DM (Diabetes Mellitus):
DM codes are
combination codes that include the type of DM and its complications.
If the type of
DM is not documented, use Type II as default code. (E11.-)
For long-term
use of insulin – Use Z79.4, (Don’t use for temporarily used
insulin)
Guidelines for Insulin pump failure:
A. Under dose:- Sequence as below
- T85.6- a Mechanical complication
- T38.3X6 underdosing of insulin
- Additional codes for the type of DM
B. Overdose:–
- T85.6- a Mechanical complication
- T38.3X1 Poisoning by insulin, accidental
- Additional codes for the type of DM
Secondary DM (DM caused by another condition), always sequenced second
A) E08. - DM due
to the underlying condition
B) E09. - Drug or
chemical induced DM
C) E13. - Other
specified DM/manifestations associated with secondary DM.
The codes
sequencing is based on the tabular list instructions for Categories E08, E09
& E13
Secondary DM due to Pancreatectomy (Lack of
insulin due to the removal of the pancreas)
- E89.1
(Postprocedural hypoinsulinemia)
- E13.
- (Other specified DM/manifestations associated with secondary DM)
- Z90.41
(Acquired absence of pancreas)
5. Mental, Behavioral and Neurodevelopment disorders (F01-F99)
Psychoactive substance Use, Abuse, and Dependence
If the provider documentation refers to the
use, abuse and dependence of the same substance (alcohol, opioid etc)
only one code should be assigned based on the following hierarchy.
1. If both use
and abuse are documented – code abuse
2. If both
abuse and dependence are documented – code dependence
3. If use and
dependence are documented – code dependence
4. If use,
abuse and dependence are all documented – code dependence alone.
Remission - A temporary end to the medical signs and symptoms of an
incurable disease.
6. Diseases of the nervous system (G00-G99)
Dominant / Non-dominant side
-
If the right side is affected – Default is dominant
-
If the left side is affected – Default is non-dominant
-
For ambidextrous patient – Default should be dominant
PAIN – Category G89
These codes
provide more details about acute or chronic pain / Neoplasm related pain
Don’t use code
from category G89 if the diagnosis is known. Unless the RFV is pain
management/control and not the treatment of the underlying condition.
Use category
G89 as the principal diagnosis and the underlying condition should be assigned
as an additional diagnosis.
Category G89 with site-specific pain codes
If the
encounter is for pain control, Category G89 followed by the site of pain.
Eg: Encounter
for pain management for acute neck pain from trauma
G89.11 Acute pain due to trauma
M54.2 Cervicalgia
If the
encounter is not for pain control, and definitive diagnosis has not been
established by the physician, Assign specific site pain first, followed by
Category G89.
Note: For post-thoracotomy and post-operative pain not specified
as acute or chronic – Acute must be the default code.
Routine
postoperative pain following surgery should not be coded.
Neoplasm related pain
If the
encounter is for pain control, G89.3 should be the first code followed by
cancer.
If the
encounter is for neoplasm, G89.3 should be the additional code.
7. The disease of Eye and Adnexa (H00-H59)
Glaucoma – Category H40:
Need to code
all the type of glaucoma, the affected eye and the stage of glaucoma.
B/L glaucoma with the same type and same stage
If a patient
has glaucoma with the same type and the same stage in both eyes, report only
one code (bilateral) for the type of glaucoma, with the appropriate 7th
character for the stage.
If a bilateral
code is not available (H40.10, H40.11 and H40.20), report only one code for the
type with appropriate 7th character.
B/L glaucoma with different types or stages
If a patient
has glaucoma with the different type or different stage, assign an appropriate
code for each eye based on laterality (Right and Left) with an appropriate 7th
character for the stage of glaucoma.
If laterality
is not available (H40.10, H40.11 and H40.20), assign two codes for the
different type of glaucoma with an appropriate 7th character for the stage.
If the type of
glaucoma is the same but the stages are different (H40.10, H40.11 and H40.20),
assign two codes for each eye with an appropriate 7th character for the
different stages.
Note: Indeterminate stage – Stage cannot be clinically determined
Unspecified stage – No documentation regarding the
stage
Note: If a patient is admitted with glaucoma and the stage progresses,
code the highest stage documented.
Eye-related abbreviations:
-
OS (Oculus sinister) – Left side
- OD (Oculus dextrus) – Right side
- OU (Oculus uterque) – Both sides
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