ICD-10 Ophthalmology Part 2 Handouts

IC D- 10- C M O PHTHALMO LO G Y C O DING WO RKSHO P

PA RT 2

PRESENTED:

AG ENDA

G o a l: Pa rtic ip a nts will b e a b le to und e rsta nd the p rinc ip le s o f IC D-10-C M c o d ing re la te d to o p htha lmo lo g y ? C ha p te r 6: Dise a se s o f the Ne rvo us syste m ? C ha p te r 7: Dise a se s o f the e ye a nd the a d ne xa ? C ha p te r 9: Dise a se s o f the C irc ula to ry syste m ? C ha p te r 12: Dise a se s o f the Skin a nd the Sub c uta ne o us ? C ha p te r 13: Dise a se s o f the Musc ulo ske le ta l Syste m a nd C o nne c tive Tissue ? C ha p te r 17: C o ng e nita l Ma lfo rma tio ns, d e fo rma tio ns a nd c hro mo so ma l a b no rma litie s ? C ha p te r 18: Sig ns a nd Symp to ms ? C ha p te r 19: Injurie s a nd Po iso ning s ? C ha p te r 20: Exte rna l C a use s ? C ha p te r 21: Fa c to rs Influe nc ing C o nta c t with He a lth Se rvic e s

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C ha pte r 6

IC D- 10- C M

DISEASES O F THE NERVO US SYSTEM

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C ha pte r 6

Dise a se s o f the Ne rvo us Syste m

C a te g o ry (G 00-G 99) C o d e s fo r TIA a re no w inc lud e d in the ne rvo us

syste m c ha p te r o f IC D-10-C M. C o d e s fo r mig ra ine ha ve b e e n e xp a nd e d to

5th a nd 6th c ha ra c te rs to re fle c t a d d itio na l

sp e c ific ity. C o d e s fo r se c o nd a ry Pa rkinso nism ha ve b e e n

e xp a nd e d . C o d e s fo r he mip le g ia a nd mo no p le g ia

id e ntify d o mina nt o r no n-d o mina nt sid e . If no t

d o c ume nte d : Fo r a mb id e xtro us p a tie nts, the d e fa ult sho uld b e

d o mina nt. If the le ft sid e is a ffe c te d the d e fa ult is no nd o mina nt If the rig ht sid e is a ffe c te d the d e fa ult is d o mina nt

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C ha pte r 6

Dise a se s o f the Ne rvo us Syste m

G REATER SPEC IFIC ITY

? Ep ile p sy te rmino lo g y up d a te d

? Lo c a liza tio n-re la te d id io p a thic ? G e ne ra lize d id io p a thic ? Sp e c ia l e p ile p tic synd ro me s

? Pro vid e s sp e c ific ity fo r:

? Se izure s o f lo c a lize d o nse t ? C o mp le x p a rtia l se izure s ? Intra c ta b le ? Sta tus e p ile p tic us

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C ATEG O RY G 40 (EPILEPSY AND REC URRENTSEIZURES) AND G 43 (MIG RAINE)

Note: The following terms are equivalent to intractable: pharmacoresistent (pharmacologically resistant), treatment resistant, refractory (medically), and poorly controlled.

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G 89: PAIN NO TELSEWHERE C LASSIFIED

? C a n b e use d with c o d e s fro m o the r c a te g o rie s to p ro vid e mo re d e ta il, inc lud ing site -sp e c ific c o d e s

? Do no t use G 89 if the re is a d e finitive d ia g no sis unle ss the re a so n fo r the e nc o unte r is p a in c o ntro l/ ma na g e me nt

? C hro nic p a in synd ro me is d iffe re nt tha n " c hro nic p a in," a nd m ust b e d o c um e nte d b y the p ro vid e r

? Exc lud e s1: p a in NO S a nd p a in d iso rd e rs e xc lusive ly re la te d to

p syc ho lo g ic a l fa c to rs

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SC ENARIO 1

Pa tie nt ha s a histo ry o f mig ra ine s whic h re sp o nd to sta nd a rd tre a tme nts, a nd p re se nts to the p hysic ia n to d a y c o mp la ining o f a he a d a c he fo r the p a st 2 d a ys tha t wo n' t g o a wa y, a nd this time she is a lso e xp e rie nc ing so me visio n lo ss a nd b lind sp o ts. Afte r e xa mina tio n, the p a tie nt is d ia g no se d with a n o c ula r mig ra ine .

G 43.B0 ? O p htha lmo p le g ic mig ra ine , no t

intra c ta b le

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SC ENARIO 2

A 34 ye a r o ld fe ma le p re se nts to he r p hysic ia n e ye lid d ro o p ing , e ye musc le we a kne ss, a nd o ve ra ll we a kne ss in the b o d y. The p hysic ia n o rd e re d a b lo o d te st. The re sults inc lud e d e le va te d le ve ls o f a c e tylc ho line re c e p to r a ntib o d ie s in whic h the d o c to r d ia g no se d the p a tie nt with mya sthe nia g ra vis.

G 70.00 ? mya sthe nia , g ra vis

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C ha pte r 7

IC D- 10- C M

National Cancer Institute

DISEASES O F THE EYE AND ADNEXA

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C ha pte r 7

Dise a se s o f the Eye a nd a dne xa

IC D-10 C ha p te r 7 (H00-H59) d e a ls sp e c ific a lly with Dise a se o f the Eye a nd Ad ne xa . Ana to m y kno wle d g e will b e c o m e m o re a nd m o re im p o rta nt. The e ye ha s se ve ra l struc ture a nd p a rts fro m the le ns (H25-H28) to c o njunc tiva (H10-H11) to the c o rne a (H15-H22), e tc .

C o d e s ha ve b e e n e xp a nd e d to inc re a se a na to m ic sp e c ific ity a nd la te ra lity.

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La te ra lity

C o nc e pt o f la te ra lity Rig ht Le ft Bila te ra l Unsp e c ifie d

If b ila te ra l is no t a va ila b le , a ssig n c o de fo r rig ht a nd le ft The te rm " se nile " is no t use d in IC D-10 to d e sc rib e a

c a ta ra c t. " Ag e -re la te d " inste a d o f se nile c a ta ra c t.

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G LAUC O MA

? C o d e s re q uire a 7th c ha ra c te r to id e ntify sta g e ? If b o th e ye s a re d o c ume nte d a s ha ving the sa me typ e a nd

sta g e , a ssig n the a p p ro p ria te b ila te ra l c o d e H40.1231, lo w te nsio n g la uc o ma , b ila te ra l, mild sta g e

? If e a c h e ye is d o c ume nte d a s ha ving the sa m e typ e b ut d iffe re nt sta g e s, a ssig n the a p p ro p ria te c o d e fo r e a c h e ye H40.1211 lo w te nsio n g la uc o ma , mild , rig ht e ye H40.1222 lo w te nsio n g la uc o ma , mo d e ra te le ft e ye

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SC ENARIO 3

This 40-ye a r-o ld wo ma n p re se nts to he r p hysic ia n with b ila te ra l e ye p a in. He r c o nd itio n is d ia g no se d a s no nulc e ra tive b ila te ra l b le p ha ritis o f the up p e r e ye lid s. Wha t is the c o rre c t d ia g no sis c o d ing fo r this c a se ?

H01.001 ? Ble p ha ritis (a ng ula ris) (c ilia ris) (e ye lid ) (ma rg ina l) (no nulc e ra tive ), rig ht, up p e r

H01.004 - Ble p ha ritis (a ng ula ris) (c ilia ris) (e ye lid )

(ma rg ina l) (no nulc e ra tive ), le ft, up p e r

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SC ENARIO 4 Re c urre nt p te ryg ium, b ila te ra l

H11.063 ? Pte ryg ium (e ye ), re c urre nt. Se e Ta b ula r fo r c o rre c t c o d e a ssig nme nt.

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