HCC Blog by Caridad

Codebusters offers a FREE, yes FREE, ICD-10-CM & PCS Training Course at  Training Course It is a "ICD-10 Training Online Course by Linda Kobayashi, RHIT, CCS: The focus is on Inpatient coding, covering diagnosis and procedure codes extensively. Conditions and complications from all 22 chapters of ICD-10-CM and associated procedures are rigorously covered through life-like coding scenarios. The full course is broken up into two sections, the first covering ICD-10-CM Chapters 1-9 and the second covering Chapters 10-19 (External cause codes are present as secondary diagnoses throughout the course)." PCS is used for inpatient procedures (in the hospital). Check out their Course Flyer

Type 2 diabetes mellitus Use additional code to identify: Insulin Use (Z79.4) ICD-9    250.52 Diabetes with ophthalmic manifestations type 2 uncontrolled ICD-10  E11.3 Type 1 diabetes mellitus with ophthalmic complications E11.311 …Type 2 dm with unspecified diabetic retinopathy with macular edema E11.319 ... Type 2 dm with unspec diabetic retinopathy without macular edema E11.36 …Type 2 dm with diabetic cataract E11.39 ... Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.65 … Type 2 diabetes mellitus with hyperglycemia Guidelines state:    “The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.” “They should be sequenced based on the reasons for a particular encounter.”  “The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reaching puberty.

Type 1 diabetes mellitus Use additional code to identify: Insulin Use (Z79.4) ICD-9    250.53 Diabetes with ophthalmic manifestations type 1 (juv type) uncontrolled ICD-10  E10.3 Type 1 diabetes mellitus with ophthalmic complications E10.311 …Type 1 dm with unspecified diabetic retinopathy with macular edema E10.319 ... Type 1 dm with unspec diabetic retinopathy without macular edema E10.36 …Type 1 dm with diabetic cataract E10.39 ... Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.65 … Type 1 diabetes mellitus with hyperglycemia Guidelines state:    “The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.”  “They should be sequenced based on the reasons for a particular encounter.”   “The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reach

These are general education comment to assist physicians in recording compliant chart notes on patients. The  Chief Complaint:  This should be a concise statement from the patient that describes the reason for today's encounter. The History of Present Illness  (HPI) :    This consists of a description of the patient's present complaint(s)……..try to include location….quality…..severity…..duration…….timing……context…..modifying factors………..associated signs and symptoms. The Review of Systems (ROS):   This is an inventory of (any/all) body systems,  it is obtained by asking the patient a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The Past/Family/ and/or Social History (PFSH):   Past = illnesses, surgeries, injuries and treatments   Family = a review of medical events, diseases and hereditary conditions that may place the patient at risk   AND   Social = includes age appropriate review of past