2023 icd 10cm coding guidelines for chapter 18
TLDRThe video script discusses the 2023 ICD-10-CM coding guidelines, focusing on Chapter 18 which deals with symptoms, signs, and abnormal clinical/lab findings. It covers the use of symptom codes in the absence of a definitive diagnosis, the use of combination codes, and guidelines for reporting signs and symptoms alongside definitive diagnoses. The script also explains the use of specific codes for conditions like coma, repeated falls, and systemic inflammatory response syndrome (SIRS), emphasizing the importance of accurate documentation and coding for medical reporting purposes.
Takeaways
- 📌 Use symptom codes for reporting when a definitive diagnosis has not been established.
- 📌 Symptom codes can be reported alongside a related definitive diagnosis if the symptom is not routinely associated with the diagnosis.
- 📌 Avoid assigning codes for signs or symptoms that are routinely associated with the disease process, unless they are unrelated.
- 📌 Combination codes that identify both the definitive diagnosis and common symptoms do not require additional symptom codes.
- 📌 Use 'R20.9' for encounters where the patient has recently fallen and the reason for the fall is being investigated.
- 📌 'Z91.81' is used for patients with a history of falling and who are at risk for future falls.
- 📌 Coma Scale codes (40.21-40.24) should be sequenced after the diagnosis codes and are primarily for use by trauma registries.
- 📌 Capture and report the initial Glasgow Coma Scale score documented on presentation at the facility.
- 📌 Use 'R65.10' or 'R65.11' for systemic inflammatory response syndrome (SIRS) due to non-infectious processes, with additional codes for acute organ failure if applicable.
- 📌 'R99' is used only in very limited circumstances for patients who have already died, been brought dead, or pronounced dead upon arrival.
- 📌 NIH Stroke Scale (29.7) codes should be sequenced after the acute stroke code and report the initial score documented.
Q & A
What is the primary purpose of using symptom codes in ICD-10-CM Chapter 18?
-The primary purpose of using symptom codes in Chapter 18 is for reporting purposes when a related definitive diagnosis has not been established. These codes describe symptoms and signs that are acceptable for reporting when no definitive clinical problem diagnosis exists.
Can symptom codes be used alongside a definitive diagnosis code?
-Yes, symptom codes can be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with the diagnosis, such as various signs and symptoms associated with complex syndromes.
When is it appropriate to use combination codes that include symptoms in ICD-10-CM Chapter 18?
-Combination codes that identify both the definitive diagnosis and common symptoms of the diagnosis should be used when they are available. These combination codes make it unnecessary to report an additional code for the symptom.
How should healthcare providers document and code for patients with signs or symptoms routinely associated with a disease process?
-For signs or symptoms that are routinely associated with the disease process, they should not be assigned separate codes. Instead, only the code for the disease process should be used, as the sign or symptom is considered inherent and associated.
What are the two scenarios where a symptom code can be used with a definitive diagnosis?
-A symptom code can be used with a definitive diagnosis when the symptom is either unrelated to the definitive diagnosis or when the symptom belongs to the definitive diagnosis but is not common or routinely associated with it.
What is the significance of the Glasgow Coma Scale (GCS) codes in ICD-10-CM Chapter 18?
-The GCS codes are used to document the level of consciousness in patients with traumatic brain injuries or other conditions requiring assessment of consciousness. They are sequenced after the diagnosis codes and should not be used as the principal diagnosis (PDX) but as a secondary diagnosis (SDX).
How should healthcare providers code for patients with a history of falls or risk of future falls?
-For encounters where the reason for a fall is being investigated, code R20.9 (repeated falls) should be used. If the patient has a history of falls and is at risk for future falls, code Z91.81 (personal history of falling) can be used. Both codes can be assigned together when appropriate.
What is the Systemic Inflammatory Response Syndrome (SIRS) and how is it coded?
-SIRS is an inflammatory state affecting the whole body, which is an exaggerated response to a noxious stressor such as infection or trauma. It can result in blood clots, impaired fibrinolysis, and organ failure. Patients with SIRS have two or more symptoms such as tachycardia, tachypnea, leukocytosis or leukopenia, fever, or hypothermia. It is coded as R65.10 without acute organ failure or R65.11 with acute organ failure, with additional codes for specific acute organ dysfunction if applicable.
What is the NIH Stroke Scale (NIHSS) and how is it used in coding?
-The NIH Stroke Scale (NIHSS) is a tool used to identify a patient's neurological status and severity of a stroke. It is coded under category 29.7 and can be used in conjunction with acute stroke codes (I63). The NIHSS code should be sequenced after the acute stroke code and at a minimum, report the initial score documented.
Under what circumstances should the code R99 be used in ICD-10-CM Chapter 18?
-Code R99 should be used only in very limited circumstances when a patient who has already died, been brought dead, or pronounced dead upon arrival is presented. It is very rarely used and does not represent the discharge disposition of death.
Who is responsible for assigning codes for the Coma Scale and NIH Stroke Scale in ICD-10-CM Chapter 18?
-Usually, the code assignment for the Coma Scale and NIH Stroke Scale is based on the documentation by the patient's provider, which can be a physician or other qualified healthcare practitioner. However, there are exceptions where code assignment may be based on medical record documentation from clinicians who are not the patient's providers.
Outlines
📚 ICD-10CM Coding Guidelines for Symptoms and Signs
This paragraph discusses the 2023 ICD-10CM coding guidelines for Chapter 18, focusing on symptoms, signs, and abnormal clinical/laboratory findings not classified elsewhere. It covers when to use symptom codes without a definitive diagnosis, guidelines for the Coma Scale, documentation for non-infectious processes, and the NIHSS Stroke Scale. The use of symptom codes is acceptable for reporting when a definitive diagnosis has not been established. The paragraph also explains the use of symptom codes in conjunction with definitive diagnoses, especially when symptoms are not routinely associated with the diagnosis. Additionally, it touches on combination codes that include both the definitive diagnosis and common symptoms, eliminating the need for additional symptom codes.
🚑 Coding for Falls and Coma Scale
The second paragraph delves into the specific coding for falls and the use of the Coma Scale. It explains the use of codes 29.6 for repeated falls and 91.z91.81 for a history of falls, including when to use them together. The paragraph also outlines the correct application of Coma Scale codes (40.21-40.24) in relation to traumatic brain injury codes and their sequencing after diagnosis codes. It emphasizes that Coma Scale codes should not be used as the principal diagnosis (PDX) and must be reported with the initial score documented. The paragraph concludes with guidelines for capturing multiple Coma Scale scores within the first 24 hours after hospital admission.
🩺 Systemic Inflammatory Response Syndrome (SIRS) and Ill-Defined Causes
This section discusses the coding for SIRS, a systemic inflammatory response to non-infectious conditions like trauma or pancreatitis. It explains the use of codes R65.10 and R65.11 for SIRS without and with acute organ failure, respectively, and the necessity of coding additional acute organ failure codes when reporting R65.11. The paragraph also addresses the coding of ill-defined causes of mortality (R99) and its limited use in specific circumstances, such as when a patient is brought dead or pronounced dead upon arrival. It further clarifies that R99 does not represent the discharge disposition of death.
🏥 Acute Pancreatitis and NIH Stroke Scale (NIHSS) Coding
The fourth paragraph focuses on the coding of acute pancreatitis and the application of the NIH Stroke Scale. It details the coding of acute pancreatitis (K85.9) and SIRS (R65.10), emphasizing the importance of capturing the initial score documented. The paragraph also discusses the NIHSS, including its use in conjunction with acute stroke codes (I63) to identify the patient's neurological status and stroke severity. It highlights the need to report the initial score and mentions that multiple NIHSS scores can be captured if desired. The paragraph concludes with an example case of a patient with acute pancreatitis and an NIHSS score of 13, illustrating the appropriate coding for this scenario.
🧠 NIH Stroke Scale Coding and Guidelines
The final paragraph concludes the discussion on the NIH Stroke Scale, emphasizing its importance in capturing a patient's neurological status post-stroke. It explains the coding of the NIHSS (29.7) and its expandability for use with acute stroke codes (I63). The paragraph outlines the sequencing of the NIHSS code after the acute stroke diagnosis and the minimum requirement to report the initial score documented. It also addresses the documentation of NIHSS scores by clinicians other than the patient's provider, noting exceptions where code assignment may be based on medical record documentation from non-provider clinicians. The paragraph ends with an example of a patient with an occlusion of the left middle cerebral artery and an NIHSS score of 13, demonstrating the correct application of the guidelines.
Mindmap
Keywords
💡ICD-10-CM
💡Symptom Codes
💡Definitive Diagnosis
💡Combination Codes
💡Repeated Falls
💡Coma Scale
💡Systemic Inflammatory Response Syndrome (SIRS)
💡NIH Stroke Scale (NIHSS)
💡Unspecified Causes
💡Documentation Guidelines
💡Coding for Non-Infectious Processes
Highlights
Discussion on 2023 ICD-10-CM coding guidelines, focusing on Chapter 18 related to symptoms, signs, and abnormal clinical/lab findings.
Use of symptom codes is acceptable for reporting purposes when a related definitive diagnosis has not been established.
Example provided: a patient with chest pain and lethargy, referred to a cardiologist without a confirmed diagnosis.
Symptom codes can be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with the diagnosis.
Signs or symptoms routinely associated with a disease process should not be assigned separate codes.
Combination codes that identify both the definitive diagnosis and common symptoms do not require an additional symptom code.
Repeated falls (R/F) codes (29.6 and 91.Z91.81) are used to indicate recent falls and a history of falls, respectively.
Coma Scale codes (40.21 and 40.24) are used in conjunction with traumatic brain injury codes and should be sequenced after the diagnosis codes.
Glasgow Coma Scale (GCS) scores should be reported with the initial score documented on presentation and can capture multiple scores within the first 24 hours.
Systemic Inflammatory Response Syndrome (SIRS) codes (R65.10 and R65.11) are used for non-infectious conditions without or with acute organ failure.
NIH Stroke Scale (NIHSS) codes (29.7) are used to identify a patient's neurological status and severity of a stroke.
Codes for body mass index, depth of non-pressure chronic ulcers, and other health indicators can be reported as secondary diagnoses.
The importance of accurate coding for medical conditions such as Crohn's disease, osteoarthritis, and intracerebral hemorrhage is emphasized.
Guidelines for using symptom codes with definitive diagnoses, including when to code symptoms as primary or secondary diagnoses.
The necessity of coding for signs and symptoms that are not commonly associated with a definitive diagnosis.
Explanation of when and how to use combination codes that include symptoms, such as for Crohn's disease with intestinal obstruction.
Details on the use of R/F codes for investigating the cause of falls and documenting a patient's history of falls.
Instructions on the proper use and sequencing of Coma Scale and NIH Stroke Scale codes in medical documentation.
The role of SIRS codes in capturing the presence of acute organ failure due to non-infectious conditions like trauma or pancreatitis.
The rare use of code R 99 for ill-defined or unknown causes of mortality, applicable only in very limited circumstances.
Transcripts
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