ICD-10 Scenarios for Internal Medicine

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

ICD-10 Clinical Scenarios for Internal Medicine

Scenario 1: Follow-Up: Kidney Stone
Scenario 2: Epigastric Pain
Scenario 3: Diabetic Neuropathy
Scenario 4: Poisoning
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.

Internal Medicine Clinical Scenarios:

Scenario 1: Follow-Up: Kidney Stone

Scenario Details

Chief Complaint

Follow-up from encounter 2 days ago, review results of tests1.

History

87 year old female with right lower back / flank pain (described as dull, achy and does not go away)3, nausea, vomiting for 6 days. Daughter is present.
Medical history significant for renal stones, diverticulitis, and Alzheimer’s dementia2.
Patient lives with daughter who reports blood tinged urine.

Exam

Patient was seen in office earlier with similar symptoms – blood in urine, pain.
Increased tenderness in lower right flank area noted. Bladder mildly distended.
VS normal, afebrile.
Lab results reviewed; creatinine is 1.48. BUN is 32, both elevated from baseline. Urine results show gross blood without signs of infection.
Chest film clear.

Assessment and Plan

Right renal calculi3. Reviewed laboratory evaluation results and CT results. Treatment options discussed with daughter and patient.
Admit orders written to include nephrologist consult.
IVF (NS) started in office.
EMS called; patient was transported to the hospital.

Summary of ICD-10-CM Impacts

Clinical Documentation

Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit and the intent (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes). In this situation, the patient is consulting for an explanation of test findings from a previous visit but her clinical condition presents as a kidney stone.
If known be sure to specify the type of dementia. Also document any behavioral disturbances if present. Since the dementia is relevant to this patient’s care and can affect the outcome of treatment it is coded.
There is no specific code for flank pain or abdominal wall pain. The flank pain should be coded to “other abdominal pain” since the pain is specific to a site location. In other clinical documentation presentations, lumbago or another code could be relevant. In this specific note, as the pain is associated with the underlying medical condition of the renal calculi, the pain codes are not listed per the official coding guidelines.

Coding

ICD-10-CM Diagnosis Codes

592.Ø Calculus of kidney
331.0 Alzheimer’s disease
V65.8 Other reasons for seeking consultation

ICD-9-CM Diagnosis Codes

N20.0 Calculus of kidney
G30.9 Alzheimer’s disease, unspecified
Z71.2 Person consulting for explanation of examination or test findings

Other Impacts

Be sure to document the medical necessity of this visit in the history, assessment, and plan.
With the implementation of ICD-10-CM reassess the data collection and documentation of the chief complaint as described by the patient, and recorded in the medical record.

Scenario 2: Epigastric Pain

Scenario Details

Chief Complaint

“My chest has been burning for three days.”

History

83 year old female with history of chronic left-sided congestive heart failure1, well controlled, CAD, mild intermittent asthma, depression, type II diabetes2, and GERD4.
Patient experiencing burning to center of chest and throat with some occasional nausea. She generally avoids spicy foods but ate Mexican meal with her friends 3 days ago. Took a friend’s nitroglycerin SL tablet, but symptoms did not improve. Has been taking over-the-counter antacids to relieve symptoms.
She finds that sleeping on three pillows lessons burning symptoms; symptoms worsen when sleeping on left side. Denies SOB or worsening of CHF symptoms. Notes bitter taste in mouth at times.
Diabetes is well controlled with subcutaneous insulin. Patient reports blood glucose is between 90 and 110.
Intermittent asthma is well controlled3, unaffected by presenting symptoms.

Exam

Chest clear. Heart sounds normal.
EKG shows no changes from prior, does show left ventricular hypertrophy.
CXR is unchanged from previous.
Abdomen is soft, non-tender to exam except to epigastric area. No guarding.
Vitals: BP is 112/60, HR is 65, O2 saturation is 99% on room air. No fever noted.

Assessment and Plan

GERD4
Modify diet to avoid spicy foods, alcohol. Avoid eating three hours before bedtime. Continue sleeping with head of bed elevated until symptoms subside.
Continue OTC antacid per label instructions to control symptoms
Begin esomeprazole 20 mg PO daily x 4 weeks.
Follow up in four weeks if symptoms not improved.

Summary of ICD-10-CM Impacts

Clinical Documentation

Document the acuity (i.e., chronic, acute, acute on chronic) and type (i.e. systolic, diastolic or both) of heart failure, as there are discrete ICD-10-CM codes for each type.
Document the type of diabetes and if appropriate, any effects due to the disease (e.g. a foot ulcer, diabetic retinopathy, etc.).
If asthma symptoms were present, then the provider should note whether or not the asthma is persistent, triggers (if known) how many attacks per day, week or month are typically experienced, and the functional impact. ICD-10 does not include the concept of extrinsic or intrinsic as represented in ICD-9-CM. In ICD-10-CM one must document whether asthma is mild intermittent, persistent, or moderate and severe persistent. Furthermore, ICD-10-CM guidelines now require the use of an additional code to indicate if a patient is exposed to tobacco smoke.
In ICD-10-CM, gastroesophageal reflux disease is differentiated by noting “with esophagitis” (K21.0) versus “without esophagitis” (K21.9). As there is no documentation under the physical exam noting that esophagitis was evident gastroesophageal reflux disease without esophagitis is coded.

Coding

ICD-9-CM Diagnosis Codes

530.81 Esophageal reflux
428.1 Left heart failure
250.00 Diabetes mellitus type II without complications not stated as uncontrolled
V58.67 Long-term use of insulin
493.10 Intrinsic asthma, unspecified

ICD-10-CM Diagnosis Codes

K21.9 Gastro-esophageal reflux disease without esophagitis
I50.1 Left ventricular failure
E11.9 Type 2 diabetes mellitus without complications
Z79.4 Long term (current) use of insulin
J45.20 Mild intermittent asthma, uncomplicated

Other Impacts
Management of chronic conditions such as diabetes, asthma or heart failure should be described in the record. The documentation of the clinical management may lead to increased reimbursement via clinical quality measures, or quality improvement pay-for-performance physician incentives, regardless of clinical
presentation/complications.

Scenario 3: Diabetic Neuropathy

Scenario Details

Chief Complaint

Right heel ulcer.

History

This 41-year-old male, established patient with Type I diabetes mellitus. He presents today with a new wound to his right heel and a contusion wound that is slow to heal on his right shin.
The patient states he discovered the right heel ulcer 5 days ago when he noticed his sock was soiled in the heel area. The contusion wound to his right shin occurred five weeks ago from bumping into furniture and it does not seem to be healing.
Past Medical History: Type I diabetes mellitus, diagnosed at age 12; bilateral lower extremity peripheral neuropathy diagnosed at age 37; hypoglycemic episodes and nephropathy.
Diet and Activity: Patient has no concerns about diet. Patient routinely exercises three days a week.
Medications: NPH and Regular insulin. He states he regulates his blood sugars based on how he feels, and admits he rarely checks his blood sugar with a glucometer.
Denies smoking, alcohol and drug use.
Laboratory evaluation significant for A1c 11.9; Microalbumin 105.

Exam

Vital Signs: BP 122/88 Pulse 104 RR 18 T 98.5 Finger stick BS 150 mg/dL.
Well nourished, well-groomed, A&Ox3.
HEENT & Neck: no visual disturbances, otherwise normal to exam.
Respiratory: lungs clear to auscultation.
Cardiac: RRR No murmurs, rubs or gallops.
Abdomen: soft and nontender, no masses.
Neuro: Significant for lower extremity numbness throughout. Bottom of right foot has a 1 cm heel ulcer. There is a small contusion on right shin, 2 cm by 1 cm, healing poorly with no signs of infection. CN II-XII grossly intact.
Normal ambulation.

Assessment and Plan

Worsening neuropathy with foot ulcer and slow healing shin wound.
Will debride and treat wounds here and refer to Wound Care Center for ongoing care and management.
Discussed importance of foot care, and the need to routinely inspect lower legs and bottoms of feet because of the bilateral peripheral neuropathy.
Counseled patient about the importance of tight, stable glycemic control to slow the progression of neuropathy and nephropathy; advised to keep a log of his blood sugars for two weeks for our review.

Summary of ICD-10-CM Impacts

Coding

Complicated wounds in ICD-9-CM are classified as “complicated” when they include “delayed healing”. ICD-10-CM does not make that “complicated” differentiation. Type I diabetes in ICD-10-CM does not utilize the Z79.4 use of insulin for Type I diabetes. The Z code Z79.4 (insulin use) is used with E08, E09,
E11, E13, O24.1-, O24.3-, O24.8-, and O24.9- diabetes categories of ICD-10-CM.

ICD-9-CM Diagnosis Codes

250.61 Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled
357.2 Polyneuropathy in diabetes
250.81 Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled (ulcer, heel)
707.14 Ulcer of heel and midfoot
250.51 Diabetes with renal manifestations, type I, [juvenile type], not stated as uncontrolled
583.81 nephropathy, NOS
791.0 Proteinuria
891.1 Wound, lower leg, complicated
V58.67 Long-term (current) use of insulin

ICD-10-CM Diagnosis Codes

E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.621 Type 1 diabetes mellitus with foot ulcer
L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin
E10.21 Type I diabetes mellitus with nephropathy
R80.9 Microalbuminuria
S81.801A Unspecified open wound, right lower leg, initial episode

Other Impacts

No specific impact noted.

Scenario 4: Poisoning

Scenario Details

Chief Complaint

Sudden onset of agitation, palpitations, diarrhea, heavy sweating, fever with shivering, and feeling “out of it” after taking OTC cough medicine.

History

45 year old male patient, is a tractor trailer driver, and states he took dextromethorphan six days ago to help with his cough while on the road. Soon after, he began to have sudden onset of irritability/agitation, palpitations, diarrhea, diaphoresis, fever with shivering, and feeling “out of it”.
Current medication: Duloxetine hydrochloride, prescribed by his psychiatrist three weeks ago for depression and generalized anxiety disorder; he has had no side effects from that medication until now. Patient states he stopped taking both medications the first day, most symptoms resolved within 24 hours, and were totally resolved by 96 hours. Feels fine now on day six.
No significant recent stressors. Wife present with patient.
No family history of any mental or behavioral illness.
Denies smoking, alcohol and illicit drug use.
Allergies: NKDA.

Exam

Vital Signs: Normal.
NEURO: A&Ox3, affect is appropriate, Patient exhibits coherent, logical thought process. He states he would like to discontinue taking the duloxetine hydrochloride.
HEENT & NECK: Normal findings.
Respiratory: Clear to auscultation with normal respiratory effort.
Cardiac: Normal findings.
Abdomen: Normal findings.

Assessment and Plan

Symptoms resolved.
Discussed case with patient’s psychiatrist, including patient’s desire to discontinue medication.
Psychiatrist will see patient in his office in 2 days for medication re-evaluation.
Counseled patient on the importance of not discontinuing his antidepressant medication abruptly, and to consult with his psychiatrist before taking OTC drugs, and supplements.
No additional treatment or supportive care necessary at this time. No labs ordered at this time.

Summary of ICD-10-CM Impacts

Clinical Documentation

The ICD-10 framework provides a single code to document the poisoning/toxic effect of substances and whether the poisoning was intentional. The 7th character of the ICD-10-CM code (T43.211A) specifies the visit is an initial patient encounter.
Poisoning is classified [according to the ICD-10-CM Official Guidelines for Coding and Reporting] if a non-prescribed drug or medicinal agent is taken in combination with a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs.
Additional code(s) are used to document manifestations of the poisoning.

Coding

Underdosing by Z91.12- and Z91.23- reference is found at the beginning of T36-T50 category in the Tabular List (Volume 1)

ICD-9-CM Diagnosis Codes

969.02 Poisoning by selective serotonin and norepinephrine reuptake inhibitor
E854.0 Accidental poisoning by antidepressants
975.4 Poisoning by antitussives
E858.6 Accidental poisoning by agents primarily acting on the smooth and skeletal muscles and respiratory system
307.9 Agitation
785.1 Palpitations
787.91 Diarrhea
780.8 Generalized hyperhidrosis
780.60 Fever, unspecified
780.97 Altered mental status
799.29 Restlessness
311 Depression
300.00 Anxiety
V15.81 Non-compliance with medical treatment

ICD-10-CM Diagnosis Codes

T43.211A Poisoning by selective serotonin and norepinephrine reuptake inhibitors, accidental (unintentional), initial encounter
T48.3X1A Poisoning by antitussives, accidental (unintentional), initial encounter
R45.1 Restlessness and agitation (Combination code)
R00.2 Palpitations
R19.7 Diarrhea, unspecified
R61 Generalized hyperhidrosis
R50.9 Fever, unspecified
R41.0 Disorientation, unspecified
F32.9 Depression
F41.9 Anxiety
Z91.128 Patient’s intentional underdosing of medication regimen for other reason

Other Impacts

No specific impact noted.

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.

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

Other Impacts

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

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

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 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 prescribed 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