ICD 10 CM Chapter Specific Guidelines I. C18
TLDRIn this ICD-10-CM coding guidelines review session, Dr. Campbell discusses Chapter 18, which covers signs, symptoms, and ill-defined conditions. He explains the classification of specific symptoms when a diagnosis is not confirmed, the use of sinus symptom codes, combination codes, and the documentation of repeated falls and coma scale codes. Additionally, he touches on the coding of systemic inflammatory response syndrome (SIRS) and the use of the NIHSS stroke scale, emphasizing the importance of accurate documentation and coding practices.
Takeaways
- 📚 Chapter 18 of ICD-10-CM covers codes 00-99, including signs, symptoms, abnormal results from clinical investigations, and ill-defined conditions.
- 🔍 Signs and symptoms that point to a specific diagnosis are classified in other chapters of the classification system.
- 🌟 Sinus symptom codes can be used when no diagnosis has been confirmed, and if the symptom is not associated with a disease.
- 🤕 Combination codes are available for both definitive diagnosis and common symptoms, eliminating the need for additional symptom codes.
- 🧗♂️ Code 29.6 is for encounters where the reason for a patient's recent fall is being investigated.
- 🚶♂️ Z9T 1.81 is used when a patient has a history of falling and is at risk for future falls, and can be reported with code 29.6 when appropriate.
- 🏥 Coma scale codes (40.2) can be used with traumatic brain injury, acute cerebral vascular disease, or their sequelae, and also to assess non-traumatic conditions.
- 📈 The coma scale requires a seventh character to identify when the scale was collected, and individual scores should not be reported for medically induced or sedated patients.
- 🔥 SIRS (Systemic Inflammatory Response Syndrome) codes (6510 and 6511) are for non-infectious processes, with or without acute organ dysfunction.
- ✅ R99 (death not otherwise specified) is used in very limited circumstances when a deceased patient is brought into a healthcare facility and pronounced dead upon arrival.
- 🩺 The NIHSS (National Institutes of Health Stroke Scale) code 29.7 can be used with acute stroke codes (I63) to identify the patient's neurological status and stroke severity.
Q & A
What is the focus of Chapter 18 in the ICD-10-CM coding guidelines?
-Chapter 18 focuses on codes ranging from 00 to 99, which include signs, symptoms, abnormal results of clinical or other investigative procedures, and ill-defined conditions where no other specific diagnosis is recorded.
How are sign and symptom codes classified if they point to a specific diagnosis?
-In cases where a sign or symptom points to a specific diagnosis, those are actually classified in other chapters of the classification system.
Can sinus symptom codes be used if no diagnosis has been confirmed?
-Yes, if a patient has a sinus symptom that is not associated with a disease, it can be coded. However, if the sign symptom is routinely associated with that disease process, it should not be coded separately.
What are combination codes in ICD-10-CM and when should they be used?
-Combination codes are used to identify both the definitive diagnosis and common symptoms of that disease. When using these codes, you should not add an additional code for the symptom because it's already included.
What are the two codes used for documenting falls and under what circumstances are they used?
-Code 29.6 is used for encounters when the patient has recently fallen and the reason for the fall is being investigated. Code Z9T 1.81 is used when the patient has a history of falling and is at risk for future falls. Both codes can be reported together when appropriate.
How are coma scale codes (ICD-10-CM code 40.2) used and what information do they capture?
-Coma scale codes are used in conjunction with traumatic brain injury codes, acute cerebral vascular disease, or the sequela of a cerebral vascular disease. They capture information based on the patient's eye opening, verbal response, and motor response. These codes are primarily for use by a trauma registry but can be used in any setting where this information is collected.
What are the three categories of coma scale codes and why is a seventh character needed?
-The three categories are eye opening, verbal response, and motor response. A seventh character is needed to identify when the scale was collected, such as by the ambulance service, on the floor, or by neurologists.
How should the coma scale codes be sequenced in a patient's record?
-The coma scale codes should be sequenced after the diagnosis. They need to be documented on presentation at the facility, and the initial score should be recorded.
What is the code for systemic inflammatory response syndrome (SIRS) due to a non-infectious process?
-The code for SIRS due to a non-infectious process is 6510 if there is no acute organ dysfunction, and 6511 if there is acute organ dysfunction.
What is the ICD-10-CM code for death not otherwise specified?
-The ICD-10-CM code for death not otherwise specified is R99. It is used in very limited circumstances when a patient who has already died is brought into a healthcare facility and pronounced dead upon arrival.
How is the NIHSS stroke scale (code 29.7) used in conjunction with acute stroke codes?
-The NIHSS stroke scale can be used in conjunction with acute stroke codes (I63) to identify the patient's neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis.
Can clinicians other than the patient's provider document coma scale or NIHSS stroke scale?
-Yes, clinicians other than the patient's provider can document coma scale or NIHSS stroke scale, but this should follow the specific guidelines outlined in the ICD-10-CM.
Outlines
📚 ICD-10-CM Coding Guidelines: Chapter 18 Overview
This paragraph introduces Dr. Campbell's ICD-10-CM coding guidelines review session, focusing on Chapter 18. It explains that Chapter 18 codes, ranging from 00 to 99, cover signs, symptoms, abnormal results from clinical investigations, and ill-defined conditions. The paragraph emphasizes that when a sign or symptom points to a specific diagnosis, it is classified in other chapters. It also discusses the use of sinus symptom codes when no diagnosis is confirmed and the appropriate handling of combination codes that include both the diagnosis and its common symptoms.
🚑 Documentation and Coding of Specific Conditions
The second paragraph delves into the documentation and coding of specific conditions such as repeated falls, coma scale codes, systemic inflammatory response syndrome (SIRS), and death not otherwise specified (R99). It provides details on the appropriate codes for each condition, including the use of code 29.6 for recent falls and Z9T 1.81 for a history of falls. The paragraph also explains the use of coma scale codes in conjunction with traumatic brain injury or other conditions and the importance of recording the initial score. Additionally, it addresses the coding of SIRS due to non-infectious processes and the use of stroke scale codes in conjunction with acute stroke diagnoses.
Mindmap
Keywords
💡ICD-10-CM Coding
💡Chapter 18
💡Sinus Symptom Codes
💡Combination Codes
💡Repeated Falls
💡Coma Scale Codes
💡Systemic Inflammatory Response Syndrome (SIRS)
💡Death Not Otherwise Specified (R99)
💡NIHSS Stroke Scale
💡Documentation Guidelines
Highlights
Chapter 18 of ICD-10-CM coding guidelines focuses on codes 00 through 99, which include signs, symptoms, abnormal results of clinical or investigative procedures, and ill-defined conditions.
Signer symptoms pointing to a specific diagnosis are classified in other chapters of the classification system.
Sinus symptom codes can be used when no diagnosis has been confirmed, and the patient has a sinus symptom not associated with the disease.
Combination codes identify both the definitive diagnosis and common symptoms of that disease, and no additional code for the symptom should be added.
Code 29.6 is for encounters when the patient has recently fallen, and the reason for the fall is being investigated.
Code Z9T 1.81 is used when the patient has a history of falling and is at risk for future falls.
Both codes 29.6 and Z9T 1.81 can be reported together in appropriate situations.
Coma scale codes (40.2) can be used with traumatic brain injury codes, acute cerebral vascular disease, or the sequela of a cerebral vascular disease.
The coma scale identifies different scores based on the patient's eye opening, verbal response, and motor response.
Coma scale codes are primarily for use by a trauma registry but can be used in any setting where this information is collected.
The coma scale may also be used to assess the status of the central nervous system for non-traumatic conditions.
Coma scale codes should be sequenced after the diagnosis and require a seventh character to identify when the scale was collected.
The initial score should be documented on presentation at the facility, and it could come from the ambulance or a neurologist.
If the total score is documented but not the individual scores, code 40.2 can still be used.
Codes for individual or combined scores should not be reported for patients in a medically induced coma or for sedated patients.
Systemic inflammatory response syndrome (SIRS) due to a non-infectious process is coded with 6510 or 6511, depending on the presence of acute organ dysfunction.
Death not otherwise specified (R99) is used only in limited circumstances when a deceased patient is brought into a healthcare facility and pronounced dead upon arrival.
The NIHSS stroke scale (code 29.7) can be used with acute stroke codes to identify the patient's neurological status and the severity of the stroke.
The initial stroke scale score should be documented, and the facility can capture multiple scores at their discretion.
Transcripts
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