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Z codes:

Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:

In the 2015 ICD In ICD-10-CM, the diagnosis code used for reporting administration of an immunization or vaccination is Z23, Encounter for immunization. Information on the specific immunization administered is provided by the procedure code.

For example, reporting code Z23 with CPT code 90655 would indicate that a split virus intramuscular influenza vaccine was administered to a child between 6 and 35 months of age.-10-CM draft, we still encounter that code Z23 applies to all vaccinations.

A 50-year-old patient presents for an office visit for ongoing monitoring and evaluation of her diabetes and, during the same visit, Fluvirin (influenza vaccine) is administered. The physician might report code 99213-25 with diagnosis code E11.9 Type II diabetes without complications.* In addition, she/he would also report Z23 encounter for immunization and the appropriate flu vaccine 90656 and administration 90471 codes.

Revenue Codes:

0636 for the vaccine
0771 for the administration

*Annual Part B deductible and coinsurance amounts do not apply. All physicians, nonphysician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine- MLN matters-1523-CMS

"Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit."

In ICD-10-CM, code Z23 contains a note that states, "Procedure codes are required to identify the types of immunizations given."

This code-Z23 is used for the description synonyms below:

For components, visit this site


Burns Coding-ICD-10-CM

The impact that ICD-10 is going to create by its implementation may be probably more than what is perceived by majority of healthcare professionals. Assumptions that a training of 15 days, or 4weeks will suffice for the preparedness, may prove dangerous.

Many coding scenarios for which a seasoned coder is habitual for assigning codes may put them in chaos. Coding of burns is such a situation. Even though the basic definitions of the degrees of burn injuries are not changed but there is change in the axis of classification and laterality that could make the work difficult to low smoothly.

ICD-10-CM burn and corrosion injury codes are classified by depth, extent and by the agent causing burn injury. Classification based on the depth of the burn injury includes first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns and corrosions of the eye and adnexa and internal organs are classified by site not by the degree and extent.

ICD-9-CM codes do not differentiate between chemical burns and burns caused by hot objects, fire, lightning, electric burns. All burn injuries are coded in ICD-9 with the same group of codes, except sunburns and friction burns. But ICD-10-CM distinguishes burns caused by chemicals with thermal burns (burns that come from a heat source). So thermal burns caused by electrical appliances, flame, hot gas, liquid or hot object, radiation, steam, radiation and friction burns are coded with one group of codes whereas burns caused by chemicals i.e., corrosions are coded with separate group of codes in the same category. The coding guidelines for thermal burns and corrosions are same with some exceptions.

A burn injury code for thermal burn can be differentiated with that of the corrosion burn injury code by looking on the fourth digit in the code i.e. the first digit after the decimal point (TXX.X). If the fourth the digit in the burn injury code is any number from 0-3 the code is for thermal burn injury whereas, if the fourth digit in the code is any number beyond 3, then the code is for corrosion burns.

All the burn injury codes for specified sites should have a 7th character extension to indicate the encounter as initial or subsequent etc. Seventh character "A" is assigned for initial treatment or "D" for subsequent care and "S" for the management of a sequela. In case of encounter related with the treatment of a scar or joint contracture developed as a result of a burn injury, the 7th character extension "S" is applied to the injury codes to indicate that it is a late-effect or sequela of the injury.

There are no separate codes in the ICD-10-CM for the late-effects of burn injuries. Similar to the other injury codes, the burn injury code is assigned with 7th character "S" for the late-effects. However the condition or nature of late-effect code eg. Scar should also be coded along with the injury code with the 7th character extension "S" (to the injury code only) that resulted in the development of sequela. The code for the condition or nature of late-effect should be sequenced first, and the seventh character extension "S" should not be added to the code for the condition or nature of late-effect.

In ICD-9-CM there are codes for burn injuries which are deep third degree without loss of body part or with loss of body part, but there are no such burn injury codes in ICD-10-CM.

Except burns for eye and adnexa(T26), respiratory tract(T27) and other internal organs(T28), current burns are classified in the categories T20-T25. Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.

Category T30 codes are extremely vague. A code from this category should be very rarely used, as a last resort when no information about the site of burn or corrosion is available.

Codes in category T31 and T32 are classified according to the extent of the body surface involved in the burn(T31) or corrosion(T32) injury. Codes from T31 and T32 are to be used as the primary code only when the site of burn or corrosion is unspecified. They should also be used as additional codes with codes from category T20-T25 when the site is specified.

To all the burn injury codes in categories T20-T28, additional external cause codes to identify the source, place and intent of the burn from (X00-X19, X75-X77, X96-X98, Y92) should also be added.

While assigning corrosion injury codes in categories T20-T28, a code from T51-T65 should be assigned first to identify the chemical and intent followed by a code from T20-T28. An additional external cause code to identify the place from category Y92 should also be added to the corrosion injury codes.

Coding guidelines for coding of burn injuries:

It is obvious that the guidelines, alphanumeric structure of the codes, laterality, 7th character extensions, code first and additional code requirements are to be given the required attention while assigning burn injury codes in the ICD-10-CM. The transition can never be underestimated as less than a challenge.

HIV Coding-ICD-10-CM

HIV Coding Under ICD-10

I.C.1.a.1. HIV Infections - Code only confirmed cases

Note that this is an exception to the hospital inpatient guidelines Section II.H.

This guideline instructs us to code only confirmed cases of HIV infection/illness. The guideline does not require documentation of a positive serology or culture for HIV within the encounter. However, a provider's diagnostic statement is needed as confirmation.

"Confirmation" does not require documentation of positive serology or culture for HIV; the physician's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient

Example: Diagnostic statements may include that the patient is HIV positive (with documented symptoms), or the patient has an HIV-related illness, or AIDS, or ARC.

Note: Code B20 Human immunodeficiency virus (HIV) disease includes:

Acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), HIV infection, symptomatic.

Does GEM files really helps:

Let us see an example:

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology.

Now analyse the GEM files:

ICD-9 to ICD-10 GEM

V08 is Mapped to the Z21. (Exact Match)

Compare the ICD-10-ICD-9-GEM

V08 is mapped to Z22.6: Z22.6 Carrier of human T-lymphotropic virus type-1 [HTLV-1] infection.

Z11.4: Encounter for screening for human immunodeficiency virus [HIV] is very specific compared to the code V73.8: Special screening examination for other specified viral diseases.

There is one more code for the carrier:

Z22.6: Carrier of human T-lymphotropic virus type-1 [HTLV-1] infection


HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old man with the AIDS complicated with recent cryptococcal infection, Kaposi's sarcoma. His viral load in July of 2008 was 244,000 and CD4 count was 11. He was recently admitted for debility and possible pneumonia. He was started on antiretroviral therapy, was also found to have pleural effusion on the right. He has overall weakness.


MEDICATIONS: Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped. His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.

ALLERGIES: He has no known allergies.

SOCIAL HISTORY: The patient is now staying with his mother. He is the youngest of six children

PHYSICAL EXAMINATION: Blood pressure 135/80, pulse 110, and respirations 27. Temperature 102.9. General Appearance: Ill-looking young man, diaphoretic. PERRLA, 3 mm. Oral mucosa moist without lesions. Lungs: Diminished breath sounds in the right middle lower lobe. Heart: RRR without murmurs. Abdomen: Distended with soft and nontender. Diminished bowel sounds. Extremities: Without cyanosis or edema. There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender. Neurological Exam: Cranial nerves II through XII are grossly intact. There is normal tone. Power is 4/5. DTRs nonreactive. Normal fine touch. Mental Status: The patient is somnolent, but arousable. Withdrawn affect. Normal speech and though process.


ICD-10 Codes: B20, R05, R50.9, G47.01

Acute Respiratory Failure

Definition: The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. The normal reference values are: oxygenPaO2 greater than 80 mmHg (11 kPa), and carbon dioxide PaCO2 less than 45 mmHg (6.0 kPa). Classification into type I or type II relates to the absence or presence of hypercapnia respectively.

Code J96.0, Acute respiratory failure, or code J96.2, Acute and chronic respiratory failure or Acute on chronic respiratory failure, may be assigned as a principal diagnosis when it meets the principal diagnosis criteria. The selection must also be supported by the Alphabetic Index and Tabular List. In order to correctly sequence respiratory failure, documentation must be reviewed for present on admission indicators as well.

Acute respiratory failure as secondary diagnosis

Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

Sequencing of acute respiratory failure and another acute condition

When a patient is admitted with respiratory failure and another acute condition, (example; myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.

If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider the clarification.

A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Acute MI-ICD-10-CM Coding

The transition from ICD-9 to ICD-10 is expected to bring more accuracy in coding, precise reporting of diagnoses, more data granularity, and better data outcome for research purpose on one hand but, there are other factors that will haunt the work flow. One of those is the number of codes required to code a condition. Some of the conditions that were coded with only one code in ICD-9-CM may be reported with more than one code. Ultimately, the average time required to code a medical record is expected to increase by an average 50% or more per code. Coding of Acute Myocardial Infarction is one such example.

The difference in the guidelines of Acute Myocardial Infarction coding in ICD-9-CM and ICD-10-CM are to be carefully understood and coding with ICD-10-CM should be thoroughly practiced by the coders well before the deadline.

Even though the basis of categories of AMI in both ICD-9-CM and ICD-10-CM are same such as categories in both identify the site of the infarction such as anterolateral wall or true posterior wall, etc., but there are changes in the guidelines. The habit of using ICD-9-CM guidelines is to be stopped suddenly from October 1, 2013.

As per the ICD-9-CM guidelines, an Acute Myocardial Infarction is considered as acute until the duration of eight weeks with the difference of episodes of care as initial or subsequent at 5th digit level, whereas the ICD-10-CM considers an Acute Myocardial Infarction as acute until 28 days or less. There are new code categories i.e., subsequent Acute Myocardial Infarctions I22 for Myocardial Infarctions which occur after an initial AMI during the first 28 days.

ICD-10-CM category I21 is used for assigning codes to all the initial Acute Myocardial Infarction episodes both STEMI and NSTEMI. All the codes in I21 except I21.4 are assigned for STEMIs. Axis of the STEMI codes in I21 at fourth position identifies the site and 5th position identifies the coronary artery involved.

The category I22 codes are assigned to code the subsequent episodes of Myocardial Infarction. Except the code I22.2 (for subsequent NSTEMI), all other codes in the category I22 will be used to code subsequent STEMI encounters.

ICD-10-CM also provides category I23 for coding of complications of AMI (both STEMI and NSTEMI) if occurred within 28 days of an AMI initial or subsequent such as hemopericardium, rupture of cardiac wall, postinfarction angina, etc.

Additional Coding Requirements:

In ICD-9-CM, only one additional coding instruction for coding hypertension, if present, is an instructional note with Myocardial Infarction codes in category 410.

In ICD-10-CM codes, additional codes are required to code for different forms of tobacco use, dependence or history of tobacco use, status post rTPA (recombinant tissue plasminogen activator) administration in another facility in and body mass index.

Coding Guidelines:

Documentation Requirements:

Coding Tips:

Interesting Fact about ICD-10-CM Codes of Myocardial Infarction:

The term "Acute" is not use in defining the Myocardial Infarction category codes. The term acute is made as a non-essential modifier in the alphabetic index. It means that the ICD-10-CM doesn't identify myocardial infarction as "Acute" when there is no chronic existing.

It is evident that a determined effort is must to learn and achieve perfection, accuracy, and expertise in coding, and required documentation for a successful transition. A systematic approach towards the transition is the need of the hour.

Osteoarthritis ICD-10-CM Coding

Osteoarthritis, also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causes; such as hereditary, developmental, metabolic, and mechanical may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax. Mechanical stress is suggested as the most common cause for OA, but overweight, loss of strength in the muscles supporting the joint, are also suggested as the among the other common causes of OA.

The disease may commonly affect the hands, feet, spine, and the weight bearing joints such as hip, and knee, but any joint of the body may be affected.

Basically osteoarthritis is divided into primary and secondary depending upon whether or not there is an associated underlying cause.

Primary osteoarthritis develops as a result of a degenerative process in joint cartilage due to aging. Whereas, secondary OA may result from a variety of underlying factors such as diabetes, congenital diseases of joint, inflammatory or metabolic diseases such as rheumatoid arthritis and gout, injury to joints, septic arthritis, obesity etc.

Coding in ICD-10-CM for osteoarthritis is somewhat similar and also different to ICD-9-CM. ICD-9-CM provides category 715 for coding of osteoarthritis including degenerative, hypertrophic and secondary to other factors with the fourth digit determines the type as OA generalized(0), OA localized primary(1), OA localized secondary(2), OA localized not specified as primary or secondary(3), OA more than one site but not specified as generalized(8), and OA unspecified as generalized or localized(9). The fifth digit in category identifies the site of OA without regard to the laterality.

ICD-10-CM provides codes for the coding osteoarthritis related encounters in the categories M15-M19. The first category M15 is used to assign the codes for generalized forms of osteoarthritis or arthritis where multiple joints are involved.

ICD-10-CM codes for localized forms of osteoarthritis are classified in much detail specificity than that of its predecessor. ICD-10-CM has reserved three categories M16-M18 for the more common form of localized osteoarthritis i.e., M16, OA of hip, M17, OA of knee and M18, OA of first carpometacarpal joint. In these categories the:

The fifth digit in the categories M16-M18 further specifies the laterality into unspecified, right, and left sided joint of the body.

ICD-10-CM category M19 is used for coding primary or secondary osteoarthritis of all the joints other than hip, knee and first carpometacarpal joint. Codes in this category are identified with:

The fifth digit in the category M19 identifies the different joints of the body and the sixth digit specifies the laterality as into unspecified joint, right, left sided joint.

Coding tips:

Documentation guidelines:

From a provider, expectations are much more than a simple abbreviated diagnosis "OA" or "arthropathy" from them in ICD-10-CM environment. There is a need to stress on making the habit of

Interesting Fact About ICD-10-CM

There are some instances where ICD-9-CM is much more specific than ICD-10-CM. Codes for unspecified arthropathies are more specific in ICD-9-CM than in ICD-10-CM. The reverse GEM of ICD-10-CM code M12.9 matches to ten (codes) possibilities in the subcategory 716.9 of ICD-9-CM.

Coding Fractures ICD-10

Coding of fractures in ICD-10-CM is quite cumbersome. A great deal of patience, with ICD-10 related knowledge of medical terminology, attentive attitude is required with proper training and practice to achieve necessary expertise in ICD-10-CM.

A lot is going to be changed in coding of fractures in ICD-10-CM. The organization of the alphabetic index the number of required digits for a code and the episode for visit are some of the important ones. In fact, the documentation requirements for coding of fractures or its related visits to a healthcare facility are also a whole lot different.

In ICD-9-CM, all the traumatic fractures were classified between categories 800-829 at one place in the chapter injury and poisoning, because the classification of injuries in ICD-9-CM is based on the type of injury. But in ICD-10-CM, the codes for the injuries are arranged by the body part rather than by type of the injury. For example, all injuries to the elbow and forearm are classified between categories S50-S59 that includes contusions, superficial injuries, open wounds, insect bites, fractures, dislocations and sprains, crushing injuries, etc. So the coder would be referring a different code range in the ICD-10-CM each time he searches a code for a different body part fracture.

The most interesting feature in all the fracture codes in ICD-10-CM is that all the codes should have a 7th character extension. The 7th character extensions are required for the fracture codes to add different type of information related to encounter. They must be assigned to all the fracture codes at seventh character position only, even if a fracture code is not of length of 6 characters by using place holder "X" in between.

It is obvious that we can add a wealth of information to the fracture codes in ICD-10-CM using the 7th character extensions.

Following here is a sample list of seventh character extension to be added to the category S82:

A - initial encounter for closed fracture

B - initial encounter for open fracture type I or II initial encounter for open fracture NOS

C - initial encounter for open fracture type IIIA, IIIB, or IIIC

D - subsequent encounter for closed fracture with routine healing

E - subsequent encounter for open fracture type I or II with routine healing

F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G - subsequent encounter for closed fracture with delayed healing

H - subsequent encounter for open fracture type I or II with delayed healing

J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K - subsequent encounter for closed fracture with nonunion

M - subsequent encounter for open fracture type I or II with nonunion

N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P - subsequent encounter for closed fracture with malunion

Q - subsequent encounter for open fracture type I or II with malunion

R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S -sequela

Each of the above 7th character adds specific meaning related to the encounter to the codes. This has eliminated the use of some additional codes related to aftercare or late-effect. The above 7th character extensions can be used as follows

An advantage of these seventh character extensions in ICD-10-CM is that they indicate to the payer about the details of an encounter (initial encounter, follow up) with the specific type of injury (open fracture, closed fracture) and the progress (routine healing, delayed healing, malunion, nonunion), etc. It will also provide an understanding to the type of injury in case of late effects. The injury code when assigned with seventh character extension "S" it explains the type of injury resulting in the present late effect.

Important Guidelines:

Additional Notes or Guidelines:

A coding example related to fracture in ICD-10-CM using seventh character extension "K":

Sam came to his physician's office with complaint of pain in left ankle, medial aspect after 2 months of active treatment for non-displaced medial malleolar fracture, closed. The imaging studies confirmed the pain is due to nonunion of fracture.

Code: S82.55XK, Nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with nonunion

The above example is coded with seventh character extension "K" since the encounter is a subsequent one and the fracture is complicated by nonunion.

Documentation Requirements:

Physicians must ensure the following documentation requirements to assist in seamless processing of claims.

Coding Tips:

Email drg@medesun.com if you have any questions..

Dr. Santosh Kumar Guptha


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