Diseases of the Ear and Mastoid Process(H60-~~95) and Diseases of the CirculatorvSystem (100-199)

'::"" ,.,r~_.F~~L-, ..;"'#

t,,~r""~ir-F'-.y

>/r'''''1I'

i"~-

r-'\';:J

t..•.--~

ICD-l0-CI\1 Chapters 8 and 9Guidelines Review

It' ,~-,

,,"'."~.:;<I'

In this chapter you will find a summary of thechapter-specific coding guidelines for Chapter 9 of theICD-lO-CM codebook (Diseases of the CirculatorySystem) followed by case studies to build ICD-lO-CMdiagnosis coding skill in this area. For diseases of theear and mastoid process (Chapter 8 of the ICD-lO-CMcodebook), general coding guidelines and instructionalnotes apply.

f"""-'

oc·-:J'f.....-.r-'"\":~'~ .» '-

1"',o,'I9\,;.-r "1;?1~,-r'-'Y::I

Many medical specialties, including primary care, ENT,otolaryngology, and cardiology, reference Chapters 8and 9 of the ICD-lO-CM codebook for codingdiseases of the ear and mastoid process and diseases ofthe circulatory system. Keep in mind that you shouldalways reference the ICD-lO-CM Official Guidelinesfor Coding and Reporting in its entirety when makinga code selection,

~....•~/"""":'F,~j:-

!,•• ,:.~'J1

~P'-

(::~,........-.~~tfi.,.,u-

r"-""'~j;,..",-"'..".,,;;i.

ICD-l0-CM Official CodingGuidelinf~sfor Diseases of theCirculatorv System

r'~i~--I~""'''''\;..,-

The following summarized guidelines apply whencoding hypertension and conditions causal to thecondition. Hypertension is coded in ICD-lO-CM as 110whether the condition is malignant, benign, essential,or unspecified,

r :~,-~'.=vI~JJ.IMo,

r"-,

HYPERTENSION WITH HEART DISEASEThe following guidelines apply to coding hypertensionwith heart disease:r--~-

I~'F--I!-"-~."~.,,-

~- W (){\< '000 k.

II When a causal relationship is stated due to hyper-tension or implies such as hypertensive heart disease,a code from category 111 is assigned for heart condi-tions classified to categories 150.- or 151.4-151.9.

" An additional code from category ISO (Heart failure)is reported for a patient with heart failu reo

I. The type of heart failure (if documented) should bereported with codes from category ISO.

II Heart conditions with hypertension that do not havea causal relationship should be coded separately. Forexample, if a patient has congestive heart failure andhypertension and there is not a causal relationship,both conditions are coded individually. Sequencingis based on the circumstance.

HYPERTENSIVE CHRONIC KIOf\IEY DISEASEHypertensive chronic kidney disease (CKD) is reportedwith codes from category 112under the followingconditions:

•• Unlike hypertension with heart: disease, ICD-lO-CMcoding presumes a cause-and-effect relationshipbetween the two conditions.

"' ICD-lO-CM classifies CKD with hypertension as"hypertensive chronic kidney disease."

" Hypertensive CKD is assigned in category 112whenboth hypertension and a condition classifiable tocategory NI8 (CKD) is present.

"' A code from category NI8 should be reported as a 'secondary diagnosis with a code from category 112 toreport the stage of the CKD whether it is stage I, II,IH, IV, or end stage.

•• If the documentation indicates the patient hashypertensive CKD with acute renal fail.ire, codethe acute renal failure (required) as an additionaldiagnosis.

47

___________________ •• I· ._ •••••••••• em~;!~,••

48 CHAPTER 5: Diseases of the Ear and Mastoid Process (H60-H95) and Diseases of the Circulatory System (IOO-/99)

HYPERTENSIVE HEART AND CHRONICKIDNEY DISEASEOften patients with hypertensive CKD also havehypertensive heart disease. The following guidelinesare applicable when reporting a diagnosis from category113,which is considered a combination code because itcombines both hypertensive heart and kidney diseasein its descriptor:

., Only report a code from category II3 (Hypertensiveheart and chronic kidney disease) when bothhypertensive kidney and hypertension heartdiseases are documented in the medical report.Always assume the relationship as stated earlierwith hypertension and CKD whether or not it isclearly stated in the documentation. If heart failure(ISO) is specified, it should be reported as anadditional diagnosis.

&! Assign a code from category NIB (Chronic kidneydisease) as a secondary diagnosis to identify the stageof the CKD.

•• Do not report hypertension and CKD separately asthey are considered causal even if a causal relation-ship is not stated in the documentation.

•• For patients with both acute renal failure andCKD, an additional code for acute renal failure isrequired.

HYPERTENSIVE CEREBROVASCULAR DISEASE

Codes from categories 160-169are reported forhypertensive cerebrovascular disease. The appropriatehypertension code is reported as a secondary diagnosis.

HYPERTENSIVE RETINOPATHYSubcategory H35.0 (Background retinopathy andretinal vascular changes) should be reported with acode from category 110-115for the hypertensive disease.

•• Hypertension is reported as code no (Essential[primary] hypertension), which includes systemichypertension.

•• Sequencing is based on the reason for the encounter.

HYPERTENSION, SECONDARYSecondary hypertension is due to an underlyingcondition. Two codes are required: (1) one code toidentify the underlying etiology and (2) one code fromcategory I15 to identify the hypertension. Sequencingof codes is determined by the reason for admission/encounter.

HYPERTHJSION, TRANSIENT (ELEVATEDBLOOD PRESSURE)A patient with elevated blood pressure does not neces-sarily mean the patient is hypertensive. There aremany reasons a patient's blood pressure may becomeelevated. Hypertension sho ild not be reported unlessstated clearly in the documentation. Elevated bloodpressure is reported with a sign and symptom codeR03.0 (Elevated blood pressure reading) .

HYPERTENSION CONTROl.LED VEflSUSUNCONTROLLEDHypertension co~troUed indicates good bloodpressure control with therapy. Hypertension uncon-trolled is when the current therapeutic treatmentdoes not effectively control the patie nt's blood pres-sure. Code categories nO-II5 are assigned to bothtypes of hypertension. There is no distinction inICD-lO-CM between controlled and uncontrolledhypertension.

ATHEROSCLEROTIC CORONARY ARTERYDISEASE Ar\ID ANGINACode I25.11 (Atherosclerotic heart disease of nativecoronary artery with angina pectoris) and code I25.7(Atherosclerosis of coronary artery bypass graftjs] andcoronary artery of transplanted heart with anginapectoris) are combination codes that include anginapectoris. The following guidelines apply:

If A causal relationship is assumed in a patient withboth atherosclerosis and angina pectoris unless thedocumentation indicates the anginas due to some-thing other than atherosclerosis.

II When a patient is admitted Foran acute myocardialinfarction (AMI) and the patient alsc has coronaryartery disease (CAD), the AMI is sequenced beforethe CAD.

INTRAOPERATIVE AND POSTPROCE[JURALCEREBROVASCULAR ACCIDENT (CVA)Medical record documentation should clearly specifythe cause-and-effect relationship between the medicalintervention and the cerebrovascular accident in orderto assign a code for intraoperative or postproceduralcerebrovascular accident. Code assignment depends onthe following:

•• \)(!hether the accident was an infarction orhemorrhage.

II Whether the accident occurre . intraoperatively orpostoperatively.

{

(

(

(

(

(

c(

eCt(:

ec'Ce

{~

(C[.~

~~

"~.s:~~,tJ'\;";'JiiIIl

CHAPTER 5: Diseases of the Ear and Mastoid Process (H60-H95) and Diseases or the Circulmory System (100-/9B)

II! If an AMI is documented as nontransmural or sub-endocardial, but the site is provided, it is still codedas a subendocardial AMI.

SUBSEQUENT ACUTE MYOCARDIAL INFARCTIONThe following guidelines apply when coding subse-quent acute myocardial infarction:

II If a patient suffers a new AMI within four weeks ofthe initial AMI, two codes are required:

• A code from category 122 (Subsequent ST eleva-tion [STEMI] and non ST elevation [NSTEMI]myocardi.al infarction).

• A code from category 122 must be used in con-junction with a code from category 121 for thecurrent AMI.

• Sequencing depends on the circumstance of theencounter.

When the patient is admitted due to an AMI and has asubsequent AMI while still hospitalized:

•• Report a code from category 121 for the first AMI asthe first listed or principal diagnosis code.

D Report a code from category 122 as the secondarydiagnosis.

If the patient suffers a subsequent AMI after thehospital discharge for the initial AMI, is admitted fortreatment of the subsequent AMI, and is within thefour-week time frame of healing from the initial AMI,the following guidelines apply:

II A code from category 122 is sequenced as the first-listed or principal diagnosis.

II A code from category 121 is reported as the second-ary diagnosis.

•• The guidelines for assigning the correct 122 code arethe same as for the initial AMI.

Now that you have a good understanding of thechapter-specific guidelines for diseases of the circula-tory system, it is time to build skill and knowledgeby coding the following exercises. Be sure to refer-ence the ICD-lO-CM codebook and the ICD-lO-CMOfficial Guidelines for Coding and Reporting, alongwith the instructional notes, when coding theseconditions.

il--------.---. --------------

Diseases of the Ear andMastoid Process (H6~I-H95)

CASE STUDY 1Thank you for referring this patient who was seenregarding her nasal allergies. She also developed apneumonia and was put on Prednisone, which has infact improved her nasal function by reducing the pol-ypoid change in the nose. She is breathing quite wellthrough the nose, has a good sense of smell, and earsare feeling well.

lEXAMINATION: Revealed a moderate degree ofhyperemic change and congestion to the nose, con-sistent with a viral rhinitis. There are some very highpolyps bilaterally, which are certainly not obstruc-tive to her ai.rway. The throat and larynx were clear.Otoscopy shows the left ear to be normal. The previ-ously inserted tube in her right ear has now extruded,the drum has healed, and there is no fluid in thisear either.

DIAGNOSIS: Ongoing allergic rhinitis and polyposisproblem with superimposed viral rhinitis.

PLAN: Once her cold settles, I have asked her to startusing the Nasacort spray again on a regular basis and tosee me again in June, or sooner if she notices a loss ofsense of smell again.

ICD-lO-CM Codets) _

CASE STUDY 2PREOPERATIVE DIAGNOSIS: Se.nsorineuralhearing loss.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDUF~E: Left middle ear hearing deviceimplantation.

INDICATIONS: Loss of hearing.

OPERATION: The patient was taken to the oper-ating room and placed on the table in the supineposition. General anesthesia was administered and alaryngeal mask airway was used for ventilation. Theleft ear was prepped in the usual sterile fashion. Ancefwas given preoperatively. Facial nerve monitoring wasperformed throughout and the patient was infiltratedwith Lidocaine and Adrenaline: postauricularlv,Standard incisions for implant surgery were performed.

---------- ..----~-.---'------;-

~,;J~

~~

Diseases of the Ear and Mastoid Process (H60-H95) 51

The sigmoid sinus, middle fossa, dura, and posteriorcanal wall were all identified. The antrum was enteredand the incus was identified. The horizontal canal wasidentified; the facial nerve and facial recess were identi-fied and opened. The chordae tympani was sectionedbecause it was interfering with adequate visualization.Bleeding was controlled as it was encountered and abed was created for the implant. Stay sutures of 2-0Prolene were fixed appropriately. The implant was sentinto the bed and the transducer was crimped to theincus without difficulty. The implant was irrigated anda layered closure performed. A Glasscock bubble wasplaced. The patient was awakened and transported tothe recovery room in stable condition with the facialnerve intact. All sponge, needle, and instrumentcounts were correct. Estimated blood loss was 10 cc.

ICD-lO-CM Code(s) _

CASE STUDY 3PREOPERATIVE DIAGNOSIS: Recurrent serousotitis media (chronic).

POSTOPERATIVE DIAGNOSIS: Same.

INDICATIONS: This is a 10-year-old who has hadmultiple episodes of otitis. We did manage to clearchronic serous otitis, but it returned shortly thereafter.It was therefore felt he would benefit from bilateralmyringotomy and tubes.

PROCEDURE: The patient was brought to the operat-ing room and placed on the operating room table and ageneral anesthetic was provided by the anesthesiologist.Following that, the left ear was cleaned of cerumen anddebris and an anterior inferior myringotomy incisionwas made and a collar button tube was slipped intoposition after encountering a dry middle ear. The sameprocedure was completed on the patient's other ear.Cortisporin otic was instilled in both ears, and cottonwas placed in the os. The patient was then awakenedand taken to The recovery room in good condition.Sponge and needle counts were correct.

ICD-lO-CM Codets) _

CASE STUDY 4Thank you for referring this patient who was seenfor an evaluation of hearing loss. Hearing allegedlyis generally reduced in both ears, but he has always,throughout his entire life, had worse hearing in his leftear, presumably subsequent to childhood otorrhea thathe does recall.

EXAMINATION: Revealed an intact right tympanicmembrane. He has a relatively small posterosuperiorperforation of the left drum which unfcrtunately over-lies the stapes incus and, to a slight degree, the roundwindow. He also has a bit of otomycosis infectioninvolving the proximal ear canal, although no evidentinvolvement of the middle ear.

LABORATORY: Audiometry shows a mild to mod-erately severe bilateral nerve deafness of symmetricdegree with a substantial additional conductive deaf-ness in his left ear 1ue t~, the perf~ratioCl.'.Speech levelsaveraged approxll:i:l1tely~,5-40dB in the right ear andabout 80 dB in the left ear.

DIAGNOSES:

1. Mild to moderately severe bilateral sensorineuralhearing loss

2. Perforated left tympanic membrane with moderateconductive deafness

3. Otomycosis, left ear canal

PLAN: The ear was cleaned and I have applied aCanesten ointment to the entire canal and will follow-up in a month. His option is either to use a hearingaid in the left and/or both ears w improve his hearing orto undergo tympanoplasty surgery to his left ear to closethe perforation. He can then see how he feels about hishearing loss, of which the sensorineural component willremain, to see whether subsequent hearing aids are stillneeded. He will give me his decision on these optionswhen he returns for a recheck of his otomycosis.

ICD-lO-CM Codets) _

CASE STUDY 5The patient is a 68-year-old woman whc has hadapproximately a four-month history of bockage,obstruction, fluid, fullness, pressure, and head noisein the right ear. She has had tubes inserted. The lasttube was placed by Dr Minor in February but it did notresolve the problem. On earlier examination today, ,the tube was noted to have been extruded into the earcanal, and the middle ear was noted to be filled withan amber, straw-colored fluid. The right ear also wasnoted to be filkd with an amber, straw-colored fluid.

With the patient positioned supine with no sedation,a small amount of Lidocaine was injected into theposterior superior vascular strip area. Following this,an anterior inferior quadrant radial myringotomy wasperformed in the good firm remn ant of the tympanicmembrane. Fluid was suctioned from the right middle