CanadianCodingStandards_2018.pdf - ICD-10-CA | CCI Canadian Coding Standards for Version 2018 ICD-10-CA and CCI Production of this document is made

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Unformatted text preview: ICD-10-CA | CCI Canadian Coding Standards for Version 2018 ICD-10-CA and CCI Production of this document is made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government. All rights reserved. The contents of this publication may be reproduced unaltered, in whole or in part and by any means, solely for non-commercial purposes, provided that the Canadian Institute for Health Information is properly and fully acknowledged as the copyright owner. Any reproduction or use of this publication or its contents for any commercial purpose requires the prior written authorization of the Canadian Institute for Health Information. Reproduction or use that suggests endorsement by, or affiliation with, the Canadian Institute for Health Information is prohibited. For permission or information, please contact CIHI: Canadian Institute for Health Information 495 Richmond Road, Suite 600 Ottawa, Ontario K2A 4H6 Phone: 613-241-7860 Fax: 613-241-8120 [email protected] ISBN 978-1-77109-675-1 (PDF) © 2018 Canadian Institute for Health Information How to cite this document: Canadian Institute for Health Information. Canadian Coding Standards for Version 2018 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2018. Cette publication est aussi disponible en français sous le titre Normes canadiennes de codification pour la version 2018 de la CIM-10-CA et de la CCI. ISBN 978-1-77109-676-8 (PDF) Table of contents Acknowledgements ...................................................................................................................12 Introduction ...............................................................................................................................13 Format of the coding standards .........................................................................................13 Amendments......................................................................................................................14 Data quality ........................................................................................................................15 Using the PDF version of the coding standards .................................................................17 History of the coding standards ..........................................................................................18 The basic structure and classification principles of the ICD ................................................19 General coding standards for ICD-10-CA ..................................................................................20 Main and Other Problem Definitions for NACRS ................................................................20 Coding of Main and Other Problems for NACRS ................................................................22 Diagnosis Typing Definitions for DAD ................................................................................25 Diagnosis Cluster ...............................................................................................................43 Diagnoses of Equal Importance .........................................................................................61 Specificity ..........................................................................................................................64 Using Diagnostic Test Results in Coding ...........................................................................65 Dagger/Asterisk Convention ..............................................................................................67 Acute and Chronic Conditions ............................................................................................71 Impending or Threatened Conditions .................................................................................72 Underlying Symptoms or Conditions ..................................................................................73 Unconfirmed Diagnosis ......................................................................................................77 Use Additional Code/Code Separately Instructions ............................................................84 Sequelae ...........................................................................................................................86 Admissions From Emergency Department .........................................................................88 Cancelled Interventions .....................................................................................................90 General coding standards for CCI .............................................................................................94 Selection of Interventions to Code for Ambulatory Care (Emergency, Clinic and Day Surgery Visits) ...................................................................................................................94 Selection of Interventions to Code for Acute Inpatient Care .............................................102 Composite Codes in CCI .................................................................................................110 Multiple Codes in CCI ......................................................................................................111 Canadian Coding Standards for Version 2018 ICD-10-CA and CCI Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction ....................117 Combined Diagnostic and Therapeutic Interventions .........................................................118 Endoscopic Interventions .................................................................................................121 Interventions to Manage Bleeding ....................................................................................127 Destruction or Excision of Aberrant/Ectopic Tissue ..........................................................129 Debulking of a Space-Occupying Lesion..........................................................................130 Abandoned Interventions .................................................................................................131 Failed Interventions..........................................................................................................133 Change of Plans During an Intervention...........................................................................135 Converted Interventions ...................................................................................................135 Revised Interventions ......................................................................................................136 Chapter I — Certain infectious and parasitic diseases ............................................................144 Infections .........................................................................................................................144 Drug-Resistant Microorganisms .......................................................................................146 Septicemia/Sepsis ...........................................................................................................151 Human Immunodeficiency Virus (HIV) Disease................................................................158 Chapter II — Neoplasms .........................................................................................................164 Primary and Secondary Neoplasms .................................................................................164 Multiple Independent Primary Neoplasms ........................................................................168 Acquired Absence of Breast and Lung Due to Primary Malignancy..................................170 Neoplasms Arising in Lymphoid, Hematopoietic and Related Tissue ...............................172 Neoplasms Extending Into Adjacent Tissue .....................................................................174 Neoplasms With Overlapping Boundaries (Contiguous Sites) ..........................................175 Admissions Following Diagnosis of Cancer ......................................................................176 Complications of Malignant Disease ................................................................................177 Recurrent Malignancies ...................................................................................................180 Interventions Relevant to Neoplasm Coding ....................................................................182 Sentinel Lymph Node Biopsy ...........................................................................................184 Brachytherapy..................................................................................................................186 Chapter III — Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism ...........................................................................................189 Acute Blood Loss Anemia ................................................................................................189 Anemia of Chronic Disease..............................................................................................192 4 Table of contents Chapter IV — Endocrine, nutritional and metabolic diseases ..................................................196 Diabetes Mellitus .............................................................................................................196 Dehydration .....................................................................................................................211 Chapter VI — Diseases of the nervous system .......................................................................213 Cranioplasty and/or Duraplasty Concomitant With Intracranial Interventions ...................213 Hierarchy for Classification of Intracranial Lesion Resection ............................................216 Revision of Cerebrospinal Fluid (CSF) Shunt Systems (Ventricle, Brain Stem, Spinal Canal) ...................................................................................................................218 Seizures...........................................................................................................................220 Neurological Deficits Following a Stroke ..........................................................................225 Neurologically Determined Death.....................................................................................227 Chapter IX — Diseases of the circulatory system....................................................................231 Hypertension and Associated Conditions .........................................................................231 Acute Coronary Syndrome (ACS) ....................................................................................233 Selection of Status Attribute for Percutaneous Coronary Intervention (PCI) .....................246 Thrombolytic Therapy ......................................................................................................248 Angina .............................................................................................................................252 Chronic Ischemic Heart Disease ......................................................................................254 Occlusion Following Coronary Artery Bypass Grafts (CABGs) .........................................256 Cardiac Arrest ..................................................................................................................258 Strokes: Hemorrhagic, Ischemic and Unspecified ............................................................262 Peripheral Vascular Disease ............................................................................................266 Aneurysms .......................................................................................................................268 Central Venous Catheters ................................................................................................270 Anticoagulation Therapy: Management and Adverse Effects ...........................................275 Chapter X — Diseases of the respiratory system ....................................................................283 Pneumonia ......................................................................................................................283 Pneumonia in Patients With Chronic Obstructive Pulmonary Disease (COPD) ................286 Asthma ............................................................................................................................288 Resection of Space-Occupying Lesions (Polyps) of Nose ................................................290 Septoplasty for Deviated Nasal Septum ...........................................................................292 Invasive Ventilation ..........................................................................................................295 5 Canadian Coding Standards for Version 2018 ICD-10-CA and CCI Chapter XI — Diseases of the digestive system ......................................................................300 Gastroenteritis and Diarrhea ............................................................................................300 Bleeding Esophageal Varices ..........................................................................................301 Gastrointestinal Bleeding .................................................................................................304 Selection of Attributes at Hernia Repair ...........................................................................306 Chapter XII — Diseases of the skin and subcutaneous tissue.................................................308 Cellulitis ...........................................................................................................................308 Chapter XIII — Diseases of the musculoskeletal system and connective tissue ......................310 Osteoarthritis ...................................................................................................................310 Arthrectomy and Arthroplasty...........................................................................................314 Fractures .........................................................................................................................315 Joint Fracture Reduction, Fixation and Fusion .................................................................320 Excision (of Lesion) of Bone, Soft Tissue and Skin ..........................................................321 Spinal Stenosis ................................................................................................................323 Chapter XIV — Diseases of the genitourinary system .............................................................325 Stages of Chronic Kidney Disease (CKD) ........................................................................325 Acute on Chronic Kidney Disease ....................................................................................326 Continuous Ambulatory Peritoneal Dialysis (CAPD) Peritonitis ........................................330 Menorrhagia as the Most Responsible Diagnosis (MRDx) ...............................................332 Chapter XV — Pregnancy, childbirth and the puerperium .......................................................333 Selection of the Sixth Digit in Obstetrical Coding .............................................................333 Sequencing Obstetrical Diagnosis Codes ........................................................................338 Intrauterine Death ............................................................................................................342 Pregnancy With Abortive Outcome ..................................................................................343 Continuing Pregnancy After Abortion/Selective Fetal Reduction in Multiple Gestation .....354 Complications Following Abortion and Ectopic and Molar Pregnancy ..............................358 Streptococcal Group B Infection/ Carrier in Pregnancy ....................................................359 Delivery in a Normal Case ...............................................................................................361 Complicated Pregnancy Versus Uncomplicated Pregnancy .............................................364 Delivery With History of Cesarean Section .......................................................................373 Multiple Gestation ............................................................................................................374 Maternal Care Related to the Fetus, Amniotic Cavity and Possible Delivery Problems ....376 Prolonged Pregnancy/Post-Dates Pregnancy ..................................................................379 6 Table of contents Premature Rupture of Membranes ...................................................................................381 Preterm Labor ..................................................................................................................382 Long Labor ......................................................................................................................383 Precipitate Labor..............................................................................................................385 Obstructed Labor .............................................................................................................386 Labor and Delivery Complicated by Fetal Stress..............................................................390 Postpartum Hemorrhage ..................................................................................................391 Complications of Anesthesia During Labor and Delivery ..................................................395 Interventions Associated With Delivery ............................................................................396 Dilation and Curettage .....................................................................................................403 Chapter XVI — Certain conditions originating in the perinatal period ......................................405 Low Birth Weight and/or Preterm Infant ...........................................................................406 Fetal Acidemia .................................................................................................................411 Neonatal Jaundice ...........................................................................................................413 Confirmed Sepsis and Risk of Sepsis in the Neonate ......................................................414 Birth Trauma ....................................................................................................................419 Perinatal Stroke ...............................................................................................................421 Chapter XVII — Congenital malformations, deformations and chromosomal abnormalities ....423 Congenital Anomaly Syndromes and Specific Manifestations ..........................................423 Chapter XVIII — Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified ..........................................................................................................428 Systemic Inflammatory Response Syndrome (SIRS) .......................................................428 Vital Signs Absent (VSA) .................................................................................................433 Chapter XIX — Injury, poisonings and certain other consequences of external causes...........437 Adverse Reactions in Therapeutic Use Versus Poisonings ..............................................437 Aller...
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