Update ICD 10 Coding Changes and Preview of OASIS D
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The I20 – I25 Issue
• Use additional code to identify presence of
hypertension (I10‐I16)
Update ICD‐10 Coding • This is sequencing direction.
• This means that if the patient has hypertensive
Changes and Preview heart failure as the focus of care, but happens to
have CAD or an old MI, that has to be coded prior
of OASIS D to the hypertensive heart failure.
Lisa Selman‐Holman, JD, BSN, RN, HCS‐D, COS‐C, HCS‐O, HCS‐H
My email to NCHS and their response Related Issue at I60‐I69
• I submitted a proposal regarding the sequencing convention
found at I20‐I25 indicating that any code in I20‐I25 needed to be • Use additional code to identify presence of:
coded prior to hypertension. I noted that it was not included in • Hypertension (I10‐I15)
the agenda of last week's meeting, nor was it included in the
draft changes to the tabular list. Please provide an update to its • Sequencing direction meaning even if
status please. Was the agenda too full? Or was the proposal
denied for some other reason? hypertension, hypertensive heart failure, etc was
the focus of care, the old stroke would have to be
• In review of inquires received in this office, it appears there may coded first.
have been an oversight in response to you regarding your
inquiry. Please accept my sincere apologies. • This direction, however, is related to the guideline
• Over the next few weeks, the ICD‐10‐CM Classification team will regarding Hypertensive Cerebrovascular Disease. If
be reviewing this issue along with new issues / proposals that that is not documented, do we have to code the
are for consideration for the upcoming September C&M
Meeting and possible guideline updates. cerebrovascular disease before the hypertension?
• I will update you accordingly.
• Thank you for bringing this to our attention.The Resolving Complication without the 7th
Character Issue Based on what guideline?
• Body system complications do not have 7th
characters • 7th character “D” subsequent encounter is used for
• Transplant complications encounters after the patient has completed active
treatment of the condition and is receiving routine
• Amputation complications care for the condition during the healing or
recovery phase.
• Do we continue to code the complication until • The aftercare Z codes should not be used for
healed? aftercare for conditions such as injuries or
• Or do we switch to aftercare? poisonings, where 7th characters are provided to
identify subsequent care.
• Answer from CC via letter: switch to aftercare.
• And if the D is not provided, use aftercare.
For example: Diabetes, with
The patient has a bowel obstruction with adhesions • Skin ulcer NEC
post gastric bypass surgery. • Arthropathy NEC
• K95.89 Other complications of other bariatric • Circulatory NEC
procedures
• Do not assume a causal relationship when the
• K56.52 Bowel obstruction diabetic complication is “NEC.”
Now, the surgeon has fixed the problem—but there • Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018
is not a D to use until the wound, etc heals.
Revert to aftercare…
Z48.815 Aftercare following GI surgeryDiabetes, with Examples
Diabetic atherosclerosis of the extremities
• Peripheral arteriosclerosis, peripheral vascular • E11.51 Diabetes with peripheral angiopathy
disease and peripheral arterial disease in a diabetic
patient should be linked and coded as “diabetic • I70.2‐ Atherosclerosis of the extremities
peripheral angiopathy.” Diabetic atherosclerosis with gangrene
• Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018 • E11.52 Diabetes with peripheral angiopathy with
gangrene
• I70.2‐6 Atherosclerosis with gangrene
Other ‘with’ and ‘in’ issues Diabetes, Hypertension and CKD
• Anemia
• CKD • Diabetes and hypertension are assumed related to
CKD.
• Neoplasms
• Chemotherapy • What if the physician says ‘diabetic CKD’ or
‘hypertensive CKD’?
• Arthropathy
• Code them all related.
• Exception is if the physician specifically says the
diabetes or the hypertension is NOT related.Changes in the Code Set Lots of Changes Like This
• Every year effective October 1. • Revise from: L98495 • Revise from: I63219
Non‐pressure chronic Cerebral infarction due to
• Changes in the code set made by NCHS with input from ulcer of other sites with unspecified occlusion or
us! muscle involvement stenosis of unspecified
• Some limitations because code set is owned by WHO. without evidence of vertebral arteries
• Types of Changes necrosis • Revise to: I63219
1. New codes • Revise to: L98495 Non‐ Cerebral infarction due to
2. Deleted codes pressure chronic ulcer of unspecified occlusion or
3. Changes to the tabular list skin of other sites with stenosis of unspecified
muscle involvement vertebral artery
4. Changes to the index without evidence of
5. Guidelines necrosis
What? You don’t see the change? Fixes Like This
• Revise from: R402330 Coma scale, best motor response, abnormal, unspecified time
Revise from: M5001 Cervical disc disorder with myelopathy, • Revise to: R402330 Coma scale, best motor response, abnormal flexion, unspecified
high cervical region time
• Revise from: R402331 Coma scale, best motor response, abnormal, in the field [EMT
Revise to: M5001 Cervical disc disorder with myelopathy, high or ambulance]
cervical region • Revise to: R402331 Coma scale, best motor response, abnormal flexion, in the field
Revise from: M86621 Other chronic osteomyelitis, right [EMT or ambulance]
humerus • Revise from: R402332 Coma scale, best motor response, abnormal, at arrival to
emergency department
Revise to: M86621 Other chronic osteomyelitis, right humerus • Revise to: R402332 Coma scale, best motor response, abnormal flexion, at arrival to
emergency department
• Revise from: R402333 Coma scale, best motor response, abnormal, at hospital
admission
• Revise to: R402333 Coma scale, best motor response, abnormal flexion, at hospital
admission
• Revise from: R402334 Coma scale, best motor response, abnormal, 24 hours or more
after hospital admission
• Revise to: R402334 Coma scale, best motor response, abnormal flexion, 24 hours or
more after hospital admissionNew Postoperative Infection Codes
And things like this…
• T81.4xxA, T81.4xxD, T81.4xxS are deleted
• Added (each with a choice of A, D, or S):
• Medial phalanx changed to middle phalanx of the • T81.40X‐ Infection following a procedure,
finger unspecified
• T43641A Poisoning by ecstasy Who knew
baby stroller
• T81.41X‐ Infection following a procedure, superficial
incisional surgical site
• V00821S Fall from babystroller, sequela was 2
words? • T81.42X‐ Infection following a procedure, deep
• V00821S Fall from baby stroller, sequela incisional surgical site
• E671 Hypercarotinemia • T81.43X‐ Infection following a procedure, organ and
space surgical site
• Revise to: E671 Hypercarotenemia • T81.44X‐ Sepsis following a procedure
• T81.49X‐ Infection following a procedure, other
surgical site
Postoperative Infection Definitions Tabular Changes
• These are standardized definitions from the CDC: • T81.41‐ (Infection following a procedure, superficial incisional
• Superficial incisional infection surgical site)
• Involves only skin & subcutaneous tissue • Subcutaneous abscess following a procedure
• May be indicated by localized signs such as redness, pain, heat or • Stitch abscess following a procedure
swelling at the site of the incision or by the drainage of pus • T81.42‐ (Infection following a procedure, deep incisional surgical
• Deep incisional site)
• Involves deep tissues, such as fascial and muscle layers • Intra‐muscular abscess following a procedure
• May be indicated by the presence of pus or an abscess, fever with • T81.43‐ (Infection following a procedure, organ and space
tenderness of the wound, or separation of incision edges exposing surgical site)
deeper tissues
• Intra‐abdominal abscess following a procedure
• Organ and space • Subphrenic abscess following a procedure
• Involves any part of the anatomy in organs and spaces other than
the incision, which was opened or manipulated during operation,
such as the joint or the peritoneum • T81.44‐ (Sepsis following a procedure)
• May be indicated by the drainage of pus or the formation of an • Tabular instruction:
abscess detected by histopathological or radiological examination • Code first the post op infection, e.g. T81.42‐
or during re‐operation; does not include organ infection.
Sources: Medscape, NIH, ICD‐10 Coordination & Maintenance Committee September 2017 • Use Additional code to identify the sepsis
proposal
• (this is not changed as far as sequencing)Tabular & Index Updates New Neoplasm Codes
• Index entries added or revised: • Current codes specify the eyelid for non‐melanoma
• “Abscess, intra‐abdominal, following procedure” – skin cancer, but not whether the upper or lower is
T81.43 involved.
• “Abscess, intramuscular, following procedure” – 45 new codes:
T81.42
• Skin cancers (melanoma, basal cell, squamous cell,
• “Abscess, stitch” – T81.41
sebaceous cell, Merkel cell carcinoma, & unspecified,
• “Cellulitis, drainage site (following operation)” – as well as in situ cancers) affecting the upper and lower
T81.49 eyelid
• “Fever, due to infection” – T81.40
• Melanocytic nevi and other benign neoplasms affecting
• “Infection, postoperative” – T81.40 the upper & lower eyelid
• “Sepsis, local, in operation wound” –T81.44
• “Sepsis, postprocedural” – T81.44
Types of Skin Cancer & Benign Skin
Examples of New Neoplasm Codes
Neoplasms
• Melanoma – begins in melanocytes cells; the least common but
most serious type of skin cancer • C43.111 (Malignant melanoma of right upper eyelid,
• Basal cell carcinoma – abnormal, uncontrolled growths or lesions including canthus)
in the skin’s basal cells, the deepest layer of the epidermis
• Squamous cell carcinoma – uncontrolled growth in the skin’s • C43.112 (Malignant melanoma of right lower eyelid,
squamous cells, skin’s outermost layers; second‐most common including canthus)
skin cancer • C43.121 (Malignant melanoma of left upper eyelid,
• Sebaceous cell carcinoma – rare skin cancer that mostly begins on including canthus)
the eyelid
• Merkel cell carcinoma – rare type of skin cancer that usually • C43.122 (Malignant melanoma of left lower eyelid, including
appears as a flesh‐colored or bluish‐red nodule, often on your canthus)
face, head or neck
• Melanocytic nevi – Moles made up of skin cells that produce
melanin • Note: C43.11 & C43.12 will both be invalid codes in FY2019
• Other benign skin neoplasms – other non‐cancerous skin lesions • You’ll need to know whether the melanoma is affecting
the upper or lower eyelid!
Sources: American Cancer Society, Skin Cancer Foundation, American Academy of Dermatology, Mayo
ClinicG71.0 Muscular dystrophy
But watch out for those crazy C44 codes
• C44.1121 Basal cell carcinoma of skin of right upper • G71.00 Muscular dystrophy, unspecified
eyelid, including canthus • G71.01 Duchenne or Becker muscular dystrophy
• C44.1122 Basal cell carcinoma of skin of right lower • genetic disorder characterized by progressive muscle
eyelid, including canthus degeneration and weakness. Starts as early as 3yo
• C44.1191 Basal cell carcinoma of skin of left upper • G71.02 Facioscapulohumeral muscular dystrophy
eyelid, including canthus • muscles of the face, shoulder blades and upper arms
• C44.1192 Basal cell carcinoma of skin of left lower are among the most affected. By the age of 20
eyelid, including canthus • G71.09 Other specified muscular dystrophies
CADASIL CADASIL
• I67.850 Cerebral autosomal dominant arteriopathy
with subcortical infarcts and leukoencephalopathy
• Code also any associated diagnoses, such as:
• What is it?
• epilepsy (G40.‐)
• Inherited disorder that causes strokes, brain lesions,
and other impairments • stroke (I63.‐)
• Frequently begins with migraines & mood disorders • vascular dementia (F01.‐)
in 20s & 30s, followed by strokes in 40s & 50s • Found in the index under:
• Epilepsy can occur • CADASIL
• Multiple strokes generally leads to vascular • Arteriopathy
dementia
• Death 10 to 20 years after strokes & dementia begin
Source: ICD‐10 Coordination & Maintenance Committee March 2017 proposalFor example: Urethral Stricture
• According to the proposal:
• The patient has a diagnosis of CADASIL with • The etiology (i.e. post‐traumatic, post‐infective, etc.) of
vascular dementia and a recent stroke resulting in a patient’s urethral stricture is often unknown or
monoplegia of the right leg. unspecified
• Current codes don’t allow for the specification of the
• I67.850 CADASIL location of the stricture if the etiology isn’t known
• F01.50 Vascular dementia • Nor do current codes allow for the capture of strictures
involving overlapping sites
• I69.341 (I69.841) monoplegia following cerebral
infarction affecting right dominant side Source: ICD‐10 Coordination & Maintenance Committee March 2017 proposal
• Site
• Male, female
• Cause
• N35 has 16 new codes plus another in N99
Anal and Rectal Abscesses Cannabis Withdrawal
• K61.‐ category (Abscess of anal and rectal regions) • Common among those with cannabis dependence
• K61.0 Anal abscess • those with cannabis dependence make up a substantial
percentage of treatment admission for substance use
• K61.1 Rectal abscess disorders
• K61.2 Anorectal abscess • Symptoms (develop within a week of ceasing heavy,
• K61.3 Ischiorectal abscess prolonged cannabis use) include
• K61.31 Horseshoe Abscess • irritability, anger, or aggression
• K61.39 Other ischiorectal abscess • nervousness or anxiety
• sleep difficulty
• K61.4 Intrasphincteric abscess
• decreased appetite or weight loss
• K61.5 Supralevator abscess • restlessness
• depressed mood
• physical symptoms such as abdominal pain,
shakiness/tremors, sweating, fever, chills, or headacheCannabis Use, Dependence & Withdrawal Remember this:
• 2 new codes added to 2 subcategories within F12.‐ • The Official Guidelines for Coding and Reporting,
(Cannabis related disorders): Psychoactive Substance (I.C.5.b.3.) state, “As with all
• Within F12.2‐ (Cannabis dependence) other diagnoses, the codes for psychoactive substance
• F12.23 (Cannabis dependence with withdrawal) use (F10.9‐, F11.9‐ F12.9‐, F13.9‐, F14.9‐, F15.9‐, F16.9‐
• For cases of cannabis withdrawal in the context ) should only be assigned based on provider
of dependence documentation and when they meet the definition of a
• Within F12.9‐ (Cannabis use, unspecified) reportable diagnosis (see Section III, Reporting
• F12.93 (Cannabis use, unspecified, with Additional Diagnoses). The codes are to be used only
withdrawal when the psychoactive substance use is associated
• For cases of cannabis withdrawal in contexts with a physical, mental or behavioral disorder, and such
other than dependence a relationship is documented by the provider.”
Source: ICD‐10 Coordination & Maintenance Committee Sept. 2017 proposal
Sepsis
• For infections following a procedure, a code from
T81.40, to T81.43 Infection following a procedure,
…that identifies the site of the infection should be
coded first, if known. Assign an additional code for
sepsis following a procedure (T81.44). Use an
Guideline Changes additional code to identify the infectious agent
(A40 or A41).Post‐procedural Septic Shock Index
2019 Change
• If a postprocedural infection has resulted in • List of heart conditions
postprocedural septic shock, assign the codes excludes I51.81
indicated above for sepsis due to a postprocedural • Takotsubo Syndrome is
infection, followed by code T81.12‐, not related to
Postprocedural septic shock. hypertension. It is related
• Do not assign code R65.21, Severe sepsis with to stress, so it was
septic shock. Additional code(s) should be omitted from the list of
assigned for any acute organ dysfunction. conditions assumed
caused by hypertension.
Hypertension Hypertensive Chronic Kidney Disease
• Hypertension with heart conditions classified to I50.‐ • The classification assumes a relationship
or I51.4‐ I51.7, I51.89, I51.9, are assigned to a code between hypertension and chronic kidney
from category I11, Hypertensive heart disease. disease.
• Use an additional code from category I50, Heart • CKD should not be coded as hypertensive if
failure, to identify the type of heart failure in those the provider indicates the CKD is not related
patients with heart failure. to the hypertension. 2019
• The same heart conditions (I50.‐, I51.4‐I51.7, I51.89, • Code to I12.‐
I51.9) with hypertension are coded separately if the • Stage 5 or ESRD with hypertension I12.0
provider has specifically documented a different • Stage 1‐4 or unspecified CKD with hypertension
cause. 2018 I12.9
• New language: if the provider has documented they • Specific sequencing required with CKD
are unrelated to the hypertension. 2019
39Documentation by Clinicians Other than
the Patient's Provider Documentation by Clinicians Other than
• Code assignment is based on the documentation by the Patient's Provider
patient's provider (i.e., physician or other qualified
healthcare practitioner legally accountable for
establishing the patient's diagnosis).
• There are a few exceptions, such as codes for the Body • However, the associated diagnosis (such as
Mass Index (BMI), depth of non‐pressure chronic overweight, obesity, acute stroke, or pressure ulcer)
ulcers, pressure ulcer stage, coma scale, and NIH stroke must be documented by the patient’s provider.
scale (NIHSS) codes, code assignment may be based on
medical record documentation from clinicians who are
not the patient’s provider (i.e., physician or other
qualified healthcare practitioner legally accountable for • BMI codes should only be assigned when the
establishing the patient’s diagnosis), since this associated diagnosis (such as overweight or
information is typically documented by other clinicians
involved in the care of the patient (e.g., a dietitian obesity) meets the definition of a reportable
often documents the BMI, a nurse often documents the diagnosis (see Section III, Reporting Additional
pressure ulcer stages, and an emergency medical Diagnoses).
technician often documents the coma scale).
Documentation by Clinicians Other than the Other Changes
Patient's Provider • 2 MIs of 2 different types (Type 1 and Type 2) in the
same 4 week period
• MI due to ischemia I21.A1
• Z55‐Z65, Persons with potential health hazards • AMI I21.9
related to socioeconomic and psychosocial • Do not use I22 for the subsequent MI in this
circumstances, code assignment may be based on case.
medical record documentation from clinicians
involved in the care of the patient who are not the
patient’s provider since this information
represents social information, rather than medical
diagnoses.Other Changes Underdosing
• Guideline: Codes for underdosing should never be
assigned as principal or first‐listed codes. If a patient
• Underdosing refers to taking less of a medication has a relapse or exacerbation of the medical
than is prescribed by a provider or a condition for which the drug is prescribed because of
manufacturer’s instruction. Discontinuing the use the reduction in dose, then the medical condition
of a prescribed medication on the patient's own itself should be coded.
initiative (not directed by the patient's provider) is • Noncompliance or complications of care codes are to
also classified as an underdosing. For underdosing, be used with an underdosing code to indicate intent,
assign the code from categories T36‐T50 (fifth or if known.
sixth character “6”).
• C—Condition
• T—T code for underdosing of the drug
• Z—Z code for Underdosing reason (or sometimes Y)
46
Underdosing Example
• Patient with diagnosis of Hypertension continued to
experience elevated blood pressure while taking blood
pressure meds. Upon patient interview, it was found
the patient was taking medication once daily instead of
twice daily because of the cost of the drug.
• I10 Essential (primary) hypertension
• T46.5x6D Underdosing of other antihypertensive
drugs, subsequent encounter
Changes to the OASIS!!!!
• Z91.120 Patient's intentional underdosing of
medication regimen due to financial hardship
47How OASIS Changes Affect Coding
How OASIS Changes Affect Coding • Only items that cannot be updated in the 5 day
Effective Now (as of August 2017) timeframe for SOC
• Extension of the one clinician rule • Pressure Ulcers
• First clinician may not complete the assessment and • When did the skin assessment occur?
wait for someone else to complete (team
assessments)
• May collaborate more on assessment findings
• Skin assessment is biggest impact
Example Example
1. RN says that patient wouldn’t allow him to look at • 2. RN says that the patient wouldn’t allow him to
her bottom when he did skin assessment. Female assess her bottom and so he did not complete the
nurse visits on day 3 and documents pressure ulcer skin assessment. Female nurse visits on day 3 and
on coccyx. completes skin assessment and documents
• Pressure ulcer marked in M1300 items? pressure ulcer on the coccyx.
• Should it still be coded (considering physician • Pressure ulcer marked in M1300 items?
verified)? • Should it still be coded (considering physician
• Can the care still be added to the POC? verified)?
• Can the care still be added to the POC?How OASIS Changes Affect Coding
Effective January 1 BAM!
• M1011 They’re
• M1017 gone!
• M1025
• PDGM – up to 25 diagnoses
But also items like: M1350
• Tracking down the etiology of wounds
• Should still be there
Conventions—Relational Terms With
• And—interpreted to mean ‘and/or’ when it The classification presumes a causal relationship
appears in a code title within the tabular list between the two conditions linked by these terms
(C34 Malignant neoplasm of bronchus and in the Alphabetic Index or Tabular List. These
lung) conditions should be coded as related even in the
2018
absence of provider documentation explicitly linking
them, unless the documentation clearly states the
• The word “with” or “in” should be conditions are unrelated or when another guideline
interpreted to mean “associated with” or exists that specifically requires a documented
“due to” when it appears in a code title, the linkage between two conditions (e.g., sepsis
Alphabetic Index, (either under a main term 2019 guideline for “acute organ dysfunction that is not
or subterm) or an instructional note in the clearly associated with the sepsis”).
Tabular List.
55 56“With” or “in” Examples of ‘With’
• Reference diabetes in the index AS AN EXAMPLE
For conditions not
• Diabetes
specifically linked by with
these relational terms in If the condition is not amyotrophy
the classification or specifically listed under arthropathy NEC
when a guideline with or in, then it cannot
requires that a linkage be linked without the
autonomic (poly) neuropathy
between two conditions physician’s say‐so. cataract (yes, even cataracts)
be explicitly Charcot’s joints
Does a guideline say it
documented, provider And so on…
requires physician
documentation must link
the conditions in order to
documentation? • Not limited to diabetes…see dementia, with…
code them as related. • Dementia, with, Parkinson’s
• Anemia in…
• Arthropathy in…
58
Diabetic Manifestations (and Others) Examples
• It’s not the coder that assumes—the classification
assumes a cause and effect relationship between • The physician documents foot ulcer on a diabetic
diabetes and the listed manifestations patient.
• The only time you do not code those manifestations • The physician documents pressure ulcer on the right
specifically listed, as diabetic is if the physician has buttock on a diabetic patient.
documented a different cause it is unrelated. • The patient has diabetes and also has
• It is imperative that all documentation be polyneuropathy.
reviewed for indications that there is another • The patient has diabetes and also has alcoholic
cause before assigning the manifestation to polyneuropathy documented.
diabetes.
• The diabetic has a gangrenous pressure ulcer.
59 60Examples
• The diabetic patient has PVD • Arthropathy NEC • For conditions not
• The diabetic patient has arterial ulcers. • Circulatory complication NEC specifically linked by
these relational
• Complication, specified NEC terms in the
• The diabetic has an ulcer • Kidney complications NEC classification,
provider
on his lower leg associated • Neurologic complication NEC documentation must
• Oral complication NEC link the conditions in
with stasis dermatitis with order to code them
• Skin complication NEC
hemosiderin staining and a as related.
• Skin ulcer NEC
beefy wet appearance.
• Know when you should really CC Q4 2017 Do NOT link conditions
ask not specifically listed!
61 62
• The patient has diabetes and OA. Do we code that
as diabetic arthropathy?
• What about if the physician documents
arthropathy? E ‐‐Endocrine, Metabolic
• The patient has diabetes and CAD. Is that diabetic
CAD? No, but… and Nutritional
• (If diabetic CAD is documented: E11.59, I25.10)
63 64Diabetes Categories E08 DM due to underlying condition
E08 DM due to underlying condition
• Code first underlying condition (e.g., pancreatitis, pancreatic cancer, injury to
pancreas, cystic fibrosis, malnutrition, Cushing’s)
• Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84) • Any condition that impacts the pancreas function
E09 DM due to drug or chemical • Cystic fibrosis‐ Cystic fibrosis produces abnormally
• Sequencing depends on adverse effect or poisoning (Adverse Effect—e.g.,
steroids, pentamidine; E09.‐, then T code for drug) (Poisoning—e.g., Dioxin, thick mucus, which blocks the pancreas.
arsenic; T code for drug or chemical, then E09.‐)
• Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84) • Pancreatic cancer, Pancreatitis, and trauma can all
E10 DM Type I No insulin coded harm the pancreatic beta cells or impair insulin
• Brittle, ketosis prone
production, thus causing diabetes.
E11 DM Type II
• Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84) • Malnutrition
• Includes unspecified diabetes
E13 Other specified DM • Cushing’s syndrome‐‐induces insulin resistance.
• Secondary diabetes NEC Cushing’s syndrome is marked by excessive
• Use additional code for insulin (Z79.4) or oral antiglycemics (Z79.84)
• Special sequencing when caused by removal of pancreas (E89.1, E13.‐,
production of cortisol—sometimes called the “stress
Z90.41‐, Z79.4 or Z79.84) hormone.”
65 66
E09 Drug or chemical induced DM E09 Drug or chemical induced DM
Adverse Effect Poisoning
• Many chemical toxins can damage or destroy beta cells in
• Some medications, such as nicotinic acid and animals, but only a few have been linked to diabetes in
certain types of diuretics, anti‐seizure drugs, humans. For example, dioxin—a contaminant of the
psychiatric drugs, and drugs to treat HIV, can impair herbicide Agent Orange, used during the Vietnam War—
beta cells or disrupt insulin action. Pentamidine, a
drug prescribed to treat a type of pneumonia, can may be linked to the development of type 2 diabetes. In
increase the risk of pancreatitis, beta cell damage, 2000, based on a report from the Institute of Medicine,
and diabetes. Also, glucocorticoids—steroid the U.S. Department of Veterans Affairs (VA) added
hormones that are chemically similar to naturally diabetes to the list of conditions for which Vietnam
produced cortisol—may impair insulin action. veterans are eligible for disability compensation. Also, a
Glucocorticoids are used to treat inflammatory chemical in a rat poison no longer in use has been shown
illnesses such as rheumatoid arthritis, asthma, to cause diabetes if ingested. Some studies suggest a high
lupus, and ulcerative colitis. intake of nitrogen‐containing chemicals such as nitrates
and nitrites might increase the risk of diabetes. Arsenic
67 has also been studied for possible links to diabetes. 68Examples Coding Clinic
• How do you code a patient with chronic respiratory
• The patient has steroid induced diabetes from taking failure due to a valium overdose 3 months ago?
corticosteroids for an upper respiratory infection last
year. • Chronic respiratory failure
• E09.9 Drug or chemical induced diabetes • Poisoning by valium, sequela
• T38.0x5S Adverse effect of glucocorticoids,
sequela • Wait! Isn’t this a poisoning? Shouldn’t this be
coded:
• The patient has diabetes from exposure to Agent • Poisoning by valium, sequela
Orange during the Vietnam conflict. • Chronic respiratory failure
• T53.7x1S Toxic effect of other halogen derivatives Response: Code it as a sequela (without
of aromatic hydrocarbons, accidental, sequela explanation).
• E09.9 Drug or chemical induced diabetes
69
Compare E10 Type 1 DM
Poisoning Guideline Sequela Guideline (option)
T53.7x1S Toxic effect E09.9 Drug or • Type 1 diabetes is caused by a lack of insulin
of other halogen chemical induced due to the destruction of insulin‐producing
derivatives of diabetes beta cells in the pancreas. In type 1
aromatic diabetes—an autoimmune disease—the
hydrocarbons, T53.7x1S Toxic effect body’s immune system attacks and destroys
accidental, sequela of other halogen the beta cells.
derivatives of • Genetic susceptibility
E09.9 Drug or aromatic
chemical induced hydrocarbons,
diabetes accidental, sequela
72E11 Type II DM E13 Other Specified Diabetes
• Caused by a combination of factors, including insulin
resistance, a condition in which the body’s muscle, • Genetic defects of beta cell function or insulin action
fat, and liver cells do not use insulin effectively. Type • Postpancreatectomy/post procedural DM
2 diabetes develops when the body can no longer
produce enough insulin to compensate for the • Secondary DM, NEC
impaired ability to use insulin. • Specific guideline postpancreatectomy DM
• The role of genes is suggested by the high rate of • E89.1 Postprocedural hypoinsulinemia
type 2 diabetes in families and identical twins and
wide variations in diabetes prevalence by ethnicity. • E13 code(s)
Type 2 diabetes occurs more frequently in African • Z90.41‐ Acquired absence of pancreas
Americans, Alaska Natives, American Indians,
Hispanics/Latinos, and some Asian Americans, Native • Z79.4 insulin or Z79.84 anti‐glycemics
Hawaiians, and Pacific Islander Americans than it
does in non‐Hispanic whites.
73 74
Type 1.5 LADA Type 3 Alzheimers Disease
• Latent autoimmune diabetes in adults (LADA) is a
slow progressing form of autoimmune diabetes. • Pronounced insulin resistance in the brain
Like type 1 diabetes, LADA occurs because your • Code? E13 Other specified diabetes
pancreas stops producing adequate insulin, most
likely from some "insult" that slowly damages the
insulin‐producing cells in the pancreas.
• Unlike type 1 diabetes, with LADA, insulin will not
be needed for several months up to years after
diagnosis.
• Code? E13Diabetes Categories Diabetes Categories
• Diabetes E11
• Diabetes
• Diabetes as an adverse effect of steroids with
• E08 • Diabetes as an adverse effect of
steroids with hyperglycemia E09
hyperglycemia
• E09 • Diabetes as a result of cystic E08
• Diabetes as a result of cystic fibrosis fibrosis
• E10 • Diabetes after a pancreatectomy E13
• Diabetes after a pancreatectomy
• E11 • Ketosis prone diabetes E10
• Ketosis prone diabetes
• Diabetes as a result of arsenic
• E13 poisoning E09
• Diabetes as a result of arsenic poisoning
• Type II DM with hyperglycemia
due to taking steroids E11
• Type II DM with hyperglycemia due to taking steroids
Which one is it? Which one is it?
• Steroid induced diabetes • Other types of diabetes • Diabetes as a result of • Diabetes as a result of
E09 with hyperglycemia pancreatitis, pancreatic removing the pancreas
• The patient did not have because of taking cancer of other injury (E13)
diabetes prior to taking steroids is not steroid to the pancreatic beta
the medication impacting induced diabetes— cells (E08)
the pancreatic beta cells. continue to code the
• Hyperglycemia with specific type with .65 as
taking the medication 4th and 5th digits.
may be temporary—
before coding the patient
as diabetic, ask the
physician!!Guidelines Guidelines
• The diabetes mellitus codes are combination codes • If the type of diabetes mellitus is not documented
that include: in the medical record the default is E11.‐, Type 2
• the type of diabetes mellitus (E08‐E13), diabetes mellitus.
• the body system affected, (4th character) and • Old policy:
• the complications affecting that body system (5th, • If the documentation in a medical record does
6th characters). not indicate the type of diabetes, code E11,
• Diabetes codes should be sequenced based on the Type 2 diabetes mellitus, should be assigned.
reason for a particular encounter. • (Type 2 is the DEFAULT—do NOT code Type I just
• Assign as many codes from the appropriate category because the patient takes insulin)
(E08 –E13) as needed to identify all of the associated • Physician says insulin dependent diabetes
conditions that the patient has. (MANY Assumptions) mellitus—code type 2
81 82
Now code these… Now code these…answers
• Secondary Diabetes
• Secondary Diabetes • E13.9
• Diabetes as an adverse effect of steroids with hyperglycemia
• Diabetes as an adverse effect of steroids with
hyperglycemia • E09.65, T38.0x5D
• Diabetes as a result of cystic fibrosis and CKD
• Diabetes as a result of cystic fibrosis and CKD • E84.8, E08.22, N18.9
• Diabetes after a pancreatectomy taking insulin
• Diabetes after a pancreatectomy taking insulin
• E89.1, E13.9, Z90.410, Z79.4
• Ketosis prone diabetes • Ketosis prone diabetes
• E10.9
• Diabetes as a result of arsenic poisoning years
• Diabetes as a result of arsenic poisoning years ago and chronic ago and chronic osteomyelitis of the 5th
osteomyelitis of the 5th lumbar vertebrae (patient had post lumbar vertebrae • T57.0x1S, E09.9, M46.26
op infection after laminectomy 5 years ago) NEED to QUERY
• Type II DM with hyperglycemia due to taking
steroids • E11.65, T38.0x5D
• Type II DM with hyperglycemia due to taking steroidsDiabetes 4th characters 0 and 1 Example
• Diabetes with hyperosmolarity • The patient is admitted to home care after a
• Does not occur with Type 1 DM hospitalization for episode of diabetic ketosis with
• No choice in Type 1 diabetics (no E10.0‐) blood sugar of 857. The physician documents type
2 DM, polyneuropathy and CKD. The neuropathy
• Diabetes with ketoacidosis required pain management and the CKD required
• Occurs rarely with Type 2 diabetics dialysis for 2 days as a precaution. Codes for M1011
• New choice in Type 2 diabetics (E11.1‐) include:
• Type 2 DM with ketoacidosis E11.10 a. E10.10, E10.65, E10.42, N18.9
• Do not code hyperglycemia with ketoacidosis.
b. E11.10, E11.65, E11.42, E11.22, N18.9
• If the type of diabetes is unspecified but
documented with ketoacidosis, do not code Type 2. c. E13.10, E11.42, E11.22, N18.9
Query physician. d. E11.10, E11.42, E11.22, N18.9
85
Explanation: Diabetes 4th Characters
2 as 4th character
• Do not code hyperglycemia with ketoacidosis. • R‐ Renal/Kidney complications
• Neuropathy and CKD are assumed related to 3 as 4th character
diabetes. • O‐Ophthalmic
4 as 4th character
• N‐Neurological
5 as 4th character
• Remember that diabetes type is unspecified, then
• C‐Circulatory
type 2 is coded?
6 as 4th character
• Diabetic ketoacidosis is not assumed to be type 2
• O‐Other—arthropathy, skin complications, oral
because the type of diabetes is unspecified. Query complications, hypoglycemia, hyperglycemia and
the physician for type. other
88Diabetes (Other) Diabetic Manifestation Notables
• E11.22 Use additional code for CKD (N18.1‐ N18.6)
• 7—no 4th character 7 • Use additional code note (OK to code N18.9, but this
may change)
• 8—unspecified complications (do NOT use) Patients with CKD may also suffer from other conditions,
• 9—without complications (equivalent to 250.00) most commonly diabetes and hypertension. The
sequencing of the CKD in relationship to codes for other
contributing conditions is based on the coding conventions.
FOLLOW THE TABULAR INSTRUCTIONS
NOT Diabetes
• Borderline diabetes Do not mark • The classification assumes a relationship between CKD
and HTN.
• Latent diabetes, and diabetes on
• The classification assumes a relationship between CKD
• Prediabetes M1028. and Diabetes.
R73.03 • Diabetes, CKD and HTN
89 • E11.22, I12.9, N18.9 OR I12.9, E11.22, N18.9 90
N18‐Chronic kidney disease Related Except If They’re Not
• If the physician says diabetic CKD and the patient • The ICD‐10‐CM classification makes a linkage between
also has hypertension, code BOTH as related to hypertension with CKD and also makes a link between
CKD. diabetes and CKD. If there is no documentation clearly
stating that the hypertension nor diabetes mellitus is
• If the physician says hypertensive CKD and the the cause of the CKD, codes I12.0, Hypertensive chronic
kidney disease and code E11.22, Type 2 diabetes
patient also has diabetes, code BOTH as related to mellitus with diabetic chronic kidney disease, may be
CKD. reported.
• The only time you do not code one or the other as • However, if provider documentation were to clearly
state that the CKD is due to a different cause such as
related is if the physician specifically says they are diabetes mellitus, and was not due to hypertension, a
not related. code from category I12 would not be assigned.
Likewise, if provider documentation were to clearly
state that the CKD is not due to diabetes mellitus but
was due to a different cause, such as hypertension,
• If the physician documents diabetic nephropathy code E11.22 would not be reported.
(E11.21) and CKD (E11.22), code E11.22. • Coding Clinic Letter December 2017
91Diabetic Manifestation Notables Diabetes, with
• E11.3‐ Macular edema includes the type of • Peripheral arteriosclerosis, peripheral vascular
retinopathy disease and peripheral arterial disease in a diabetic
• E11.4‐ includes neuropathy unspecified, patient should be linked and coded as “diabetic
mononeuropathy, polyneuropathy, etc peripheral angiopathy.”
• Source: AHA Coding Clinic Volume 5 Second Quarter Number 2 2018
• E11.43 Includes gastroparesis/gastroparalysis
• E11.5 DM with gangrene includes the peripheral • A letter from Coding Clinic
angiopathy (disease of the peripheral arteries) • E11.51 Diabetes with peripheral angiopathy
• atherosclerosis is related to diabetes… • I170.2‐ Atherosclerosis of lower extremity
• E11.610 Includes Charcot’s
• Not M14.6
• Neurogenic arthropathy
Diabetes with Atherosclerosis of Lower
Diabetic Manifestation Notables
Extremities
Other issues without resolution:
Atherosclerotic ulcer in a diabetic????
• E11.621 or E11.622 (ankle and above)
• E11.51
• Use additional code for ulceration
• I70.2‐ MMTA
• L97.‐ • E11.64‐ Hypoglycemia
Diabetic ulcer in a patient with atherosclerosis???? • E11.65 Hyperglycemia
• E11.62‐ • Remember not to use this with ketoacidosis.
• L97.‐ • E11.69 Other manifestations of diabetes
• E11.51 • Use additional code, e.g. osteomyelitis
Wound
• I70.2‐
96Sequencing Several Diabetic Sequencing Several Diabetic
Complications/Manifestations Complications/Manifestations
Mrs Wolfe:
• Mrs. Wolfe has diabetic ulcers on three toes of her • E11.621 DMII with foot ulcers
right foot (muscle necrosis on the worst), diabetic
gangrene on a 4th toe and poorly controlled blood • L97.513 Ulcer other part of foot (toes), right,
sugars. muscle necrosis
• She also had CHF and hypertension. • E11.65 DMII with hyperglycemia
• The ulceration and the blood sugars are the focus • E11.52 DMII with peripheral angiopathy with
of care. The physician says we’re going to let the gangrene
toe fall off.
Where do we put the
CHF and hypertension?
97 98
Hyperglycemia
• With, Hyperglycemia
• Inadequately controlled –code to diabetes, by type
with hyperglycemia
Diabetes
with foot E11 6 2 1
• Out of control –code to diabetes, by type with
Symptom
ulcer control
hyperglycemia
required on • Poorly controlled –code to diabetes, by type with
Foot ulcer
all. hyperglycemia
L9 7 5 1 3
DM E1 1 6 5 • Uncontrolled
hyperglycemia
E11 5 2
‐ meaning
Hypertension hyperglycemia ‐ see Diabetes, by
type, with, hyperglycemia
CHF
hypoglycemia ‐ see Diabetes, by type,
DM angiopathy 99
with, hypoglycemia 100M1028 Active Diagnoses Applicable Codes
• “-” means unable to assess
• Leave blank if the patient doesn’t have either diagnosis.
• 3 None of the Above will be added with OASIS D
• Mark 1 and 2 if the patient has diabetic PVD (e.g.,
E11.51)
101 102
Guideline: Hypertension
• The classification presumes a causal relationship
between hypertension and heart involvement and
between hypertension and kidney involvement, as
the two conditions are linked by the term “with” in
the Alphabetic Index.
• These conditions should be coded as related even in
the absence of provider documentation explicitly
linking them, unless the documentation clearly states
Hypertension “with” the conditions are unrelated.
• For hypertension and conditions not specifically
linked by relational terms such as “with,” “associated
with” or “due to” in the classification, provider
documentation must link the conditions in order to
code them as related.
103 104Index Hypertension
2019 Change • Hypertension with heart conditions classified to I50.‐
or I51.4‐ I51.7, I51.89, I51.9, are assigned to a code
• List of heart conditions
from category I11, Hypertensive heart disease.
excludes I51.81
• Use an additional code from category I50, Heart
• Takotsubo Syndrome is
failure, to identify the type of heart failure in those
not related to
patients with heart failure.
hypertension. It is
related to stress, so it • The same heart conditions (I50.‐, I51.4‐I51.7, I51.89,
was omitted from the I51.9) with hypertension are coded separately if the
list of conditions provider has specifically documented a different
assumed caused by cause.
hypertension. • New language: if the provider has documented they
are unrelated to the hypertension.
106
Significant Change? Hypertensive Heart Disease
• Just a clarification? Look at I11
• The patient has documented rheumatic heart • I51.4‐I51.9 (but not I51.81) are included
failure. The patient also has hypertension. however use an additional code for heart
• specifically documented a different cause: code
failure, if present.
rheumatic heart failure followed by the appropriate • Specific sequencing required
heart failure code. Code hypertension separately.
• documented they are unrelated to the • The hypertension must be coded prior to the
heart failure.
hypertension: Code hypertension with I11.0, and
• Note the ‘code first’ note at I50
rheumatic heart failure, and appropriate heart
failure code. • The conditions included in I11 are not coded
separately.
• Patient has hypertension and cardiomegaly
107 (I51.7), then code I11.9 ONLYPractice Practice
• Hypertensive left ventricular hypertrophy • Hypertensive left ventricular hypertrophy
a. I11.9 a. I11.9
b. I11.9, I51.7 b. I11.9, I51.7
• End stage heart disease patient also has • End stage heart disease patient also has
hypertension hypertension
a. I11.9 a. I11.9
b. I11.9, I51.9 b. I11.9, I51.9
• Senile cardiomyopathy with hypertension • Senile cardiomyopathy with hypertension
a. I11.9 a. I11.9
b. I11.9, I51.5 b. I11.9, I51.5
Hypertensive Chronic Kidney Disease Hypertensive Heart and Kidney
• The classification assumes a relationship • Assign codes from combination category I13,
between hypertension and chronic kidney Hypertensive heart and chronic kidney disease, when
disease. there is hypertension with both heart and kidney
• CKD should not be coded as hypertensive if involvement.
the provider indicates the CKD is not related • If heart failure is present, assign an additional code
to the hypertension. 2019 from category I50 to identify the type of heart failure.
• Code to I12.‐ • The appropriate code from category N18, Chronic
• Stage 5 or ESRD with hypertension I12.0 kidney disease, should be used as a secondary code
• Stage 1‐4 or unspecified CKD with hypertension with a code from category I13 to identify the stage of
I12.9 chronic kidney disease.
• Specific sequencing required with CKD
112Still there in the guidelines Diabetes, Hypertension and CKD
Chronic kidney disease with other conditions • Diabetes and hypertension are assumed related to
CKD.
• Patients with CKD may also suffer from other serious
conditions, most commonly diabetes mellitus and • What if the physician says ‘diabetic CKD’ or
hypertension. The sequencing of the CKD code in ‘hypertensive CKD’?
relationship to codes for other contributing • Code them all related.
conditions is based on the conventions in the Tabular • Exception is if the physician specifically says the
List. diabetes or the hypertension is NOT related.
113
Examples Name that category
• The patient has diabetes, HTN and CKD
• E11.22, I12.9, N18.9 OR
• Hypertension and ESRD • I10
• I12.9, E11.22, N18.9 • Hypertension and CHF
These are coded like this even if the physician states • Systolic heart failure due • I11
“diabetic CKD” or “hypertensive CKD” to hypertension
• The patient has diabetes, HTN, heart failure and CKD • Malignant hypertension • I12
• E11.22, I13.0, I50.9, N18.9 OR
• I13.0, E11.22, I50.9, N18.9 OR maybe
• Patient has CKD and
hypertensive • I13
• I13.0, I50.9, E11.22, N18.9
cardiomegaly
• “Diabetic hypertension” • I15
115 116Name that category Answers
• Hypertension and ESRD I12 • Hypertension and ESRD I12.0, N18.6
• Hypertension and CHF I11 • Hypertension and CHF I11.0, I50.9
• Systolic heart failure due I11 • Systolic heart failure due to hypertension
to hypertension I11.0, I50.20
• Malignant hypertension I10 • Malignant hypertension I10
• Patient has CKD and • Patient has CKD and hypertensive
hypertensive I13 cardiomegaly I13.10, N18.9
cardiomegaly • Diabetic hypertension E11.59, I15.2
• Diabetic hypertension I15
117 118
Definitions
• Sepsis—Sepsis is a potentially life‐threatening complication
of an infection. Sepsis occurs when chemicals released into
the bloodstream to fight the infection trigger inflammation
throughout the body. This inflammation can trigger a
cascade of changes that can damage multiple organ
systems, causing them to fail. If sepsis progresses to septic
shock, blood pressure drops dramatically, which may lead to
death.
• Localized infection—An infection that is limited to a specific
part of the body and has local symptoms.
• Septicemia—Septicemia is bacteria in the blood
(bacteremia) that often occurs with severe infections. (No
separate code)
120Sepsis Why is Sepsis becoming more common?
• Becoming more common in home care • Aging population. Americans are living longer, which is
swelling the ranks of the highest risk age group — people
• Sepsis Coded the
same way
older than 65.
• Septicemia • Drug‐resistant bacteria. Many types of bacteria can resist
Add R65.2‐ and organ the effects of antibiotics that once killed them. These
• Severe sepsis failure
antibiotic‐resistant bacteria are often the root cause of the
infections that trigger sepsis.
• Sepsis from a localized infection Sequencing
• Weakened immune systems. More Americans are living
• Postprocedural sepsis with weakened immune systems, caused by HIV, cancer
treatments or transplant drugs.
121 • Source: http://www.mayoclinic.org/diseases‐conditions/sepsis/symptoms‐causes/dxc‐20169787
More on Sepsis Example of Sepsis vs Septicemia
• Many doctors view sepsis as a three‐stage syndrome,
starting with sepsis and progressing through severe sepsis • Sepsis from Strep pneumoniae
to septic shock. The goal is to treat sepsis during its early
stage, before it becomes more dangerous.
• A40.3 Sepsis due to Strep pneumoniae
Sepsis
To be diagnosed with sepsis, you must exhibit at least two of • Septicemia from Strep pneumoniae
the following symptoms, plus a probable or confirmed • A40.3
infection:
• Body temperature above 101 F (38.3 C) or below 96.8 F (36 • Index directs to A41.9 (Septicemia NOS)
C)
• Heart rate higher than 90 beats a minute
• Respiratory rate higher than 20 breaths a minute
• A41.9 is also used when the physician documents
• Source: http://www.mayoclinic.org/diseases‐conditions/sepsis/symptoms‐causes/dxc‐20169787
sepsis without the bacteria
124Coding Sepsis Septic Shock
‘
• Septic shock generally refers to circulatory failure
• A’ codes for sepsis. Sequencing depends on associated with severe sepsis, and therefore, it
circumstances. See the codes. represents a type of acute organ dysfunction.
• A40 Streptococcal sepsis • Low BP that does not respond to treatment.
• A41 Other sepsis • Not usually a home care diagnosis, but could be a
• And others hospice diagnosis.
• R65.20 Severe sepsis without septic shock
• R65.21 Severe sepsis with septic shock
(if acute organ dysfunction is documented). 125
Severe Sepsis Severe Sepsis Guidelines
• In severe sepsis the patient will also exhibit at least • If a patient has sepsis and an associated acute
one of the following signs and symptoms, which organ dysfunction or multiple organ dysfunction,
indicate an organ may be failing: follow the instructions for coding severe sepsis.
• Query if not clear whether the organ dysfunction
• Significantly decreased urine output is related to the sepsis.
• Abrupt change in mental status • The ‘with’ doesn’t count.
• Decrease in platelet count • Minimum of two (but usually three) codes
• Difficulty breathing • Underlying systemic infection
• Code from subcategory R65.2‐
• Abnormal heart pumping function • Additional code for the associated organ
• Abdominal pain dysfunction.
• Source: http://www.mayoclinic.org/diseases‐ • No need to code circulatory collapse if
conditions/sepsis/symptoms‐causes/dxc‐20169787 present
128Examples Severe because
Sepsis with localized infection
of associated
organ failure • Such as pneumonia, UTI
• Strep sepsis with acute kidney failure • If admitted with sepsis Usually this one
• A40.9 Streptococcal sepsis, unspecified • Assign sepsis code first (A40‐41)
• R65.20 SIRS (severe) without septic shock • Then localized infection
• N17.9 Acute kidney failure, unspecified • Severe? Add R65.2‐ & organ dysfunction
• If admitted with localized and develops into sepsis
• Strep sepsis with septic shock • Code localized infection first
• A40.9 Streptococcal sepsis, unspecified
• R65.21 SIRS (severe) with septic shock Sequencing is dependent on whether the
This counts patient was admitted with sepsis or developed
as organ
failure.
sepsis after admission.
130
Sepsis with localized infection Code it
• Patient was admitted with sepsis due to
• Sepsis due to Serratia from a UTI
MRSA pneumonia with continued IV
• Sepsis A41.53
• Localized infection, UTI N39.0
antibiotics
• SIRS (R65.2‐) if organ dysfunction is related
(severe sepsis)
• Organ dysfunction, if applicable.
131Sepsis due to MRSA pneumonia Code it:
• A41.02 MRSA sepsis • Patient was admitted for E coli sepsis due to acute
cystitis.
• J15.212 MRSA pneumonia N30.00, B96.20
• Z45.2 Management of vascular device A41.51, N30.00, B96.20
A41.51, N30.00
A49.51, N39.0, B96.20
E coli sepsis due to acute cystitis Urosepsis
• Patient was admitted for E coli sepsis due to acute
cystitis. • The term urosepsis is a
N30.00, B96.20 nonspecific term. It is not to
A41.51, N30.00, B96.20
be considered synonymous
with sepsis. It has no default
A41.51, N30.00 code in the Alphabetic Index.
A49.51, N39.0, B96.20 Should a provider use this
term, he/she must be
queried for clarification.Reminder‐‐7th Character A Postprocedural Sepsis (until September 30)
• 7th character “A”, initial encounter is used while the
• Must be documented by the physician—
patient is receiving active treatment for the condition. • Start with the specific postprocedural infection code
Examples of active treatment are: surgical treatment, (e.g., T81.4‐)
emergency department encounter, and evaluation and
continuing treatment by the same or a different • Use appropriate A40‐41 code next.
physician
• Patient with postprocedural sepsis related to infected
• Additional examples of “initial” encounter (examples of
active treatment) surgical wound caused by MRSA. IV antibiotics.
• Antibiotic therapy for postoperative infection • T81.4xxA Post‐op sepsis
• Wound vac treatment of wound dehiscence • A41.02 MRSA sepsis
• Z45.2 Management of vascular device
• Z79.2 LT use antibiotics 138
Postprocedural Sepsis (October 1) Change in Guideline
As with all postprocedural complications, code
• Must be documented by the physician— assignment is based on the provider’s documentation of
• Start with the specific postprocedural infection code the relationship between the infection and the
(e.g., T81.4‐) procedure.
• Code the T81.44x‐ next.
• Use appropriate A40‐41 code next. For infections following a procedure, a code from
T81.40, to T81.43 Infection following a procedure, … that
• Patient with postprocedural intramuscular abscess identifies the site of the infection should be coded first,
resulting in sepsis caused by MRSA. IV antibiotics. if known.
• T81.42xA Post surgical infection, deep incisional Assign an additional code for sepsis following a
surgical site procedure (T81.44)... Use an additional code to identify
• T81.44xA Post‐op sepsis the infectious agent.
• A41.02 MRSA sepsis If the patient has severe sepsis, the appropriate code
• Z45.2 Management of vascular device from subcategory R65.2 should also be assigned with the
• Z79.2 LT use antibiotics additional code(s) for any acute organ dysfunction.
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