A & B: Infections (Antibiotics; Bugs/Bacteria) C D: Blood (Dracula) E: Endocrine, Nutritional & Metabolic (Endocrine, Energy & Eating) F: Mental

Health (Freud) G: Nervous System (Ganglion) H: Eye and Ear (Hearing and Hindsight)
Admission Aftercare Attention (to) Behavior Birth Bite Block Care (of) Carrier Checking Contraception Change Contact Counseling Delivery Dialysis Donor Embolism Examination False Fitting Heat

A-Z ICD-10 I: Circulatory System (Ischemia) J: Respiratory System (Just Breath) K: Digestive System (Kaopectate) L: Skin and Subcutaneous Tissue (Largest Organ) M: Musculoskeletal (Musculoskeletal) N: Genitourinary (Nephrology) O: Obstetrics (Obstetrics)
ICD-10-CM COMMON LOOK UPS Healthy History Injury Maintenance Maladjustment Observation Personality Premature Problem Procedure Prophylactic Common Codes

P: Perinatal Disorders (Perinatal) Q: Congenital (NonQuired) R: Signs & Symptoms (Reason undetermined) S & T: Injuries, Poisonings and Burns (Sprains, Scratches and Trauma) VWX&Y: (Vehicles, Watch out, eXposure, Why)

Newborn Replacement Screening Status Supervision Test Transplant Unavailability Vaccination Victim Water

Alcohol, dependence and use-F10 Chemo-Z51.11 (always first listed) COPD-J44.9 Dialysis-Z99.2 End stage renal disease-N18.6 High risk behavior, bisexual-Z72.53 High risk behavior, heterosexual-Z72.51 High risk behavior, homosexual-Z72.52 HIV test- Z11.4 HIV, asymptomatic status-Z21 HIV, exposure -Z20.6 HIV-B20 Immunotherapy-Z51.12 (Always first listed) Infection with drug resistant microorganism-Z16 (always listed after infection, infection first listed) Mental disorder, unspecified-F99 Neoplasm, person history of malignant neoplasm-Z85 Pain (acute, chronic, generalized, NOS), unspecified-R52 Pain, NEC acute due to trauma-G89.11 Pain, NEC chronic due to trauma-G89.21 Pain, related to psychological factors (bad day)-F45.41 Pain-G89 Radiation therapy-Z51.0 (Always first listed) Sepsis (systemic inflammatory response syndrome), sever-R65 (infection first listed) Sepsis (systemic inflammatory response syndrome), unspecified-A41.9 (infection first listed) Serology (examination of blood serum), inconclusive-R75 Tonsilitis-J35.01 Diabetes-250.00 (9)

Inpatient Coding Instructions 1.Follow UHDDS definitions and all guidelines 2. Principal diagnosis first for inpatient 3. Code diagnosis that coexist at the time of admission, develop subsequently or that affect the treatment received and/or the length of the stay. These represent additional conditions that affect pt. care in terms of: Requiring clinical evaluation, therapeutic treatment, diagnostic procedures, or extending length of hospital stay, or increased nursing care and/or monitoring. Code: Do Not code: Present on admission conditions Localized conditions that have no effect on PT management Chronic diseases requiring active intervention during visit Chronic systemic or generalized conditions that may have Status post previous surgeries or conditions that have no effect on PT management a bearing on the management of the patient Abnormal findings (lab, x-ray, pathologic, other diagnostic Status post previous surgeries or status post previous testing results) unless documentation from the physician is condition that are likely to recur and that may have an present effect on PT management Signs or symptoms that are characteristic of a diagnosis Social history condition(s) that has no bearing on PT management. 4. Do not assign: M-codes, E-codes except those to identify the cause or substance for an adverse effect of a drug that is correctly prescribed and properly administered (E850-E982) 5.Code all procedures that fall within the code range 00.01 thorough 86.99, but do not code 57.94 (foley catheter) 6.Do not code procedures that fall within the code range 87.01 through 99.99, but code procedures in the following ranges: Cholangiograms 87.51-87.54 Retrogrades, urinary systems 87.74 and 87.76 Arteriography and angiography 88.40-88.58 Radiation therapy 92.21-92.29 Psychiatric therapy 94.24-94.27 Alcohol/drug detoxification and rehabilitation 94.61-94.69 Insertion of Endotracheal tube 96.04 Other lavage of bronchus and trachea 96.56 Mechanical ventilation 96.70-96.72 ESWL 98.51-98.59 Chemotherapy 99.25

AMBULATORY CARE CODING INSTRUCTIONS 1.Select diagnosis, conditions, problems, or other reasons for care that require ICD-10-CM coding in an ambulatory care visit or encounter in a hospital clinic, outpatient surgical area, ER, physicians office, or other ambulatory care setting. Follow ICD-10-CM notations, conventions; current approved Coding Guidelines for Outpatient Services and Diagnostic Coding and Reporting Requirements for Physicians Billing 2.In sequencing diagnosis codes, the first code shown for the case should describe the condition chiefly responsible for the outpatient services provided during the encounter 3. Code Secondary Diagnosis as follows 4.Do not assign Code and report chronic diseases that are E-codes, except for those that identify the treated on an ongoing basis as many times as causative substance for an adverse effect of a the patient receives treatment and care for drug that is correctly prescribed and properly the condition(s) administered Code all documented conditions that coexist M-codes at the time of the encounter that require or ICD-9-CM Vol. 3 procedures affect patient care, treatment or HCPCS Level II (alphanumeric) codes management Do not code conditions that no longer exist 5.Assign CPT codes for all surgical procedures that fall 6. Assign CPT codes from the following sections ONLY IF in the surgery section indicated on the case cover sheet Anesthesia Medicine E/m services Radiology Laboratory and Pathology 7.Assign CPT/HCPCS modifiers for hospital-based 8.Do not assign HCPCS Level II (alphanumeric) codes facilities if applicable (regardless of payer)