Endocrinology ICD-10 CM Training - PowerPoint Presentation

1. EndocrinologyICD-10 CM Training

2. ICD-10-CM will be valid for dates of service on or after October 1, 2015Outpatient dates of service of October 1, 2015 and beyond. Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015ICD-10-CM Compliance Dates

3. Covered EntitiesEveryone covered by the Health Insurance Portability Accountability Act (HIPAA)Non-Covered EntitiesWorker’s CompensationAuto InsuranceNon covered HIPAA entities are exempt but are encouraged to adapt the new code setCovered and Non-Covered Entities

4. 21 ChaptersAlpha-numeric codes; not case-sensitiveCodes begin with Alpha letter, A-Z, excluding UCommon errorsI verses 1O verses 0“x” Placeholder3 to 7 characters Decimal following 3rd characterICD-10 Code Structure

5. Placeholder “x”Used for future expansion of a codeFills in empty characters when a 6th and/or 7th character applyThe placeholder may be used in different scenarios but should never serve as the final character.Example: W19.XXXA Unspecified fall, Initial EncounterICD-10 Code Structure

6. 7th CharacterProvides specified information regarding the clinical visitIs required for certain categories and must be reported in the seventh positionMay be alpha or numericHas different meanings depending on the coding categoryICD-10 Code Structure

7. 7th CharacterDescriptionAInitial encounter for closed fractureBInitial encounter for open fracture type I or II, or NOSCInitial encounter for open fracture type IIIA, IIIB, or IIICDSubsequent encounter for closed fracture with routine healingESubsequent encounter for open fracture of type I or II with routine healingFSubsequent encounter for open fracture of type IIIA, IIIB, or IIIC with routine healingGSubsequent encounter for closed fracture with delayed healingHSubsequent encounter for open fracture of type I or II with delayed healingJSubsequent encounter for open fracture of type IIIA, IIIB, or IIIC with delayed healingKSubsequent encounter for closed fracture with nonunionMSubsequent encounter for open fracture of type I or II with nonunionNSubsequent encounter for open fracture of type IIIA, IIIB, or IIIC with nonunionPSubsequent encounter for closed fracture with malunionQSubsequent encounter for open fracture of type I or II with malunionRSubsequent encounter for open fracture of type IIIA, IIIB, or IIIC with malunionSSequelaICD-10 Code Structure

8. LateralitySome ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13ICD-10 Code Structure

9. “Other” CodesCodes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist.“Unspecified” CodesCodes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code.OGCR section 1.A.9.a.bICD-10 Code Structure

10. Excludes NotesExcludes1A type 1 Excludes note is a pure excludes noteIt means “NOT CODED HERE”The code excluded should never be used at the same timeWhen two conditions cannot occur togetherExcludes2Represents “Not included here”The condition excluded is not part of the condition represented by the codeIt is acceptable to use both the code and the excluded code together, when appropriateOGCR section 1.A.12.a.bICD-10 Structure

11. “Code First” and “Use Additional Code”ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.These instructional notes indicate the proper sequencing order of the codes.OGCR section 1.A.13The “-” indicates there are additional reporting optionsICD-10 Code Structure

12. Most Common Diagnosis Codes

13. Vitamin D deficiency, unspecifiedICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2268.9E55.9Vitamin D deficiency, unspecifiedApplicable To:Avitaminosis DAdult osteomalacia (M83.-)Osteoporosis (M80.-)Sequelae of rickets (E64.3)Nutritional anemias (D50-D53)

14. Mixed hyperlipidemiaICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2272.2E78.2Mixed hyperlipidemiaApplicable To:Broad- or floating-betalipoproteinemiaCombined hyperlipidemia NOSElevated cholesterol with elevated triglycerides NECFredrickson's hyperlipoproteinemia, type IIb or IIIHyperbetalipoproteinemia with prebetalipoproteinemiaHypercholesteremia with endogenous hyperglyceridemiaHyperlipidemia, group CTubo-eruptive xanthomaXanthoma tuberosumSphingolipidosis (E75.0-E75.3)cerebrotendinous cholesterosis [van Bogaert-Scherer- Epstein] (E75.5)familial combined hyperlipidemia (E78.4)N/A

15. TypeMixedOtherUnspecifiedHyperlipidemia Documentation Tips

16. Elevated C-reactive protein (CRP)ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2790.95R79.82Elevated C-reactive protein (CRP)abnormality of fluid, electrolyte or acid-base balance (E86-E87)asymptomatic hyperuricemia (E79.0)hyperglycemia NOS (R73.9)hypoglycemia NOS (E16.2)neonatal hypoglycemia (P70.3-P70.4)specific findings indicating disorder of amino-acid metabolism (E70-E72)specific findings indicating disorder of carbohydrate metabolism (E73-E74)specific findings indicating disorder of lipid metabolism (E75.-)N/AThere are more specific code choice selections below:R79.81Abnormal blood-gas levelR79.89Other specified abnormal findings of blood chemistry

17. Use additional code to identify any retained foreign body, if applicable (Z18.-)Documentation Tips

18. ICD-10-CM R00-R99Acceptable to code when a related definitive diagnosis has not been established (confirmed) by the provider.Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.Signs and symptoms

19. Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom codeUse of symptom codes

20. ObesityICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2278.00E66.9Obesity, unspecifiedObesity NOSCode first obesity complicating pregnancy, childbirth and the puerperium, if applicable (O99.21-)Use additional code to identify body mass index (BMI), if known (Z68.-)Adiposogenital dystrophy (E23.6)Lipomatosis NOS (E882.)Lipomatosis dolorosa [Dercum] (E88.2)Prader-Willi Syndrome (Q87.1)N/AThere are more specific code choice selections below:278.01E66.01Morbid (severe) obesity due to excess calories278.00E66.09Other obesity due to excess calories278.00E66.1Drug-induced obesity278.03E66.2Morbid (severe) obesity with alveolar hypoventilation278.02E66.3Overweight278.00E66.8Other obesity

21. Overweight and Obesity Weight Status CategoryBody Mass Index RangeOverweight25.0-29.9Obese30.0-49.9Morbid Obese50.0-59.9Adult, 21 years and olderPediatric, 2-20 yearsWeight Status CategoryPercentile RangeUnderweightLess than the 5th percentileNormal or Healthy Weight5th percentile to less than the 85th percentileOverweight85th to less than the 95th percentileObeseEqual to or greater than the 95th percentile

22. Identify condition:ObesityDrug-inducedUse additional code for adverse effect, if applicable to identify drug (T36-T50) with fifth or sixth character 5)Due to excess caloriesMorbidOtherMorbid/severe with alveolar hypoventilation (Body Mass Index 50-59.9, )OtherOverweight (Body Mass Index 25-29.9)Use additional code to identify body mass index (BMI), if known (Z68Obesity Documentation Tips

23. Body Mass Index (BMI) 21 years of ageand olderZ68.1Body mass index (BMI) 19 or less, adultZ68.20Body mass index (BMI) 20.0-20.9, adultZ68.21Body mass index (BMI) 21.0-21.9, adultZ68.22Body mass index (BMI) 22.0-22.9, adultZ68.23Body mass index (BMI) 23.0-23.9, adultZ68.24Body mass index (BMI) 24.0-24.9, adultZ68.25Body mass index (BMI) 25.0-25.9, adultZ68.26Body mass index (BMI) 26.0-26.9, adultZ68.27Body mass index (BMI) 27.0-27.9, adultZ68.28Body mass index (BMI) 28.0-28.9, adultZ68.29Body mass index (BMI) 29.0-29.9, adultOverweight

24. Body Mass Index (BMI) 21 years of ageand olderZ68.30Body mass index (BMI) 30.0-30.9, adultZ68.31Body mass index (BMI) 31.0-31.9, adultZ68.32Body mass index (BMI) 32.0-32.9, adultZ68.33Body mass index (BMI) 33.0-33.9, adultZ68.34Body mass index (BMI) 34.0-34.9, adultZ68.35Body mass index (BMI) 35.0-35.9, adultZ68.36Body mass index (BMI) 36.0-36.9, adultZ68.37Body mass index (BMI) 37.0-37.9, adultZ68.38Body mass index (BMI) 38.0-38.9, adultZ68.39Body mass index (BMI) 39.0-39.9, adultObese

25. Body Mass Index (BMI) 21 years of ageand olderZ68.41Body mass index (BMI) 40.0-44.9, adultZ68.42Body mass index (BMI) 45.0-49.9, adultZ68.43Body mass index (BMI) 50-59.9 , adultZ68.44Body mass index (BMI) 60.0-69.9, adultZ68.45Body mass index (BMI) 70 or greater, adultMorbid Obese

26. Body Mass Index (BMI) 2-20 years of ageZ68.51Body mass index (BMI) pediatric, less than 5th percentile for ageZ68.52Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for ageZ68.53Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for ageZ68.54Body mass index (BMI) pediatric, greater than or equal to 95th percentile for agePediatric BMI

27. Abnormal GlucoseICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2790.21R73.01Impaired Fasting glucoseElevated fasting glucoseAbnormal glucose in pregnancy (O99.81-)Diabetes mellitus (E08-E13)Dysmetabolic syndrome X (E88.81)Gestational diabetes (O24.4-)Glycosurai (R81)Hypoglycemia (E16.2)N/AThere are more specific code choice selections below:790.22R73.02Impaired glucose tolerance (oral)790.29R73.09Other abnormal glucose

28. TypeElevated fasting glucose R73.01Elevated glucose tolerance R73.02Abnormal glucose NOS R73.09Abnormal non-fasting glucose toleranceLatent diabetesPre-diabetesAbnormal Glucose Documentation Tips

29. Menopausal and female climacteric statesICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2627.2N95.1Menopausal and female climacteric statesexcessive bleeding in the premenopausal period (N92.4)menopausal and perimenopausal disorders due to artificial or premature menopause (E89.4-, E28.31-)premature menopause (E28.31-)asymptomatic menopausal state (Z78.0)symptoms associated with artificial menopause (E89.41)symptoms associated with premature menopause (E28.310)postmenopausal osteoporosis (M81.0-)postmenopausal osteoporosis with current pathological fracture (M80.0-)postmenopausal urethritis (N34.2)Use additional code for associated symptoms

30. Symptoms such as flushing, sleeplessness, headache, lack of concentration, associated with natural (age-related) menopauseMenopausal Documentation Tips

31. HypothyroidismICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2244.9E03.9Hypothyroidism, unspecifiedIodine-deficiency related hypothyroidism (E00-E02)Postprocedural hypothyroidism (E89.0)N/AThere are more specific code choice selections below:243E03.0Congenital hypothyroidism with diffuse goiter243E03.1Congenital hypothyroidism without goiter244.2244.3E03.2Hypothyroidism due to medicaments and other exogenous substances244.8E03.3Postinfectious hypothyroidism246.8E03.4Atrophy of thyroid (acquired)780.01E03.5Myxedema coma244.8E03.8Other specified hypothyroidism

32. Identify Congenital HypothyroidismWith goiterWithout goiterIdentify Acquired HypothyroidismDue to acquired atrophy of the thyroidDue to medicationPostinfectiousPostproceduralSubclinical iodine-deficiencyOtherUnspecified typeHypothyroidism Documentation Tips

33. Vitamin B DeficiencyICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2266.2E53.8Deficiency of other specified B group vitaminsApplicable to:Biotin deficiencyCyanocobalamin deficiencyFolate deficiencyFolic acid deficiencyPantothenic acid deficiencyVitamin B12 deficiencySequelae of vitamin B deficiency (E64.8)Folate deficiency anemia (D52.1-)Vitamin B12 deficiency anemianutritional anemias (D50-D53)266.0E53.0Riboflavin deficiency Ariboflavinosis Vitamin B2 deficiencyN/AN/A266.1E53.1Pyridoxine deficiency Vitamin B6 deficiency266.9E53.9Vitamin B deficiency, unspecifiedN/AN/A

34. Disorder of adrenal gland, unspecifiedICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2255.9E27.9Disorder of adrenal gland, unspecifiedgalactorrhea (N64.3)gynecomastia (N62)N/AThere are more specific code choice selections below:E27.0Other adrenocortical overactivityE27.1Primary adrenocortical insufficiencyE27.2Addisonian crisisE27.3Drug-induced adrenocortical insufficiencyE27.40Unspecified adrenocortical insufficiencyE27.41Other adrenocortical insufficiencyE27.5Adrenomedullary hyperfunctionE27.8Other specified disorders of adrenal gland

35. Other abnormal blood chemistryICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2790.6R79.89Finding of other specified substances, not normally found in bloodabnormalities (of)(on):abnormal findings on antenatal screening of mother (O28.-)coagulation hemorrhagic disorders (D65-D68)lipids (E78.-)platelets and thrombocytes (D69.-)white blood cells classified elsewhere (D70-D72)diagnostic abnormal findings classified elsewhere - see Alphabetical Indexhemorrhagic and hematological disorders of newborn (P50-P61)abnormality of fluid, electrolyte or acid-base balance (E86-E87)asymptomatic hyperuricemia (E79.0)hyperglycemia NOS (R73.9)hypoglycemia NOS (E16.2)neonatal hypoglycemia (P70.3-P70.4)specific findings indicating disorder of amino-acid metabolism (E70-E72)specific findings indicating disorder of carbohydrate metabolism (E73-E74)specific findings indicating disorder of lipid metabolism (E75.-)N/AR79.0Abnormal level of blood mineralUse additional code to identify any retained foreign body, if applicable (Z18.-)

36. Testicular hypofunctionICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2257.2E29.1Testicular hypofunctionApplicable To:Defective biosynthesis of testicular androgen NOS5-delta-Reductase deficiency (with male pseudohermaphroditism)Testicular hypogonadism NOSgalactorrhea (N64.3)gynecomastia (N62)androgen insensitivity syndrome (E34.5-)azoospermia or oligospermia NOS (N46.0-N46.1)isolated gonadotropin deficiency (E23.0)Klinefelter's syndrome (Q98.0-Q98.2, Q98.4)postprocedural testicular hypofunction (E89.5)N/AUse Additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

37. All neoplasms, whether functionally active or not, are classified in Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.-) may be used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere.Testicular hypofunction Documentation Tips

38. DiabetesICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2250.00E11.9Type 2 Diabetes mellitus without complicationsDiabetes (mellitus) due to insulin secretory defectDiabetes (NOS)Insulin resistant diabetes (mellitus)Use additional code to identify any insulin use (Z79.4)Diabetes mellitus due to underlying condition (E08.-)Drug or chemical induced diabetes mellitus (E09.1-)Gestational diabetes (O24.4-)Neonatal diabetes mellitus (P70.2)Postpancreatectomy diabetes mellitus (E13.-)Postprocedural diabetes mellitus (E13.-)Secondary diabetes mellitus NEC (E13.-)Type 1 diabetes mellitus (E10.-)N/A

39. Diabetes is a chronic condition that requires multi-specialty management. The documentation should indicate relevant details regarding the management of each case as it relates to the services rendered or actions taken to coordinate the patients care. The HPI, at a minimal, should include some indication of the historical timeline or duration of the illness, levels as it relates to the date of service, manifestations or impairments associated with the condition and effectiveness of current medication regimen. The examination should notate any physical signs related to the diabetic conditions. (Ulcers, nails, edema, discoloration, sensitivity to touch) Diabetes Documentation Tips

40. Indicate TypeIndicate additional conditions, manifestations, or complicationsCataractCirculatory complicationFoot ulcerGastroparesisNotate causal relationships (due to, with, secondary)State due to drugs or chemicalsDiabetes Documentation Tips

41. HypertensionICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2401.1401.9401.0I10Essential (Primary) HypertensionIncludes: high blood pressure, Hypertension (arterial) (benign) (essential) (malignant) (systemic)Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16)Neonatal hypertension (P29.2)Primary pulmonary hypertension (I127.0)Essential (primary) hypertension involving vessels of brain (I60-I69)Essential (primary) hypertension involving vessels of eye (H35.0-)Hypertensive Diseases Categories (I10-I15)The use additional codes and Excludes1 codes apply for all categories.(I10-I15)Use additional code to identify:Exposure to environmental tobacco smoke (Z77.22)History of tobacco use (Z87.891)Occupational exposure to environmental tobacco smoke (Z57.31)Tobacco dependence (F17.-)Tobacco use (Z72.0)Hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11. O13-O16)Neonatal hypertension (P29.2)Primary Pulmonary hypertension (I27.0)

42. Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2402.01402.11402.91I11.0Hypertensive Heart Disease with heart failureUse additional code to identify type of heart failure (I50.-)N/AN/A402.00402.10402.90I11.9Hypertensive Heart Disease without heart failureN/AN/A403.01403.11403.91I12.0Hypertensive Chronic Kidney Disease with stage 5 Chronic Kidney Disease or end stage renal disease.Use additional code to identify the stage of chronic kidney disease (N185.5, N18.6)Hypertension due to Kidney Disease (I15.0, I15.1)Renovascular Hypertension (I15.0)Secondary Hypertension (I115.-)Acute Kidney Failure (N17.-)403.00403.10403.90I12.9Hypertensive Chronic Kidney Disease with stage 1-4 Chronic Kidney Disease, or unspecified Chronic Kidney Disease.Use additional code to identify the stage of chronic kidney disease (N18.1-N18.9)Hypertension due to Kidney Disease (I15.0, I15.1)Renovascular Hypertension (I15.0)Secondary Hypertension (I115.-)Acute Kidney Failure (N17.-)

43. Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2404.01404.11404.91I13.0Hypertensive heart and chronic kidney disease with heart failure and stage 1-4 chronic kidney disease, or unspecified chronic kidney diseaseUse additional code to identify type of heart failure (I50.-)Use additional code to identify stage of chronic kidney disease (N18.1-NN18.4, N18.9)N/AN/A404.00404.10404.90I13.10Hypertensive Heart and Chronic Kidney Disease without heart failure, with stage 1-4 chronic kidney disease, or unspecified chronic kidney disease.Use additional code to identify the stage of chronic kidney disease (N18.1-N18.4, N18.9)N/AN/A404.02404.12404.92I13.11Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease or end stage renal disease.Use additional code to identify the stage of chronic kidney disease (N18.5, N18.6)N/AN/A404.03404.13404.93I13.2Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease.Use additional code to identify type of heart failure (I50.-)Use additional code to identify the stage of chronic kidney disease (N18.5. N18.6)N/AN/A

44. Hypertension cont.ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2405.01405.11405.91I15.0Renovascular HypertensionCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)405.91I15.1Hypertension secondary to other renal disordersCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)405.99I15.2Hypertension secondary to endocrine disordersCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)405.09405.19405.99I15.8Other secondary hypertensionCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)405.99I15.9Secondary hypertension, unspecifiedCode also underlying conditionPostprocedural hypertension (I97.3)Secondary hypertension involving vessels of brain (I60-I69)Secondary hypertension involving vessels of eye (H35.0-)

45. Hypertension is no longer classified as benign, malignant or unspecified.ICD-10 Codes have been grouped according to disease progression:I10 Essential HypertensionI11.- Hypertensive Heart DiseaseI12.- Hypertensive CKDFurther subdivided by stage of kidney diseaseI13.- Hypertensive Heart and CKDFurther subdivided by stage of kidney diseaseI15.- Secondary HypertensionTransient HypertensionA code for hypertension is NOT assigned unless the patient has a documented, established diagnosis of hypertension.R03.0 Elevated blood pressure reading without diagnosis of hypertensionDocument requirementsTypeCurrent StatusAssociated relationshipsHypertension Documentation Tips

46. Other Malaise and FatigueICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2780.79R53.1Weakness Asthenia NOSage-related weakness (R54)muscle weakness (M62.8-)senile asthenia (R54)N/A780.79R53.81Other malaise Chronic debility Debility NOS General physical deterioration Malaise NOS Nervous debilityage-related physical debility (R54)N/A780.79R53.82Chronic fatigue, unspecifiedPostviral fatigue syndrome NOSN/A780.79R53.83Other fatigue Fatigue NOS Lack of energy Lethargy TirednessN/AN/A

47. Identify type of malaise and fatigueNeoplastic related fatigueWeaknessFunctional quadriplegiaOther malaiseChronic fatigue, unspecifiedOther fatigueOther Malaise and Fatigue Documentation Tips

48. Mineral deficiency not elsewhere classifiedICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2269.3E58Mineral deficiency not elsewhere classifieddisorders of calcium metabolism (E83.5-)sequelae of calcium deficiency (E64.8)nutritional anemias (D50-D53)E59Dietary selenium deficiencyE60Dietary zinc deficiencyE61.4Chromium deficiencyE61.5Molybdenum deficiency

49. All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.Site specificityDocument notation of qualifiersExacerbationManifestationsRelapseStatusStagesIndicate acute or chronicIndicate underlying or external cause factorsMedicationSmokeAccidentsMechanical failureLateralityBilateralRight LeftDocumentation – Start Now

50. Episode of Care for injuries, poisoning, external causes and other conditionsInitial EncounterUse while the patient is receiving active treatment of the conditionActive treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physicianSubsequent EncounterUsed on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.Medication adjustments, aftercare, device adjustments, cast changeSequelaUsed for complications or conditions that arise as a direct result of a condition, late effectDocumentation – Start Now

51. Combination codes that captureEtiology and manifestationRelated conditionsDisease, injury or other medical condition and complicationsDisease or other medical conditions and common signs or symptomsDocumentation – Start Now

52. UnderdosingUnderdosing refers to taking less of a medication than is prescribed by a provider or a manufacturer’s instruction. For underdosing, assign the code from categories T36-T50 (fifth or sixth character “6”).Codes for underdosing should never be assigned as principal or first-listed codes. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose, then the medical condition itself should be coded.Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.OGCR Section 1.C.19.e.5.cOfficial Guidelines for Coding and Reporting

53. codingresource@g1hs.comCenters for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htmQuestions