Lesson 2.

1
Overview of ICD
 WHO: World Health Organization ; Manages each
revision

History of ICD 9 : Used prior to October 2015; Implemented

1979

Diagnosis ICD 10 : Originally introduced 1993 ; Effective

October 1, 2015 ; Other countries were already using
Codes prior; final update in 2019

ICD11: Estimated to start no sooner than 2022

 Evaluate Evaluate Healthcare costs

Predict Predict healthcare costs

Function of
ICD Process
and Process and receive payment from insurance
companies
receive

Track Track utilization of services

 Advancements to Medicine

Mortality
Why the
Need for Morbidity

different Research

Revisions? Digital

Decision Made in 2007 for ICD 11

 u While morbidity refers to your level of
health and well-being, mortality is
related to your risk of death. They are
Morbidity VS not the same thing. Morbidity doesn't
necessarily mean that your ill-health is
Mortality immediately life-threatening. Over
time, however, if an illness continues it
may increase your risk of mortality
(death).
ICD 10

u Approved by World
Health Assembly in 1989
u US Implemented in 2015
u Translated into 43
Languages
u Used in over 100
Countries
u 30 years old already !
ICD 10 Structure
ICD 11 Addition to New Chapters

Immune Health
Blood and Blood Organs
Sexual Health
Sleep and Wake Disorders
Traditional Medicine
ICD 11 Coding Scheme

u Letter in the second position to differentiate from the codes of ICD–10.

u First character of the code always relates to the chapter number. It may be a
number or a letter. The code range of a single chapter always has the same
character in the first position.
u In order to describe a causal relationship between conditions in a code title the
preferred term is ‘due to’.
u In order to indicate the concurrence of two conditions in a code title the preferred
term is ‘associated with’.
u The codes of the ICD–11 are alphanumeric and cover the range from 1A00.00 to
[Link]. Codes starting with ‘X’ indicate an extension code (see Extension codes).
The inclusion of a forced number at the 3rd character position prevents spelling
‘undesirable words. The letters ‘O’ and ‘I’ are omitted to prevent confusion with
the numbers ‘0’ and ‘1’. Chapters are indicated by the first character. For
example, 1A00 is a code in Chapter 1, and BA00 is a code in Chapter 11.
ICD 11 Words to know

u Stem Code :Stem codes are codes that can be used alone. They are found in
the tabular list of ICD-11 for Mortality and Morbidity Statistics. Stem codes
may be entities or groupings of high relevance, or clinical conditions that
should always be described as one single category. The design of stem codes
makes sure that in use cases that require only one code per case, a
meaningful minimum of information is collected.
u Extension Code :extension codes are designed to standardize the way
additional information is added to a stem code when users and settings are
interested in reporting more detail than is included in a stem code. Extension
codes can never be used without a stem code and can never appear in the
first position in a cluster.
u Cluster coding refers to a convention used (either forward slash (/) or
ampersand (&)) to show more than one code used together (e.g. stem
code/stem code(s)&extension code(s)) to describe a documented clinical
concept

u Post coordination refers to linking (through cluster coding) multiple codes

(i.e. stem codes and/or extension codes) together, to fully describe a
documented clinical concept.
Cluster Code

Example: Diagnosis: Duodenal ulcer

with acute hemorrhage, Cluster:
DA63.Z/ME24.90; Condition - DA63
Duodenal ulcer, unspecified; Has
manifestation (use additional code, if
desired) - ME24.90 Acute
gastrointestinal bleeding, not
elsewhere classified
 Problems associated with transferring
patients (Code QA82)

Gender incongruence (Code HA4Z)

New Codes
Gaming disorder (Code 6C51)

Post-traumatic stress disorder (Code

6B40)
 u Example : Alzheimer's Disease
ICD Code u ICD 9 331.0

Changes u

u
ICD 10
ICD 11
G30
8A20
Cross Walks
Building Blocks to
Coding
u 1. Identify the main term(s) in the
assessment statement of the medical note.
u Go to Alphabetic Index and find the term
u Review any sub terms under the main term
in the Index
u Cross reference with any special words
such as “see”
u Verify code selected in the Tabular Section
u Review instructional notations in Tabular
u Assign codes to highest level of specificity
u Code all elements of the diagnosis codes in
the medical note
Use Additional Codes
Yearly Updates
 u The ICD 10 was originally introduced in 1993 by
______________.
u A. CMS
Review Question u B. AHIMA
u C. BBC
u D. WHO
Lesson 2.2
OUTPATIENT GUIDELINES
 Found Beginning of ICD Manual

What are the Several pages from General to

specific Chapters
Guidelines ?

Set of rules when assigning code

 Laterality

Sequela (Late effects)

Basic
Diagnosis
Acute and Chronic Conditions

Coding Signs and Symptoms

Guidelines Multiple codes for single condition

Combination Codes
 u We do not code the following
conditions:
u “probable “
u “suspected”
Uncertain u “questionable”

Diagnosis u

u
“rule out “
“working diagnosis “

u **Code instead signs , symptoms or

abnormal findings ***
Excluded
“With”
“Code First”
“See Also”
Level of Coding
Laterality
First Listed Diagnosis

Also known as Take precedence over Diagnosis not normally Always start Tabular List will trick
principal diagnosis outpatient guidelines established in initial Alphabetic Index you into errors !
encounter/visit
 Acute : less than 4 weeks

Acute Vs Subacute : 4-12 weeks

Chronic
Chronic : Greater than 12
weeks
Z Codes

u Located at end of Tabular

u Contact/ Exposure
u Status
u Vaccinations
u External Cause
u Gives more pieces to the puzzle
Z Code Examples

Z59.0 Homelessness

Z76.82 Awaiting Organ Transplant

Z22 Carrier of Infectious disease

Z95 Presence of cardiac and vascular

implants and grafts

Z88.0 Allergy status to penicillin

 QD71.1 Homelessness

QB12.0 Awaiting organ transplant

ICD 11 QD0Z Carrier of infectious disease

Comparison QB50 Presence of cardiac and vascular
implant

QC44.2 Personal history allergy to penicillin

 Assign code for the medical condition that patient is admitted
Assign for

Outpatient Code
When patient presents for outpatient surgery and develops
complication requiring admission to observation , code reason
for surgery then code the complications as secondary diagnosis

Status
.example post operative infection

Z03 and Z04 : report for observation as primary diagnosis for

Report medical conditions that are suspected or rule out conditions
 Chronic diseases treated on ongoing basis
may be coded and reported as many
times as patient receives treatment and
care for these conditions

Chronic Asthma

Conditions

Diabetes
Sequela (late effects)

Condition produced after acute phase of an illness or

injury has terminated .

No time limit ; could be early or years later

Example : Scars after burn

 A Initial Encounter ; ER
visit after car accident

7 TH D Subsequent Encounter ;
Character Physical Therapy

S Sequela ; 6 months
later scar
 X37.0 Hurricane

W54.0 Bitten By a Dog

External
Codes Z31 Exposure to excessive natural cold

X38 Flood
 Z34.00 Encounter for
supervision of normal pregnancy

Pregnancy
O09 Supervision of high-risk
pregnancy as primary diagnosis
then code specific condition
 u Sally has breast cancer and reports for her
scheduled chemotherapy appointment at an
outpatient hospital . Sally receives treatment
for her breast cancer .
u Index: Chemotherapy, neoplasm Z51.11
u Tabular : Z51 Encounter for other aftercare
u Z51.1 Encounter for antineoplastic chemotherapy
and immunotherapy

Open Book u
u Z51.11 Chemotherapy treatment

Code also : C50.919 ICD 10 (breast cancer)

Discovery u ICD11 : 2C6Z (breast cancer)

u Laterality (use additional code, if desired .)
u XK9J Bilateral
u XK8G Left
u XK9K Right
u XK70 Unilateral, unspecified
u XK6G Unspecified laterality
u END ICD11 CODE : 2C6Z&XK9J
Lesson 2.3
Infectious
and parasitic
Certain infectious and parasitic
diseases
u Includes:
u diseases generally recognized as communicable or transmissible
u Use Additional code to identify resistance to antimicrobial drugs (Z16.-)
u Excludes1
u certain localized infections - see body system-related chapters
u Excludes2
u carrier or suspected carrier of infectious disease (Z22.-)
u infectious and parasitic diseases complicating pregnancy, childbirth and the
puerperium (O98.-)
u infectious and parasitic diseases specific to the perinatal period (P35-P39)
u influenza and other acute respiratory infections (J00-J22)
Infectious Disease ICD 10 Codes

u A32 Listeriosis
u A33 Tetanus neonatorum
u A34 Obstetrical tetanus
u A35 Other tetanus
u Inclusion term(s):
u Tetanus NOS

u A36 Diphtheria
u A37 Whooping cough
u A38 Scarlet fever
u A39 Meningococcal infection
u A40 Streptococcal sepsis
u A41 Other sepsis
u A42 Actinomycosis
 u HIV infection/illness is coded as a
diagnosis only for confirmed cases.
Confirmation does not require
HIV Diagnosis documentation of a positive blood test
or culture for HIV; the physician’s
Coding diagnostic statement that the patient
is HIV positive or has an HIV-related
illness is sufficient.
 u The proper sequencing for HIV depends
on the reason for the admission or
encounter. When a patient is admitted
for an HIV-related condition, sequence
B20 Human immunodeficiency virus
[HIV] disease first, followed by
additional diagnosis codes for all
Sequencing reported HIV-related conditions.
Conditions always considered HIV-
related include Kaposi’s sarcoma,
lymphoma, Pneumocystis carinii
pneumonia (PCP), cryptococcal
meningitis, and cytomegaloviral
disease. These conditions are
considered opportunistic infections.
u If a patient with HIV disease is admitted for an unrelated condition (e.g.,
fracture), sequence the code for the unrelated condition, first. Report B20 as
an additional diagnosis, along with any HIV-related conditions.
u Apply Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
when the patient is HIV positive and does not have any documented symptoms
of an HIV-related illness. Do not use this code if the term AIDS is used. If the
patient is treated for any HIV-related illness or is described as having any
condition resulting from HIV positive status, use B20.
u Patients with inconclusive HIV serology, and no definitive diagnosis or
manifestations of the illness, may be assigned code R75 Inconclusive
laboratory evidence of human immunodeficiency virus [HIV].
u Known prior diagnosis of an HIV-related illness should be coded to B20. After a
patient has developed an HIV-related illness, the patient’s condition should be
assigned code B20 on every subsequent admission/encounter. Never assign
R75 or Z21 to a patient with an earlier diagnosis of AIDS or symptomatic HIV
(B20).
u If a patient is being seen to determine HIV status, use code Z11.4 Encounter
for screening for human immunodeficiency virus [HIV]. Should a patient with
signs, symptoms or illness, or a confirmed HIV-related diagnosis be tested for
HIV, code the signs and symptoms or the diagnosis. If the results are positive
and the patient is symptomatic, report B20 with codes for the HIV-related
symptoms or diagnosis. The HIV counseling code (Z71.7) may be used if
counseling is provided for patients with positive test results. When a patient
believes that he/she has been exposed to or has come into contact with the
HIV virus, report Z20.6.
HIV Stages added to ICD 11

1 2 3 4
Stage 1: Stage 2: Stage 3: Stage 4 :
Primary HIV Clinically Symptomatic Progression
infection Asymptomatic HIV Infection from HIV to
Stage AIDS
 u This stage of infection lasts for a few
weeks and is often accompanied by a
short flu–like illness. In up to about 20%
of people the symptoms are serious
enough to consult a doctor, but the
diagnosis of HIV infection is frequently
Stage 1 missed.
u Clinical findings:
u Asymptomatic.
u Persistent generalized
lymphadenopathy.
Stage 2

u This stage lasts for an average of ten years and, as its name suggests, is free from major
symptoms, although there may be swollen glands. The level of HIV in the peripheral blood
drops to very low levels but people remain infectious and HIV antibodies are detectable in
the blood, so antibody tests will show a positive result.
u Moderate unexplained* weight loss (under 10% of presumed or measured body weight)**
u Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
u Herpes zoster.
u Angular chelitis.
u Recurrent oral ulceration.
u Papular pruritic eruptions.
u Seborrhoeic dermatitis.
u Fungal nail infections.
Stage 3

u Unexplained* severe weight loss (over 10% of presumed or measured body

weight).**
u Unexplained* chronic diarrhea for longer than one month.
u Unexplained* persistent fever (intermittent or constant for longer than one
month).
u Persistent oral candidiasis.
u Oral hairy leukoplakia.
u Pulmonary tuberculosis.
u Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint
infection, meningitis, bacteremia).
u Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
u Unexplained* anemia (below 8 g/dl), neutropenia (below 0.5 billion/l) and/or
chronic thrombocytopenia (below 50 billion/l)
Stage 4

u HIV wasting syndrome.

u Pneumocystis pneumonia.
u Recurrent severe bacterial pneumonia.
u Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month's duration or
visceral at any site).
u Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs).
u Extrapulmonary tuberculosis.
u Kaposi sarcoma.
u Cytomegalovirus infection (retinitis or infection of other organs).
u Central nervous system toxoplasmosis.
u HIV encephalopathy.
u Extrapulmonary cryptococcosis including meningitis.
u Disseminated non–tuberculous mycobacteria infection.
u Progressive multifocal leukoencephalopathy.
Note “code elsewhere “
B20

u HIV WITH SYMPTOMS. ONCE ASSIGNED ALWAYS B20. REPORT ONLY CONFIRMED
CASES. STATEMENT FROM THE DOCTOR THAT PATIENT IS POSITIVE FOR HIV OR
HAS AN HIV RELATED ILLNESS.
u B20 does not have a crosswalk to 11, thus you must refer to the stage.
 R75 INCONCLUSIVE LAB OF HIV

Z20.6 EXPOSURE TO HIV

Z11.4 PRIMARY CODE FOR AN ENCOUNTER FOR SCREENING FOR HIV

ICD 10 Z71.7 HIV COUNSELING (NEGATIVE RESULT)

Z21 ASYMPTOMATIC HIV (POSITIVE RESULTS WITH NO SYMPTOMS)

B20 HIV WITH SYMPTOMS. ONCE ASSIGNED ALWAYS B20. REPORT ONLY
CONFIRMED CASES. STATEMENT FROM THE DOCTOR THAT PATIENT IS POSITIVE FOR
HIV OR HAS AN HIV RELATED ILLNESS.
 MA14.0 Laboratory evidence of human
immunodeficiency virus

QC90.6 Contact with or exposure to human

immunodeficiency virus

ICD 11 QA08.4 Screening HIV

QA14 human immunodeficiency virus

counselling

1C62.0 HIV stage 1

PREGNANCY u FIRST CODE: O98.7 (11-JB63.7)
SECOND: Z21 OR B20
AND HIV THIRD: HIV RELATED CONDITIONS
 u Reason for encounter such as fracture

Sequencing HIV u B20

u HIV related condition
Sepsis, Severe Sepsis, and Septic
Shock
u Sepsis: It’s a severe infection caused by an organism.
u Severe sepsis: it’s a severe infection by organism and leads to organ
dysfunction
u Severe sepsis with septic shock: it’s a severe infection caused by organism
refers to circulatory failure and is a form of organ dysfunction associated with
sepsis and cannot occur in the absence of severe sepsis.
 u For a diagnosis of sepsis, assign the
appropriate code for the underlying
systemic infection. If the type of
Sepsis infection or causal organism is not
further specified, assign code A41.9,
Sepsis, unspecified organism.
Sepsis Guidelines

u A code from subcategory R65.2, Severe sepsis, should not be assigned unless
severe sepsis or an associated acute organ dysfunction is documented.
u (i) Negative or inconclusive blood cultures and sepsis Negative or inconclusive
blood cultures do not preclude a diagnosis of sepsis in patients with clinical
evidence of the condition; however, the provider should be queried.
u ii) Urosepsis : is a nonspecific term. It is not to be considered synonymous
with sepsis. It has no default code in the Alphabetic Index. Should a provider
use this term, he/she must be queried for clarification.
Sepsis Guidelines

u Sepsis with organ dysfunction: If a patient has sepsis and associated acute
organ dysfunction or multiple organ dysfunction (MOD), follow the instructions
for coding severe sepsis.

u Acute organ dysfunction that is not clearly associated with the sepsis If a
patient has sepsis and an acute organ dysfunction, but the medical record
documentation indicates that the acute organ dysfunction is related to a
medical condition other than the sepsis, do not assign a code from
subcategory R65.2, Severe sepsis. An acute organ dysfunction must be
associated with the sepsis in order to assign the severe sepsis code. If the
documentation is not clear as to whether an acute organ dysfunction is
related to the sepsis or another medical condition, query the provider.
 u The coding of severe sepsis requires a
minimum of 2 codes:
u First a code for the underlying systemic
infection,
u Second a code from subcategory R65.2,
Severe sepsis.
u If the causal organism is not
documented, assign code A41.9, Sepsis,
Severe sepsis unspecified organism, for the infection.
Additional code(s) for the associated
acute organ dysfunction are also
required.
u Due to the complex nature of severe
sepsis, some cases may require
querying the provider prior to
assignment of the codes.
Sequencing of severe sepsis

u If severe sepsis is present on admission, and meets the definition of principal

diagnosis, the underlying systemic infection should be assigned as principal
diagnosis followed by the appropriate code from subcategory R65.2 as
required by the sequencing rules in the Tabular List. A code from subcategory
R65.2 can never be assigned as a principal diagnosis. When severe sepsis
develops during an encounter (it was not present on admission), the
underlying systemic infection and the appropriate code from subcategory
R65.2 should be assigned as secondary diagnosis. Severe sepsis may be
present on admission, but the diagnosis may not be confirmed until sometime
after admission. If the documentation is not clear whether severe sepsis was
present on admission, the provider should be queried.
 u (a) Septic shock generally refers to circulatory failure
associated with severe sepsis, and therefore, it

Septic Shock u
represents a type of acute organ dysfunction
(b) Minimum 3 codes
Sequencing of septic shock

u First systemic infection code

u Second a code R65.21, Severe sepsis with septic shock or code T81.12, Post
procedural septic shock.
u Any additional codes for the other acute organ dysfunctions should also be
assigned.
u As noted in the sequencing instructions in the Tabular List, the code for septic
shock cannot be assigned as a principal diagnosis.
ICD 11 Additional Code Examples

u 1G41 Sepsis with septic shock

u Description Septic shock is a subset of sepsis in which circulatory, cellular and
metabolic abnormalities are profound enough to substantially increase mortality.
u Exclusions Bacteraemia (MA15.0)
u Matching Terms
u Bacterial sepsis with septic shock
u Viral sepsis with septic shock
u Fungal sepsis with septic shock
u Protozoal sepsis with septic shock
u Coding Note
u Any type of infection - bacterial, viral, fungal or protozoal, can cause sepsis and must be
coded first. When the site of infection is unknown, select a code for Infection of
unspecified site by organism followed by the appropriate code for sepsis.
 u Patient coming to hospital because of severe
sepsis associated with hepatic failure. What are

Coding Scenario your diagnosis codes ?

u ICD 10: A41.9, R65.20, K72.90
u ICD11 : IG40, DB99.7
Lesson 2.4
Neoplasms
Neoplasms

u The term neoplasm refers to an abnormal growth of tissue caused by the

rapid division of cells that have undergone some form of mutation.
u Benign- Noncancerous
u Malignant- Cancerous ; gets worse over time
u Metastasis- capacity to spread to distant organs via blood vessels or lymphatic
channels
u In Situ- (CIS)cancerous tumor that has not invaded other tissue
u Uncertain behavior : not sure yet ; often need biopsy
Neoplasm Table
Treatment directed at the malignancy

u If the treatment is directed at the malignancy, designate the malignancy as

the principal diagnosis. The only exception to this guideline is if a patient
admission/encounter is solely for the administration of chemotherapy,
immunotherapy or radiation therapy, assign the appropriate Z51.-(QB9Z)-
code as the first-listed or principal diagnosis, and the diagnosis or problem for
which the service is being performed as a secondary diagnosis.
Treatment of secondary site

u When a patient is admitted because of a primary neoplasm with metastasis

and treatment is directed toward the secondary site only, the secondary
neoplasm is designated as the principal diagnosis even though the primary
malignancy is still present.
Coding and sequencing of complications

u Anemia associated with malignancy

u When admission/encounter is for management of an anemia associated with the
malignancy, and the treatment is only for anemia, the appropriate code for the
malignancy is sequenced as the principal or first-listed diagnosis followed by the
appropriate code for the anemia (such as code D63.0,(3A71.Z) Anemia in neoplastic
disease).
Anemia associated with chemotherapy,
immunotherapy and radiation therapy
u When the admission/encounter is for management of an anemia associated
with an adverse effect of the administration of chemotherapy or
immunotherapy and the only treatment is for the anemia, the anemia code is
sequenced first followed by the appropriate codes for the neoplasm and the
adverse effect (T45.1X5, Adverse effect of antineoplastic and
immunosuppressive drugs). When the admission/encounter is for management
of an anemia associated with an adverse effect of radiotherapy, the anemia
code should be sequenced first, followed by the appropriate neoplasm code
and code Y84.2, Radiological procedure and radiotherapy as the cause of
abnormal reaction of the patient, or of later complication, without mention
of misadventure at the time of the procedure.
Administration of chemotherapy,
immunotherapy and radiation therapy
u If a patient admission/encounter is solely for the administration of
chemotherapy, immunotherapy or radiation therapy assign code Z51.0,
Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for
antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic
immunotherapy as the first-listed or principal diagnosis. If a patient receives
more than one of these therapies during the same admission more than one of
these codes may be assigned, in any sequence. The malignancy for which the
therapy is being administered should be assigned as a secondary diagnosis.
Sequencing of neoplasm codes

u Malignant neoplasm in a pregnant patient

u When a pregnant woman has a malignant neoplasm, a code from subcategory
O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the
puerperium, should be sequenced first, followed by the appropriate code from
Chapter 2 to indicate the type of neoplasm
u Encounter for treatment of primary malignancy
u If the reason for the encounter is for treatment of a primary malignancy, assign the
malignancy as the principal/first-listed diagnosis. The primary site is to be
sequenced first, followed by any metastatic sites.
Encounter for complication associated
with a neoplasm
u When an encounter is for management of a complication associated with a
neoplasm, such as dehydration, and the treatment is only for the
complication, the complication is coded first, followed by the appropriate
code(s) for the neoplasm. The exception to this guideline is anemia. When
the admission/encounter is for management of an anemia associated with the
malignancy, and the treatment is only for anemia, the appropriate code for
the malignancy is sequenced as the principal or first-listed diagnosis followed
by code D63.0, Anemia in neoplastic disease
Current malignancy versus personal
history of malignancy
u When a primary malignancy has been excised but further treatment, such as
an additional surgery for the malignancy, radiation therapy or chemotherapy
is directed to that site, the primary malignancy code should be used until
treatment is completed. When a primary malignancy has been previously
excised or eradicated from its site, there is no further treatment (of the
malignancy) directed to that site, and there is no evidence of any existing
primary malignancy, a code from category Z85, Personal history of malignant
neoplasm, should be used to indicate the former site of the malignancy. See
Section I.C.21. Factors influencing health status and contact with health
services, History (of)
Breast Cancer Stages

u Stage 0 breast cancer is a non-invasive condition sometimes described as pre-

cancerous. Stage 0 breast cancers include ductal carcinoma in situ (DCIS) and
lobular carcinoma in situ (LCIS). These diseases are not considered life-
threatening but can become invasive over time if not appropriately treated.
Both increase the risk of developing breast cancer in the future.
u Stage I cancer usually involves a tumor that is two centimeters or smaller and
has not spread outside the breast. Stage I cancers are almost always curable.
u Stage II and III cancer includes medium- to larger-sized tumors as well as
tumors with positive lymph nodes. With advances in breast care treatment,
stage II and stage III cancers are often curable, but many require additional
treatments to achieve this goal.
u In Stage IV, the cancer has spread to other organs of the body, most often the
bones, lungs, or liver. Another name for Stage IV cancer is metastatic cancer.
Rectal Cancer
Pancreatic Cancer
Stages

u Stage 0: No spread. Pancreatic cancer is limited to top layers of cells in the

ducts of the pancreas. The pancreatic cancer is not visible on imaging tests or
even to the naked eye.
u Stage I: Local growth. Pancreatic cancer is limited to the pancreas but has
grown to less than 2 centimeters across (stage IA) or greater than 2 but no
more than 4 centimeters (stage IB).
u Stage II: Local spread. Pancreatic cancer is over 4 centimeters and is either
limited to the pancreas or there is local spread where the cancer has grown
outside of the pancreas or has spread to nearby lymph nodes. It has not
spread to distant sites.
u Stage III: Wider spread. The tumor may have expanded into nearby major
blood vessels or nerves but has not metastasized to distant sites.
u Stage IV: Confirmed spread. Pancreatic cancer has spread to distant organs.
Sickle Cell
Leukemia
 u John presents for immunotherapy for a
malignant , primary neoplasm of the trigone of
the bladder . How would you properly code this
Open Book ?

Discovery u ICD 10 : Z51.12, C67.01

u ICD 11 : QB97, 2C94.Z
Lesson 2.5 Diseases of the blood and
blood-forming organs
 D50-D53 - Nutritional anemias
D55-D59 - Hemolytic anemias
Diseases of D60-D64 - Aplastic and other anemias and other bone marrow
failure syndromes
the blood and D65-D69 - Coagulation defects, purpura and other hemorrhagic

blood-forming
conditions
D70-D77 - Other disorders of blood and blood-forming organs

organs D78 - Intraoperative and postprocedural complications of the spleen

D80-D89 - Certain disorders involving the immune mechanism
 D50 Iron deficiency anemia

D51 Vitamin B12 deficiency anemia

Nutritional
Anemias D52 Folate deficiency anemia

D53 Other nutritional anemias

 u D66 Hereditary factor VIII deficiency
u Inclusion term(s):
u Classical hemophilia
Deficiency factor VIII (with functional defect)
Coagulation u

u Hemophilia NOS
defects, purpura u Hemophilia A

and other u D67 Hereditary factor IX deficiency

u Inclusion term(s):
hemorrhagic u Christmas disease
conditions u Factor IX deficiency (with functional defect)
u Hemophilia B
u Plasma thromboplastin component [PTC] deficiency
 u D55 Anemia due to enzyme disorders
u D56 Thalassemia
Hemolytic u D57 Sickle-cell disorders
u D58 Other hereditary hemolytic anemias
anemias
u D59 Acquired hemolytic anemia
 u John has chronic , simple anemia . What would
be your path to code this ?

Open Book u Index: Anemia D64.9 , chronic simple D53.9

u Tabular : D53.9 Nutritional anemia, unspecified

Discovery u

u
Simple Chronic Anemia

Correct code : ICD 10 D53.9

u ICD 11
3A03.Y
 Endocrine, nutritional and metabolic
Lesson 2.6 diseases
Endocrine, nutritional and metabolic
diseases
u Use for Diabetes mellitus, nutritional deficiencies, and other metabolic and
endocrine disorders not elsewhere classified.
u All neoplasms, whether functionally active or not, are classified in Chapter 2.
Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.-) may be
used as additional codes to indicate either functional activity by neoplasms
and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine
glands associated with neoplasms and other conditions classified elsewhere.
 u E00 Congenital iodine-deficiency syndrome
u E01 Iodine-deficiency related thyroid disorders and
allied conditions
u E02 Subclinical iodine-deficiency hypothyroidism

Disorders of u E03 Other hypothyroidism

u E04 Other nontoxic goiter
thyroid gland u E05 Thyrotoxicosis [hyperthyroidism]
u E06 Thyroiditis
u E07 Other disorders of thyroid
Overweight, obesity and other
hyperalimentation
u E65 Localized adiposity
u Inclusion term(s):
u Fat pad
u E66 Overweight and obesity
u E67 Other hyperalimentation
u E68 Sequelae of hyperalimentation
 u E20 Hypoparathyroidism
u E21 Hyperparathyroidism and other
disorders of parathyroid gland
u E22 Hyperfunction of pituitary gland

Disorders of u E23 Hypofunction and other disorders

of the pituitary gland
other endocrine u E24 Cushing's syndrome

glands u E25 Adrenogenital disorders

u E26 Hyperaldosteronism
 u E08 Diabetes mellitus due to underlying
condition
u E09 Drug or chemical induced diabetes
mellitus
Diabetes
u E10 Type 1 diabetes mellitus
mellitus u E11 Type 2 diabetes mellitus
u E13 Other specified diabetes mellitus
Specific Diabetes Guidelines

u Type of diabetes
u The age of a patient is not the sole determining factor, though most type 1
diabetics develop the condition before reaching puberty. For this reason type 1
diabetes mellitus is also referred to as juvenile diabetes.
u Type of diabetes mellitus not documented
u If the type of diabetes mellitus is not documented in the medical record the
default is E11.-, Type 2 diabetes mellitus
Type 1 A closer look

E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease

E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.3211 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
E10.3212 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
E10.3213 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eye
E10.3291 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
E10.3292 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
E10.3293 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye
Type 2 A closer look

u E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

u Billable - E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
u Billable - E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
u Billable - E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
u Billable - E11.3211 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye
u Billable - E11.3212 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye
u Billable - E11.3213 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral
u Billable - E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified
eye
u Billable - E11.3291 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye
u Billable - E11.3292 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye
u Billable - E11.3293 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral
u Billable - E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema,
unspecified eye
Excludes

u diabetes mellitus due to underlying condition (E08.-)

u drug or chemical induced diabetes mellitus (E09.-)
u gestational diabetes (O24.4-)
u neonatal diabetes mellitus (P70.2)
u postpancreatectomy diabetes mellitus (E13.-)
u postprocedural diabetes mellitus (E13.-)
u secondary diabetes mellitus NEC (E13.-)
u type 1 diabetes mellitus (E10.-)
Diabetes ICD 11

u 5A14 Diabetes mellitus, type unspecified

u diabetes NOS *
u 5A10 Type 1 diabetes mellitus
u 5A11 Type 2 diabetes mellitus
u 5A13.4 Diabetes mellitus due to drug or chemical
u 5A22.Z Diabetic acidosis, unspecified
u 5A23 Diabetic coma
Complications u Overdose of insulin due to insulin pump failure
u The principal or first-listed code for an encounter due to
due to insulin an insulin pump malfunction resulting in an overdose of
insulin, should also be T85.6-, Mechanical complication of
pump other specified internal and external prosthetic devices,
implants and grafts, followed by code T38.3X1-, Poisoning

malfunction
by insulin and oral hypoglycemic [antidiabetic] drugs,
accidental (unintentional).
 u Secondary diabetes mellitus due to
Assigning and pancreatectomy

sequencing u For postpancreatectomy diabetes

mellitus (lack of insulin due to the
surgical removal of all or part of the
secondary pancreas), assign code E89.1,
Postprocedural hypoinsulinemia. Assign
diabetes codes a code from category E13 and a code
from subcategory Z90.41, Acquired
and its causes absence of pancreas, as additional
codes.
 u Betty has diabetes mellitus with hypoglycemic
Open Book coma . What is the code you would use ?

Discovery u

u
ICD 10 :E11.641
ICD 11 : 5A21.1
Lesson 2.7 Mental and Behavior Health
 Mild intellectual disabilities: IQ level
50-55 to approximately 70

Moderate intellectual disabilities: IQ

level 35-40 to 50-55
Intellectual
disorders Severe intellectual disabilities :IQ 20-
25 to 35-40

Profound intellectual disabilities: IQ

level below 20-25
 u Mental disorders grouped together
based on their having in common a
demonstrable etiology in cerebral
disease, brain injury, or other insult
Mental disorders leading to cerebral dysfunction. The
dysfunction may be primary, as in
due to known diseases, injuries, and insults that
affect the brain directly and
physiological selectively; or secondary, as in
systemic diseases and disorders that
conditions attack the brain only as one of the
multiple organs or systems of the body
that are involved.
 u Vascular dementia
u Delirium due to known physiological
condition
u Unspecified dementia
Conditions u Presenile dementia NOS

associated with u

u
Presenile psychosis NOS
Primary degenerative dementia NOS
dementia u Senile dementia NOS
u Senile dementia depressed or paranoid
type
u Senile psychosis NOS
Dementia in other diseases classified
elsewhere
u Code first the underlying physiological condition, such as:
Alzheimer's (G30.-)
cerebral lipidosis (E75.4)
Creutzfeldt-Jakob disease (A81.0-)
dementia with Lewy bodies (G31.83)
dementia with Parkinsonism (G31.83)
epilepsy and recurrent seizures (G40.-)
frontotemporal dementia (G31.09)
hepatolenticular degeneration (E83.0)
human immunodeficiency virus [HIV] disease (B20)
Huntington's disease (G10)
hypercalcemia (E83.52)
hypothyroidism, acquired (E00-E03.-)
intoxications (T36-T65)
 u F10 Alcohol related disorders
u F11 Opioid related disorders
u F12 Cannabis related disorders

Mental and u F13 Sedative, hypnotic, or anxiolytic

related disorders
behavioral u F14 Cocaine related disorders

disorders due to u F15 Other stimulant related disorders

u F16 Hallucinogen related disorders
psychoactive u F17 Nicotine dependence
substance use u F18 Inhalant related disorders
u F19 Other psychoactive substance
related disorders
 Schizophrenia

Schizophrenia, Schizotypal disorder

schizotypal,
Delusional disorders
delusional, and
other non-mood Brief psychotic disorder

psychotic Shared psychotic disorder

disorders Unspecified psychosis not due to a substance or known

physiological condition
Schizophrenia

u - F20.0 Paranoid schizophrenia

u - F20.1 Disorganized schizophrenia
u - F20.2 Catatonic schizophrenia
u - F20.3 Undifferentiated schizophrenia
u - F20.5 Residual schizophrenia
u - F20.81 Schizophreniform disorder
u - F20.89 Other schizophrenia
u - F20.9 Schizophrenia, unspecified
Mood Disorders

u F30 Manic episode

u F31 Bipolar disorder
u F32 Major depressive disorder, single episode
u F33 Major depressive disorder, recurrent
u F34 Persistent mood [affective] disorders
u F39 Unspecified mood [affective] disorder
u Inclusion term(s):
u Affective psychosis NOS
Anxiety and stress related disorders

u F40 Phobic anxiety disorders

u F41 Other anxiety disorders
u F42 Obsessive-compulsive disorder
u F43 Reaction to severe stress, and adjustment disorders
u F44 Dissociative and conversion disorders
u F45 Somatoform disorders
u F48 Other nonpsychotic mental disorders
 u F60 Specific personality disorders
u F63 Impulse disorders
u F64 Gender identity disorders
u F65 Paraphilias
Disorders of adult u F66 Other sexual disorders
personality and u Inclusion term(s):
u Sexual maturation disorder
behavior u Sexual relationship disorder
u F68 Other disorders of adult personality
and behavior
u F69 Unspecified disorder of adult
personality and behavior
 u Code the following :
Open Book u Depression with anxiety

Discovery u

u
ICD 10
ICD 11
F41.8
6A70
Lesson 2.8
Pregnancy, childbirth and the
puerperium
u PREGNANCY CODES ARE FOR USE ONLY ON MATERNAL RECORDS, NEVER ON
NEWBORN RECORDS
They are for use for conditions related to or aggravated by the pregnancy,
childbirth, or by the puerperium (maternal causes or obstetric causes)
u
Trimesters are counted from the first day of the last menstrual period. They are
defined as follows:
1st trimester- less than 14 weeks 0 days
2nd trimester- 14 weeks 0 days to less than 28 weeks 0 days
3rd trimester- 28 weeks 0 days until delivery
Weeks of gestation

u - Z3A.01 Less than 8 weeks gestation of pregnancy

u - Z3A.08 8 weeks gestation of pregnancy
u - Z3A.09 9 weeks gestation of pregnancy
u - Z3A.10 10 weeks gestation of pregnancy
u - Z3A.11 11 weeks gestation of pregnancy
u - Z3A.12 12 weeks gestation of pregnancy
u - Z3A.13 13 weeks gestation of pregnancy
u - Z3A.14 14 weeks gestation of pregnancy
u - Z3A.15 15 weeks gestation of pregnancy
u - Z3A.16 16 weeks gestation of pregnancy
Pregnancy with abortive outcome

u O00 Ectopic pregnancy

u O01 Hydatidiform mole
u O02 Other abnormal products of conception
u O03 Spontaneous abortion
u Note: Incomplete abortion includes retained products of conception following
spontaneous abortion
u O04 Complications following (induced) termination of pregnancy
u O07 Failed attempted termination of pregnancy
u O08 Complications following ectopic and molar pregnancy
Supervision High Risk pregnancy

u - O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified

trimester
u - O09.31 Supervision of pregnancy with insufficient antenatal care, first trimester
u - O09.32 Supervision of pregnancy with insufficient antenatal care, second
trimester
u - O09.33 Supervision of pregnancy with insufficient antenatal care, third trimester
u - O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester
u - O09.41 Supervision of pregnancy with grand multiparity, first trimester
u - O09.42 Supervision of pregnancy with grand multiparity, second trimester
u - O09.43 Supervision of pregnancy with grand multiparity, third trimester
u - O09.511 Supervision of elderly primigravida, first trimester
 •O10 Pre-existing hypertension complicating
pregnancy, childbirth and the puerperium
•O11 Pre-existing hypertension with pre-
eclampsia
Disorders •O12 Gestational [pregnancy-induced] edema
and proteinuria without hypertension
during •O13 Gestational [pregnancy-induced]
hypertension without significant proteinuria
pregnancy •O14 Pre-eclampsia
•O15 Eclampsia
•O16 Unspecified maternal hypertension
Gestational Diabetes

u A condition caused by dysfunctional maternal insulin receptors. This condition

is characterized by glucose intolerance with onset or first recognition during
pregnancy, with at least one of the following criteria met: fasting plasma
glucose greater than or equal to 7.0 millimoles per litre (126 mg/ dL); 2-hour
plasma glucose greater than or equal to 11.1 millimoles per litre (200 mg/dL)
following a 75 gram oral glucose load; random plasma glucose greater than or
equal to 11.1 millimoles per litre (200 mg/ dL). Confirmation is by an oral
glucose tolerance test.
ICD 11 PATH

u 18 Pregnancy, childbirth or the puerperium

u Certain specified maternal disorders predominantly related to pregnancy
u JA63 Diabetes mellitus in pregnancy
Complications of Delivery

u O60 Preterm labor

u O61 Failed induction of labor
u O62 Abnormalities of forces of labor
u O63 Long labor
u O64 Obstructed labor due to malposition and malpresentation of fetus
u O65 Obstructed labor due to maternal pelvic abnormality
u O66 Other obstructed labor
u O67 Labor and delivery complicated by intrapartum hemorrhage, not
elsewhere classified
 O80-O82 - Encounter for delivery
•O80 Encounter for full-term uncomplicated delivery
Inclusion term(s):

Encounter for •Delivery requiring minimal or no assistance, with or without

episiotomy, without fetal manipulation [e.g., rotation version] or

Delivery instrumentation [forceps] of a spontaneous, cephalic, vaginal, full-

term, single, live-born infant. This code is for use as a single diagnosis
code and is not to be used with any other code from chapter 15.

O82 Encounter for cesarean delivery without indication

What is the outcome ?
 u Code the following :
Open Book u False labor 38-week pregnancy , undelivered

Discovery u

u
ICD10 :O47.1
ICD 11: JA8D.1
Lesson 2.9
Certain
conditions
originating in the
perinatal period
After baby is born

u This section codes are used for principal diagnosis for birth record and NEVER for
use on maternal record. For reporting purposes, the perinatal period is defined as
before birth through the 28th day following birth.
u Includes:
u conditions that have their origin in the fetal or perinatal period (before birth
through the first 28 days after birth) even if morbidity occurs later
u Excludes2
u congenital malformations, deformations and chromosomal abnormalities (Q00-
Q99)
u endocrine, nutritional and metabolic diseases (E00-E88)
u injury, poisoning and certain other consequences of external causes (S00-T88)
u neoplasms (C00-D49)
u tetanus neonatorum (A33)
Newborn effected by Maternal factors

u P00 Newborn affected by maternal conditions that may be unrelated to

present pregnancy
u P01 Newborn affected by maternal complications of pregnancy
u P02 Newborn affected by complications of placenta, cord and membranes
u P03 Newborn affected by other complications of labor and delivery
u P04 Newborn affected by noxious substances transmitted via placenta or
breast milk
Birth Trauma

u P10 Intracranial laceration and hemorrhage due to birth injury

u P11 Other birth injuries to central nervous system
u P12 Birth injury to scalp
u P13 Birth injury to skeleton
u P14 Birth injury to peripheral nervous system
u P15 Other birth injuries
Bacterial Sepsis of Newborn

u - P36.0 Sepsis of newborn due to streptococcus, group B

u - P36.10 Sepsis of newborn due to unspecified streptococci
u - P36.19 Sepsis of newborn due to other streptococci
u - P36.2 Sepsis of newborn due to Staphylococcus aureus
u - P36.30 Sepsis of newborn due to unspecified staphylococci
u - P36.39 Sepsis of newborn due to other staphylococci
u - P36.4 Sepsis of newborn due to Escherichia coli
u - P36.5 Sepsis of newborn due to anaerobes
u - P36.8 Other bacterial sepsis of newborn
u - P36.9 Bacterial sepsis of newborn, unspecified
Other problems with newborn

u Inclusion term(s):
u Inclusion terms
u List of terms is included under some codes. These terms are the conditions for which that code is to be
used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms
are a list of the various conditions assigned to that code. The inclusion terms are not necessarily
exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
u Acidemia of newborn
u Acidosis of newborn
u Anoxia of newborn NOS
u Asphyxia of newborn NOS
u Hypercapnia of newborn
u Hypoxemia of newborn
u Hypoxia of newborn NOS
u Mixed metabolic and respiratory acidosis of newborn
 u P90 Convulsions of newborn
u P91 Other disturbances of cerebral
status of newborn
u P92 Feeding problems of newborn
u P93 Reactions and intoxications due to
drugs administered to newborn
Other disorders u P94 Disorders of muscle tone of
newborn
originating in the u P95 Stillbirth
u Inclusion term(s):
perinatal period u Deadborn fetus NOS
u Fetal death of unspecified cause
u Stillbirth NOS
u P96 Other conditions originating in the
perinatal period
 u Code the following

Open Book u Newborn female delivered in the hospital via c-

section and with Down syndrome (trisomy 21)
Discovery u ICD 10 Z38.01, Q90.9, F79
u ICD 11 QA47.01, LD40, 6A00.Z
Lesson 2.10

SSymptoms, signs and abnormal

clinical and laboratory findings, not
elsewhere classified
Guidelines

u This section includes symptoms, signs, abnormal results of clinical or other

investigative procedures, and ill-defined conditions regarding which no
diagnosis classifiable elsewhere is recorded.
Signs and symptoms that point rather definitely to a given diagnosis have
been assigned to a category in other chapters of the classification. In general,
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 perhaps equally to two or more diseases or to two or more
systems of the body. Practically all categories in the chapter could be
designated 'not otherwise specified', 'unknown etiology' or 'transient'. The
Alphabetical Index should be consulted to determine which symptoms and
signs are to be allocated here and which to other chapters. The residual
subcategories, numbered .8, are generally provided for other relevant
symptoms that cannot be allocated elsewhere in the classification.
Excludes

u abnormal findings on antenatal screening of mother (O28.-)

u certain conditions originating in the perinatal period (P04-P96)
u signs and symptoms classified in the body system chapters
u signs and symptoms of breast (N63, N64.5)
General Symptoms

u R50 Fever of other and unknown origin

u R51 Headache
u R52 Pain, unspecified
u R53 Malaise and fatigue
u R54 Age-related physical debility
u R55 Syncope and collapse
u R59 Enlarged lymph nodes
Respiratory and Circulatory

u R00 Abnormalities of heart beat

u R01 Cardiac murmurs and other cardiac sounds
u R03 Abnormal blood-pressure reading, without diagnosis
u R04 Hemorrhage from respiratory passages
u R05 Cough
u R06 Abnormalities of breathing
u R07 Pain in throat and chest
u R09 Other symptoms and signs involving the circulatory and respiratory
system
Digestive

u R10 Abdominal and pelvic pain

u R11 Nausea and vomiting
u R12 Heartburn
u R13 Aphagia and dysphagia
u R14 Flatulence and related conditions
u R15 Fecal incontinence
u R16 Hepatomegaly and splenomegaly, not elsewhere classified
u R17 Unspecified jaundice
Nervous and musculoskeletal

u R25 Abnormal involuntary movements

u R26 Abnormalities of gait and mobility
u R27 Other lack of coordination
u R29 Other symptoms and signs involving the nervous and musculoskeletal
systems
Abnormal Finding related to blood

u R70 Elevated erythrocyte sedimentation rate and abnormality of plasma

viscosity
u R71 Abnormality of red blood cells
u R73 Elevated blood glucose level
u R74 Abnormal serum enzyme levels
u R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV]
u R78 Findings of drugs and other substances, not normally found in blood
Radiology abnormal findings

u R90 Abnormal findings on diagnostic imaging of central nervous system

u R91 Abnormal findings on diagnostic imaging of lung
u R92 Abnormal and inconclusive findings on diagnostic imaging of breast
u R93 Abnormal findings on diagnostic imaging of other body structures
u R94 Abnormal results of function studies
Abnormal findings of urine

u Excludes1
u abnormal findings on antenatal screening of mother (O28.-)
u diagnostic abnormal findings classified elsewhere - see Alphabetical Index
u specific findings indicating disorder of amino-acid metabolism (E70-E72)
u specific findings indicating disorder of carbohydrate metabolism (E73-E74)
u R80 Proteinuria
u R81 Glycosuria
u R82 Other and unspecified abnormal findings in urine
 u Code the following :

Open Book u Nonspecific abnormal finding of cervical

Papanicolaou smear
Discovery u ICD 10 R87.619
u ICD 11 MF6Y
Lesson 2.11

Injury, poisoning and certain other

consequences of external causes
 u S41 Open wound of shoulder and upper arm
u S42 Fracture of shoulder and upper arm
u Note: A fracture not indicated as displaced
or nondisplaced should be coded to
displaced
A fracture not indicated as open or closed
should be coded to closed
u S43 Dislocation and sprain of joints and
ligaments of shoulder girdle
Injuries to the u S44 Injury of nerves at shoulder and upper arm
level
shoulder and u S45 Injury of blood vessels at shoulder and
upper arm level
upper arm u S46 Injury of muscle, fascia and tendon at
shoulder and upper arm level
u S47 Crushing injury of shoulder and upper arm
u S48 Traumatic amputation of shoulder and
upper arm
u S49 Other and unspecified injuries of shoulder
and upper arm
Code to highest level

u - S43.081A Other subluxation of right shoulder joint, initial encounter

u - S43.081D Other subluxation of right shoulder joint, subsequent encounter
u - S43.081S Other subluxation of right shoulder joint, sequela
u - S43.082A Other subluxation of left shoulder joint, initial encounter
u - S43.082D Other subluxation of left shoulder joint, subsequent encounter
u - S43.082S Other subluxation of left shoulder joint, sequela
u - S43.083A Other subluxation of unspecified shoulder joint, initial encounter
u - S43.083D Other subluxation of unspecified shoulder joint, subsequent encounter
u - S43.083S Other subluxation of unspecified shoulder joint, sequela
u - S43.084A Other dislocation of right shoulder joint, initial encounter
u - S43.084D Other dislocation of right shoulder joint, subsequent encounter
Toxic effects

u T51 Toxic effect of alcohol

u T52 Toxic effect of organic solvents
u T53 Toxic effect of halogen derivatives of aliphatic and aromatic hydrocarbons
u T54 Toxic effect of corrosive substances
u T55 Toxic effect of soaps and detergents
u T56 Toxic effect of metals
u T57 Toxic effect of other inorganic substances
u T58 Toxic effect of carbon monoxide
u T59 Toxic effect of other gases, fumes and vapors
u T60 Toxic effect of pesticides
Unspecified effects

u T73 Effects of other deprivation

u T74 Adult and child abuse, neglect and other maltreatment, confirmed
u T75 Other and unspecified effects of other external causes
u T76 Adult and child abuse, neglect and other maltreatment, suspected
u T78 Adverse effects, not elsewhere classified
Surgical complications

u T80 Complications following infusion, transfusion and therapeutic injection

u T81 Complications of procedures, not elsewhere classified
u T82 Complications of cardiac and vascular prosthetic devices, implants and grafts
u T83 Complications of genitourinary prosthetic devices, implants and grafts
u T84 Complications of internal orthopedic prosthetic devices, implants and grafts
u T85 Complications of other internal prosthetic devices, implants and grafts
u T86 Complications of transplanted organs and tissue
u T87 Complications peculiar to reattachment and amputation
u T88 Other complications of surgical and medical care, not elsewhere classified
Surgical Excludes

u any encounters with medical care for postprocedural conditions in which no complications are
present, such as:
u artificial opening status (Z93.-)
u closure of external stoma (Z43.-)
u fitting and adjustment of external prosthetic device (Z44.-)
u burns and corrosions from local applications and irradiation (T20-T32)
u complications of surgical procedures during pregnancy, childbirth and the puerperium (O00-O9A)
u mechanical complication of respirator [ventilator] (J95.850)
u poisoning and toxic effects of drugs and chemicals (T36-T65 with fifth or sixth character 1-4 or 6)
u postprocedural fever (R50.82)
u specified complications classified elsewhere, such as:
u cerebrospinal fluid leak from spinal puncture (G97.0)
Poisoning

u T39 Poisoning by, adverse effect of and underdosing of nonopioid analgesics, antipyretics and
antirheumatics
u T40 Poisoning by, adverse effect of and underdosing of narcotics and psychodysleptics
[hallucinogens]
u T41 Poisoning by, adverse effect of and underdosing of anesthetics and therapeutic gases
u T42 Poisoning by, adverse effect of and underdosing of antiepileptic, sedative- hypnotic and
antiparkinsonism drugs
u T43 Poisoning by, adverse effect of and underdosing of psychotropic drugs, not elsewhere
classified
u T44 Poisoning by, adverse effect of and underdosing of drugs primarily affecting the
autonomic nervous system
u T45 Poisoning by, adverse effect of and underdosing of primarily systemic and hematological
agents, not elsewhere classified
u T46 Poisoning by, adverse effect of and underdosing of agents primarily affecting the
cardiovascular system
 Step 1 Code the Location and Degree of Burn

Report the TBSA (total body surface

Burns Step 2 area)

Step 3 Report the Cause of the Burn

 u Your patient has a second degree burn of the left foot
from hot bath water. It is 2% of body This is a
subsequent encounter for the injury.
Apply the u Step 1 : T25.222D (Burn of second degree of left foot ...
subsequent encounter
steps u Step 2 : T31.0 (Burns involving less than 10% of body area)
u Step 3 : X11.0xxD (Contact with hot water in bath or tub,
subsequent
ICD 11 goes deeper
 u Code the following

Open Book u Traumatic fracture of the right hip with

dislocation , initial
Discovery u ICD 10 S72.001A
u ICD 11 NC72.2Z plus XK9K (right side)
Lesson 2.12 Diseases of the skin and
subcutaneous tissue
Infections of the skin

u L01 Impetigo
u L02 Cutaneous abscess, furuncle and carbuncle
u L03 Cellulitis and acute lymphangitis
u L04 Acute lymphadenitis
u L05 Pilonidal cyst and sinus
u L08 Other local infections of skin and subcutaneous tissue
Dermatitis

u L20 Atopic dermatitis

u L21 Seborrheic dermatitis
u L22 Diaper dermatitis
u L23 Allergic contact dermatitis
u L24 Irritant contact dermatitis
u L25 Unspecified contact dermatitis
u L26 Exfoliative dermatitis
Radiation Related

u L55 Sunburn
u L56 Other acute skin changes due to ultraviolet radiation
u L57 Skin changes due to chronic exposure to nonionizing radiation
u L58 Radiodermatitis
u L59 Other disorders of skin and subcutaneous tissue related to radiation
Disorders of skin appendages

u L63 Alopecia areata

u L64 Androgenic alopecia
u L65 Other nonscarring hair loss
u L66 Cicatricial alopecia [scarring hair loss]
u L67 Hair color and hair shaft abnormalities
u L68 Hypertrichosis
u L70 Acne
u L71 Rosacea
Ulcers

u Ulcers are broadly classified based on the organ they are present.
u 1) Gastric ulcer (K25)
u 2) Duodenal ulcer (K26)
u 3) Peptic ulcer (K27)
u 4) Gastrojejunal ulcer (K28)
u Each type of ulcer is further classified into acute or chronic. If the nature of
ulcer cannot be determined, an “unspecified” code may be used.
 u Joan, age 36 years, presented with
abdominal pain, nausea, vomiting and
melena. She was scheduled for EGD
ICD Coding after unsatisfactory PPI treatment. EGD
revealed acute duodenal ulcer which
Scenario was bleeding along with perforations.
She consumes alcohol every day and
shows withdrawal delirium. Her blood
alcohol levels were 72 mg/100ml.
u The coding for this scenario would be as follows:
u Primary code: K26.2 (because the type of ulcer is duodenal and it is acute
with hemorrhage and perforation)
Secondary code: F10.231 (because she exhibits alcohol dependence with
withdrawal delirium)
Tertiary code: Y90.3 (because of the range of her blood alcohol level is 60-79
mg/100 ml)
 Site
Pressure
Ulcers
Stage

Laterality
Stages

u Stage 1: Skin changes limited to persistent focal edema

u Stage 2: An abrasion, blister, and partial thickness skin loss involving the
dermis and epidermis
u Stage 3: Full thickness skin loss involving damage and necrosis of
subcutaneous tissue
u Stage 4: Necrosis of soft tissues through the underlying muscle, tendon, or
bone
ICD 10 Pressure Ulcer
ICD 11 Ulcers
 u EH90&XA4RR4
Final Code
 u Code the following :

Open Book u Cellulitis left small finger due to Staphylococcus

aureus
Discovery u ICD 10 L03.011, B95.61
u ICD 11 IB70 + XA5EN3+XN6BM
Lesson 2.13 External causes of
morbidity
Guidelines

u External cause codes are intended to provide data for injury research and
evaluation of injury prevention strategies. The external causes of morbidity
codes should never be sequenced as the first-listed or principal diagnosis.
u This section permits the classification of environmental events and
circumstances as the cause of injury, and other adverse effects. Where a code
from this section is applicable, it is intended that it shall be used secondary
to a code from another chapter of the Classification indicating the nature of
the condition. Most often, the condition will be classifiable to Chapter 19,
Injury, poisoning and certain other consequences of external causes (S00-
T88). Other conditions that may be stated to be due to external causes are
classified in Chapters I to XVIII. For these conditions, codes from Chapter 20
should be used to provide additional information as to the cause of the
condition.
 V02 Pedestrian injured in collision with two- or three-
wheeled motor vehicle

Pedestria V03 Pedestrian injured in collision with car, pick-up truck

or van

n injured V04 Pedestrian injured in collision with heavy transport

vehicle or bus
in V05 Pedestrian injured in collision with railway train or
railway vehicle
transport V06 Pedestrian injured in collision with other nonmotor
accident vehicle

V09 Pedestrian injured in other and unspecified transport

accidents
Exposure to smoke, fire and flames

u X00 Exposure to uncontrolled fire in building or structure

u X01 Exposure to uncontrolled fire, not in building or structure
u X02 Exposure to controlled fire in building or structure
u X03 Exposure to controlled fire, not in building or structure
u X04 Exposure to ignition of highly flammable material
Exposure to natural forces

u X32 Exposure to sunlight

u X34 Earthquake
u X35 Volcanic eruption
u X36 Avalanche, landslide and other earth movements
u X37 Cataclysmic storm
u X38 Flood
Intentional self harm

u X71 Intentional self-harm by drowning and submersion

u X72 Intentional self-harm by handgun discharge
u X73 Intentional self-harm by rifle, shotgun and larger firearm discharge
u X74 Intentional self-harm by other and unspecified firearm and gun discharge
u X75 Intentional self-harm by explosive material
u X76 Intentional self-harm by smoke, fire and flames
u X77 Intentional self-harm by steam, hot vapors and hot objects
u X78 Intentional self-harm by sharp object
u X79 Intentional self-harm by blunt object
Assault

u X99 Assault by sharp object

u Y00 Assault by blunt object
u Y01 Assault by pushing from high place
u Y02 Assault by pushing or placing victim in front of moving object
u Y03 Assault by crashing of motor vehicle
u Y04 Assault by bodily force
u Y07 Perpetrator of assault, maltreatment and neglect
Activity Codes

u Y93.1 Activities involving water and water craft

Y93.2 Activities involving ice and snow
Y93.3 Activities involving climbing, rappelling, and jumping off
Y93.4 Activities involving dancing and other rhythmic movement
Y93.5 Activities involving other sports and athletics played individually
Y93.6 Activities involving other sports and athletics played as a team or group
Y93.7 Activities involving other specified sports and athletics
Y93.A Activities involving other cardiorespiratory exercise
Y93.B Activities involving other muscle strengthening exercises
Y93.C Activities involving computer technology and electronic devices
Y93.D Activities involving arts and handcrafts
Y93.E Activities involving personal hygiene and interior property and clothing
maintenance
Y93.F Activities involving caregiving
Y93.G Activities involving food preparation, cooking and grilling
 u Bonnie was crossing the road in Miami and was
hit by a car . What would the correct external
cause code be ?
Open Book u A. V03

Discovery u B. X04
u C. X01
u D. V09
 Factors influencing health
Lesson 2.14 status and contact with health
services
Health services for examination

u Z03 Encounter for medical observation for suspected diseases and conditions
ruled out
u Z08 Encounter for follow-up examination after completed treatment for
malignant neoplasm
Contact

u Z20 Contact with and (suspected) exposure to communicable diseases

u Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
u Inclusion term(s):
u HIV positive NOS
u Z22 Carrier of infectious disease
u Z23 Encounter for immunization
u Note: procedure codes are required to identify the types of immunizations
given
u Z28 Immunization not carried out and underimmunization status
u Z29 Encounter for other prophylactic measures
Reproduction

u Z30 Encounter for contraceptive management

u Z31 Encounter for procreative management
u Z32 Encounter for pregnancy test and childbirth and childcare instruction
u Z33 Pregnant state
u Z34 Encounter for supervision of normal pregnancy
u Z36 Encounter for antenatal screening of mother
Outcome of delivery

u Z37.0 Single live birth

u Z37.1 Single stillbirth
Z37.2 Twins, both liveborn
u Z37.3 Twins, one liveborn and one stillborn
u Z37.4 Twins, both stillborn
u Z37.50 Multiple births, unspecified, all liveborn
Body mass Index

u - Z68.31 Body mass index (BMI) 31.0-31.9, adult

u - Z68.32 Body mass index (BMI) 32.0-32.9, adult
u - Z68.33 Body mass index (BMI) 33.0-33.9, adult
u - Z68.34 Body mass index (BMI) 34.0-34.9, adult
u - Z68.35 Body mass index (BMI) 35.0-35.9, adult
u - Z68.36 Body mass index (BMI) 36.0-36.9, adult
u - Z68.37 Body mass index (BMI) 37.0-37.9, adult
u - Z68.38 Body mass index (BMI) 38.0-38.9, adult
u - Z68.39 Body mass index (BMI) 39.0-39.9, adult
History

u Z81 Family history of mental and behavioral disorders

u Z82 Family history of certain disabilities and chronic diseases (leading to
disablement)
u Z83 Family history of other specific disorders
u Z84 Family history of other conditions
u Z85 Personal history of malignant neoplasm
u Z86 Personal history of certain other diseases
u Z87 Personal history of other diseases and conditions
u Z88 Allergy status to drugs, medicaments and biological substances
u Z89 Acquired absence of limb
Personal History Neoplasms

u Z85.060 Personal history of malignant carcinoid tumor of small intestine

u - Z85.068 Personal history of other malignant neoplasm of small intestine
u - Z85.07 Personal history of malignant neoplasm of pancreas
u - Z85.09 Personal history of malignant neoplasm of other digestive organs
u - Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung
u - Z85.118 Personal history of other malignant neoplasm of bronchus and lung
u - Z85.12 Personal history of malignant neoplasm of trachea
Family History

u - Z80.2 Family history of malignant neoplasm of other respiratory and

intrathoracic organs
u - Z80.3 Family history of malignant neoplasm of breast
u - Z80.41 Family history of malignant neoplasm of ovary
u - Z80.42 Family history of malignant neoplasm of prostate
u - Z80.43 Family history of malignant neoplasm of testis
u - Z80.49 Family history of malignant neoplasm of other genital organs
u - Z80.51 Family history of malignant neoplasm of kidney
u - Z80.52 Family history of malignant neoplasm of bladder
u - Z80.59 Family history of malignant neoplasm of other urinary tract organ
u - Z80.6 Family history of leukemia
 u What is the best example of procreative
management ?
Open Book u A. putting IUD in

Discovery u

u
B. Tracking cycle and running labs for fertilization
C. Having sterilization procedure
u D. Getting STD test
 Factors influencing health
Lesson 2.14 status and contact with health
services
Health services for examination

u Z03 Encounter for medical observation for suspected diseases and conditions
ruled out
u Z08 Encounter for follow-up examination after completed treatment for
malignant neoplasm
Contact

u Z20 Contact with and (suspected) exposure to communicable diseases

u Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
u Inclusion term(s):
u HIV positive NOS
u Z22 Carrier of infectious disease
u Z23 Encounter for immunization
u Note: procedure codes are required to identify the types of immunizations
given
u Z28 Immunization not carried out and underimmunization status
u Z29 Encounter for other prophylactic measures
Reproduction

u Z30 Encounter for contraceptive management

u Z31 Encounter for procreative management
u Z32 Encounter for pregnancy test and childbirth and childcare instruction
u Z33 Pregnant state
u Z34 Encounter for supervision of normal pregnancy
u Z36 Encounter for antenatal screening of mother
Outcome of delivery

u Z37.0 Single live birth

u Z37.1 Single stillbirth
Z37.2 Twins, both liveborn
u Z37.3 Twins, one liveborn and one stillborn
u Z37.4 Twins, both stillborn
u Z37.50 Multiple births, unspecified, all liveborn
Body mass Index

u - Z68.31 Body mass index (BMI) 31.0-31.9, adult

u - Z68.32 Body mass index (BMI) 32.0-32.9, adult
u - Z68.33 Body mass index (BMI) 33.0-33.9, adult
u - Z68.34 Body mass index (BMI) 34.0-34.9, adult
u - Z68.35 Body mass index (BMI) 35.0-35.9, adult
u - Z68.36 Body mass index (BMI) 36.0-36.9, adult
u - Z68.37 Body mass index (BMI) 37.0-37.9, adult
u - Z68.38 Body mass index (BMI) 38.0-38.9, adult
u - Z68.39 Body mass index (BMI) 39.0-39.9, adult
History

u Z81 Family history of mental and behavioral disorders

u Z82 Family history of certain disabilities and chronic diseases (leading to
disablement)
u Z83 Family history of other specific disorders
u Z84 Family history of other conditions
u Z85 Personal history of malignant neoplasm
u Z86 Personal history of certain other diseases
u Z87 Personal history of other diseases and conditions
u Z88 Allergy status to drugs, medicaments and biological substances
u Z89 Acquired absence of limb
Personal History Neoplasms

u Z85.060 Personal history of malignant carcinoid tumor of small intestine

u - Z85.068 Personal history of other malignant neoplasm of small intestine
u - Z85.07 Personal history of malignant neoplasm of pancreas
u - Z85.09 Personal history of malignant neoplasm of other digestive organs
u - Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung
u - Z85.118 Personal history of other malignant neoplasm of bronchus and lung
u - Z85.12 Personal history of malignant neoplasm of trachea
Family History

u - Z80.2 Family history of malignant neoplasm of other respiratory and

intrathoracic organs
u - Z80.3 Family history of malignant neoplasm of breast
u - Z80.41 Family history of malignant neoplasm of ovary
u - Z80.42 Family history of malignant neoplasm of prostate
u - Z80.43 Family history of malignant neoplasm of testis
u - Z80.49 Family history of malignant neoplasm of other genital organs
u - Z80.51 Family history of malignant neoplasm of kidney
u - Z80.52 Family history of malignant neoplasm of bladder
u - Z80.59 Family history of malignant neoplasm of other urinary tract organ
u - Z80.6 Family history of leukemia
 u What is the best example of procreative
management ?
Open Book u A. putting IUD in

Discovery u

u
B. Tracking cycle and running labs for fertilization
C. Having sterilization procedure
u D. Getting STD test
Lesson 2.15
Circulatory System
 Malignant : uncontrolled or
untreated ; headaches,
blurred vision ,organ damage
Hypertension
Benign: controlled mild
elevated blood pressure
Hypertension in 11
Other forms of heart disease
Other diseases of veins
Open Book What is the correct ICD 10 and
11 code for congestive heart

Discovery failure ?
 u ICD 10 : I59.9
Rational u ICD 11 : BD10
Lesson 2.16
Eye
Age Related Macular Degeneration
Glaucoma
Eyelid Laterality
Cataracts ICD 11
Open Book u What is the correct ICD code for Primary open –
angle glaucoma?
Discovery
 u ICD 10 :H40.11X0
Rational u ICD 11: 9C61.0
Lesson 2.17
Respiratory
Subsections of 10
Looking at 11
Pneumonia
Add detail based on documentation
Other respiratory disorders
Asthma
Add detail based on documentation
Open Book u What is the ICD code for Pneumonia due to
Klebsiella pneumoniae?
Discovery
 u ICD 10 : J15.0
Rational u ICD 11 : CA40.0Y
Lesson 2.18
Digestive System
 Barrett's Esophagus—An abnormal growth of
stomach or intestinal cells at the distal end of
the esophagus, which may develop because of
chronic gastroesophageal reflux disease.

Common Esophagitis—An inflammation of the lining of

the esophagus; can be caused by an infection or
Disorders irritation in the esophagus.

Esophageal Varices—Extremely dilated sub-

mucosal veins in the lower end of the
esophagus.
Mallory-Weiss Tear—Occurs in the mucous
membrane of the esophagus, where it connects to
the stomach; usually caused by forceful or long-
term vomiting, coughing, or epileptic convulsions.

Hiatal Hernia—Part of the stomach protrudes or

herniates through the opening of the diaphragm,
into the chest.

Swallowing Disorders/Dysphagia—Any condition

that causes impairment of the movement of solids
or fluids from the mouth, down the throat, and
into the stomach.
Breakdown
of 11
Hernias
 u Crohn’s disease is a chronic
inflammation of the gastrointestinal
tract that most frequently affects the
end of the small bowel and the
beginning of the large bowel. Potential
symptoms include persistent diarrhea,
cramping, abdominal pain, fever, rectal
Crohn’s Disease bleeding, fatigue, loss of appetite, and
weight loss. The disease is not limited
to the gastrointestinal tract, and may
affect the joints, eyes, skin, and liver.
Crohn’s disease can occur at any age,
but usually occurs between the ages of
15-35.
10:Start with location, complication

u K50.012 Crohn’s disease of small intestine with intestinal obstruction

u K50.013 Crohn’s disease of small intestine with fistula
u K50.014 Crohn’s disease of small intestine with abscess
u K50.018 Crohn’s disease of small intestine with other complication
u K50.019 Crohn’s disease of small intestine unspecified complications
u K50.10 Crohn’s disease of large intestine without complications
u K50.111 Crohn’s disease of large intestine with rectal bleeding
u K50.112 Crohn’s disease of large intestine with intestinal obstruction
u K50.113 Crohn’s disease of large intestine with fistula
Looking at 11
Open Book u What is the ICD code for diverticulitis of the
colon with perforation and abscess with
Discovery hemorrhage ?
 u ICD 10 : K57.21
Rational u ICD 11 : DC80.Z&XA03U9/ME24.31