M131/HIM1125 Rasmussen College SEC4 Raynauds Disease Discussion Post Research a disease of the Nervous, Circulatory, Respiratory or Digestive system. Descr

M131/HIM1125 Rasmussen College SEC4 Raynauds Disease Discussion Post Research a disease of the Nervous, Circulatory, Respiratory or Digestive system. Describe the disease/condition including the signs/symptoms and treatment. Emphasize what the coder needs to know to accurately code this disease/condition and discuss any specific guidelines. Be sure to choose a condition that has not already been posted. Include the name of the disease in the post title. The following provides an overview of the chapter specific guidelines. This overview will provide a brief
introduction. These guidelines will be explored further in this week’s Live Classroom and Reading
assignments.
Chapter 6 describes diseases of the nervous system; conditions and codes included in chapter 6 of ICD10-CM, Diseases of the nervous system (G00-G99). Here we will differentiate the coding of hemiplegia
and hemiparesisand other paralytic conditions and the coding of epilepsy, seizures, and convulsions.
When coding, research conditions that you are not familiar with. Use websites such as the American
Brain Tumor Association, American Stroke Association, the Epilepsy Foundation, National Multiple
Sclerosis Society, National Headache Foundation, or UCLA Neurosurgery.Diseases to enhance your
understanding.
Dominant/nondominant side
Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower
limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, identify whether the
dominant or nondominant side is affected. Should the affected side be documented but not specified as
dominant or nondominant, and the classification system does not indicate a default, code selection is as
follows:
•
For ambidextrous patients, the default should be dominant.
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If the left side is affected, the default is non-dominant.
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If the right side is affected, the default is dominant.
Pain
Codes in category G89, Pain, not elsewhere classified, may be used in conjunction with codes from other
categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain,
unless otherwise indicated in the full guidelines.
•
If the pain is not specified as acute or chronic, postthoracotomy, postprocedural, or neoplasmrelated, do not assign codes from category G89.
•
A code from category G89 should not be assigned if the underlying (definitive) diagnosis is
known, unless the reason for the encounter is pain control/ management and not management
of the underlying condition.
•
When an admission or encounter is for a procedure aimed at treating the underlying condition,
a code for the underlying condition should be assigned as the principal diagnosis.
•
Category G89 Codes as Principal or First-Listed Diagnosis Category G89 codes are acceptable as
principal diagnosis or the first-listed code when pain control or pain management is the reason
for the admission/encounter with the underlying cause of the pain should be reported as an
additional diagnosis, if known.
See the full guidelines for further detail and sequencing guidance.
Chapter 9 includes codes describing of conditions of the heart and circulatory system as well as the
cerebrovascular system. You will be able to describe the organization of the conditions and diseases
included in chapter 9 of ICD-10-CM I00-I99. Pay particular attention to the chapter specific guidelines
when coding hypertension with heart disease, heart failure and CKD, CVAs and acute myocardial
infarctions.
Hypertension with Heart Disease
•
Assign codes from category I11 when a causal relationship is stated (due to hypertension) or
implied (hypertensive). Use an additional code from category I50, Heart failure, to identify the
type of heart failure in those patients with heart failure.
•
The same heart conditions with hypertension, but without a stated causal relationship, are
coded separately. Sequence according to the circumstances of the admission/encounter.
Hypertensive Chronic Kidney Disease
•
Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension
and a condition classifiable to category N18, Chronic kidney disease (CKD), are present.
•
Unlike hypertension with heart disease, ICD-10-CM presumes a cause-and-effect relationship
between hypertension and CKD.
•
The appropriate code from category N18 should be used as a secondary code with a code from
category I12 to identify the stage of chronic kidney disease.
Hypertensive Heart and Chronic Kidney Disease
•
Assign codes from combination category I13, Hypertensive heart and chronic kidney disease,
when both hypertensive kidney disease and hypertensive heart disease are stated in the
diagnosis and there is a causal statement between the hypertension and heart disease. Assume
a relationship between the hypertension and the chronic kidney disease, whether or not the
condition is so designated.
o
If heart failure is present, assign an additional code from category I50 to identify the
type of heart failure.
o
The appropriate code from category N18, Chronic kidney disease, should be used as a
secondary code with a code from category I13 to identify the stage of chronic kidney
disease.
Atherosclerotic Coronary Artery Disease and Angina
•
ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris.
•
It is not necessary to use an additional code for angina pectoris.
•
A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris,
unless the documentation indicates the angina is due to something other than the
atherosclerosis.
Category I69, Sequelae of Cerebrovascular disease
Sequela or “late effects” include neurologic deficits that persist after initial onset of conditions
classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be
present from the onset or may arise at any time after the onset of the condition classifiable to
categories I60-I67.
See the full guidelines for sequencing and additional code requirements.
Myocardial Infarction
•
For encounters occurring while the myocardial infarction is equal to, or less than, four weeks
old, including transfers to another acute setting or a postacute setting, and the patient requires
continued care for the myocardial infarction, codes from category I21 may continue to be
reported.
•
For encounters after the 4-week time frame and the patient is still receiving care related to the
myocardial infarction, the appropriate aftercare code should be assigned, rather than a code
from category I21. For old or healed myocardial infarctions not requiring further care, code
I25.2, Old myocardial infarction, may be assigned.
•
Subsequent acute myocardial infarction requires a code from category I22,
•
Category I22 codes are to be used when a patient who has suffered an AMI has a new AMI
within the 4-week time frame of the initial AMI.
•
A code from category I22 must be used in conjunction with a code from
category I21. The sequencing of the I22 and I21 codes depends on the
circumstances of the encounter.
See the full guidelines for sequencing and additional code requirements.
Chapter 10 focuses on diseases of the respiratory system, J00-J99 and provide guidance on the coding of
respiratory failure and sequencing, influenza and ventilator assisted pneumonia. The coding of H1N1
contradicts our general coding guideline that allows us to code suspected conditions. This diagnosis
requires a confirmation by the provider.
Acute respiratory failure
Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the
respiratory failure and the other acute condition are equally responsible for occasioning the admission
to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more
diagnoses that equally meet the definition for principal diagnosis may be applied in these situations.
•
Acute and/or chronic respiratory failure, may be assigned as a principal diagnosis when it is the
condition established after study to be chiefly responsible for occasioning the admission to the
hospital. However, chapter specific coding guidelines (such as obstetrics, poisoning, HIV,
newborn) that provide sequencing direction take precedence.
•
Acute respiratory failure as secondary diagnosis Respiratory failure may be listed as a secondary
diagnosis if it occurs after admission, or if it is present on admission, but does not meet the
definition of principal diagnosis.
Influenza due to certain identified influenza viruses
Code only confirmed cases of influenza due to certain identified influenza viruses (category J09), and
due to other identified influenza virus (category J10). This is an exception to the hospital inpatient
guideline Section II, H. (Uncertain Diagnosis).
•
If the provider records “suspected” or “possible” or “probable” avian influenza, or novel
influenza, or other identified influenza, then the appropriate influenza code from category J11,
Influenza due to unidentified influenza virus, should be assigned.
See the full guidelines for sequencing and additional code requirements.
Chapter 11 describes Disorders of the upper and lower GI tract, Inflammations and infections of the GI
tract and other diseases of the GI tract, including hernia, ulcer, and hemorrhage. In this chapter of ICD,
note of the different types of hernias and the definition of ‘obstruction’. Carefully Index entries for
cholecystitis, cholelithiasis, and choledocholithiasis; paying attention to the connecting term “with” that
is used when both conditions exist.
•
Chapter 11: Diseases of the Digestive System (K00-K95) guidelines are reserved for future
guideline expansion

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