HCC Guidebook

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.


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


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.


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


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:


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.


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.


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.


• 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.


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


(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.


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.


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).


¤ 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.


• 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


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.


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


• 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.


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.


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.


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.


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.


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


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


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.


• 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.


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.


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.


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.


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.


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


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.


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

aFr

ance

Ger

man

yaA

ustr

alia

aO

ECD

M

edia

nU

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d K

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omJa

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New

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alan

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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


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.


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.


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.


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.

Diagnoses in Alphabetical O

rder


41

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de t

o R

isk

Adj

ustm

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and

the

CM

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Mod

el

DiA

Gn

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n AlP

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789.

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e doc

umen

tatio

n in

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hat

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atien

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epig

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ain.

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ener

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iagn

osed

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nal

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otH

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use

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en th

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umen

tatio

n de

scrib

es a

bdom

inal

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in in

an

area

of th

e abd

omen

that

doe

s not

hav

e a sp

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c cod

e.

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inclu

des d

escr

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ms s

uch

as a

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gia,

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lic.

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ain/

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pain

uns

pcf

site

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ed w

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docu

men

tatio

n st

ates

abd

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al

pain

and

a q

uadr

ant i

s not

spec

ified

.No

n-sp

ecifi

c abd

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al p

ain,

dia

gnos

ed cl

inica

lly

aBno

rm B

looD

cHe

mis

trY

nec

790.

6Th

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

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42

| A

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for

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aBno

rm e

lect

roca

rDio

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794.

31Th

is co

de is

only

used

whe

n th

e doc

umen

tatio

n in

dica

tes t

hat t

he E

KG is

ab

norm

al b

ut th

e nat

ure o

f the

abn

orm

ality

is u

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wn or

uns

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d.Ab

norm

al E

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ndin

gs

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rm f

inDi

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lunG

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whe

n th

e doc

umen

tatio

n in

dica

tes l

ung

shad

ow, a

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mal

ra

diolo

gy fi

ndin

g in

lung

, lun

g in

filtra

te, o

r lun

g co

in.

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rmal

lesio

ns in

the l

ungs

, inc

ludi

ng in

filtra

te, m

ass/

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bces

s, et

c, di

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sed

by im

age s

tudi

es

aBno

rm l

oss

of W

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t78

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whe

n th

e doc

umen

tatio

n in

dica

tes a

bnor

mal

we

ight

loss

, or w

eight

loss

of u

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use.

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g m

ore t

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of th

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al w

eight

over

3-

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agno

sed

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indi

cate

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xic g

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ralyt

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astic

gai

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agge

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gait

or im

bala

nce.

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pat

tern

of w

alkin

g, d

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osed

clin

ically

ac V

nus

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& tH

rmB

uns

Dp

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lW e

Xt45

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ular

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ase

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n th

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umen

tatio

n in

dica

tes d

eep

veno

us th

rom

bus o

f the

leg,

ac

ute d

eep

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

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ltras

ound

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nogr

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43

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a su

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enta

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d sh

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er b

e use

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one.

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ode w

hen

the d

ocum

enta

tion

indi

cate

s th

at th

e pat

ient s

uffe

red

an in

jury

in th

eir h

ome.

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ent a

t hom

e

acti

nic

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tosi

s70

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whe

n th

e doc

umen

tatio

n in

dica

tes a

ctin

ic ke

rato

sis, A

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nile

ke

rato

sis, s

enile

hyp

erke

rato

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enile

kera

tom

a, ke

rato

sis se

nilis

, so

lar k

erat

osis,

seni

le wa

rt, ve

rruca

seni

lis, o

r sen

ile w

art.

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ance

rous

skin

gro

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lly ca

used

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un-

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, dia

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nd b

y skin

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sy

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e Br

oncH

itis

466.

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ed w

hen

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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

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h an

d/or

sput

um p

rodu

ction

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gnos

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s46

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d wh

en th

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umen

tatio

n in

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ute p

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, sor

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ectio

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ation

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cally

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nal

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ure

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docu

men

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n in

dica

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enal

failu

re or

acu

te re

nal f

ailu

re.

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nic R

enal

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re is

nev

er a

ssum

ed, i

t mus

t be e

xplic

itly s

tate

d.Su

dden

rise

in C

reat

inin

e lev

el (>

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g/dL

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ecre

ase i

n ur

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outp

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ation

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cate

s res

pira

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n th

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umen

tatio

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mm

ation

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cally

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44

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umen

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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


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


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

ars

0.50

41.

085

1.10

81.

689

66 Ye

ars

0.50

60.

920

1.04

31.

457

67 Ye

ars

0.50

60.

920

1.04

31.

457

68 Ye

ars

0.54

30.

957

1.08

01.

494

69 Ye

ars

0.56

90.

983

1.10

61.

520

70–7

4 Ye

ar0.

660

0.99

11.

274

1.60

5

75–7

9 Ye

ar0.

864

1.16

51.

478

1.77

9

13

0 |

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

NoN-

Med

icai

d &

orig

iNal

ly d

isab

led

Med

icai

d &

orig

iNal

ly d

isab

led

80–8

4 Ye

ar1.

057

1.35

81.

671

1.97

2

85–8

9 Ye

ar1.

264

1.56

51.

878

2.17

9

90–9

4 Ye

ar1.

264

1.56

51.

878

2.17

9

95 Ye

ars o

r Ove

r1.

264

1.56

51.

878

2.17

9

Mal

e0–

34 Ye

ars

0.23

30.

788

——

35–4

4 Ye

ars

0.51

01.

065

——

45–5

4 Ye

ars

0.75

41.

309

——

55–5

9 Ye

ars

0.88

51.

440

——

60–6

4 Ye

ars

0.95

11.

506

——

65 Ye

ars

0.51

71.

248

0.93

11.

662

66 Ye

ars

0.53

21.

135

1.08

31.

686

67 Ye

ars

0.57

91.

182

1.13

01.

733

68 Ye

ars

0.61

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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

.pdf

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

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on th

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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

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orde

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by th

e wo

man

’s cli

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14

8 |

A G

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to

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d th

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MS

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odel

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QUEN

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Coun

selin

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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

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avior

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Coun

selin

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sity,

15 m

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rt a

code

from

one o

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rang

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Med

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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

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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.


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