ICD CHAPTER SPECIFIC

GUIDELINES
 ICD CHAPTERS
Chapter 1: Certain Infectious and Parasitic Diseases
A00–B99
Chapter 2: Neoplasms
C00–D49
Chapter 3: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism
D50–D89
Chapter 4: Endocrine, Nutritional, and Metabolic Diseases
E00–E89
Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders
F01–F99
Chapter 6: Diseases of the Nervous System
G00–G99
Chapter 7: Diseases of the Eye and Adnexa
H00–H59
Chapter 8: Diseases of the Ear and Mastoid Process
H60–H95
Chapter 9: Diseases of the Circulatory System
I00–I99
Chapter 10: Diseases of the Respiratory System
J00–J99
Chapter 11: Diseases of the Digestive System
K00–K95
Chapter 12: Diseases of the Skin and Subcutaneous Tissue
L00–L99
Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue
M00–M99
Chapter 14: Diseases of the Genitourinary System
N00–N99
Chapter 15: Pregnancy, Childbirth and the Puerperium
O00–O99
Chapter 16: Certain Conditions Originating in the Perinatal Period
P00–P96
Chapter 17: Congenital Malformations, Deformations and Chromosomal Abnormalities
Q00–Q99
Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified
R00–R99
Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes
S00–T88
Chapter 20: External Causes of Morbidity
V00–Y99
Chapter 21: Factors Influencing Health Status and Contact with Health Services
Z00–Z99
Chapter 22: Codes for special purposes
U00-U85
 I C D C H A P T E R 1 ( C O D E RA N G E A 0 0 – B 9 9 )
C E RTA I N I N F E C T I O N S A N D PA RA S I T I C D I S E A S E
 HIV/AIDS
Code Description
• Code only confirmed cases.
B20 HIV/AIDS
providers statement that patient is having HIV is sufficient
• Sequencing guidelines Z21 Asymptomatic HIV and
 If the reason for the encounter is an HIV/AIDS related conditions, (Positive test result with no symptoms)
then HIV/AIDS is sequenced first. R75 Inconclusive Laboratory evidence of HIV
1st code- HIV/B20,
098.7 HIV disease complicating pregnancy,
2nd code-additional diagnosis/HIV related conditions
childbirth and the puerperium

 If the reason for the encounter is not related to HIV/AIDS, then Z20.6 Contact with and suspected

sequence the reason for the encounter first. exposure to HIV

1st code- Unrelated condition Z11.4 Encounter for screening for HIV
2nd code- HIV
Z71.7 HIV counselling
• Example
(Negative Result/ no symptoms).
A 45-year-old AIDS patient is seen by the physician .patient suffering
through seasonal allergies
J30.2, B20 • Use additional code for organism if it is not
included in infection code
1st code - infection
2nd cod – organism
SEPSIS

Septic
shock
Sepsis is a serious condition in which the body responds improperly
to an infection. Severe
sepsis

Sepsis

Septic shock can lead

to:

•Brain damage.
•Lung failure.
•Heart failure.
•Kidney failure.
•Gangrene.
•Death.
SEPSIS

Sepsis:
Sepsis is life-threatening condition .It happens when
your immune system overreacts to an infection.

Severe sepsis:
This is when sepsis causes your organs to
malfunction. This is usually because of low blood
pressure, a result of inflammation throughout your
body.

Septic shock:
Septic shock is the last stage of sepsis and is
defined by extremely low blood pressure, despite
lots of IV (intravenous) fluids.
Organ failure occurs as a results
Coding /sequencing of sepsis codes

o Encounter for sepsis

Severe sepsis with septic
sepsis A41 shock
R65.21

o Encounter for severe sepsis Severe sepsis

R65.20
Sepsis, severe sepsis

Sepsis =A41
o Encounter for septic shock
Sepsis, severe sepsis with septic shock
• Severe Sepsis with Acute Organ dysfunction ( 2 minimum codes required)

Sequencing order:
1st Code : Sepsis Underlying Organism (A41.- or A41.9 unknown)
2nd Code : R65.2 (Severe Sepsis) ---Never sequenced 1st
3rd Code : Organ Dysfunction

• Septic Shock with Organ Dysfunction ( 2 minimum codes required)

Sequencing order:
1st Code : Sepsis Underlying Organism (A41.- or A41.9 (unknown)
2nd Code : R65.21 (Septic Shock) *Never sequenced 1st
3rd Code : Organ Dysfunction/ Kidney Failure (N17.9)

• Sepsis/severe sepsis with localized infection

Sequencing order
Reason for encounter sepsis/severe sepsis and localized infection (Pneumonia)
1st Code : Sepsis with underlying Organism (A41.- or A41.9 (unknown)
2nd Code :Localized infection
3rd Code : Severe sepsis
4th Code : Organ Dysfunction

Reason for encounter is localized infection (Pneumonia) and sepsis/severe sepsis develops after admission
1st Code : Localized infection
2nd Code :Sepsis/severe sepsis
 Postprocedural Severe Sepsis with Septic Shock

Must be documented as complication of procedure.

o 1st Code : T81.40-T81.43 postprocedural infection

o 2nd Code :T81.44 - sepsis following procedure
o 3rd Code : Code for infectious agent
o 4th Code : T81.12- Postprocedural septic shock
o 5th code : Any organ dysfunction if appropriate

Do not list code for severe sepsis with septic shock R65.21
(see Excludes1 note under T81.1)
EXAMPLES
o A patient arrives to the ED with fever, chills, and rapid breathing. The
ED physician diagnoses the patient with Escherichia coli sepsis
A41.51 - sepsis due to Escherichia coli

o Severe sepsis due to Enterococcus with septic shock, causing acute

kidney failure.
A41.81- sepsis due to Enterococcus,
R65.21- Severe sepsis with septic shock,
N17.9 -kidney failure.
 COVID -19

o Code Only Confirmed Cases of the 2019

novel coronavirus (COVID-19) as

documented by the provider documentation

of a positive COVID-19 test result, or a

presumptive positive COVID-19 test result.

COVID-19 = U07.1

o If the provider documents "suspected,"

"possible," "probable," or "inconclusive"

COVID-19, do not assign code U07.1.

 SEQUENCING OF COVID -19 CODES

Covid 19 with manifestation condition

1st code : COVID-19
2nd code : Manifestation condition
Example -Pneumonia due to COVID-19
1st code : U07.1 COVID-19
2nd code: J12.82, Pneumonia due to coronavirus disease 2019

Example -Acute bronchitis

1st code : U07.1 COVID-19
2nd code: J20.8, Acute bronchitis due to other specified organisms.

Exception in case of pregnancy

1st code : O98.5 Obstetrics patients COVID-19 in pregnancy, childbirth, and the puerperium.
2nd code : U07.1 /COVID-19
• Z11.52 -- Encounter foe screening test for COVID-19

• Z86.16 –Personal history of COVID-19

• Z28.310, Unvaccinated for COVID-19

• Z28.311, Partially vaccinated for COVID-19

• Z01.84, Encounter for antibody response examination.

• Follow-up visits after COVID-19 infection has resolved

1st code :Z09, Encounter for follow-up examination after completed treatment for
conditions other than malignant neoplasm
2nd code: Z86.16, Personal history of COVID-19.

• For sequela of COVID-19, or associated symptoms or conditions that develop following a

previous COVID-19 infection

1st code: Specific symptom(s) or condition(s) related to the previous COVID-19
2nd code: U09.9, Post COVID-19 condition, unspecified
 ICD-10-CM CHAPTER 2

NEOPLASMS
C O D E RA N G E : C 0 0 - D 4 9

Neo- New
Plasm- Growth/formation

This chapter Guide to coding various types

of tumors and growths.

covers a broad range of neoplastic

conditions,

• malignant
• benign
• In situ
• Uncertain
• Unspecified
TABLE OF NEOPL ASM
Example :
Patient arrived for the treatment of primary
malignant neoplasm of prostate
 Sequencing Order
Anemia Associated with Malignancy/ Malignancy Caused the Anemia Code 1st: Malignancy
Code 2nd: D63 (anemia)

Anemia associated with Chemotherapy/Immunotherapy/Radiation therapy Code 1st: D63.0 (Anemia)

Encounter is ONLY for the treatment of Anemia caused by Chemotherapy Code 2nd: Malignancy
Code 3rd: T45.1X5 (Adverse Effect)

Management of Dehydration due to Malignancy Code 1st: E86 (Dehydration)

Encounter: Management of Dehydration due to malignancy (only dehydration is treated) Code 2nd: Malignancy

Treatment for a Complication resulting from a Surgical Procedure Code 1st: Complication
Code 2nd: T81.4-(Infection following a procedure)
Code 3rd: Malignancy

Encounter solely for Administration of chemotherapy/Immunotherapy/External Beam Radiation Therapy Code 1st:
Code the Reason for Encounter (RFE) Z51.0-chemotherapy
Z51.11-Immunotherapy
Z51.12-External Beam Radiation Therapy
Code 2nd: malignancy

Encounter for Administration of 1st: therapy

chemotherapy/Immunotherapy/External Beam Radiation Therapy which developed a complication. 2nd: complication

Code 1st :09A.112

Malignant neoplasm in a pregnant patient Code 2nd: Malignancy

Code 1st : Complications

Malignant neoplasm associated with Transplanted Organ Code 2nd: C80.2Malignant neoplasm associated
This is coded as transplant complication. with transplanted organ
Code 3rd: Specific Malignancy
 EXAMPLE
o A patient was diagnosed with primary cancer of the left bronchus which
spreads to the hip bone. The patient's treatment is for the secondary
cancer.
C79.51- Secondary malignant neoplasm of bone
C34.92- Malignant neoplasm of unspecified part of left bronchus or lung

o Ana, a 45-year-old female with cancer of the temporal lobe arrives at the
radiation treatment facility for her second series of radiation treatment.

Z51.0- Encounter for antineoplastic radiation therapy

C71.2- Malignant neoplasm of temporal lobe
 ICD chapter 4
ENDOCRINE , NUTRITIONAL
A N D M E TA BO L I C D I S E A S E S

C O D E RA N G E
E00-E89

The endocrine system is a complex network

of glands that produce and secrete
hormones, which are chemical messengers
that regulate various bodily functions.
TYPE 1 DIABETES TYPE 2 DIABETES
o AUTOIMMUNE CONDITION oINSULIN RESISTANCE, WHERE THE
BODY'S CELLS DO NOT RESPOND
o VERY LITTLE OR NO INSULIN
EFFECTIVELY TO INSULIN.
PRODUCTION.

o INSULIN DEPENDENT, REQUIRE oNON-INSULIN DEPENDENT/CAN USE

INSULIN TO SURVIVE INSULIN WHEN REQUIRED

GUIDELINES

If the Type of Diabetes is not documented, the default Type 2 Diabetes.

Age is NOT the determining factor of the type of diabetes

Insulin use – Z79.4

Do not assign insulin code with type 1 diabetes
Assign insulin code for type 2 diabetes only when used for long term .
Do not code insulin if given for temporary period

E08.—DM due to underlying conditions

E09.—Drug induced DM
E10.—Diabetes Type I
E11.— Diabetes Type 2
E13.— Other specified DM
Diabetes
and
pregnancy
Complication due to insulin pump malfunction
EXAMPLE
o A 60-year-old female patient arrives to the Dr.'s office for a routine office visit. She has
diabetes mellitus and is on insulin.
E11.9- Type 2 Diabetes mellitus
Z79.4- long term current use of insulin

o A 30-year-old 11 weeks pregnant patient who has diabetes mellitus arrives for a routine
prenatal visit. The patient's blood sugars are normal. The patient uses insulin to control
the diabetes. Select the correct answer.

024.111 -Type 2 Diabetes mellitus complicating pregnancy

E11.9 - Type 2 Diabetes mellitus
Z79.4 - long term current use of insulin
Z3A.11 - 11 weeks' gestation of pregnancy
 ICD chapter 5 :
Mental, Behavioral, and Neurodevelopmental Disorders
Code Range F01-F99

Mental disorders
Depression
anxiety
schizophrenia

Behavioral disorders
substance abuse or
dependance .

Neurodevelopmental
disorders ADHD
Do not code F45.41 – with G89 G89 can be coded with F45.42
autism spectrum
disorders.
TYPES OF PAIN DISORDERS
F45.41 - Pain Disorder Exclusively Related to F45.42 - Pain Disorder with Related
Psychological Factors: Psychological Factors:

Use this code when the pain is primarily psychological, Use this code when pain is influenced by both
with no physical cause is identified physiological and psychological factors.

The pain is influenced or caused by psychological The disorder involves a known physical cause, but
factors, such as anxiety, stress, depression, or trauma. psychological factors play a significant role in the
patient's perception of or reaction to the pain. e.g.,
back injury, arthritis

Example- A patient reports chronic back pain, but no Example- A patient suffers from chronic pain
physical cause can be identified. Psychological due to arthritis but also has significant depression,
assessment reveals significant anxiety and past trauma which worsens the pain perception.
contributing to the pain experience. Codes
Codes
F45.42 - Pain disorder with related psychological
F45.41 - Pain disorder exclusively related to factors.
psychological factors. Additional code:
Additional code: M19.90 - Unspecified osteoarthritis, unspecified site
F41.1 - Generalized anxiety disorder (if documented). (for the physical condition).
F32.9 - Major depressive disorder, single episode,
unspecified (for the psychological condition).
P S YC H O A C T I V E S U B S TA N C E U S E D I S O R D E R S ( F 1 0 – F 1 9 )

Examples of
Dependence psychoactive
substances
o Alcohol
Abuse o Heroin
o Opioids

Use o Cannabis
o Oxycodone
FACTITIOUS DISORDER (FALSELY REPORTING)

• Perpetrator- F68.A​

• Victim-​
T74 - Adult and Child Abuse,
Neglect, and Other
Maltreatment, Confirmed​

T76 - Adult and Child Abuse,

Neglect, and Other
Maltreatment, Suspected​
​
Dementia is a broad term that refers to a group of symptoms affecting memory,
cognitive functions, and the ability to perform daily activities
EXAMPLES

o Cocaine abuse and dependence

F14.20- Cocaine dependence, uncomplicated

o Anxiety disorder due to cocaine dependence.

F14.280- Cocaine dependence with cocaine-induced anxiety disorder
 ICD CHAPTER 6
D I S E A S E S O F N E RV O U S S Y S T E M
G00- G99

Hemiparesis - Partial weakness affecting one side of the body.

Hemiplegia-Complete paralysis on one side of the body.
Monoplegia-Monoplegia is a form of paralysis that affects a single limb, typically an arm or a leg
 DOMINANT NON
DOMINANT
Code selection is as follows:
If the left side is affected - default is non-dominant.
If the right side is affected - default is dominant.
For ambidextrous patients - default should be dominant

Examples

Monoplegia of right upper limb in right-handed patient G83.21

Monoplegia of RIGHT upper limb in left-handed patient G83.23

Monoplegia of upper limb G83.20

Ambidextrous affected right side G83.21

G 8 9 – P A I N C O D E C AT E G O R Y

Category G89 Codes as Principal or

First-Listed Diagnosis

 When pain control or pain management is the reason

for the admission/encounter .The underlying cause of
the pain should be reported as an additional diagnosis,
if known.
1st code- G89
2nd code- underlying cause of pain
 When a patient is admitted for the insertion of a e.g., encounter for pain management
neurostimulator for pain control, assign the
appropriate pain code as the principal or first-listed for acute neck pain from trauma
diagnosis.
G89.11--Acute pain due to trauma
1st code –G89
M54.2--Cervicalgia,
to identify the site of pain
Postoperative pain
o The default for post-thoracotomy and other postoperative pain not specified as acute
or chronic is the code for the acute form.
o Routine or expected postoperative pain immediately after surgery should not be
coded.
Neoplasm Related Pain
o Code G89.3 Related/associated or due to cancer, this code is assigned regardless of
whether the pain is acute or chronic.

Example:
Patient referred today for pain management due to acute pain related to malignancy of
the right breast
G89.3-Neoplasm Related Pain
C50.911- Malignant neoplasm of unspecified site of right female breast
ICD chapter 7
Diseases of the Eye and Adnexa (H00-H59)

GLAUCOMA
A group of eye diseases characterized by damage to the optic nerve, often
associated with increased intraocular pressure (IOP).

Codes based on

The affected eye

type of glaucoma
glaucoma stage.
• Patient admitted with glaucoma and stage evolves during the admission- Assign the code for
highest stage documented.

Example –
o Pt admitted with mild stage chronic angle closure
glaucoma of right eye and during admission the stage
is progressed to moderate stage
H40.2212- chronic angle closure glaucoma, right
eye, moderate stage

o Bilateral chronic angle – closure glaucoma

right eye documented as mild stage left eye documented
as moderate stage
H40.2211 - Chronic angle – closure glaucoma, right
eye mild stage

H40.2222 - Chronic angle – closure glaucoma, left

eye moderate stage
 ICD
CHAPTER 9
CIRCUL ATORY SYSTEM
I00-I99

Hypertension

I10

Hypertension Hypertension Hypertension

with heart with kidney with heart and
disease disease kidney disease
I11 I12 I13
Example
o Hypertension with left heart failure
I11.0, I50.1

o Thomas arrives at his PCPs office with complaints of chest pain and
edema. The physician did a full body work up and diagnosed
Thomas with HTN ,GERD, DM and congestive heart failure . which
answer best describes the encounter
I11.0, I50.9, K21.9, E11.9
ACUTE MYOCARDIAL
INFARCTION(AMI)
o Acute Myocardial Infarction is commonly
referred to as a heart attack, which occurs
when blood flow to the heart is severely
reduced or blocked, leading to damage or
death of heart tissue.
STEMI NSTEMI
 Occurs due to a complete  Results from a partial blockage or
blockage of a coronary artery, temporary disruption of blood flow.
leading to significant damage to the
heart muscle.  The ECG typically shows ST
 The ECG will display persistent ST segment depression
segment elevation
 S U BS E Q U E N T AC U T E M YO C A R D I A L I N FA RC T I O N
o I21 - Initial AMIS
I22- Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
o used when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4-week
time frame of the initial AMI.
o Codes from category I22 should only be assigned if both the initial and subsequent myocardial
infarctions are type 1 or unspecified
o Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified.
o A code from category I22 must be used in conjunction with a code from category I21. Category I22 is
never used alone.
o The sequencing of the I22 and I21 codes depends on the circumstances of the encounter.
ICD chapter 10
Diseases of Respiratory System
Code Range J00-J99 and U07.0

Functions of Respiratory system

[Link] Exchange
2. Protection Against Pathogens and
Irritants through filtration
[Link] of Temperature and Humidity
4. Speech Production
5. Sense of Smell
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
(COPD) AND ASTHMA
o Chronic Obstructive Pulmonary Disease
(COPD)
COPD is a group of progressive lung diseases that
cause obstructed airflow from the lungs.
o Asthma is a chronic inflammatory disease of the
airways characterized by recurrent breathing
problems, including wheezing, shortness of breath,
chest tightness, and coughing. Asthma is often
triggered by allergens, irritants, or respiratory
infections.

J44 -Chronic bronchitis with acute exacerbation

J45- Asthma
Code only J44.89 .
No need to code separately asthma Code J44.89 and J45.20 since Asthma is
since it is unspecified specified
A C U T E R E S P I R AT O RY FA I L U R E Coding for Influenza

• Influenza, commonly known as the flu, is an acute

viral infection caused by the influenza virus.
It primarily affects the respiratory system, including
the nose, throat, bronchi, and occasionally the lungs.
Influenza is highly contagious and typically occurs in
seasonal outbreaks
V E N T I L AT O R- Ventilator-Associated Pneumonia (VAP)
A S S O C I AT E D
PNEUMONIA
( VA P )

• It is a type of hospital-acquired
pneumonia (HAP) that develops in
patients who have been on
mechanical ventilation for at least 48
hours or more.

• It occurs when the ventilator tubing

becomes contaminated with bacteria,
leading to lung infection.

• J95.851: Ventilator-associated
pneumonia
• Do not assign an additional
code from categories J12- J18 to
identify the type of pneumonia.
• Vaping is the action or practice of inhaling and exhaling vapour containing nicotine and flavouring
produced by a device designed for this purpose.
• U07.0- Vaping-related disorder
For patients presenting with condition(s) related to vaping,
assign code U07.0, Vaping-related disorder, as the principal diagnosis.
 For lung injury due to vaping, assign only code U07.0.
 Assign additional codes for other manifestations, such as acute respiratory failure
(subcategory J96.0-) or pneumonitis (code J68.0).
 ICD-CHAPTER 15
P R E G N A N C Y , C H I L D B I RT H , A N D T H E P U E R P E R I U M
C O D E RA N G E O 0 0 T O O 9 A

• COVERS C O D E S R E L AT E D T O P R E G N A N C Y , C H I L D B I RT H , A N D T H E P U E R P E R I U M ( T H E P E R I O D
F O L LO W I N G C H I L D B I RT H ) .

• I N C L U D E S M A T E R N A L H E A LT H C O N D I T I O N S A N D C O M P L I C A T I O N S T H A T A R I S E D U R I N G P R E G N A N C Y
A N D P O S T PA RT U M .

• T H E C O D E S S P E C I F I C A L LY D E S I G N E D F O R U S E I N M A T E R N A L R E C O R D S O N LY , N O T I N N E W B O R N
RECORDS.

• S E Q U E N C I N G P R I O R I T Y:

 C O D E S F R O M C H A P T E R 1 5 H AV E P R I O R I T Y OV E R C O D E S F R O M O T H E R C H A P T E R S W H E N
D O C U M E N T I N G C O N D I T I O N S R E L A T E D T O P R E G N A N C Y.

 I F A P R E G N A N T W O M A N I S T R E AT E D F O R A N U N R E L AT E D C O N D I T I O N , T H E P R I M A RY D I A G N O S I S
S H O U L D R E F L E C T T H AT C O N D I T I O N , F O L LO W E D BY Z 3 3 . 1 ( P R E G N A N T S TAT E , I N C I D E N TA L ) .

M A T E R N A L R E C O R D O N LY:

C H A P T E R 1 5 C O D E S S H O U L D O N LY B E U S E D O N T H E M A T E R N A L R E C O R D . T H E Y A R E N O T A P P L I C A B L E
FOR NEWBORN RECORDS.
• Final character for Trimester
1st Trimester: Less than 14 weeks
2nd Trimester: 14 weeks to less than 28 weeks
3rd Trimester: 28 weeks until delivery
Seventh Character for Fetus
Identification:
In cases of multiple gestations, a seventh character is
used to identify the specific fetus (e.g., Fetus 1, Fetus
2).

• Patient has twins of which 1st fetus is affected-1

• Patient has twins of which 2nd fetus is affected-2

• Patient has triplets of which 3rd fetus is affected-3

• Patient has single pregnancy and the fetus is

affected -0

• Patient has twins of which one fetus is affected-0

51
PRE-EXISTING CONDITIONS VS. CONDITIONS DUE TO PREGNANCY

• Diabetes Mellitus in pregnancy • HIV in Pregnancy

Pre-existing Diabetes Asymptomatic
1st Code : 024 .1 Code 1st: 098.7 HIV complicating
• pregnancy
Diabetes was caused by the
pregnancy (Gestational diabetes) Code 2nd: Z21

1st Code : 024.4

HIV with symptoms
Code 1st: 098.7 HIV complicating
• Pre-existing hypertension in pregnancy
pregnancy Code 2nd: B20 HIV
Code 1st: 010 Pre-existing HTN Code 3rd: HIV related conditions
complicating pregnancy
Code 2nd: Hypertension code (Chapter 9)
• Covid 19 infection in pregnancy
1st code – O98.5
2nd code –U07.1
Example
What is the ICD-10-CM code for Type 2 Diabetes in pregnancy,
first trimester?
O24.111- Pre-existing type 2 diabetes mellitus, in pregnancy, first trimester
E11.9- Type 2 diabetes mellitus without complications
1 6 . C H A P T E R 1 6 : C E RTA I N C O N D I T I O N S O R I G I N AT I N G I N THE
P E R I N ATA L P E R I O D ( P 0 0 - P 9 6 )

 Perinatal period is defined as before birth through the 28th day following birth.

 Codes only used on newborns record and never use on the maternal record.

 Codes may be used throughout the life of the patient if the condition is still present.

 Principal Diagnosis for Birth Record -Z38, Liveborn infants is assigned only once,

to a newborn at the time of birth

 A code from category Z38 is used only on the newborn record, not on the mother's record.

 Conditions due to Birth process - code from Chapter 16 should be used.

community acquired conditions- a code from Chapter 16 should not be assigned.

Default is due to the birth process

Example
o A 3-week-old baby is admitted for cough and fever, and on the discharge summary the physician
documents pneumonia.
P23.9 = Congenital pneumonia, unspecified

o The infant was born via vaginal delivery and suffered a fractured clavicle caused by the delivery

Z38.00 = Single liveborn infant, delivered vaginally

P13.4 = Fracture of clavicle due to birth injury

 ICD Chapter 18
Symptoms, signs, and abnormal clinical and laboratory
findings, not elsewhere classified
(R00-R99)

Use of signs and symptom code

o Conditions in which signs and symptoms can be coded

when a related definitive diagnosis has not been established (confirmed)
by the provider.
when the sign or symptom is not routinely associated with that diagnosis

o Conditions in which signs and symptoms should not be coded

Signs or symptoms that are associated routinely with a disease
Combination codes that include symptoms
 ICD Chapter 19
Injury, Poisoning, and Certain Other
Consequences of External Causes S00-T88
7th Character
Coding of Injuries
• separate codes for each injury unless a combination code is provided
• The code for the most serious injury, as determined by the provider and the focus of
treatment, is sequenced first.

1) Superficial injuries
Superficial injuries such as abrasions or contusions are not coded when associated with more
severe injuries of the same site.

2) Primary injury with damage to nerves/blood vessels

• primary injury is sequenced first
additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to
blood vessels (such as category S15).
• When the primary injury is to the blood vessels or nerves, that injury should be sequenced
first.

3) latrogenic injuries
Injuries that occur during, or as a result of, a medical intervention.
Coding of Traumatic Fractures
• A fracture not indicated as open or closed should be coded to closed.
• A fracture not indicated whether displaced or not displaced should be coded to displaced.

• Example
Injuries to the Neck S10.9: Unspecified injury of neck
 Coding Burns/ Corrosions
Coding of Burns and Corrosions When Multiple burns are there on the same
(T20-T25) anatomic site and on the same side but of
different degrees to the subcategory:
Burns- Thermal Burns except sunburns Code the Most Severe Degree
burns resulting from fire or hot appliance.
burns resulting from electricity and radiation.

Corrosions - burns due to chemicals

• Current burns are classified by depth, extent

and by agent (X code).
• Burns are classified by depth as first degree
(erythema), second degree (blistering), and
third degree (full-thickness involvement).
• Burns of the eye and internal organs (T26-T28)
are classified by site, but not by degree.
Example
Which code would be used for a second-
degree burn on the left palm?

T23.252A- Burn of second degree of left

palm, initial encounter
 ICD -10-CM
CHAPTER 20
EXTERNAL CAUSES OF MORBIDITY
VOO -Y99

C A P T U R I N G D ATA R E L AT E D T O H O W I N J U R I E S A N D H E A LT H
C O N D I T I O N S O C C U R , A S W E L L A S T H E C I R C U M S TA N C E S

SURROUNDING THESE EVENTS.

• S H O U L D N E V E R S E Q U E N C E A S F I R S T L I S T E D / P R I M A RY C O D E

F I R S T C O D E C O N D I T I O N / I N J U RY

I T I N C LU D E S EXAMPLE

C- CAUSE A C C I D E N T / FA L L
I – INTENT I N T E N T I O N A L / A C C I D E N TA L
P- PL ACE OF OCCURRENCE SCHOOL/GARDEN/ROAD
A - A C T I V I T Y AT T H E T I M E O F I N J U RY C O O K I N G / S W I M M I N G / P L AY I N G
S - S TAT U S C I V I L I A N / M I L I TA R Y / S T U D E N T

EXTERNAL CAUSES CODES SHOULD BE SEQUENCED IN ABOVE SEQUENCE

O N LY

Significance
• Provides data for injury research
• Evaluation of injury prevention strategies
Reporting Guidelines
 Non-Mandatory Reporting: There are no national guidelines mandating the use of external
cause codes.
 Secondary Codes: External cause codes are never to be used as primary or principal
diagnosis codes; they should always be reported as secondary codes to provide
supplementary information about injuries and health conditions
 Used with all other chapter codes. Most applicable to injuries
 Alphabetic Index of External Causes
 Use 7th character where applicable
 Use the full range of external cause codes
 cause, the intent, the place of occurrence, the activity of the patient at the time of the
event, and the patient's status
 Combination external cause codes
 No external cause code needed in certain circumstances(e.g., T36.0X1-, Poisoning by
penicillins, accidental (unintentional)
Place of Activity Status Intent
occurrence o Y93 o Y07
o Y99
o Y92 o Assign
 Accidental
o Assign
o Assign only only once
 Self-harm
once at  Assault
only once at initial
initial encounter
at initial encount
 Unknown/

encounte er
 Military undeterminate
r  Nonmilitary o If not
o No 7th  Student specified
o No 7th characte  Volunteer default is
character r accidental
 GENERAL SEQUENCING GUIDELINES

Order of Priority: When multiple external causes are involved, they should be sequenced based on
the following priority:

Sequencing Priority

Child and adult abuse

Terrorism events

Cataclysmic events (natural

disasters )

Transport accidents
ADULT AND CHILD
ABUSE
Terrorism- Y38

More than one Y38 codes can assign

Suspected terrorism cases should be
coded as Assault
Y38.9- Terrorism secondary effects
QUESTIONS

• Patient falls over a rock at the park and get injury to left knee (contusion)

S80.02XA , W20.8XXA , Y92.830

THANK YOU