icd-10-cm: prl training session 2 practice resources, llc 20151

ICD-10-CM: PRL Training Session 2

Practice Resources, LLC 2015 1

Tobacco

• Nicotine dependence will need to be classified as cigarettes, chewing tobacco or other tobacco product– Further breaks down codes for remission,

withdrawal, uncomplicated, other induced nicotine disorder or unspecified nicotine disorder• Example code- F17.213 Nicotine dependence,

cigarettes, with withdrawal


Example

A 54 year old male present to office inquiring about help to stop smoking. He has smoked 3 cigars daily for over 25 years. Due to much influence from his wife, he feels its time to stop. Patient is counseled for over 15 minutes on options for smoking cessation. After much discussion, patient agrees to start Chantix. Provider goes over side effects of medication and tells patient to follow up in 1 month to see how he is progressing. Call sooner if any side effects or concerns.

What is the correct diagnosis code(s) for this?


Medical Examinations

• Diagnosis for adult medical examinations (annual physicals) will now need to clarify if any abnormal finding were discovered during the exam.– Z00.00 Encounter for general adult medical examination

without abnormal findings– Z00.01 Encounter for general adult medical examination

with abnormal findingsUse additional code to identify any abnormal findings


ExampleA 61 year old female present to office for her yearly physical. A complete and thorough examination and history is performed. During the exam an abnormal heart beat was detected. This was checked again by the provider at the end of the physical exam, heart beat was still abnormal. All other areas of the exam were unremarkable. Provider orders EKG to be performed. Slight abnormality is seen on report. Provider feels it is an innocent heart murmur, but orders Chest X-ray to be done just to be sure. Patient to follow up next week after X-ray is performed.

What is the diagnosis code(s) for this visit?


Obesity & BMI

• There are multiple obesity codes to choose from. Take note of the ‘code first’ and ‘use additional code’ under the initial entry in the tabular, E66 Overweight and obesity.

• BMI should not be calculated by coder/biller. Provider should have this in their documentation. (this is also qualifying HCC code)


What is Morbid Obesity?

• There are several medically accepted criteria for defining morbid obesity. You are likely morbidly obese if you are:– More than 100 lbs. over your ideal body weight – Have a Body Mass Index (BMI) of over 40 – Have a BMI of over 35 and are experiencing severe

negative health effects, such as high blood pressure or diabetes, related to being severely overweight

– Unable to achieve a healthy body weight for a sustained period of time, even through medically supervised dieting


Example

• Patient presents today for a complete physical exam. Patient is obese. Provider documents patient’s BMI of 42.5. Patient is having no adverse effects from their obesity. Weight reduction and diet was discussed with patient. Follow up in 3 months to see how patient is progressing.

• What would be the correct ICD-10 code(s) related to the obesity for this visit?

• Would there be any additional ICD-10 codes that could be utilized?


AnswersSlide 3- F17.290 Nicotine dependence, other tobacco product, uncomplicatedSlide 5- Z00.01 Encounter for general adult examination with abnormal findings

R01.0 Benign & innocent cardiac murmurSlide 8 -E66.01 Morbid (severe) obesity due to excess calories

– Z68.41- Body Mass Index 40.0-44.9– Z00.00 encounter for adult general medical exam without abnormal findings.


icd-10-cm: prl training session 2 practice resources, llc 20151

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