ICD-10 Coding standards Chapters IV-X

Question 1

What do the fourth character subdivisions at categories E10-E14 represent?

Answer 1

The fourth character subdivisions at categories E10-E14 Diabetes mellitus classify manifestations and complications of diabetes. In order to assign fourth characters .0 - .8 it must be clearly documented in the medical record that the manifestation(s) or
complication(s) is due to diabetes. Any doubt as to whether a condition is linked to the diabetes must be referred back to the responsible consultant for clarification.

Question 2

How must multiple complications of diabetes be coded?

Answer 2

• Where the patient has multiple complication of diabetes that classify to a dagger and asterisk combination, a dagger and asterisk must be assigned for each complication. This applies whether the fourth character diabetes code is the same or not.
• Where a patient has multiple complications classified to E10-E14 with the fourth character .0,.1,.5 or .6 each complication must be coded following a code from E10-E14, unless the fourth character code from E10-E14 is the same for all complications in which case only one code from E10-E14 is require with the codes for each complications listed afterwards.The exceptions are myocardial infarction, cardiac failure or angina due to diabetes
• The fourth character .7 must only be assigned when it is only stated that the patient has multiple complications of diabetes, and the specific conditions are not identified in the medical record.

Question 3

How must diabetic gangrene and diabetic ulcer be coded?

Answer 3

Diabetic gangrene or diabetic leg ulcer must be coded to the fourth character subdivision .5
With peripheral circulatory complications and the code(s) to identify the gangrene and/or leg ulcer must be coded in a secondary position.

Question 4

How must myocardial infarction, cardiac failure or angina due to diabetes be coded?

Answer 4

If a patient is admitted with an acute myocardial infarction, cardiac failure or angina that is a
complication of diabetes, the diabetes must be recorded in a secondary position with a
fourth character of .6 With other specified complications.

Question 5

How must Hypoglycaemia and hypoglycaemic coma in diabetes be coded?

Answer 5

• When it is documented that a patient has hypoglycaemia in diabetes. A code from E16.- must be assigned followed by a code classifying the diabetes with the fourth character .9 as hypoglycaemia is not considered a complication.
• A code from E16.- must also be assigned following a code from E10-E14 with the fourth character .0 when the patient has diabetes with hypoglycaemic coma.
• Coma and/or hypoglycaemia due to a patient taking insulin correctly must be coded as an adverse effect of insulin.
• Coma and/or hypoglycaemia due to a patient taking too much insulin must be coded as a poisoning.

Question 6

How is hyperglycaemia in diabetes coded?

Answer 6

Hyperglycaemia in diabetic patients is not considered a complication of diabetes within the ICD classification (with the exception of hyperglycaemic hyperosmolar state), and must be coded with the appropriate code from E10-E14 with the fourth character .9 and addition code to classify hyperglycaemia is not required. (This includes patients with hyperglycaemic coma with fourth character .0)

Question 7

How must Hyperglycaemic hyperosmolar state in diabetes mellitus be coded?

Answer 7

Patients with HHS with coma:
E10-E14 with the fourth character .0 
E87.0
Patients with HHS without coma
E10-E14 with fourth character .6
E87.0

Question 8

What must coders not use when assign codes E40-E46 malnutrition?

Answer 8

The notes in the Tabular List at block and category level E40-E46 Malnutrition must not
be used by coders to diagnose malnutrition in a patient. Code assignment must be based
on the diagnosis documented in the medical record, and any uncertainty must be referred
back to the responsible consultant.

Question 9

What must coders not take into account when assigning E66.-?

Answer 9

Codes in category E66 Obesity must only be coded when a diagnosis of obesity is recorded in the medical record. Where body mass index (BMI) has been recorded in the medical record, this must not be used to assign a code from category E66.- Obesity. A
clinical coder must always refer to the responsible consultant to confirm the clinical significance of a test result, e.g. BMI reading and/or relationship to a specific condition.

Question 10

DCS.IV.5: Pure hypercholesterolaemia (E78.0)

Answer 10

A diagnosis of ‘high cholesterol’ or ‘Cholesterol’ must only be coded to E78.0 Pure hypercholesterolaemia if confirmed to be a definitive diagnosis of hypercholesterolaemia by the responsible consultant and it is not merely an abnormal test result.
Abnormal cholesterol detected from a blood test without a definitive diagnosis of hypercholesterolaemia must be coded to R79.8 Other specified abnormal findings of blood chemistry instead.

Question 11

DCS.IV.6: Cystic fibrosis with manifestations (E84)

Answer 11

When cystic fibrosis is documented with a manifestation(s), an additional code or codes
identifying the manifestation(s) must be assigned immediately after a code from category
E84.- Cystic fibrosis, where doing so adds further information about the specific
manifestation(s).
Multiple codes from category E84.- must be used where multiple manifestations are present.

Question 12

When must dehydration and hypovolaemia always be coded?

Answer 12

Dehydration must always be coded when:
•	It is documented as severe.
•	Is treated with IV fluids.
•	Dehydration in a newborn.
Hypovolaemia must always be coded when it is confirmed to have been treated with iV fluids or blood transfusion.

Question 13

What are Glossary descriptions in chapter V

Answer 13

In addition to inclusion and exclusion terms, chapter V uses glossary descriptions to indicate the content of categories and codes. This is because the terminology of mental disorders varies greatly.

The glossary descriptions must not be used by coders to assign codes. Code selection must be made on the basis of the diagnoses documented by the consultant, even if this conflicts with the definition.

Question 14

DCS.V.2: Mixed dementia or mixed vascular and Alzheimer dementia (G30.8† and
F00.2*)

Answer 14

Must be coded as:
G30.8† Other Alzheimer disease
F00.2* Dementia in Alzheimer disease, atypical or mixed type (G30.8†)

Question 15

DCS.V.3: Delirium and acute confusional state

Answer 15

Whenever a documented diagnosis of ‘delirium’, or ‘acute confusional state’, is made in the
patient’s medical record this must be coded using the appropriate ICD-10 code.

Where the cause of the delirium or acute confusional state is known, this must also becoded using the appropriate ICD-10 code. The correct sequencing will depend on the main condition treated or investigated during the consultant episode, in line with DGCS.1:
Primary diagnosis.

A documented diagnosis of ‘delirium’ together with a documented co-morbidity/diagnosis of
‘dementia’ must be coded using the following code:
F05.1 Delirium superimposed on dementia

Question 16

How must a statement of heavy drinker be coded?

Answer 16

A statement of ‘heavy drinker’ when written in the medical record must only be coded using
a code from F10.-, if:
• the patient has been advised by the responsible consultant to stop drinking because
it will have an adverse effect on their medical condition
or
• the responsible consultant states that the patient is dependent on alcohol.

Question 17

DCS.V.6: Mephedrone

Answer 17

If the patient is described by the responsible consultant as having ‘acute intoxication’ from
taking Mephedrone, code F15.0 Mental and behavioural disorders due to use of other
stimulants, including caffeine, acute intoxication must be assigned.

Question 18

How must current smoker be coded?

Answer 18

When it is documented in the medical record that a patient smokes, code F17.1 Mental
and behavioural disorders due to use of tobacco, harmful use must be assigned. If further information is given such as dependence, then the fourth character code may change.

Code Z72.0 Tobacco use must not be assigned for a current smoker.

Question 19

When can codes in category F19 be used?

Answer 19

Codes in category F19 must only be used when it is documented in the medical record that there two or more psychoactive substances known to be involved and:

The exact identity of some or even all of the psychoactive substances being used is uncertain or unknown
Or
It is not evident which substance the patient is most dependent upon
Or
it is not possible to identify which substance is contributing most to the disorder.

If there are more than more psychoactive substances involved none of which is stated to be contributing most to the disorder and they are also a current smoker a code from F19 must in assigned in addition to F17.1 if more information is given regarding the smoking a different fourth character from F17 must be assigned

Question 20

DCS.V.9: Anxiety depression (F41.2)

Answer 20

Whilst a stated diagnosis of ‘depression anxiety’ or ‘anxiety depression’ can be indexed to
the ICD-10 code F41.2 Mixed anxiety and depressive disorder; if diagnoses of anxiety
and depression are documented individually by the responsible consultant both diagnoses
must be recorded separately and the code F41.2 must not be used.

Question 21

DCS.V.11: Learning disability (F70-F79)

Answer 21

The more common terms for the disorders classified at categories F70-F79 are ‘learning disability or ‘intellectual disability’

If these terms are used within the medical record than the coder must liaise with the responsible consultant to ensure the correct code assignment is made:

• If it is confirmed the patient has a true learning disability i.e skills that contribute to the overall level of intelligence. Then a code from F70-F79 must be assigned.
• If it is confirmed the patient actually has a scholastic disorder i.e problems with reading, spelling arithmetic) a code from F80.-,F81.- must be assigned.

If the patient is described as having more than one level of impairment classified at fourth character level in codes in categories F70-F79 then code to the most severe level of impairment.

Question 22

DCS.V.12: Mixed developmental disorders (F80–F83)

Answer 22

If a patient is diagnosed with dysfunctions classified to two or more of the codes within categories F80.- Specific developmental disorders of speech and language, F81.- Specific developmental disorders of scholastic skills or F82.X Specific developmental disorders of motor function, a code from category F83.- Mixed specific developmental disorders must be used instead.

Question 23

How must an injury sustained during an epileptic fit be coded?

Answer 23

If an epileptic patient is admitted for treatment of an injury sustained during an epileptic fit, the injury must be coded as the primary diagnosis followed by the appropriate external cause code and the relevant epilepsy code.

Question 24

DCS.VI.2: Amaurosis fugax (G45.3)

Answer 24

An additional code must not be assigned to classify loss of vision in patients with Amaurosis fugax as this is inherent in the code G45.3 Amaurosis fugax.

Question 25

DCS.VI.3: Hemiplegia, paraplegia and tetraplegia and other paralytic syndromes (G81-G83)

Answer 25

Codes within categories G81-G83 must only be assigned in the primary position if their cause is not recorded. If the cause is known they are assigned in a secondary position. The exception is when the cause is no longer present and the hemiplegia, paraplegia, tetraplegia or other paralytic syndrome is a sequela of the cause.

Question 26

How must POEMS syndrome be classified?

Answer 26

Must be coded using the following codes: C90.0D G63.1A These codes must only be assigned when all the features of this disease are present and have been confirmed.

Question 27

How is presistant vegetative state coded?

Answer 27

G93.1 | R40.2

Question 28

How must an age related cataract be coded?

Answer 28

Age-related cataract must be coded to category H25.- Senile cataract.

Question 29

How must mature, advanced and white cataracts be coded?

Answer 29

Mature, advanced or white cataract must be coded using H26.9 Cataract, unspecified.

Question 30

Describe DCS.VII.3: Visual impairment including blindness (H54)

Answer 30

The severity of visual impairment table at category H54.- Visual impairment including blindness (binocular or monocular) must not be used for coding purposes to diagnose levels of visual impairment. For patients who are visually impaired or blind and the cause is documented in the medical record the following codes and sequencing must be applied: Code for the cause of visual impairment or blindness H54.- Visual impairment including blindness (binocular or monocular) ``` The exception is G45.3 Amaurosis fugax where only this code is required, see DCS.VI.2: Amaurosis fugax (G45.3). ``` Patients who are registered blind must be coded to the level of visual impairment (eg. severe, moderate, mild) documented in the medical record. If no detail is given about the level of visual impairment one of the following codes must be assigned: H54.0 Blindness, binocular (if unspecified or stated of both eyes) or H54.4 Blindness, monocular (if stated to be of one eye only).

Question 31

How must severe or profund hearing loss be coded?

Answer 31

Hearing loss documented as severe or profound must always be code using a code either H90.- or H91.- depending on the type of hearing loss documented. If the cause for hearing loss is documented then both conditions must be coded, the sequencing will depend on the main condition treated or investigated DGCS.1:Primary diagnosis

Question 32

How must hypertension be coded?

Answer 32

Hypertension must only be coded when a patient has been diagnosed as hypertensive. I10.X Essential (primary) hypertension must not be used to record a diagnosis of raised or elevated BP without mention of hypertension. This would be coded to R03.0 Elevated blood-pressure reading, without diagnosis of hypertension.

Question 33

How must hypertensive renal or heart disease be coded?

Answer 33

Categories I11.- Hypertensive heart disease, I12.- Hypertensive renal disease and I13.- Hypertensive heart and renal disease must be used when the responsible consultant clearly states a link between hypertension and heart disease (I50.- or I51.4-I51.9) or renal disease (N00-N07, N18.-, N19.- or N26.-). If there is no link stated the conditions must be coded separately. Where the patient has a condition in category I11.- together with a condition in category I12.-, a code from category I13.- must be used instead. When a patient has hypertensive renal disease, or hypertensive heart and renal disease, and the renal disease is a condition within category N18.- Chronic kidney disease, the code from category N18.- is assigned to identify the stage of the chronic kidney disease together with a code from category I12.- or I13.-. Sequencing is dependent on the main condition treated or investigated.

Question 34

How must Myocardial infarctions be coded

Answer 34

The time reference of four weeks (28 days) stated in categories I21-I25 signifies the interval elapsing between the onset of the ischaemic episode and admission to hospital; this time reference must be observed by coders to ensure consistency in recording myocardial infarctions. Acute myocardial infarction A code from category I21.- Acute myocardial infarction must be assigned every time a patient has an acute myocardial infarction (MI), except when a subsequent MI occurs within 4 weeks of the onset of a previous infarction, in which case a code from category I22.- Subsequent myocardial infarction must be used as described below. Where a new acute MI is diagnosed more than four weeks (28 days) after a previous MI, acode from category I21.- Acute myocardial infarction must be assigned. Acute NSTEMI and STEMI Non-ST segment elevation myocardial infarction (NSTEMI) must be coded to I21.4 Acute subendocardial myocardial infarction. ST segment elevation myocardial infarction (STEMI) must be classified using a code in the range I21.0 - I21.3 depending on the site of the damage to the heart documented in the medical record. Where the site of the damage is not known, code I21.3 Acute transmural myocardial infarction of unspecified site must be assigned. Subsequent MI, NSTEMI and STEMI Category I22.- Subsequent myocardial infarction must only be used to code an MI occurring within four weeks (28 days) from onset of a previous infarction, regardless of site and includes the following: • Subsequent/further acute myocardial infarction • extension to an existing MI • recurrent MI • reinfarction Subsequent NSTEMI must be classified using I22.9 Subsequent myocardial infarction of unspecified sites. Subsequent STEMI must be classified using a code in the range I22.0 - I22.8 depending on the site of the damage to the heart documented in the medical record. Where the site of the damage is not known, code I22.8 Subsequent myocardial infarction of other sites must be assigned. If a patient has multiple subsequent MIs in the same consultant episode, or any consultant episode within the same or a different hospital provider spell, occurring within four weeks (28 days) from onset of the original infarction, a code from category I22.- Subsequent myocardial infarction must be assigned for each subsequent MI. Chronic MI and ongoing treatment of MI after 4 weeks If an MI is stated as chronic, or the patient is admitted for treatment of the original MI after four weeks (28 days) from onset of the MI, code I25.8 Other forms of chronic ischaemic heart disease must be assigned. Treatment of another condition within 4 weeks of an MI When a patient is admitted to hospital within four weeks (28 days) of an acute MI for treatment or investigation of another condition, code I24.9 Acute ischaemic heart disease, unspecified must be assigned in a secondary position.

Question 35

How must Coronary artery disease interventions and acute myocardial infarctions be coded?

Answer 35

If a patient who has coronary artery disease is admitted with and treated for an acute MI, and is transferred from one hospital provider to another for an intervention to treat the coronary artery disease (for example coronary angioplasty etc), the coronary artery disease must be assigned as the primary diagnosis. If the patient undergoes all treatments at the same Trust, the acute MI must be recorded as the primary diagnosis, followed by the code for the coronary artery disease, as the MI is considered more clinically significant.

Question 36

How must complications of following acute myocardial infarction (I23) be coded?

Answer 36

Codes in category I23.- Certain current complications following acute myocardial infarction must be assigned when the complications occurred following an acute myocardial infarction. Where a complication occurs concurrently with (i.e. at the same time as) the myocardial infarction a code from categories I21–I22 is assigned instead.

Question 37

How must cardiac arrests be coded?

Answer 37

Code I46.0 Cardiac arrest with successful resuscitation must always be assigned when a cardiac arrest with successful resuscitation has occurred; this includes patients who are admitted to hospital following a cardiac arrest outside of the hospital. As any patient who survives a cardiac arrest will have received resuscitation, all patients who live through a cardiac arrest must be coded to I46.0. If the underlying cause of the arrest is documented in the patient’s medical record then this must be sequenced before code I46.0. A sudden cardiac death, specifically described as such by the responsible consultant, must be coded to I46.1 Sudden cardiac death, so described. This is with the exception of sudden cardiac death due to conditions specifically listed as exclusions at this code, i.e. myocardial infarction and conduction disorders. In these cases, the code I46.1 is not necessary. Cardiac arrest without successful resuscitation (and thus fatal) and not described as ‘sudden cardiac death’ must be coded to I46.9 Cardiac arrest, unspecified.

Question 38

Heart failure?

Answer 38

If both congestive cardiac failure (CCF) (I50.0) and left ventricular failure (LVF) (I50.1) are documented in the medical record only assign code I50.0 Congestive heart failure as this code includes both right and left ventricular failure. If a diagnosis of LVF is made together with mention of pulmonary oedema, only assign code I50.1 as this code includes pulmonary oedema. If pulmonary oedema is mentioned in the medical record with hypertensive heart disease with (congestive) heart failure (I11.0) or a condition classified to a code from category I13.- Hypertensive heart and renal disease only assign I11.0 or I13.-

Question 39

DCS.IX.11: Stroke, not specified as haemorrhage or infarction (I64.X)

Answer 39

Strokes must be classified by type, i.e. haemorrhagic or infarction (ischaemic), when known. The code I64.X Stroke, not specified as haemorrhage or infarction does not indicate the type of stroke. The coder must always endeavour to obtain the results of a CT scan report of the brain (or similar report) which should confirm the type of stroke. Whilst coders must not attempt to interpret data from a report to make a diagnosis themselves, the CT report may document a definitive diagnosis to enable the assignment of a more accurate code. Where there is a documented diagnosis of cerebrovascular accident (CVA) or stroke and this is confirmed by the responsible consultant to be due to a thrombosis or embolism, this must be coded to category I63 Cerebral infarction.

Question 40

How must a Lacunar infarction be coded?

Answer 40

A documented diagnosis of lacunar infarction must be coded to I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries.

Question 41

How must a stroke with hemiplegia be coded?

Answer 41

On emergency admissions for strokes, the stroke code must be assigned in the primary position. Hemiplegia due to a stroke must be coded in a secondary position to the stroke as sepcified by the note at G81

Question 42

How must dysphagia and dysphasia be coded on stroke patients?

Answer 42

Symptoms of a stroke such as Dysphagia and Dysphasia must only be coded when they have been treated as a problem in their own right. They must be sequenced in a secondary position.

Question 43

DCS.IX.13: Cerebral atherosclerosis (I67.2)

Answer 43

Cerebral atherosclerosis I67.2 must be assigned when it co-exists with any condition in categories I63.- or I66.-

Question 44

DCS.IX.14: Atherosclerosis (I70)

Answer 44

The fifth characters at category I70 are used to indicate the absence (0) or presence (1) of gangrene, the site of which is located at fourth character. In the absence of information in the medical record the default is (0) to indicate without gangrene. The code I70.8 must be used to indicate Atherosclerosis of the Iliac arteries.

Question 45

DCS.IX.15: Peripheral vascular diseases (I73.9)

Answer 45

If a patient is admitted for an arteriogram or any such test, the diagnosis made from the report confirmed by the responsible consultant must be used in preference to I73.9 I.e code to the cause of PVD. Only used I73.9 if the cause is unknown.