ICD-10-CM: PRL Training Session 3

Practice Resources, LLC 2015 1

Anxiety & Depression

• Depression now will be classified as mild, moderate, severe without psychotic features or severe with psychotic features.

• Also can be recurrent, in partial remission or in full remission.

• Anxiety has many ‘inclusion terms’ associated with it. Take note of these when coding.

Practice Resources, LLC 2015 2

Example

• The patient presents today for a follow up for anxiety. The physical exam finds the patient is anxious. Not having suicidal tendencies and does not seem dangerous to themselves or others. Is lacking insight and seems depressed throughout the visit. Provider prescribes Zoloft to see if this will help with the anxiety/depressive disorder.

• What ICD-10 code(s) would be correct for this encounter?

Practice Resources, LLC 2015 3

Injury

• One of the biggest areas of additional specification for ICD-10.

• Most categories have three 7th character values. (fractures have more)

– A- initial encounter– D- subsequent encounter– S- sequela

Practice Resources, LLC 2015 4

7th Characters

• Character A– Active treatment for the conditions. Examples; surgical treatment, ER

encounter, evaluation by a new physician.• Would still be ‘A’ when patient is taken to operating room by

surgeon, even if that surgeon had seen patient prior. Patient is still in active treatment for injury.

• Character D– Encounters after patient has received active treatment & is receiving

routine care during healing process.

• Character S– Complications or conditions that arise as a direct result of injury.

Example; scar formation from a burn

Practice Resources, LLC 2015 5

Example• Patient presents to office after cutting right thumb on broken glass about

3 hours ago. Patient states she washed cut out with water and applied gauze bandage. Exam shows no damage to nail. Provider irrigated laceration with saline. No pieces of glass were found on inspection. Sutures used to close the wound. Bandage applied. Patient to return in 7 days for suture removal.

• What ICD-10 code would be correct for this visit?

• What ICD-10 code would be correct for suture removal in 7 days?

Practice Resources, LLC 2015 6

Example

• Patient presents to office with complaint of pain and drainage from bottom of left foot. Patient had stepped on a nail 3 months ago. Patient had no complaints or issues after initial repair. The drainage started last week. Per patient no additional event or injury to foot. Provider cleaned and minimally debrided wound. Applied bandage. Prescribed antibiotic, patient to follow up in 5 days. *Initial repair was done by this same provider

• What is the correct ICD-10 code for this visit?

Practice Resources, LLC 2015 7

Example

• Patient presents to office after tripping and falling down stairs, landing on right knee. Patient states she can walk ok, just very sore. On exam, no abrasions or open areas found. Slightly swollen and large bruise on knee. Provider states to take Tylenol as needed for pain, apply ice to help reduce swelling. Follow up as needed.

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

Practice Resources, LLC 2015 8

AnswersSlide 3- F41.8 Other Specified anxiety disordersSlide 6- S61.011A Laceration without foreign body of right thumb without damage to nail, initial encounter.

S61.011D Laceration without foreign body of right thumb without damage to nail, subsequent encounter, Z48.02- encounter for removal of sutures

Slide 7- S91.332S Puncture wound without foreign body, left foot, sequela Slide 8- S80.01XA Contusion of right knee, initial encounter

Practice Resources, LLC 2015 9