The Top 5 Codes in a Family Practice

ICD-x: Major Differences for Five Common Diagnoses

Test your cognition of ICD-10 coding and documentation requirements for 5 diagnoses you're likely to run into in family medicine.

Fam Pract Manag. 2015 Sep-Oct;22(5):fifteen-21.

Author disclosure: no relevant fiscal affiliations disclosed.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

Commodity Sections

Introduction
First, why should yous intendance?
What to report
Five common diagnoses
Number five: asthma
Number 4: otitis media
Number three: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the elevation v
Don't panic
References

The time has come. Are you lot ready for the October. one transition to ICD-10 diagnosis coding? If yous are non sure, you are not solitary. Many elements of this transition accept depended on your software vendors, clearinghouses, payers, and staff, but there is i thing you can control: your documentation of the information necessary to support the diagnosis codes you choose to bill. Your documentation probably does not demand a major overhaul, but you will need to be more specific and detailed in certain areas. In this article, we will look at the documentation elements required to support ICD-10 code selection, focusing on five mutual conditions in family unit medicine. Quizzes will test your cognition throughout the article.

First, why should you lot care?

Abstruse
First, why should you care?
What to report
Five mutual diagnoses
Number five: asthma
Number four: otitis media
Number 3: diabetes
Number two: well-child examinations
And the number 1 diagnosis is…
Beyond the top five
Don't panic
References

The increased specificity required in your documentation and coding under ICD-10 may seem unnecessarily burdensome. However, diagnosis coding has a wider affect than you might immediately recognize.

Question: In which of the following ways does diagnosis coding affect doc practices and patient care?

Diagnosis codes support the medical necessity of services provided.
Diagnosis codes support claims payment.
Diagnosis data is increasingly used to evaluate cost and quality of care.
Diagnosis information is used to influence public health policy.
All of the higher up.

Answer: The diagnosis codes reported on physician claims must exist supported not simply to facilitate payment but also because they become the information upon which decisions beyond claims payment are made. The correct reply to the to a higher place question, so, is East, all of the higher up.

Documentation that supports specific diagnosis coding also may alleviate burdensome medical record requests from third parties. Take for instance the following statement a physician forwarded to me from a claims administrator regarding medical tape requests to support chance adjustment: "ICD-9-CM (or its successor ICD-10-CM) diagnosis codes determine a patient'south risk score. The more than diagnosis item submitted with claims and encounters, the less likelihood that [insurer name redacted] will need to request and inspect medical records." In other words, if your documentation supports the level of service coded and the selected diagnosis codes specifically identify the nature of your patient's condition, you are less probable to receive a request for your medical record. If a request is made, your documentation will back up both the service provided and why it was provided.

DOCUMENTATION ELEMENTS FOR Common DIAGNOSES

This article contains seven tables outlining the documentation elements for common diagnoses. All seven tables are bachelor for download every bit a single resource.

Download in PDF format

What to study

Abstract
Get-go, why should you lot care?
What to report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number iii: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the top v
Don't panic
References

Before we review common diagnoses, it is important to know when codes should and should non be reported for a status.

Question: According to the official guidelines for ICD-10, which of the following conditions should be reported?

All conditions listed in the problem list.
Only conditions with confirmed and differential diagnoses.
All conditions that require or affect patient intendance or treatment at the time of the run into.
Only the status related to the chief complaint.
Conditions that are probable.

Answer: The ICD-ten guidelines (like ICD-9) specify that physicians should not report the post-obit:

Conditions documented as likely, likely, or to be ruled-out (rules differ for facilities),
Codes for symptoms that are integral to an established diagnosis,
Conditions that are no longer present,
Weather condition that did not affect management or handling at the current run into.

Therefore, the answer to the question is C. All atmospheric condition that require or impact patient intendance or treatment at the fourth dimension of the see should be reported. Physicians should list get-go the condition that is chiefly responsible for the services provided and code what is known at the fourth dimension of the encounter.

This instruction to code what is known at the time of the encounter is of import. Based on this guideline, physicians should report unspecified codes such as J12.nine, unspecified viral pneumonia, when the information known at the time of the encounter does not support a more specific diagnosis. The guidelines state, "Information technology would be inappropriate to select a specific code that is non supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code."

Other important documentation guidelines include the post-obit:

List first a affliction and so associated manifestations,
Link sequelae (late or residuum weather) to the history of an injury or past medical status,
Written report personal or family history codes when the history affects care or influences treatment.

5 mutual diagnoses

Abstruse
First, why should yous care?
What to report
V common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-kid examinations
And the number one diagnosis is…
Beyond the meridian five
Don't panic
References

With and then many diagnoses in primary care, it makes sense to focus your ICD-10 education efforts on those that are common in your specialty. The National Center for Health Statistics provides this data.1

Question: Which status is the pinnacle reason for office or other outpatient visits to family unit physicians?

Diabetes.
Hypertension.
Otitis media.
Asthma.
Well-child examinations.

Reply: All of the higher up conditions are near the top of the list for family medicine, but for the number i diagnosis, you'll have to read on. Let'south have a wait at five unremarkably reported diagnoses and their documentation requirements nether ICD-10.

Number five: asthma

Abstract
First, why should you care?
What to report
Five common diagnoses
Number five: asthma
Number 4: otitis media
Number three: diabetes
Number 2: well-child examinations
And the number 1 diagnosis is…
Across the top five
Don't panic
References

Asthma classification in ICD-10 mirrors the guidelines from the National Asthma Education and Prevention Program, which differs from ICD-ix.ii

Question: Which of the following is not an selection for the classification of asthma in ICD-x?

Intrinsic.
Mild intermittent.
Balmy persistent.
Moderate persistent.
Severe persistent.

Answer: All of the above classifications are options in ICD-10 except A, intrinsic. That was the old terminology used in ICD-9.

In addition to documenting the asthma classification, physicians should document the status of the condition at each encounter. "Table 1: Documentation elements for asthma" includes the codes for each asthma classification by status.

Tabular array one:

Documentation elements for asthma

Asthma classification	Status	Code
Mild intermittent	Unproblematic	J45.xx
	With exacerbation	J45.21
	Status asthmaticus	J45.22
Mild persistent	Elementary	J45.xxx
	With exacerbation	J45.31
	Status asthmaticus	J45.32
Moderate persistent	Uncomplicated	J45.40
	With exacerbation	J45.41
	Status asthmaticus	J45.42
Astringent persistent	Uncomplicated	J45.50
	With exacerbation	J45.51
	Condition asthmaticus	J45.52

If you were to document asthma without specifying the classification or status, that would be reported with code J45.909, unspecified and simple asthma. However, consider the implications of reporting J45.909 for a patient who is non compliant with control medications, is seen for an acute exacerbation, and requires a revised care program. This code not only fails to identify the nature of the patient presentation but also fails to convey the assessment of the asthma condition and the complicating gene of noncompliance. Documenting a bit more than detail – moderate persistent asthma with exacerbation, J45.41 – better conveys the nature of the encounter. Lawmaking Z91.fourteen could be added to specify the patient'southward poor compliance with control medication and explain the patient management complications.

Number 4: otitis media

Abstruse
Starting time, why should y'all care?
What to report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number 2: well-child examinations
And the number 1 diagnosis is…
Beyond the top five
Don't panic
References

Both ICD-ix and ICD-10 provide codes to specifically identify otitis media as acute or chronic and every bit serous, allergic, or suppurative. Despite the availability of more specific codes, ICD-9 lawmaking 382.nine (unspecified otitis media) was frequently reported. Utilise of an unspecified code is appropriate when no further information is known at the fourth dimension of the encounter; however, more specific reporting is appropriate when further information is known, and information technology typically better supports the level of service rendered.

Question: Specific reporting of otitis media includes which of the following documentation elements?

Type (east.yard., serous).
Laterality (e.g., left).
Occurrence (e.g., chronic).
Tympanic membrane status (due east.m., ruptured).
All of the in a higher place.

Answer: Each of the in a higher place documentation elements is important to fully identify the nature of the otitis media – answer Due east. An assessment of bilateral acute otitis media without indication of type (serous, suppurative, or in a disease classified elsewhere) would support code H66.93 (otitis media, unspecified, bilateral). But better documentation, such as acute recurrent bilateral suppurative otitis media without spontaneous rupture of the ear pulsate (H66.006), may help to identify the demand for higher levels of medical determination-making or additional services. (Encounter "Table two: Documentation elements for otitis media.")

Tabular array two:

Documentation elements for otitis media

Otitis media blazon	Code family	Occurrence	Laterality	Tympanic membrane status
Serous/nonsuppurative	H65.--	Acute/subacute Acute recurrent Chronic	Correct Left Bilateral	Ruptured Not ruptured
Suppurative/purulent	H66.--
In a disease classified elsewhere (flu, measles, viral disease), follow index instruction (combination lawmaking or H67)	H67.-- or combination code

Number iii: diabetes

Abstruse
First, why should you care?
What to report
Five common diagnoses
Number v: asthma
Number iv: otitis media
Number three: diabetes
Number two: well-child examinations
And the number 1 diagnosis is…
Across the elevation five
Don't panic
References

Key documentation elements for diabetes are the type of diabetes, manifestations of the illness, and apply of insulin (not necessary for type 1 diabetes). "Tabular array three: Documentation elements for diabetes" illustrates the requirements.

Tabular array three:

Documentation elements for diabetes

Diabetes type	Code family	Manifestation	Insulin apply
Type 1	E10.--	Consider whether the condition is controlled; uncontrolled is a manifestation (hyperglycemia) Make a connection (e.yard., diabetic ulcer vs. diabetes, ulcer) Depict the manifestation (eastward.g., site and severity of ulcer)	n/a
Blazon 2*	E11.--		Z79.4 Long-term (current) insulin use
Due to underlying status	E08.--
Drug or chemical induced	E09.--

Question: Which of the following documentation elements would be required to accurately code an see with a patient who has diabetes, loss of protective sensation, a foot ulcer, and an elevated A1C result?

Type of diabetes.
Location of the ulcer.
Related weather (manifestations).
Condition condition/characteristics (e.thou., uncontrolled).
All of the higher up.

Answer: If you chose East, all of the above, you are correct. Because this patient has manifestations, additional codes should be reported to draw the documented manifestations. Conditions such as type-2 diabetic neuropathy may be captured in a single combination lawmaking (east.1000., E11.40 for diabetes type 2 with neuropathy). Withal, fifty-fifty combination codes cannot adequately describe some manifestations. A diabetic foot ulcer may be separately reported based on 3 documentation elements: site, laterality, and severity. (See "Tabular array four: Documentation elements for foot ulcer.") Codes describing nonpressure ulcers (categories L97.i-L97.9 and L98.41-L98.49) may be reported in add-on to codes describing type 2 diabetes with foot or other skin ulcer (categories E11.621-E11.622).

Table iv:

Documentation elements for nonpressure chronic foot ulcer

Foot ulcer site	Code family	Laterality	Severity
Heel and midfoot	L97.4--	Right Left	Express to breakdown of peel Fat layer exposed Necrosis of muscle Necrosis of bone
Other part of pes including toe	L97.5--	Right Left

(For more information on documenting diabetes in ICD-10, run into "Getting Ready for ICD-ten: How Information technology Will Affect Your Documentation," FPM, November/December 2013.)

The following codes would be reported to describe care of a patient with poorly controlled diabetes, loss of protective awareness, and diabetic ulcer of the left great toe with the fatty layer exposed:

E11.65, diabetes type two with hyperglycemia,
E11.xl, diabetes type ii with neuropathy,
E11.621, diabetic foot ulcer,
L97.502, ulcer left human foot, toe, fat layer exposed.

Annotation that codes for type 2 diabetes are reported even though the documentation did not specify the type of diabetes. This is because the guidelines instruct that type 2 is the default when documentation does not specify the blazon. Likewise, the ICD-10 index includes subterms for inadequately controlled and poorly controlled diabetes that direct physicians to report diabetes by type with hyperglycemia.

Number two: well-child examinations

Abstract
First, why should y'all intendance?
What to written report
Five common diagnoses
Number five: asthma
Number 4: otitis media
Number three: diabetes
Number two: well-kid examinations
And the number 1 diagnosis is…
Beyond the top five
Don't panic
References

The 2d-near common diagnosis is the well-kid visit. Documentation for this come across requires two elements. The kickoff is the age of the child.

Question: What is the second element you would need to document for a well-child visit for ICD-10?

Whether the examination resulted in abnormal findings.
Whether the patient is new.
Established conditions from the problem listing.
Suspected atmospheric condition.
Symptoms related to an established diagnosis.

Reply: Bated from the age of the kid, the other element you would need to certificate for ICD-10 is whether the examination resulted in abnormal findings – reply A. New in ICD-10 are separate codes for routine child health examinations with abnormal findings (Z00.121) or without abnormal findings (Z00.129). Even if an aberrant finding does not merit a separately identifiable evaluation and management service, if it requires future surveillance it should be reported as an additional diagnosis. Report Z00.121 every bit the commencement code and then add the code for the finding.

Similarly, routine adult health and gynecological examinations are reported based on the presence or absence of aberrant findings; see codes Z00.00-Z00.01 and Z01.411-Z01.419.

Every bit with ICD-nine, ICD-10 includes carve up codes for reporting examinations of newborns less than 8 days old and newborns 8 days to 28 days former. These codes practise not place the presence or absenteeism of aberrant findings:

Z00.110 Health examination for newborn under 8 days onetime,
Z00.111 Health exam for newborn 8 to 28 days old.

(See "Table 5: Documentation elements for well-child visits.")

Table v:

Documentation elements for well-child visits

Age of kid	Exam findings	Lawmaking
Newborn under 8 days old	due north/a	Z00.110
Newborn 8 to 28 days one-time	due north/a	Z00.111
Child	Aberrant Without abnormal	Z00.121 Z00.129

And the number one diagnosis is…

Abstract
First, why should you care?
What to report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the tiptop 5
Don't panic
References

Hypertension is the condition nearly often reported as the reason for an ambulatory care encounter in family medicine.

Question: Which of the post-obit are options for the classification of hypertension in ICD-ten?

Benign.
Malignant.
Unspecified.
Elementary.
None of the higher up.

Answer: Under ICD-9, physicians were challenged to allocate hypertension as beneficial, malignant, or unspecified. This is simplified in ICD-10 with a single code, I10, for reporting hypertension, whether described as benign, cancerous, or simply essential hypertension. The respond to the higher up question, then, is E, none of the above. Still, coding for hypertensive atmospheric condition such every bit hypertensive middle or kidney affliction tin can exist more specific. Key documentation guidelines for these conditions include the post-obit:

Categories I11, I12, and I13 include combination codes that describe hypertensive eye affliction with or without heart failure, hypertensive chronic kidney disease, and hypertensive heart and chronic kidney disease. (See "Table 6: Documentation elements for hypertensive diseases.")
The causal relationship between hypertension and center illness must be documented (e.thou., due to hypertension or hypertensive). If documentation does not indicate hypertension as a crusade of the heart disease, separate codes for hypertension and the specified heart condition must be reported.
An additional code from category I50 must exist assigned to identify the type of heart failure in patients with hypertensive heart disease with heart failure.
Unlike hypertension with heart disease, a crusade-and-outcome relationship is presumed for hypertension with chronic kidney affliction. Report hypertensive chronic kidney disease when both diseases are nowadays.
Codes in category N18 are reported in addition to the code for hypertensive chronic kidney affliction to indicate the phase of the disease.

Table six:

Documentation elements for hypertensive diseases

Hypertensive affliction type	Lawmaking family	Complication
Essential hypertension	I10	n/a
Hypertensive heart affliction*	I11.-	With or without heart failure**
Hypertensive chronic kidney affliction	I12.-	With stage 5 chronic kidney disease or cease stage renal disease With stage 1 through phase 4 chronic kidney disease, or unspecified chronic kidney affliction
Hypertensive centre and chronic kidney disease*	I13.--	With or without heart failure** With stage 5 chronic kidney disease or stop phase renal disease With phase 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

To further illustrate these documentation elements, consider a patient for whom you have made the post-obit assessment: hypertension and left ventricular hypertrophy. Codes assigned for this encounter would be I10 for hypertension and I51.seven for cardiomegaly. However, if your cess was hypertension and hypertensive left ventricular hypertrophy, code I11.ix would be assigned for hypertensive heart disease without centre failure.

(For more information on documenting hypertension in ICD-10, run across "How to Document and Lawmaking for Hypertensive Diseases in ICD-10," FPM, March/April 2014.)

Beyond the top five

Abstruse
First, why should you lot care?
What to written report
Five common diagnoses
Number five: asthma
Number 4: otitis media
Number 3: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the top five
Don't panic
References

Several common documentation elements support ameliorate coding for weather beyond just the pinnacle five diagnoses. These elements – blazon, location, occurrence, characteristics, and related atmospheric condition – are listed with examples of each in "Table seven: Common documentation elements." Equally you lot review the table, consider how each chemical element might exist applied to diagnoses that you often manage.

Table 7:

Common documentation elements

Blazon	Secondary, drug-induced Allergic contact, irritant contact Hyperactive, inattentive, combined Congenital, acquired Clinical classification Nicotine dependence – cigarettes, chewing tobacco, or other
Location	Musculus, tendon, ligament, or joint Sinus cavity Diverticulosis – large or modest intestine Colitis - Surface area of colon – pancolitis Localized or generalized (e.g., edema)
Occurrence	Acute Chronic Acute recurrent Astute on chronic
Characteristics	With or without infarction Refractory, intractable, or not intractable With or without aureola With exacerbation Tension-blazon In remission, with withdrawal, or uncomplicated
Related weather condition	Insomnia due to medical condition Influenza with respiratory symptoms Late upshot (sequelae) of disease Identified infectious agent

Don't panic

Abstract
First, why should you care?
What to written report
Five common diagnoses
Number five: asthma
Number four: otitis media
Number three: diabetes
Number two: well-child examinations
And the number one diagnosis is…
Beyond the top five
Don't panic
References

It may take a while to gain proficiency and assemble resource to assistance you certificate and select ICD-10 codes that appropriately report the weather you are managing. Acknowledging this, the Centers for Medicare & Medicaid Services and the American Medical Association recently announced a one-year grace flow during which Medicare claims volition non exist denied solely considering the diagnosis lawmaking is non specific enough – as long as it is from the appropriate family of ICD-x codes (the iii-graphic symbol category) and is a valid lawmaking.

Equally you go more than familiar with the codes, piece of work toward greater specificity and accurateness, and expect for ways to amend your coding and documentation processes and systems. For example, you might inquire your electronic health record vendor well-nigh creating a "favorites" list of ICD-10 codes. Just recall that this fourth dimension of transition will pass, just adopting improve documentation and coding habits that capture the truthful nature of the conditions you manage and the quality of intendance you provide will be to your advantage as heath care transitions from fee-for-service to value-based payment.

Manufactures IN FPM'S ICD-ten Serial

Yous can access the following manufactures in FPM's ICD-10 topic drove:

"ICD-x: Major Differences for Five Common Diagnoses," FPM, September/October 2015.

"ICD-10 Sprains, Strains, and Motorcar Accidents," FPM, May/June 2015.

"Digesting the ICD-10 GI Codes," FPM, January/February 2015.

"Coding Common Respiratory Problems in ICD-10," FPM, November/December 2014.

"ICD-10 Simplifies Preventive Intendance Coding, Sort Of," FPM, July/August 2014.

"ICD-10 Coding for the Undiagnosed Problem," FPM, May/June 2014.

"How to Document and Code for Hypertensive Diseases in ICD-10," FPM, March/April 2014.

"10 Steps to Preparing Your Office for ICD-10 – At present," FPM, January/Feb 2014.

"Getting Ready for ICD-ten: How It Volition Touch on Your Documentation," FPM, November/December 2013.

"The Anatomy of an ICD-ten Code," FPM, July/August 2012.

"ICD-ten: What Yous Demand to Know Now," FPM, March/Apr 2012.

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About the Writer

Cindy Hughes is an independent coding consultant based in El Dorado, Kan., and a contributing editor to Family unit Exercise Direction.

Author disclosure: no relevant fiscal affiliations disclosed.

References

1. National Ambulatory Medical Care Survey, 2009. Hyattsville, MD: National Eye for Health Statistics; 2011.

two. National Asthma Pedagogy and Prevention Programme. Expert Panel Report iii: Guidelines for the Diagnosis and Direction of Asthma. Bethesda, MD: National Heart, Lung, and Blood Found; 2007.

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