01.50 Vascular dementia without behavioral disturbance


Combination Codes

There is also an instructional note found under code F01.51 that states to use an additional code, if applicable, to identify wandering in vascular dementia (Z91.83). In these cases, with complete documentation, three codes would be reported, sequenced following the guidance in the code book.

EXAMPLEJohn is brought in to be seen in the clinic. He has cerebral arteriosclerosis with vascular dementia. His behavior has become suspicious and aggressive towards family members. He has been awakening multiple times during the night and is prone to wandering. The family is requesting options for his continued care with these new developments. I67.2 Cerebral atherosclerosis F01.51 Vascular dementia with behavioral disturbance Z91.83 Wandering in diseases classified elsewhere

Other DementiaAs stated previously, vascular dementia is the second most common dementia type. The most common is dementia in Alzheimer’s disease. According to the Center for Disease control, up to 5.3 million people in the United States have Alzheimer’s disease.

There are two codes in ICD-10-CM for dementia in diseases classified elsewhere:

� F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance � F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance

The same examples of behavioral disturbance are listed under code F02.81: aggressive behavior, combative behavior, and violent behavior.

The same instructional notes also appear for category F02 that are found under category F01. However, the instructional note that states to code first the underlying physiological conditions is much more extensive:

� Alzheimer’s(G30.-)—The most common form of dementia marked by a progressive memory loss, decrease in thinking ability, disability in performing activities of daily living, and recognition.

� Cerebral lipidosis (E75.4)—A group of inherited diseases associated with abnormal storage of sphingomyelin and related lipids in the brain. Four types are recognized: infantile type, early juvenile type, late juvenile type, and adult type (also called Kufs disease).

� Creutzfeldt-Jakob disease (CJD) (A81.0-)—CJD is a rare, degenerative brain disorder. According to the National Institutes of Health, there are only about 200 cases per year in the United States. It is characterized by rapidly progressive dementia.

� Dementia with Lewy bodies (G31.83)—This is a progressive form of dementia that involves the death of cells in the brain’s outer layer and part of the midbrain. Many of the surviving cells in these areas contain abnormal cells called Lewy bodies.

� Epilepsy and recurrent seizures (G40.-)—A progressive mental and intellectual deterio-ration that occurs in a small fraction of cases of epilepsy.


Combination Codes

� Frontotemporal dementia (FTD) (G31.09)—Caused by damage to the frontal or temporal lobes of the brain.

� Hepatolenticular degeneration (E83.)—Also called Wilson’s disease. An inherited disorder of copper metabolism in which copper accumulates in the liver, the red blood cells, and the brain.

� Human immunodeficiency virus (HIV) disease (B20)—HIV infection can cause a number of problems with the brain, including neurocognitive impairment and dementia.

� Hypercalcemia (E83.52)—Calcium helps regulate your nervous system. Hypercalcemia can lead to confusion, dementia, and coma.

� Hypothyroidism, acquired (E00-E03.-) - A metabolic cause of dementia due to low levels of thyroid hormone.

� Intoxications (T36-T65)—Dementia due to exposure to, use, or abuse of a substance, usually with permanent and worsening deficits.

� Multiple sclerosis (MS) (G35)—Some people with multiple sclerosis may suffer from dementia if damage caused by the MS occurs in certain parts of the brain.

� Neurosyphilis (A52.17)—Dementia is one of the manifestations of late syphilis. � Niacin deficiency (E52)—Also called Pellagra. Characterized by diarrhea, dermatitis,

and dementia. � Parkinson’s disease (G20)—According to the Alzheimer’s Association, although not fully

understood, people with Parkinson’s disease have a higher-than-average risk of devel-oping dementia.

� Pick’s disease (G31.01)—In Pick’s disease dementia is caused by a slow shrinking of brain cells due to excess protein build-up.

� Polyarteritis nodosa (M30.0)—Vasculitis of medium and small-sized vessels. � Systemic lupus erythematosus (SLE) (M32.-)—SLE affects many organ systems,

including the central and peripheral nervous systems. Dementia is a rare neurologic manifestation.

� Trypanosomiasis (B56.-, B57.-)—There are two forms of trypanosomiasis: African (B56), in which infection is caused by the bite of infected tsetse flies that results in swelling of the brain; and American (B57), in which infection is caused by blood-sucking triatomine bugs.

� Vitamin B deficiency (E53.8)—Long-term vitamin B deficiency can damage the nerve cells, which may lead to numbness, difficulty walking, mood changes, and dementia.

As in the codes for vascular dementia, there is also an instructional note under code F02.81 that states to use an additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83). In these cases, with complete documentation, three codes would be reported, sequenced following the guidance in the code book. The same sequencing rules apply.


Combination Codes

EXAMPLEA 75-year-old late onset Alzheimer’s patient presents to the clinic with his spouse. She reports that he has become combative and angry towards her again because he cannot remember things. He gets quite agitated at times. He also has occasional wandering in the late afternoon. His risperidone dosage is increased and discussion is held on ways to limit wandering, including addressing potential triggers, providing visual cues, and distractions. G30.1 Alzheimer’s diseases with late onset F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance Z91.83 Wandering in diseases classified elsewhere

The last two ICD-10-CM codes that relate to dementia are the unspecified dementia codes:

� F03.90 Unspecified dementia without behavioral disturbance � F03.91 Unspecified dementia with behavioral disturbance

The same guidelines are given for these codes as with the others. Examples of unspecified dementia from an ICD-10-CM standpoint include presenile dementia, senile dementia, senile psychosis, and primary degenerative dementia.

Anxiety and Stress-related Disorders Anxiety is a normal reaction to stressful situations and can be beneficial in some instances. When it becomes excessive, though, it may become difficult to control and negatively impact on a person’s day-to-day living. According to the National Institute of Mental Health, anxiety disorders affect about 40 million American adults age 18 years and older in a given year, accounting for 18 percent of the population. Women are more likely to suffer from anxiety and stress-related disorders.

There are several disorders recognized in ICD-10-CM:

� Social phobia (F40.1-): Patients with social phobia suffer overwhelming worry and self-consciousness about everyday social activities and situations. The worry often centers on a fear of being judged by others, or behaving in an embarrassing manner. There are two codes in ICD-10-CM for social phobia: F40.10, Social phobia, unspecified; and F40.11, Social phobia, generalized.

� Specific (isolated) phobias (F40.2-): Patients with isolated phobias suffer from a specific, intense fear of a specific object or situation that is at an inappropriate level. ICD-10-CM codes for isolated phobias include the following subcategories:

� F40.21- Animal type phobia � F40.22- Natural environment type phobia � F40.23- Blood, injection, injury type phobia � F40.24- Situational type phobia � F40.29- Other specified phobia

� Panic disorder (F41.0): Patients with panic disorder suffer from sudden attacks of terror that strike without warning repeatedly. The patients usually also suffer sweating, chest pain, palpitations, and a choking feeling during the attacks.


Combination Codes

� Generalized anxiety disorder (GAD) (F41.1): Patients with generalized anxiety disorder have excessive, unrealistic worry and tension about many things and find it hard to control.

� Obsessive-compulsive disorder (OCD) (F42): Patients with this anxiety disorder have unwanted and repeated thoughts, feelings, ideas, sensations, or behaviors that make them perform certain rituals or routines.

� Acute stress reaction (F43.0): This disorder develops within one month of a traumatic event and is characterized by a cluster of dissociative and anxiety symptoms.

� Post-traumatic stress disorder (PTSD) (F43.1-): PTSD develops after a person suffers a terrifying order involving physical harm or the threat of physical harm. The patient may experience flashbacks of the event, nightmares, a sense of numbness or emotional blunting, hyperarousal, detachment from others, anhedonia (inability to experience pleasure from pleasurable activities), and avoidance of activities or situations remi-niscent of the trauma. ICD-10-CM has three codes for post-traumatic stress disorder, broken down by temporal parameters:

� F43.10 Post-traumatic stress disorder, unspecified � F43.11 Post-traumatic stress disorder, acute � F43.12 Post-traumatic stress disorder, chronic

� Adjustment disorders (F43.2-): Patients that have an emotional or behavioral reaction to a stressful or life-changing event that is considered maladaptive or not an expected healthy response to such an event. The codes in ICD-10-CM are broken down by mani-festation:

� F43.20 Adjustment disorder, unspecified � F43.21 Adjustment disorder with depressed mood � F43.22 Adjustment disorder with anxiety � F43.23 Adjustment disorder with mixed anxiety and depressed mood � F43.24 Adjustment disorder with disturbance of conduct � F43.25 Adjustment disorder with mixed disturbance of emotions and conduct � F43.29 Adjustment disorder with other symptoms

EXAMPLECarla presents to the office for evaluation. She was in a major car crash one month ago. She complains of nightmares about the crash, having thoughts of the accident “pop into her head” all the time. She says she now avoids getting in cars if she can and walks when possible. She jumps every time a car passes close, or if she hears a car horn. She is not sleeping well and feels detached and exhausted all the time. She stated she thought the feelings would go away, but they are getting worse and she “just can’t take it anymore.” She is diagnosed with acute post-traumatic stress disorder. F43.11 Post-traumatic stress disorder, acute


Combination Codes

EXAMPLEPaul presents for a visit. He suffered a myocardial infarction 5 weeks ago. He says that he is feeling down regarding his condition, thinking he will not live a full life any longer. He is anxious regarding physical activity or doing anything that is stressful to the body, fearing another myocardial infarction, even though he has been cleared by cardiology. He is diagnosed with adjustment disorder with anxiety and depressed mood and referred for therapy to include one-on-one and family counseling. F43.23 Adjustment disorder with mixed anxiety and depressed mood

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