Coronavirus (COVID-19): Get the latest information about how Practice Fusion is supporting providers and patients during the outbreak COVID-19 Resources

The clinical concepts for family practice guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

ICD-10 Clinical Scenarios for Family Practice

  • Scenario 1: Abdominal Pain
  • Scenario 2: Annual Physical Exam
  • Scenario 3: Earache
  • Scenario 4: Anemia
  • Scenario: COPD with Acute Pneumonia Example
  • Scenario: Cervical Disc Disease
  • Scenario: Abdominal Pain
  • Scenario: Diabetes
  • Scenario: ER Follow Up

Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

Family Practice Clinical Scenarios:

Scenario 1: Abdominal Pain

Scenario Details

Chief Complaint

  • “My stomach hurts and I feel full of gas.”

History

  • 47 year old male with mid-abdominal epigastric pain1, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
  • Has had an estimated 13 pound weight loss over the past month.
  • Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.
  • Patient admits to a history of alcohol dependence2. Consuming 5 – 6 beers per day now, down from 10 – 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.

Exam

  • VS: T 99.8°F, otherwise normal.
  • Mild jaundice noted.
  • Abdomen distended and tender across upper abdomen3. Guarding is present. Bowel sounds diminished in all four quadrants.
  • Oral mucosa dry, chapped lips, decreased skin turgor

Assessment and Plan

  • Dehydration and suspected acute pancreatitis.
  • Admit to the hospital. Orders written and sent to on-call hospitalist.
  • 1L IV NS started in office. Blood drawn for labs.
  • Recommend behavioral health counseling for substance abuse assessment and possible treatment.
  • Patient’s wife notified of plan; she will transport to hospital by private vehicle.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. Describe the pain as specifically as possible based on location.
  2. When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.
  3. Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.

Coding

ICD-9-CM Diagnosis Codes

789.06 Abdominal pain, epigastric
789.60 Abdominal tenderness, unspecified site
782.4 Jaundice NOS
276.51 Dehydration
303.90 Other and unspecified alcohol dependence, unspecified

ICD-10-CM Diagnosis Codes

R10.13 Epigastric pain
R10.819 Abdominal tenderness, unspecified site
R17 Unspecified jaundice
E86.0 Dehydration
F10.20 Alcohol dependence, uncomplicated

Other Impacts

No specific impacts noted.

Scenario 2: Annual Physical Exam

Scenario Details

Chief Complaint

  • “I’m here for my annual check-up.1”

History

  • 73 year old male with history of coronary artery disease, stent placement, hyperlipidemia, HTN and GERD.
  • Recent admission to hospital following a hypertensive crisis. Discharged home on olmesartan medoxomil 20 mg daily.
  • Patient stopped taking olmesartan medoxomil due to side effects2, including a headache that began after starting the medication and still exists, and tiredness.
  • Regular activity includes walking, golfing. Active social life. No complaints of chest pain, or dyspnea on exertion.
  • Last colonoscopy was 9 months ago. No significant pathology found; some diverticular disease.
  • Medications were reviewed.

Exam

  • Chest clear. Heart sounds normal. Mental status exam intact.
  • EKG shows no changes from prior EKG.
  • Vitals: BP is 159/95, otherwise normal. Per patient, he had good control of BP on meds, but it has risen without medication.
  • BUN/creatinine normal limits.

Assessment and Plan

  • HTN noted on exam today. Change from olmesartan medoxomil to metoprolol tartrate 50 mg once daily, will titrate dosage every two weeks until BP normalizes.
  • Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP medication as prescribed; he verbalizes understanding.
  • Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy, and repeat BUN/creatinine.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes). In this situation, the patient is requesting an encounter without a complaint, suspected or reported diagnosis.
  2. Document that the patient is noncompliant with his medication. This “underdosing” concept can often be coded, along with the patient’s reason for not taking the prescribed medications. Document if there is a medical condition linked to the underdosing that is relevant to the encounter, and ensure the connection is clearly made. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. In this note the side effects of stopping the medication include headache, which remains as a patient complaint for this encounter. When documenting headache do differentiate if intractable versus non-intractable.

Coding

ICD-9-CM Diagnosis Codes

V70.0 Routine medical exam
401.9 Unspecified essential hypertension
339.3 Drug-induced headache, not elsewhere classified

ICD-10-CM Diagnosis Codes

Z00.01 Encounter for general adult medical examination with abnormal findings
I10 Essential (primary) hypertension
G44.40 Drug-induced headache, not else where classified, not intractable
T46.5X6A Underdosing of other antihypertensive drugs, initial encounter
Z91.128 Patient’s intentional underdosing of medication regimen for other reason

Other Impacts

  • Assess if the new patient-centric preventative health incentives for annual exams are relevant to your practice.
  • For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.

Scenario 3: Earache

Scenario Details

Chief Complaint

  • Right earache and ear pain.

History

  • This 20 year old male is an established patient and well known to me. He is a full-time college student, and presents with a right sided ear pain, noted 8/10. The symptoms started yesterday and continue to worsen with no pain relief using acetaminophen. Denies discharge, hearing loss, or ringing/roaring. He denies trauma or recent barotrauma to ear. He denies fever, sore throat, and cough today. He reports recently having an URI that resolved with OTC medications.
  • He is up to date on his influenza, HPV, Tdap, and meningococcal immunizations.
  • Patient does not use tobacco, alcohol, or illicit drugs. He denies exposure to second hand smoke.
  • Medical history includes major depressive disorder with recurrent episodes of mild severity, and bipolar II disorder. His current medications include aripiprazole, and duloxetine.
  • No known allergies.
  • 16 point review of systems negative except for notations above.

Exam

  • Healthy appearing male. A&Ox3. He appears calm and is cooperative.
  • Vital signs: BP: 130/78 HR: 70 bpm T: 99.8 °F Wt: 235 lbs Ht: 5’ 10”.
  • ENT: auricle and external canals normal bilaterally. Right ear: erythematous membrane, bulging, with loss of landmarks. Pharynx, teeth, and nose exam normal. No cervical adenopathy bilaterally.
  • Integumentary: Skin is flushed, warm, and dry with no edema. Mucous membranes are moist.
  • Respiratory: Lungs clear CTA with normal respiratory effort.
  • Abdomen: non-tender, no organomegely.

Assessment and Plan

  • New onset AOM AD, suppurative, with pain unrelieved by acetaminophen.
  • Prescriptions: amoxicillin for AOM; ibuprofen for pain.
  • Return in one week if symptoms persist.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. In diagnosing otitis media using ICD-9-CM you should document items such as acute, chronic, not specified as acute or chronic, nonsuppurative or suppurative, and with or without spontaneous rupture of the eardrum. In ICD-10-CM, you will need to document these characteristics plus left, right or bilateral that are affected and is the problem initial or recurrent to assign a correct code.
  2. In this fictional test case we gave this young male a diagnosis of bipolar II disorder. You would not report the bipolar disorder unless it affects treatment at today’s encounter. Conditions that are not treated or that do not affect patient treatment nor are treated should not be reported.

Coding

ICD-9-CM Diagnosis Codes

382.00 Acute suppurative otitis media without spontaneous rupture of eardrum

ICD-10-CM Diagnosis Codes

H66.001 Acute suppurative otitis media without spontaneous rupture of ear drum, right ear

Other Impacts

No specific impact noted.

Scenario 4: Anemia

Scenario Details

Chief Complaint

  • Discuss laboratory results.

History

  • 38 year old established female seen by me over one week ago for decreased exercise tolerance and general malaise over the past four weeks when doing her daily aerobics class. Labs were ordered on that visit. She presents today with pale skin, weakness, and epigastric pain; symptoms are unchanged since previous visit. Laboratory studies reviewed today are as follows: HGB 8.5 gm/dL, HCT 27%, platelets 300,000/mm3, reticulocytes 0.24%, MCV 75, serum iron 41 mcg/dL, serum ferritin 9 ng/ml, TIBC 457 mcg/dL; Fecal occult blood test is positive.
  • She takes Esomeprazole daily for GERD with esophagitis and reports taking OTC antacids at bedtime for epigastric pain for the past three months. She also uses ibuprofen as needed for headaches.
  • Current pain is 0/10.
  • Medical history significant for GERD, peptic ulcer, pre-eclampsia with last pregnancy.
  • LMP: two weeks ago, normal flow, unchanged in last three months.
  • Married; three children ages 15, 12, and 1 year old.
  • Patient does not use tobacco, alcohol, or illicit drugs.
  • No known allergies.
  • No changes in interval history and review of systems noted from encounter 8 days ago.

Exam

  • Well-nourished, well groomed, pleasant female who shows good judgment and insight. Oriented X 3. Good recent and remote memory. Appropriate mood and affect.
  • Vital signs: T 98.7, RR 18, BP: 118/75, standing 120/60, HR: 90.
  • HEENT: PERRLA.
  • Neck: Supple. No thyromegaly.
  • Lungs: clear to auscultation with normal respiratory effort.
  • Cardiovascular: Regular rate and rhythm. No pedal edema.
  • Integumentary: Pale, clear of rashes and lesions, no ulcers. Early cheilosis noted.
  • Rectal: No gross blood on exam one week ago; stool sample results noted above.
  • Lymphatics: No lymphadenopathy.
  • Musculoskeletal: The patient had good, stable gait.

Assessment and Plan

  • Iron-deficiency anemia secondary to blood loss.
  • Continue esomeprazole as prescribed.
  • Replace ibuprofen use with acetaminophen extra strength for headaches, dosage as per label.
  • Prescribed iron sulfate supplements for three month trial. Counseled patient on appropriate use of iron supplementation and side effects.
  • Patient to return in one week for repeat laboratory studies.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. In ICD-10-CM, gastro-esophageal reflux disease is differentiated by noting “with esophagitis” versus “without esophagitis.” “With esophagitis” must be documented in the record.

Coding

ICD-9-CM Diagnosis Codes

280.0 Iron deficiency anemia secondary to blood loss (chronic)
530.81 Disease, Gastroesophageal reflux (GERD)

ICD-10-CM Diagnosis Codes

D50.0 Iron deficiency anemia secondary to blood loss (chronic)
K21.0 Gastro-esophageal reflux disease with esophagitis

Other Impacts

  • 530.11 Reflux esophagitis is not coded when GERD is coded in ICD-9-CM because 530.11 is an “excluded code” from 530.81 in ICD-9-CM but it is a combination code in ICD-10-CM.

Scenario: COPD with Acute Pneumonia Example

Scenario Details

Chief Complaint

  • “I just got out of the hospital 2 days ago. I’m a little better, but still can barely breathe.”

History

  • 67-year-old male with 40 pack/year history of cigarette use (still smoking) and severe oxygen dependent COPD developed cough with increased production of green/gray sputum 2 weeks prior to office visit. Admitted to hospital through Emergency Department with diagnosis of presumed pneumonia superimposed on severe COPD. Hospital exam confirmed acute RLL pneumococcal pneumonia. Patient treated with an IV cephalosporin as he has known penicillin allergy, and was discharge from hospital to home 2 days prior to office visit.
  • PMH shows severe O2 dependent COPD, with type II diabetes mellitus secondary to chronic prednisone therapy, which is treated with oral hypoglycemics.

Patient also has known hypertension, on ACE inhibitor therapy.

Review of Systems, Physical Exam, Laboratory Tests

  • T 99, BP 145/105, P 92 and irregular, RR 28
  • Chest exam shows decreased lung sounds throughout all lung fields except in RLL where there were mild rhonchi and wheezes noted
  • ABG’s on 2L O2 by nasal cannula show PO2 62, PCO2 47, pH 7.40
  • CXR shows hyperinflation of lungs with small RLL alveolar infiltration. Comparison to CXR from hospitalization shows approximately 75% resolution of pneumonia.
  • ECG reveals persistent atrial fibrillation which was not present on previous ECG of 6 months earlier, but had been found at time of recent hospitalization. Labs show finger stick glucose of 195mg%.

Assessment and Plan

  • Acute Community Acquired Pneumococcal Pneumonia: continue oral cephalosporin. Schedule office follow up visit in 1 week with repeat CXR.
  • Severe COPD: continue O2, low dose Prednisone, and inhaled bronchodilator.
  • Chronic Hypoxemic, Hypercarbic Respiratory Failure
  • Persistent Atrial Fibrillation: continue digoxin initiated during recent hospitalization
  • Hypertension: continue ACE inhibitor therapy
  • Diabetes Mellitus, Type II, secondary to prednisone therapy; continue oral hypoglycemic therapy
  • Penicillin Allergy
  • Tobacco Dependence

Summary of ICD-10-CM Impacts

Clinical Documentation

  • ICD-10-CM separates pneumonia by infectious agent. Document the infectious agent of pneumonia, as there are discrete ICD-10-CM codes for each type.
  • ICD-10-CM separates by acuity of respiratory failure, and hypoxia or hypercapnia, if present.
  • Document drug allergies with ICD-10-CM status” Z” codes from Chapter 21 to identify these.
  • Document the type of cardiac arrhythmia. Atrial fibrillation in ICD-10-CM separates into paroxysmal, persistent, chronic, typical, atypical, unspecified. Acute atrial fibrillation defaults to unspecified in ICD-10-CM.
  • The Table of Drugs & Chemicals has a code assignment for Adverse effect of the drug that would be followed by the secondary diabetes code. Go to the Volume 3 Index to Table of Drugs and Chemicals. Along the left hand side proceed alphabetically to “Glucocorticoids” and then move horizontally across to the column for Adverse Effect”. In Volume 1 (Tabular List) the instruction at the beginning of the code category T38 are the instructions for the 7th character.
  • Note: Drug-induced Diabetes Mellitus is a secondary type of diabetes due to the use of glucocorticoids. This code can only be coded as an “additional code” and would never be first-listed

The code categories for secondary diabetes are :

  • Due to underlying disease (E08)
  • Due to drug (E09)
  • Due to other specified condition such as post pancreatectomy. (E13)

These three categories can never be first-listed per ICD-10-CM guidelines. The underlying cause would be first-listed diagnosis.

Coding

ICD-9-CM Diagnosis Codes

481 Pneumonia, Pneumococcal
496 COPD
V46.2 Oxygen dependence
427.31 Atrial fibrillation
249.00 Diabetes, secondary, drug induced
E932.0 Therapeutic use of Prednisone
401.9 HTN
V14.0 Allergy, Penicillin
305.1 Tobacco dependence

ICD-10-CM Diagnosis Codes

J13 Pneumonia due to Streptococcus pneumoniae
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
Z99.81 Dependence on supplemental oxygen
I48.1 Persistent atrial fibrillation
E09.9 Drug or chemical induced diabetes mellitus without complications
T38.0x5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
I10 Essential (primary) hypertension
Z88.0 Allergy status to penicillin
F17.210 Nicotine dependence, cigarettes, uncomplicated

Scenario: Cervical Disc Disease

Scenario Details

Chief Complaint

  • “My neck hurts and I have a tingling pain sensation going down my right arm.”

History

  • Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history.

Review of Systems, Physical Exam, Laboratory Tests

  • Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm.
  • Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand.
  • MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted.

Assessment and Plan

  • Cervical transforaminal injection at C5-6

Summary of ICD-10-CM Impacts

Clinical Documentation

  • Subcategory M50.1 describes cervical disc disorders. M50.12 Cervical disc disease that includes degeneration of the disc as a combination code. The 5th character differentiates various regions of the cervical spine (high cervical C2-3 and C3-4; mid-cervical C4-5, C5-6, and C6-7; cervicothoracic C7-T1 and the associated radiculopathies at each level). This is a combination code that includes the disc degeneration and radiculopathy

Coding

ICD-9-CM Diagnosis Codes

722.0 Cervical disc displacement without myelopathy
722.4 Degeneration of cervical intervertebral disc

ICD-10-CM Diagnosis Codes

M50.12 Cervical disc disorder with radiculopathy, mid-cervical region

Other Impacts

  • Management of chronic conditions such as COPD, Diabetes Mellitus, Hypertension, and Atrial Fibrillation should be described in the record.

Scenario: Abdominal Pain

Scenario Details

Chief Complaint

  • “My stomach hurts.”

History

  • Patient is a 65-year-old male admitted to the hospital with abdominal pain. He has a history of Crohn’s disease of the large intestine. He also has a history of coronary artery disease, had a heart attack 5 years ago, but has had no problems since then. He smoked cigarettes for 45 years, but quit after his myocardial infarction. He also has a history of allergic reactions to Penicillins and Cephalosporins.

Review of Systems, Physical Exam, Laboratory Tests

  • 99.8
  • Abdomen: diffuse tenderness over entire abdomen
  • CT scan of abdomen: abscess secondary to Crohn’s disease of descending colon

Assessment and Plan

  • Crohn’s disease, large intestine with abscess.
  • Awaiting GI consultation

Summary of ICD-10-CM Impacts

Clinical Documentation

  • Crohn’s disease in ICD-10-CM is separated by small, large intestine or both (small and large intestine), with or without complications of rectal bleeding, obstruction, fistula, or abscess (combination codes).

Coding

ICD-9-CM Diagnosis Codes

555.1 Regional enteritis, large intestine
567.22 Abscess, abdominal
412 Old myocardial infarction
V15.82 History of tobacco use
V14.0 History of allergy to Penicillin
V14.1 History of allergy to other antibiotic (cephalosporins)

ICD-10-CM Diagnosis Codes

K50.114 Crohn’s disease of the large intestine with abscess
I25.2 Old myocardial infarction
Z87.891 Personal history of nicotine dependence or personal history of tobacco use.
Z88.0 Allergy status to Penicillin
Z88.1 Allergy status to other antibiotic agent

Other Impacts

  • Coding allergies to specific medications allows the providers who share a common EHR to be notified of these allergies. They can be placed into the ongoing problem list therefore becoming available whenever relevant for coding on the claim.
  • At the beginning of Chapter 10 Respiratory conditions this instruction is found:

Use additional code, where applicable, to identify:

  • exposure to environmental tobacco smoke (Z77.22)
  • exposure to tobacco smoke in the perinatal period (P96.81)
  • history of tobacco use (Z87.891)
  • occupational exposure to environmental tobacco smoke (Z57.31)
  • tobacco dependence (F17.-)
  • tobacco use (Z72.0)
  • These tobacco-related codes should also be coded into the ongoing problem list for future coding situations as indicated in ICD-10-CM.

Scenario: Diabetes

Scenario Details

Chief Complaint

  • “I am here for my quarterly evaluation of my diabetes.”

History

  • Patient is a 50-year-old woman with Type 1 diabetes since childhood. She has been on insulin since age 13. As a result of her diabetes she has chronic kidney disease and is currently on dialysis for ESRD. She also has diabetic neuropathy affecting both lower extremities.

Review of Systems, Physical Exam, Laboratory Tests

  • No changes in underlying condition during the last 3 months. She continues to perform selftesting of her blood sugar levels on a daily basis, is on dialysis every other day, most recently 24 hours ago, and has not noticed any changes in the numbness in her legs.
  • BP 140/75, P 80, R 16 and T 98.8
  • Dialysis fistula without any signs of infection
  • Decreased sensation over lower extremities below the knees
  • Lab: BUN/Cr nl, K+ 3.5, glu 105, Hgb A1c 7.9

Assessment and Plan

  • Continue BS checks daily with sliding scale as previously prescribed
  • Start Capsaicin topically and defer to nephrologist for any Rx at this time. She has an appointment 10 am tomorrow.

Summary of ICD-10-CM Impacts

Coding

ICD-9-CM Diagnosis Codes

250.41 Diabetes with renal manifestations, type 1, not stated as uncontrolled
585.6 End stage renal disease
250.61 Diabetes with neurological manifestations, type 1, not stated as uncontrolled
357.2 Polyneuropathy in diabetes
V45.11 Renal dialysis status

ICD-10-CM Diagnosis Codes

E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
N18.6 End-stage renal disease
Z99.2 Dependence on renal dialysis Presence of AV shunt for dialysis
E10.42 Type 1 diabetes mellitus with polyneuropathy

Other Impacts

E10.22 is a combination code in ICD-10-CM incorporating both the type of diabetes (type 1 is E10) and the manifestation chronic kidney disease (after decimal point.22). Instructions from Volume 1 under the code E10.22 is to “use additional code to identify stage of chronic kidney disease N18.1 –N18.6”. In
this documentation the ESRD is documented.

Code the type of diabetes and each associated complication (diabetes with renal disease and diabetic neuropathy) in ICD-10-CM.

Code the stage of the patient’s chronic kidney disease per instruction under the diabetic code E10.22

Code the dialysis and AV graft by the use of “status codes” (Z codes). The key word to find this status code in the Index to Diseases from Volume 3 is “Dependence” and then sub indent to the word “on” and then to the words renal dialysis Z99.2

Scenario: ER Follow Up

Scenario Details

Chief Complaint

  • “Seen in the ER over the weekend.”

History

  • Mrs. Jones is a 64-year-old female, with a history of morbid obesity, type 2 diabetes with nephropathy, and asthma, presents here for follow-up ER visit two days ago for shortness of breath. Patient was discharged with a diagnosis of bronchitis, an Albuterol and Beclomethasone inhaler prescription, along with five day course of Z pack and a six-day steroid dose pack. Patient is improving on the regimen. She is no longer wheezing and her phlegm is now scant. Her sugars however, have been poorly controlled with the Prednisone with fasting sugars greater than 200.
  • Patient has long-standing asthma with 2-3 exacerbations per week and daily need for rescue inhalers. Patient is still smoking half a pack a day. She is compliant with her inhalers when she is not feeling well.
  • Patient has diabetes with overt proteinuria with her last creatinine of 1.3
  • Hypertension
  • Morbid Obesity

Review of Systems, Physical Exam, Laboratory Tests

  • BMI 44; central adiposity; no respiratory distress; able to speak in full sentences
  • BP 142/64 HR94 RR 12 Sats: 98% on RA
  • HEENT: TM clear; conjunctiva clear; no sinus tenderness; mallampati 3 airway
  • Neck: thick; no adenopathy
  • Lungs: scattered wheezing; no consolidation prolonged expiratory phase
  • Ext: thin no edema

Assessment and Plan

  • Asthma: moderate persistent, with acute exacerbation
  • Bronchitis
  • Current Smoker
  • Diabetes Type 2 with nephropathy and poorly controlled hyperglycemia secondary to prescribe use of steroid medication

Summary of ICD-10-CM Impacts

Clinical Documentation

  • Choosing the first-listed diagnosis in this scenario is determined by the Section IV Guidelines of ICD-10-CM found in Volume 2 of ICD-10-CM
  • Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services
  • Selection of first-listed condition
  • In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.
  • ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit
  • List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/ visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
  • Asthma was chosen as first-listed in this scenario.
  • Asthma is classified as mild, moderate and severe with additional detail as intermittent, persistent and severe; include if there is acute exacerbation or status asthmaticus. Bronchitis was not specified as “acute” so the assignment is made to not specify as acute or chronic. In ICD-10-CM both bronchitis and asthma are reported separately.
  • Bronchitis is reported separately from asthma per ICD-10-CM guidelines. Bronchitis was not specified as acute or chronic and the default code would be J40.
  • Conditions involving infectious processes will have “acute” versus “chronic” choice. Providers should document whenever possible “acute” or “chronic”.
  • Guidelines require reporting of tobacco use or exposure for respiratory, vascular and some other chronic illnesses such as oral and esophageal cancer codes.
  • The guideline message for using these codes is found at the beginning of the respiratory Chapter 10 in this scenario.
  • Diabetic manifestations are incorporated into the primary code for Diabetes Mellitus (combination codes). In this case diabetes with nephropathy is a combination code.
  • “Uncontrolled” diabetes is no longer a concept in ICD-10. Diabetes that is poorly controlled should include whether hyperglycemia or hypoglycemia is present; whenever either is present it should be coded accordingly. This patient would also have hyperglycemia reported as the recorded Blood sugars show hyperglycemia.
  • Adverse effects of prescribed medications are reported from the Table of Drugs & Chemicals and then a final code assignment from Tabular List for the 7th character. Identify which medications are causing adverse reactions and go to The Table of Drugs and Chemicals found in Volume 3 of ICD-10-CM. Along the left side of that table find the drug or (drug class if individual drug is not found.) Then the 7th characters are found at the beginning of the T38 category in Volume 1 (Tabular List) of ICD-10-CM. The choices for 7th character for this Table are:

A= initial encounter
D= subsequent encounter
S= Sequela

In this scenario it would be an initial encounter as this is the first time this provider is evaluating the patient for this adverse effect.

  • Hypertension and Obesity are documented as co-morbid conditions and reported when treatment is given for affected by these conditions. Instructions found at the obesity code instruct to also report the BMI if documented.
  • Note: In ICD-10-CM “Nephritis” is not referenced in the diabetes complication codes with nephropathy

Coding

ICD-9-CM Diagnosis Codes

493.92 Asthma, unspecified with (acute) exacerbation
305.1 Tobacco use disorder
250.42 Diabetes with renal manifestations, Type II or unspecified type, uncontrolled
583.81 Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
995.20 Effect, adverse to medication properly administered
401.9 Hypertension, unspecified
278.01 Morbid obesity
V85.41 BMI 40.0 – 44.9

ICD-10-CM Diagnosis Codes

J45.41 Moderate persistent asthma with (acute) exacerbation
J40 Bronchitis, not specified as acute or chronic
F17.210 Nicotine dependence, cigarettes, uncomplicated
E11.21 Type 2 Diabetes Mellitus with diabetic nephropathy
E11.65 Type 2 diabetes mellitus with hyperglycemia
T38.0x5A Adverse effect of glucocorticoids and synthetic analogues, initial encounter
I10 Essential (primary) hypertension.
E66.01 Morbid (severe) obesity due to excess calories
Z68.41 Body mass index (BMI) 40.0-44.9, adult