Case 1
To get the final diagnosis ICD-10 code, you first must look in the alphabet section of the ICD-10-CM manual. Look for gout—chronic vs. acute. Then go to drug-induced gout. Next, you would go to the tabular section of the manual to complete the code by first looking for the anatomical site. This code requires seven characters, but there is no sixth character for laterality because the location is the vertebra. Therefore, you’ll have to use a dummy placeholder for the missing sixth character. The seventh character is identifying the tophi. The With/Without rule could be applied to this code: M1A.28X0—which states, When “with” and “without” are two options for the final character of a set code, the default is always “without” if it is not stated in the documentation.
In ICD-10, if the provider documents obesity, then the BMI code must be reported on the claim as a secondary diagnosis. As with all other secondary diagnosis codes, the BMI codes should only be assigned when they meet the definition of an additional code that can be reported. The codes would be listed as: M1A.28X0, E66.01 and Z68.41.
Case 2
First, locate lupus erythematosus (systemic) in the alphabet section. Look for organ or system involvement. Then choose which organ is diagnosed; in this case, lung involvement is documented. Then verify the code in the tabular section to see if any additional code extension is needed. Keep in mind that the pulmonary hypertension does not need to be coded as an additional diagnosis because the rheumatologists did not treat or address the hypertension (Note: this is FYI in the patient record for lung involvement and would relate more to the E/M level of visit). The final code should be reported as: M32.13.
Case 3
To find the correct code, look under arthritis in the alphabet section of the ICD-10-CM manual, and then locate rheumatoid. You will have to verify in the alphabet section if it is “with” or “without” RH factor; the documentation indicates that it is seronegative, and so you will choose M06. Next, look for the location of the problem in the tabular section, which would be for multiple sites (i.e., wrists, elbow and knee). Finally, you would verify if the code is complete, and this would be coded as: M06.09 (without RH factor).
Case 4
Locate the code in the alphabet section of the ICD-10-CM manual for osteoporosis, which is in category M81 (without current pathological fracture). The documentation states that the patient has a healed pathological fracture. The next step is to verify the complete code in the tabular section under M81, which will indicate “age-related,” because the patient is 72 years old and postmenopausal. An additional code is required if the patient has a personal history of (healed) osteoporosis fracture. The final codes are: M81.0, Z87.310.
