ICD-10 in Action: Coding sequence and coding specificity/unspecified codes

July 18, 2017

The ICD-10 Spotlight: Know the codes article series that appeared throughout Partners in Health UpdateSM in 2012 communicated various coding conventions, general guidelines, and chapter-specific guidelines in ICD-10. These conventions and guidelines are rules and instructions that must be followed to classify and assign the most appropriate code. As with ICD-9, adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

In 2013, we introduced Putting ICD-10 into Practice: Coding exercises and scenarios. Each month, using the guidelines and conventions communicated the previous year, specific coding scenarios and exercises were created to assess your knowledge.

This year, we are introducing a new series: ICD-10 in Action. Each article will recap some of the ICD-10 diagnosis code changes, introduce new coding scenarios, and/or communicate updates to ICD-10 coding conventions.

Coding sequence

Drug underdosing is new clinical terminology in ICD-10. ICD-10 contains codes for ?underdosing,? whereas ICD-9 did not. This term identifies situations in which a patient has taken less of a medication than prescribed by his or her physician or less than instructed by the manufacturer, whether inadvertently or deliberately.

Scenario 1:

Mary is prescribed the antibiotic tetracycline to treat a urinary tract infection. She did not take the medication as prescribed, which resulted in acute pyelonephritis (kidney infection).

Code Narrative Coding sequenceN10 Acute pyelonephritis The first-listed code would be the event triggered or prolonged due to this circumstance.T36.4X6A Underdosing of tetracyclines, initial encounter The underdosing code would be the secondary code assignment.

Scenario 2:

Jan is prescribed prednisone for rheumatoid arthritis and has been taking it long term. Jan abruptly stopped the medication, which resulted in hypotension. Though she is aware of the risk of not being weaned from steroidal drugs, she could not afford to pay for the medication.

Code Narrative Coding sequenceI95.89 Other hypotension The first-listed code would be the event triggered or prolonged due to this circumstance.T38.0X6A Underdosing of glucocorticoids and synthetic analogues, initial encounter The underdosing code would be the secondary code assignment.Z91.120 Patient's intentional underdosing of medication regimen due to financial hardship The additional code explains why the patient is not taking the medication.

Note: In this scenario, I95.2 (drug-induced hypotension) would not be appropriate, as the condition is not drug-induced but is directly attributed to the abrupt discontinuation of the medication.

Coding specificity: unspecified codes

Unspecified codes are used when there is not enough information in the medical record to assign the most specific code. It is very important that medical records contain adequate clinical documentation to support accurate coding to avoid using unspecified codes inappropriately. Therefore, avoid using unspecified diagnosis codes when clinical documentation supports a more detailed code.

For example:

  • Major depressive disorders are commonly miscoded and not taken to the highest level of specificity. Correct code assignment of major depressive disorders is based on the number and severity of symptoms (mild, moderate, severe) and status (e.g., psychotic features, in remission, recurrent).
  • Polyneuropathies are classified in various ways, such as by known cause, presentation, and class of polyneuropathy.
  • Chronic obstructive pulmonary disease (COPD) is a progressive lung disease in which obstruction in the flow of air disturbs the normal breathing pattern. COPD includes pathologies such as emphysema or chronic bronchitis. ICD-10 codes for COPD are more specific and allow for clear description of the disease as either an uncomplicated case or in acute exacerbation.

Stay tuned

Throughout 2017, we will continue to communicate ICD-10-specific information through this new article series to review some of the ICD-10 diagnosis code changes. We encourage you to keep up with the latest news and information by visiting the ICD-10 section of our website.

Test your knowledge: Coding specificity

Code the following scenarios per ICD-10 coding conventions and guidelines.

Scenario 1:

Major depressive disorders are commonly miscoded and not taken to the highest level of specificity. Correct code assignment of major depressive disorders is based on the number and severity of symptoms (mild, moderate, severe) and status (e.g., psychotic features, in remission, recurrent).

Hint: Refer to the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) for diagnostic criteria in assigning severity.

John presents to the office to obtain a refill for his Prozac® (Fluoxetine) medication. He has been on the medication for two years. John has diminished interest and pleasure in most of his daily activities and expressed his loss of energy and fatigue.

Choose the appropriate code:

  1. F32.0 Major depressive disorder, single episode, mild
  2. F32.9 Major depressive disorder, single episode, unspecified
  3. F33.1 Major depressive disorder, recurrent, moderate
  4. F33.42 Major depressive disorder, recurrent, in full remission

Scenario 2:

Polyneuropathies are classified in various ways, such as by known cause, presentation, and class of polyneuropathy.

The medical record for James documents the following symptoms: feeling of burning and tingling sensations in his legs. He has been experiencing this for several months. He is now experiencing the same sensation in his arms. He describes the sensations as ?pins and needles.? James indicates he experiences muscle weakness and spasms in those areas as well. During James?s history review, it is determined the he abuses alcohol and has been for some time. The provider?s assessment of James is polyneuropathy.

Choose the appropriate code:

  1. G60.3 Idiopathic progressive neuropathy
  2. G62.1 Alcoholic polyneuropathy
  3. G62.9 Polyneuropathy, unspecified
  4. G63 Polyneuropathy in diseases classified elsewhere

Scenario 3:

COPD is a progressive lung disease in which obstruction in the flow of air disturbs the normal breathing pattern. COPD includes pathologies such as emphysema or chronic bronchitis. ICD-10 codes for COPD are more specific and allow for clear description of the disease as either an uncomplicated case or in acute exacerbation.

Sam is not responding to his asthma treatment; therefore, his wife rushed him to the emergency room. He was ultimately admitted and received additional treatment. His record indicates a diagnosis of moderate persistent asthma with status asthmaticus and acute exacerbation of COPD.

Choose the appropriate code:

  1. J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
  2. J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation, J45.42 Moderate persistent asthma with status asthmaticus
  3. J44.9 Chronic obstructive pulmonary disease, unspecified
  4. J44.9 Chronic obstructive pulmonary disease, unspecified; J45.41 Moderate persistent asthma with (acute) exacerbation
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