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Accuracy in Documentation and Coding: A Guide to Risk Adjustment and the CMS-HCC Model
2012–2013 Edition
Cover & Tabs.indd 1 6/7/12 12:35 PM
A Guide to Risk Adjustment and the CMS-HCC Model | 1
Authors:randy schwartz
stacey hernandez, CCs-P
Moon Leung, PhD
stuart Levine, MD, MhA
Contributors:Zachary Gerbarg, MD, CPC Principal Eagle Medical Management LLC
huan Guu, MD Assistant Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles
tim schwab, MD Chief Medical Officer SCAN Health Plan
tam Pham
Judy Yip, PhD
russell brower, MD Medical Director SCAN Health Plan
susan Erickson
CLiniCAL PEEr PAnEL:Chester Choi, MD Program Director & Academic Chief of Medicine St. Mary’s Medical Center
robin K. Dore, MD Clinical Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles
C. Gregory Albers, MD, FACG Medical Director Diagnostic GI Services University of California, Irvine Comprehensive Digestive Diseases Center
William J. French, MD, FACC Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles Director, Anticoagulation Service Harbor-UCLA Medical Center
stuart Levine, MD, MhA Corporate Medical Director Health Care Partners Assistant Clinical Professor, Internal Medicine David Geffen School of Medicine at University of California, Los Angeles
2 | A Guide to Risk Adjustment and the CMS-HCC Model
John tayek, MD Associate Professor (in Residence) of Medicine David Geffen School of Medicine at University of California, Los Angeles Harbor-UCLA Medical Center
Lewis rosenberg, MD Board Certified Ophthalmologist Long Beach, CA
©2012 SCAN Health Plan®. All Rights Reserved.
This publication is intended for educational purposes only and is provided “as is” without warranty of any kind, either expressed or implied. Despite the best efforts to provide accurate material, any publication may include technical inaccuracies or typographical errors. SCAN Health Plan assumes no responsibility for and disclaims all liability for any errors or omissions in this publication or in other documents, which are referred to within or linked to this publication. In the event that the reader has any questions regarding the CMS risk-adjusted reimbursement methodology or the coding of any particular diagnosis, the reader is advised to consult experienced counsel or other appropriately trained professional advisors.
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Table of ConTenTs
Chapter 1. Introduction ....................................................5
Chapter 2. General Principles of Documentation and ICD-9-CM Coding ............................................................9
Chapter 3. Avoiding Errors in Documentation ...................21
Chapter 4. Risk Adjustment Data Validation (RADV) ..........25
Chapter 5. EMR White Paper: A Primer for the Practical-Minded Clinician ...................................29
Chapter 6. Diagnostic and Coding Criteria of Common Geriatric Conditions ......................................39
Diagnoses in alphabetical order ......................................41
Diagnoses by ICD-9 Code ...............................................81
appendix 1. CMS-HCC Risk Adjustment Model— Community and Institutional Factors .............................115
appendix 2. Disease Hierarchies for the CMS-HCC Model ...............................................125
appendix 3. CMS-HCC Model Relative Factors for Aged and Disabled New Enrollees .............................129
appendix 4. Approved Physician Specialties for Risk Adjustment .....................................................133
appendix 5. Clinical Abbreviations for the Medical Record .................................................135
appendix 6. Medicare Preventive Services......................141
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Chapter 1. IntRoduCtIon
CMS-hCC riSk adjuStMent Capitation payMent SySteM
the Balanced Budget Act of 1997 directed the Centers for Medicare & Medicaid Services (CMS) to replace the demographic-based capitation payment system to Medicare Advantage (MA) plans with one that took enrollees’ health status into account. After evaluating several risk-adjustment models, CMS adopted the Hierarchical Condition Categories (HCC) model, developed with CMS funding by researchers at RtI International and Boston university, with clinical input from physicians at Harvard Medical School. Prior to implementation, CMS staff and HCC model developers simplified the original model with fewer HCCs and used Medicare subpopulations to develop weights, resulting in the CMS-HCC model. this risk-adjusted payment methodology stratifies Medicare beneficiaries on the basis of the number and severity of concomitant chronic diseases. Implemented in a 5-year phase-in process, all health plans were fully risk adjusted as of 2008.
diagnostic classification systems aggregate ICd-9-CM codes into broader categories for various purposes. Although HCC looks like other diagnostic classification systems such as the major diagnostic categories (MdC) or the clinical classification system (CCS), it is a risk-adjustment model. It not only classifies ICd-9-CM codes to clinically similar groupings, but also assigns weights to each grouping to account for severity. CMS-HCC is an attempt to capture the beneficiaries’ health burden so that MA plans caring for these beneficiaries will be reimbursed accurately.
Commonly within a group of HCCs, several conditions are more severe than the others. under the CMS-HCC model, the more severe manifestation of a given disease process will be weighted more heavily than the less severe one. to address how the more severe condition has a greater impact on cost of care, the model imposes a hierarchy among related HCCs, such that an enrollee is only assigned the most severe manifestation among the related diseases. For unrelated HCCs, the model treats them as additive. Each HCC carries a weighted score, relative to the cost of care. A more severe HCC would have a higher weighted score, and a less severe HCC would have a lower weighted score. Weighted scores are then summed for the individual patient. Although the original model includes 189 HCCs using all the ICd-9-CM codes, only 70 HCCs are currently included in the CMS-HCC payment model. In addition to the diagnosis categories, the CMS-HCC model also has demographic and eligibility/enrollment adjusters, including mutually exclusive age/sex demographic adjusters and indicators of Medicaid and disability status.
Currently, approximately 3200 of 13,000+ ICd-9 codes are used in the CMS-HCC model for coding the diagnoses listed in patients’ medical records. these 3200 ICd-9 codes correspond to 70 HCCs, which are used, along with its weighted score, to reimburse Medicare Parts A and B services to MA plans. Medical information used in assigning HCCs for payment is derived from any of the following three (3) sources: hospital inpatient, hospital outpatient, and face-to-face physician (which includes chiropractors, podiatrists, nPs, PAs and psychologists) visits.
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iCd-9 Coding SySteM
Assigning numerical codes to diagnoses is no easy task. Because of the complexity of diseases, etiology, manifestation, and complications, different ways of classifying diseases exists. the official format in the united States is the International Classification of diseases, 9th Revision, Clinical Modification (ICd-9-CM). the ICd-9-CM system is developed and revised by four cooperating parties: the Centers for Medicare and Medicaid Services (CMS), the national Centers for Health Statistics (nCHS), the American Health Information Management Association (AHIMA) and the American Hospital Association. the ICd-9-CM is used to code and classify disease information (signs, injuries, diseases, symptoms) in both inpatient and outpatient settings. different from the other official coding systems, Current Procedure terminology, CPt and Healthcare Common Procedure Coding System, HCPCS (which are used to code procedures), ICd-9-CM primarily focuses on the clinical reasons for which a medical service is necessary (table 1). the ICd-9-CM also includes a procedural coding system which is used only by inpatient facilities.
250.42
Table 1Basic Structure of an ICD-9-CM Code
These 3 digits provide basic diagnosis categories(e.g. 250 diabetesmellitus)
The 4th digit identifies complications related to the primary disease (e.g. 250.4 diabetes with renal manifestations)
The 5th digit identifies additional specific evaluation of the primary disease (sub-classifications) (e.g. 250.42 uncontrolled type II or unspecified type diabetes)
the ICd-9-CM manual is made up of three volumes:
• Volume 1 is a tabular listing of disease code numbers and descriptions;
• Volume 2 an alphabetical index to the disease entries; and
• Volume 3 is a listing of procedure codes used solely by hospitals.
to properly and accurately assign codes to diagnoses, providers are required to follow the ICd-9-CM official Guidelines for Coding and Reporting.
aCCurate CodeS
Maintaining an accurate coding practice not only facilitates better care for patients, but also helps physicians maintain more accurate reimbursement. Accurate coding facilitates the capture of conditions underlying the manifested symptoms and helps determine the
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overall disease burden that might affect the care of the patient. As an example, under section 250-259 diseases of other Endocrine Glands, 250 is the code for diabetes mellitus and the 4th and 5th digits describe the complications, type, and control level of the disease in the individual patient diagnosed. From a medical coding perspective, physicians need to specify the condition more by adding a 4th or 5th digit to the preceding three-digit code (250). Just coding 250 is incomplete. At the 4th digit level, providers are able to specify the manifestation of the condition, but 250.0-250.9 still requires a 5th digit to be submitted. It is at the 5th digit level (the highest level) that providers can accurately capture the condition of the patient. In this example, at the 5th digit level, it specifies if the diabetic condition is type 1 or type 2, and/or if the condition is controlled or not. It is at this level that the code documents to the highest level of specificity and is most accurate.
ChallengeS to the phySiCian CoMMunity
the CMS-HCC system (and HIPAA) mandates accurate coding, but more importantly, an accurate retrospective and prospective analysis of each patient’s acute and chronic conditions may lead to better care. While most MA plans argue that this is a “coding challenge”, it is actually a challenge for the physician community which must more accurately understand and manage the complex array of chronic diseases of each patient. Physicians will be challenged to work with their respective delivery systems, including fellow physicians and specialists, to collect the most accurate and complete assessment of each patient’s acute and chronic conditions, and to develop a comprehensive and individualized treatment plan. through this approach, quality of care will be markedly improved, and the need for comprehensive patient care will be reinforced. In addition, accurate and complete collection and documentation of this diagnosis data drives an enhanced revenue engine, which in turn will support the additional cost of providing high-quality care.
Since the CMS-HCC system is designed to reimburse health plans more accurately, plans have been working aggressively with physician partners to collect accurate and timely encounter data. Significant efforts are being devoted to accurately coding diagnoses and procedures and effectively documenting the clinical rationale for these codes in the medical chart. Health plans and physicians should note the following:
1. Although MA plans submit diagnosis codes to CMS, only those with the most severe manifestations of each disease within a specific disease category will be considered in the final risk score according to the CMS-HCC system.
2. Accurate diagnosis related documentation yields accurate reimbursement.
3. Current-year reimbursement is based on encounter data from last year. If no encounter data is submitted, payment in the following year will be based only on demographic data, resulting in decreased reimbursement. CMS does not carry over chronic diagnoses, so these diagnoses must be evaluated and reported at least yearly.
4. Because physician diagnostic data account for approximately 80% of the entire encounter submission, physician documentation drives the amount CMS pays on behalf of each member.
the message of needing more specific and more accurate coding is very clear. At a broader level, the physician community is challenged to:
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1. understand and manage the complex array of chronic diseases of each patient;
2. Work with respective delivery systems, including fellow physicians and specialists, to collect the most accurate and complete picture of each patient’s acute and chronic conditions;
3. develop a comprehensive and individualized treatment plan;
4. Maintain a balance between generating a thorough record for better continuity of care and treatment and an enhanced revenue engine that in turn supports the additional cost of providing high-quality care.
An accurate, improved diagnosis coding and documentation practice has many benefits to physicians in the clinical management of their patients, as well as in the financial management of their practice. Accurate diagnosis documentation and coding improves:
1. Patient medical record problem lists
2. tracking of patient’s current diagnosis
3. Patient risk stratification for care management
4. Risk management
general approaCh to proper Coding
1. Good and accurate coding starts with accurate documentation. Make sure the disease/condition is documented in the medical record: “If it is not documented in the medical record, it didn’t exist!”
2. Fully assess all chronic conditions annually in face-to-face patient visits. Remember to code not only the conditions related to the symptoms for the immediate visit, but also any chronic conditions that are assessed and/or treated that affect the care of the patient. Conditions may be coded for face–to-face physician visits in inpatient hospital, outpatient hospital, office and visits to the patient’s home.
3. Clearly and thoroughly document in the medical chart all conditions evaluated during each visit.
4. Code to the highest level of specificity; fully utilize the ICd-9 diagnosis coding system.
5. document and code the most comprehensive or all inclusive diagnoses for the patient’s condition.
6. document and code for all secondary or associated diagnoses when clinically indicated.
Whether to improve quality of patient care, reduce the exposure to risk-related liabilities, or achieve more accurate reimbursement, it is the physician’s responsibility to provide accurate coding and documentation of the patients’ health-related conditions. this guidebook provides coding criteria and tips on medical record documentation designed to assist physicians and their practice.
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Chapter 2. GeneRAl PRinCiPleS of DoCuMentAtion AnD iCD-9-CM CoDinG
I. Only a physICIan Or apprOved ClInICIan Can Make a dIagnOsIs fOr rIsk adjustMent purpOses.
• if the doctor1 documents clearly that a patient has specific diagnoses, then the correct iCD-9 diagnosis codes can be selected.
• if an iCD-9 code has been submitted for a patient visit, then the medical record must include language which supports the diagnosis in a signed and dated progress note.
• it is not enough for the doctor to know the patient’s diagnosis; the doctor must write it down (or dictate) clearly in a progress note for an iCD-9-CM diagnosis code to be valid. if you know a patient has CHf, but do not mention it anywhere in your note, you cannot submit the diagnosis code for CHf (428.0).
• A medical record progress note signed by a nurse practitioner (nP), a certified clinical nurse specialist, or physician assistant (PA) is also a valid source for diagnosis coding. (A complete list of valid specialties appears in the appendix.)
• A note from a nurse, wound specialist, marriage family therapist, medical assistant or other healthcare worker cannot be used to for coding purposes.
• A licensed clinical psychologist or social worker (lCSW), physician assistant (PA) or nurse practitioner (nP) may code mental health diagnoses resulting from a face-to-face patient visit.
• A lab test, order for a test, authorization for a service or other administrative record cannot be used for coding purposes. the physician must interpret a test and document the resulting diagnosis in the progress note.
• the written report of an anatomical pathology service may be used for coding purposes. this is an exception to the requirement for a face-to-face visit.
• only information recorded in a progress note as the result of a face-to-face patient visit that has been signed by a doctor or approved clinician can be used for coding purposes.
• in addition to stating that a patient has a particular diagnosis, there should be evidence in the medical record to support that diagnosis.
• for example, a patient who is newly diagnosed with “major depression, single episode” should have some documentation of the criteria necessary for making that diagnosis.
• Suspicions or “rule outs” cannot be coded as diagnoses. if a definitive diagnosis has not been made, the symptoms or signs should be coded. note
1 Although the term doctor is used throughout the text, the term includes other approved clinicians. Please see the appendix for a list of approved clinicians.
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that there are diagnosis codes for most symptoms. these are found in the 78X series of iCD-9-CM.
• All chronic conditions must be fully assessed annually to properly report the member’s health status to CMS.
• Physicians must thoroughly document in the chart all conditions evaluated during each visit and code to the highest level of specificity based on their documentation.
• each encounter in the medical record must stand alone, and only conditions evaluated during the encounter should be documented and coded.
• Some examples of terms that indicate evaluation and treatment:
• Stable on meds
• Condition worsening—medication adjusted (include name of medication and change made)
• tests ordered—documentation reviewed and results incorporated into treatment plan
• Condition improving (include any changes to treatment plan made).
• listing medications and prescriptions in a medical record does not meet documentation requirements to indicate that an evaluation for a condition was performed.
• Checking off a code on an encounter form or listing a diagnosis on a medical record problem list does not meet documentation requirements. the diagnosis must be present in the progress note in order to meet documentation requirements.
• Diagnostic statements should be clear and unambiguous. listing a series of symptoms, signs and laboratory results cannot substitute for a diagnosis.
II. a valId MedICal reCOrd has tO Meet speCIfIC CrIterIa
• Legibility:
• the medical record must be legible. A reviewer must be able to read what is written.
• if others cannot read your writing, you should dictate or move to an eMR system.
• it is the responsibility of the physician to review dictated notes, make any corrections according to accepted medical record principles, and sign them.
• PatientNameandID:
• for a medical record to be valid, every page must clearly identify the patient by last name, first name, and some other form of identification, such as a medical record number, account number, or date of birth.
• VisitDate:
• the medical record documentation must include the date of the patient visit with month, day, and year clearly stated. if the note spans multiple pages, the date must appear on each page.
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• StandardAbbreviations:
• only standard abbreviations should be used to ensure clear understanding. (See a brief listing of some of the most common abbreviations for significant diagnoses in the back of this book.) the use of symbols is discouraged because they cannot be used for coding purposes. for example, “↑ lipids” cannot be coded as hyperlipidemia.
• OrganizedNote:
• the visit note should be organized in a logical fashion and clearly demonstrate that this was a face-to-face visit (usually identified by documenting the presence of physical findings). the most common example is the use of the SoAP format (S = subjective; o = objective; A = Assessment; P = Plan). Diagnoses should be clearly noted as part of the assessment.
• PatientDiagnoses:
• All the patient’s diagnoses should be documented at least once each year in a progress note, with a brief update of the status of each diagnosis.
• Follow-upPlan:
• the medical record should include the follow-up plan comprising tests ordered, referrals made, patient instructions, and when the next appointment should be scheduled.
• Signature and Credential:
• the progress note must include a clear clinician signature, with a credential after the name. it is important to know which clinician is responsible for the note.
III. OffICIal OutpatIent COdIng guIdelInes2
dIagnOstIC COdIng and repOrtIng guIdelInes fOr OutpatIent servICes, effeCtIve 10-1-2011
these coding guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.
information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the iCD-9-CM tabular list (code numbers and titles), can be found in Section iA of these guidelines, under “Conventions used in the tabular list.” information about the correct sequence to use in finding a code is also described in Section i.
the terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
2 Although these guidelines are called the outpatient coding guidelines, they apply to all services performed by a physician, regardless of place of service, based on Coding Clinic, Q3, 2000 pages 6–7.
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though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:
the uniform Hospital Discharge Data Set (uHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals.
Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
a. seleCtIOn Of fIrst-lIsted COndItIOn
in the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. in determining the first-listed diagnosis, the coding conventions of iCD-9-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. it may take two or more visits before the diagnosis is confirmed.
the most critical rule involves beginning the search for the correct code assignment through the Alphabetic index. never begin searching initially in the tabular list as this will lead to coding errors.
1. OutpatIent surgery
When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
2. ObservatIOn stay
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
b. COdes frOM 001.0 thrOugh v91.99
the appropriate code or codes from 001.0 through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.
C. aCCurate repOrtIng Of ICd-9-CM dIagnOsIs COdes
for accurate reporting of iCD-9-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. there are iCD-9-CM codes to describe all of these.
d. seleCtIOn Of COdes 001.0 thrOugh 999.9
the selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. these codes are from the section of iCD-9-CM for the classification of diseases and injuries
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(e.g. infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc.).
e. COdes that desCrIbe syMptOMs and sIgns
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of iCD-9-CM, Symptoms, Signs, and ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms.
f. enCOunters fOr CIrCuMstanCes Other than a dIsease Or Injury
iCD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. the Supplementary Classification of factors influencing Health Status and Contact with Health Services (V01.0- V91.99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.
g. level Of detaIl In COdIng
1. ICd-9-CM COdes wIth 3, 4, Or 5 dIgIts
iCD-9-CM is composed of codes with either 3, 4, or 5 digits. Codes with three digits are included in iCD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater specificity.
2. use Of full nuMber Of dIgIts requIred fOr a COde
A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code.
h. ICd-9-CM COde fOr the dIagnOsIs, COndItIOn, prObleM, Or Other reasOn fOr enCOunter/vIsIt
list first the iCD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. list additional codes that describe any coexisting conditions. in some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
I. unCertaIn dIagnOsIs
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Please note: this differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.
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j. ChrOnIC dIseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
k. COde all dOCuMented COndItIOns that COexIst
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
l. patIents reCeIvIng dIagnOstIC servICes Only
for patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign V72.5 and/or a code from subcategory V72.6. if routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.
for outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Please note: this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
M. patIents reCeIvIng therapeutIC servICes Only
for patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
the only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
n. patIents reCeIvIng preOperatIve evaluatIOns Only
for patients receiving preoperative evaluations only, sequence first a code from category V72.8, other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.
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O. aMbulatOry surgery
for ambulatory surgery, code the diagnosis for which the surgery was performed. if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
p. rOutIne OutpatIent prenatal vIsIts
for routine outpatient prenatal visits when no complications are present, codes V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy, should be used as the principal diagnosis. these codes should not be used in conjunction with chapter 11 codes.
Iv. keys tO suCCessful dOCuMentatIOn and COdIng fOr MedICare patIents
See each Medicare patient at least once each year and document and code every significant diagnosis in your progress note for that visit. treatment plans should be added or modified as appropriate based on these findings. According to coding guidelines, you cannot submit a code based only on what is written in a patient problem list. following are some tips for specific significant diagnoses.
• Cardiology
• be specific. if the patient has stable angina or a history of myocardial infarction (Mi), document this condition as opposed to a less specific diagnosis such as coronary artery disease (CAD) or atherosclerotic heart disease (ASHD).
• documenting myocardial infarction. for coding purposes, an Mi is considered acute within the first 8 weeks of the event—after that, you should document an old Mi. Also, for an acute Mi, the coding is defined by “episodes of care”, so from initial hospitalization through the 8 weeks is the initial episode. if the patient is re-hospitalized for care related to the Mi, a subsequent episode of care begins which has a different diagnosis code.
• arrhythmias. Do not forget to document and code ongoing chronic conditions such as atrial fibrillation or arrhythmias, whether symptomatic or asymptomatic due to pharmacological treatment. Arrhythmias that no longer exist due to ablation should not be coded.
• heart failure. Documentation of heart failure should be specific. Codes exist in category 428 for systolic, diastolic and congestive heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure. Codes also exist for acute on chronic heart failure.
• Endocrine
¤ Diabetic Complications are frequently omitted conditions in physician medical records.
• if you simply document DM or diabetes in your progress note in the medical record, the correct code is the code for uncomplicated diabetes, type ii or unspecified type (250.00).
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¤ only the doctor can make a diagnosis of a manifestation of diabetes—the person coding the medical record cannot assume anything. for example, if a patient has diabetes and a lab test with a creatinine of 3.0, the coder can only code diabetes unless the doctor documents the renal complications of diabetes.
• even the clinician cannot code something he or she did not write. that same notation of a creatinine of 3.0 along with a diagnosis of “DM” is still only 250.00. the clinician must document the complication in a clear diagnostic statement.
• additional codes. for many diabetic manifestations, a second diagnosis code is required along with the primary diagnosis. for example, for a patient with adult diabetic nephropathy, you should submit the code 250.4X for Diabetes with nephropathy as well as Diabetic nephropathy 583.9 or Chronic Kidney Disease (CKD) Stages i—V 585.X if appropriate.
• evaluate every patient with diabetes, especially those with renal disease, for the presence of malnutrition (see below/monitor the patient’s albumin and/or weight loss/BMi) and anemia and code appropriately.
• evaluate every patient with diabetes for all manifestations and comorbidities of the disease. All complications should be coded in addition to the diabetes code(s) when applicable.
• diabetic control. the 5th digit in diabetes coding is used to refer to the level of diabetic control. for example, 250.00 is uncomplicated type ii diabetes, not stated as uncontrolled and 250.02 is uncomplicated type ii diabetes, stated as uncontrolled.
¤ note that “poor control” in the record is coded as controlled, per coding guidelines.
¤ in addition, remember to use the V code when a patient documented to be on insulin.
• Category 249 represents secondary diabetes. this category uses the same 5th digit classifications as category 250. When documenting secondary diabetes, your documentation should include the cause of the diabetes, e.g., diabetes secondary to long term steroid use.
• Neurology
• documenting and coding stroke. Patients with acute cerebrovascular accident (CVA) usually present in an eR or hospital setting. Patients who recover from CVA without sequelae should be documented as “history of CVA” and assigned code V12.54 as an additional code for history of cerebrovascular disease when no neurologic deficits are present. unless the patient is still hospitalized for the CVA, you should not be using codes in the 434.XX series.
• late effects of stroke. Assess and document all late effects of CVA. late effects such as aphasia, aphagia, hemiparesis, etc., should be documented and coded using codes from the 438.XX series.
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• epilepsy should be fully described (e.g., convulsive, non-convulsive, petit mal status, grand mal status) and should describe intractable epilepsy (e.g. pharmacology resistant, medically refractive) if present.
• Dementia should be described fully and include a description of causative factors if they exist.
• Nutritional
• Physicians sometimes neglect to document nutritional deficiency in patients with illnesses such as cancer, CoPD, CHf, or renal failure. Assuming they do assess, physicians often neglect to document and code nutritional deficiency in patients with chronic illnesses.
• Malnutrition and cachexia. typically, malnutrition or cachexia results from involuntary weight loss as the result of a chronic illness. Be sure to evaluate, and document these conditions when they occur in your patients. Regularly check on the patient’s albumin, weight and BMi trend/loss, especially in the frail, older adult, patients with dementia, and in patients with CKD.
• Oncology
• the iCD-9 guidelines for oncology are often counterintuitive to physicians and do not follow current thinking on oncology. Review them to code malignancies properly.
• Malignancies are considered active disease until the patient has completed “definitive treatment”, which includes any combination of surgical excision, chemotherapy or radiation, and shows no sign of the disease. this criterion means that patients who are not treated still have active disease.
• Patients with no sign of the disease (e.g., those under post treatment surveillance with no evidence of recurrence or metastases) must be documented and coded as having a history of the malignancy.
• note any metastases and code them as metastatic disease, not as a new primary malignancy. Metastatic disease is coded at the site of the metastasis, not the primary site. So, breast CA metastatic to bone would be 198.5, secondary neoplasm of bone and bone marrow and 174.9, breast cancer, site unspecified.
• Metastatic disease. Document and code the primary as well as the metastatic sites of the cancer.
• Patients on adjuvant therapy for breast and prostate cancer (e.g., tamoxifen, lupron®) continue to be coded as having an active malignancy, even in the absence of any sign of the disease. this guideline is an exception to the general rules.
• Psychiatry
¤ Making the specific diagnosis is the key to appropriate documentation.
• Many physicians are hesitant to document psychiatric disorders because of concerns that this information will be shared with a clearinghouse that provides medical information on people who apply for
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insurance. Diagnoses submitted to SCAn Health Plan are not shared with any agency except CMS.
• depression. if you simply document “depression” in the medical record, then the correct code is a 311, depression not otherwise specified. However, if your patient meets the clinical criteria for major depression, then your documentation should indicate that the patient has major depression, and indicate whether it’s a single episode or recurrent episode. Patients on chronic antidepressant therapy for major depression should also be documented appropriately.
• once bipolar, obsessive-compulsive disorder (oCD), and schizophrenia is diagnosed, it is a lifetime diagnosis as long as it is documented.
• alcohol dependence. Dependence on alcohol is common in Medicare patients, so be sure to document these conditions at least once each year in your progress notes and then code them. A CAGe questionnaire can be completed to screen for alcohol dependence.
• Sleep disorders are common in geriatrics patients. Patients should be screened for sleep disorders and their medications reviewed for long-term hypnotics. Also, alcohol-induced sleep disorder is common and should be evaluated when patients are screened positive for alcohol dependence.
• Delirium is also a common condition in the elderly. When possible, the underlying cause of the delirium should be identified and documented, which leads to more accurate code selection. treatment of the delirium should be documented as well.
• Pulmonary
• Do not forget to document and code chronic pulmonary diseases at least once each year.
• COpd, chronic bronchitis, and emphysema. these chronic conditions should be documented and coded at least once each calendar year. Be sure to include chronic respiratory failure for those patients who meet the clinical criteria of Pao2 value of less than 60 mm Hg while breathing air or PaCo2 of more than 50 mm Hg.
• Do yearly spirometry screening for all at-risk patients. Review all patients for recurrent acute bronchitis and multiple-inhaler prescriptions for possible chronic bronchitis and CoPD.
• for bacterial pneumonia, be sure to document the causative organism and/or the radiologic findings.
• Renal
• CKD coding (585.X) has been changed to conform with the stages of CKD. these changes include stages i-V based on a patient’s glomerular filtration rate (GfR), which is estimated from a urinalysis and/or serum creatinine and basic patient demographics. Remember that some Medicare patients with “normal” creatinine levels may still have significantly impaired renal function.
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for people at risk, creatinine clearance or GfR should be estimated at least twice per year.
• note that stages i and ii of CKD must have 3 months of reduced GfR or evidence of kidney damage documented.
• SkinandOrthopedics
• Chronic skin ulcers. Be sure to document and code chronic skin ulcers as either decubitus or caused by other factors. the location of the ulcer should also be documented to facilitate accurate code selection.
¤ if caused by vascular disease, this finding should be documented and coded as well.
¤ if it is a decubitus ulcer, the ulcer must be staged, and an iCD-9-CM code for the stage of ulcer (707.20-707.25) should be submitted as well.
• Because amputations are permanent, they should be assessed, documented and coded on a yearly basis.
• Coding of traumatic fractures. the site and type (closed vs. open) must be documented in order to choose an accurate code. the acute fracture codes are only used during active treatment, which iCD-9-CM describes as surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. After active treatment, the aftercare codes (V54.X) for healing fractures should be used.
• Coding of pathological fractures - acute fractures vs. aftercare. Pathologic fractures are reported using subcategory 733.1, when the fracture is newly diagnosed. Subcategory 733.1 may be used while the patient is receiving active treatment for the fracture. examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. Aftercare codes are in the V54 series.
• StatusCodes
• there are a number of important codes that describe a patient’s status which are often overlooked in documentation and coding. Physicians know the patient has these conditions, but because they are often long-standing, annual documentation is omitted. Common status conditions include:
¤ Gastrostomy, ileostomy, tracheostomy or colostomy status (V44.X)
¤ Cystostomy or nephrostomy status (V44.X)
¤ Renal dialysis status (V45.1)
¤ lower limb amputation status, including toes (V49.7X)
¤ long term use of medications (V58.6X)
¤ Wheelchair dependence (V46.3); describe and code the reason the patient is wheelchair dependent first
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• Vascular
• peripheral vascular disease (pvd). PVD is relatively common in elderly patients, especially where it may be a manifestation of diabetes. When PVD is documented as due to diabetes, code the diabetic code first (250.70) and then the PVD (443.81).
• atherosclerosis. Aortic atherosclerosis and peripheral atherosclerosis are chronic conditions that should be assessed, documented and coded each year. these conditions may have been identified through findings on a radiology procedure, but must be assessed by the treating physician. to code these conditions, the diagnosis must be stated in the progress note. they cannot be coded from the radiology report. According to Coding Clinic, the term “aortic atherosclerosis” is inadequate for coding because it isn’t clear if it is the vessel or the valve. Your wording should make it clear which is ivolved.
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Chapter 3. AvoidinG ERRoRS in doCuMEntAtion
over the past 5 years, CMS has audited thousands of MA members’ charts. the results have been both alarming and encouraging. Alarming because the error rate remains high, Risk Adjustment data validation (RAdv) studies (audits) have increased in scope, and the potential effect on both MA organizations and providers. CMS has published a final rule on RAdv, and overpayments will be extrapolated across a health plan’s network.
However, it should encourage physicians to know that a small handful of errors in documentation make up the vast majority of coding errors. Better yet, these errors are easily corrected, once physicians understand the underlying iCd-9 coding rules.
First and foremost, physicians must understand that the iCd-9 and clinical medicine have little in common. Second, physicians must distance themselves from their clinical knowledge, both in general and specifically, about the patient at hand. the iCd-9 doesn’t allow assumption, and relies solely on what’s written in the progress note1. this is the point at which the iCd-9 begins to make no sense to the practicing physician, who often writes a note, and then chooses a code reflecting what’s wrong with the patient, not what they’ve documented in the medical record. the physician may document signs, symptoms, and historical data, and fail to record a diagnosis. then, knowing what’s wrong with the patient, they may choose a diagnosis on a superbill—without it having been recorded in the progress note.
So, what are the most common mistakes made, and more importantly, what can physicians do to support their diagnosis code selections?
problem: Choosing a code that looks right, without knowing the rules for using that code.
example: Coronary atherosclerosis of unspecified type of vessel, native or graft (414.00).
Solution: understand the rules for use of commonly used codes in your practice. to use code 414.00, you must state that the patient has had a CABG, but fail to state whether a native or non-native vessel is affected. if your note simply says “coronary atherosclerosis” or “ASHd”, and does not reference a previous CABG, then the correct code is 414.01.
1 Coding rules don’t allow choosing a code based on lab or radiology reports, unless the physician references them in the body of the progress note. Further, such references must be specific—noting that the result is abnormal or writing a lab value doesn’t support iCd-9 selection.
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problem: trying to use iCd-9 titles to support a code selection, or simply writing the iCd-9 code in the medical record.
example: diabetes with renal manifestations (250.40).
Solution: document both diseases in a brief narrative. For example, if the patient has Stage 3 CKd due to diabetes mellitus, then your note should reflect that.
problem: Writing only a diagnosis code in the chart.
example: impression: 250.40.
Solution: Since coding is derived from a narrative description of the disease state, writing 250.40 in the chart cannot be coded. documentation should clearly reflect the condition of the patient. in this case, a notation such as: end stage renal disease secondary to dM clearly describes the condition.
problem: documenting and coding CvA in the office setting. A CvA is an acute event. once the patient is discharged from the hospital or rehabilitation setting, the diagnosis of acute CvA is inaccurate and leads to miscoding.
example: Each time a status post CvA patient is evaluated, the physician documents “CvA” in the record and codes 434.91 (CvA, ischemic or unspecified).
Solution: document that the patient is status post CvA or has a history of CvA (v12.54). What is often overlooked are the sequelae of CvA, since they have often been present for many years. When assessing the patient, it’s important to document and code these as well. there are iCd-9 codes for all of the common and pertinent sequelae of CvA in the 438.XX series of iCd-9.
problem: documenting acute, severe, past illnesses as if they were current conditions.
example: diseases like sepsis, unstable angina, and acute respiratory failure that the patient was hospitalized for previously.
Solution: document these conditions as a “history of” and do not code the previous conditions.
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problem: Malignancy coded when the correct coding would be personal history of malignancy of ___________. in the case of malignancies, the iCd-9 again differs from current clinical thinking. the iCd-9 allows coding of the malignancy until definitive treatment is finished (unless there are signs of active disease). definitive treatment is that aimed at eradicating the cancer, such as surgery, chemotherapy and/or radiation therapy. Patients with biopsy proven malignancies who are not treated continue to be coded with the diagnosis of cancer.
example: Patient who is status post pneumonectomy for lung cancer 5 years ago. the patient is on no therapy, but surveillance is continued for the patient’s lifetime.
Solution: document and code personal history of the cancer. these codes are found in the v10.XX series of the iCd-9.
problem: documentation of multiple primary sites of malignancies when the patient has metastatic disease.
example: Patient has primary breast cancer which has metastasized to the brain.
Solution: if the patient is being assessed or treated for both, then coding for the breast cancer would be in the 174.X (depending on area of the breast) and 198.3, secondary neoplasm of brain or spinal cord.
problem: not restating and coding long standing disease. the iCd-9 and the CMS HCC risk adjustment model have no inherent memory. A disease only exists at the time it is assessed, documented and coded. All chronic diseases disappear from the risk adjustment model each year, and must be resubmitted.
example: A patient who is 10 years status post colon resection for carcinoma, with colostomy.
Solution: When your attention is directed to the illness, or in this case the site (assessing skin integrity or signs and symptoms of a recurrence of the cancer) it is appropriate and important to document and code these conditions. there are codes for artificial openings (tracheostomy, colostomy, ileostomy, etc.) in the v44.X series.
problem: “History of” means the disease is in the past. You cannot code an active disease you have documented as a “history of.”
example: History of CHF.
Solution: Remember to use the term “history of” only for diseases which have resolved. in the case of chronic conditions like CHF and atrial fibrillation, use terms like compensated or controlled to reflect their ongoing status.
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problem: using a general term to support a specific disease.
example: depression
Solution: the term depression is very general, and could mean anything from a mild, transient condition to major depression with suicidal ideation. the iCd-9 codes for depression are very specific, and require you to fully describe the patient’s depression. in the case of major depressive disorder, the iCd-9 requires that you indicate if this is a single episode, or recurrent episode of depression. describing the depression fully allows you to choose the code that correctly describes your patient’s condition.
Although there are thousands of rules in the iCd-9 coding system, following a few simple changes in documentation will help you accurately document and code your patient’s illnesses.
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Chapter 4. RiSk AdjuStMent dAtA VAlidAtion (RAdV)
CMS has instituted the RAdV process in order to ensure payment integrity and accuracy of the Medicare Advantage CMS-HCC payment model. As the CMS-HCC model is predictive of care delivery costs, and the members’ diagnoses drive monetary reimbursement to plans and onward to groups and physicians, it is necessary to validate that these diagnoses are appropriately documented in medical records, demonstrating care delivery and treatment.
the CMS RAdV process results in revenue adjustments based on whether the medical records submitted support paid HCCs or not. the process occurs after the final data submission deadline for a given calendar year. Beginning with the 2007 Calendar Year Plan level RAdV, based on 2006 dates of service, CMS has determined that validation error rates will result in statistically extrapolated revenue adjustments impacting a plan’s entire membership.
there are six stages in the RAdV process, which are outlined in the instructions sent to selected health plans. the process may change over time, as CMS gains more experience with the RAdV process.
1. Sampling and Medical record request: in this stage, CMS or its vendor selects contracted Medicare Advantage organizations (MAos) to be included in the process and subsequently selects the members for which medical records will be requested. CMS’ sampling methodology may be random or targeted. the latter method may be based upon prior RAdV error rates or HCC prevalence rates compared to other MAos or specific contract types. the CY 2007 CMS-RAdV plan level sample was based upon the MA Coding intensity Study, which analyzed differences in risk score changes between MA and Medicare Fee for Service.
next, CMS or its vendor provides the MAo with member and paid HCC lists and asks the MAo to select the “one best medical record” to support each paid HCC. the MAo collects medical records from groups and providers, reviews these records to identify the “one best record”, and submits the record for each paid HCC. lastly, the MAo reconciles to receipt reports to ensure that submitted records are noted as received. Records submitted must fulfill all CMS-HCC model requirements, including qualified provider type and specialty, a face to face visit, within the appropriate dates of service, and coded according to iCd-9-CM official Guidelines. the CY 2007 RAdV allotted 12 weeks for MAos to submit the records.
2. Medical record review: CMS uses Medical Record Review Contractors (MRRCs) who employ certified coders to perform medical record review. CMS’ initial Validation
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Contractor (iVC) vendor reviews the submitted records and identifies risk adjustment discrepancies where the submitted record does not match the paid HCC for a member. All discrepancies undergo second review by the CMS Second Validation Contractor (SVC). Coders review records based on record type (inpatient, outpatient, or physician) and the relevant iCd-9-CM official Guidelines for each record type.
3. Documentation Dispute: the documentation dispute process will apply only to the errors that arise out of operational processing of medical records selected for RAdV audit and submitted to CMS by established deadlines. For example, if an MAo submits a two-page medical record that inadvertently becomes separated into “two” medical records upon receipt by the CMS Medical Record Review Contractor, CMS would permit the MAo to resubmit the two-page medical record so that the record can be reviewed in its intended two-page format. Another example of an error relating to logistical/operational processing would be technical failures that led to missed/or obliterated pages.
4. Contract Level Findings and payment adjustments: CMS shares medical record review findings, risk adjustment discrepancies, payment adjustment amounts and adjustment timeframe with the MAo.
5. post Documentation Dispute payment adjustments: CMS recalculates payment error rates based upon outcomes from documentation dispute findings and provides this information to MAos.
6. appeals: CMS has not fully defined this stage of the RAdV process, but has stated that Appeals will be facilitated by the CMS office of Hearings. the appeals process will be more fully described by CMS at a later date.
to be prepared to fully support the RAdV process, consider the following checklist:
✓ RADVpreparation
• ensure that your data systems appropriately track claims and encounter data at the diagnoses and provider level and that reporting is readily available.
• ensure your enrollment information is up-to-date.
• Provide and keep updated RAdV point of contact information
¤ to the MAos that your group contracts with
¤ to the physicians that your group contracts with.
• ensure that your contact information for physicians, hospitals and other facilities is up-to-date to be able to send out notifications
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in advance of the start of a RAdV and to make sure record collection processes are efficient.
• if your coding chart audit process includes receipt of image files, create indexing and storage processes for these files for future RAdV efforts.
• Build your processes to be HiPAA compliant, limiting health information disclosure to the minimum necessary persons and entities.
✓ Buildappropriateeducationprograms
• educate physicians on the technical components required on each visit note: member name, member identifier such as date of birth, clinician signature and credentials, and date of visit.
• educate physicians on documentation requirements that support diagnoses submitted.
• educate billers and coders on the CMS-HCC model and the RAdV process. Audit their work for accuracy in data submission of claims and encounters.
✓ EvaluateyourElectronicHealthRecord(EHR)systemfordocumentationcomplianceandprinting
• Review eHR system to ensure that its signature format is within standards published by CMS in the Risk Adjustment data technical Assistance Participant Guide.
• Check that your eHR is submitting valid and accurate diagnoses via the Practice Management module that generates claims. do not submit diagnoses on the historical problem lists that are not related to the current date of service.
• ensure that your eHR is able to readily print records for a given member for a full calendar year period.
✓ ConductongoingmockorindependentRADVstoevaluateaccuracybyclinician,andeducatebaseduponoutcomes
• Resource and/or identify your internal RAdV team to support record pursuit.
• Build appropriate systems to make your efforts efficient.
• Create a transparent RAdV calendar that your team can adhere to.
• develop and use coversheets that quickly identify the member, date of service, and clinician or facility contained in a record submission.
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• Create processes to carry out RAdV that include quality assurance.
✓ NetworkManagement
• Consider incentive plans that reward physicians whose documentation appropriately supports diagnoses submitted.
• ensure your contract language supports medical record collection efforts.
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Chapter 5. EMR WHitE PAPER: A PRiMER foR tHE PRACtiCAl-MindEd CliniCiAn
this chapter is a reprint of the White Paper presented at SCAn’s EMR EHR Conference on october 24, 2009. this information may be useful to you if you are planning to implement an EMR.
IntroduCtIon
the “primer” is an old-fashioned concept, a book that covers the basic elements of a subject. Here, then, is a brief primer on EMRs because, for all the literature and discussion of EMRs, surprisingly few start with the very basics, like what are they, what should they do, and which one should i buy (and when).
the subject of EMRs merits an old-fashioned approach simply because there is so much being said about them, many assertions, and many promises. Among what is being said, it may be difficult to sort out the practical first steps, practical to achieve amidst the day-to-day challenges of caring for patients and sustaining an office to continue caring for those patients. first and next steps; these are the objectives of this paper and, if useful, more will follow.
this White Paper is not intended to be a whole book, but it is intended for clinicians and their staff as busy professionals who don’t have time to read a whole book, but do need to know the basic facts about EMRs, their current importance and practical utility.
how thIs prImer works
objeCtIves:
• establish basic Information
• offer practical recommendations
the Primer establishes basic information and offer recommendations on where each reader might build from that base. Some information here will be too elementary for some readers, so it should be used accordingly, skimming the easy to prepare for the harder. Each section will have one or more key points highlighted as bullets, so it can also be read in sections or referred to by section. don’t print or copy it all. only use those sections that capture your attention or apply to some issue or problem you are focused on today. other parts you can return to tomorrow as needed, since it will be available at all times in its entirety on your SCAn website. As with any “advice from a distance” always make sure it makes sense for your needs and requirements.
the very, very basICs
for those who find themselves somewhat bewildered by all the EMR discussions these days, welcome to a very, very large club. let’s start with just the term itself. despite all the well-informed and knowledgeable resources on the subject, there is even still a lot of inconsistent use of words, descriptions, and terms. Remember, for most, this is a whole new area and it will take time for even the vocabulary to settle in. Meanwhile, some of the most basic terms remain sources of vigorous debate among experts, so one needn’t worry about finding the territory a bit uncertain to navigate. nobody has all the answers; nobody knows everything they need to know. if you’re feeling uncertain, that is entirely appropriate. All of us are figuring this one at the same time.
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if the reader is not among the “somewhat bewildered” or the “uncertain”, though, reviewing key areas of this paper will also work to serve very well nonetheless for two reasons: 1) the EMR landscape is changing rapidly and 2) many people have not looked at EMRs from the point of view of basic business records and medical records fundamentals which, unfortunately, can be a source of substantial potential problems, implementation failures, and possibly even patient harm or legal risk; “trust, but verify”.
terms
Consider first the terms EMR (Electronic Medical Records) and EHR (Electronic Health Records). Even these get used in different and irregular ways. for the purposes of this primer, we’ll refer to all as EMRs, as electronic replacements of your practice’s clinical record. Even in settings where formal EMR standards are being developed, the use of a key term can be inconsistent and confusing. there was one authoritative attempt to settle the “What is an EMR vs. an EHR” discussion, also not entirely accepted1. this all naturally results from the fact that we’re far from fully adapted to these new tools and capabilities. More specifically, here an EMR will be considered a compilation of hardware and software systems that, at the minimum, support computerized capabilities2 to:
1. Create, maintain, and manage patient care records that include:
a. All patient care and pertinent records created by the practice itself (including prescriptions)
b. Pertinent records created elsewhere (including test reports, consults, discharge summaries, etc.) that are commonly and routinely used in the clinicians’ medical decision making.
2. Exchange important business operations information with a Practice Management (PM) system
a. Coding assistance and capture
b. Patient demographics consistency
3. Provide basic intra-office messaging, task and event management function, for secure, PHi-appropriate communications for information exchange that may or may not be individual patient-specific.
4. Provide commonly used and key required outputs that include:
a. Patient summaries configurable to the practice’s needs (e.g., an easily accessible view that summarizes a patient’s active and past problems, past pertinent histories, medications, and allergies. Especially handy are indicators of gaps in the patient’s care and the practice’s quality guidelines.)
1 Garets, dave, and davis, Mike, Electronic Medical Records vs. Electronic Health Records: Yes, there is a difference A HiMSS Analytics White Paper http://www.himssanalytics.org/docs/wp_emr_ehr.pdf
2 note: it is important to note that just because a computerized system has a particular capability doesn’t require that it is used for all tasks. for example, an EMR must have a way to capture images of paper documents. However, all paper documents need not be in the EMR. A 5 year old discharge summary doesn’t necessarily have to be in the EMR, but key points from it might be entered into a patient record, with a notation that the original is kept elsewhere, maybe even in its original paper form.
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b. Properly detailed and configured encounter notes on demand, electronic or print formats, including appropriate level of associated integrity authentication data.
c. frequently used clinical communications outputs (e.g., patient summaries, consult requests or consult reports, and, for those contemplating federal incentives programs, Care Quality data exports).
d. HiPAA Security Audit Reports, Release of Records outputs.
Any EMR project is very likely to have a longer list than this one, but it is recommended that all lists include these. indeed, while this may seem a comparatively short list, these are actually very complex functions and include the fundamentals that every system must do to provide a proper platform for thereafter adding more complex functions. if a system cannot properly create and maintain a valid, trustworthy, and user-friendly encounter note, then all the whistles and bells are like putting chrome on a car with no wheels. Unfortunately, the current EMR marketplace has some that are heavily chrome-plated but with suspect and missing wheels. We’ll return to this point shortly.
FIgure 1: FunCtIon-orIented emr deFInItIon wIth outlIne oF the mInImum neCessary FunCtIonal requIrements For an emr system.
Support computerized capabilities3 to:
1. Create, maintain, and manage patient care records that include:
a. All patient care and pertinent records created by the practice itself (including prescriptions)
b. Pertinent records created elsewhere (including test reports, consults, discharge summaries, etc.) that are commonly and routinely used in the clinicians’ medical decision making.
2. Exchange important business operations information with a Practice Management (PM) system
a. Coding assistance and capture
b. Patient demographics consistency
3. Provide basic intra-office, intra-system messaging, task and event management function, for secure, PHi-appropriate communications for information exchanges that may or may not be individual patient-specific.
4. Provide commonly used and key required outputs that include:
a. Patient summaries configurable to the practice’s needs (e.g., an easily accessible view that summarizes a patient’s active and past problems,
3 note: it is important to note that just because a computerized system has a particular capability doesn’t require that it is used for all tasks. for example, an EMR must have a way to capture images of paper documents. However, all paper documents need not be in the EMR. A 5 year old discharge summary doesn’t necessarily have to be in the EMR, but key points from it might be entered into a patient record, with a notation that the original is kept elsewhere, maybe even in its original paper form.
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past pertinent histories, medications, and allergies. Especially handy are indicators of gaps in the patient’s care and the practice’s quality guidelines.)
b. Properly detailed and configured encounter notes on demand, electronic or print formats.
c. frequently used clinical communications outputs (e.g., patient summaries, consult requests or consult reports, and, for those contemplating federal incentives programs, Care Quality data exports).
d. HiPAA Security Audit Reports, Release of Records outputs.
welCome to the world oF dIgItal ClInICal reCords
objeCtIves:
• understanding that emrs are not yet “plug and play”
• how (and when) to move Forward
the world of EMRs is truly a diverse one, with so many different EMRs using different technologies, approaches, and widely varying costs. the EMR marketplace is still young, with a lot of competing products out there. furthermore, despite the availability of technical and functional standards, it will take a while yet before these standards are incorporated into actual EMR designs. for now, then, EMRs are not yet standardized and probably won’t be for, in this author’s opinion, another 3–10 years. EMR certification helps narrow the pack some; but, at least as of late 2009 and into mid-2010, certification still doesn’t cover key requirements that every doctor must have, like the ability to create, maintain, and manage records according to known requirements for records and electronic records in general, and for medical records in particular.4 Even those systems that have the capability of creating a proper record can be installed or inadvertently used in a way that is problematic and risky, which is a key reason why this primer will be of use—to help steer clear of such pitfalls as you navigate this diverse world.
Although their origins are quite recent, EMRs cannot be called “new” in information technology terms. EMRs have been around for over 30 years, most commonly in Western Europe and, in the US, in large academic and governmental institutions. these have tended to be very large systems where everyone uses the same function the same way, with minimal customization or flexibility. in the US, though, we’ve generally decided we aren’t yet ready for one big national health care system; we like the idea of variety and choice. Since we want variety and choice, we need variety and choice in EMRs. Achieving this is much more difficult than building one big system and telling everyone they have to use it. to have lots of different, smaller and more flexible systems, we had to wait
4 two examples: Current Certification, using 2009 CCHit requirements, will, after long delay, include a basic requirement for all records management-retention of the original version of an amended or corrected record. few would consider modifying a finalized version of a medical record, but that is permitted under CCHit requirements through 2008 and until a product is Certified against 2009 requirements. Accurate assignment of authorship in display, electronic or printed versions of a multi-author record is not currently required but is roadmapped for the future. Both of these are long-standing requirements for all legal business records types, including medical records, for admissibility purposes.
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until the cost of computing power and software development fell far enough to become affordable to the many different types and sizes of medical practices.
think about the computer you were using ten years ago and the one you’re using today. these changes have been nothing short of incredible. Similarly, an EMR that might cost $10,000 today would have cost $10,000,000 ten years ago, and their costs will continue to fall and their sophistication rise.
Again, for now there is a huge amount of variation in EMRs. they range from old, reputable, and expensive, to newer, less expensive and shorter track record. Some are installed in computers in the purchaser’s office, others are accessed over the internet, and some involve a mixture of both. for the purpose of the busy medical office, though, the most important attribute is not the technology but the usability; a fancy system that nobody understands can be worse than no EMR at all. Reportedly, up to one third of EMR implementations fall short of goals or fail completely, but well-planned and supported implementations fail much less5. this is testimony to the importance of making sure the acquired system works and meets the actual daily and practical needs of the staff. Being able to create visually attractive color graphs of a patient’s blood pressures over time may be impressive, but taking 10 clicks to find the most recent lab test, which used to always be on top of the lab section of the paper chart, will quickly kill enthusiasm for the system.
inevitably, as EMRs are becoming more affordable, they will become more common; which, in turn, will speed their improvement to becoming safe and reliable. Unfortunately, part of that process will be doctors, nurses, and other clinicians finding out that their records, when challenged, won’t hold up. Such events will appear in the press and in the legal system, with the unwary innocent caught in the process as well. Again, that is why this Primer focuses on the very basic functions required for a reliable EMR; to make sure that the reader can make an informed and educated decision among the many products available. the system chosen must meet basic functional requirements and it must be used correctly as a record system. Until EMRs comply with EMR standards, it will remain the purchasers’ and users’ choice and duty to make sure what they’re buying will meet their clinical needs and their business and medical records requirements. for now, if you have seen one EMR, you have seen just one EMR. Every single one has significant differences from the next one. furthermore, any given EMR can be installed in so many different ways that the same system in one place can be set up very different in another.
Is It tIme to move Into the world oF dIgItal ClInICal reCords?
Simply, yes, it is time to plan that move. there is one circumstance, though, where you should necessarily plan on selecting, implementing, and using one within the next 9–12 months and that is if you are starting a new practice “from scratch”. for existing organizations, the practice assessment and planning phases are 5 Goroll, Allan H., Md, Simon, Steven R., Md, MPH, tripathi,
Micky, MPP, Ascenzo, Carl, BS, Bates, david, Md, MSc, “Community-wide implementation of Health information technology: the Massachusetts eHealth Collaborative Experience” in Journal of the American Medical informatics Association (JAMiA), Vol. 16, no. 1, Jan/feb 2009, pp. 132–139. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605598/pdf/132.S1067502708001850.main.pdf
34 | A Guide to Risk Adjustment and the CMS-HCC Model
absolutely necessary to minimize the disruption and productivity losses for patient care. there are so many differences among EMRs, and since nobody is protecting you against a choice that doesn’t work out, how (and when) to select EMR is critical. the most important “when” is when there is understanding of, in a given specific practice, what functions are needed to improve patient care, solve real problems, and improve your practice’s operations sufficient to justify the monetary and “headache” costs.
Conversely, unless an office is planning to cease operations in 5 years or less, do begin today evaluating and planning; because, while still small, the body of knowledge on care quality improvement with EMRs is growing. in that cause alone implementing an EMR in time is both operationally sound and a professional duty, but again only in due course with a plan, knowing what problems the EMR is intended to solve and what improvements it is intended to support. Again, unless the situation is a brand new practice, the planning and requirements assessment process will take at least 6–12 months. during that time EMRs will only improve further, making it a win-win all around.
that is the other main purpose for this series of essays, to outline the simple steps to take to identify what you need from any EMR you might buy, and then make sure that’s what you get. Currently there is no entity enforcing minimum standards6 for all EMRs, so it is up to you to make sure that those standards that do apply to you, like business records and medical records requirements, are met by whatever system you have or choose.
why all the push For emrs now?
objectives:
• understand why the us government is pressing you now
• maintaining Focus on Improving patient Care and Improving practice operations
for a practice already busy seeing patients, a new cost and complication like an EMR nonetheless makes good sense if it helps improves patient care, improves office operations, or both. Right now relatively few medical practices are using EMRs and there are many reasons for that. Before addressing those reasons, though, let’s look at the “big picture” reasons why the federal Government is now pushing them forward so hard, first with a carrot (paying incentives to help cover the costs) then later with a stick (eventually cutting payments to those without EMRs). What’s the hurry?
the push From washIngton dC and saCramento: the bIg pICture
federal and State Governments are hurrying EMRs along in the hope that they’ll help cut health care costs. those costs are enormous and expected to grow even more unless something changes soon and of those enormous costs, half are paid by federal and State governments. for States, health care is tied with education for the number one spot on their costs. the problem isn’t just that we’re just paying a lot of money for health care, it’s also two more factors:
6 Comment: it is accurate to say that there are no minimum requirements for an EMR. there are minimum requirements to receive subsidy funding; but, if a given EMR doesn’t meet them, it doesn’t mean you cannot use it, it only means you don’t get the subsidies or the other incentives.
A Guide to Risk Adjustment and the CMS-HCC Model | 35
We pay two to three times more compared to other countries; but, we get either only slightly better or worse results7.
Cha
rt I
I-1
Hea
lth
Car
e S
pend
ing
per
Cap
ita
in 2
00
4A
djus
ted
for
Dif
fere
nces
in C
ost
of L
ivin
g
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000 $0
Uni
ted
Stat
esC
anad
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ance
Ger
man
yaA
ustr
alia
aO
ECD
M
edia
nU
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d K
ingd
omJa
pana
New
Ze
alan
dN
ethe
rland
s
this trend, rising costs and shrinking results, with widening performance gaps compared to other countries, means that we’re becoming uncompetitive as a country. furthermore, it isn’t just the absolute dollar cost, it is also what economists refer to as “opportunity Cost”, the fact that a dollar spent on health care also loses the opportunity to spend it on, say, education or improved mass transit systems or to leave those dollars in the pockets of individuals to save or spend as they want.
7 Cylus, Jonathan, and Anderson, Gerald f., Multinational Comparisons of Health Systems data 2006, Johns Hopkins University, May 2007, p. 14. http://www.commonwealthfund.org/~/media/files/Publications/Chartbook/2007/May/Multinational%20Comparisons%20of%20Health%20Systems%20data%20%202006/Cylus_multinationalcomparisonshltsysdata2006_chartbook_972%20pdf.pdf
36 | A Guide to Risk Adjustment and the CMS-HCC Model
the people of the United States, including all the people who work in the health care industry, need for that industry to improve; because, while some parts are going great, others are doing very poorly. Some parts are very efficient, and some are not only inefficient, but dangerous, with thousands injured or dead yearly because of mistakes. Add up all the problems and the result is that we the people are not getting our money’s worth from our collective dollars and so we spend more than necessary to get enough. Money we spend on health care isn’t getting spent on building more modern factories, improving schools, or repairing roads, so then our factories become obsolete, our schools don’t keep up, and our roads and bridges fall apart. So we need to do better, but how do we define “better”? We define “better” with information, where we measure what we are doing, and we compare that with what we’ve decided is “better”, and try different ways of doing. Which ever way gets us results that are “better”, that is the “better” way. to do that, though, requires better information.
there is some general evidence that information technology can improve care and improve clinical operations. However, it’s not like a straightforward change, such as it takes an hour to get to work, but when “technology” is applied (like a bicycle), then it only takes 10 minutes. Even in such a simple case, there can be complexities and complications. What if you’ve never ridden a bicycle? What if your walking route is over rough, rocky ground and the bike route is twice or three times as long? What if the bike doesn’t work right and the nearest repair shop is 10 miles distant?
onCe you know what you need then just add teChnology?
Unfortunately, there is just no thing as “just add technology”, because technology alone won’t give the desired improvements, just as an EMR, to be a success, should and must be much more than a computerized substitute for your paper chart. furthermore, what you end up calling your EMR is more likely to be several different systems that all operate together. this isn’t significantly different from having several “systems” on your home computer; one for email, another for word processing, yet another for downloading pictures from your digital camera, with the ability to send information from any of these to another device, like a printer.
Some readers will be old enough to remember a time not long ago when getting your printer to work with your computer could be difficult, and some software didn’t work well with others. in a way, this is not unlike the state of EMRs today; there are lots of components and lots of programs, and one isn’t necessarily compatible with another. for example, you may have an electronic practice management (PM) system that you use already, and you want to add an EMR. not every EMR will work well with your PM system and even a PM system that works with one particular EMR may not completely work with it. Your PM system may be able to receive information (unidirectional interface or integration) from your EMR, but not also send information back to it (bidirectional). these matters are best sorted out in the planning stages or they can become a major cause of future headaches as we will later see. if you have other systems you rely on already, like laboratory test order entry and results retrieval, these also may or may not work with a given EMR and may cost substantially more to install and to maintain.
A Guide to Risk Adjustment and the CMS-HCC Model | 37
plannIng the FIrst small steps
three attributes recur in evaluation of successful EMR implementations: Planning, Champions, and Support from leadership. there are a number of good tools available8 for planning EMR implementations and assistance identifying goals and objectives that will help inventory how an EMR will support improvements in your practice. Remember, it’s these improvements that must be understood and measured to judge whether you should move to implement sooner or later, but in all cases now is the time to begin the planning.
this, then, brings us to the first tasks as you consider migrating to an EMR:
• identify who is going to be in the EMR Readiness Group that will plan the first steps.
• then, begin to collect information on two basic questions:
question 1: What computerized or computer-installed functions do you and your office staff use now? (You may use a lot more than you first think.)
Examples:
• Practice Management software for patient appointments, electronic billing
• dictation/transcription
• Voice recognition
• laboratory services ordering and/or results retrieval
• Electronic communications (such as email, electronic reminder phone calls, etc.)
• Electronic charge capture for hospital rounds
• Electronic prescribing
• Registries
When you add an EMR to your practice, it works best when all electronic functions are connected and it works worst when none are connected, so you end up entering the same information (like a prescription) into more than one system.
question 2: two parts: What practice or clinical-care issues is the EMR intended to address and how will you identify (measure) improvements to know you’ve been successful?
these first steps will be built upon in the months ahead. for the purposes of this first paper, though, we’ll conclude with reading assignments, in preparation for our next one, on practical steps for making sure your EMR meets all your medical records system needs.
readIng lIst (all avaIlable Free)
5. AHiMA e-HiM Work Group on Maintaining the legal EHR. “Update: Maintaining a legally Sound Health Record—Paper and Electronic.” Journal of AHiMA 76, no.10 (november-december 2005): 64A-l. Available on the AHiMA website by search or the direct link below: http://
8 Each State’s Quality improvement organization built a library of EMR implementation tools under the doctor’s office Quality-information technology (doQ-it) Program ending early 2009. these have been developed and improved in the course of actual EMR implementations.
38 | A Guide to Risk Adjustment and the CMS-HCC Model
library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?ddocname=bok1_028509
6. for general rules on required documentation content, see CMS’s 1995 or 1997 documentation Guidelines for Evaluation and Management Services: http://www.cms.hhs.gov/MlnEdwebGuide/25_EMdoC.asp
7. See the october, 2009 Presentations from the SCAn EMR EHR Education Seminar, available to you on the SCAn website:
a. Achieving Meaningful Use of EHRs by dr. Paul tang
b. EHR documentation Pitfalls by dr. Reed Gelzer
bIblIography
Cylus, Jonathan, and Anderson, Gerald f., Multinational Comparisons of Health Systems data 2006, Johns Hopkins University, May 2007, p. 14 http://www.commonwealthfund.org/~/media/files/Publications/Chartbook/2007/May/Multinational%20Comparisons%20of%20Health%20Systems%20data%20%202006/Cylus_multinationalcomparisonshltsysdata2006_chartbook_972%20pdf.pdf
Garets, dave, and davis, Mike, Electronic Medical Records vs. Electronic Health Records: Yes, there is a difference A HiMSS Analytics White Paper. http://www.himssanalytics.org/docs/wp_emr_ehr.pdf
Goroll, Allan H., Md, Simon, Steven R., Md, MPH, tripathi, Micky, MPP, Ascenzo, Carl, BS, Bates, david, Md, MSc, “Community-wide implementation of Health information technology: the Massachusetts eHealth Collaborative Experience”, in Journal of the American Medical informatics Association (JAMiA), Vol. 16, no. 1, Jan/feb 2009, pp. 132–139. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605598/pdf/132.S1067502708001850.main.pdf
trites, Patricia A. and Gelzer, Reed d., How to Evaluate Electronic Health Record (EHR) Systems, AHiMA, 2008.
A Guide to Risk Adjustment and the CMS-HCC Model | 39
Chapter 6. DiAGnoStiC AnD CoDinG CRiteRiA of CoMMon GeRiAtRiC ConDitionS
this chapter is a dictionary of the most common diagnoses utilized in the practice of medicine for SCAn seniors in Southern California. every diagnosis has the necessary iCD-9 coding criteria as well as validated diagnosis criteria.
this chapter is not definitive nor is it meant to replace any of the valuable reference texts available for physicians. the purpose is to provide a quick but accurate guide for the practicing physician to assist in the accuracy of making a diagnosis and the use of specific iCD-9 codes.
40 | A Guide to Risk Adjustment and the CMS-HCC Model
Diagnoses in Alphabetical O
rder
Cover & Tabs.indd 3 6/7/12 12:35 PM
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42
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43
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find
ings
44
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, URI
, or v
iral r
espi
rato
ry in
fect
ion.
Nons
pecifi
c acu
te vi
ral i
nfec
tion
of u
pper
repi
rato
ry tra
ct,
invo
lving
nos
e and
thro
at ch
arac
teriz
ed b
y run
ny n
ose,
sore
th
roat
, hea
dach
e and
ill-f
eelin
g, d
iagn
osed
clin
ically
acut
e, il
l De
fine
D ce
reBr
oVas
cula
r Di
seas
e43
696
Ische
mic
or
Unsp
ecifi
ed S
troke
Use o
nly w
hen
unsp
ecifi
ed ce
rebr
ovas
cula
r dise
ase i
s doc
umen
ted.
Cod
ing
Clin
ic co
mm
ents
indi
cate
this
code
shou
ld ra
rely
be u
sed.
It is
not
the
corre
ct co
de fo
r CVA
. The
corre
ct se
ries o
f cod
es fo
r CVA
s is 4
34.1
X.
Unsp
ecifi
ed a
cute
cere
brov
ascu
lar d
iseas
e oth
er th
an C
VA
alle
rGic
rHi
niti
s no
s47
7.9
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
llerg
ic rh
initi
s, Bo
stoc
k’s
dise
ase,
febr
is ae
stiva
, hay
feve
r, al
lergi
c rhi
nitis
, vas
omot
or
rhin
itis,
paro
xysm
al rh
inor
rhea
, or s
pasm
odic
rhin
orrh
ea.
Nons
pecifi
c alle
rgic
infla
mm
ation
of n
ose,
leadi
ng to
snee
zing,
cong
estio
n,
a ru
nny/i
tchy
nos
e, di
agno
sed
clini
cally
and
/or b
y rhi
nosc
ope
alte
reD
men
tal
stat
us78
0.97
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s alte
red
men
tal
stat
us, a
ltera
tion
of m
enta
l sta
tus o
r cha
nges
in m
enta
l sta
tus.
A los
s or d
ecre
ase i
n th
e lev
el of
awa
rene
ss of
self
and
envir
onm
ent
com
bine
d wi
th m
arke
dly r
educ
ed re
spon
siven
ess t
o env
ironm
enta
l stim
uli
alZH
eim
er’s
Dis
ease
331.
0Us
e whe
n do
cum
enta
tion
indi
cate
s Alzh
eimer
’s di
seas
e, at
roph
ic
brai
n de
gene
ratio
n, or
Alzh
eimer
’s typ
e dem
entia
.De
men
tia ch
arac
teriz
ed b
y im
pairm
ent i
n m
emor
y, th
inkin
g an
d be
havio
r, di
agno
sed
clini
cally
and
by m
ini-m
enta
l sta
te ex
amin
ation
0 m
inim
um co
g
anem
ia in
cHr
onic
KiD
neY
Dise
ase
285.
21Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t has
an
emia
of ch
roni
c kid
ney d
iseas
e, or
ESR
D or
EPO
resis
tant
ane
mia
. The
un
derly
ing
chro
nic c
ondi
tion
(e.g
., ES
RD 5
85.6
) sho
uld
also
be c
oded
.
Anem
ia in
chro
nic k
idne
y dise
ase
45
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
anem
ia n
os28
5.9
Used
whe
n th
e doc
umen
tatio
n sa
ys a
nem
ia, e
rythr
ocyto
peni
a or
low
hem
atoc
rit.
Nons
pecifi
c Low
RBC
leve
l (Hg
b <
16 fo
r men
; Hgb
<
14 fo
r wom
en),
diag
nose
d by
labo
rato
ry va
lues
anGi
na p
ecto
ris
nec/
nos
413.
983
Angi
na P
ecto
ris/
Old
Myo
card
ial
Infa
rctio
n
Use w
hen
docu
men
tatio
n sa
ys a
ngin
a, a
ngin
a pe
ctor
is,
Hebe
rden
s syn
drom
e, Lik
off’s
synd
rom
e, Sc
hauf
enst
er kr
ankh
eit,
angi
nosu
s, st
enoc
ardi
a, st
erna
lgia
, or s
tabl
e ang
ina.
Nons
pecifi
c atyp
ical c
ardi
ac ch
est p
ain,
dia
gnos
ed cl
inica
lly
anXi
etY
stat
e no
s30
0.00
Use w
hen
docu
men
tatio
n sa
ys a
nxiet
y, ne
uros
is, n
euro
tic st
ate,
abno
rmal
ap
preh
ensio
n, a
ppre
hens
ivene
ss, p
sych
ogen
ic an
xiety,
anx
iety s
tate
, ps
ycho
neur
otic
anxie
ty, a
sphy
ctic
anxie
ty or
anx
iety d
isord
er.
Cond
ition
char
acte
rized
by a
pat
tern
of fr
eque
nt w
orry
and
anxie
ty
abou
t sev
eral
diff
eren
t eve
nts/
activ
ities
, dia
gnos
ed cl
inica
lly
aort
ic a
tHer
oscl
eros
is44
0.0
105
Vasc
ular
Dise
ase
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s scle
rotic
aor
ta,
arte
riosc
lerot
ic ao
rta, c
alcifi
ed a
orta
or a
ther
oscle
rosis
of th
e aor
ta.
Cond
ition
whe
re fa
tty m
ater
ial i
s dep
osite
d in
the w
alls
of
aorta
lead
ing
to n
arro
wing
, har
deni
ng a
nd/o
r bloc
kage
, di
agno
sed
clini
cally
or b
y ang
iogra
m/im
age s
tudi
es
aort
ic V
alVe
Dis
orDe
r42
4.1
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
cqui
red
aorti
c val
ve
diso
rder,
aor
tic d
efor
mity
, end
ocar
ditis
with
aor
tic va
lve in
volve
men
t, ar
terio
scler
otic
aorti
c val
ve, a
ortic
valve
insu
fficie
ncy,
aorti
c va
lve ob
stru
ction
, aor
tic va
lve st
enos
is, or
aor
tic m
urm
ur.
Diso
rder
or d
amag
e inv
olvin
g ao
rtic v
alve
, ste
nosis
or in
suffi
cienc
y re
gurg
itatio
n, d
iagn
osed
by e
cho,
angi
ogra
m or
othe
r im
age s
tudi
es
aort
ocor
onar
Y BY
pass
V45.
81Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he
patie
nt is
stat
us p
ost c
oron
ary b
ypas
s sur
gery.
If th
ere i
s res
idua
l di
seas
e, th
is sh
ould
be f
ully
desc
ribed
and
code
d.
s/p
CABG
46
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
artH
ropa
tHY
nos-
unsp
ec71
6.90
Use t
his c
ode w
hen
the d
ocum
enta
tion
stat
es a
rthrit
is,
nonp
yoge
nic a
rthrit
is, a
rthro
path
y, joi
nt in
flam
mat
ion, o
r rh
eum
atism
and
no a
rea
of th
e bod
y is m
entio
ned.
Nons
peici
fic jo
int p
ain
diag
nose
d cli
nica
lly
astH
ma
nos
493.
90Us
ed w
hen
docu
men
tatio
n in
dica
tes a
sthm
a, a
nd
ther
e is n
o ind
icatio
n of
an
exac
erba
tion.
Reve
rsib
le re
activ
e airw
ay d
iseas
e res
ultin
g fro
m a
n al
lergi
c rea
ction
to
fore
ign
subs
tanc
es su
ch a
s vap
or, p
ollen
, etc
. dia
gnos
ed cl
inica
lly a
nd/o
r by
PFT
show
ing
obst
ruct
ive p
atte
rn (F
EV1/
FVC
< 80
%) a
nd re
vers
ibili
ty
asti
Gmat
ism
nos
367.
20Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s ast
igm
atism
, acq
uire
d as
tigm
atism
, co
ngen
ital a
stig
mat
ism, r
efra
ctive
ast
igm
atism
or co
ngen
ital a
stig
mat
ism.
Refra
ction
erro
r of t
he ey
e cha
ract
erize
d by
an
asph
erica
l co
rnea
lead
ing
to d
istor
ted
imag
e, di
agno
sed
clini
cally
atri
al f
iBri
llat
ion
427.
3192
Spec
ified
Hea
rt Ar
rhyth
mia
sUs
ed w
hen
docu
men
tatio
n st
ates
atri
al fi
brill
ation
. Be s
ure t
o also
do
cum
ent a
nd co
de lo
ng te
rm or
curre
nt u
se of
ant
icoag
ulan
t V58
.61.
Rapi
d irr
egul
ar h
eartb
eat d
iagn
osed
by e
xam
, ECG
or rh
ythm
mon
itor
BacK
acHe
nos
724.
5Us
ed w
hen
docu
men
tatio
n st
ates
bac
kach
e, or
verte
brog
enic
synd
rom
e.No
nspe
cific b
ack p
ain
Beni
Gn H
Yp H
t Di
s W
/o H
f40
2.10
Used
whe
n th
e doc
umen
tatio
n in
dica
tes b
enig
n hy
perte
nsive
hea
rt di
seas
e,
hype
rtens
ive h
eart
dise
ase o
r hea
rt di
seas
e sec
onda
ry to
hyp
erte
nsion
.An
y car
diac
cond
ition
due
to H
TN, i
nclu
ding
card
iomeg
aly,
card
iomyo
path
y, ca
rdiov
ascu
lar d
iseas
e with
out C
HF, d
iagn
osed
clin
ically
Beni
Gn H
Yper
tens
ion
401.
1Do
cum
enta
tion
mus
t ind
icate
ben
ign
or b
enig
n es
sent
ial h
yper
tens
ion.
If do
cum
enta
tion
only
indi
cate
s hyp
erte
nsion
, see
401
.9, b
elow.
HTN
(SBP
>14
0, D
BP >
90
on 2
occa
sions
) with
out a
ny en
d or
gan
(eye
, kid
ney,
or ca
rdiov
ascu
lar)
dam
age,
diag
nose
d cli
nica
lly
47
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Beni
Gn n
eopl
asm
lG
BoW
el21
1.3
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
deno
mat
osis,
Cro
nkhi
te-C
anad
a sy
ndro
me,
colon
poly
p, a
ppen
dix p
olyp,
capu
t coli
poly
p, ce
cum
poly
p,
ileoc
ecal
poly
p, h
epat
ic fle
xure
poly
p or
fam
ilial
ade
nom
atou
s poly
p.
Non-
canc
erou
s les
ion in
colon
, dia
gnos
ed b
y co
lonos
copy
and
/or r
adiol
ogic
stud
ies
Bone
& c
arti
laGe
Dis
nos
733.
90Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s bon
e les
ion, o
steo
lytic
lesion
, bon
e m
ass,
oste
ocop
ic pa
in, o
steo
dyni
a, os
teop
enia
, bon
e pai
n, ca
rtila
ge p
ain,
tibi
a pa
in, x
ypho
id p
ain,
scap
ulal
gia,
xiph
oiden
ia, x
ipho
idal
gia
or b
one c
hang
es.
Nons
pecifi
c abn
orm
ality
invo
lving
bon
e and
carti
lage
, dia
gnos
ed cl
inica
lly
BpH
W/o
uri
narY
oBs
/lut
s60
0.00
Used
whe
n do
cum
enta
tion
stat
es B
PH.
Enla
rgem
ent o
f pro
stat
e with
out o
bstru
ctive
sx’s
(urin
ary
rete
ntion
, drip
ping
or h
esita
ncy),
dia
gnos
ed cl
inica
lly
Bron
cHit
is n
os49
0Th
is co
de is
use
d wh
en b
ronc
hitis
is th
e onl
y des
crip
tion
in m
edica
l re
cord
. In
dise
ases
whe
re th
ere i
s bot
h a
chro
nic a
nd a
cute
form
of th
e di
seas
e, it’s
impo
rtant
to n
ote w
hich
form
of th
e dise
ase i
s pre
sent
.
Infe
ction
or in
flam
mat
ion of
bro
nchu
s cha
rate
rized
by c
ough
an
d/or
CXR
nor
mal
(no i
nfiltr
ate)
dia
gnos
ed cl
inica
lly
carD
iac
DYsr
HYtH
mia
nos
427.
9Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s onl
y arry
thm
ia, c
ardi
ac
dysr
hyth
mia
or ca
rdia
c arry
thm
ia. W
hen
the t
ype o
f arry
thm
ia is
kn
own,
it sh
ould
be d
ocum
ente
d an
d co
ded
appr
opria
tely.
Nons
pecifi
c non
-sin
us rh
ythm
dia
gnos
ed b
y EKG
or rh
ythm
mon
itor
carD
iac
DYsr
HYtH
mia
s ne
c42
7.89
Used
whe
n th
e doc
umen
tatio
n in
dica
tes c
ardi
ac a
rrhyth
mia
, car
diac
dy
sryth
mia
, gal
lop rh
ythm
, nod
al rh
ythm
diso
rder,
alte
rnat
ing
pulse
, big
emin
y, bi
gem
inal
rhyth
m, t
rigem
iny,
trige
min
al rh
ythm
, pu
lsus a
ltern
ans,
a-v n
odal
rhyth
m or
ecto
pic r
hyth
m.
Nons
inus
rhyth
m d
iagn
osed
by E
CG or
rhyth
m m
onito
r
48
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
carD
iom
eGal
Y42
9.3
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es on
ly ca
rdiom
egal
y, wi
thou
t any
indi
catio
n of
the u
nder
lying
dise
ase.
If do
cum
enta
tion
indi
cate
s it i
s due
to H
TN u
se co
des 4
02.0
-402
.9.
Enla
rged
hea
rt, d
iagn
osed
clin
ically
or b
y im
age s
tudi
es
cata
ract
nos
366.
9Us
ed w
hen
docu
men
tatio
n in
dica
tes c
atar
act,
lens c
hang
es,
intu
mes
cent
lens
, or l
ens o
pacit
y with
out f
urth
er d
escr
iptio
n.Op
acifi
catio
n of
lens
lead
ing
to im
paire
d vis
ion, d
iagn
osed
clin
ically
cell
ulit
is &
aBs
cess
leG
eX
cept
foo
t68
2.6
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
bsce
ss of
leg/
ankle
, ce
llulit
is of
leg/
ankle
, abs
cess
/cell
uliti
s of h
ip, f
emor
al a
bsce
ss/
cellu
litis
of kn
ee, p
oplit
eal a
bsce
ss/c
ellul
itis,
pre-
pate
llar
absc
ess/
cellu
litis,
or a
bsce
ss/c
ellul
itis o
f the
thig
h.
Nons
pecifi
c inf
ectio
n of
the s
kin le
adin
g to
war
mth
, eryt
hem
a,
swell
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
cell
ulit
is n
os68
2.9
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s cell
uliti
s,
diffu
se ce
llulit
is, ch
roni
c cell
uliti
s, ph
legm
onou
s cell
uliti
s or
whe
n m
ultip
le sit
es of
cellu
litis
are d
ocum
ente
d.
Nons
pecifi
c inf
ectio
n of
the s
kin le
adin
g to
war
mth
, eryt
hem
a,
swell
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
cerV
ical
Gia
723.
1Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes c
ervic
algi
a, n
eck
pain
or ce
rvica
l pai
n an
d no
caus
e of t
he p
ain
is do
cum
ente
d.Sy
mpt
oms o
f nec
k pai
n/di
scom
fort,
dia
gnos
ed cl
inica
lly
cHes
t pa
in n
ec78
6.59
Used
whe
n th
e doc
umen
tatio
n st
ates
ches
t pai
n, ch
est d
iscom
fort,
atyp
ical
ches
t pai
n, m
uscu
loske
letal
ches
t pai
n or
non
card
iac c
hest
pai
n.No
nspe
cific n
onca
rdia
c che
st p
ain/
disc
omfo
rt, d
iagn
osed
clin
ically
49
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
cHes
t pa
in n
os78
6.50
Used
whe
n do
cum
enta
tion
indi
cate
s che
st p
ain
or ri
b pa
in.
Nons
pecifi
c or n
on ca
rdia
c che
st p
ain
/ disc
omfo
rt, d
iagn
osed
clin
ically
cHf
nos
428.
080
Cong
estiv
e He
art F
ailu
reUs
ed w
hen
docu
men
tatio
n sa
ys B
ernh
eim’s
synd
rom
e, CH
F or h
eart
failu
re.
Card
inal
sym
ptom
s inc
lude
SOB
, ede
ma,
or C
P, di
agno
sed
by
clini
cal fi
ndin
gs a
nd +
PVC
on C
XR...
echo
may
reve
al lo
w EF
(<
50%
) and
/or n
orm
al E
F with
dia
stoli
c dys
func
tion
cHro
nic
airW
aY o
Bstr
uct
nec
496
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n do
cum
enta
tion
indi
cate
s “CO
PD”.
Whe
n kn
own,
the t
ype o
f airw
ay
obst
ruct
ion sh
ould
be d
ocum
ente
d an
d co
ded
(e.g
., ch
roni
c bro
nchi
tis).
Chro
nic o
bstru
ctive
lung
dise
ase o
ften
diag
nose
d wi
th sm
okin
g hx
, wh
eezin
g, P
FT sh
owin
g ob
stru
ctive
pat
tern
(FEV
1/FV
C <
80%
)
cHro
nic
iscH
emic
Hrt
Dis
nos
414.
9Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
sche
mic
coro
nary
ch
ange
s, co
rona
ry da
mag
e, isc
hem
ic he
art,
coro
nary
dise
ase,
ische
mic
he
art d
iseas
e, ca
rdia
c isc
hem
ia, c
oron
ary i
sche
mia
, or a
cqui
red
coro
nary
ische
mia
and
no a
dditi
onal
info
rmat
ion is
give
n.
Nons
pecifi
c chr
onic
ische
mic
hear
t dise
ase,
di
agno
sed
clini
cally
and
/or c
ardi
ac te
stin
g
cHro
nic
KiDn
eY D
is n
os58
5.9
131
Rena
l Fai
lure
Use w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
kidne
y dise
ase,
ch
roni
c ren
al fa
ilure
, chr
onic
kidne
y dise
ase o
r chr
onic
urem
ia. N
ote
that
chro
nic k
idne
y dise
ase c
odin
g sh
ould
inclu
de a
dia
gnos
tic
stat
emen
t of t
he st
age o
f kid
ney d
iseas
e whe
neve
r pos
sible.
Nons
pecifi
c chr
onic
rena
l dys
func
tion
char
acte
rized
by i
mpa
ired
GFR.
cHro
nic
KiDn
eY D
is s
taGe
ii
(mil
D)58
5.2
131
Rena
l Fai
lure
Used
whe
n do
cum
enta
tion
indi
cate
s tha
t the
pat
ient h
as C
KD
stag
e 2 a
nd th
ere i
s a d
ocum
ente
d GF
R of
60-
89.
Chro
nic r
enal
dys
func
tion
char
acte
rized
by G
FR of
60-
89
50
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
cHro
nic
KiDn
eY D
is s
taGe
iii
585.
313
1Re
nal F
ailu
reTh
is co
de is
use
d on
ly wh
en th
e doc
umen
tatio
n in
dica
tes S
tage
III
Chro
nic K
idne
y Dise
ase A
ND th
ere i
s a d
ocum
ente
d GF
R fro
m 3
0-59
.Ch
roni
c ren
al d
ysfu
nctio
n ch
arac
teriz
ed b
y GFR
of 3
0-59
cHro
nic
KiDn
eY D
is s
taGe
iV
(seV
ere)
585.
413
1Re
nal F
ailu
reUs
ed w
hen
docu
men
tatio
n in
dica
tes t
hat t
he p
atien
t has
st
age 4
CKD
and
ther
e is a
doc
umen
ted
GFR
of 1
5-29
Chro
nic r
enal
dys
func
tion
char
acte
rized
by G
FR of
15-
29 ≥
3 m
os or
with
sig
ns of
kidn
ey d
amag
e (e.g
., m
icroa
lbum
inur
ia, p
rote
inur
ia, e
tc.)
cHro
nic
resp
irat
orY
fail
ure
518.
8379
Card
io-Re
spira
tory
Fa
ilure
and
Sho
ckTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes c
hron
ic
resp
irato
ry fa
ilure
, or c
hron
ic re
spira
tion
failu
re.
Clin
ical m
arke
rs of
chro
nic h
ypox
emia
, suc
h as
poly
cyth
emia
or co
r pu
lmon
ale,
sugg
est a
long
-sta
ndin
g di
sord
er. M
ay m
anife
st a
s CO2
re
tent
ion re
sulti
ng in
a re
spira
tory
acid
osis.
Chr
onic
resp
irato
ry ac
idos
is
resu
lts in
a m
etab
olic a
lkalos
is wi
th el
evat
ed se
rum
bica
rbon
ate l
evel.
clos
fra
ctur
e un
spec
par
t ne
cK f
em82
0.8
158
Hip
Frac
ture
/Di
sloca
tion
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s fra
ctur
e of t
he n
eck
of fe
mur
, fra
ctur
e of t
he fe
mur
, upp
er en
d of
the f
emur
, or h
ip.
Frac
ture
of fe
mur
, dia
gnos
ed b
y x-ra
y.
cons
tipa
tion
nos
564.
00Us
e whe
n do
cum
enta
tion
stat
es co
nstip
ation
.No
nspe
cific c
onst
ipat
ion, d
iagn
osed
by h
istor
y
couG
H78
6.2
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s co
ugh,
laryn
geal
sync
ope o
r tus
sive s
ynco
pe.
Sym
ptom
of co
ugh,
dia
gnos
ed cl
inica
lly
51
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
crBl
art
ocl
nos
W in
frc
434.
9196
Ische
mic
or
Unsp
ecifi
ed S
troke
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s CVA
, Cer
ebra
l ac
ciden
t, ce
rebr
ovas
cula
r acc
iden
t, ac
ute c
ereb
rova
scul
ar
dise
ase,
ische
mic
CVA,
bra
in st
em in
farc
t(ion
), la
cuna
r inf
arct
ion,
cere
bella
r inf
arct
ion, c
ortic
al in
farc
tion,
or st
roke
.
Deve
lopm
ent o
f bloo
d clo
t in
the c
ereb
ral a
rterie
s with
bra
in
tissu
e dam
age l
eadi
ng to
mot
or, se
nsor
y, an
d/or
spee
ch
defic
it, d
iagn
osed
clin
ically
and
/or b
y im
age s
tudi
es
crnr
Y at
H un
sp V
sl n
tV/G
ft41
4.00
Use w
hen
docu
men
tatio
n in
dica
tes c
oron
ary a
ther
oscle
rosis
or a
rterio
scler
osis
AN
D yo
u ha
ve st
ated
that
the p
atien
t has
bot
h na
tive a
nd n
on-n
ative
ve
ssels
--bu
t you
hav
e not
indi
cate
d wh
ich ty
pe of
vess
el is
affe
cted
.
Athe
rosc
leros
is of
coro
nary
arte
ries d
efine
d by
pos
itive
stre
ss te
st
or p
ositi
ve ca
rdia
c cat
h wi
thou
t spe
cifica
tion
of w
heth
er n
ative
or
gra
ft ve
ssel
is in
volve
d in
a p
atien
t with
gra
ft ve
ssels
crnr
Y at
Hrsc
l na
tVe
Vssl
414.
01Us
e onl
y whe
n at
hero
scler
osis
or a
rterio
scler
osis
is st
ated
to b
e of
nativ
e ves
sel o
r the
re is
no d
ocum
enta
tion
of a
prio
r CAB
G.At
hero
scler
osis
of co
rona
ry ar
terie
s defi
ned
by p
ositi
ve
stre
ss te
st or
pos
itive
card
iac c
athe
teriz
ation
DeHY
Drat
ion
276.
51Th
is co
de is
use
d wh
en d
ocum
enta
tion
says
Luet
sche
r’s sy
ndro
me,
Lu
etsc
her’s
deh
ydra
tion,
deh
ydra
tion
or a
nhyd
ratio
n.Lo
ss of
flui
d fro
m th
e bod
y lea
ding
to w
eakn
ess,
thirs
t, fa
st h
eartb
eat,
poor
skin
turg
or, h
yper
natre
mia
, etc
, dia
gnos
ed cl
inica
lly
Dem
enti
a cc
e W
/o B
eHaV
Di
stur
B29
4.10
This
code
is on
ly us
ed a
s a se
cond
ary c
ode.
In a
ny d
iseas
e tha
t may
ha
ve d
emen
tia a
s a sy
mpt
om, t
he p
rimar
y dise
ase (
e.g.,
Hunt
ingt
on’s
Chor
ea, A
lzheim
er’s
dise
ase,
Pick
’s Di
seas
e, et
c.), a
nd d
emen
tia
with
out m
entio
n of
beh
avior
al d
istur
banc
e is m
entio
ned,
this
code
sh
ould
be u
sed
in a
dditi
on to
the c
ode f
or th
e prim
ary d
iseas
e.
A pr
ogre
ssive
, neu
rode
gene
rativ
e dise
ase c
hara
cter
ized
by lo
ss of
fu
nctio
n an
d de
ath
of n
erve
cells
in se
vera
l are
as of
the b
rain
lead
ing
to lo
ss of
cogn
itive
func
tion
such
as m
emor
y and
lang
uage
.
Depr
essi
Ve D
isor
Der
nec
311
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s “de
pres
sion”
or
dep
ress
ive d
isord
er w
ith n
o fur
ther
des
crip
tion.
Depr
essiv
e diso
rder
not
else
wher
e cla
ssifi
ed, m
ay h
ave s
ome s
ympt
oms o
f de
pres
sed
moo
d an
d los
s of i
nter
est,
chan
ge in
app
etite
, slee
p di
stur
banc
e,
beha
vior c
hang
e, de
crea
se in
ener
gy, g
uilt,
inab
ility
to co
ncen
trate
but
not
MDD
52
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
Depr
essi
Ve p
sYcH
osis
-uns
pec
296.
2055
Maj
or D
epre
ssive
, Bi
pola
r, an
d Pa
rano
id
Diso
rder
s
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
n ep
isode
of in
volu
tiona
l de
pres
sion,
mela
ncho
lia, d
epre
ssive
psy
chos
is, m
elanc
holia
, inv
olutio
nal
mela
ncoli
a, m
enop
ausa
l mela
ncho
lia, s
tupo
rous
mela
ncho
lia,
agita
ted
depr
essio
n, p
sych
otic
depr
essio
n, or
mela
ncho
ly.
Nons
pecifi
c dep
ress
ion (d
epre
ssed
moo
d, lo
ss of
inte
rest
, cha
nge i
n ap
petit
e,
sleep
dist
urba
nce,
beha
vior c
hang
e, de
crea
se in
ener
gy, g
uilt,
inab
ility
to
conc
entra
te, o
r sui
cide t
houg
hts)
with
delu
sion
and/
or h
allu
cinat
ion
Derm
atit
is n
os69
2.9
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
erm
atiti
s, ve
nena
ta
derm
atiti
s, co
ntac
t der
mat
itis,
aller
gic d
erm
atiti
s, oc
cupa
tiona
l de
rmat
itis,
acne
iform
der
mat
itis,
anap
hyla
ctic
derm
atiti
s, al
lergi
c ag
ent (
unsp
ecifi
ed) o
r ecz
emat
oid d
erm
atiti
s (un
spec
ified
).
Infla
mm
ation
of th
e skin
lead
ing
to er
ythem
a,
swell
ing,
itch
ines
s, di
agno
sed
clini
cally
Derm
atop
HYto
sis
of n
ail
110.
1Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s der
mat
ophy
tosis
of
nail,
fung
us of
nai
l, to
enai
l fun
gus,
or fi
nger
nail
fung
us.
Fung
al in
fect
ion of
the n
ail,
diag
nose
d cli
nica
lly or
by b
iopsy
Diap
HraG
mat
ic H
erni
a55
3.3
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
iatu
s her
nia,
dia
phra
gmat
ic
hern
ia, s
lidin
g di
aphr
agm
atic
hern
ia, B
ochd
alek
her
nia,
Mor
gagn
i(an)
he
rnia
, hia
tal h
erni
a, p
arae
soph
agea
l her
nia,
Sai
nt tr
iad,
or S
aint
’s he
rnia
.
Prot
rusio
n of
the u
pper
par
t of t
he st
omac
h in
to th
e tho
rax t
hrou
gh a
tear
or
wea
knes
s in
the d
iaph
ragm
, dia
gnos
ed b
y EGD
and
/or i
mag
e stu
dies
Diar
rHea
787.
91Th
is co
de w
as u
sed
when
the d
ocum
enta
tion
indi
cate
s dia
rrhea
, ac
ute d
iarrh
ea, a
utum
n di
arrh
ea, b
iliou
s dia
rrhea
, bloo
dy d
iarrh
ea,
cata
rrhal
dia
rrhea
, cho
lerai
c dia
rrhea
, chr
onic
diar
rhea
, dia
rrhea
gr
avis,
gre
en d
iarrh
ea, i
nfan
tile d
iarrh
ea, o
r lien
teric
dia
rrhea
.
Sym
ptom
s of d
iarrh
ea (f
requ
ent s
tool:
> 3
dai
ly), d
iagn
osed
cli
nica
lly. A
lso d
iagn
osed
bas
ed on
stoo
l app
eara
nce (
wate
ry)
53
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Diff
icul
tY W
alKi
nG71
9.7
Used
whe
n do
cum
enta
tion
indi
cate
s tha
t the
pat
ient h
as
diffi
culty
in w
alkin
g, b
ut n
o cau
se is
des
crib
ed.
Diffi
culty
wal
king,
dia
gnos
ed cl
inica
lly
Dise
ases
of
nail
nec
703.
8Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes a
chro
mia
un
guiu
m, a
cqui
red
anon
ychi
a, a
troph
ia u
ngui
um, B
eau’s
line
s, br
ittle
na
ils, c
lubn
ail,
deflu
vium
ung
uium
, nai
l disc
olora
tion,
eggs
hell
nails
, fra
gilit
as u
ngui
um, f
ragi
le na
ils or
furro
wing
nai
ls.
Spec
ified
lesio
n or
pro
cess
invo
lving
the n
ail,
inclu
ding
def
orm
ity,
disc
olora
tion,
abn
orm
al g
rowt
h, et
c, di
agno
sed
clini
cally
DiZZ
ines
s an
D Gi
DDin
ess
780.
4Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes d
izzin
ess,
gi
ddin
ess,
dyse
quili
briu
m, l
ight
head
edne
ss, s
wim
min
g in
the h
ead,
Mal
de D
ebar
quem
ent o
r ver
tigo.
Sym
ptom
s of f
eelin
g di
zzy,
imba
lanc
ed, d
iagn
osed
clin
ically
Dmi W
o cm
p nt
st
uncn
trlD
250.
0119
Diab
etes
with
out
Com
plica
tion
This
code
shou
ld b
e use
d wh
en yo
u ha
ve d
ocum
ente
d DM
1 or
juve
nile
diab
etes
is d
ocum
ente
d.Co
ntro
lled
DM 1
with
out c
ompl
icatio
n
Dmii
circ
nt
st u
ncnt
rlD
250.
7015
Diab
etes
wi
th R
enal
or
Per
iphe
ral
Circ
ulat
ory
Man
ifest
ation
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t circ
ulat
ory
diso
rder
s are
seco
ndar
y to o
r cau
sed
by d
iabe
tes m
ellitu
s. Fo
r ex
ampl
e, di
abet
ic an
giop
athy
, gan
gren
e 2º d
iabe
tes,
perip
hera
l cir
cula
tory
dise
ase 2
º dia
bete
s, or
dia
betic
micr
oang
iopat
hy.
DM 2
, not
stat
ed a
s unc
ontro
lled,
and
vasc
ular
find
ings
inclu
ding
cla
udica
tion,
ulce
rs, g
angr
ene,
athe
rosc
leros
is (i.
e. pe
riphe
ral
vasc
ular
dise
ase,
erec
tile d
ysfu
nctio
n, C
VA, C
AD) o
r pos
itive
fin
ding
s on
ABI,
ultra
soun
d, C
T an
giog
ram
, MRA
or a
ngiog
ram
Dmii
neur
o nt
st
uncn
trlD
250.
6016
Diab
etes
with
Ne
urolo
gic o
r Ot
her S
pecifi
ed
Man
ifest
ation
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
pa
tient
has
a n
euro
logica
l com
plica
tion
of th
eir d
iabe
tes.
The
docu
men
tatio
n m
ust i
ndica
te th
at th
e com
plica
tion
is se
cond
ary t
o th
e dia
bete
s. Th
e neu
rolog
ical c
ompl
icatio
n m
ust b
e spe
cified
.
Cont
rolle
d DM
2, w
ith n
euro
logica
l man
ifest
ation
s 2º D
M in
cludi
ng
num
bnes
s, tin
glin
g, b
urni
ng se
nsat
ions,
gast
ropa
resis
, ere
ctile
dy
sfun
ction
, aut
onom
ic in
stab
ility
or p
ositi
ve fi
ndin
g on
ner
ve
cond
uctio
n st
udy o
r fai
led m
onofi
lam
ent t
est o
f foo
t
54
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
Dmii
opHt
H nt
st
uncn
trlD
250.
5018
Diab
etes
with
Op
htha
lmolo
gic
or U
nspe
cified
M
anife
stat
ion
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
hat o
phth
alm
ologi
cal
cond
ition
s are
seco
ndar
y to,
or ca
used
by d
iabe
tes.
The d
ocum
enta
tion
mus
t ind
icate
the c
ausa
l rela
tions
hip.
This
code
is n
ot u
sed
when
an
eye c
ondi
tion
simpl
y co-
exist
s (i.e
., co
mor
bid)
with
dia
bete
s.
Cont
rolle
d DM
2, w
hich
has
caus
ed ey
e find
ings
such
as
Mac
ula
edem
a, vi
sion
chan
ge, r
etin
opat
hy, c
atar
act,
retin
al
edem
a, vi
treou
s hem
orrh
age,
micr
oane
urys
ms,
and
blin
dnes
s,
diag
nose
d cli
nica
lly a
nd/o
r by o
phth
alm
osco
pic e
xam
Dmii
otH
nt s
t un
cntr
lD25
0.80
16Di
abet
es w
ith
Neur
ologi
c or
Othe
r Spe
cified
M
anife
stat
ion
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
re is
a
diab
etic
com
plica
tion
(i.e.,
a co
nditi
on C
AUSE
D by
the d
iabe
tes)
th
at is
not
inclu
ded
in a
mor
e spe
cific d
iabe
tes c
ompl
icatio
n co
de.
For e
xam
ple:
diab
etic
bone
chan
ges,
diab
etic
derm
atiti
s.
Cont
rolle
d DM
2 w
ith ot
her c
ompl
icatio
ns ca
used
by t
he d
iabe
tes
such
as s
kin fi
ndin
gs, i
nfec
tions
, etc
, not
stat
ed a
s unc
ontro
lled
Dmii
renl
nt
st u
ncnt
rlD
250.
4015
Diab
etes
wi
th R
enal
or
Per
iphe
ral
Circ
ulat
ory
Man
ifest
ation
Use o
nly w
hen
docu
men
tatio
n in
dica
tes t
he p
atien
t has
rena
l dise
ase
that
is se
cond
ary t
o dia
bete
s, or
dia
betic
rena
l dise
ase.
The I
CD-9
do
es n
ot a
ssum
e a ca
usal
rela
tions
hip,
so yo
u m
ust i
nclu
de it
in
your
doc
umen
tatio
n. Yo
u m
ust a
lso co
de th
e ren
al d
iseas
e.
Cont
rolle
d DM
2 w
ith re
nal m
anife
stat
ions c
ause
d by
the
diab
etes
(ren
al m
anife
stat
ion in
clude
d al
bum
inur
ia, p
rote
inur
ia,
decr
ease
d GF
R, C
r, et
c) D
iabe
tic N
euro
path
y MA/
CR>2
99
Dmii
W/r
enal
uns
/unc
ntrl
D25
0.42
15Di
abet
es
with
Ren
al
or P
erip
hera
l Ci
rcul
ator
y M
anife
stat
ion
Use w
hen
the d
ocum
enta
tion
indi
cate
s unc
ontro
lled
or
out o
f con
trol d
iabe
tes(
eithe
r typ
e II o
r no t
ype s
tate
d)
with
rena
l man
ifest
ation
s or c
ompl
icatio
ns.
Diab
etes
with
abn
orm
al b
lood
gluc
ose v
alue
s and
pr
otein
uria
or ot
her e
viden
ce of
kidn
ey d
amag
e
55
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Dmii
Wo
cmp
nt s
t un
cntr
lD25
0.00
19Di
abet
es w
ithou
t Co
mpl
icatio
nIf
diag
nosis
indi
cate
s DM
, dia
bete
s mell
itus o
r dia
bete
s, th
is is
th
e cor
rect
code
. Whe
n un
spec
ified
in th
e med
ical r
ecor
d, d
iabe
tes
is as
sum
ed to
be t
ype I
I bas
ed on
ICD-
9 gu
ideli
nes.
DM 2
with
out c
ompl
icatio
n, n
ot st
ated
as u
ncon
trolle
d, d
iagn
osed
clin
ically
Dmii
Wo
cmp
uncn
trlD
250.
0219
Diab
etes
with
out
Com
plica
tion
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient h
as D
M II
(o
r the
type
is n
ot st
ated
) and
the p
hysic
ian
spec
ifica
lly st
ates
that
the d
iabe
tes
is “u
ncon
trolle
d” or
“out
of co
ntro
l.” N
OTE:
poo
r/poo
rly co
ntro
l is n
ot a
ccep
tabl
e.
Unco
ntro
lled
DM 2
with
out e
nd-o
rgan
com
plica
tion.
Micr
o alb
umin
/Cr r
atio<
299
DVrt
clo
colo
n W
/o H
mrH
G56
2.10
Used
whe
n do
cum
enta
tion
stat
es d
iverti
culos
is.No
n-bl
eedi
ng co
lon d
iverti
culos
is di
agno
sed
by
colon
osco
py or
othe
r im
age s
tudi
es
DYsp
HaGi
a un
spec
ifie
D78
7.20
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
ysph
agia
, or d
ifficu
lty sw
allow
ing.
Diffi
culty
swal
lowin
g, d
iagn
osed
clin
ically
or b
y rad
iolog
ical s
tudi
es.
Diag
nose
d ge
nera
lly cl
inica
lly, x
-rays
only
if pa
tient
is a
phas
ic.
eDem
a78
2.3
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s ana
sarc
a,
Secr
etan
’s ed
ema,
infe
ctiou
s ede
ma,
pitt
ing
edem
a, or
edem
a.Ac
cum
ulat
ion of
flui
d, u
sual
ly in
the l
ower
extre
miti
es
and
depe
nden
t are
a, d
iagn
osed
clin
ically
elVt
D pr
stat
e sp
cf a
ntGn
790.
93Th
is co
de is
to b
e use
d wh
en yo
u ha
ve d
ocum
ente
d th
at th
e pa
tient
has
an
eleva
ted
PSA.
If yo
u on
ly no
te th
e lab
valu
e, yo
u ca
nnot
code
this—
you
mus
t sta
te th
at it
is el
evat
ed.
Elev
ated
PSA
leve
l, di
agno
sed
base
d on
lab
valu
e
empH
Ysem
a ne
c49
2.8
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n th
e doc
umen
tatio
n in
dica
tes e
mph
ysem
a, a
troph
ic,
cent
riacin
ar, c
entri
lobul
ar, c
hron
ic, d
iffus
e, es
sent
ial,
hype
rtrop
hic,
in
terlo
bula
r, lu
ng, o
bstru
ctive
, pan
lobul
ar, p
arac
icatri
cial,
para
cinar
, po
stur
al, p
ulm
onar
y, se
nile,
subp
leura
l, or
trac
tion
pulm
onar
y dise
ase.
Dam
age t
o alve
oli fr
eque
ntly
diag
nose
d by
smok
ing
hist
ory,
whee
zing,
CXR
find
ing
and
obst
ruct
ive P
FT (F
EV1/
FVC
< 70
%)
56
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
enD
staG
e re
nal
Dise
ase
585.
613
1Re
nal F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umat
ion in
dica
tes e
nd st
age
rena
l dise
ase,
ESRD
, or k
idne
y dise
ase r
equi
ring
dial
ysis.
End-
stag
e ren
al d
iseas
e (ES
RD) i
s an
adm
inist
rativ
e ter
m b
ased
on th
e co
nditi
ons f
or p
aym
ent f
or h
ealth
care
by t
he M
edica
re E
SRD
Prog
ram
. Thi
s te
rm d
enot
es ki
dney
dise
ase a
t a le
vel t
hat r
equi
res d
ialys
is or
tran
spla
ntat
ion.
esop
HaGe
al r
eflu
X53
0.81
Used
whe
n do
cum
enta
tion
indi
cate
s GER
D or
reflu
x.Ba
ckflo
w of
stom
ach
fluid
to es
opha
gus l
eadi
ng to
acid
ic ta
ste i
n th
e m
outh
, epi
gast
ric a
bdom
inal
pai
n di
agno
sed
clini
cally
and
/or b
y EGD
eXuD
atV
senl
mac
ulr
DeGe
nrat
-ret
362.
52Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s Kuh
nt-Ju
nius
dise
ase,
disc
iform
m
acul
a, ex
udat
ive m
acul
ar d
egen
erat
ion, w
et m
acul
ar d
egen
erat
ion,
Kuhn
t-Jun
ias r
etin
a, K
uhnt
-Juni
as d
egen
erat
ion or
disc
iform
is re
tiniti
s.
Decr
ease
visu
al a
cuity
or ce
ntra
l visi
on lo
ss d
ue to
agi
ng d
iagn
osed
cli
nica
lly. S
houl
d be
bas
ed on
prio
r or c
oncu
rrent
exam
by o
phth
alm
ologi
st.
eYe
& Vi
sion
eXa
min
atio
nV7
2.0
Used
to in
dica
te a
pat
ient s
een
for e
ye ex
amin
ation
Perfo
rman
ce of
eye a
nd vi
sion
exam
inat
ion
fall
nos
E888
.9Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he
patie
nt fe
ll, w
ithou
t fur
ther
info
rmat
ion. T
he co
de se
ries E
888.
X ha
s ve
ry sp
ecifi
c cod
es fo
r fal
ls, b
ased
on h
ow or
whe
re th
ey oc
curre
d.
Whe
n th
is in
form
ation
is a
vaila
ble,
it sh
ould
be d
ocum
ente
d.
Used
to in
dica
te th
e cau
se of
an
inju
ry
feVe
r un
spec
ifie
D78
0.60
Used
whe
n th
e doc
umen
tatio
n in
dica
tes f
ever,
chill
s with
feve
r, py
rexia
, fev
er of
unk
nown
orig
in, e
phem
eral
feve
r, or
febr
icula
.Pr
esen
ce of
feve
r with
out f
urth
er d
etai
l; ge
nera
lly >
= 99
.5 F
or 3
7.5
C
57
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Gast
r/DD
nts
nos
W/o
Hm
rHG
535.
50Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s gas
tritis
, gas
trodu
oden
itis,
ga
stro
hepa
titis,
gas
trojej
uniti
s or p
ylorit
is an
d th
ere i
s no
men
tion
in th
e doc
umen
tatio
n of
hem
orrh
age o
r blee
ding
.
Nonb
leedi
ng in
flam
mat
ion of
stom
ach
or d
uode
num
dia
gnos
ed
clini
cally
and
/or b
y end
osco
py/im
age s
tudi
es
Gast
roin
test
Hem
orr
nos
578.
9Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s gas
tric b
leedi
ng, g
astro
inte
stin
al
blee
ding
, sto
mac
h bl
eedi
ng, e
nter
orrh
agia
, bow
el he
mor
rhag
e, ce
cal
blee
ding
, gas
tric h
emor
rhag
e or g
astro
ente
ric h
emor
rhag
e.
Nons
pecifi
c blee
ding
invo
lving
GI t
ract
, dia
gnos
ed cl
inica
lly
and
or b
y end
osco
pies
or ra
diolo
gica
l stu
dies
Gen
oste
oart
Hros
is in
VlV
mX
site
s71
5.09
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s gen
eral
ized
oste
oarth
ritis/
oste
oarth
rosis
, poly
artic
ular
oste
oarth
rosis
, id
iopat
hic g
ener
al os
teoa
rthos
is/ar
thrit
is, p
olyar
ticul
ar a
rthro
sis,
gene
raliz
ed jo
int d
iseas
e, or
gen
eral
ized
arth
ritis.
Pain
in m
ultip
le joi
nts w
ithou
t infl
amm
ation
.
Gene
ral
oste
oart
Hros
is71
5.00
Used
whe
n th
e doc
umen
tatio
n in
dica
tes g
ener
alize
d os
teoa
rthro
sis
or g
ener
alize
d ar
thrit
is. Th
is co
de sh
ould
not
be u
sed
when
th
e med
ical r
ecor
d in
dica
tes “
arth
ritis”
, whi
ch is
code
d 71
5.9—
not s
tate
d wh
ethe
r loc
alize
d or
gen
eral
ized.
Gene
raliz
ed O
A in
volvi
ng m
ultip
le joi
nts,
diag
nose
d cli
nica
lly or
by i
mag
e stu
dies
Glau
com
a no
s36
5.9
Used
whe
n do
cum
enta
tion
only
stat
es g
lauc
oma
with
no f
urth
er in
form
ation
.In
crea
se in
intra
ocul
ar p
ress
ure
caus
ing
optic
ner
ve d
amag
e, lea
ding
to
visua
l im
pairm
ent d
iagn
osed
by t
onom
etry
and/
or op
htha
lmos
copi
c exa
m
Gout
nos
274.
9Us
ed w
hen
docu
men
tatio
n in
dica
tes g
out,
urat
e the
saur
ismos
is,
uric
acid
dia
sthe
sis, g
outy
dias
thes
is or
pod
agra
.Co
nditi
on ca
used
by t
he a
ccum
ulat
ion of
uric
acid
crys
tals,
may
de
posit
in jo
ints
(arth
ritis)
, kid
ney (
ston
e), g
allb
ladd
er (s
tone
), di
gnos
ed cl
inica
lly w
ith/w
ithou
t elev
ated
uric
acid
58
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
HeaD
acHe
784.
0Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s hea
dach
e, ce
phal
gia,
va
scul
ar h
eada
che,
face
or fa
cial p
ain
or h
ead
pain
.Sy
mpt
oms o
f hea
dach
e or h
ead
disc
omfo
rt, d
iagn
osed
clin
ically
Hear
inG
loss
nos
389.
9Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s hea
ring
loss,
deaf
ness
, au
dito
ry de
afne
ss, i
mpa
ired
hear
ing,
aud
itory
impe
rcep
tion,
he
redi
tary
deaf
ness
, con
geni
tal d
eafn
ess,
or a
cqui
red
deaf
ness
wi
th n
o des
crip
tion
of th
e etio
logy o
f the
impa
irmen
t.
Nons
pecifi
c los
s of h
earin
g, d
iagn
osed
clin
ically
or b
y aud
iolog
y
Hem
atur
ia u
nspe
cifi
eD59
9.70
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
emat
uria
, bloo
d in
the
urin
e, To
mm
asell
i’s d
iseas
e, bl
oody
urin
e, id
iopat
hic h
emat
uria
, in
term
itten
t hem
atur
ia, p
arox
ysm
al h
emat
uria
or su
lfona
mid
e he
mat
uria
(if c
orre
ct d
rug
adm
inist
ered
pro
perly
).
Bloo
d in
the u
rine,
diag
nose
d cli
nica
lly or
by U
A (+
bloo
d or
+RB
C)
Hem
ipl
affc
t un
s si
De-
cere
BrVa
sc D
Z43
8.20
100
Hem
ipleg
ia/
Hem
ipar
esis
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
emip
legia
/hem
ipar
esis
fo
llowi
ng (o
r sta
tus p
ost)
CVA,
hem
ipleg
ia a
s a la
te ef
fect
of C
VA or
CV
A wi
th h
emip
legia
or h
emip
ares
is. N
OTE:
Per
Cod
ing
Clin
ic, Q
1 20
05,
“wea
knes
s” st
atus
pos
t CVA
is co
ded
as 4
38.8
9, O
ther
late
effe
cts o
f ce
rebr
ovas
cula
r dise
ase a
nd co
de 7
28.8
7, M
uscle
wea
knes
s, fo
r res
idua
l m
uscle
wea
knes
s sec
onda
ry to
late
effe
ct of
cere
brov
ascu
lar a
ccid
ent.
Hem
ipleg
ia/H
emip
ares
is as
a re
sult
of p
rior C
VA
59
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Ht p
ros
W/u
r oB
st &
otH
lut
s60
0.01
Use w
hen
docu
men
tatio
n in
dica
tes e
nlar
gem
ent o
f the
pro
stat
e wi
th lo
wer u
rinar
y tra
ct sy
mpt
oms,
pros
tate
hyp
erpl
asia
with
lowe
r ur
inar
y tra
ct sy
mpt
oms,
enla
rgem
ent/h
yper
plas
ia of
the p
rost
ate w
ith
obst
ruct
ion, e
nlar
gem
ent/h
yper
plas
ia of
the p
rost
ate w
ith u
rinar
y re
tent
ion, h
yper
troph
y of t
he p
rost
ate w
ith u
rinar
y ret
entio
n/ob
stru
ction
or
hyp
ertro
phic
pros
tate
with
lowe
r urin
ary t
ract
sym
ptom
s. Us
e ad
ditio
nal c
ode t
o ide
ntify
sym
ptom
s suc
h as
freq
uenc
y 788
.41
etc.
Enla
rgem
ent/h
yper
plas
ia of
the
pros
tate
with
urin
ary r
eten
tion.
HX o
f Br
east
mal
iGna
ncY
V10.
3Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t ha
s had
bre
ast c
ance
r and
has
com
plet
ed tr
eatm
ent (
surg
ically
, ra
diat
ion, c
hem
othe
rapy
or a
ny co
mbi
natio
n) w
hen
ther
e is n
o ind
icatio
n th
at th
ere i
s tum
or st
ill p
rese
nt. P
atien
ts u
nder
goin
g tre
atm
ent w
ith
tam
oxife
n or
sim
ilar d
rugs
shou
ld b
e cod
ed a
s hav
ing
activ
e dise
ase.
Hist
ory o
f bre
ast c
ance
r, no
act
ive ca
ncer,
dia
gnos
ed b
y hist
ory
HX o
f to
Bacc
o us
eV1
5.82
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
hist
ory o
f tob
acco
us
e, pr
ior to
bacc
o use
or h
istor
y of c
igar
ette
smok
ing.
Hist
ory o
f prio
r tob
acco
use
, dia
gnos
ed b
y hist
ory
HYp
cKD
Ben
cKD
staG
e i t
Hru
iV/u
ns40
3.10
Used
whe
n th
e doc
umen
tatio
n in
dica
tes b
enig
n hy
perte
nsion
with
CKD
stag
e 1-
4 or
ben
ign
hype
rtens
ion w
ith C
KD, o
r hyp
erte
nsion
with
rena
l inv
olvem
ent,
rena
l scle
rosis
with
hyp
erte
nsion
, or h
yper
tens
ion w
ith g
lomer
ulos
clero
sis.
CKD
of a
ny st
age i
n th
e pre
senc
e of e
ssen
tial (
prim
ary,
not
reno
vasc
ular
) HTN
, but
exclu
ding
mal
igna
nt H
TN (s
udde
n an
d ra
pid
deve
lopm
ent o
f extr
emely
hig
h bl
ood
pres
sure
usu
ally
with
a d
iast
olic
of >
125
and
card
iac,
rena
l, or
cere
bral
man
ifest
ation
s) a
nd a
lso
exclu
ding
acu
te or
rena
l fai
lure
due
to ot
her (
non
HTN)
caus
es
60
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
HYp
cKD
uns
cKD
staG
e i t
Hru
iV/u
ns40
3.90
Used
whe
n do
cum
enta
tion
indi
cate
s hyp
erte
nsive
kidn
ey d
iseas
e, re
nova
scul
ar
hype
rtens
ion, a
rterio
lar g
lomer
ulon
ephr
itis,
arte
riosc
lerot
ic gl
omer
ulon
ephr
itis,
hy
perte
nsion
with
chro
nic k
idne
y dise
ase (
unsp
ecifi
ed or
Sta
ge 1
-4).
Uns
pecifi
ed h
yper
tens
ive re
nal d
iseas
e
HYp
KiD
nos
W c
r Ki
D V
403.
9113
1Re
nal F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he
patie
nt h
as b
oth
Stag
e V C
KD a
nd h
yper
tens
ion. N
OTE:
Cod
es in
th
e 403
.X se
ries a
re a
n ex
cept
ion to
the r
ule t
hat t
he p
hysic
ian
mus
t doc
umen
t a ca
usal
rela
tions
hip
betw
een
two d
iseas
es.
Hype
rtens
ive ki
dney
dise
ase w
ith ch
roni
c kid
ney d
amag
e, su
ch a
s alb
umin
uria
, pr
otein
uria
, hem
atur
ia, g
lomer
ulon
ephr
itis,
abno
rmal
crea
tinin
e or r
enal
fa
ilure
, cha
ract
erize
d by
GFR
< 1
5, n
eedi
ng d
ialys
is or
tran
spla
ntat
ion
HYpe
rlip
iDem
ia n
ec/n
os27
2.4
Whe
n do
cum
enta
tion
only
indi
cate
s hyp
erlip
idem
ia, t
his i
s the
corre
ct co
de.
High
lipi
d st
ate c
hara
cter
ized
by el
evat
ed LD
L or t
riglyc
erid
e
HYpe
rmet
ropi
a36
7.0
Used
whe
n do
cum
enta
tion
stat
es h
yper
met
ropi
a, h
yper
opia
, or f
arsig
hted
ness
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
ility
to fo
cus o
n clo
se
objec
ts of
ten
asso
ciate
d wi
th a
ging
, dia
gnos
ed cl
inica
lly
HYpe
rpot
asse
mia
276.
7Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s hyp
erpo
tass
emia
, exc
ess
pota
ssiu
m, h
yper
kalem
ia, p
otas
sium
over
load
or h
yper
kalem
ic.Bl
ood
test
show
ing
pota
ssiu
m is
gre
ater
than
upp
er li
mit
of n
orm
al (5
.0 m
Eq/L
)
HYpe
rten
sion
nos
401.
9W
hen
docu
men
tatio
n on
ly in
dica
tes h
yper
tens
ion, o
r un
cont
rolle
d hy
perte
nsion
, thi
s is t
he co
rrect
code
.Hy
perte
nsion
with
SBP
>14
0, D
BP >
90
on 2
or m
ore o
ccas
ions
HYpo
pota
ssem
ia27
6.8
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
ypop
otas
sem
ia, p
otas
sium
de
plet
ion, p
otas
sium
defi
cienc
y, hy
poka
lemia
or h
ypok
alem
ic.Lo
w po
tasiu
m st
ate,
diag
nose
d by
lab
valu
e
61
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
HYpo
smol
alit
Y27
6.1
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s anh
ydra
tion
with
hy
pona
trem
ia, d
ehyd
ratio
n wi
th h
ypon
atre
mia
, sal
t dep
letion
, sod
ium
dep
letion
, so
dium
defi
cienc
y, flu
id lo
ss w
ith h
ypon
atre
mia
, hyp
osm
olalit
y or s
ick ce
ll.
Low
elect
rolyt
e sta
te, f
requ
ently
ass
ocia
ted
with
deh
ydra
tion
and
low so
dium
, dia
gnos
ed b
y lab
orat
ory v
alue
s
HYpo
tens
ion
nos
458.
9Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s low
bloo
d pr
essu
re, l
ow p
ress
ure,
arte
rial h
ypot
ensio
n, h
ypot
ensio
n,
cons
titut
ional
hyp
oten
sion,
or h
ypos
ysto
lic p
ress
ure.
Nons
pecifi
c sta
te of
low
bloo
d pr
essu
re, d
iagn
osed
clin
ically
HYpo
tHYr
oiDi
sm n
os24
4.9
Used
whe
n do
cum
enta
tion
indi
cate
s hyp
othy
roid
ism,
or p
ost-s
urgi
cal h
ypot
hyro
idsm
.Lo
w th
yroid
stat
e cha
ract
erize
d by
low
ener
gy st
ate,
depr
essio
n, w
eakn
ess,
ed
ema,
cons
tipat
ion, d
iagn
osed
by h
igh
TSH
and
usua
lly lo
w To
tal T
3, To
tal T
4
HYpo
Xem
ia79
9.02
79Ca
rdio-
Resp
irato
ry
Failu
re a
nd S
hock
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
ypox
ia, a
noxia
, an
oxem
ia, p
atho
logica
l ano
xia, o
r hyp
oxem
ia.
Lowe
r tha
n no
rmal
bloo
d ox
ygen
leve
l.
iDio
per
ipH
neur
ptHY
nos
356.
971
Polyn
euro
path
yTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
nter
stiti
al h
yper
troph
ic
prog
ress
ive n
eurit
is, h
ered
itary
neur
opat
hy, i
nter
stiti
al h
yper
troph
ic ne
urop
athy
, m
ultip
le ne
urop
athy
, poly
neur
opat
hy, p
erip
hera
l neu
ropa
thy,
atro
phic
ne
urop
athy
, Per
iphe
ral p
rogr
essiv
e neu
ropa
thy,
polyn
eurit
is or
trop
hone
uros
is.
Nons
pecifi
c los
s of s
ensa
tion
or m
ovem
ent d
ue to
idiop
athi
c ne
rve d
amag
e, di
agno
sed
clini
cally
and
/or b
y NCS
/EM
G
impa
cteD
cer
umen
380.
4Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
impa
cted
ceru
men
, im
pact
ed ea
r wax
, abn
orm
al ce
rum
en
prod
uctio
n, w
ax in
ear,
or ce
rum
en a
ccum
ulat
ion.
Ear w
ax im
pact
ion d
iagn
osed
by d
irect
visu
aliza
tion
inGr
oWin
G na
il70
3.0
Use w
hen
docu
men
tatio
n st
ates
ingr
own
nail,
onyc
hocr
ypto
sis,
onyx
is, U
ngui
s inc
arna
tus o
r ing
rowi
ng n
ail.
Pain
ful c
ondi
tion
of th
e gre
at to
e in
which
the n
ail g
rows
into
the s
kin on
eit
her s
ide,
caus
ing
infla
mm
ation
and
/or i
nfec
tion,
dia
gnos
ed cl
inica
lly
62
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
inso
mni
a no
s78
0.52
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s ins
omni
a, sl
eepl
essn
ess,
ag
rypni
a, d
isrup
tion
in sl
eep
initi
ation
or m
aint
enan
ce, o
r hyp
osom
nia.
Inab
ility
or d
ifficu
lty fa
lling
asle
ep or
rem
aini
ng a
sleep
int
Hem
orrH
oiD
W/o
com
pl45
5.0
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s int
erna
l hem
orrh
oids.
Pres
ence
of in
tern
al h
emor
rhoid
, dia
gnos
ed cl
inica
lly
inte
rmeD
cor
onar
Y sY
nD41
1.1
82Un
stab
le An
gina
an
d Ot
her A
cute
Isc
hem
ic He
art
Dise
ase
Used
whe
n th
e doc
umen
tatio
n in
dica
tes i
nter
med
iate
coro
nary
sy
ndro
me,
impe
ndin
g co
rona
ry sy
ndro
me,
impe
ndin
g m
yoca
rdia
l in
farc
tion,
impe
ndin
g in
farc
t, ac
ute c
oron
ary s
yndr
ome,
corn
ary
insu
fficie
ncy s
yndr
ome,
unst
able
angi
na or
inte
rmed
iate
coro
nary.
New
onse
t ang
ina
(car
diac
CP)
or a
ngin
a wi
th in
crea
se in
freq
uenc
y or i
nten
sity,
diag
nose
d cli
nica
lly w
ith T
inve
rsion
on E
CG a
nd h
ypok
ines
is on
echo
card
iogra
m
iron
Def
ic a
nem
ia n
os28
0.9
Used
whe
n th
e dia
gnos
is is
iron
defic
iency
ane
mia
, Witt
’s an
emia
, ach
lorhy
dic
anem
ia, g
reen
sick
ness
, sid
erop
enia
, Fab
er’s
dise
ase,
or H
ayem
-Fab
er d
iseas
e.Lo
w RB
C lev
el (H
gb <
16
for m
en; H
gb <
14
for w
omen
) due
to ir
on
defic
iency
, cha
ract
erize
d by
low
MCV
, low
ferri
tin, l
ow ir
on, e
levat
ed TI
BC
Join
t pa
in-a
nKle
719.
47Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s pai
n in
the a
nkle,
foot
or m
etat
arsa
ls.Jo
int d
iscom
fort/
pain
invo
lving
ank
le, d
iagn
osed
clin
ically
Join
t pa
in-l
/leG
719.
46Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t ha
s kne
e pai
n, p
atell
ofem
oral
synd
rom
e, or
pat
ellof
emor
al p
ain.
Lowe
r extr
emity
pai
n in
volvi
ng th
e kne
e join
t, di
agno
sed
clini
cally
Join
t pa
in-p
elVi
s71
9.45
Used
whe
n do
cum
enta
tion
stat
es co
xala
gia,
hip
pai
n, or
pelv
ic pa
in.
Join
t disc
omfo
rt in
volvi
ng p
elvic
area
, dia
gnos
ed cl
inica
lly
Join
t pa
in-s
HlDe
r71
9.41
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s sho
ulde
r join
t pai
n.Jo
int d
iscom
fort
invo
lving
shou
lder,
dia
gnos
ed cl
inica
lly
63
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
Kera
toDe
rma,
acq
uire
D70
1.1
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s ac
anth
oker
atod
erm
ia, a
cqui
red
allig
ator
skin
dise
ase,
allig
ator
sk
in, a
cqui
red
fish
skin
, Kyrl
e’s sy
ndro
me,
hype
rker
atos
is
folli
cula
ris in
cute
m p
enet
rans
, or L
utz-
Mies
cher
synd
rom
e.
Skin
diso
rder
cons
istin
g of
a g
rowt
h th
at a
ppea
rs h
orny
, dia
gnos
ed cl
inica
lly
Knee
Join
t re
plac
emen
t ot
Her
mea
nsV4
3.65
Used
whe
n do
cum
enta
tion
indi
cate
s kne
e join
t rep
lace
men
t, kn
ee re
plac
emen
t, kn
ee/k
nee j
oint p
rost
hesis
, kne
e join
t dev
ice, o
r arti
ficia
l kne
e join
t.St
atus
of kn
ee re
plac
emen
t with
pro
sthe
sis
laBo
rato
rY e
Xam
inat
ion
unsp
ecif
ieD
V72.
60Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
that
the p
atien
t had
labo
rato
ry se
rvice
s don
e.Pe
rform
ance
of la
bora
tory
test
s onl
y
lens
rep
lace
men
t ne
cV4
3.1
Used
whe
n yo
ur n
ote i
ndica
tes t
hat t
he le
ns of
the e
ye h
as b
een
repl
aced
.St
atus
pos
t len
s rep
lace
men
t
lipo
iD m
etaB
ol D
is n
os27
2.9
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
bnor
mal
lipi
ds,
cong
enita
l abn
orm
al li
pid
met
aboli
sm, o
r abn
orm
al ch
olest
erol
m
etab
olism
. (No
te th
at m
etab
olism
mus
t be m
entio
ned.
The
term
“hyp
erlip
idem
ia” o
r “dy
slipi
dem
ia” c
odes
to 2
72.4
).
Abno
rmal
lipi
d m
etab
olism
, dia
gnos
ed cl
inica
lly
and
by a
bnor
mal
labo
rato
ry va
lues
loc
prim
ost
eoar
t-l/
leG
715.
16Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n sp
ecifi
cally
stat
es
that
oste
oarth
ritis
is pr
esen
t in
the l
ower
extre
mity
(leg
).OA
invo
lving
lowe
r extr
emity
, dia
gnos
ed cl
inica
lly
lonG
-ter
m u
se a
ntic
oaGu
lV5
8.61
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t is o
n lon
g-te
rm
antic
oagu
lant
ther
apy.
The u
nder
lying
cond
ition
(e.g
., hi
stor
y of D
VT
or ch
roni
c atri
al fi
brill
ation
) mus
t also
be d
ocum
ente
d an
d co
ded.
Stat
us of
usin
g lon
g te
rm a
ntico
agul
ation
ther
apy
64
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
lonG
-ter
m u
se m
eDs
nec
V58.
69Us
ed w
hen
the p
atien
t has
long
term
med
icatio
n us
e tha
t doe
s not
ha
ve a
spec
ific c
ode.
For e
xam
ple t
here
are
spec
ific c
odes
for l
ong
term
use
of a
ntico
agul
ants
(V58
.61)
, lon
g te
rm u
se of
ant
ibiot
ics
(V58
.62)
and
long
term
use
of st
eroid
s (V5
8.65
). It’s
app
ropr
iate
to
use
this
code
for l
ong
term
use
of op
ioid
pain
med
icatio
n.
Stat
us of
(cur
rent
) med
icatio
n us
e lon
g te
rm
lonG
-ter
m u
se o
f in
suli
nV5
8.67
19Di
abet
es w
ithou
t Co
mpl
icatio
nUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s cur
rent
insu
lin u
se,
long
term
insu
lin u
se, o
r ong
oing
insu
lin th
erap
y.St
atus
of lo
ng te
rm u
se of
insu
lin.
lum
B/lu
mBo
sac
Disc
DeG
en72
2.52
This
code
is a
ssig
ned
if th
e doc
umen
tatio
n st
ates
OA
AND
the
locat
ion of
the l
umba
r or s
acra
l spi
ne is
spec
ifica
lly st
ated
.OA
invo
lving
lum
bar a
nd/o
r sac
ral a
rea,
dia
gnos
ed cl
inica
lly
lum
BaGo
724.
2Us
ed w
hen
docu
men
tatio
n sa
ys lu
mba
go or
low
back
pai
n.Pa
in in
the l
umba
r reg
ion d
iagn
osed
clin
ically
lum
Bosa
cral
neu
riti
s no
s72
4.4
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s lum
bar n
erve
root
di
sord
er, lu
mbo
sacr
al n
erve
root
diso
rder,
thor
acic
nerv
e roo
t diso
rder,
lu
mbo
sacr
al ra
dicu
lar p
ain,
ant
erior
crur
al ra
dicu
litis,
leg
radi
culit
is,
lum
bar,
lum
bosa
cral
radi
culit
is, or
lum
bosa
cral
radi
culop
athy
.
Nons
pecifi
c infl
amm
ation
of lu
mba
rsac
ral n
erve
(s) l
eadi
ng to
pai
n,
num
bnes
s or t
ingl
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by E
MG/
NCS
lum
Bosa
cral
spo
nDYl
osis
721.
3Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s lum
bar s
pond
ylosis
, lu
mbo
sacr
al sp
ondy
losis,
or sa
cral
spon
dylos
is.OA
invo
lving
lum
bar a
nd/o
r sac
ral a
rea,
dia
gnos
ed cl
inica
lly or
by i
mag
e stu
dies
65
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
mal
aise
anD
fat
iGue
nec
780.
79Us
ed w
hen
docu
men
tatio
n in
dica
tes m
alai
se,
fatig
ue, a
sthe
nia,
or ch
roni
c Eps
tein
Bar
r.Sy
mpt
oms o
f mal
aise
and
fatiq
ue, d
iagn
osed
clin
ically
mal
iGn
neop
l Br
east
nos
174.
910
Brea
st, P
rost
ate,
Co
lorec
tal a
nd
Othe
r Can
cers
an
d Tu
mor
s
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s bre
ast c
ance
r or
mal
igna
nt n
eopl
asm
of th
e bre
ast a
nd th
e pat
ient h
as n
ot co
mpl
eted
trea
tmen
t ai
med
at e
radi
catin
g th
e dise
ase.
Afte
r defi
nitiv
e tre
atm
ent i
s com
plet
e,
docu
men
tatio
n sh
ould
indi
cate
hist
ory o
f bre
ast c
ance
r, an
d co
ded
as V
10.3
.
Activ
e mal
igna
nt ca
ncer
of b
reas
ts d
iagn
osed
by +
mam
ogra
m w
ith +
bx
mal
iGn
neop
l Br
oncH
us &
lun
G un
s si
te16
2.9
8Lu
ng, U
pper
Di
gest
ive Tr
act,
and
Othe
r Sev
ere
Canc
ers
Used
whe
n th
e doc
umen
tatio
n in
dica
tes l
ung
canc
er, b
ronc
hoge
nic
canc
er, p
ulm
onar
y can
cer,
sub-
pleu
ral c
ance
r, or
bro
ncho
geni
c ca
rcin
oma
with
out i
ndica
tion
of th
e spe
cific s
ite.
Diag
nosis
of lu
ng ca
ncer
bas
ed u
pon
post
ive b
iopsy
resu
lt.
mal
iGn
neop
l pr
osta
te18
510
Brea
st, P
rost
ate,
Co
lorec
tal a
nd
Othe
r Can
cers
an
d Tu
mor
s
This
code
is u
sed
when
pro
stat
e can
cer i
s doc
umen
ted.
This
code
ca
n be
use
d fo
r pat
ients
on lo
ng-te
rm Lu
pron
ther
apy.
Note
that
pa
tient
s who
hav
e com
plet
ed th
erap
y for
their
canc
er sh
ould
be
docu
men
ted
with
a h
istor
y of t
he m
alig
nanc
y and
code
d as
V10
.46.
Mal
igna
nt ca
ncer
of th
e pro
stat
e gla
nd d
iagn
osed
by b
iopsy
mal
iGn
neop
l sK
in f
ace
nec
173.
3Th
is co
de is
use
d fo
r mal
igna
ncies
on th
e skin
of th
e fac
e whi
ch
do n
ot h
ave a
spec
ified
code
. If t
here
is a
spec
ific c
ode w
hich
de
scrib
es th
e mal
igna
ncy d
ocum
ente
d, u
se th
at co
de in
stea
d.
Mal
igna
nt sk
in ca
ncer
on th
e fac
e, di
agno
sed
by b
iopsy
66
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
mal
iGna
nt H
Yper
tens
ion
401.
0Th
is co
de sh
ould
only
be u
sed
if th
e med
ical r
ecor
d in
dica
tes
acce
lerat
ing
hype
rtens
ion, n
ecro
tizin
g hy
perte
nsion
or m
alig
nant
hy
perte
nsion
. Thi
s cod
e sho
uld
rare
ly be
seen
in a
phy
sicia
n of
fice
setti
ng. I
t is N
OT sy
nonm
ous w
ith u
ncon
trolle
d hy
perte
nsion
.
Very
eleva
ted
bloo
d pr
essu
re re
sulti
ng in
eye,
kidne
y, an
d ca
rdiov
ascu
lar d
amag
e, di
agno
sed
clini
cally
men
tal
Diso
r ne
c ot
H Di
s29
4.8
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s chr
onic
br
ain
infe
ction
, chr
onic
intra
cran
ial i
nfec
tion,
chro
nic b
rain
tra
uma,
mixe
d af
fect
ive a
nd p
aran
oid st
ate,
mixe
d pa
rano
id a
nd
affe
ctive
pyc
hosis
or d
emen
tia. I
t is a
lso u
sed
when
a sp
ecifi
ed
type o
f men
tal d
isord
er d
oes n
ot h
ave a
mor
e spe
cific c
ode.
Nons
pecifi
c psy
chia
tric c
ondi
tion
may
inclu
de a
ffect
ive,
para
noid
and
psy
chot
ic st
ate,
diag
nose
d cli
nica
lly
mit
ral
ValV
e Di
sorD
er42
4.0
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s mitr
al
valve
diso
rder,
bal
looni
ng p
oste
rior l
eafle
t, Ba
rlow’
s pro
laps
e,
mitr
al va
lve p
rola
pse,
or fl
oppy
mitr
al va
lve.
Any d
isord
er or
dam
age i
nvolv
ing
mitr
al va
lve, i
nclu
ding
sten
osis,
regu
rgita
tion
or p
rola
pse d
iagn
osed
by e
cho,
angi
ogra
m or
othe
r im
age s
tudi
es
miX
eD H
Yper
lipi
Dem
ia27
2.2
Used
whe
n do
cum
enta
tion
stat
es ty
pe II
hy
perli
popr
otein
emia
, xan
thom
a, or
bet
a di
seas
e.Hy
perli
pide
mia
char
acte
rized
by e
levat
ed LD
L (>1
60m
g/dL
) and
ele
vate
d tri
glyc
erid
e (>1
60m
g/dL
), di
agno
sed
by la
b va
lues
mus
cle
Wea
Knes
s (G
ener
aliZ
eD)
728.
87Us
e thi
s cod
e if t
he d
ocum
enta
tion
indi
cate
s tha
t the
pa
tient
is m
yast
heni
c, or
has
mus
cle w
eakn
ess.
A re
duct
ion in
the s
treng
th of
one o
r mor
e mus
cles.
67
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
mYa
lGia
anD
mYo
siti
s no
s72
9.1
Used
whe
n th
e doc
umen
tatio
n in
dica
tes m
yalg
ia, fi
brom
yalg
ia,
myo
sitis,
myo
facia
l pai
n, fi
brom
yosit
is, m
uscle
pai
n,
neur
omus
cula
r pai
n, or
rheu
mat
ic m
uscu
lar p
ain.
Nons
pecifi
c pai
n in
volvi
ng m
uscle
, dia
gnos
ed cl
inica
lly
mYo
pia
367.
1Us
ed w
hen
docu
men
tatio
n in
dica
tes m
yopi
a,
near
sight
edne
ss, o
r sho
rtsig
hted
ness
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
lility
to
focu
s far
way o
bjec
ts, d
iagn
osed
clin
ically
naus
ea W
itH
Vom
itin
G78
7.01
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
he p
rese
nce o
f bot
h na
usea
and
vom
iting
. For
nau
sea
w/o v
omiti
ng, u
se 7
87.0
2;
for v
omiti
ng w
/o n
ause
a do
cum
ente
d, u
se 7
87.0
3
Sym
ptom
s of n
ause
a an
d vo
miti
ng, d
iagn
osed
clin
ically
neur
opat
HY in
Dia
Bete
s35
7.2
71Po
lyneu
ropa
thy
This
code
is u
sed
to d
escr
ibe d
iabe
tic n
euro
path
y, ne
urop
athy
se
cond
ary t
o dia
bete
s, or
dia
bete
s with
neu
ropa
thy.
DM ca
used
neu
rolog
ical m
anife
stat
ions i
nclu
ding
num
bnes
s, tin
glin
g,
burn
ing
sens
ation
s, ga
stro
pare
sis, e
rect
ile d
ysfu
nctio
n, a
uton
omic
inst
abili
ty
or p
ositi
ve fi
ndin
g on
ner
ve co
nduc
tion
stud
y, di
agno
sed
clini
cally
none
XuDa
t m
acul
ar D
eGen
362.
51Us
ed w
hen
the d
ocum
enta
tion
stat
es a
troph
ic m
acul
a, d
ry
mac
ula,
or n
onex
udat
ive m
acul
ar d
egen
erat
ion.
Decr
ease
d vis
ual a
cuity
or ce
ntra
l visi
on lo
ss d
ue to
agi
ng, d
iagn
osed
clin
ically
noni
nf G
astr
oent
erit
nec
558.
9Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes c
hron
ic
ileiti
s, no
n-in
fect
ious i
lieiti
s, ile
ocoli
tis, b
owel/
colon
infla
mm
ation
, in
flam
mat
ory b
owel/
colon
, gas
troin
test
inal
infla
mm
ation
, ilea
l in
flam
mat
ion, j
ejuni
tis, a
cute
colit
is or
cata
rrhal
colit
is.
An in
flam
mat
ion of
the s
tom
ach
and
inte
stin
e res
ultin
g in
dia
rrhea
, with
vom
iting
and
cram
ps w
ith in
fect
ious
work
up b
eing
nega
tive,
diag
nose
d cli
nica
lly
nons
peci
f sK
in e
rupt
nec
782.
1Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s pus
tula
r ras
h,
rash
, ros
e ras
h, to
xic ra
sh, s
kin ra
sh or
exan
them
a.No
nspe
cific r
aise
d, it
chy,
red-
welts
on th
e sur
face
of th
e skin
, usu
ally
due t
o alle
rgic
reac
tion
to fo
od, m
edica
tion,
etc,
diag
nose
d cli
nica
lly
68
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
oBes
itY
nos
278.
00Us
e whe
n th
e med
ical r
ecor
d in
dica
tes o
besit
y.Ch
arac
teriz
ed b
y 20%
over
idea
l bod
y weig
ht or
BM
I of m
ore t
han
30
oBes
itY,
mor
BiD
278.
01Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s mor
bid
obes
ity, m
orbi
dly o
bese
, or s
ever
e obe
sity.
Grad
e 3 ov
erwe
ight
(mor
bid
obes
ity) c
hara
cter
ized
by
a BM
I equ
al to
or g
reat
er th
an 4
0 kg
/m2.
oBs
cHr
Bron
c W
(ac)
eXa
c49
1.21
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n th
e doc
umen
tatio
n in
dica
tes e
xace
rbat
ion of
chro
nic
bron
chiti
s or b
lue b
loate
r with
acu
te ex
acer
batio
n.Ch
roni
c bro
nchi
tis w
ith w
orse
ning
coug
h, sh
ortn
ess o
f br
eath
or h
ypox
ia (p
O2 <
60)
, dia
gnos
ed cl
inica
lly
oBst
ruct
iVe
slee
p ap
nea
327.
23Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes o
bstru
ctive
sle
ep a
pnea
or sl
eep
apne
a wi
th ob
stru
ction
.Ap
nea,
defi
ned
as a
cess
ation
of a
irflow
for a
t lea
st 1
0 se
cond
s wh
ich oc
curs
dur
ing
sleep
due
to ob
stru
ction
(non
cent
ral).
ocl
crtD
art
Wo
infr
ct43
3.10
Used
whe
n th
e doc
umen
tatio
n in
dica
tes c
arot
id st
enos
is, st
enos
is of
caro
tid
arte
ry (c
omm
on, i
nter
nal),
or ca
rotid
occlu
sion,
with
out m
entio
n of
infa
rct.
Sten
osis
or oc
clusio
n of
caro
tid a
rtery
with
out C
VA sy
mpt
oms,
di
agno
sed
clini
cally
and
/or b
y im
agin
g st
udies
olD
mYo
carD
ial
infa
rct
412
83An
gina
Pec
toris
/Ol
d M
yoca
rdia
l In
farc
tion
Use w
hen
a hi
stor
y of m
yoca
rdia
l inf
arct
ion is
doc
umen
ted.
H/O
MI a
s evid
ent b
y Q w
aves
on E
KG or
char
acte
ristic
ab
norm
al w
all m
otion
on ec
ho
69
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
oste
oart
Hros
nos
-l/l
eG71
5.96
Use t
his c
ode w
hen
the d
ocum
enta
tion
stat
es a
rthrit
is,
nonp
yoge
nic a
rthrit
is, a
rthro
path
y, joi
nt in
flam
mat
ion, o
r rh
eum
atism
of th
e low
er p
art o
f the
leg
is do
cum
ente
d.
Non-
spec
ific j
oint p
ain
invo
lving
lowe
r extr
emity
, dia
gnos
ed cl
inica
lly
oste
oart
Hros
nos
-uns
pec
715.
90Us
ed w
hen
docu
men
tatio
n sa
ys a
rthrit
is or
oste
oarth
rosis
or
dege
nera
tive j
oint d
iseas
e and
no s
ite is
des
crib
ed.
Non-
spec
ific O
A ch
arac
teriz
ed b
y join
t pai
n an
d st
iffne
ss, d
iagn
osed
cli
nica
lly or
by x
-ray fi
ndin
gs (n
arro
w joi
nt sp
ace,
bone
spur
s, et
c)
oste
opor
osis
nos
733.
00Us
ed w
hen
docu
men
tatio
n sa
ys os
teop
oros
is.No
nspe
cific d
ecre
ase i
n bo
ne m
ass o
r den
sity,
diag
nose
d cli
nica
lly or
by D
EXA
scan
or ot
her i
mag
e stu
dies
otHe
r al
ter
cons
ciou
snes
780.
09Us
ed w
hen
docu
men
tatio
n st
ates
: deli
rium
, dro
wsin
ess,
hypo
resp
onsiv
e sta
te,
loss o
f con
sciou
snes
s, se
mi c
oma,
sem
i con
sciou
snes
s or s
omno
lence
.No
n-sp
ecifi
c cha
nge i
n m
enta
l sta
tus,
inclu
ding
deli
rium
, dr
owsin
ess,
hypo
resp
onsiv
e sta
te, l
oss o
f con
sciou
snes
s,
sem
i com
a, se
mi c
onsc
iousn
ess o
r som
nolen
ce.
otHe
r co
nVul
sion
s78
0.39
74Se
izure
Diso
rder
s an
d Co
nvul
sions
Use i
f the
doc
umen
tatio
n in
dica
tes e
pilep
tifor
m a
ttack
, sen
sory
and
mot
or a
ttack
, tox
ic ce
rebr
al a
ttack
, ecla
mpt
ic co
ma,
conv
ulsio
ns,
idiop
athi
c con
vulsi
ons,
cere
bral
conv
ulsio
ns, c
ereb
rosp
inal
conv
ulsio
ns,
ecla
mpt
ic co
nvul
sions
, eth
er co
nvul
sions
, gen
eral
ized
conv
ulsio
ns,
infa
ntile
conv
ulsio
ns, i
nter
nal c
onvu
lsion
s, re
curre
nt co
nvul
sions
, re
petit
ive co
nvul
sions
, spa
smod
ic co
nvul
sions
, epi
lepto
id se
izure
s,
ethe
r seiz
ures
, gen
eral
ized
seizu
res,
or co
nvul
sive d
isord
er.
Sudd
en, i
nvolu
ntar
y ske
letal
mus
cula
r con
tract
ions
of ce
rebr
al or
bra
in st
em or
igin
otHe
r Ge
nera
l sY
mpt
oms
780.
99Us
ed w
hen
docu
men
tatio
n in
dica
tes r
igor
s, su
bnor
mal
tem
pera
ture
, fu
nctio
nal a
ctivi
ty de
crea
se, o
r oth
er g
ener
al sy
mpt
oms.
Nons
pecifi
c gen
eral
sym
ptom
s, di
agno
sed
clini
cally
70
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
otHe
r lu
nG D
isea
se n
ec51
8.89
This
code
is u
sed
when
the d
ocum
ente
d typ
e of l
ung
dise
ase h
as n
o oth
er
class
ifica
tion.
Doc
umen
tatio
n sh
ould
indi
cate
one o
f the
follo
wing
: hon
eyco
mb
lung
, bro
nchi
olias
is, p
ulm
olith
iasis
, cal
cifica
tion
of lu
ng, o
r lun
g di
seas
e.
Lung
dise
ase i
nclu
ding
lung
calci
ficat
ion, p
ulm
olith
iasis
, etc
otHe
r sB
orHe
ic K
erat
osis
702.
19Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes s
ebor
rheic
ke
rato
sis, s
ebor
rhea
, seb
orrh
eic w
art o
r ver
ruca
sebo
rrheic
a.Pa
inles
s ben
ign
skin
war
t-like
gro
wth,
dia
gnos
ed cl
inica
lly or
by b
iopsy
otHe
r sp
cf p
reop
eXa
mV7
2.83
This
code
is u
sed
to in
dica
te a
spec
ified
pre
-ope
rativ
e exa
min
ation
th
at d
oes n
ot h
ave a
mor
e spe
cific c
ode,
e.g. r
enal
func
tion
stud
ies
in a
pat
ient w
ith ki
dney
dise
ase,
befo
re u
nder
goin
g su
rger
y.
Perfo
rman
ce of
spec
ific p
reop
erat
ive ex
amin
ation
otHe
r sp
ec r
eHaB
ilit
atio
n pr
oc o
tHV5
7.89
Used
whe
n th
e doc
umen
tatio
n in
dica
tes m
ultip
le typ
es of
on
goin
g re
habi
litat
ion, o
r whe
n th
ere i
s no s
pecifi
c cod
e for
the
type o
f reh
abili
tatio
n th
at th
e pat
ient i
s und
ergo
ing.
N/A
pain
in l
imB
729.
5Pa
in in
arm
, leg
, han
d, fo
ot, fi
nger
s or t
oes.
Pain
in a
rm, l
eg, h
and,
foot
, fing
ers o
r toe
s, di
agno
sed
clini
cally
palp
itat
ions
785.
1Us
e whe
n do
cum
enta
tion
indi
cate
s pal
pita
tions
, pul
ses i
n th
e nec
k, or
you
have
reco
rded
that
the p
atien
t has
an
awar
enes
s of t
heir
hear
tbea
t.Pr
esen
ce of
pal
pita
tion,
dia
gnos
ed cl
inica
lly
71
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
para
lYsi
s aG
itan
s33
2.0
73Pa
rkin
son’s
and
Hu
ntin
gton
’s Di
seas
es
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s Par
kinso
n’s,
Park
inso
n’s d
iseas
e, pa
ralys
is ag
itans
, par
kinso
n’s, s
hakin
g pa
lsy.
Prog
ress
ive, d
egen
erat
ive d
isord
er of
the n
ervo
us sy
stem
char
acte
rized
by
trem
ors,
rigid
ity, b
rady
kines
ia, p
ostu
ral i
nsta
bilit
y, an
d ga
it ab
norm
aliti
es;
caus
ed b
y a lo
ss of
neu
rons
and
a d
ecre
ase o
f dop
amin
e in
the b
asal
gan
glia
.
peri
pH V
ascu
lar
Dis
nos
443.
910
5Va
scul
ar D
iseas
eTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes p
erip
hera
l va
scul
ar d
iseas
e, Ch
arcô
t’s sy
ndro
me,
inte
rmitt
ent c
laud
icatio
n,
vaso
mot
or d
ilata
tion,
ang
iospa
smod
ic di
seas
e, pe
riphe
ral
arte
rial d
iseas
e, va
scul
ar d
iseas
e or s
mal
l ves
sel d
iseas
e.
Athe
rocle
rosis
invo
lving
per
iphe
ral a
rterie
s lea
ding
to p
ain,
ulce
ratio
n or
ga
ngre
ne, d
iagn
osed
clin
ically
with
ank
le-br
achi
al in
dex o
r by a
ngiog
ram
pers
HX
tia
& ci
W/o
res
iDl
Defi
cts
V12.
54Us
e whe
n do
cum
enta
tion
indi
cate
s old
CVA
or h
ealed
CVA
, with
out m
entio
n of
defi
cits,
hist
ory o
f TIA
, old
or h
ealed
cere
bral
hem
orrh
age,
TIA, t
rans
ient
ische
mic
atta
ck or
pro
longe
d re
vers
ible
ische
mic
neur
ologi
c defi
cit (P
RIND
).
Patie
nt w
ith a
per
sona
l hist
ory o
f CVA
with
resid
ual d
eficit
.
pers
onal
His
torY
of
fall
V15.
88Us
ed w
hen
docu
men
tatio
n in
dica
tes f
all,
at ri
sk fo
r fal
ls, fa
ll/fa
lling
haz
ard,
falli
ng d
isord
er, or
falli
ng ri
sk.
Patie
nt w
ith h
istor
y of f
all.
pHYs
ical
tHe
rapY
nec
V57.
1Th
is co
de sh
ould
be u
sed
only
when
the p
atien
t pre
sent
s for
ph
ysica
l the
rapy
, and
this
is no
ted
in th
e med
ical r
ecor
d.Us
ed b
y the
phy
sical
ther
apist
for p
atien
ts p
rese
ntin
g fo
r phy
sical
ther
apy
pleu
ral
effu
sion
nos
511.
9Us
ed w
hen
the d
escr
iptio
n of
the c
ondi
tion
is “p
leura
l ef
fusio
n” w
ithou
t fur
ther
char
acte
rizat
ion.
Nons
pecifi
c pleu
ral fl
uid
in lu
ng ca
vity,
diag
nose
d cli
nica
lly or
by i
mag
e stu
dies
72
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
pneu
mon
ia, o
rGan
ism
nos
486
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s pne
umon
ia, l
ung
infla
mm
ation
; acu
te, b
ilate
ral,
doub
le, or
sept
ic Pl
euro
pneu
mon
ia,
or P
neum
onia
des
crib
ed a
s: ac
ute,
Alpe
nstic
h, b
enig
n, b
ilate
ral,
brai
n, ce
rebr
al, c
ircum
scrib
ed, c
onge
stive
, cre
epin
g.
Bact
eria
l pne
umon
ia ca
used
by a
non
spec
ified
orga
nism
, di
agno
sed
clini
cally
and
/or b
y im
age s
tudy
prec
orDi
al p
ain
786.
51Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n st
ates
pre
cord
ial
pain
, car
dial
gia,
ang
inoid
pai
n, m
idst
erna
l pai
n, su
bste
rnal
pa
in, h
eart
pain
, per
icard
ial p
ain,
or re
trost
erna
l pai
n. If
the
docu
men
tatio
n sa
ys a
ngin
a, th
en th
e cor
rect
code
is 4
13.9
.
Nons
pecifi
c or n
on ca
rdia
c che
st d
iscom
fort
othe
r th
an a
ngin
a, d
iagn
osed
clin
ically
preo
p ca
rDio
Vscl
r eX
amV7
2.81
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
ex
amin
ation
is fo
r car
diov
ascu
lar c
leara
nce p
reop
erat
ively.
Perfo
rman
ce of
pre
-ope
rativ
e car
diov
ascu
lar e
valu
tion
preo
p eX
am u
nspc
fV7
2.84
Use o
nly w
hen
your
doc
umen
tatio
n in
dica
tes y
ou a
re d
oing
a hi
stor
y an
d ph
ysica
l exa
min
ation
for a
pat
ient h
avin
g a
surg
ical p
roce
dure
Perfo
rman
ce of
H &
P p
rior t
o sur
gica
l pro
cedu
re
pres
BYop
ia36
7.4
Used
whe
n do
cum
enta
tion
indi
cate
s “pr
esby
opia
” or i
nsuf
ficien
t acc
omod
ation
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
ility
to fo
cus o
n clo
se ob
jects
due
to a
ging
, dia
gnos
ed cl
inica
lly
73
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
prim
car
Diom
Yopa
tHY
nec
425.
480
Cong
estiv
e He
art F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umen
ation
indi
cate
s prim
ary
card
iomyo
path
y, id
iopat
hic c
ardi
omyo
path
y, id
iopat
hic m
yoca
rdia
l hy
pertr
ophy
, myo
card
iopat
hy d
escr
ibed
as:
cong
estiv
e, co
nstri
ctive
, fam
ilial
, hy
pertr
ophi
c non
obst
ruct
ive, i
diop
athi
c or i
nfiltr
ative
card
iomyo
path
y.
Abno
rmal
card
iac f
unct
ion w
here
SOB
, CP
and
perip
hera
l ede
ma
are
card
inal
sym
ptom
s, in
cludi
ng id
iopat
hic,
dila
ted,
rest
rictiv
e, co
nstri
ctive
and
hy
pertr
ophi
c etio
logies
, dia
gnos
ed b
y ech
o, an
giog
ram
and
othe
r im
age s
tudi
es
prim
ope
n an
Gle
Glau
com
a36
5.11
Use w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
glau
com
a, si
mpl
e gl
auco
ma,
or op
en a
ngle
glau
com
a. N
OTE:
DO
NOT U
SE th
is co
de
if yo
ur n
ote s
ays o
nly “
Glau
com
a”, w
hich
is co
ded
365.
9.
Chro
nic i
ncre
ase i
n in
traoc
ular
pre
ssur
e cau
sing
optic
ner
ve d
amag
e, lea
ding
to
visu
al im
pairm
ent d
iagn
osed
by t
onom
etry
and/
or op
htha
lmos
copi
c exa
m
pulm
onar
Y co
llap
se51
8.0
Used
whe
n do
cum
enta
tion
indi
cate
s Bro
ck’s
synd
rom
e, at
elect
asis,
rig
ht m
iddl
e lob
e syn
drom
e, po
stin
fect
ive a
telec
tasis
, par
tial
atele
ctas
is, co
mpr
essio
n at
elect
asis,
pul
mon
ary a
telec
tasis
, com
plet
e at
elect
asis,
pre
ssur
e coll
apse
or re
laxa
tion
atele
ctas
is.
Com
plet
e or p
artia
l coll
apse
of a
por
tion
of th
e lun
g, d
iagn
osed
cli
nica
lly a
nd/o
r by i
mag
e stu
dies
/bro
ncho
scop
y
pulm
onar
Y co
nGes
t/HY
post
asis
514
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s che
st
cong
estio
n, p
ulm
onar
y con
gest
ion, p
ulm
onar
y hyp
osta
tis, h
ypos
tatic
lu
ng, c
hron
ic lu
ng h
ypos
tasis
, lun
g co
nges
tion,
pas
sive l
ung,
Po
tain
’s di
seas
e/sy
drom
e, lu
ng ed
ema,
or te
rmin
al lu
ng.
Incr
ease
flui
d wi
thin
the l
ungs
lead
ing
to co
ugh
and
SOB,
di
agno
sed
clini
cally
and
or b
y im
age s
tudi
es
pure
HYp
ercH
oles
tero
lem
272.
0Us
ed w
hen
docu
men
tatio
n in
dica
tes h
yper
chole
ster
olem
ia,
Hype
rbet
alip
opro
tein
emia
, or c
holes
tero
lemia
.Co
nditi
on ch
arac
teriz
ed b
y elev
ated
chole
stro
l (>
200)
rect
al &
ana
l He
mor
rHaG
e56
9.3
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient
has r
ecta
l blee
ding
, ana
l blee
ding
, rec
tal h
emor
rhag
e, an
al h
emor
rhag
e,
BRBP
R (b
right
red
bloo
d pe
r rec
tum
) or h
emor
rhag
e of a
nus.
Blee
ding
from
rect
um a
nd/o
r anu
s, di
agno
sed
clini
cally
an
d/or
by e
ndos
copy
/imag
e stu
dies
74
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
recu
rr D
epr
psYc
Hos-
unsp
296.
3055
Maj
or D
epre
ssive
, Bi
pola
r, an
d Pa
rano
id
Diso
rder
s
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
recu
rrent
(thi
s mus
t be
spec
ified
) epi
sode
of in
volu
tiona
l dep
ress
ion, r
ecur
rent
mela
ncho
lia,
recu
rrent
dep
ress
ive p
sych
osis,
inte
rmitt
ent r
ecur
rent
mela
ncho
lia,
recu
rrent
invo
lutio
nal m
elanc
olia
or re
curre
nt m
enop
ausa
l dep
ress
ion.
Nons
pecifi
ed re
curre
nt d
epre
ssion
(dep
ress
ed m
ood,
loss
of in
tere
st, c
hang
e in
app
etite
, slee
p di
stur
banc
e, be
havio
r cha
nge,
decr
ease
in en
ergy
, gui
lt,
inab
ility
to co
ncen
trate
, or s
uicid
e tho
ught
s) w
ith d
elusio
n an
d/or
hal
lucin
ation
refl
uX e
sopH
aGit
is53
0.11
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es re
flux
esop
hagi
tis, o
r eso
phag
eal r
eflux
with
esop
hagi
tis.
Infla
mm
ation
of es
opha
gus c
ause
d by
bac
kflow
of st
omac
h flu
id le
adin
g to
acid
ic ta
ste i
n th
e mou
th, e
piga
stric
ab
dom
inal
pai
n di
agno
sed
clini
cally
and
/or b
y EGD
refr
acti
on D
isor
Der
nos
367.
9Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
amet
ropi
a, re
fract
ion er
ror,
refra
ction
diso
rder,
refra
ctive
erro
r, su
bnor
mal
acc
omod
ation
or a
ccom
odat
ion d
isord
er.
Refra
ctive
erro
r of t
he ey
e, ex
cludi
ng m
yopi
a an
d pr
esby
opia
, dia
gnos
ed cl
inica
lly
reGu
lar
asti
Gmat
ism
367.
21Us
e thi
s cod
e whe
n th
e doc
umen
tatio
n in
dica
tes a
stig
mat
ism.
Refra
ction
erro
r of t
he ey
e cha
ract
erize
d by
an
asph
erica
l co
rnea
lead
ing
to d
istor
ted
imag
e, di
agno
sed
clini
cally
rena
l &
uret
eral
Dis
nos
593.
9Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s im
paire
d kid
ney
func
tion,
kidn
ey in
actio
n, ki
dney
inef
ficien
cy, k
idne
y infi
ltrat
e,
kidne
y dise
ase,
acut
e kid
ney d
iseas
e, ac
ute r
enal
dise
ase,
salt
synd
rom
e, sa
lt los
ing
dise
ase o
r sal
t was
ting
dise
ase.
Nons
pecifi
c ren
al a
nd/o
r ure
tera
l dys
func
tion,
dia
gnos
ed cl
inica
lly
75
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
rena
l Di
alYs
is s
tatu
sV4
5.11
130
Dial
ysis
Stat
usTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
that
the p
atien
t rec
eives
hem
odia
lysis.
Patie
nts u
nder
goin
g re
nal d
ialys
is.
rena
l fa
ilur
e no
s58
613
1Re
nal F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes u
rem
ia, r
enal
fa
ilure
, ure
mic
com
a, re
nal s
hutd
own,
kidn
ey st
asis,
rena
l sta
sis, r
enal
su
ppre
ssion
, ure
mic
toxe
mia
, urin
ary t
oxem
ia, u
rem
ic ab
sorp
tion,
ur
emic
amau
rosis
, ure
mic
ambl
yopi
a, or
ure
mic
apha
sia.
Loss
of ki
dney
func
tion
char
acte
rized
by r
ise in
crea
tinin
e, de
crea
sed
GFR
and/
or in
abili
ty to
pro
duce
urin
e, di
agno
sed
clini
cally
or b
y lab
valu
es
resp
irat
orY
aBno
rm n
ec78
6.09
This
code
is u
sed
when
the d
ocum
enta
tion
says
hyp
erca
pnia
, hy
pove
ntila
tion,
irre
gula
r bre
athi
ng or
labo
red
brea
thin
g al
so d
yspn
ea
on ex
ertio
n, re
spira
tory
dist
ress
and
resp
irato
ry in
suffi
cienc
y.
Nons
pecifi
c pul
mon
ary s
ympt
oms i
nclu
ding
shor
tnes
s of b
reat
h,
hypo
vent
ilatio
n, d
yspn
ea on
exer
cise,
hype
rcap
nia,
etc
rHeu
mat
oiD
artH
riti
s71
4.0
38Rh
eum
atoid
Ar
thrit
is an
d In
flam
mat
ory
Conn
ectiv
e Tis
sue D
iseas
e
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es rh
eum
atoid
arth
ritis,
rh
eum
atic
arth
ritis,
chro
nic p
olyar
thrit
is, rh
eum
atoid
torti
colli
s, pr
imar
y pr
ogre
ssive
arth
ritis,
pro
lifer
ative
arth
ritis,
or a
troph
ic ar
thrit
is.
Chro
nic i
nflam
mat
ory d
isord
er fo
r mor
e tha
n 6
wks,
diag
nose
d cli
nica
lly w
ith 4
out o
f the
follo
wing
: affe
ctin
g 3
or m
ore j
oints
, m
orni
ng st
iffne
ss, s
ymm
etric
al jo
int p
ain,
PIP
/MCP
join
t inv
olvem
ent,
rheu
mat
oid n
odul
es, e
rosio
n on
x-ra
y and
+RF
or +
CCP
rout
ine
GYn
eXam
inat
ion
V72.
31Us
ed on
ly wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t pr
esen
ted
for a
rout
ine g
ynec
ologi
cal e
xam
inat
ion. T
his c
ode i
s not
to
be u
sed
for p
atien
ts w
ith a
know
n gy
neco
logica
l con
ditio
n.
Perfo
rman
ce of
rout
ine g
ynec
ologi
cal e
xam
rout
ine
meD
ical
eXa
mV7
0.0
Used
to in
dica
te th
at th
e pat
ient i
s see
n fo
r a ro
utin
e (e.g
., pr
even
tive)
serv
ice.
Perfo
rman
ce of
rout
ine m
edica
l exa
min
ation
76
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
scia
tica
724.
3Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes C
otun
go’s
dise
ase,
Cotu
ngo’s
synd
rom
e, Isc
hial
gia,
sacr
oilia
c join
t neu
ralg
ia,
scia
tic n
eura
lgia
, scia
tic p
ain,
infe
ction
al sc
iatic
a or
scia
tica.
Irrita
tion
of sc
iatic
ner
ve le
adin
g to
pai
n an
d tin
glin
g se
nsat
ion
radi
atin
g do
wn lo
wer e
xtrem
ities
, dia
gnos
ed cl
inica
lly
scre
en m
aliG
neo
p-ce
rViX
V76.
2Th
is co
de is
use
d wh
en th
e pat
ient p
rese
nts f
or a
scre
enin
g Pa
p sm
ear.
Perfo
rman
ce of
pap
smea
r for
cerv
ical c
ance
r scr
eeni
ng
scre
en m
aliG
neo
p-co
lon
V76.
51Us
e thi
s cod
e whe
n th
e pat
ient h
as n
o sym
ptom
s and
you
are
perfo
rmin
g a
colon
osco
py or
stoo
l for
occu
lt bl
ood.
Perfo
rman
ce of
colon
canc
er sc
reen
ing,
inclu
ding
colon
osco
py,
chec
king
stoo
l for
occu
lt bl
ood,
or b
ariu
m en
ema
scre
en m
amm
oGra
m n
ecV7
6.12
Used
by t
he sc
reen
ing
mam
mog
raph
y cen
ter o
r int
erpr
etin
g ra
diolo
gist
wh
en th
e pat
ient i
s see
n fo
r a sc
reen
ing
mam
mog
ram
.Pe
rform
ance
of m
amm
ogra
m fo
r bre
ast c
ance
r scr
eeni
ng
seco
nDar
Y HY
perp
arat
HYro
iDis
m58
8.81
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s se
cond
ary h
yper
para
thyro
idism
.El
evat
ed P
TH le
vel s
econ
dary
to re
nal d
iseas
e.
seni
le c
atar
act
nos
366.
10Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes s
enile
ca
tara
ct, o
r cat
arac
ta se
nilis
is d
ocum
ente
d.Ag
e rela
ted
opac
ifica
tion
of le
ns le
adin
g to
impa
ired
vision
, dia
gnos
ed cl
inica
lly
seni
le D
emen
tia
unco
mp
290.
0Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s dem
entia
, dem
entia
of ol
d ag
e, se
nile
de
men
tia, s
enile
ane
rgas
ia, i
diop
athi
c sen
ility,
seni
le or
seni
le ex
haus
tion.
Loss
of in
telle
ctua
l fun
ction
s due
to ol
d ag
e lea
ding
to
inte
rfere
nce o
f dai
ly fu
nctio
n, d
iagn
osed
clin
ically
77
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
seni
le n
ucle
ar c
atar
act
366.
16Us
ed w
hen
the d
ocum
enta
tion
stat
es se
nile
cata
ract
, cat
arac
ta
brun
ecen
s cat
arac
ta n
igra
or n
uclea
r cat
arac
t.Ag
e rela
ted
cata
ract
, dia
gnos
ed cl
inica
lly
seni
le o
steo
poro
sis
733.
01Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes o
steo
poro
sis,
seni
le os
teop
oros
is or
pos
t-men
opau
sal o
steo
poro
sis.
Decr
ease
in b
one m
ass o
r den
sity d
ue to
old
age d
iagn
osed
cli
nica
lly b
y DEX
A sc
an a
nd/o
r im
age s
tudi
es
seVe
re s
epsi
s99
5.91
Use w
hen
docu
men
tatio
n in
dica
tes s
ever
e sep
sis,
gene
raliz
ed se
psis,
or S
IRS
due t
o inf
ectio
n.Se
vere
seps
is is
an a
dmin
istra
tive d
iagn
osis,
whi
ch is
de
fined
as s
epsis
with
ass
ocia
ted
orga
n dy
sfun
ction
.
sHor
tnes
s of
Bre
atH
786.
05Us
ed w
hen
the d
ocum
enta
tion
says
shor
tnes
s of b
reat
h.Sy
mpt
om of
shor
tnes
s of b
reat
h
sino
atri
al n
oDe
DYsf
unct
427.
8192
Spec
ified
Hea
rt Ar
rhyth
mia
sUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
sinus
bra
dyca
rdia
, sin
o-at
rial (
SA) b
rady
card
ia (w
ith or
with
out p
arox
ysm
al
tach
ycar
dia)
NOT
E: A
cute
sinu
s bra
dyca
rdia
is 4
27.8
9.
Dise
ase a
nd/o
r Dys
func
tion
of S
A no
de le
adin
g to
non
-sin
us
rhyth
m, b
rady
card
ia d
iagn
osed
by E
CG or
rhyth
m m
onito
r
sKin
Dis
orDe
r no
s70
9.9
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
erm
atos
is,
skin
dise
ase,
perin
eal i
rrita
tion,
or sk
in so
res.
Nons
pecifi
c skin
diso
rder,
inclu
ding
infla
mm
ation
, disc
olora
tion,
in
fect
ion, g
rowt
h, ir
ritat
ion, e
tc, d
iagn
osed
clin
ically
and
/or b
y biop
sy
spin
al s
teno
sis-
lum
Bar
724.
02Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
lum
bar s
pina
l ste
nosis
or lu
mbo
sacr
al st
enos
is.Na
rrowi
ng of
the s
pina
l can
al le
adin
g to
the c
ompr
essio
n of
th
e spi
nal c
ord
and
nerv
es le
adin
g to
pai
n an
d/or
abn
orm
al
sens
ation
, dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
stat
us c
arDi
ac p
acem
aKer
V45.
01Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat
the p
atien
t has
a ca
rdia
c pac
emak
er in
pla
ce.
Pace
mak
er p
lace
men
t, di
agno
sed
clini
cally
or b
y im
agin
g st
udy
sWel
linG
of
lim
B72
9.81
Used
whe
n th
e doc
umen
tatio
n in
dica
tes s
welli
ng in
a li
mb,
inclu
ding
dig
its.
Swell
ing
in a
lim
b in
cludi
ng d
igits
, dia
gnos
ed cl
inica
lly
78
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
sYnc
ope
anD
coll
apse
780.
2Th
is co
de sh
ould
be u
sed
when
the d
ocm
enta
tion
indi
cate
s syn
cope
(w
ithou
t und
erlyi
ng ca
use)
, coll
apse
, unc
onsc
iousn
ess,
vaso
-vag
al
atta
ck, v
agal
sync
ope,
vaso
mot
or a
ttack
, bla
ckou
t, fa
intin
g, G
ower
’s sy
ndro
me,
vasc
ular
hyp
erre
acto
r, or
vaso
mot
or in
stab
ility.
Loss
of co
nscio
usne
ss d
ue to
inad
equa
te b
lood
flow
to th
e bra
in, d
iagn
osed
clin
ically
tear
fil
m in
suff
ic n
os37
5.15
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
ry ey
e syn
drom
e, in
suffi
cient
tear
s,
insu
fficie
nt te
ar se
cret
ion, d
eficie
nt la
crim
al fl
uid,
tear
film
defi
cienc
y or d
ry ey
e.In
suffi
cient
tear
secr
etion
with
sym
ptom
s of e
ye ir
ritat
ion,
injec
tion,
dia
gnos
ed cl
inica
lly a
nd/o
r by S
chirm
er te
st
toBa
cco
use
Diso
rDer
305.
1Us
ed w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient i
s a cu
rrent
smok
er.
Past
hist
ory o
f sm
okin
g is
code
d as
V15
.89
(per
sona
l hist
ory o
f tob
acco
use
).Cu
rrent
toba
cco u
ser,
diag
nose
d by
hist
ory
tran
s al
ter
aWar
enes
s78
0.02
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
ltera
tion
of co
nscio
usne
ss,
trans
ient a
ltera
tion
of a
ware
ness
or tr
ansie
nt a
ltera
tion
of co
nscio
usne
ss.
Trans
ient a
ltera
tion
of co
nscio
usne
ss, d
iagn
osed
clin
ically
tran
s ce
reB
iscH
emia
nos
435.
9Us
ed w
hen
docu
men
tatio
n in
dica
tes t
rans
ient i
sche
mic
atta
ck, o
r TIA
.Su
dden
brie
f or t
rans
ient f
ocal
bra
in n
euro
defi
cit,
last
ing
less t
han
24 h
rs d
iagn
osed
clin
ically
unc
BeHa
V ne
o sK
in23
8.2
Used
whe
n th
e doc
umen
tatio
n in
dica
tes
Kera
toac
anth
oma
or b
athi
ng tr
unk n
evus
.A
nonc
ance
rous
, rap
idly
grow
ing
skin
tum
or th
at u
sual
ly oc
curs
on
sun-
expo
sed
area
s of t
he sk
in th
at ca
n go
awa
y with
out t
reat
men
t.
unsp
ecif
ieD
DeBi
litY
799.
3Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n st
ates
gen
eral
(ized
) de
bilit
y, de
bilit
y, or
gen
eral
dec
line a
re d
ocum
ente
d.Un
spec
ified
deb
ility.
Exc
lude
s ast
heni
a, n
ervo
us
debi
lity,
neur
asth
enia
and
seni
le as
then
ia
79
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
unsp
ecif
ieD
rete
ntio
n of
ur
ine
788.
20Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes u
rinar
y re
tent
ion, b
ladd
er re
tent
ion, u
rine s
topp
age,
or u
rine s
tasis
.In
com
plet
e em
ptyin
g of
the b
ladd
er
unsp
ecif
ieD
sept
icem
ia03
8.9
2Se
ptice
mia
/Sho
ckUs
ed if
the d
ocum
enta
tion
indi
cate
s pye
mia
, pye
mic
feve
r, py
emic
in
fect
ion, n
adir
seps
is, se
ptice
mia
, sep
ticem
ic, se
ptic
toxe
mia
, or b
lood
poiso
ning
. NOT
E: Th
is co
de sh
ould
not
be u
sed
in a
phy
sicia
n’s of
fice
setti
ng. P
atien
ts w
ith se
psis
are t
reat
ed in
a h
ospi
tal s
ettin
g. If
this
is
a fo
llow
up vi
sit fo
r a re
cent
ly di
scha
rged
pat
ient w
ho h
ad se
psis,
the
corre
ct co
de is
V12
.09,
hist
ory o
f oth
er in
fect
ious a
nd p
aras
itic d
iseas
e.
For t
hese
pur
pose
s, th
e ter
m se
ptice
mia
is a
n ad
min
stra
tive t
erm
. Se
ptice
mia
is d
efine
d as
syst
emic
dise
ase a
ssoc
iate
d wi
th th
e pre
senc
e of
pat
holog
ical m
icroo
rgan
isms
or to
xins i
n th
e bloo
dstre
am.
unsp
ecif
ieD
Vita
min
D
Defi
cien
cY26
8.9
Use w
hen
the d
ocum
enta
tion
indi
cate
s Vita
min
D d
eficie
ncy,
calci
fero
l de
ficien
cy, e
rgos
tero
l defi
cienc
y, or
vioe
ster
ol de
ficien
cy.
Vita
min
D 2
5 Hy
drox
y Lev
el of
less
than
50
ng/m
L
urin
arY
inco
ntin
ence
nos
788.
30Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n on
ly st
ates
that
the p
atien
t ha
s urin
ary i
ncon
tinen
ce w
ithou
t sta
ting
the e
tiolog
y or t
ype.
Unsp
ecifi
ed lo
ss of
cont
rol o
f urin
e, di
agno
sed
clini
cally
urin
arY
trac
t in
fect
ion
nos
599.
0Us
ed w
hen
docu
men
tatio
n sa
ys U
TI.Co
nditi
on ch
arac
teriz
ed w
ith sy
mpt
oms o
f urin
ary f
requ
ency
, dy
suria
, hem
atur
ia, d
iagn
osed
clin
ically
and
/or p
ositi
ve U
A
Vacc
in f
or in
flue
nZa
V04.
81Us
ed to
indi
cate
that
the p
atien
t is s
een
for i
nflue
nza
vacc
ine.
Perfo
rman
ce of
influ
enza
vacc
inat
ion
Vacc
in s
trpt
cs p
neum
ni B
V03.
82Th
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
he p
atien
t re
ceive
d st
rept
ococ
cus p
neum
onia
e [pn
eum
ococ
cus]
vacc
ine.
Adm
inist
ratio
n of
pne
umoc
occa
l vac
cinat
ion
80
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX D
escr
ipti
onDX
coD
e de
Hcc
Hcc
Desc
ript
ion
Docu
men
tati
on r
equi
rem
ents
for
coD
e us
ecl
inic
al c
rite
ria
Diagnoses by ICD
-9 Code
Cover & Tabs.indd 4 6/7/12 12:35 PM
81
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DiA
Gn
oSeS b
y ICD-9CO
DE
DX C
oDe
DX D
escr
iptio
nHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
038.
9UN
SPEC
IFIED
SEP
TICEM
IA2
Sept
icem
ia/
Shoc
kUs
ed if
the d
ocum
enta
tion
indi
cate
s pye
mia
, pye
mic
feve
r, py
emic
infe
ction
, nad
ir se
psis,
sept
icem
ia, s
eptic
emic,
sept
ic to
xem
ia, o
r bloo
d po
isoni
ng. N
OTE:
This
code
sh
ould
not
be u
sed
in a
phy
sicia
n’s of
fice s
ettin
g. P
atien
ts w
ith se
psis
are t
reat
ed in
a
hosp
ital s
ettin
g. If
this
is a
follo
w up
visit
for a
rece
ntly
disc
harg
e pat
ient w
ho h
ad
seps
is, th
e cor
rect
code
is V
12.0
9, h
istor
y of o
ther
infe
ctiou
s and
par
asiti
c dise
ase.
For t
hese
pur
pose
s, th
e ter
m se
ptice
mia
is a
n ad
min
stra
tive t
erm
. Se
ptice
mia
is d
efine
d as
syst
emic
dise
ase a
ssoc
iate
d wi
th th
e pre
senc
e of
pat
holog
ical m
icroo
rgan
isms o
r tox
ins i
n th
e bloo
dstre
am.
110.
1DE
RMAT
OPHY
TOSI
S OF
NAI
LUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s der
mat
ophy
tosis
of n
ail,
fung
us of
nai
l, to
enai
l fun
gus,
or fi
nger
nail
fung
us.
Fung
al in
fect
ion of
the n
ail,
diag
nose
d cli
nica
lly or
by b
iopsy
162.
9M
ALIG
N NE
OPL B
RONC
HUS
& LU
NG U
NS S
ITE8
Lung
, Upp
er
Dige
stive
Trac
t, an
d Ot
her
Seve
re C
ance
rs
Used
whe
n th
e doc
umen
tatio
n in
dica
tes l
ung
canc
er, b
ronc
hoge
nic
canc
er, p
ulm
onar
y can
cer,
sub-
pleu
ral c
ance
r, or
bro
ncho
geni
c ca
rcin
oma
with
out i
ndica
tion
of th
e spe
cific s
ite.
Diag
nosis
of lu
ng ca
ncer
bas
ed u
pon
post
ive b
iopsy
resu
lt.
173.
3M
ALIG
N NE
OPL
SKIN
FACE
NEC
This
code
is u
sed
for m
alig
nanc
ies on
the s
kin of
the f
ace w
hich
do
not h
ave a
spec
ified
code
. If t
here
is a
spec
ific c
ode w
hich
des
crib
es
the m
alig
nanc
y doc
umen
ted,
use
that
code
inst
ead.
Mal
igna
nt sk
in ca
ncer
on th
e fac
e, di
agno
sed
by b
iopsy
82
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
174.
9M
ALIG
N NE
OPL
BREA
ST N
OS10
Brea
st, P
rost
ate,
Co
lorec
tal a
nd
Othe
r Can
cers
an
d Tu
mor
s
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s bre
ast c
ance
r or
mal
igna
nt n
eopl
asm
of th
e bre
ast a
nd th
e pat
ient h
as n
ot co
mpl
eted
trea
tmen
t ai
med
at e
radi
catin
g th
e dise
ase.
Afte
r defi
nitiv
e tre
atm
ent i
s com
plet
e,
docu
men
tatio
n sh
ould
indi
cate
hist
ory o
f bre
ast c
ance
r, an
d co
ded
as V
10.3
.
Activ
e mal
igna
nt ca
ncer
of b
reas
ts d
iagn
osed
by +
mam
ogra
m w
ith +
bx
185
MAL
IGN
NEOP
L PRO
STAT
E10
Brea
st, P
rost
ate,
Co
lorec
tal a
nd
Othe
r Can
cers
an
d Tu
mor
s
This
code
is u
sed
when
pro
stat
e can
cer i
s doc
umen
ted.
This
code
can
be u
sed
for p
atien
ts on
long
-term
Lupr
on th
erap
y. No
te th
at p
atien
ts
who h
ave c
ompl
eted
ther
apy f
or th
eir ca
ncer
shou
ld b
e doc
umen
ted
with
a h
istor
y of t
he m
alig
nanc
y and
code
d as
V10
.46.
Mal
igna
nt ca
ncer
of th
e pro
stat
e gla
nd d
iagn
osed
by b
iopsy
211.
3BE
NIGN
NEO
PLAS
M
LG B
OWEL
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
deno
mat
osis,
Cro
nkhi
te-C
anad
a sy
ndro
me,
colon
poly
p, a
ppen
dix p
olyp,
capu
t coli
poly
p, ce
cum
poly
p,
ileoc
ecal
poly
p, h
epat
ic fle
xure
poly
p or
fam
ilial
ade
nom
atou
s poly
p.
Non-
canc
erou
s les
ion in
colon
, dia
gnos
ed b
y colo
nosc
opy a
nd/o
r rad
iolog
ic st
udies
238.
2UN
C BE
HAV
NEO
SKIN
Used
whe
n th
e doc
umen
tatio
n in
dica
tes K
erat
oaca
ntho
ma
or b
athi
ng tr
unk n
evus
.A
nonc
ance
rous
, rap
idly
grow
ing
skin
tum
or th
at u
sual
ly oc
curs
on su
n-ex
pose
d ar
eas o
f the
skin
that
can
go a
way w
ithou
t tre
atm
ent.
244.
9HY
POTH
YROI
DISM
NOS
Used
whe
n do
cum
enta
tion
indi
cate
s hyp
othy
roid
ism, o
r pos
t-sur
gica
l hyp
othy
roid
sm.
Low
thyro
id st
ate c
hara
cter
ized
by lo
w en
ergy
stat
e, de
pres
sion,
wea
knes
s,
edem
a, co
nstip
ation
, dia
gnos
ed b
y hig
h TS
H an
d us
ually
low
Tota
l T3,
Tota
l T4
250.
00DM
II W
O CM
P NT
ST
UNC
NTRL
D19
Diab
etes
with
out
Com
plica
tion
If di
agno
sis in
dica
tes D
M, d
iabe
tes m
ellitu
s or d
iabe
tes,
this
is
the c
orre
ct co
de. W
hen
unsp
ecifi
ed in
the m
edica
l rec
ord,
dia
bete
s is
assu
med
to b
e typ
e II b
ased
on IC
D-9
guid
eline
s.
DM 2
with
out c
ompl
icatio
n, n
ot st
ated
as u
ncon
trolle
d, d
iagn
osed
clin
ically
83
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
250.
01DM
I WO
CMP
NT
ST U
NCNT
RLD
19Di
abet
es w
ithou
t Co
mpl
icatio
nTh
is co
de sh
ould
be u
sed
when
you
have
doc
umen
ted
DM 1
or ju
veni
le di
abet
es is
doc
umen
ted.
Cont
rolle
d DM
1 w
ithou
t com
plica
tion
250.
02DM
II W
O CM
P UN
CNTR
LD19
Diab
etes
with
out
Com
plica
tion
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient h
as D
M II
(or
the t
ype i
s not
stat
ed) a
nd th
e phy
sicia
n sp
ecifi
cally
stat
es th
at th
e dia
bete
s is
“unc
ontro
lled”
or “o
ut of
cont
rol.”
NOT
E: p
oor/p
oorly
cont
rol i
s not
acc
epta
ble.
Unco
ntro
lled
DM 2
with
out e
nd-o
rgan
com
plica
tion.
Micr
o alb
umin
/Cr r
atio<
299
250.
40DM
II RE
NL N
T ST
UNCN
TRLD
15Di
abet
es
with
Ren
al
or P
erip
hera
l Ci
rcul
ator
y M
anife
stat
ion
Use o
nly w
hen
docu
men
tatio
n in
dica
tes t
he p
atien
t has
rena
l dise
ase
that
is se
cond
ary t
o dia
bete
s, or
dia
betic
rena
l dise
ase.
The I
CD-9
do
es n
ot a
ssum
e a ca
usal
rela
tions
hip,
so yo
u m
ust i
nclu
de it
in
your
doc
umen
tatio
n. Yo
u m
ust a
lso co
de th
e ren
al d
iseas
e.
Cont
rolle
d DM
2 w
ith re
nal m
anife
stat
ions c
ause
d by
the
diab
etes
(ren
al m
anife
stat
ion in
clude
d al
bum
inur
ia, p
rote
inur
ia,
decr
ease
d GF
R, C
r, et
c) D
iabe
tic N
euro
path
y MA/
CR>2
99
250.
42DM
II W
/REN
AL U
NS/
UNCN
TRLD
15Di
abet
es
with
Ren
al
or P
erip
hera
l Ci
rcul
ator
y M
anife
stat
ion
Use w
hen
the d
ocum
enta
tion
indi
cate
s unc
ontro
lled
or ou
t of c
ontro
l dia
bete
s(eit
her
type I
I or n
o typ
e sta
ted)
with
rena
l man
ifest
ation
s or c
ompl
icatio
ns.
Diab
etes
with
abn
orm
al b
lood
gluc
ose v
alue
s and
pr
otein
uria
or ot
her e
viden
ce of
kidn
ey d
amag
e.
250.
50DM
II OP
HTH
NT
ST U
NCNT
RLD
18Di
abet
es w
ith
Opht
halm
ologi
c or
Uns
pecifi
ed
Man
ifest
ation
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
hat o
phth
alm
ologi
cal
cond
ition
s are
seco
ndar
y to,
or ca
used
by d
iabe
tes.
The d
ocum
enta
tion
mus
t ind
icate
the c
ausa
l rela
tions
hip.
This
code
is n
ot u
sed
when
an
eye c
ondi
tion
simpl
y co-
exist
s (i.e
., co
mor
bid)
with
dia
bete
s.
Cont
rolle
d DM
2, w
hich
has
caus
ed ey
e find
ings
such
as M
acul
a ed
ema,
visio
n ch
ange
, ret
inop
athy
, cat
arac
t, re
tinal
edem
a, vi
treou
s hem
orrh
age,
micr
oane
urys
ms,
an
d bl
indn
ess,
diag
nose
d cli
nica
lly a
nd/o
r by o
phth
alm
osco
pic e
xam
84
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
250.
60DM
II NE
URO
NT
ST U
NCNT
RLD
16Di
abet
es w
ith
Neur
ologi
c or
Othe
r Spe
cified
M
anife
stat
ion
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient h
as a
neu
rolog
ical
com
plica
tion
of th
eir d
iabe
tes.
The d
ocum
enta
tion
mus
t ind
icate
that
the c
ompl
icatio
n is
seco
ndar
y to t
he d
iabe
tes.
The n
euro
logica
l com
plica
tion
mus
t be s
pecifi
ed.
Cont
rolle
d DM
2, w
ith n
euro
logica
l man
ifest
ation
s 2º D
M in
cludi
ng n
umbn
ess,
tin
glin
g, b
urni
ng se
nsat
ions,
gast
ropa
resis
, ere
ctile
dys
func
tion,
aut
onom
ic in
stab
ility
or
pos
itive
find
ing
on n
erve
cond
uctio
n st
udy o
r fai
led m
onofi
lam
ent t
est o
f foo
t
250.
70DM
II CI
RC N
T ST
UNCN
TRLD
15Di
abet
es
with
Ren
al
or P
erip
hera
l Ci
rcul
ator
y M
anife
stat
ion
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t circ
ulat
ory
diso
rder
s are
seco
ndar
y to o
r cau
sed
by d
iabe
tes m
ellitu
s. Fo
r ex
ampl
e, di
abet
ic an
giop
athy
, gan
gren
e 2º d
iabe
tes,
perip
hera
l cir
cula
tory
dise
ase 2
º dia
bete
s, or
dia
betic
micr
oang
iopat
hy.
DM 2
, not
stat
ed a
s unc
ontro
lled,
and
vasc
ular
find
ings
inclu
ding
clau
dica
tion,
ulce
rs,
gang
rene
, ath
eros
clero
sis (i
.e. p
erip
hera
l vas
cula
r dise
ase,
erec
tile d
ysfu
nctio
n, C
VA,
CAD)
or p
ositi
ve fi
ndin
gs on
ABI
, ultr
asou
nd, C
T ang
iogra
m, M
RA or
ang
iogra
m
250.
80DM
II OT
H NT
ST U
NCNT
RLD
16Di
abet
es w
ith
Neur
ologi
c or
Othe
r Spe
cified
M
anife
stat
ion
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
re is
a
diab
etic
com
plica
tion
(i.e.,
a co
nditi
on C
AUSE
D by
the d
iabe
tes)
th
at is
not
inclu
ded
in a
mor
e spe
cific d
iabe
tes c
ompl
icatio
n co
de.
For e
xam
ple:
diab
etic
bone
chan
ges,
diab
etic
derm
atiti
s.
Cont
rolle
d DM
2 w
ith ot
her c
ompl
icatio
ns ca
used
by t
he d
iabe
tes s
uch
as sk
in fi
ndin
gs, i
nfec
tions
, etc
, not
stat
ed a
s unc
ontro
lled
268.
9UN
SPEC
IFIED
VITA
MIN
D
DEFIC
IENC
YUs
e whe
n th
e doc
umen
tatio
n in
dica
tes V
itam
in D
defi
cienc
y, ca
lcife
rol
defic
iency
, erg
oste
rol d
eficie
ncy,
or vi
oest
erol
defic
iency
.Vi
tam
in D
25
Hydr
oxy L
evel
of le
ss th
an 5
0 ng
/ml
272.
0PU
RE
HYPE
RCHO
LEST
EROL
EMUs
ed w
hen
docu
men
tatio
n in
dica
tes h
yper
chole
ster
olem
ia,
Hype
rbet
alip
opro
tein
emia
, or c
holes
tero
lemia
.Co
nditi
on ch
arac
teriz
ed b
y elev
ated
chole
stro
l (>
200)
272.
2M
IXED
HYP
ERLIP
IDEM
IAUs
ed w
hen
docu
men
tatio
n st
ates
type
II h
yper
lipop
rote
inem
ia,
xant
hom
a, or
bet
a di
seas
e.Hy
perli
pide
mia
char
acte
rized
by e
levat
ed LD
L (>1
60m
g/dL
) and
ele
vate
d tri
glyc
erid
e (>1
60m
g/dL
), di
agno
sed
by la
b va
lues
85
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
272.
4HY
PERL
IPID
EMIA
NEC
/NOS
Whe
n do
cum
enta
tion
only
indi
cate
s hyp
erlip
idem
ia, t
his i
s the
corre
ct co
de.
High
lipi
d st
ate c
hara
cter
ized
by el
evat
ed LD
L or t
riglyc
erid
e
272.
9LIP
OID
MET
ABOL
DIS
NOS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
bnor
mal
lipi
ds, c
onge
nita
l abn
orm
al li
pid
met
aboli
sm, o
r abn
orm
al ch
olest
erol
met
aboli
sm. (
Note
that
met
aboli
sm m
ust
be m
entio
ned.
The t
erm
“hyp
erlip
idem
ia” o
r “dy
slipi
dem
ia” c
odes
to 2
72.4
).
Abno
rmal
lipi
d m
etab
olism
, dia
gnos
ed cl
inica
lly a
nd b
y abn
orm
al la
bora
tory
valu
es
274.
9GO
UT N
OSUs
ed w
hen
docu
men
tatio
n in
dica
tes g
out,
urat
e the
saur
ismos
is,
uric
acid
dia
sthe
sis, g
outy
dias
thes
is or
pod
agra
.Co
nditi
on ca
used
by t
he a
ccum
ulat
ion of
uric
acid
crys
tals,
may
de
posit
in jo
ints
(arth
ritis)
, kid
ney (
ston
e), g
allb
ladd
er (s
tone
), di
gnos
ed cl
inica
lly w
ith/w
ithou
t elev
ated
uric
acid
276.
1HY
POSM
OLAL
ITYTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes a
nhyd
ratio
n wi
th
hypo
natre
mia
, deh
ydra
tion
with
hyp
onat
rem
ia, s
alt d
eplet
ion, s
odiu
m d
eplet
ion,
sodi
um d
eficie
ncy,
fluid
loss
with
hyp
onat
rem
ia, h
ypos
mola
lity o
r sick
cell.
Low
elect
rolyt
e sta
te, f
requ
ently
ass
ocia
ted
with
deh
ydra
tion
and
low so
dium
, dia
gnos
ed b
y lab
orat
ory v
alue
s
276.
51DE
HYDR
ATIO
NTh
is co
de is
use
d wh
en d
ocum
enta
tion
says
Luet
sche
r’s sy
ndro
me,
Lu
etsc
her’s
deh
ydra
tion,
deh
ydra
tion
or a
nhyd
ratio
n.Lo
ss of
flui
d fro
m th
e bod
y lea
ding
to w
eakn
ess,
thirs
t, fa
st h
eartb
eat,
poor
skin
turg
or, h
yper
natre
mia
, etc
, dia
gnos
ed cl
inica
lly
276.
7HY
PERP
OTAS
SEM
IAUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s hyp
erpo
tass
emia
, exc
ess
pota
ssiu
m, h
yper
kalem
ia, p
otas
sium
over
load
or h
yper
kalem
ic.Bl
ood
test
show
ing
pota
ssiu
m is
gre
ater
than
upp
er li
mit
of n
orm
al (5
.0 m
Eq/L
)
276.
8HY
POPO
TASS
EMIA
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
ypop
otas
sem
ia, p
otas
sium
de
plet
ion, p
otas
sium
defi
cienc
y, hy
poka
lemia
or h
ypok
alem
ic.Lo
w po
tasiu
m st
ate,
diag
nose
d by
lab
valu
e
278.
00OB
ESITY
NOS
Use w
hen
the m
edica
l rec
ord
indi
cate
s obe
sity.
Char
acte
rized
by 2
0% ov
er id
eal b
ody w
eight
or B
MI o
f mor
e tha
n 30
278.
01OB
ESITY
, MOR
BID
Used
whe
n th
e doc
umen
tatio
n in
dica
tes m
orbi
d ob
esity
, mor
bidl
y obe
se, o
r sev
ere o
besit
y.Gr
ade 3
over
weig
ht (m
orbi
d ob
esity
) cha
ract
erize
d by
a
BMI e
qual
to or
gre
ater
than
40
kg/m
2.
86
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
280.
9IR
ON D
EFIC
ANE
MIA
NOS
Used
whe
n th
e dia
gnos
is is
iron
defic
iency
ane
mia
, Witt
’s an
emia
, ach
lorhy
dic
anem
ia, g
reen
sick
ness
, sid
erop
enia
, Fab
er’s
dise
ase,
or H
ayem
-Fab
er d
iseas
e.Lo
w RB
C lev
el (H
gb <
16
for m
en; H
gb <
14
for w
omen
) due
to ir
on
defic
iency
, cha
ract
erize
d by
low
MCV
, low
ferri
tin, l
ow ir
on, e
levat
ed TI
BC
285.
21AN
EMIA
IN C
HRON
IC
KIDN
EY D
ISEA
SETh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t has
an
emia
of ch
roni
c kid
ney d
iseas
e, or
ESR
D or
EPO
resis
tant
ane
mia
. The
un
derly
ing
chro
nic c
ondi
tion
(e.g
., ES
RD 5
85.6
) sho
uld
also
be c
oded
.
Anem
ia in
chro
nic k
idne
y dise
ase
285.
9AN
EMIA
NOS
Used
whe
n th
e doc
umen
tatio
n sa
ys a
nem
ia, e
rythr
ocyto
peni
a or
low
hem
atoc
rit.
Nons
pecifi
c Low
RBC
leve
l (Hg
b <
16 fo
r men
; Hgb
< 1
4 fo
r wom
en),
diag
nose
d by
labo
rato
ry va
lues
290.
0SE
NILE
DEM
ENTIA
UN
COM
PUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s dem
entia
, dem
entia
of ol
d ag
e, se
nile
de
men
tia, s
enile
ane
rgas
ia, i
diop
athi
c sen
ility,
seni
le or
seni
le ex
haus
tion.
Loss
of in
telle
ctua
l fun
ction
s due
to ol
d ag
e lea
ding
to
inte
rfere
nce o
f dai
ly fu
nctio
n, d
iagn
osed
clin
ically
294.
10DE
MEN
TIA C
CE W
/O
BEHA
V DI
STUR
BTh
is co
de is
only
used
as a
seco
ndar
y cod
e. In
any
dise
ase t
hat m
ay h
ave d
emen
tia
as a
sym
ptom
, the
prim
ary d
iseas
e (e.g
., Hu
ntin
gton
’s Ch
orea
, Alzh
eimer
’s di
seas
e,
Pick
’s Di
seas
e, et
c.), a
nd d
emen
tia w
ithou
t men
tion
of b
ehav
ioral
dist
urba
nce i
s m
entio
ned,
this
code
shou
ld b
e use
d in
add
ition
to th
e cod
e for
the p
rimar
y dise
ase.
A pr
ogre
ssive
, neu
rode
gene
rativ
e dise
ase c
hara
cter
ized
by lo
ss of
fu
nctio
n an
d de
ath
of n
erve
cells
in se
vera
l are
as of
the b
rain
lead
ing
to lo
ss of
cogn
itive
func
tion
such
as m
emor
y and
lang
uage
.
294.
8M
ENTA
L DI
SOR
NEC
OTH
DIS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s chr
onic
brai
n in
fect
ion,
chro
nic i
ntra
cran
ial i
nfec
tion,
chro
nic b
rain
trau
ma,
mixe
d af
fect
ive a
nd p
aran
oid
stat
e, m
ixed
para
noid
and
affe
ctive
pyc
hosis
or d
emen
tia. I
t is a
lso u
sed
when
a
spec
ified
type
of m
enta
l diso
rder
doe
s not
hav
e a m
ore s
pecifi
c cod
e.
Nons
pecifi
c psy
chia
tric c
ondi
tion
may
inclu
de a
ffect
ive,
para
noid
and
psy
chot
ic st
ate,
diag
nose
d cli
nica
lly
87
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
296.
20DE
PRES
SIVE
PS
YCHO
SIS-
UNSP
EC55
Maj
or
Depr
essiv
e,
Bipo
lar,
and
Para
noid
Di
sord
ers
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
n ep
isode
of in
volu
tiona
l de
pres
sion,
mela
ncho
lia, d
epre
ssive
psy
chos
is, m
elanc
holia
, inv
olutio
nal
mela
ncoli
a, m
enop
ausa
l mela
ncho
lia, s
tupo
rous
mela
ncho
lia,
agita
ted
depr
essio
n, p
sych
otic
depr
essio
n, or
mela
ncho
ly.
Nons
pecifi
c dep
ress
ion (d
epre
ssed
moo
d, lo
ss of
inte
rest
, cha
nge i
n ap
petit
e,
sleep
dist
urba
nce,
beha
vior c
hang
e, de
crea
se in
ener
gy, g
uilt,
inab
ility
to
conc
entra
te, o
r sui
cide t
houg
hts)
with
delu
sion
and/
or h
allu
cinat
ion
296.
30RE
CURR
DEP
R PS
YCHO
S-UN
SP55
Maj
or
Depr
essiv
e,
Bipo
lar,
and
Para
noid
Di
sord
ers
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
recu
rrent
(thi
s mus
t be s
pecifi
ed)
episo
de of
invo
lutio
nal d
epre
ssion
, rec
urre
nt m
elanc
holia
, rec
urre
nt
depr
essiv
e psy
chos
is, in
term
itten
t rec
urre
nt m
elanc
holia
, rec
urre
nt
invo
lutio
nal m
elanc
olia
or re
curre
nt m
enop
ausa
l dep
ress
ion.
Nons
pecifi
ed re
curre
nt d
epre
ssion
(dep
ress
ed m
ood,
loss
of in
tere
st, c
hang
e in
appe
tite,
sleep
dist
urba
nce,
beha
vior c
hang
e, de
crea
se in
ener
gy, g
uilt,
inab
ility
to
conc
entra
te, o
r sui
cide t
houg
hts)
with
delu
sion
and/
or h
allu
cinat
ion
300.
00AN
XIET
Y ST
ATE
NOS
Use w
hen
docu
men
tatio
n sa
ys a
nxiet
y, ne
uros
is, n
euro
tic st
ate,
abno
rmal
ap
preh
ensio
n, a
ppre
hens
ivene
ss, p
sych
ogen
ic an
xiety,
anx
iety s
tate
, ps
ycho
neur
otic
anxie
ty, a
sphy
ctic
anxie
ty or
anx
iety d
isord
er.
Cond
ition
char
acte
rized
by a
pat
tern
of fr
eque
nt w
orry
and
anxie
ty
abou
t sev
eral
diff
eren
t eve
nts/
activ
ities
, dia
gnos
ed cl
inica
lly
305.
1TO
BACC
O US
E DI
SORD
ERUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient i
s a cu
rrent
smok
er.
Past
hist
ory o
f sm
okin
g is
code
d as
V15
.89
(per
sona
l hist
ory o
f tob
acco
use
).Cu
rrent
toba
cco u
ser,
diag
nose
d by
hist
ory
311
DEPR
ESSI
VE
DISO
RDER
NEC
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s “de
pres
sion”
or
dep
ress
ive d
isord
er w
ith n
o fur
ther
des
crip
tion.
Depr
essiv
e diso
rder
not
else
wher
e cla
ssifi
ed, m
ay h
ave s
ome s
ympt
oms o
f de
pres
sed
moo
d an
d los
s of i
nter
est,
chan
ge in
app
etite
, slee
p di
stur
banc
e,
beha
vior c
hang
e, de
crea
se in
ener
gy, g
uilt,
inab
ility
to co
ncen
trate
but
not
MDD
327.
23OB
STRU
CTIV
E SL
EEP
APNE
ATh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes o
bstru
ctive
sle
ep a
pnea
or sl
eep
apne
a wi
th ob
stru
ction
.Ap
nea,
defi
ned
as a
cess
ation
of a
irflow
for a
t lea
st 1
0 se
cond
s wh
ich oc
curs
dur
ing
sleep
due
to ob
stru
ction
(non
cent
ral).
331.
0AL
ZHEI
MER
’S D
ISEA
SEUs
e whe
n do
cum
enta
tion
indi
cate
s Alzh
eimer
’s di
seas
e, at
roph
ic
brai
n de
gene
ratio
n, or
Alzh
eimer
’s typ
e dem
entia
.De
men
tia ch
arac
teriz
ed b
y im
pairm
ent i
n m
emor
y, th
inkin
g an
d be
havio
r, di
agno
sed
clini
cally
and
by m
ini-m
enta
l sta
te ex
amin
ation
0 m
inim
um co
g
88
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
332.
0PA
RALY
SIS
AGITA
NS73
Park
inso
n’s a
nd
Hunt
ingt
on’s
Dise
ases
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s Par
kinso
n’s,
Park
inso
n’s d
iseas
e, pa
ralys
is ag
itans
, par
kinso
n’s, s
hakin
g pa
lsy.
Prog
ress
ive, d
egen
erat
ive d
isord
er of
the n
ervo
us sy
stem
char
acte
rized
by
trem
ors,
rigid
ity, b
rady
kines
ia, p
ostu
ral i
nsta
bilit
y, an
d ga
it ab
norm
aliti
es; c
ause
d by
a lo
ss of
neu
rons
and
a d
ecre
ase o
f dop
amin
e in
the b
asal
gan
glia
.
356.
9ID
IO P
ERIP
H NE
URPT
HY N
OS71
Polyn
euro
path
yTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
nter
stiti
al h
yper
troph
ic
prog
ress
ive n
eurit
is, h
ered
itary
neur
opat
hy, i
nter
stiti
al h
yper
troph
ic ne
urop
athy
, m
ultip
le ne
urop
athy
, poly
neur
opat
hy, p
erip
hera
l neu
ropa
thy,
atro
phic
neur
opat
hy,
Perip
hera
l pro
gres
sive n
euro
path
y, po
lyneu
ritis
or tr
opho
neur
osis.
Nons
pecifi
c los
s of s
ensa
tion
or m
ovem
ent d
ue to
idiop
athi
c ne
rve d
amag
e, di
agno
sed
clini
cally
and
/or b
y NCS
/EM
G
357.
2NE
UROP
ATHY
IN D
IABE
TES
71Po
lyneu
ropa
thy
This
code
is u
sed
to d
escr
ibe d
iabe
tic n
euro
path
y, ne
urop
athy
se
cond
ary t
o dia
bete
s, or
dia
bete
s with
neu
ropa
thy.
DM ca
used
neu
rolog
ical m
anife
stat
ions i
nclu
ding
num
bnes
s, tin
glin
g,
burn
ing
sens
ation
s, ga
stro
pare
sis, e
rect
ile d
ysfu
nctio
n, a
uton
omic
inst
abili
ty
or p
ositi
ve fi
ndin
g on
ner
ve co
nduc
tion
stud
y, di
agno
sed
clini
cally
362.
51NO
NEXU
DAT
MAC
ULAR
DEG
ENUs
ed w
hen
the d
ocum
enta
tion
stat
es a
troph
ic m
acul
a, d
ry
mac
ula,
or n
onex
udat
ive m
acul
ar d
egen
erat
ion.
Decr
ease
d vis
ual a
cuity
or ce
ntra
l visi
on lo
ss d
ue to
agi
ng, d
iagn
osed
clin
ically
362.
52EX
UDAT
V SE
NL M
ACUL
R DE
GENR
AT-R
ETUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s Kuh
nt-Ju
nius
dise
ase,
disc
iform
m
acul
a, ex
udat
ive m
acul
ar d
egen
erat
ion, w
et m
acul
ar d
egen
erat
ion, K
uhnt
-Ju
nias
retin
a, K
uhnt
-Juni
as d
egen
erat
ion or
disc
iform
is re
tiniti
s.
Decr
ease
visu
al a
cuity
or ce
ntra
l visi
on lo
ss d
ue to
agi
ng d
iagn
osed
clin
ically
. Sh
ould
be b
ased
on p
rior o
r con
curre
nt ex
am b
y oph
thal
molo
gist
.
365.
11PR
IM O
PEN
ANGL
E GL
AUCO
MA
Use w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
glau
com
a, si
mpl
e gl
auco
ma,
or op
en a
ngle
glau
com
a. N
OTE:
DO
NOT U
SE th
is co
de
if yo
ur n
ote s
ays o
nly “
Glau
com
a”, w
hich
is co
ded
365.
9.
Chro
nic i
ncre
ase i
n in
traoc
ular
pre
ssur
e cau
sing
optic
ner
ve d
amag
e, lea
ding
to
visu
al im
pairm
ent d
iagn
osed
by t
onom
etry
and/
or op
htha
lmos
copi
c exa
m
89
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
365.
9GL
AUCO
MA
NOS
Used
whe
n do
cum
enta
tion
only
stat
es g
lauc
oma
with
no f
urth
er in
form
ation
.In
crea
se in
intra
ocul
ar p
ress
ure c
ausin
g op
tic n
erve
dam
age,
leadi
ng to
vis
ual i
mpa
irmen
t dia
gnos
ed b
y ton
omet
ry an
d/or
opht
halm
osco
pic e
xam
366.
10SE
NILE
CAT
ARAC
T NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s sen
ile
cata
ract
, or c
atar
acta
seni
lis is
doc
umen
ted.
Age r
elate
d op
acifi
catio
n of
lens
lead
ing
to im
paire
d vis
ion, d
iagn
osed
clin
ically
366.
16SE
NILE
NUC
LEAR
CA
TARA
CTUs
ed w
hen
the d
ocum
enta
tion
stat
es se
nile
cata
ract
, cat
arac
ta
brun
ecen
s cat
arac
ta n
igra
or n
uclea
r cat
arac
t.Ag
e rela
ted
cata
ract
, dia
gnos
ed cl
inica
lly
366.
9CA
TARA
CT N
OSUs
ed w
hen
docu
men
tatio
n in
dica
tes c
atar
act,
lens c
hang
es,
intu
mes
cent
lens
, or l
ens o
pacit
y with
out f
urth
er d
escr
iptio
n.Op
acifi
catio
n of
lens
lead
ing
to im
paire
d vis
ion, d
iagn
osed
clin
ically
367.
0HY
PERM
ETRO
PIA
Used
whe
n do
cum
enta
tion
stat
es h
yper
met
ropi
a, h
yper
opia
, or f
arsig
hted
ness
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
ility
to fo
cus o
n clo
se
objec
ts of
ten
asso
ciate
d wi
th a
ging
, dia
gnos
ed cl
inica
lly
367.
1M
YOPI
AUs
ed w
hen
docu
men
tatio
n in
dica
tes m
yopi
a, n
ears
ight
edne
ss, o
r sho
rtsig
hted
ness
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
lility
to fo
cus
farw
ay ob
jects
, dia
gnos
ed cl
inica
lly
367.
20AS
TIGM
ATIS
M N
OSUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s ast
igm
atism
, acq
uire
d as
tigm
atism
, co
ngen
ital a
stig
mat
ism, r
efra
ctive
ast
igm
atism
or co
ngen
ital a
stig
mat
ism.
Refra
ction
erro
r of t
he ey
e cha
ract
erize
d by
an
asph
erica
l cor
nea
leadi
ng to
dist
orte
d im
age,
diag
nose
d cli
nica
lly
367.
21RE
GULA
R AS
TIGM
ATIS
MUs
ed th
is co
de w
hen
the d
ocum
enta
tion
indi
cate
s ast
igm
atism
.Re
fract
ion er
ror o
f the
eye c
hara
cter
ized
by a
n as
pher
ical c
orne
a lea
ding
to d
istor
ted
imag
e, di
agno
sed
clini
cally
367.
4PR
ESBY
OPIA
Used
whe
n do
cum
enta
tion
indi
cate
s “pr
esby
opia
” or i
nsuf
ficien
t acc
omod
ation
.Re
fract
ive er
ror o
f the
eye l
eadi
ng to
inab
ility
to fo
cus o
n clo
se ob
jects
due
to a
ging
, dia
gnos
ed cl
inica
lly
367.
9RE
FRAC
TION
DISO
RDER
NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s am
etro
pia,
refra
ction
erro
r, re
fract
ion d
isord
er, re
fract
ive er
ror,
subn
orm
al a
ccom
odat
ion or
acc
omod
ation
diso
rder.
Refra
ctive
erro
r of t
he ey
e, ex
cludi
ng m
yopi
a an
d pr
esby
opia
, dia
gnos
ed cl
inica
lly
90
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
375.
15TE
AR F
ILM IN
SUFF
IC N
OSUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s dry
eye s
yndr
ome,
insu
fficie
nt te
ars,
in
suffi
cient
tear
secr
etion
, defi
cient
lacr
imal
flui
d, te
ar fi
lm d
eficie
ncy o
r dry
eye.
Insu
fficie
nt te
ar se
cret
ion w
ith sy
mpt
oms o
f eye
irrit
ation
, in
jectio
n, d
iagn
osed
clin
ically
and
/or b
y Sch
irmer
test
380.
4IM
PACT
ED C
ERUM
ENTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
mpa
cted
ceru
men
, im
pact
ed
ear w
ax, a
bnor
mal
ceru
men
pro
duct
ion, w
ax in
ear,
or ce
rum
en a
ccum
ulat
ion.
Ear w
ax im
pact
ion d
iagn
osed
by d
irect
visu
aliza
tion
389.
9HE
ARIN
G LO
SS N
OSUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s hea
ring
loss,
deaf
ness
, aud
itory
deaf
ness
, im
paire
d he
arin
g, a
udito
ry im
perc
eptio
n, h
ered
itary
deaf
ness
, con
geni
tal d
eafn
ess,
or
acq
uire
d de
afne
ss w
ith n
o des
crip
tion
of th
e etio
logy o
f the
impa
irmen
t.
Nons
pecifi
c los
s of h
earin
g, d
iagn
osed
clin
ically
or b
y aud
iolog
y
401.
0M
ALIG
NANT
HY
PERT
ENSI
ONTh
is co
de sh
ould
only
be u
sed
if th
e med
ical r
ecor
d in
dica
tes a
ccele
ratin
g hy
perte
nsion
, ne
crot
izing
hyp
erte
nsion
or m
alig
nant
hyp
erte
nsion
. Thi
s cod
e sho
uld
rare
ly be
seen
in
a p
hysic
ian
offic
e set
ting.
It is
NOT
syno
nmou
s with
unc
ontro
lled
hype
rtens
ion.
Very
eleva
ted
bloo
d pr
essu
re re
sulti
ng in
eye,
kidne
y, an
d ca
rdiov
ascu
lar d
amag
e, di
agno
sed
clini
cally
401.
1BE
NIGN
HYP
ERTE
NSIO
NDo
cum
enta
tion
mus
t ind
icate
ben
ign
or b
enig
n es
sent
ial h
yper
tens
ion.
If do
cum
enta
tion
only
indi
cate
s hyp
erte
nsion
, see
401
.9, b
elow.
HTN
(SBP
>14
0, D
BP >
90
on 2
occa
sions
) with
out a
ny en
d or
gan
(eye
, kid
ney,
or ca
rdiov
ascu
lar)
dam
age,
diag
nose
d cli
nica
lly
401.
9HY
PERT
ENSI
ON N
OSW
hen
docu
men
tatio
n on
ly in
dica
tes h
yper
tens
ion, o
r un
cont
rolle
d hy
perte
nsion
, thi
s is t
he co
rrect
code
.Hy
perte
nsion
with
SBP
>14
0, D
BP >
90
on 2
or m
ore o
ccas
ions
402.
10BE
NIGN
HYP
HT
DIS
W/O
HF
Used
whe
n th
e doc
umen
tatio
n in
dica
tes b
enig
n hy
perte
nsive
hea
rt di
seas
e,
hype
rtens
ive h
eart
dise
ase o
r hea
rt di
seas
e sec
onda
ry to
hyp
erte
nsion
.An
y car
diac
cond
ition
due
to H
TN, i
nclu
ding
card
iomeg
aly,
card
iomyo
path
y, ca
rdiov
ascu
lar d
iseas
e with
out C
HF, d
iagn
osed
clin
ically
91
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
403.
10HY
P CK
D BE
N CK
D ST
AGE
I THR
U IV
/UNS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes b
enig
n hy
perte
nsion
with
CKD
stag
e 1-
4 or
ben
ign
hype
rtens
ion w
ith C
KD, o
r hyp
erte
nsion
with
rena
l inv
olvem
ent,
rena
l scle
rosis
with
hyp
erte
nsion
, or h
yper
tens
ion w
ith g
lomer
ulos
clero
sis.
CKD
of a
ny st
age i
n th
e pre
senc
e of e
ssen
tial (
prim
ary,
not r
enov
ascu
lar)
HTN,
bu
t exc
ludi
ng m
alig
nant
HTN
(sud
den
and
rapi
d de
velop
men
t of e
xtrem
ely h
igh
bloo
d pr
essu
re u
sual
ly wi
th a
dia
stoli
c of
> 1
25 a
nd ca
rdia
c, re
nal,
or ce
rebr
al
man
ifest
ation
s) a
nd a
lso ex
cludi
ng a
cute
or re
nal f
ailu
re d
ue to
othe
r (no
n HT
N) ca
uses
403.
90HY
P CK
D UN
S CK
D ST
AGE
I THR
U IV
/UNS
Used
whe
n do
cum
enta
tion
indi
cate
s hyp
erte
nsive
kidn
ey d
iseas
e, re
nova
scul
ar
hype
rtens
ion, a
rterio
lar g
lomer
ulon
ephr
itis,
arte
riosc
lerot
ic gl
omer
ulon
ephr
itis,
hy
perte
nsion
with
chro
nic k
idne
y dise
ase (
unsp
ecifi
ed or
Sta
ge 1
-4).
Uns
pecifi
ed h
yper
tens
ive re
nal d
iseas
e
403.
91HY
P KI
D NO
S W
CR
KID
V13
1Re
nal F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t has
bot
h St
age
V CK
D an
d hy
perte
nsion
. NOT
E: C
odes
in th
e 403
.X se
ries a
re a
n ex
cept
ion to
the r
ule
that
the p
hysic
ian
mus
t doc
umen
t a ca
usal
rela
tions
hip
betw
een
two d
iseas
es.
Hype
rtens
ive ki
dney
dise
ase w
ith ch
roni
c kid
ney d
amag
e, su
ch a
s alb
umin
uria
, pr
otein
uria
, hem
atur
ia, g
lomer
ulon
ephr
itis,
abno
rmal
crea
tinin
e or r
enal
fa
ilure
, cha
ract
erize
d by
GFR
< 1
5, n
eedi
ng d
ialys
is or
tran
spla
ntat
ion
411.
1IN
TERM
ED
CORO
NARY
SYN
D82
Unst
able
Angi
na
and
Othe
r Ac
ute I
sche
mic
He
art D
iseas
e
Used
whe
n th
e doc
umen
tatio
n in
dica
tes i
nter
med
iate
coro
nary
synd
rom
e, im
pend
ing
coro
nary
synd
rom
e, im
pend
ing
myo
card
ial i
nfar
ction
, im
pend
ing
infa
rct,
acut
e cor
onar
y sy
ndro
me,
corn
ary i
nsuf
ficien
cy sy
ndro
me,
unst
able
angi
na or
inte
rmed
iate
coro
nary.
New
onse
t ang
ina
(car
diac
CP)
or a
ngin
a wi
th in
crea
se in
freq
uenc
y or i
nten
sity,
diag
nose
d cli
nica
lly w
ith T
inve
rsion
on E
CG a
nd h
ypok
ines
is on
echo
card
iogra
m
412
OLD
MYO
CARD
IAL I
NFAR
CT83
Angi
na P
ecto
ris/
Old
Myo
card
ial
Infa
rctio
n
Use w
hen
a hi
stor
y of m
yoca
rdia
l inf
arct
ion is
doc
umen
ted.
H/O
MI a
s evid
ent b
y Q w
aves
on E
KG or
char
acte
ristic
abn
orm
al w
all m
otion
on ec
ho
413.
9AN
GINA
PEC
TORI
S NE
C/NO
S83
Angi
na P
ecto
ris/
Old
Myo
card
ial
Infa
rctio
n
Use w
hen
docu
men
tatio
n sa
ys a
ngin
a, a
ngin
a pe
ctor
is,
Hebe
rden
s syn
drom
e, Lik
off’s
synd
rom
e, Sc
hauf
enst
er kr
ankh
eit,
angi
nosu
s, st
enoc
ardi
a, st
erna
lgia
, or s
tabl
e ang
ina.
Nons
pecifi
c atyp
ical c
ardi
ac ch
est p
ain,
dia
gnos
ed cl
inica
lly
92
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
414.
00CR
NRY
ATH
UNSP
VS
L NTV
/GFT
Use w
hen
docu
men
tatio
n in
dica
tes c
oron
ary a
ther
oscle
rosis
or a
rterio
scler
osis
AN
D yo
u ha
ve st
ated
that
the p
atien
t has
bot
h na
tive a
nd n
on-n
ative
ve
ssels
—bu
t you
hav
e not
indi
cate
d wh
ich ty
pe of
vess
el is
affe
cted
.
Athe
rosc
leros
is of
coro
nary
arte
ries d
efine
d by
pos
itive
stre
ss te
st
or p
ositi
ve ca
rdia
c cat
h wi
thou
t spe
cifica
tion
of w
heth
er n
ative
or
gra
ft ve
ssel
is in
volve
d in
a p
atien
t with
gra
ft ve
ssels
414.
01CR
NRY
ATHR
SCL
NATV
E VS
SLUs
e onl
y whe
n at
hero
scler
osis
or a
rterio
scler
osis
is st
ated
to b
e of
nativ
e ves
sel o
r the
re is
no d
ocum
enta
tion
of a
prio
r CAB
G.At
hero
scler
osis
of co
rona
ry ar
terie
s defi
ned
by p
ositi
ve
stre
ss te
st or
pos
itive
card
iac c
athe
teriz
ation
414.
9CH
RONI
C IS
CHEM
IC
HRT D
IS N
OSTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
sche
mic
coro
nary
ch
ange
s, co
rona
ry da
mag
e, isc
hem
ic he
art,
coro
nary
dise
ase,
ische
mic
he
art d
iseas
e, ca
rdia
c isc
hem
ia, c
oron
ary i
sche
mia
, or a
cqui
red
coro
nary
ische
mia
and
no a
dditi
onal
info
rmat
ion is
give
n.
Nons
pecifi
c chr
onic
ische
mic
hear
t dise
ase,
diag
nose
d cli
nica
lly a
nd/o
r car
diac
test
ing
424.
0M
ITRAL
VAL
VE D
ISOR
DER
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s mitr
al va
lve d
isord
er, b
alloo
ning
po
ster
ior le
aflet
, Bar
low’s
prola
pse,
mitr
al va
lve p
rola
pse,
or fl
oppy
mitr
al va
lve.
Any d
isord
er or
dam
age i
nvolv
ing
mitr
al va
lve, i
nclu
ding
sten
osis,
regu
rgita
tion
or p
rola
pse d
iagn
osed
by e
cho,
angi
ogra
m or
othe
r im
age s
tudi
es
424.
1AO
RTIC
VAL
VE D
ISOR
DER
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
cqui
red
aorti
c val
ve d
isord
er, a
ortic
def
orm
ity,
endo
card
itis w
ith a
ortic
val
ve in
volve
men
t, ar
terio
scler
otic
aorti
c val
ve, a
ortic
valve
in
suffi
cienc
y, ao
rtic v
alve
obst
ruct
ion, a
ortic
valve
sten
osis,
or a
ortic
mur
mur
.
Diso
rder
or d
amag
e inv
olvin
g ao
rtic v
alve
, ste
nosis
or in
suffi
cienc
y re
gurg
itatio
n, d
iagn
osed
by e
cho,
angi
ogra
m or
othe
r im
age s
tudi
es
425.
4PR
IM C
ARDI
OMYO
PATH
Y NE
C80
Cong
estiv
e He
art F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umen
ation
indi
cate
s prim
ary
card
iomyo
path
y, id
iopat
hic c
ardi
omyo
path
y, id
iopat
hic m
yoca
rdia
l hy
pertr
ophy
, myo
card
iopat
hy d
escr
ibed
as:
cong
estiv
e, co
nstri
ctive
, fam
ilial
, hy
pertr
ophi
c non
obst
ruct
ive, i
diop
athi
c or i
nfiltr
ative
card
iomyo
path
y.
Abno
rmal
card
iac f
unct
ion w
here
SOB
, CP
and
perip
hera
l ede
ma
are c
ardi
nal
sym
ptom
s, in
cludi
ng id
iopat
hic,
dila
ted,
rest
rictiv
e, co
nstri
ctive
and
hyp
ertro
phic
et
iolog
ies, d
iagn
osed
by e
cho,
angi
ogra
m a
nd ot
her i
mag
e stu
dies
93
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
427.
31AT
RIAL
FIBR
ILLAT
ION
92Sp
ecifi
ed H
eart
Arrh
ythm
ias
Used
whe
n do
cum
enta
tion
stat
es a
trial
fibr
illat
ion. B
e sur
e to a
lso
docu
men
t and
code
long
term
or cu
rrent
use
of a
ntico
agul
ant V
58.6
1.Ra
pid
irreg
ular
hea
rtbea
t dia
gnos
ed b
y exa
m, E
CG or
rhyth
m m
onito
r
427.
81SI
NOAT
RIAL
NOD
E DY
SFUN
CT92
Spec
ified
Hea
rt Ar
rhyth
mia
sUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
sinus
bra
dyca
rdia
, sin
o-at
rial (
SA) b
rady
card
ia (w
ith or
with
out p
arox
ysm
al
tach
ycar
dia)
NOT
E: A
cute
sinu
s bra
dyca
rdia
is 4
27.8
9.
Dise
ase a
nd/o
r Dys
func
tion
of S
A no
de le
adin
g to
non
-sin
us
rhyth
m, b
rady
card
ia d
iagn
osed
by E
CG or
rhyth
m m
onito
r
427.
89CA
RDIA
C DY
SRHY
THM
IAS
NEC
Used
whe
n th
e doc
umen
tatio
n in
dica
tes c
ardi
ac a
rrhyth
mia
, car
diac
dys
rythm
ia,
gallo
p rh
ythm
, nod
al rh
ythm
diso
rder,
alte
rnat
ing
pulse
, big
emin
y, bi
gem
inal
rhyth
m,
trige
min
y, tri
gem
inal
rhyth
m, p
ulsu
s alte
rnan
s, a-
v nod
al rh
ythm
or ec
topi
c rhy
thm
.
Nons
inus
rhyth
m d
iagn
osed
by E
CG or
rhyth
m m
onito
r
427.
9CA
RDIA
C DY
SRHY
THM
IA N
OSUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s onl
y arry
thm
ia, c
ardi
ac
dysr
hyth
mia
or ca
rdia
c arry
thm
ia. W
hen
the t
ype o
f arry
thm
ia is
kn
own,
it sh
ould
be d
ocum
ente
d an
d co
ded
appr
opria
tely.
Nons
pecifi
c non
-sin
us rh
ythm
dia
gnos
ed b
y EKG
or rh
ythm
mon
itor
428.
0CH
F NOS
80Co
nges
tive
Hear
t Fai
lure
Used
whe
n do
cum
enta
tion
says
Ber
nheim
’s sy
ndro
me,
CHF o
r hea
rt fa
ilure
.Ca
rdin
al sy
mpt
oms i
nclu
de S
OB, e
dem
a, or
CP,
diag
nose
d by
cli
nica
l find
ings
and
+PV
C on
CXR
...ec
ho m
ay re
veal
low
EF
(<50
%) a
nd/o
r nor
mal
EF w
ith d
iast
olic d
ysfu
nctio
n
429.
3CA
RDIO
MEG
ALY
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es on
ly ca
rdiom
egal
y, wi
thou
t any
indi
catio
n of
the u
nder
lying
dise
ase.
If do
cum
enta
tion
indi
cate
s it i
s due
to H
TN u
se co
des 4
02.0
-402
.9.
Enla
rged
hea
rt, d
iagn
osed
clin
ically
or b
y im
age s
tudi
es
433.
10OC
L CRT
D AR
T WO
INFR
CTUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s car
otid
sten
osis,
sten
osis
of ca
rotid
ar
tery
(com
mon
, int
erna
l), or
caro
tid oc
clusio
n, w
ithou
t men
tion
of in
farc
t.St
enos
is or
occlu
sion
of ca
rotid
arte
ry wi
thou
t CVA
sym
ptom
s,
diag
nose
d cli
nica
lly a
nd/o
r by i
mag
ing
stud
ies
94
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
434.
91CR
BL A
RT O
CL
NOS
W IN
FRC
96Isc
hem
ic or
Un
spec
ified
St
roke
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s CVA
, Cer
ebra
l acc
iden
t, ce
rebr
ovas
cula
r acc
iden
t, ac
ute c
ereb
rova
scul
ar d
iseas
e, isc
hem
ic CV
A, b
rain
stem
in
farc
t(ion
), la
cuna
r inf
arct
ion, c
ereb
ellar
infa
rctio
n, co
rtica
l inf
arct
ion, o
r stro
ke.
Deve
lopm
ent o
f bloo
d clo
t in
the c
ereb
ral a
rterie
s with
bra
in ti
ssue
dam
age l
eadi
ng
to m
otor,
sens
ory,
and/
or sp
eech
defi
cit, d
iagn
osed
clin
ically
and
/or b
y im
age s
tudi
es
435.
9TR
ANS
CERE
B IS
CHEM
IA N
OSUs
ed w
hen
docu
men
tatio
n in
dica
tes t
rans
ient i
sche
mic
atta
ck, o
r TIA
.Su
dden
brie
f or t
rans
ient f
ocal
bra
in n
euro
defi
cit,
last
ing
less t
han
24 h
rs d
iagn
osed
clin
ically
436
ACUT
E, IL
L DEF
INED
CE
REBR
OVAS
CULA
R DI
SEAS
E
96Isc
hem
ic or
Un
spec
ified
St
roke
Use o
nly w
hen
unsp
ecifi
ed ce
rebr
ovas
cula
r dise
ase i
s doc
umen
ted.
Cod
ing
Clin
ic co
mm
ents
indi
cate
this
code
shou
ld ra
rely
be u
sed.
It is
not
the
corre
ct co
de fo
r CVA
. The
corre
ct se
ries o
f cod
es fo
r CVA
s is 4
34.1
X.
Unsp
ecifi
ed a
cute
cere
brov
ascu
lar d
iseas
e oth
er th
an C
VA
438.
20HE
MIP
L AFF
CT U
NS
SIDE
-CER
EBRV
ASC
DZ10
0He
mip
legia
/He
mip
ares
isUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s hem
ipleg
ia/h
emip
ares
is fo
llowi
ng (o
r sta
tus
post
) CVA
, hem
ipleg
ia a
s a la
te ef
fect
of C
VA or
CVA
with
hem
ipleg
ia or
hem
ipar
esis.
NO
TE: P
er C
odin
g Cl
inic,
Q1
2005
, “we
akne
ss” s
tatu
s pos
t CVA
is co
ded
as 4
38.8
9,
Othe
r lat
e effe
cts o
f cer
ebro
vasc
ular
dise
ase a
nd co
de 7
28.8
7, M
uscle
wea
knes
s,
for r
esid
ual m
uscle
wea
knes
s sec
onda
ry to
late
effe
ct of
cere
brov
ascu
lar a
ccid
ent.
Hem
ipleg
ia/H
emip
ares
is as
a re
sult
of p
rior C
VA
440.
0AO
RTIC
ATHE
ROSC
LERO
SIS
105
Vasc
ular
Di
seas
eTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes s
clero
tic a
orta
, ar
terio
scler
otic
aorta
, cal
cified
aor
ta or
ath
eros
clero
sis of
the a
orta
.Co
nditi
on w
here
fatty
mat
eria
l is d
epos
ited
in th
e wal
ls of
aor
ta le
adin
g to
nar
rowi
ng,
hard
enin
g an
d/or
bloc
kage
, dia
gnos
ed cl
inica
lly or
by a
ngiog
ram
/imag
e stu
dies
443.
9PE
RIPH
VAS
CULA
R DI
S NO
S10
5Va
scul
ar
Dise
ase
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s per
iphe
ral v
ascu
lar d
iseas
e,
Char
côt’s
synd
rom
e, in
term
itten
t cla
udica
tion,
vaso
mot
or d
ilata
tion,
ang
iospa
smod
ic
dise
ase,
perip
hera
l arte
rial d
iseas
e, va
scul
ar d
iseas
e or s
mal
l ves
sel d
iseas
e.
Athe
rocle
rosis
invo
lving
per
iphe
ral a
rterie
s lea
ding
to p
ain,
ulce
ratio
n or
ga
ngre
ne, d
iagn
osed
clin
ically
with
ank
le-br
achi
al in
dex o
r by a
ngiog
ram
95
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
453.
40AC
VNU
S EM
B &
THRM
B UN
S DP
VES
LW E
XT10
5Va
scul
ar
Dise
ase
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
eep
veno
us th
rom
bus o
f the
leg,
acu
te
deep
veno
us th
rom
bus o
f the
leg,
or d
eep
veno
us th
rom
bosis
of th
e leg
.Th
rom
bus o
f low
er ex
trem
ity, c
onfir
med
by u
ltras
ound
or ve
nogr
am.
455.
0IN
T HEM
ORRH
OID
W/O
COM
PLTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes i
nter
nal h
emor
rhoid
s.Pr
esen
ce of
inte
rnal
hem
orrh
oid, d
iagn
osed
clin
ically
458.
9HY
POTE
NSIO
N NO
SUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s low
bloo
d pr
essu
re, l
ow p
ress
ure,
arte
rial
hypo
tens
ion, h
ypot
ensio
n, co
nstit
ution
al h
ypot
ensio
n, or
hyp
osys
tolic
pre
ssur
e.No
nspe
cific s
tate
of lo
w bl
ood
pres
sure
, dia
gnos
ed cl
inica
lly
461.
9AC
UTE
SINU
SITIS
NOS
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s acu
te si
nusit
is.Ac
ute i
nfec
tion
or in
flam
mat
ion of
sinu
s, of
ten
diag
nose
d cli
nica
lly a
nd/o
r by x
-ray,
CT fi
ndin
gs
462
ACUT
E PH
ARYN
GITIS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s pha
ryngi
tis,
acut
e pha
ryngi
tis, s
ore t
hroa
t, ad
enop
haryn
gitis
, cat
arrh
al a
ngin
a,
fauc
es, h
ypop
haryn
gitis
, or p
hleg
mon
ous p
haryn
gitis
.
Acut
e inf
ectio
n or
infla
mm
ation
of p
haryn
x, di
agno
sed
clini
cally
465.
9AC
UTE
URI N
OSUs
ed w
hen
docu
men
tatio
n in
dica
tes r
espi
rato
ry
infe
ction
, URI
, or v
iral r
espi
rato
ry in
fect
ion.
Nons
pecifi
c acu
te vi
ral i
nfec
tion
of u
pper
repi
rato
ry tra
ct, i
nvolv
ing
nose
and
thro
at
char
acte
rized
by r
unny
nos
e, so
re th
roat
, hea
dach
e and
ill-f
eelin
g, d
iagn
osed
clin
ically
466.
0AC
UTE
BRON
CHITI
SUs
ed w
hen
docu
men
tatio
n st
ates
acu
te b
ronc
hitis
.Ac
ute i
nfec
tion/
infla
mm
ation
of b
ronc
hus o
ften
leadi
ng to
pro
duct
ive
coug
h an
d/or
sput
um p
rodu
ction
dia
gnos
ed cl
inica
lly
477.
9AL
LERG
IC R
HINI
TIS N
OSUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s alle
rgic
rhin
itis,
Bost
ock’s
di
seas
e, fe
bris
aest
iva, h
ay fe
ver,
aller
gic r
hini
tis, v
asom
otor
rh
initi
s, pa
roxy
smal
rhin
orrh
ea, o
r spa
smod
ic rh
inor
rhea
.
Nons
pecifi
c alle
rgic
infla
mm
ation
of n
ose,
leadi
ng to
snee
zing,
cong
estio
n,
a ru
nny/i
tchy
nos
e, di
agno
sed
clini
cally
and
/or b
y rhi
nosc
ope
486
PNEU
MON
IA,
ORGA
NISM
NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s pne
umon
ia, l
ung
infla
mm
ation
; ac
ute,
bila
tera
l, do
uble,
or se
ptic
Pleu
ropn
eum
onia
, or P
neum
onia
des
crib
ed a
s: ac
ute,
Al
pens
tich,
ben
ign,
bila
tera
l, br
ain,
cere
bral
, circ
umsc
ribed
, con
gest
ive, c
reep
ing.
Bact
eria
l pne
umon
ia ca
used
by a
non
spec
ified
orga
nism
, di
agno
sed
clini
cally
and
/or b
y im
age s
tudy
96
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
490
BRON
CHITI
S NO
STh
is co
de is
use
d wh
en b
ronc
hitis
is th
e onl
y des
crip
tion
in m
edica
l re
cord
. In
dise
ases
whe
re th
ere i
s bot
h a
chro
nic a
nd a
cute
form
of th
e di
seas
e, it’s
impo
rtant
to n
ote w
hich
form
of th
e dise
ase i
s pre
sent
.
Infe
ction
or in
flam
mat
ion of
bro
nchu
s ch
arat
erize
d by
coug
h an
d/or
CXR
nor
mal
(no i
nfiltr
ate)
dia
gnos
ed cl
inica
lly
491.
21OB
S CH
R BR
ONC
W(A
C) E
XAC
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n th
e doc
umen
tatio
n in
dica
tes e
xace
rbat
ion of
chro
nic
bron
chiti
s or b
lue b
loate
r with
acu
te ex
acer
batio
n.Ch
roni
c bro
nchi
tis w
ith w
orse
ning
coug
h, sh
ortn
ess o
f bre
ath
or h
ypox
ia (p
O2 <
60)
, dia
gnos
ed cl
inica
lly
492.
8EM
PHYS
EMA
NEC
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n th
e doc
umen
tatio
n in
dica
tes e
mph
ysem
a, a
troph
ic, ce
ntria
cinar
, ce
ntril
obul
ar, c
hron
ic, d
iffus
e, es
sent
ial,
hype
rtrop
hic,
inte
rlobu
lar,
lung
, obs
truct
ive, p
anlob
ular
, par
acica
tricia
l, pa
racin
ar, p
ostu
ral,
pulm
onar
y, se
nile,
subp
leura
l, or
trac
tion
pulm
onar
y dise
ase.
Dam
age t
o alve
oli fr
eque
ntly
diag
nose
d by
smok
ing
hist
ory,
whee
zing,
CX
R fin
ding
and
obst
ruct
ive P
FT (F
EV1/
FVC
< 70
%)
493.
90AS
THM
A NO
SUs
ed w
hen
docu
men
tatio
n in
dica
tes a
sthm
a, a
nd
ther
e is n
o ind
icatio
n of
an
exac
erba
tion.
Reve
rsib
le re
activ
e airw
ay d
iseas
e res
ultin
g fro
m a
n al
lergi
c rea
ction
to
fore
ign
subs
tanc
es su
ch a
s vap
or, p
ollen
, etc
. dia
gnos
ed cl
inica
lly a
nd/o
r by
PFT s
howi
ng ob
stru
ctive
pat
tern
(FEV
1/FV
C <
80%
) and
reve
rsib
ility
496
CHRO
NIC
AIRW
AY
OBST
RUCT
NEC
108
Chro
nic
Obst
ruct
ive
Pulm
onar
y Di
seas
e
Used
whe
n do
cum
enta
tion
indi
cate
s “CO
PD”.
Whe
n kn
own,
the t
ype o
f airw
ay
obst
ruct
ion sh
ould
be d
ocum
ente
d an
d co
ded
(e.g
., ch
roni
c bro
nchi
tis).
Chro
nic o
bstru
ctive
lung
dise
ase o
ften
diag
nose
d wi
th sm
okin
g hx
, wh
eezin
g, P
FT sh
owin
g ob
stru
ctive
pat
tern
(FEV
1/FV
C <
80%
)
97
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
511.
9PL
EURA
L EFF
USIO
N NO
SUs
ed w
hen
the d
escr
iptio
n of
the c
ondi
tion
is “p
leura
l ef
fusio
n” w
ithou
t fur
ther
char
acte
rizat
ion.
Nons
pecifi
c pleu
ral fl
uid
in lu
ng ca
vity,
diag
nose
d cli
nica
lly or
by i
mag
e stu
dies
514
PULM
ONAR
Y CO
NGES
T/HY
POST
ASIS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s che
st co
nges
tion,
pul
mon
ary
cong
estio
n, p
ulm
onar
y hyp
osta
tis, h
ypos
tatic
lung
, chr
onic
lung
hyp
osta
sis, l
ung
cong
estio
n, p
assiv
e lun
g, P
otai
n’s d
iseas
e/sy
drom
e, lu
ng ed
ema,
or te
rmin
al lu
ng.
Incr
ease
flui
d wi
thin
the l
ungs
lead
ing
to co
ugh
and
SOB,
di
agno
sed
clini
cally
and
or b
y im
age s
tudi
es
518.
0PU
LMON
ARY
COLL
APSE
Used
whe
n do
cum
enta
tion
indi
cate
s Bro
ck’s
synd
rom
e, at
elect
asis,
righ
t mid
dle l
obe
synd
rom
e, po
stin
fect
ive a
telec
tasis
, par
tial a
telec
tasis
, com
pres
sion
atele
ctas
is,
pulm
onar
y ate
lecta
sis, c
ompl
ete a
telec
tasis
, pre
ssur
e coll
apse
or re
laxa
tion
atele
ctas
is.
Com
plet
e or p
artia
l coll
apse
of a
por
tion
of th
e lun
g, d
iagn
osed
cli
nica
lly a
nd/o
r by m
age s
tudi
es/b
ronc
hosc
opy
518.
81AC
UTE
RESP
IRAT
RY
FAILU
RE79
Card
io-Re
spira
tory
Fa
ilure
and
Sh
ock
This
code
is u
sed
when
the d
ocum
enat
ion in
dica
tes r
espi
rato
ry
failu
re, p
ulm
onar
y fai
lure
, or a
cute
resp
irato
ry fa
ilure
.Ac
ute p
ulm
onar
y fai
lure
as d
efine
d by
seve
re h
ypox
ia (p
O2 <
60)
or h
yper
capn
ia
(pCO
2>40
) ofte
n ne
edin
g em
erge
nt in
terv
entio
n su
ch a
s int
ubat
ion
518.
83CH
RONI
C RE
SPIR
ATOR
Y FA
ILURE
79Ca
rdio-
Resp
irato
ry
Failu
re a
nd
Shoc
k
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s chr
onic
re
spira
tory
failu
re, o
r chr
onic
resp
iratio
n fa
ilure
.Cl
inica
l mar
kers
of ch
roni
c hyp
oxem
ia, s
uch
as p
olycy
them
ia or
cor
pulm
onal
e, su
gges
t a lo
ng-s
tand
ing
diso
rder.
May
man
ifest
as C
O2
rete
ntion
resu
lting
in a
resp
irato
ry ac
idos
is. C
hron
ic re
spira
tory
acid
osis
re
sults
in a
met
aboli
c alka
losis
with
elev
ated
seru
m b
icarb
onat
e lev
el.
518.
89OT
HER
LUNG
DIS
EASE
NEC
This
code
is u
sed
when
the d
ocum
ente
d typ
e of l
ung
dise
ase h
as n
o oth
er
class
ifica
tion.
Doc
umen
tatio
n sh
ould
indi
cate
one o
f the
follo
wing
: hon
eyco
mb
lung
, bro
nchi
olias
is, p
ulm
olith
iasis
, cal
cifica
tion
of lu
ng, o
r lun
g di
seas
e.
Lung
dise
ase i
nclu
ding
lung
calci
ficat
ion, p
ulm
olith
iasis
, etc
530.
11RE
FLUX
ESO
PHAG
ITIS
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es re
flux
esop
hagi
tis, o
r eso
phag
eal r
eflux
with
esop
hagi
tis.
Infla
mm
ation
of es
opha
gus c
ause
d by
bac
kflow
of st
omac
h flu
id le
adin
g to
acid
ic
tast
e in
the m
outh
, epi
gast
ric a
bdom
inal
pai
n di
agno
sed
clini
cally
and
/or b
y EGD
98
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
530.
81ES
OPHA
GEAL
REF
LUX
Used
whe
n do
cum
enta
tion
indi
cate
s GER
D or
reflu
x.Ba
ckflo
w of
stom
ach
fluid
to es
opha
gus l
eadi
ng to
acid
ic ta
ste i
n th
e m
outh
, epi
gast
ric a
bdom
inal
pai
n di
agno
sed
clini
cally
and
/or b
y EGD
535.
50GA
STR/
DDNT
S NO
S W
/O H
MRH
GUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s gas
tritis
, gas
trodu
oden
itis,
ga
stro
hepa
titis,
gas
trojej
uniti
s or p
ylorit
is an
d th
ere i
s no m
entio
n in
the d
ocum
enta
tion
of h
emor
rhag
e or b
leedi
ng.
Nonb
leedi
ng in
flam
mat
ion of
stom
ach
or d
uode
num
dia
gnos
ed
clini
cally
and
/or b
y end
osco
py/im
age s
tudi
es
553.
3DI
APHR
AGM
ATIC
HER
NIA
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
iatu
s her
nia,
dia
phra
gmat
ic
hern
ia, s
lidin
g di
aphr
agm
atic
hern
ia, B
ochd
alek
her
nia,
Mor
gagn
i(an)
her
nia,
hi
atal
her
nia,
par
aeso
phag
eal h
erni
a, S
aint
tria
d, or
Sai
nt’s
hern
ia.
Prot
rusio
n of
the u
pper
par
t of t
he st
omac
h in
to th
e tho
rax t
hrou
gh a
tear
or
weak
ness
in th
e dia
phra
gm, d
iagn
osed
by E
GD a
nd/o
r im
age s
tudi
es
558.
9NO
NINF
GAS
TROE
NTER
IT
NEC
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s chr
onic
ileiti
s, no
n-in
fect
ious
ilieit
is, il
eoco
litis,
bow
el/co
lon in
flam
mat
ion, i
nflam
mat
ory b
owel/
colon
, gas
troin
test
inal
in
flam
mat
ion, i
leal i
nflam
mat
ion, j
ejuni
tis, a
cute
colit
is or
cata
rrhal
colit
is.
An in
flam
mat
ion of
the s
tom
ach
and
inte
stin
e res
ultin
g in
dia
rrhea
, with
vom
iting
an
d cr
amps
with
infe
ctiou
s wor
kup
bein
g ne
gativ
e, di
agno
sed
clini
cally
562.
10DV
RTCL
O CO
LON
W/O
HM
RHG
Used
whe
n do
cum
enta
tion
stat
es d
iverti
culos
is.No
n-bl
eedi
ng co
lon d
iverti
culos
is di
agno
sed
by co
lonos
copy
or ot
her i
mag
e stu
dies
564.
00CO
NSTIP
ATIO
N NO
SUs
e whe
n do
cum
enta
tion
stat
es co
nstip
ation
.No
nspe
cific c
onst
ipat
ion, d
iagn
osed
by h
istor
y
569.
3RE
CTAL
& A
NAL
HEM
ORRH
AGE
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient
has r
ecta
l blee
ding
, ana
l blee
ding
, rec
tal h
emor
rhag
e, an
al h
emor
rhag
e,
BRBP
R (b
right
red
bloo
d pe
r rec
tum
) or h
emor
rhag
e of a
nus,.
Blee
ding
from
rect
um a
nd/o
r anu
s, di
agno
sed
clini
cally
an
d/or
by e
ndos
copy
/imag
e stu
dies
99
| A
Gui
de t
o R
isk
Adj
ustm
ent
and
the
CM
S-H
CC
Mod
el
578.
9GA
STRO
INTE
ST
HEM
ORR
NOS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes g
astri
c blee
ding
, gas
troin
test
inal
bl
eedi
ng, s
tom
ach
blee
ding
, ent
eror
rhag
ia, b
owel
hem
orrh
age,
ceca
l bl
eedi
ng, g
astri
c hem
orrh
age o
r gas
troen
teric
hem
orrh
age.
Nons
pecifi
c blee
ding
invo
lving
GI t
ract
, dia
gnos
ed cl
inica
lly
and
or b
y end
osco
pies
or ra
diolo
gica
l stu
dies
584.
9AC
UTE
RENA
L FA
ILURE
NOS
131
Rena
l Fai
lure
Used
whe
n do
cum
enta
tion
indi
cate
s ren
al fa
ilure
or a
cute
rena
l fai
lure
. Ch
roni
c Ren
al Fa
ilure
is n
ever
ass
umed
, it m
ust b
e exp
licitl
y sta
ted.
Sudd
en ri
se in
Cre
atin
ine l
evel
(>1.
4mg/
dL) o
r dec
reas
e in
urin
e ou
tput
(<30
cc/h
r), d
iagn
osed
clin
ically
or b
y lab
find
ings
585.
2CH
RONI
C KI
DNEY
DIS
ST
AGE
II (M
ILD)
131
Rena
l Fai
lure
Used
whe
n do
cum
enta
tion
indi
cate
s tha
t the
pat
ient h
as C
KD
stag
e 2 a
nd th
ere i
s a d
ocum
ente
d GF
R of
60-
89.
Chro
nic r
enal
dys
func
tion
char
acte
rized
by G
FR of
60-
89
585.
3CH
RONI
C KI
DNEY
DI
S ST
AGE
III13
1Re
nal F
ailu
reTh
is co
de is
use
d on
ly wh
en th
e doc
umen
tatio
n in
dica
tes S
tage
III C
hron
ic
Kidn
ey D
iseas
e AND
ther
e is a
doc
umen
ted
GFR
from
30-
59.
Chro
nic r
enal
dys
func
tion
char
acte
rized
by G
FR of
30-
59
585.
4CH
RONI
C KI
DNEY
DIS
ST
AGE
IV (S
EVER
E)13
1Re
nal F
ailu
reUs
ed w
hen
docu
men
tatio
n in
dica
tes t
hat t
he p
atien
t has
stag
e 4
CKD
and
ther
e is a
doc
umen
ted
GFR
of 1
5-29
Chro
nic r
enal
dys
func
tion
char
acte
rized
by G
FR of
15-
29 ≥
3 m
os or
with
sig
ns of
kidn
ey d
amag
e (e.g
., m
icroa
lbum
inur
ia, p
rote
inur
ia, e
tc.)
585.
6EN
D ST
AGE
RENA
L DI
SEAS
E13
1Re
nal F
ailu
reTh
is co
de is
use
d wh
en th
e doc
umat
ion in
dica
tes e
nd st
age r
enal
di
seas
e, ES
RD, o
r kid
ney d
iseas
e req
uirin
g di
alys
is.En
d-st
age r
enal
dise
ase (
ESRD
) is a
n ad
min
istra
tive t
erm
bas
ed on
the
cond
ition
s for
pay
men
t for
hea
lth ca
re b
y the
Med
icare
ESR
D Pr
ogra
m. T
his t
erm
de
note
s kid
ney d
iseas
e at a
leve
l tha
t req
uire
s dia
lysis
or tr
ansp
lant
ation
.
585.
9CH
RONI
C KI
DNEY
DIS
NOS
131
Rena
l Fai
lure
Use w
hen
the d
ocum
enta
tion
indi
cate
s chr
onic
kidne
y dise
ase,
ch
roni
c ren
al fa
ilure
, chr
onic
kidne
y dise
ase o
r chr
onic
urem
ia. N
ote
that
chro
nic k
idne
y dise
ase c
odin
g sh
ould
inclu
de a
dia
gnos
tic
stat
emen
t of t
he st
age o
f kid
ney d
iseas
e whe
neve
r pos
sible.
Nons
pecifi
c chr
onic
rena
l dys
func
tion
char
acte
rized
by i
mpa
ired
GFR.
10
0 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
586
RENA
L FAI
LURE
NOS
131
Rena
l Fai
lure
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s ure
mia
, ren
al
failu
re, u
rem
ic co
ma,
rena
l shu
tdow
n, ki
dney
stas
is, re
nal s
tasis
, ren
al
supp
ress
ion, u
rem
ic to
xem
ia, u
rinar
y tox
emia
, ure
mic
abso
rptio
n,
urem
ic am
auro
sis, u
rem
ic am
blyo
pia,
or u
rem
ic ap
hasia
.
Loss
of ki
dney
func
tion
char
acte
rized
by r
ise in
crea
tinin
e, de
crea
sed
GFR
and/
or in
abili
ty to
pro
duce
urin
e, di
agno
sed
clini
cally
or b
y lab
valu
es
588.
81SE
COND
ARY
HYPE
RPAR
ATHY
ROID
ISM
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s sec
onda
ry hy
perp
arat
hyro
idism
.El
evat
ed P
TH le
vel s
econ
dary
to re
nal d
iseas
e.
593.
9RE
NAL &
URE
TERA
L DI
S NO
SUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s im
paire
d kid
ney f
unct
ion, k
idne
y ina
ction
, kid
ney i
neffi
cienc
y, kid
ney i
nfiltr
ate,
kidne
y dise
ase,
acut
e kid
ney d
iseas
e, ac
ute
rena
l dise
ase,
salt
synd
rom
e, sa
lt los
ing
dise
ase o
r sal
t was
ting
dise
ase.
Nons
pecifi
c ren
al a
nd/o
r ure
tera
l dys
func
tion,
dia
gnos
ed cl
inica
lly
599.
0UR
INAR
Y TR
ACT
INFE
CTIO
N NO
SUs
ed w
hen
docu
men
tatio
n sa
ys U
TI.Co
nditi
on ch
arac
teriz
ed w
ith sy
mpt
oms o
f urin
ary f
requ
ency
, dy
suria
, hem
atur
ia, d
iagn
osed
clin
ically
and
/or p
ositi
ve U
A
599.
70HE
MAT
URIA
UNS
PECI
FIED
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
emat
uria
, bloo
d in
the u
rine,
Tom
mas
elli’s
di
seas
e, bl
oody
urin
e, id
iopat
hic h
emat
uria
, int
erm
itten
t hem
atur
ia, p
arox
ysm
al
hem
atur
ia or
sulfo
nam
ide h
emat
uria
(if c
orre
ct d
rug
adm
inist
ered
pro
perly
).
Bloo
d in
the u
rine,
diag
nose
d cli
nica
lly or
by U
A (+
bloo
d or
+RB
C)
600.
00BP
H W
/O U
RINA
RY
OBS/
LUTS
Used
whe
n do
cum
enta
tion
stat
es B
PH.
Enla
rgem
ent o
f pro
stat
e with
out o
bstru
ctive
sx’s
(urin
ary
rete
ntion
, drip
ping
or h
esita
ncy),
dia
gnos
ed cl
inica
lly
10
1 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
600.
01HT
PRO
S W
/UR
OBST
&
OTH
LUTS
Use w
hen
docu
men
tatio
n in
dica
tes e
nlar
gem
ent o
f the
pro
stat
e with
lowe
r ur
inar
y tra
ct sy
mpt
oms,
pros
tate
hyp
erpl
asia
with
lowe
r urin
ary t
ract
sym
ptom
s,
enla
rgem
ent/h
yper
plas
ia of
the p
rost
ate w
ith ob
stru
ction
, enl
arge
men
t/hyp
erpl
asia
of
the p
rost
ate w
ith u
rinar
y ret
entio
n, h
yper
troph
y of t
he p
rost
ate w
ith u
rinar
y re
tent
ion/o
bstru
ction
or h
yper
troph
ic pr
osta
te w
ith lo
wer u
rinar
y tra
ct sy
mpt
oms.
Us
e add
ition
al co
de to
iden
tify s
ympt
oms s
uch
as fr
eque
ncy 7
88.4
1 et
c.
Enla
rgem
ent/h
yper
plas
ia of
the p
rost
ate w
ith u
rinar
y ret
entio
n.
682.
6CE
LLUL
ITIS
& AB
SCES
S LE
G EX
CEPT
FOO
TUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s abs
cess
of le
g/an
kle, c
ellul
itis o
f leg
/an
kle, a
bsce
ss/c
ellul
itis o
f hip
, fem
oral
abs
cess
/cell
uliti
s of k
nee,
popl
iteal
abs
cess
/ce
llulit
is, p
re-p
atell
ar a
bsce
ss/c
ellul
itis,
or a
bsce
ss/c
ellul
itis o
f the
thig
h.
Nons
pecifi
c inf
ectio
n of
the s
kin le
adin
g to
war
mth
, eryt
hem
a,
swell
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
682.
9CE
LLUL
ITIS
NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s cell
uliti
s, di
ffuse
cellu
litis,
chro
nic
cellu
litis,
phl
egm
onou
s cell
uliti
s or w
hen
mul
tiple
sites
of ce
llulit
is ar
e doc
umen
ted.
Nons
pecifi
c inf
ectio
n of
the s
kin le
adin
g to
war
mth
, eryt
hem
a,
swell
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
692.
9DE
RMAT
ITIS
NOS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
erm
atiti
s, ve
nena
ta
derm
atiti
s, co
ntac
t der
mat
itis,
aller
gic d
erm
atiti
s, oc
cupa
tiona
l de
rmat
itis,
acne
iform
der
mat
itis,
anap
hyla
ctic
derm
atiti
s, al
lergi
c ag
ent (
unsp
ecifi
ed) o
r ecz
emat
oid d
erm
atiti
s (un
spec
ified
).
Infla
mm
ation
of th
e skin
lead
ing
to er
ythem
a, sw
ellin
g, it
chin
ess,
diag
nose
d cli
nica
lly
701.
1KE
RATO
DERM
A, A
CQUI
RED
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s aca
ntho
kera
tode
rmia
, ac
quire
d al
ligat
or sk
in d
iseas
e, al
ligat
or sk
in, a
cqui
red
fish
skin
, Kyrl
e’s sy
ndro
me,
hy
perk
erat
osis
folli
cula
ris in
cute
m p
enet
rans
, or L
utz-
Mies
cher
synd
rom
e.
Skin
diso
rder
cons
istin
g of
a g
rowt
h th
at a
ppea
rs h
orny
, dia
gnos
ed cl
inica
lly
702.
0AC
TINIC
KER
ATOS
ISUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s act
inic
kera
tosis
, AK,
seni
le
kera
tosis
, sen
ile h
yper
kera
tosis
, sen
ile ke
rato
ma,
kera
tosis
seni
lis,
sola
r ker
atos
is, se
nile
wart,
verru
ca se
nilis
, or s
enile
war
t.
Prec
ance
rous
skin
gro
wth
usua
lly ca
used
by s
un-e
xpos
ure,
di
agno
sed
clini
cally
and
by s
kin b
iopsy
10
2 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
702.
19OT
HER
SBOR
HEIC
KE
RATO
SIS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s seb
orrh
eic
kera
tosis
, seb
orrh
ea, s
ebor
rheic
war
t or v
erru
ca se
borrh
eica.
Pain
less b
enig
n sk
in w
art-l
ike g
rowt
h, d
iagn
osed
clin
ically
or b
y biop
sy
703.
0IN
GROW
ING
NAIL
Use w
hen
docu
men
tatio
n st
ates
ingr
own
nail,
onyc
hocr
ypto
sis,
onyx
is, U
ngui
s inc
arna
tus o
r ing
rowi
ng n
ail.
Pain
ful c
ondi
tion
of th
e gre
at to
e in
which
the n
ail g
rows
into
the s
kin on
eit
her s
ide,
caus
ing
infla
mm
ation
and
/or i
nfec
tion,
dia
gnos
ed cl
inica
lly
703.
8DI
SEAS
ES O
F NA
IL NE
CTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes a
chro
mia
ung
uium
, acq
uire
d an
onyc
hia,
atro
phia
ung
uium
, Bea
u’s li
nes,
britt
le na
ils, c
lubn
ail,
deflu
vium
ung
uium
, na
il di
scolo
ratio
n, eg
gshe
ll na
ils, f
ragi
litas
ung
uium
, fra
gile
nails
or fu
rrowi
ng n
ails.
Spec
ified
lesio
n or
pro
cess
invo
lving
the n
ail,
inclu
ding
def
orm
ity,
disc
olora
tion,
abn
orm
al g
rowt
h, et
c, di
agno
sed
clini
cally
709.
9SK
IN D
ISOR
DER
NOS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes d
erm
atos
is, sk
in
dise
ase,
perin
eal i
rrita
tion,
or sk
in so
res.
Nons
pecifi
c skin
diso
rder,
inclu
ding
infla
mm
ation
, disc
olora
tion,
infe
ction
, gr
owth
, irri
tatio
n, et
c, di
agno
sed
clini
cally
and
/or b
y biop
sy
714.
0RH
EUM
ATOI
D AR
THRI
TIS38
Rheu
mat
oid
Arth
ritis
and
Infla
mm
ator
y Co
nnec
tive
Tissu
e Dise
ase
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es rh
eum
atoid
arth
ritis,
rh
eum
atic
arth
ritis,
chro
nic p
olyar
thrit
is, rh
eum
atoid
torti
colli
s, pr
imar
y pr
ogre
ssive
arth
ritis,
pro
lifer
ative
arth
ritis,
or a
troph
ic ar
thrit
is.
Chro
nic i
nflam
mat
ory d
isord
er fo
r mor
e tha
n 6
wks,
diag
nose
d cli
nica
lly w
ith 4
out
of th
e foll
owin
g: a
ffect
ing
3 or
mor
e join
ts, m
orni
ng st
iffne
ss, s
ymm
etric
al jo
int p
ain,
PI
P/M
CP jo
int i
nvolv
emen
t, rh
eum
atoid
nod
ules
, ero
sion
on x-
ray a
nd +
RF or
+CC
P
715.
00GE
NERA
L OS
TEOA
RTHR
OSIS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes g
ener
alize
d os
teoa
rthro
sis or
gen
eral
ized
arth
ritis.
This
code
shou
ld n
ot b
e use
d wh
en th
e med
ical r
ecor
d in
dica
tes
“arth
ritis”
, whi
ch is
code
d 71
5.9—
not s
tate
d wh
ethe
r loc
alize
d or
gen
eral
ized.
Gene
raliz
ed O
A in
volvi
ng m
ultip
le joi
nts,
diag
nose
d cli
nica
lly or
by i
mag
e stu
dies
10
3 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
715.
09GE
N OS
TEOA
RTHR
OSIS
IN
VLV
MX
SITE
SUs
e thi
s cod
e whe
n th
e doc
umen
tatio
n in
dica
tes g
ener
alize
d os
teoa
rthrit
is/os
teoa
rthro
sis, p
olyar
ticul
ar os
teoa
rthro
sis, i
diop
athi
c gen
eral
oste
oarth
osis/
arth
ritis,
poly
artic
ular
arth
rosis
, gen
eral
ized
joint
dise
ase,
or g
ener
alize
d ar
thrit
is.
Pain
in m
ultip
le joi
nts w
ithou
t infl
amm
ation
.
715.
16LO
C PR
IM
OSTE
OART
-L/L
EGTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n sp
ecifi
cally
stat
es
that
oste
oarth
ritis
is pr
esen
t in
the l
ower
extre
mity
(leg
).OA
invo
lving
lowe
r extr
emity
, dia
gnos
ed cl
inica
lly
715.
90OS
TEOA
RTHR
OS
NOS-
UNSP
ECUs
ed w
hen
docu
men
tatio
n sa
ys a
rthrit
is or
oste
oarth
rosis
or
dege
nera
tive j
oint d
iseas
e and
no s
ite is
des
crib
ed.
Non-
spec
ific O
A ch
arac
teriz
ed b
y join
t pai
n an
d st
iffne
ss, d
iagn
osed
cli
nica
lly or
by x
-ray fi
ndin
gs (n
arro
w joi
nt sp
ace,
bone
spur
s, et
c)
715.
96OS
TEOA
RTHR
OS
NOS-
L/LE
GUs
e thi
s cod
e whe
n th
e doc
umen
tatio
n st
ates
arth
ritis,
no
npyo
geni
c arth
ritis,
arth
ropa
thy,
joint
infla
mm
ation
, or
rheu
mat
ism of
the l
ower
par
t of t
he le
g is
docu
men
ted.
Non-
spec
ific j
oint p
ain
invo
lving
lowe
r extr
emity
, dia
gnos
ed cl
inica
lly
716.
90AR
THRO
PATH
Y NO
S-UN
SPEC
Use t
his c
ode w
hen
the d
ocum
enta
tion
stat
es a
rthrit
is, n
onpy
ogen
ic ar
thrit
is,
arth
ropa
thy,
joint
infla
mm
ation
, or r
heum
atism
and
no a
rea
of th
e bod
y is m
entio
ned.
Nons
peici
fic jo
int p
ain
diag
nose
d cli
nica
lly
719.
41JO
INT P
AIN-
SHLD
ERTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes s
houl
der j
oint p
ain.
Join
t disc
omfo
rt in
volvi
ng sh
ould
er, d
iagn
osed
clin
ically
719.
45JO
INT P
AIN-
PELV
ISUs
ed w
hen
docu
men
tatio
n st
ates
coxa
lagi
a, h
ip p
ain,
or p
elvic
pain
.Jo
int d
iscom
fort
invo
lving
pelv
ic ar
ea, d
iagn
osed
clin
ically
719.
46JO
INT P
AIN-
L/LE
GTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t ha
s kne
e pai
n, p
atell
ofem
oral
synd
rom
e, or
pat
ellof
emor
al p
ain.
Lowe
r extr
emity
pai
n in
volvi
ng th
e kne
e join
t, di
agno
sed
clini
cally
719.
47JO
INT P
AIN-
ANKL
EUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s pai
n in
the a
nkle,
foot
or m
etat
arsa
ls.Jo
int d
iscom
fort/
pain
invo
lving
ank
le, d
iagn
osed
clin
ically
719.
7DI
FFIC
ULTY
WAL
KING
Used
whe
n do
cum
enta
tion
indi
cate
s tha
t the
pat
ient h
as
diffi
culty
in w
alkin
g, b
ut n
o cau
se is
des
crib
ed.
Diffi
culty
wal
king,
dia
gnos
ed cl
inica
lly.
10
4 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
721.
3LU
MBO
SACR
AL
SPON
DYLO
SIS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes l
umba
r spo
ndylo
sis,
lum
bosa
cral
spon
dylos
is, or
sacr
al sp
ondy
losis.
OA in
volvi
ng lu
mba
r and
/or s
acra
l are
a, d
iagn
osed
clin
ically
or b
y im
age s
tudi
es
722.
52LU
MB/
LUM
BOSA
C DI
SC D
EGEN
This
code
is a
ssig
ned
if th
e doc
umen
tatio
n st
ates
OA
AND
the
locat
ion of
the l
umba
r or s
acra
l spi
ne is
spec
ifica
lly st
ated
.OA
invo
lving
lum
bar a
nd/o
r sac
ral a
rea,
dia
gnos
ed cl
inica
lly
723.
1CE
RVIC
ALGI
ATh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes c
ervic
algi
a, n
eck
pain
or ce
rvica
l pai
n an
d no
caus
e of t
he p
ain
is do
cum
ente
d.Sy
mpt
oms o
f nec
k pai
n/di
scom
fort,
dia
gnos
ed cl
inica
lly
724.
02SP
INAL
STE
NOSI
S-LU
MBA
RTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes
lum
bar s
pina
l ste
nosis
or lu
mbo
sacr
al st
enos
is.Na
rrowi
ng of
the s
pina
l can
al le
adin
g to
the c
ompr
essio
n of
th
e spi
nal c
ord
and
nerv
es le
adin
g to
pai
n an
d/or
abn
orm
al
sens
ation
, dia
gnos
ed cl
inica
lly a
nd/o
r by i
mag
e stu
dies
724.
2LU
MBA
GOUs
ed w
hen
docu
men
tatio
n sa
ys lu
mba
go or
low
back
pai
n.Pa
in in
the l
umba
r reg
ion d
iagn
osed
clin
ically
724.
3SC
IATIC
ATh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes C
otun
go’s
dise
ase,
Cotu
ngo’s
synd
rom
e, Isc
hial
gia,
sacr
oilia
c join
t neu
ralg
ia,
scia
tic n
eura
lgia
, scia
tic p
ain,
infe
ction
al sc
iatic
a or
scia
tica.
Irrita
tion
of sc
iatic
ner
ve le
adin
g to
pai
n an
d tin
glin
g se
nsat
ion
radi
atin
g do
wn lo
wer e
xtrem
ities
, dia
gnos
ed cl
inica
lly
724.
4LU
MBO
SACR
AL
NEUR
ITIS
NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s lum
bar n
erve
root
di
sord
er, lu
mbo
sacr
al n
erve
root
diso
rder,
thor
acic
nerv
e roo
t diso
rder,
lu
mbo
sacr
al ra
dicu
lar p
ain,
ant
erior
crur
al ra
dicu
litis,
leg
radi
culit
is,
lum
bar,
lum
bosa
cral
radi
culit
is, or
lum
bosa
cral
radi
culop
athy
.
Nons
pecifi
c infl
amm
ation
of lu
mba
rsac
ral n
erve
(s) l
eadi
ng to
pai
n,
num
bnes
s or t
ingl
ing,
dia
gnos
ed cl
inica
lly a
nd/o
r by E
MG/
NCS
724.
5BA
CKAC
HE N
OSUs
ed w
hen
docu
men
tatio
n st
ates
bac
kach
e, or
verte
brog
enic
synd
rom
e.No
nspe
cific b
ack p
ain
10
5 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
728.
87M
USCL
E W
EAKN
ESS
(GEN
ERAL
IZED
)Us
e thi
s cod
e if t
he d
ocum
enta
tion
indi
cate
s tha
t the
pa
tient
is m
yast
heni
c, or
has
mus
cle w
eakn
ess.
A re
duct
ion in
the s
treng
th of
one o
r mor
e mus
cles.
729.
1M
YALG
IA A
ND
MYO
SITIS
NOS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes m
yalg
ia, fi
brom
yalg
ia, m
yosit
is, m
yofa
cial
pain
, fibr
omyo
sitis,
mus
cle p
ain,
neu
rom
uscu
lar p
ain,
or rh
eum
atic
mus
cula
r pai
n.No
nspe
cific p
ain
invo
lving
mus
cle, d
iagn
osed
clin
ically
729.
5PA
IN IN
LIM
BPa
in in
arm
, leg
, han
d, fo
ot, fi
nger
s or t
oes.
Pain
in a
rm, l
eg, h
and,
foot
, fing
ers o
r toe
s, di
agno
sed
clini
cally
729.
81SW
ELLIN
G OF
LIM
BUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s swe
lling
in a
lim
b, in
cludi
ng d
igits
.Sw
ellin
g in
a li
mb
inclu
ding
dig
its, d
iagn
osed
clin
ically
733.
00OS
TEOP
OROS
IS N
OSUs
ed w
hen
docu
men
tatio
n sa
ys os
teop
oros
is.No
nspe
cific d
ecre
ase i
n bo
ne m
ass o
r den
sity,
diag
nose
d cli
nica
lly or
by D
EXA
scan
or ot
her i
mag
e stu
dies
733.
01SE
NILE
OST
EOPO
ROSI
STh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes o
steo
poro
sis,
seni
le os
teop
oros
is or
pos
t-men
opau
sal o
steo
poro
sis.
Decr
ease
in b
one m
ass o
r den
sity d
ue to
old
age d
iagn
osed
cli
nica
lly b
y DEX
A sc
an a
nd/o
r im
age s
tudi
es
733.
90BO
NE &
CAR
TILAG
E DI
S NO
SUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s bon
e les
ion, o
steo
lytic
lesion
, bon
e m
ass,
oste
ocop
ic pa
in, o
steo
dyni
a, os
teop
enia
, bon
e pai
n, ca
rtila
ge p
ain,
tibi
a pa
in, x
ypho
id p
ain,
scap
ulal
gia,
xiph
oiden
ia, x
ipho
idal
gia
or b
one c
hang
es.
Nons
pecifi
c abn
orm
ality
invo
lving
bon
e and
carti
lage
, dia
gnos
ed cl
inica
lly
780.
02TR
ANS
ALTE
R AW
AREN
ESS
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
ltera
tion
of co
nscio
usne
ss, t
rans
ient
alte
ratio
n of
awa
rene
ss or
tran
sient
alte
ratio
n of
cons
cious
ness
.Tra
nsien
t alte
ratio
n of
cons
cious
ness
, dia
gnos
ed cl
inica
lly
780.
09OT
HER
ALTE
R CO
NSCI
OUSN
ESUs
ed w
hen
docu
men
tatio
n st
ates
: deli
rium
, dro
wsin
ess,
hypo
resp
onsiv
e sta
te,
loss o
f con
sciou
snes
s, se
mi c
oma,
sem
i con
sciou
snes
s or s
omno
lence
.No
n-sp
ecifi
c cha
nge i
n m
enta
l sta
tus,
inclu
ding
deli
rium
, dro
wsin
ess,
hypo
resp
onsiv
e st
ate,
loss o
f con
sciou
snes
s, se
mi c
oma,
sem
i con
sciou
snes
s or s
omno
lence
.
10
6 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
780.
2SY
NCOP
E AN
D CO
LLAP
SETh
is co
de sh
ould
be u
sed
when
the d
ocm
enta
tion
indi
cate
s syn
cope
(w
ithou
t und
erlyi
ng ca
use)
, coll
apse
, unc
onsc
iousn
ess,
vaso
-vag
al
atta
ck, v
agal
sync
ope,
vaso
mot
or a
ttack
, bla
ckou
t, fa
intin
g, G
ower
’s sy
ndro
me,
vasc
ular
hyp
erre
acto
r, or
vaso
mot
or in
stab
ility.
Loss
of co
nscio
usne
ss d
ue to
inad
equa
te b
lood
flow
to th
e bra
in, d
iagn
osed
clin
ically
780.
39OT
HER
CONV
ULSI
ONS
74Se
izure
Di
sord
ers a
nd
Conv
ulsio
ns
Use i
f the
doc
umen
tatio
n in
dica
tes e
pilep
tifor
m a
ttack
, sen
sory
and
mot
or a
ttack
, to
xic ce
rebr
al a
ttack
, ecla
mpt
ic co
ma,
conv
ulsio
ns, i
diop
athi
c con
vulsi
ons,
ce
rebr
al co
nvul
sions
, cer
ebro
spin
al co
nvul
sions
, ecla
mpt
ic co
nvul
sions
, eth
er
conv
ulsio
ns, g
ener
alize
d co
nvul
sions
, inf
antil
e con
vulsi
ons,
inte
rnal
conv
ulsio
ns,
recu
rrent
conv
ulsio
ns, r
epet
itive
conv
ulsio
ns, s
pasm
odic
conv
ulsio
ns, e
pilep
toid
se
izure
s, et
her s
eizur
es, g
ener
alize
d se
izure
s, or
conv
ulsiv
e diso
rder.
Sudd
en, i
nvolu
ntar
y ske
letal
mus
cula
r con
tract
ions o
f cer
ebra
l or b
rain
stem
orig
in
780.
4DI
ZZIN
ESS
AND
GIDD
INES
STh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes d
izzin
ess,
gi
ddin
ess,
dyse
quili
briu
m, l
ight
head
edne
ss, s
wim
min
g in
the h
ead,
Mal
de D
ebar
quem
ent o
r ver
tigo.
Sym
ptom
s of f
eelin
g di
zzy,
imba
lanc
ed, d
iagn
osed
clin
ically
780.
52IN
SOM
NIA
NOS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s ins
omni
a, sl
eepl
essn
ess,
ag
rypni
a, d
isrup
tion
in s
leep
initi
ation
or m
aint
enan
ce, o
r hyp
osom
nia.
Inab
ility
or d
ifficu
lty fa
lling
asle
ep or
rem
aini
ng a
sleep
780.
60FE
VER
UNSP
ECIFI
EDUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s fev
er, ch
ills w
ith fe
ver,
pyre
xia, f
ever
of u
nkno
wn or
igin
, eph
emer
al fe
ver,
or fe
bricu
la.
Pres
ence
of fe
ver w
ithou
t fur
ther
det
ail;
gene
rally
>=
99.5
F or
37.
5 C
780.
79M
ALAI
SE A
ND FA
TIGUE
NEC
Used
whe
n do
cum
enta
tion
indi
cate
s mal
aise
, fat
igue
, ast
heni
a, or
chro
nic E
pste
in B
arr.
Sym
ptom
s of m
alai
se a
nd fa
tique
, dia
gnos
ed cl
inica
lly
10
7 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
780.
97AL
TERE
D M
ENTA
L STA
TUS
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s alte
red
men
tal
stat
us, a
ltera
tion
of m
enta
l sta
tus o
r cha
nges
in m
enta
l sta
tus.
A los
s or d
ecre
ase i
n th
e lev
el of
awa
rene
ss of
self
and
envir
onm
ent c
ombi
ned
with
mar
kedl
y red
uced
resp
onsiv
enes
s to
envir
onm
enta
l stim
uli
780.
99OT
HER
GENE
RAL
SYM
PTOM
SUs
ed w
hen
docu
men
tatio
n in
dica
tes r
igor
s, su
bnor
mal
tem
pera
ture
, fu
nctio
nal a
ctivi
ty de
crea
se, o
r oth
er g
ener
al sy
mpt
oms.
Nons
pecifi
c gen
eral
sym
ptom
s, di
agno
sed
clini
cally
781.
2AB
NORM
ALITY
OF
GAIT
Used
whe
n th
e doc
umen
tatio
n in
dica
tes a
taxic
gai
t, ga
it ab
norm
ality
, gai
t di
stur
banc
e, pa
ralyt
ic ga
it, sc
issor
gai
t, sp
astic
gai
t, st
agge
ring
gait
or im
bala
nce.
Abno
rmal
pat
tern
of w
alkin
g, d
iagn
osed
clin
ically
782.
1NO
NSPE
CIF S
KIN
ERUP
T NEC
Used
whe
n th
e doc
umen
tatio
n in
dica
tes p
ustu
lar r
ash,
rash
, ro
se ra
sh, t
oxic
rash
, skin
rash
or ex
anth
ema.
Nons
pecifi
c rai
sed,
itch
y, re
d-we
lts on
the s
urfa
ce of
the s
kin, u
sual
ly du
e to
alle
rgic
reac
tion
to fo
od, m
edica
tion,
etc,
diag
nose
d cli
nica
lly
782.
3ED
EMA
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s ana
sarc
a, S
ecre
tan’s
ed
ema,
infe
ctiou
s ede
ma,
pitt
ing
edem
a, or
edem
a.Ac
cum
ulat
ion of
flui
d, u
sual
ly in
the l
ower
extre
miti
es
and
depe
nden
t are
a, d
iagn
osed
clin
ically
783.
21AB
NORM
LOSS
OF W
EIGH
TUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s abn
orm
al w
eight
los
s, or
weig
ht lo
ss of
unk
nown
caus
e.Lo
sing
mor
e tha
n 10
% of
the u
sual
weig
ht ov
er 3
-6 m
onth
s, di
agno
sed
clini
cally
784.
0HE
ADAC
HEUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s hea
dach
e, ce
phal
gia,
va
scul
ar h
eada
che,
face
or fa
cial p
ain
or h
ead
pain
.Sy
mpt
oms o
f hea
dach
e or h
ead
disc
omfo
rt, d
iagn
osed
clin
ically
785.
1PA
LPITA
TIONS
Use w
hen
docu
men
tatio
n in
dica
tes p
alpi
tatio
ns, p
ulse
s in
the n
eck,
or yo
u ha
ve re
cord
ed th
at th
e pat
ient h
as a
n aw
aren
ess o
f the
ir he
artb
eat.
Pres
ence
of p
alpi
tatio
n, d
iagn
osed
clin
ically
786.
05SH
ORTN
ESS
OF B
REAT
HUs
ed w
hen
the d
ocum
enta
tion
says
shor
tnes
s of b
reat
h.Sy
mpt
om of
shor
tnes
s of b
reat
h
786.
09RE
SPIR
ATOR
Y AB
NORM
NEC
This
code
is u
sed
when
the d
ocum
enta
tion
says
hyp
erca
pnia
, hy
pove
ntila
tion,
irre
gula
r bre
athi
ng or
labo
red
brea
thin
g al
so d
yspn
ea
on ex
terti
on, r
espi
rato
ry di
stre
ss a
nd re
spira
tory
insu
fficie
ncy.
Nons
pecifi
c pul
mon
ary s
ympt
oms i
nclu
ding
shor
tnes
s of b
reat
h,
hypo
vent
ilatio
n, d
yspn
ea on
exer
cise,
hype
rcap
nia,
etc
10
8 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
786.
2CO
UGH
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s co
ugh,
laryn
geal
sync
ope o
r tus
sive s
ynco
pe.
Sym
ptom
of co
ugh,
dia
gnos
ed cl
inica
lly
786.
50CH
EST P
AIN
NOS
Used
whe
n do
cum
enta
tion
indi
cate
s che
st p
ain
or ri
b pa
in.
Nons
pecifi
c or n
on ca
rdia
c che
st p
ain
/ disc
omfo
rt, d
iagn
osed
clin
ically
786.
51PR
ECOR
DIAL
PAI
NTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n st
ates
pre
cord
ial p
ain,
card
ialg
ia,
angi
noid
pai
n, m
idst
erna
l pai
n, su
bste
rnal
pai
n, h
eart
pain
, per
icard
ial p
ain,
or
retro
ster
nal p
ain.
If th
e doc
umen
tatio
n sa
ys a
ngin
a, th
en th
e cor
rect
code
is 4
13.9
.
Nons
pecifi
c or n
on ca
rdia
c che
st d
iscom
fort
othe
r tha
n an
gina
, dia
gnos
ed cl
inica
lly
786.
59CH
EST P
AIN
NEC
Used
whe
n th
e doc
umen
tatio
n st
ates
ches
t pai
n, ch
est d
iscom
fort,
atyp
ical
ches
t pai
n, m
uscu
loske
letal
ches
t pai
n or
non
card
iac c
hest
pai
n.No
nspe
cific n
onca
rdia
c che
st p
ain/
disc
omfo
rt, d
iagn
osed
clin
ically
787.
01NA
USEA
WITH
VOM
ITING
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
he p
rese
nce o
f bot
h na
usea
and
vom
iting
. For
na
usea
w/o
vom
iting
, use
787
.02;
for v
omiti
ng w
/o n
ause
a do
cum
ente
d, u
se 7
87.0
3Sy
mpt
oms o
f nau
sea
and
vom
iting
, dia
gnos
ed cl
inica
lly
787.
20DY
SPHA
GIA
UNSP
ECIFI
EDUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s dys
phag
ia, o
r diffi
culty
swal
lowin
g.Di
fficu
lty sw
allow
ing,
dia
gnos
ed cl
inica
lly or
by r
adiol
ogica
l stu
dies
. Di
agno
sed
gene
rally
clin
ically
, x-ra
ys on
ly if
patie
nt is
aph
asic.
787.
91DI
ARRH
EATh
is co
de w
as u
sed
when
the d
ocum
enta
tion
indi
cate
s dia
rrhea
, ac
ute d
iarrh
ea, a
utum
n di
arrh
ea, b
iliou
s dia
rrhea
, bloo
dy d
iarrh
ea,
cata
rrhal
dia
rrhea
, cho
lerai
c dia
rrhea
, chr
onic
diar
rhea
, dia
rrhea
gr
avis,
gre
en d
iarrh
ea, i
nfan
tile d
iarrh
ea, o
r lien
teric
dia
rrhea
.
Sym
ptom
s of d
iarrh
ea (f
requ
euen
t sto
ol: >
3 d
aily)
, dia
gnos
ed
clini
cally
. Also
dia
gnos
ed b
ased
on st
ool a
ppea
ranc
e (wa
tery)
788.
20UN
SPEC
IFIED
RE
TENT
ION
OF U
RINE
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s urin
ary
rete
ntion
, bla
dder
rete
ntion
, urin
e sto
ppag
e, or
urin
e sta
sis.
Inco
mpl
ete e
mpt
ying
of th
e bla
dder
10
9 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
788.
30UR
INAR
Y IN
CONT
INEN
CE N
OSTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n on
ly st
ates
that
the p
atien
t ha
s urin
ary i
ncon
tinen
ce w
ithou
t sta
ting
the e
tiolog
y or t
ype.
Unsp
ecifi
ed lo
ss of
cont
rol o
f urin
e, di
agno
sed
clini
cally
789.
00AB
DMNA
L PA
IN
UNSP
CF S
ITEUs
ed w
hen
docu
men
tatio
n st
ates
abd
omin
al p
ain
and
a qu
adra
nt is
not
spec
ified
.No
n-sp
ecifi
c abd
omin
al p
ain,
dia
gnos
ed cl
inica
lly
789.
06AB
DMNA
L PAI
N EP
IGAS
TRIC
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t th
e pat
ient h
as ep
igas
tric a
bdom
inal
pai
n.Ep
igas
tric p
ain/
disc
omfo
rt, d
iagn
osed
clin
ically
789.
07AB
DMNA
L PAI
N GE
NERA
LIZED
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s gen
eral
ized
abdo
min
al p
ain.
Gene
raliz
ed a
bdom
inal
pai
n/di
scom
fort,
dia
gnos
ed cl
inica
lly
789.
09AB
DMNA
L PAI
N OT
H SP
CF S
TTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n de
scrib
es a
bdom
inal
pai
n in
an
area
of th
e abd
omen
that
doe
s not
hav
e a sp
ecifi
c cod
e. Th
is
inclu
des d
escr
iptiv
e ter
ms s
uch
as a
bdom
inal
gia,
or co
lic.
Abdo
min
al p
ain/
disc
omfo
rt, d
iagn
osed
clin
ically
790.
6AB
NORM
BLO
OD
CHEM
ISTR
Y NE
CTh
is co
de is
ass
igne
d wh
en th
e doc
umen
tatio
n in
dica
tes
an a
bnor
mal
(bloo
d) la
bora
tory
test
, but
the s
igni
fican
ce or
re
late
d di
agno
sis is
not
det
erm
ined
or d
ocum
ente
d.
Abno
rmal
bloo
d te
st va
lue,
diag
nose
d ba
sed
on la
b va
lue
790.
93EL
VTD
PRST
ATE
SPCF
ANT
GNTh
is co
de is
to b
e use
d wh
en yo
u ha
ve d
ocum
ente
d th
at th
e pa
tient
has
an
eleva
ted
PSA.
If yo
u on
ly no
te th
e lab
valu
e, yo
u ca
nnot
code
this—
you
mus
t sta
te th
at it
is el
evat
ed.
Elev
ated
PSA
leve
l, di
agno
sed
base
d on
lab
valu
e
793.
1AB
NORM
FIND
INGS
-LU
NG FI
ELD
Used
whe
n th
e doc
umen
tatio
n in
dica
tes l
ung
shad
ow, a
bnor
mal
ra
diolo
gy fi
ndin
g in
lung
, lun
g in
filtra
te, o
r lun
g co
in.
Abno
rmal
lesio
ns in
the l
ungs
, inc
ludi
ng in
filtra
te, m
ass/
nodu
les, a
bces
s, et
c, di
agno
sed
by im
age s
tudi
es
794.
31AB
NORM
EL
ECTR
OCAR
DIOG
RAM
This
code
is on
ly us
ed w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
EKG
is
abno
rmal
but
the n
atur
e of t
he a
bnor
mal
ity is
unk
nown
or u
nsta
ted.
Abno
rmal
ECG
find
ings
,
11
0 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
799.
02HY
POXE
MIA
79Ca
rdio-
Resp
irato
ry
Failu
re a
nd
Shoc
k
Used
whe
n th
e doc
umen
tatio
n in
dica
tes h
ypox
ia, a
noxia
, an
oxem
ia, p
atho
logica
l ano
xia, o
r hyp
oxem
ia.
Lowe
r tha
n no
rmal
bloo
d ox
ygen
leve
l.
799.
3UN
SPEC
IFIED
DEB
ILITY
This
code
is u
sed
when
the d
ocum
enta
tion
stat
es g
ener
al(iz
ed)
debi
lity,
debi
lity,
or g
ener
al d
eclin
e are
doc
umen
ted.
Unsp
ecifi
ed d
ebili
ty. E
xclu
des a
sthe
nia,
ner
vous
de
bilit
y, ne
uras
then
ia a
nd se
nile
asth
enia
820.
8CL
OS FR
ACTU
RE U
NSPE
C PA
RT N
ECK
FEM
158
Hip
Frac
ture
/Di
sloca
tion
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s fra
ctur
e of t
he n
eck
of fe
mur
, fra
ctur
e of t
he fe
mur
, upp
er en
d of
the f
emur
, or h
ip.
Frac
ture
of fe
mur
, dia
gnos
ed b
y x-ra
y.
995.
91SE
VERE
SEP
SIS
Use w
hen
docu
men
tatio
n in
dica
tes s
ever
e sep
sis,
gene
raliz
ed se
psis,
or S
IRS
due t
o inf
ectio
n.Se
vere
seps
is is
an a
dmin
istra
tive d
iagn
osis,
whi
ch is
defi
ned
as se
psis
with
ass
ocia
ted
orga
n dy
sfun
ction
.
E849
.0AC
CIDE
NT IN
HOM
ETh
is is
a su
pplem
enta
l cod
e, an
d sh
ould
nev
er b
e use
d al
one.
Use t
his c
ode w
hen
the d
ocum
enta
tion
indi
cate
s tha
t the
pat
ient s
uffe
red
an in
jury
in th
eir h
ome.
Accid
ent a
t hom
e
E888
.9FA
LL N
OSTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t fe
ll, w
ithou
t fur
ther
info
rmat
ion. T
he co
de se
ries E
888.
X ha
s ver
y sp
ecifi
c cod
es fo
r fal
ls, b
ased
on h
ow or
whe
re th
ey oc
curre
d. W
hen
this
info
rmat
ion is
ava
ilabl
e, it
shou
ld b
e doc
umen
ted.
Used
to in
dica
te th
e cau
se of
an
inju
ry
V03.
82VA
CCIN
STR
PTCS
PN
EUM
NI B
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s the
pat
ient
rece
ived
stre
ptoc
occu
s pne
umon
iae [
pneu
moc
occu
s] va
ccin
e.Ad
min
istra
tion
of p
neum
ococ
cal v
accin
ation
11
1 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
V04.
81VA
CCIN
FOR
INFL
UENZ
AUs
ed to
indi
cate
that
the p
atien
t is s
een
for i
nflue
nza
vacc
ine.
Perfo
rman
ce of
influ
enza
vacc
inat
ion
V10.
3HX
OF B
REAS
T M
ALIG
NANC
YTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t has
ha
d br
east
canc
er a
nd h
as co
mpl
eted
trea
tmen
t (su
rgica
lly, r
adia
tion,
ch
emot
hera
py or
any
com
bina
tion)
whe
n th
ere i
s no i
ndica
tion
that
ther
e is
tum
or st
ill p
rese
nt. P
atien
ts u
nder
goin
g tre
atm
ent w
ith ta
mox
ifen
or si
mila
r dru
gs sh
ould
be c
oded
as h
avin
g ac
tive d
iseas
e.
Hist
ory o
f bre
ast c
ance
r, no
act
ive ca
ncer,
dia
gnos
ed b
y hist
ory
V12.
54PE
RS H
X TIA
& C
I W/O
RE
SIDL
DEF
ICTS
Use w
hen
docu
men
tatio
n in
dica
tes o
ld C
VA or
hea
led C
VA, w
ithou
t men
tion
of d
eficit
s, hi
stor
y of T
IA, o
ld or
hea
led ce
rebr
al h
emor
rhag
e, TIA
, tra
nsien
t isc
hem
ic at
tack
or p
rolon
ged
reve
rsib
le isc
hem
ic ne
urolo
gic (
PRIN
D).
Patie
nt w
ith a
per
sona
l hist
ory o
f CVA
with
resid
ual d
eficit
.
V15.
82HX
OF T
OBAC
CO U
SEUs
ed w
hen
the d
ocum
enta
tion
indi
cate
s a h
istor
y of t
obac
co
use,
prior
toba
cco u
se or
hist
ory o
f cig
aret
te sm
okin
g.Hi
stor
y of p
rior t
obac
co u
se, d
iagn
osed
by h
istor
y
V15.
88PE
RSON
AL H
ISTO
RY
OF FA
LLUs
ed w
hen
docu
men
tatio
n in
dica
tes f
all,
at ri
sk fo
r fal
ls, fa
ll/fa
lling
haz
ard,
falli
ng d
isord
er, or
falli
ng ri
sk.
Patie
nt w
ith h
istor
y of f
all.
V43.
1LE
NS R
EPLA
CEM
ENT N
ECUs
ed w
hen
your
not
e ind
icate
s tha
t the
lens
of th
e eye
has
bee
n re
plac
ed.
Stat
us p
ost l
ens r
epla
cem
ent
V43.
65KN
EE JO
INT R
EPLA
CEM
ENT
OTHE
R M
EANS
Used
whe
n do
cum
enta
tion
indi
cate
s kne
e join
t rep
lace
men
t, kn
ee re
plac
emen
t, kn
ee/k
nee j
oint p
rost
hesis
, kne
e join
t dev
ice, o
r arti
ficia
l kne
e join
t.St
atus
of kn
ee re
plac
emen
t with
pro
sthe
sis
V45.
01ST
ATUS
CAR
DIAC
PA
CEM
AKER
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t th
e pat
ient h
as a
card
iac p
acem
aker
in p
lace
.Pa
cem
aker
pla
cem
ent,
diag
nose
d cli
nica
lly or
by i
mag
ing
stud
y
V45.
11RE
NAL D
IALY
SIS
STAT
US13
0Di
alys
is St
atus
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s th
at th
e pat
ient r
eceiv
es h
emod
ialys
is.Pa
tient
s und
ergo
ing
rena
l dia
lysis.
11
2 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
V45.
81AO
RTOC
ORON
ARY
BYPA
SSTh
is co
de is
use
d wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he
patie
nt is
stat
us p
ost c
oron
ary b
ypas
s sur
gery.
If th
ere i
s res
idua
l di
seas
e, th
is sh
ould
be f
ully
desc
ribed
and
code
d.
s/p
CABG
V57.
1PH
YSIC
AL TH
ERAP
Y NE
CTh
is co
de sh
ould
be u
sed
only
when
the p
atien
t pre
sent
s for
ph
ysica
l the
rapy
, and
this
is no
ted
in th
e med
ical r
ecor
d.Us
ed b
y the
phy
sical
ther
apist
for p
atien
ts p
rese
ntin
g fo
r phy
sical
ther
apy
V57.
89OT
HER
SPEC
RE
HABI
LITAT
ION
PROC
OTH
Used
whe
n th
e doc
umen
tatio
n in
dica
tes m
ultip
le typ
es of
on
goin
g re
habi
litat
ion, o
r whe
n th
ere i
s no s
pecifi
c cod
e for
the
type o
f reh
abili
tatio
n th
at th
e pat
ient i
s und
ergo
ing.
N/A
V58.
61LO
NG-T
ERM
USE
AN
TICOA
GUL
Used
whe
n th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t is o
n lon
g-te
rm
antic
oagu
lant
ther
apy.
The u
nder
lying
cond
ition
(e.g
., hi
stor
y of D
VT or
ch
roni
c atri
al fi
brill
ation
) mus
t also
be d
ocum
ente
d an
d co
ded.
Stat
us of
usin
g lon
g te
rm a
ntico
agul
ation
ther
apy
V58.
67LO
NG-T
ERM
USE
OF
INSU
LIN19
Diab
etes
with
out
Com
plica
tion
Used
whe
n th
e doc
umen
tatio
n in
dica
tes c
urre
nt in
sulin
use
, lon
g te
rm in
sulin
use
, or o
ngoin
g in
sulin
ther
apy.
Stat
us of
long
term
use
of in
sulin
.
V58.
69LO
NG-T
ERM
USE
M
EDS
NEC
Used
whe
n th
e pat
ient h
as lo
ng te
rm m
edica
tion
use t
hat d
oes n
ot h
ave a
spec
ific
code
. For
exam
ple t
here
are
spec
ific c
odes
for l
ong
term
use
of a
ntico
agul
ants
(V
58.6
1), l
ong
term
use
of a
ntib
iotics
(V58
.62)
and
long
term
use
of st
eroid
s (V5
8.65
). It’s
app
ropr
iate
to u
se th
is co
de fo
r lon
g te
rm u
se of
opioi
d pa
in m
edica
tion.
Stat
us of
(cur
rent
) med
icatio
n us
e lon
g te
rm
V70.
0RO
UTIN
E M
EDIC
AL E
XAM
Used
to in
dica
te th
at th
e pat
ient i
s see
n fo
r a ro
utin
e (e.g
., pr
even
tive)
serv
ice.
Perfo
rman
ce of
rout
ine m
edica
l exa
min
ation
11
3 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
V72.
0EY
E &
VISI
ON
EXAM
INAT
ION
Used
to in
dica
te a
pat
ient s
een
for e
ye ex
amin
ation
Perfo
rman
ce of
eye a
nd vi
sion
exam
inat
ion
V72.
31RO
UTIN
E GY
N EX
AMIN
ATIO
NUs
ed on
ly wh
en th
e doc
umen
tatio
n in
dica
tes t
hat t
he p
atien
t pr
esen
ted
for a
rout
ine g
ynec
ologi
cal e
xam
inat
ion. T
his c
ode i
s not
to
be u
sed
for p
atien
ts w
ith a
know
n gy
neco
logica
l con
ditio
n.
Perfo
rman
ce of
rout
ine g
ynec
ologi
cal e
xam
V72.
60LA
BORA
TORY
EX
AMIN
ATIO
N UN
SPEC
IFIED
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t th
e pat
ient h
ad la
bora
tory
serv
ices d
one.
Perfo
rman
ce of
labo
rato
ry te
sts o
nly
V72.
81PR
EOP
CARD
IOVS
CLR
EXAM
This
code
is u
sed
when
the d
ocum
enta
tion
indi
cate
s tha
t the
ex
amin
ation
is fo
r car
diov
ascu
lar c
leara
nce p
reop
erat
ively.
Perfo
rman
ce of
pre
-ope
rativ
e car
diov
ascu
lar e
valu
tion
V72.
83OT
HER
SPCF
PRE
OP E
XAM
This
code
is u
sed
to in
dica
te a
spec
ified
pre
-ope
rativ
e exa
min
ation
th
at d
oes n
ot h
ave a
mor
e spe
cific c
ode,
e.g. r
enal
func
tion
stud
ies
in a
pat
ient w
ith ki
dney
dise
ase,
befo
re u
nder
goin
g su
rger
y.
Perfo
rman
ce of
spec
ific p
reop
erat
ive ex
amin
ation
V72.
84PR
EOP
EXAM
UNS
PCF
Use o
nly w
hen
your
doc
umen
tatio
n in
dica
tes y
ou a
re d
oing
a hi
stor
y and
ph
ysica
l exa
min
ation
for a
pat
ient h
avin
g a
surg
ical p
roce
dure
Perfo
rman
ce of
H &
P p
rior t
o sur
gica
l pro
cedu
re
V76.
12SC
REEN
MAM
MOG
RAM
NE
CUs
ed b
y the
scre
enin
g m
amm
ogra
phy c
ente
r or i
nter
pret
ing
radi
ologi
st
when
the p
atien
t is s
een
for a
scre
enin
g m
amm
ogra
m.
Perfo
rman
ce of
mam
mog
ram
for b
reas
t can
cer s
cree
ning
V76.
2SC
REEN
MAL
IG
NEOP
-CER
VIX
This
code
is u
sed
when
the p
atien
t pre
sent
s for
a sc
reen
ing
Pap
smea
r.Pe
rform
ance
of p
ap sm
ear f
or ce
rvica
l can
cer s
cree
ning
V76.
51SC
REEN
MAL
IG
NEOP
-COL
ONUs
e thi
s cod
e whe
n th
e pat
ient h
as n
o sym
ptom
s and
you
are
perfo
rmin
g a
colon
osco
py or
stoo
l for
occu
lt bl
ood.
Perfo
rman
ce of
colon
canc
er sc
reen
ing,
inclu
ding
colon
osco
py,
chec
king
stoo
l for
occu
lt bl
ood,
or b
ariu
m en
ema
11
4 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
DX C
oDe
DX D
esCr
ipti
onHC
CHC
C De
sCri
ptio
nDo
Cum
enta
tion
req
uire
men
ts f
or C
oDe
use
Clin
iCal
Cri
teri
a
Appendices
Cover & Tabs.indd 5 6/7/12 12:35 PM
11
5 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
App
end
ix 1
. CM
S-H
CC R
iSk
Ad
juStM
en
t M
od
el—
Co
MM
un
ity
An
d i
nSti
tuti
on
Al
FAC
toR
S
Vari
able
Dis
ease
Gro
up C
omm
unit
y Fa
Ctor
s in
stit
utio
nal
FaCt
ors
Fem
ale
Fem
ale 0
-34
Year
s0.
210
0.95
0
Fem
ale 3
5-44
Year
s0.
217
0.95
0
Fem
ale 4
5-54
Year
s0.
276
0.95
0
Fem
ale 5
5-59
Year
s0.
343
1.03
1
Fem
ale 6
0-64
Year
s0.
415
1.03
1
Fem
ale 6
5-69
Year
s0.
279
1.13
1
Fem
ale 7
0-74
Year
s0.
337
1.02
5
Fem
ale 7
5-79
Year
s0.
426
0.90
0
Fem
ale
80-8
4 Ye
ars
0.52
50.
772
Fem
ale
85-8
9 Ye
ars
0.65
10.
700
Fem
ale 9
0-94
Year
s0.
786
0.57
6
11
6 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
Dis
ease
Gro
up C
ommu
nity
FaC
tors
inst
itut
iona
l FaC
tors
Fem
ale
95+
Year
s0.
822
0.44
7
mal
e
Mal
e 0-3
4 Ye
ars
0.11
71.
089
Mal
e 35-
44 Ye
ars
0.13
30.
960
Mal
e 45-
54 Ye
ars
0.19
30.
960
Mal
e 55-
59 Ye
ars
0.27
21.
020
Mal
e 60-
64 Ye
ars
0.33
71.
082
Mal
e 65-
69 Ye
ars
0.28
31.
281
Mal
e 70-
74 Ye
ars
0.34
61.
178
Mal
e 75-
79 Ye
ars
0.43
61.
178
Mal
e 80-
84 Ye
ars
0.53
41.
104
Mal
e 85-
89 Ye
ars
0.65
61.
041
Mal
e 90-
94 Ye
ars
0.82
40.
883
11
7 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Mal
e 95+
Year
s0.
993
0.79
6
meD
iCai
D &
oriG
inal
ly D
isab
leD
inte
raCt
ions
wit
h aG
e an
D se
x
Med
icaid
Fem
ale,
Aged
0.20
20.
096
Med
icaid
Fem
ale,
Disa
bled
0.10
30.
096
Med
icaid
Mal
e, Ag
ed0.
232
0.09
6
Med
icaid
Mal
e, Di
sabl
ed0.
099
0.09
6
Orig
inal
ly Di
sabl
ed, F
emal
e0.
228
—
Orig
inal
ly Di
sabl
ed, M
ale
0.16
0—
Dise
ase
CoeF
FiCi
ents
HCC1
HIV/
AIDS
0.45
81.
732
HCC2
Sept
icem
ia/S
hock
0.76
60.
796
HCC5
Oppo
rtuni
stic
Infe
ction
s0.
465
0.47
1
HCC7
Met
asta
tic C
ance
r and
Acu
te Le
ukem
ia2.
175
0.91
0
HCC8
Lung
, Upp
er D
iges
tive T
ract
, and
Oth
er S
ever
e Can
cers
0.91
90.
576
HCC9
Lym
phat
ic, H
ead
and
Neck
, Bra
in, a
nd O
ther
Maj
or C
ance
rs0.
706
0.41
3
11
8 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
Dis
ease
Gro
up C
ommu
nity
FaC
tors
inst
itut
iona
l FaC
tors
HCC1
0Br
east
, Pro
stat
e, Co
lorec
tal a
nd O
ther
Can
cers
and
Tum
ors
0.18
70.
240
HCC1
5Di
abet
es w
ith R
enal
or P
erip
hera
l Circ
ulat
ory M
anife
stat
ion0.
371
0.41
3
HCC1
6Di
abet
es w
ith N
euro
logic
or O
ther
Spe
cified
Man
ifest
ation
0.37
10.
413
HCC1
7Di
abet
es w
ith A
cute
Com
plica
tions
0.37
10.
413
HCC1
8Di
abet
es w
ith O
phth
alm
ologi
c or U
nspe
cified
Man
ifest
ation
0.37
10.
413
HCC1
9Di
abet
es w
ithou
t Com
plica
tion
0.12
70.
173
HCC2
1Pr
otein
-Cal
orie
Mal
nutri
tion
0.74
50.
358
HCC2
5En
d-St
age L
iver D
iseas
e1.
006
0.93
7
HCC2
6Ci
rrhos
is of
Live
r0.
413
0.35
0
HCC2
7Ch
roni
c Hep
atiti
s0.
262
0.35
0
HCC3
1In
test
inal
Obs
truct
ion/P
erfo
ratio
n0.
310
0.35
2
HCC3
2Pa
ncre
atic
Dise
ase
0.36
20.
374
HCC3
3In
flam
mat
ory B
owel
Dise
ase
0.30
20.
283
11
9 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
HCC3
7Bo
ne/Jo
int/M
uscle
Infe
ction
s/Ne
cros
is0.
585
0.67
0
HCC3
8Rh
eum
atoid
Arth
ritis
and
Infla
mm
ator
y Co
nnec
tive T
issue
Dise
ase
0.36
10.
304
HCC4
4Se
vere
Hem
atolo
gica
l Diso
rder
s1.
129
0.60
0
HCC4
5Di
sord
ers o
f Im
mun
ity0.
945
0.53
3
HCC5
1Dr
ug/A
lcoho
l Psy
chos
is0.
373
—
HCC5
2Dr
ug/A
lcoho
l Dep
ende
nce
0.37
3—
HCC5
4Sc
hizo
phre
nia
0.51
70.
407
HCC5
5M
ajor
Dep
ress
ive, B
ipola
r, an
d Pa
rano
id D
isord
ers
0.36
00.
301
HCC6
7Qu
adrip
legia
, Oth
er E
xtens
ive P
aral
ysis
1.14
70.
518
HCC6
8Pa
rapl
egia
1.06
10.
480
HCC6
9Sp
inal
Cor
d Di
sord
ers/
Inju
ries
0.49
10.
238
HCC7
0M
uscu
lar D
ystro
phy
0.46
4—
HCC7
1Po
lyneu
ropa
thy
0.32
10.
277
HCC7
2M
ultip
le Sc
leros
is0.
516
0.15
7
12
0 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
Dis
ease
Gro
up C
ommu
nity
FaC
tors
inst
itut
iona
l FaC
tors
HCC7
3Pa
rkin
son’s
and
Hun
tingt
on’s
Dise
ases
0.64
30.
138
HCC7
4Se
izure
Diso
rder
s and
Con
vulsi
ons
0.27
80.
192
HCC7
5Co
ma,
Bra
in C
ompr
essio
n/An
oxic
Dam
age
0.58
00.
060
HCC7
7Re
spira
tor D
epen
denc
e/Tra
cheo
stom
y Sta
tus
1.76
72.
129
HCC7
8Re
spira
tory
Arre
st1.
117
1.12
1
HCC7
9Ca
rdio-
Resp
irato
ry Fa
ilure
and
Sho
ck0.
531
0.48
5
HCC8
0Co
nges
tive H
eart
Failu
re0.
346
0.22
8
HCC8
1Ac
ute M
yoca
rdia
l Inf
arct
ion0.
294
0.43
9
HCC8
2Un
stab
le An
gina
and
Oth
er A
cute
Isch
emic
Hear
t Dise
ase
0.27
40.
439
HCC8
3An
gina
Pec
toris
/Old
Myo
card
ial I
nfar
ction
0.17
00.
331
HCC9
2Sp
ecifi
ed H
eart
Arrh
ythm
ias
0.28
90.
245
HCC9
5Ce
rebr
al H
emor
rhag
e0.
359
0.15
1
HCC9
6Isc
hem
ic or
Uns
pecifi
ed S
troke
0.26
50.
151
12
1 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
HCC1
00He
mip
legia
/Hem
ipar
esis
0.53
40.
069
HCC1
01Ce
rebr
al P
alsy
and
Oth
er P
aral
ytic S
yndr
omes
0.13
1—
HCC1
04Va
scul
ar D
iseas
e with
Com
plica
tions
0.59
40.
470
HCC1
05Va
scul
ar D
iseas
e0.
302
0.13
8
HCC1
07Cy
stic
Fibro
sis0.
385
0.37
8
HCC1
08Ch
roni
c Obs
truct
ive P
ulm
onar
y Dise
ase
0.34
00.
378
HCC1
11As
pira
tion
and
Spec
ified
Bac
teria
l Pne
umon
ias
0.73
40.
605
HCC1
12Pn
eum
ococ
cal P
neum
onia
, Em
phys
ema,
Lung
Abs
cess
0.20
60.
197
HCC1
19Pr
olife
rativ
e Dia
betic
Ret
inop
athy
and
Vitr
eous
Hem
orrh
age
0.23
60.
440
HCC1
30Di
alys
is St
atus
1.34
82.
228
HCC1
31Re
nal F
ailu
re0.
297
0.35
3
HCC1
32Ne
phrit
is0.
116
0.35
3
HCC1
48De
cubi
tus U
lcer o
f Skin
1.16
50.
517
HCC1
49Ch
roni
c Ulce
r of S
kin, E
xcep
t Dec
ubitu
s0.
476
0.29
1
HCC1
50Ex
tens
ive Th
ird-D
egre
e Bur
ns1.
246
—
12
2 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
Dis
ease
Gro
up C
ommu
nity
FaC
tors
inst
itut
iona
l FaC
tors
HCC1
54Se
vere
Hea
d In
jury
0.58
00.
060
HCC1
55M
ajor
Hea
d In
jury
0.17
1—
HCC1
57Ve
rtebr
al Fr
actu
res w
ithou
t Spi
nal C
ord
Inju
ry0.
467
0.15
4
HCC1
58Hi
p Fr
actu
re/D
isloc
ation
0.43
5—
HCC1
61Tra
umat
ic Am
puta
tion
0.79
30.
266
HCC1
64M
ajor
Com
plica
tions
of M
edica
l Car
e and
Trau
ma
0.31
10.
325
HCC1
74M
ajor
Org
an Tr
ansp
lant
Sta
tus
1.08
40.
925
HCC1
76Ar
tificia
l Ope
ning
s for
Feed
ing
or E
limin
ation
0.65
90.
861
HCC1
77Am
puta
tion
Stat
us, L
ower
Lim
b / A
mpu
tatio
n Co
mpl
icatio
ns0.
793
0.26
6
Disa
bleD
/Dis
ease
inte
raCt
ions
D_HC
C5Di
sabl
ed, O
ppor
tuni
stic
Infe
ction
s0.
597
—
D_HC
C44
Disa
bled
, Sev
ere H
emat
ologi
cal D
isord
ers
1.34
00.
633
D_HC
C51
Disa
bled
, Dru
g/Al
coho
l Psy
chos
is0.
383
0.28
4
12
3 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
D_HC
C52
Disa
bled
, Dru
g/Al
coho
l Dep
ende
nce
0.10
50.
284
D_HC
C107
Disa
bled
, Cys
tic Fi
bros
is2.
556
—
Dise
ase
inte
raCt
ions
INT1
Diab
etes
Mell
itus+
Cong
estiv
e Hea
rt Fa
ilure
0.15
00.
111
INT2
Diab
etes
Mell
itus+
Cere
brov
ascu
lar D
iseas
e0.
150
0.05
1
INT3
Cong
estiv
e Hea
rt Fa
ilure
+Chr
onic
Ob
stru
ctive
Pul
mon
ary D
iseas
e0.
278
0.24
8
INT4
Chro
nic O
bstru
ctive
Pul
mon
ary D
iseas
e+Ce
rebr
ovas
cula
r Di
seas
e+Co
rona
ry Ar
tery
Dise
ase
0.23
30.
118
INT5
Rena
l Fai
lure
+Con
gest
ive H
eart
Failu
re0.
262
—
INT6
Rena
l Fai
lure
+Con
gest
ive H
eart
Failu
re+D
iabe
tes M
ellitu
s0.
600
0.37
3
12
4 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
Dis
ease
Gro
up C
ommu
nity
FaC
tors
inst
itut
iona
l FaC
tors
12
5 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
App
end
ix 2
. D
iSe
ASe
Hie
RAR
CH
ieS f
oR
tH
e C
MS
-HC
C M
oD
el
Hier
arcH
ical
con
diti
on c
ateg
ory
(Hcc
)if
tHe
dis
ease
gro
up is
lis
ted
in t
His
colu
mn…
…tH
en d
rop
tHe
asso
ciat
ed d
isea
se g
roup
(s) l
iste
d in
tHi
s co
lum
n
dise
ase
grou
p la
bel
5Op
portu
nist
ic In
fect
ions
112
7M
etas
tatic
Can
cer a
nd A
cute
Leuk
emia
8, 9
, 10
8Lu
ng, U
pper
Dig
estiv
e Tra
ct a
nd O
ther
Sev
ere C
ance
rs9,
10
9Ly
mph
atic,
Hea
d an
d Ne
ck, B
rain
and
Oth
er M
ajor
Can
cers
10
15Di
abet
es w
ith R
enal
Man
ifest
ation
s or P
erip
hera
l Circ
ulat
ory M
anife
stat
ion16
, 17,
18,
19
16Di
abet
es w
ith N
euro
logic
or O
ther
Spe
cified
Man
ifest
ation
17, 1
8, 1
9
17Di
abet
es w
ith A
cute
Com
plica
tions
18, 1
9
18Di
abet
es w
ith O
phth
alm
ologi
c or U
nspe
cified
Man
ifest
ation
s19
25En
d-St
age L
iver D
iseas
e26
, 27
26Ci
rrhos
is of
Live
r27
12
6 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Hier
arcH
ical
con
diti
on c
ateg
ory
(Hcc
)if
tHe
dis
ease
gro
up is
lis
ted
in t
His
colu
mn…
…tH
en d
rop
tHe
asso
ciat
ed d
isea
se g
roup
(s) l
iste
d in
tHi
s co
lum
n
dise
ase
grou
p la
bel
51Dr
ug/A
lcoho
l Psy
chos
is52
54Sc
hizo
phre
nia
55
67Qu
adrip
legia
/Oth
er E
xtens
ive P
aral
ysis
68, 6
9, 1
00, 1
01, 1
57
68Pa
rapl
egia
69, 1
00, 1
01, 1
57
69Sp
inal
Cor
d Di
sord
ers/
Inju
ries
157
77Re
spira
tor D
epen
denc
e/Tra
cheo
stom
y Sta
tus
78, 7
9
78Re
spira
tory
Arre
st79
81Ac
ute M
yoca
rdia
l Inf
arct
ion82
, 83
82Un
stab
le An
gina
and
Oth
er A
cute
Isch
emic
Hear
t Dise
ase
83
95Ce
rebr
al H
emor
rhag
e96
100
Hem
ipleg
ia/H
emip
ares
is10
1
104
Vasc
ular
Dise
ase w
ith C
ompl
icatio
ns10
5, 1
49
12
7 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
107
Cyst
ic Fib
rosis
108
111
Aspi
ratio
n an
d Sp
ecifi
ed B
acte
rial P
neum
onia
s11
2
130
Dial
ysis
Stat
us13
1, 1
32
131
Rena
l Fai
lure
132
148
Decu
bitu
s Ulce
r of S
kin14
9
154
Seve
re H
ead
Inju
ry75
, 155
161
Traum
atic
Ampu
tatio
n17
7
How
pay
men
ts a
re M
ade
with
a d
isea
se H
iera
rchy
—EX
AMPL
E: If
a b
enefi
ciary
trigg
ers H
CCs 1
48 (D
ecub
itus U
lcer o
f the
Skin
) and
149
(Chr
onic
Ulce
r of S
kin, E
xcep
t Dec
ubitu
s), t
hen
HCC
149
will
be d
ropp
ed. I
n ot
her
word
s, pa
ymen
t will
alw
ays b
e ass
ocia
ted
with
the H
CC in
colu
mn
1 if
a HC
C in
colu
mn
3 al
so oc
curs
dur
ing
the s
ame c
ollec
tion
perio
d. Th
eref
ore,
the M
A or
gani
zatio
n’s p
aym
ent w
ill b
e bas
ed on
HCC
148
rath
er th
an H
CC 1
49.
12
8 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Hier
arcH
ical
con
diti
on c
ateg
ory
(Hcc
)if
tHe
dis
ease
gro
up is
lis
ted
in t
His
colu
mn…
…tH
en d
rop
tHe
asso
ciat
ed d
isea
se g
roup
(s) l
iste
d in
tHi
s co
lum
n
dise
ase
grou
p la
bel
12
9 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
App
end
ix 3
. CM
S-H
CC M
od
el
RelAt
ive F
AC
toR
S F
oR
AG
ed
An
d d
iSAb
led
ne
w e
nR
oll
eeS
Vari
able
NoN-
Med
icai
d &
NoN-
orig
iNal
ly d
isab
led
Med
icai
d &
NoN-
orig
iNal
ly d
isab
led
NoN-
Med
icai
d &
orig
iNal
ly d
isab
led
Med
icai
d &
orig
iNal
ly d
isab
led
FeM
ale
0–34
Year
s0.
545
0.91
9—
—
35–4
4 Ye
ars
0.72
31.
097
——
45–5
4 Ye
ars
0.88
11.
255
——
55–5
9 Ye
ars
0.95
71.
331
——
60–6
4 Ye
ars
1.09
41.
468
——
65 Ye
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13
0 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
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able
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icai
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ly d
isab
led
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Med
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80–8
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788
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——
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309
——
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811
13
1 |
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uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
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ars
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249
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946
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ars
1.04
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445
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142
80–8
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ars
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345
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ars o
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0
13
2 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Vari
able
NoN-
Med
icai
d &
NoN-
orig
iNal
ly d
isab
led
Med
icai
d &
NoN-
orig
iNal
ly d
isab
led
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Med
icai
d &
orig
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ly d
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led
Med
icai
d &
orig
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ly d
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led
13
3 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
App
end
ix 4
. A
ppR
ove
d p
HyS
iCiA
n S
peC
iAlt
ieS f
oR
RiS
k A
dju
StM
en
t
Code
SpeC
ialt
yCo
deSp
eCia
lty
Code
SpeC
ialt
y
01Ge
nera
l Pra
ctice
25Ph
ysica
l Med
icine
and
Reh
abili
tatio
n67
Occu
patio
nal T
hera
pist
02Ge
nera
l Sur
gery
26Ps
ychi
atry
68Cl
inica
l Psy
cholo
gist
03Al
lergy
/Imm
unolo
gy27
Geria
tric P
sych
iatry
72*
Pain
Man
agem
ent
04Ot
olaryn
golog
y28
Color
ecta
l Sur
gery
76*
Perip
hera
l Vas
cula
r Dise
ase
05An
esth
esiol
ogy
29Pu
lmon
ary D
iseas
e77
Vasc
ular
Sur
gery
06Ca
rdiol
ogy
33*
Thor
acic
Surg
ery
78Ca
rdia
c Sur
gery
07De
rmat
ology
34Ur
ology
79Ad
dict
ion M
edici
ne
08Fa
mily
Pra
ctice
35Ch
iropr
actic
80Lic
ense
d Cl
inica
l Soc
ial W
orke
r
09In
terv
entio
nal P
ain
Man
agem
ent
36Nu
clear
Med
icine
81Cr
itica
l Car
e (In
tens
ivist
)
10Ga
stro
ente
rolog
y37
Pedi
atric
Med
icine
82He
mat
ology
11In
tern
al M
edici
ne38
Geria
tric M
edici
ne83
Hem
atolo
gy/O
ncolo
gy
12Os
teop
athi
c Man
ipul
ative
Ther
apy
39Ne
phro
logy
84Pr
even
tive M
edici
ne
13
4 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Code
SpeC
ialt
yCo
deSp
eCia
lty
Code
SpeC
ialt
y
13Ne
urolo
gy40
Hand
Sur
gery
85M
axill
ofac
ial S
urge
ry
14Ne
uros
urge
ry41
Opto
met
ry (s
pecifi
cally
mea
ns O
ptom
etris
t)86
Neur
opsy
chia
try
15Sp
eech
Lan
guag
e Pat
holog
ist42
Certi
fied
Nurs
e Mid
wife
89*
Certi
fied
Clin
ical N
urse
Spe
cialis
t
16Ob
stet
rics/
Gyne
colog
y43
Certi
fied
Regi
ster
ed N
urse
Ane
sthe
tist
90M
edica
l Onc
ology
17Ho
spice
and
Pal
lativ
e Car
e44
Infe
ctiou
s Dise
ase
91Su
rgica
l Onc
ology
18Op
htha
lmolo
gy46
*En
docr
inolo
gy92
Radi
ation
Onc
ology
19Or
al S
urge
ry (D
entis
t onl
y)48
*Po
diat
ry93
Emer
genc
y Med
icine
20Or
thop
edic
Surg
ery
50*
Nurs
e Pra
ctiti
oner
94In
terv
entio
nal R
adiol
ogy
21El
ectro
phys
iolog
y62
*Ps
ycho
logist
97*
Phys
ician
Ass
istan
t
22Pa
tholo
gy64
*Au
diolo
gist
98Gy
neco
logist
/Onc
ologi
st
23Sp
orts
Med
icine
65Ph
ysica
l The
rapi
st99
Unkn
own
Phys
ician
Spe
cialty
24Pl
astic
and
Rec
onst
ruct
ive S
urge
ry66
Rheu
mat
ology
C0Sl
eep
Med
icine
not
e: Q
ualifi
ed p
hysic
ian
data
for r
isk a
djus
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t req
uire
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visit
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ervic
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rofe
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mpo
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only)
. *
Indi
cate
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umbe
r has
bee
n sk
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13
5 |
A G
uide
to
Ris
k A
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e C
MS
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App
end
ix 5
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6 |
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7 |
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on or
afte
r 1/1
/05.
Once
in a
life
time b
enefi
t per
ben
eficia
ry.
Mus
t be f
urni
shed
no l
ater
than
12
mon
ths a
fter t
he ef
fect
ive d
ate o
f the
fir
st M
edica
re P
art B
cove
rage
.
Annu
al W
ellne
ss V
isit (
AWV)
. Thi
s is
a ne
w be
nefit
beg
inni
ng fo
r dat
es
of se
rvice
on a
nd a
fter 1
/1/1
1. A
s of
1/
1/12
, the
AW
V in
clude
s an
HRA.
G043
8—Fir
st vi
sit.
G043
9—Su
bseq
uent
visit
.No
spec
ific d
iagn
osis
code
.
Cont
act t
he lo
cal M
edica
re
Cont
ract
or fo
r gui
danc
e.
All M
edica
re b
enefi
ciarie
s who
are
no l
onge
r wi
thin
12
mon
ths a
fter t
he ef
fect
ive d
ate
of th
eir fi
rst M
edica
re P
art B
cove
rage
pe
riod
and
who h
ave n
ot re
ceive
d an
IPPE
or
AW
V wi
thin
the p
ast 1
2 m
onth
s.
Once
in a
life
time f
or G
0438
. An
nual
ly fo
r G04
39.
Ultra
soun
d Sc
reen
ing
for A
bdom
inal
Ao
rtic A
neur
ysm
(AAA
)G0
389—
Ultra
soun
d ex
am A
AA sc
reen
No sp
ecifi
c dia
gnos
is co
de.
Cont
act t
he lo
cal M
edica
re
Cont
ract
or fo
r gui
danc
e.
Med
icare
ben
eficia
ries w
ith ce
rtain
risk
fa
ctor
s for
abd
omin
al a
ortic
ane
urys
m.
Impo
rtant
– El
igib
le be
nefic
iarie
s mus
t re
ceive
a re
ferra
l for
an
AAA
ultra
soun
d sc
reen
ing
as a
resu
lt of
an
IPPE
.
Once
in a
life
time b
enefi
t per
eli
gibl
e ben
eficia
ry.
14
2 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
SERV
ICE
HCP
CS/C
PT C
ODES
ICD-
9-CM
COD
ES W
HO IS
COV
ERED
FRE
QUEN
CY
Card
iovas
cula
r Dise
ase S
cree
ning
s80
061—
Lipid
Pan
el
8246
5—Ch
olest
erol
83
718—
Lipop
rote
in
8447
8—Tri
glyc
erid
es
Repo
rt on
e or m
ore o
f the
follo
wing
co
des:
V81.
0, V
81.1
, V81
.2Al
l Med
icare
ben
eficia
ries w
ithou
t app
aren
t sig
ns or
sym
ptom
s of c
ardi
ovas
cula
r dise
ase.
12
-hou
r fas
t is r
equi
red
prior
to te
stin
g.
Ever
y 5 ye
ars
Diab
etes
Scr
eeni
ng Te
sts
8294
7—Gl
ucos
e, qu
antit
ative
, bl
ood
(exc
ept r
eage
nt st
rip)
8295
0—Gl
ucos
e, po
st-g
luco
se
dose
(inc
lude
s glu
cose
)
8295
1—Gl
ucos
e Tole
ranc
e Tes
t (GT
T),
thre
e spe
cimen
s (in
clude
s glu
cose
)
V77.
1M
edica
re b
enefi
ciarie
s with
certa
in ri
sk fa
ctor
s fo
r dia
bete
s or d
iagn
osed
with
pre
-dia
bete
s.
Bene
ficia
ries p
revio
usly
diag
nose
d wi
th
diab
etes
are
not
elig
ible
for t
his b
enefi
t.
2 sc
reen
ing
test
s per
year
for b
enefi
ciarie
s di
agno
sed
with
pre
-dia
bete
s.
1 sc
reen
ing
per y
ear i
f pre
vious
ly te
sted
, but
not
di
agno
sed
with
pre
-dia
bete
s, or
if n
ever
test
ed.
Diab
etes
Self
-Man
agem
ent T
rain
ing
(DSM
T)G0
108—
DSM
T, in
divid
ual
sess
ion, p
er 3
0 m
inut
es.
G010
9—DS
MT,
grou
p se
ssion
(2
or m
ore)
, per
30
min
utes
.
No sp
ecifi
c dia
gnos
is co
de. C
onta
ct th
e loc
al M
edica
re C
ontra
ctor
for g
uida
nce.
Med
icare
ben
eficia
ries d
iagn
osed
with
di
abet
es. M
ust b
e ord
ered
by t
he p
hysic
ian
or q
ualifi
ed n
on-p
hysic
ian
prac
tition
er
treat
ing
the b
enefi
ciary’
s dia
bete
s.
Up to
10
hour
s of i
nitia
l tra
inin
g wi
thin
a
cont
inuo
us 1
2-m
onth
per
iod.
Subs
eque
nt ye
ars:
Up to
2 h
ours
of fo
llow-
up
train
ing
each
year
afte
r the
initi
al ye
ar.
Med
ical N
utrit
ion T
hera
py (M
NT)
9780
2, 9
7803
, 978
04, G
0270
, G02
71.
Serv
ices m
ust b
e pro
vided
by a
regi
ster
ed
diet
itian
or n
utrit
ion p
rofe
ssion
al.
No sp
ecifi
c dia
gnos
is co
de. C
onta
ct th
e loc
al M
edica
re C
ontra
ctor
for g
uida
nce.
Certa
in M
edica
re b
enefi
ciarie
s dia
gnos
ed w
ith
diab
etes
, ren
al d
iseas
e, or
who
hav
e rec
eived
a
kidne
y tra
nspl
ant w
ithin
the l
ast t
hree
year
s.
1st y
ear:
3 ho
urs o
f one
-on-
one c
ouns
eling
.
Subs
eque
nt ye
ars:
2 ho
urs.
14
3 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Scre
enin
g Pa
p Te
sts
G012
3, G
0124
, G01
41, G
0143
, G01
44, G
0145
, G0
147,
G01
48, P
3000
, P30
01, Q
0091
Repo
rt on
e of t
he fo
llowi
ng co
des:
V76.
2,
V76.
47, V
76.4
9, V
15.8
9, V
72.3
1Al
l fem
ale M
edica
re b
enefi
ciarie
s.An
nual
ly if
at h
igh-
risk f
or d
evelo
ping
cerv
ical
or va
gina
l can
cer,
or ch
ildbe
arin
g ag
e with
ab
norm
al P
ap te
st w
ithin
pas
t 3 ye
ars.
Ever
y 24
mon
ths f
or a
ll ot
her w
omen
.
Scre
enin
g Pe
lvic E
xam
G010
1—Ce
rvica
l or v
agin
al ca
ncer
scre
enin
g;
pelvi
c and
clin
ical b
reas
t exa
min
ation
Repo
rt on
e of t
he fo
llowi
ng co
des:
V76.
2,
V76.
47, V
76.4
9, V
15.8
9, V
72.3
1Al
l fem
ale M
edica
re b
enefi
ciarie
s.An
nual
ly if
at h
igh-
risk f
or d
evelo
ping
cerv
ical
or va
gina
l can
cer,
or ch
ildbe
arin
g ag
e with
ab
norm
al P
ap te
st w
ithin
pas
t 3 ye
ars.
Ever
y 24
mon
ths f
or a
ll ot
her w
omen
.
Scre
enin
g M
amm
ogra
phy
7705
2, 7
7057
, G02
02Re
port
one o
f the
follo
wing
co
des:
V76.
11 or
V76
.12
All f
emal
e Med
icare
ben
eficia
ries
aged
35
and
older.
Aged
35
thro
ugh
39: O
ne b
aseli
ne.
Aged
40
and
older
: Ann
ually
.
14
4 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
SERV
ICE
HCP
CS/C
PT C
ODES
ICD-
9-CM
COD
ES W
HO IS
COV
ERED
FRE
QUEN
CY
Bone
Mas
s Mea
sure
men
ts76
977,
770
78, 7
7079
, 770
80,
7708
1, 7
7083
, G01
30Us
e the
app
ropr
iate
dia
gnos
is co
de. C
onta
ct
the l
ocal
Med
icare
Con
tract
or fo
r gui
danc
e.Ce
rtain
Med
icare
ben
eficia
ries t
hat f
all i
nto
at le
ast o
ne of
the f
ollow
ing
cate
gorie
s:
Wom
en d
eter
min
ed b
y the
ir ph
ysici
an
or q
ualifi
ed n
on-p
hysic
ian
prac
tition
er
to b
e est
roge
n de
ficien
t and
at
clini
cal r
isk fo
r ost
eopo
rosis
;
Indi
vidua
ls wi
th ve
rtebr
al a
bnor
mal
ities
;
Indi
vidua
ls re
ceivi
ng (o
r exp
ectin
g to
rece
ive) g
luco
corti
coid
ther
apy
for m
ore t
han
thre
e mon
ths;
Indi
vidua
ls wi
th p
rimar
y hyp
erpa
rath
yroid
ism; o
r In
divid
uals
bein
g m
onito
red
to a
sses
s res
pons
e to
FDA-
appr
oved
oste
opor
osis
drug
ther
apy.
Ever
y 24
mon
ths.
Mor
e fr
eque
ntly
if
med
ical
ly n
eces
sary
.
14
5 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Color
ecta
l Can
cer S
cree
ning
G010
4—Fle
xible
Sigm
oidos
copy
G010
5—Co
lonos
copy
(hig
h ris
k)
G010
6—Ba
rium
Ene
ma
(alte
rnat
ive to
G01
04)
G012
0—Ba
rium
Ene
ma
(alte
rnat
ive to
G01
05)
G012
1—Co
lonos
copy
(not
hig
h ris
k)
G012
2—Ba
rium
Ene
ma
(non
-cov
ered
)
G032
8—Fe
cal O
ccul
t Bloo
d Te
st
(FOB
T) (a
ltern
ative
to 8
2270
)
8227
0—FO
BT
Use a
ppro
pria
te d
iagn
osis
code
Con
tact
the
local
Med
icare
Con
tract
or fo
r gui
danc
eAl
l Med
icare
ben
eficia
ries a
ged
50
and
older
who
are
: At n
orm
al ri
sk of
de
velop
ing
color
ecta
l can
cer;
or
At h
igh
risk o
f dev
elopi
ng co
lorec
tal c
ance
r.*
*Hig
h ris
k for
dev
elopi
ng co
lorec
tal
canc
er is
defi
ned
in 4
2 CF
R 41
0.37
(a)
(1).
See h
ttp://
www.
gpo.g
ov/fd
sys/
pkg/
CFR-
2010
-title
42-v
ol2/p
df/C
FR-2
010-
title4
2-vo
l2-s
ec41
0-37
on th
e Int
erne
t.
nor
mal
ris
k: Fe
cal O
ccul
t Bloo
d Te
st (F
OBT)
ev
ery y
ear;
Flexib
le Si
gmoid
osco
py on
ce ev
ery
4 ye
ars (
unles
s a sc
reen
ing
colon
osco
py
has b
een
perfo
rmed
and
then
Med
icare
may
co
ver a
scre
enin
g fle
xible
sigm
oidos
copy
on
ly af
ter a
t lea
st 1
19 m
onth
s); S
cree
ning
Co
lonos
copy
ever
y 10
year
s (un
less a
scre
enin
g fle
xible
sigm
oidos
copy
has
bee
n pe
rform
ed
and
then
Med
icare
may
cove
r a sc
reen
ing
colon
osco
py on
ly af
ter a
t lea
st 4
7 m
onth
s);
and
Bariu
m E
nem
a (a
s an
alte
rnat
ive to
a
cove
red
scre
enin
g fle
xible
sigm
oidos
copy
).
Hig
h ris
k: FO
BT ev
ery y
ear;
Flexib
le
Sigm
oidos
copy
once
ever
y 4 ye
ars;
Scre
enin
g Co
lonos
copy
ever
y 2 ye
ars (
unles
s a sc
reen
ing
flexib
le sig
moid
osco
py h
as b
een
perfo
rmed
an
d th
en M
edica
re m
ay co
ver a
scre
enin
g co
lonos
copy
only
afte
r at l
east
47
mon
ths)
; an
d Ba
rium
Ene
ma
(as a
n al
tern
ative
to
a co
vere
d sc
reen
ing
colon
osco
py).
Pros
tate
Can
cer S
cree
ning
G010
2—Di
gita
l Rec
tal E
xam
(DRE
)
G010
3—Pr
osta
te S
pecifi
c Ant
igen
Test
(PSA
)
V76.
44Al
l mal
e Med
icare
ben
eficia
ries
aged
50
and
older
(cov
erag
e beg
ins
the d
ay a
fter 5
0th
birth
day)
Annu
ally
14
6 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
SERV
ICE
HCP
CS/C
PT C
ODES
ICD-
9-CM
COD
ES W
HO IS
COV
ERED
FRE
QUEN
CY
Glau
com
a Sc
reen
ing
G011
7—By
an
opto
met
rist o
r oph
thal
molo
gist
G011
8—Un
der t
he d
irect
supe
rvisi
on
of a
n op
tom
etris
t or o
phth
alm
ologi
st
V80
.1M
edica
re b
enefi
ciarie
s with
dia
bete
s m
ellitu
s, fa
mily
hist
ory o
f gla
ucom
a,
Afric
an-A
mer
icans
age
d 50
and
olde
r, or
Hi
span
ic-Am
erica
ns a
ged
65 a
nd ol
der.
Annu
ally
for b
enefi
ciarie
s in
one
of th
e hig
h ris
k gro
ups.
Seas
onal
Influ
enza
Viru
s Vac
cine
9065
5, 9
0656
, 906
57, 9
0660
, 906
62,
Q203
5, Q
2036
, Q20
37, Q
2038
, Q2
039—
Influ
enza
Viru
s Vac
cine
G000
8—Ad
min
istra
tion
Repo
rt on
e of t
he fo
llowi
ng co
des:
V04.
81
V06.
6 –
Whe
n pu
rpos
e of v
isit w
as to
re
ceive
bot
h se
ason
al in
fluen
za vi
rus
and
pneu
moc
occa
l vac
cines
All M
edica
re b
enefi
ciarie
s.On
ce p
er in
fluen
za se
ason
in th
e fal
l or w
inte
r. M
edic
are
may
pro
vide
add
ition
al
flu s
hots
if m
edic
ally
nec
essa
ry.
Pneu
moc
occa
l Vac
cine
9066
9—Pn
eum
ococ
cal C
onju
gate
Vac
cine
9067
0—Pn
eum
ococ
cal C
onju
gate
Vac
cine,
13
valen
t, fo
r int
ram
uscu
lar u
se
9073
2—Pn
eum
ococ
cal P
olysa
ccha
ride V
accin
e
G000
9—Ad
min
istra
tion
Repo
rt on
e of t
he fo
llowi
ng co
des:
V03.
82
V06.
6—W
hen
purp
ose o
f visi
t was
to
rece
ive b
oth
pneu
moc
occa
l and
se
ason
al in
fluen
za vi
rus v
accin
es
All M
edica
re b
enefi
ciarie
s.On
ce in
a li
fetim
e. M
edic
are
may
pr
ovid
e ad
ditio
nal v
acci
natio
ns
base
d on
ris
k an
d pr
ovid
ed t
hat
at le
ast
5 ye
ars
have
pas
sed
sinc
e re
ceip
t of
a p
revi
ous
dose
.
Hepa
titis
B (H
BV) V
accin
e90
740,
907
43, 9
0744
, 907
46, 9
0747
—He
patit
is B
Vacc
ine G
0010
—Ad
min
istra
tion
V05.
3Ce
rtain
Med
icare
ben
eficia
ries a
t int
erm
edia
te
or h
igh
risk.
Med
icare
ben
eficia
ries t
hat
are c
urre
ntly
posit
ive fo
r ant
ibod
ies fo
r he
patit
is B
are n
ot el
igib
le fo
r thi
s ben
efit.
Sche
duled
dos
ages
requ
ired.
14
7 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
Coun
selin
g to
Pre
vent
Toba
cco
Use
This
is a
new
ben
efit
begi
nnin
g fo
r da
tes
of s
ervi
ce
on a
nd a
fter
08/
25/1
0
G043
6—Sm
okin
g an
d to
bacc
o ces
satio
n co
unse
ling
visit
for t
he a
sym
ptom
atic
pa
tient
; int
erm
edia
te, g
reat
er th
an
3 m
inut
es, u
p to
10
min
utes
G043
7—Sm
okin
g an
d to
bacc
o ces
satio
n co
unse
ling
visit
for t
he a
sym
ptom
atic
pa
tient
; int
ensiv
e, gr
eate
r tha
n 10
min
utes
Repo
rt on
e of t
he fo
llowi
ng
code
s: 30
5.1
or V
15.8
2Ou
tpat
ient a
nd h
ospi
taliz
ed b
enefi
ciarie
s wh
o use
toba
cco,
rega
rdles
s of w
heth
er th
ey
have
sign
s or s
ympt
oms o
f tob
acco
-rela
ted
dise
ase;
are c
ompe
tent
and
aler
t at t
he
time t
hat c
ouns
eling
is p
rovid
ed; a
nd w
hose
co
unse
ling
is fu
rnish
ed b
y a q
ualifi
ed p
hysic
ian
or ot
her M
edica
re-re
cogn
ized
prac
tition
er.
2 ce
ssat
ion a
ttem
pts p
er ye
ar; E
ach
atte
mpt
inclu
des m
axim
um of
4
inte
rmed
iate
or in
tens
ive se
ssion
s; up
to
8 se
ssion
s in
a 12
-mon
th p
eriod
.
Hum
an Im
mun
odefi
cienc
y Viru
s (HI
V) S
cree
ning
This
is a
new
ben
efit
begi
nnin
g fo
r da
tes
of s
ervi
ce
on a
nd a
fter
12/
08/0
9
G043
2—In
fect
ious a
gent
ant
ibod
y de
tect
ion b
y enz
yme i
mm
unoa
ssay
(EIA
) te
chni
que,
HIV-
1 an
d/or
HIV-
2, sc
reen
ing
G043
3—In
fect
ious a
gent
ant
ibod
y det
ectio
n by
en
zym
e-lin
ked
imm
unos
orbe
nt a
ssay
(ELIS
A)
tech
niqu
e, HI
V-1
and/
or H
IV-2,
scre
enin
g
G043
5—In
fect
ious a
gent
ant
ibod
y de
tect
ion b
y rap
id a
ntib
ody t
est,
HIV-
1 an
d/or
HIV-
2, sc
reen
ing
Repo
rt on
e of t
he fo
llowi
ng
code
s: V7
3.89
—Pr
imar
y
V22.
0, V
22.1
, V69
.8, o
r V23
.9—
Seco
ndar
y, as
app
ropr
iate
Bene
ficia
ries w
ho a
re a
t inc
reas
ed ri
sk
for H
IV in
fect
ion or
pre
gnan
t.**
**In
crea
sed
risk f
or H
IV in
fect
ion is
defi
ned
in
the “
Natio
nal C
over
age D
eter
min
ation
s (NC
D)
Man
ual”,
Pub
licat
ion 1
00-0
3, S
ectio
ns 1
90.1
4 (d
iagn
ostic
) and
210
.7 (s
cree
ning
). Se
e http
://ww
w.cm
s.gov
/man
uals/
down
loads
/ncd
103c
1_Pa
rt3.p
df a
nd h
ttp://
www.
cms.g
ov/m
anua
ls/do
wnloa
ds/n
cd10
3c1_
Part4
on th
e Int
erne
t.
Annu
ally
for b
enefi
ciarie
s at i
ncre
ased
ris
k. Th
ree t
imes
per
pre
gnan
cy fo
r be
nefic
iarie
s who
are
pre
gnan
t:
a.
Whe
n wo
man
is d
iagn
osed
with
pre
gnan
cy;
b.
Durin
g th
e 3rd tr
imes
ter;
and
c. At
labo
r, if
orde
red
by th
e wo
man
’s cli
nicia
n.
14
8 |
A G
uide
to
Ris
k A
djus
tmen
t an
d th
e C
MS
-HC
C M
odel
SERV
ICE
HCP
CS/C
PT C
ODES
ICD-
9-CM
COD
ES W
HO IS
COV
ERED
FRE
QUEN
CY
Coun
selin
g fo
r Obe
sity
This
is a
new
bene
fit b
egin
ning
for d
ates
of
serv
ice on
and
afte
r 11/
29/1
1
G044
7, Fa
ce-to
-Fac
e Beh
avior
al
Coun
selin
g fo
r Obe
sity,
15 m
inut
es.
Repo
rt a
code
from
one o
f the
follo
wing
rang
es:
V85.
30-V
85.3
9, V
85.4
1-V8
5.45
Med
icare
ben
eficia
ries w
ith
obes
ity (B
MI ≥
30 kg
/m2)
.On
e fac
e-to
-face
visit
ever
y wee
k for
the fi
rst
mon
th; O
ne fa
ce-to
-face
visit
ever
y oth
er
week
for m
onth
s 2–6
; and
one f
ace-
to-fa
ce
visit
ever
y mon
th fo
r mon
ths 7
–12
if th
e be
nefic
iary
mee
ts th
e 3kg
(6.6
lbs)
weig
ht
loss r
equi
rem
ent d
urin
g th
e firs
t 6 m
onth
s.
SCAN Health Plan® is a not-for-profit organization focused exclusively on helping to make life better for Medicare beneficiaries in California and Maricopa and Pima counties in Arizona. For 35 years SCAN has demonstrated a unique passion for finding innovative ways to enhance seniors’ ability to manage their own health and continue to control how and where they live.
SCAN is committed to partnering with our physician providers in offering high-quality geriatric care to our members. A significant part of that effort is to assist our providers in the provision of accurate documentation and coding that will contribute to the quality of care and support the expected revenue from the Medicare program. To this end, we developed “Accuracy in Documentation and Coding: A Guide to Risk Adjustment and the CMS-HCC Model” for all the physicians and groups providing care to our members.
G5885 06/2012
©2012 SCAN Health Plan®. All Rights Reserved.
Cover & Tabs.indd 2 6/7/12 12:35 PM