ICD-10-CM and ICD-10-PCS Coding Handbook, with

Answers, 2019

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ICD-10-CM AND ICD-10-PCS
Coding Handbook
 ICD-10-CM AND ICD-10-PCS
Coding Handbook
with Answers
2019 Revised Edition

NELLY LEON-CHISEN, RHIA

CENTRAL OFFICE ON ICD-10-CM AND ICD-10-PCS

OF THE
AMERICAN HOSPITAL ASSOCIATION
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To my husband, Penku (Jorge) Chisen, who supported and encouraged me
with his patience and understanding throughout the long and arduous
months it took to complete this handbook
Table of Contents
ICD-10-CM and ICD-10-PCS Coding Handbook 2019, with Answers
Title Page
Copyright Information
Dedication
List of Tables and Figures
About the Author and Contributors
Acknowledgments
How to Use This Handbook
Format and Conventions and Current Coding Practices for ICD-10-CM and ICD-10-PCS
1 Background of the ICD-10-CM and ICD-10-PCS Classification
2 Introduction to the ICD-10-CM Classification
3 ICD-10-CM Conventions
4 Uniform Hospital Discharge Data Set
5 The Medical Record as a Source Document
6 Basic ICD-10-CM Coding Steps
7 Basic ICD-10-CM Coding Guidelines
8 Introduction to the ICD-10-PCS Classification
9 Basic ICD-10-PCS Coding Steps
10 ICD-10-PCS Root Operations in the Medical and Surgical Section
11 ICD-10-PCS Medical- and Surgical-Related, Ancillary, and New Technology Procedure
Sections
12 Z Codes and External Cause of Morbidity Codes
Coding of Signs and Symptoms
13 Symptoms, Signs, and Ill-Defined Conditions
Coding of Infectious and Parasitic Diseases, Endocrine Diseases and Metabolic Disorders, and
Mental Disorders
14 Infectious and Parasitic Diseases
15 Endocrine, Nutritional, and Metabolic Diseases
16 Mental Disorders
Coding of Diseases of the Blood and Blood-Forming Organs, Certain Disorders Involving the
Immune Mechanism, and Diseases of the Nervous System
17 Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the
Immune Mechanism
18 Diseases of the Nervous System and Sense Organs
Coding of Diseases of the Respiratory, Digestive, and Genitourinary Systems
19 Diseases of the Respiratory System
20 Diseases of the Digestive System
21 Diseases of the Genitourinary System
Coding of Diseases of the Skin and Diseases of the Musculoskeletal System
22 Diseases of the Skin and Subcutaneous Tissue
23 Diseases of the Musculoskeletal System and Connective Tissue
Coding of Pregnancy and Childbirth Complications, Abortion, Congenital Anomalies, and Perinatal
Conditions
24 Complications of Pregnancy, Childbirth, and the Puerperium
25 Abortion and Ectopic Pregnancy
26 Congenital Anomalies
 27 Perinatal Conditions
Coding of Circulatory System Diseases and Neoplastic Diseases
28 Diseases of the Circulatory System
29 Neoplasms
Coding of Injuries, Burns, Poisoning, and Complications of Care
30 Injuries
31 Burns
32 Poisoning, Toxic Effects, Adverse Effects, and Underdosing of Drugs
33 Complications of Surgery and Medical Care
Final Review Exercise
Appendix A Coding and Reimbursement
Appendix B Reporting of the Present on Admission Indicator
Appendix C Case Summary Exercises
Index
List of Tables and Figures
TABLE 1.1 Major Differences between ICD-9-CM and ICD-10-CM
FIGURE 1.1 ICD-9-CM versus ICD-10-CM Code Structure
TABLE 1.2 Major Differences between ICD-9-CM and ICD-10-PCS
FIGURE 1.2 ICD-9-CM versus ICD-10-PCS Code Structure
FIGURE 2.1 Table of Contents from ICD-10-CM
FIGURE 8.1 Sample Excerpt of ICD-10-PCS Table
FIGURE 8.2 Structure of Codes in the Medical and Surgical Section
FIGURE 8.3 Examples of Body Part Values
TABLE 8.1 ICD-10-PCS Sections and Their Corresponding
Character Value
TABLE 8.2 Medical and Surgical Section Body Systems and
Values
TABLE 8.3 ICD-10-PCS Root Operations and Their Corresponding
Values
FIGURE 8.4 Excerpt from Table Showing Bilateral Body Part
TABLE 8.4 Medical and Surgical Section Approaches
FIGURE 8.5 Illustrations of Medical and Surgical Section
Approaches
FIGURE 8.6 Excerpt from the Device Aggregation Table
FIGURE 9.1 Excerpt of 0FT Table from ICD-10-PCS
FIGURE 9.2 Excerpt of 0Y6 Table from ICD-10-PCS
FIGURE 10.1 Table Excerpt Demonstrating Location of Root
Operation Definition
TABLE 10.1 Root Operations to Take Out Some or All of a Body
Part
TABLE 10.2 Root Operations to Take Out Solids/Fluids/Gases from
a Body Part
TABLE 10.3 Root Operations Involving Cutting or Separation Only
TABLE 10.4 Root Operations That Put In/Put Back or Move
Some/All of a Body Part
TABLE 10.5 Root Operations to Alter the Diameter or Route of a
Tubular Body Part
TABLE 10.6 Root Operations That Always Involve a Device
TABLE 10.7 Root Operations That Involve Examination Only
TABLE 10.8 Root Operations That Include Other Repairs
TABLE 10.9 Root Operations That Include Other Objectives
TABLE 11.1 Medical- and Surgical-Related Sections
FIGURE 11.1 Structure of Codes in the Placement Section
TABLE 11.2 Placement Section Root Operation Values and
Definitions
FIGURE 11.2 Structure of Codes in the Administration Section
FIGURE 11.3 Structure of Codes in the Measurement and
Monitoring Section
FIGURE 11.4 Structure of Codes in the Extracorporeal or Systemic
Assistance and Performance Section
FIGURE 11.5 Structure of Codes in the Extracorporeal or Systemic
Therapies Section
FIGURE 11.6 Structure of Codes in the Osteopathic Section
FIGURE 11.7 Structure of Codes in the Other Procedures Section
FIGURE 11.8 Structure of Codes in the Imaging Section
FIGURE 11.9 Structure of Codes in the Nuclear Medicine Section
FIGURE 11.10 Structure of Codes in the Radiation Therapy Section
FIGURE 11.11 Structure of Codes in the Physical Rehabilitation and
Diagnostic Audiology Section
TABLE 11.3 Physical Rehabilitation and Diagnostic Audiology
Root Types, Values, and Definitions
FIGURE 11.12 Structure of Codes in the New Technology Section
TABLE 14.1 Gram-Negative and Gram-Positive Bacteria
FIGURE 15.1 Major Organs of the Endocrine System
FIGURE 16.1 Side View of the Brain
TABLE 16.1 Root Type Values in the Mental Health Section
TABLE 16.2 Root Type Values in the Substance Abuse Treatment
Section
FIGURE 17.1 Four Major Types of Blood Cells
FIGURE 18.1 The Nervous System
FIGURE 18.2 The Eye
TABLE 18.1 Coding of Glaucoma
FIGURE 18.3 The Ear
FIGURE 19.1 The Respiratory System
FIGURE 20.1 The Digestive System
FIGURE 20.2 Excerpt from ICD-10-PCS Table for Hepatobiliary
System Extirpation
FIGURE 20.3 Illustrations of Bariatric Surgery
FIGURE 21.1 The Urinary System
TABLE 21.1 Hypertensive Chronic Kidney Disease and
Hypertensive Heart and Chronic Kidney Disease and
the Applicable CKD Stages
FIGURE 21.2 The Male Reproductive System
FIGURE 21.3 Common Sites of Endometriosis Implantation
FIGURE 21.4 The Female Reproductive System
FIGURE 21.5 Breast Reconstruction Surgery
FIGURE 22.1 The Skin and Subcutaneous Tissue
FIGURE 23.1 The Human Skeleton
FIGURE 23.2 The Spinal Column
TABLE 23.1 Components of Each Column of the Spine
FIGURE 23.3 Structure of the Spine Involved in Spinal Fusion
FIGURE 23.4 Columns of the Spine, Lateral View
FIGURE 23.5 Types of Spinal Fusion Surgeries
TABLE 23.2 Common Fusion and Refusion ICD-10-PCS Qualifiers
FIGURE 24.1 Primary Organs of the Female Reproductive System
FIGURE 24.2 Examples of Fetal Presentations
FIGURE 24.3 Structure of Codes in the Obstetrics Section
FIGURE 24.4 Root Operations in the Obstetrics Section
FIGURE 25.1 Excerpt from ICD-10-PCS Table for Abortion
Procedures
FIGURE 28.1 Major Vessels of the Arterial System
FIGURE 28.2 Major Vessels of the Venous System
FIGURE 28.3 The Interior of the Heart
FIGURE 28.4 Decision Tree for Coding Acute Type 1 Myocardial
Infarction
FIGURE 28.5 Types of Cerebral Infarction
FIGURE 28.6 Pacemaker Insertion
FIGURE 28.7 Angioplasty with Stent Insertion
FIGURE 28.8 Coronary Artery Bypass Graft
FIGURE 28.9 Central Venous Catheter (CVC)
FIGURE 28.10 Peripherally Inserted Central Catheter (PICC)
FIGURE 28.11 Open Aneurysmectomy
FIGURE 28.12 Open Surgical Aneurysm Repair via Tube Graft
FIGURE 28.13 Endovascular Aneurysm Repair
TABLE 29.1 Section of the Neoplasm Table in the Alphabetic Index
of Diseases and Injuries
FIGURE 29.1 Lymphatic System
FIGURE 30.1 Examples of Open and Closed Fractures
FIGURE 30.2 Sample Tabular List Seventh-Character Values
FIGURE 30.3 Gustilo Classification of Open Fractures
TABLE 30.1 Definitions of Terms Used for Qualifiers for
“Detachment” Procedures
FIGURE 31.1 Skin Layers
FIGURE 32.1 Decision Tree for Coding Adverse Effects of Drugs or
Poisoning Due to Drugs or Medicinal or Biological
Substances
FIGURE 32.2 Excerpt from ICD-10-CM Table of Drugs and Chemicals
About the Author and Contributors
Nelly Leon-Chisen, RHIA, is the director of coding and classification at the
American Hospital Association (AHA), where she heads the Central Office on
ICD-10-CM and ICD-10-PCS (formerly the Central Office on ICD-9-CM) and
the Central Office on HCPCS. She represents the AHA as one of the
Cooperating Parties responsible for the development of AHA Coding Clinic® for
ICD-10-CM and ICD-10-PCS, the ICD-10-CM Official Guidelines for Coding
and Reporting, and the ICD-10-PCS Official Coding Guidelines. She is the
executive editor for the AHA Coding Clinic® publications.
Ms. Leon-Chisen’s other ICD-10 activities include past membership in the
ICD-10-PCS Technical Advisory Panel, past co-chair of the Workgroup for
Electronic Data Interchange (WEDI) ICD-10 Implementation Workgroup, and
numerous testimonies on ICD-10-CM and ICD-10-PCS before the ICD-9-CM
Coordination and Maintenance Committee and the National Committee on Vital
and Health Statistics. She was also the AHA lead project manager on the joint
American Hospital Association–American Health Information Management
Association (AHIMA) ICD-10-CM Field Study. She was a first-generation
AHIMA-approved ICD-10 Trainer.
Ms. Leon-Chisen has lectured on ICD-9-CM, ICD-10, and POA coding,
data quality, and DRGs throughout the United States, Europe, Asia, and Latin
America. She has often served as a speaker for the popular AHA Coding Clinic®
webinar series. She has broad health information management (HIM) experience
in hospital inpatient and outpatient management, consulting, and teaching. She
has been an instructor in the HIM and Health Information Technology Programs
for the University of Illinois and Truman Community College, both in Chicago.
She is a past president of the Chicago Area Health Information Management
Association and the recipient of its Distinguished Member Award. She is the
recipient of the Professional Achievement Award from the Illinois Health
Information Management Association. She was a member of the Advisory Board
of the Health Information Technology Program of DeVry University in Chicago.

The Central Office on ICD-9-CM and the Central Office on ICD-10-CM

and ICD-10-PCS were first created through a written Memorandum of
Understanding between the AHA and the National Center for Health Statistics in
1963 to do the following:

Serve as the U.S. clearinghouse for issues related to the use of ICD-9-CM,
ICD-10-CM, and ICD-10-PCS
Work with the National Center for Health Statistics and the Centers for
Medicare & Medicaid Services to maintain the integrity of the classification
system
Recommend revisions and modifications to the current and future revisions
of the ICD
Develop educational material and programs on ICD-9-CM, ICD-10-CM,
and ICD-10-PCS

The Central Office on ICD-10-CM and ICD-10-PCS provides expert advice

by serving as the clearinghouse for the dissemination of information on ICD-10-
CM and ICD-10-PCS.
In 2014, the Central Office stopped providing ICD-9-CM advice and fully
transitioned to ICD-10 advice while launching the stand-alone publication AHA
Coding Clinic® for ICD-10-CM and ICD-10-PCS.
Acknowledgments
Nelly Leon-Chisen gratefully acknowledges the invaluable contributions of
Anita Rapier, Gretchen Young-Charles, and Denene M. Harper, members of the
American Hospital Association’s Central Office on ICD-10-CM and ICD-10-
PCS, who assisted in the revision and review of the manuscript for the handbook
and the case summary exercises, as well as the preparation of instructors’
ancillary materials.

Anita Rapier, RHIT, CCS, is a senior coding consultant with the AHA
Central Office on ICD-10-CM and ICD-10-PCS. She is also the managing
editor of AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, for which
she is responsible for developing educational material. She has more than
25 years of experience in health information management and has held
several positions in HIM, including education, quality, compliance,
hospital-based outpatient and acute care, and long-term care. Ms. Rapier
has presented numerous educational seminars and has authored articles on
coding and compliance. She is also a speaker for the popular AHA Coding
Clinic® webinar series.

Gretchen Young-Charles, RHIA, is a senior coding consultant at the AHA

Central Office on ICD-10-CM and ICD-10-PCS. In this role, she develops
educational articles on official coding advice for publication in AHA Coding
Clinic® for ICD-10-CM and ICD-10-PCS. Ms. Young-Charles has more
than 25 years of experience in the HIM field. She has worked in numerous
HIM roles, including education, quality, and hospital-based outpatient and
acute care. She also spent a number of years with the Peer Review
Organization for the state of Illinois. She is also a speaker for the popular
AHA Coding Clinic® webinar series.
 Denene M. Harper, RHIA, is a senior coding consultant at the AHA
Central Office on ICD-10-CM and ICD-10-PCS. She is responsible for
writing articles on official coding advice for publication in AHA Coding
Clinic® for ICD-10-CM and ICD-10-PCS. Ms. Harper has more than 25
years of experience in the HIM field, including hospital-based outpatient
and acute care, utilization review, and quality improvement. She is also the
moderator for the popular AHA Coding Clinic® webinar series.

In addition, Nelly Leon-Chisen gratefully acknowledges the significant

contributions of Janatha Ashton, MS, RHIA, who authored the original case
summary exercises in appendix C, and Therese (Teri) Jorwic, who revised those
exercises and converted them from ICD-9 to ICD-10.

Therese (Teri) Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA, is an

assistant professor in Health Information Management at the University of
Illinois at Chicago. She presents numerous workshops and develops
educational material for in-class and online courses on ICD-10-CM/PCS,
ICD-9-CM, and HCPCS/CPT coding as well as on reimbursement systems
for hospitals, physicians, and other health care providers. She also presents
workshops for associations and serves as external faculty for the AHIMA
ICD-10 Academy programs.

Thanks are due to Richard Hill, a senior editor at the American Hospital
Association, who read the author’s drafts and helped me to say in plain English
what I wanted to say, even without being a coding professional himself.
Additional thanks are due to Jennifer Gillespie, who took over from Rick Hill as
production manager of the 2019 edition.
A sincere thanks to the representatives of the Cooperating Parties: Donna
Pickett, RHIA, MPH; Pat Brooks, RHIA; and Sue Bowman, RHIA, CCS—
whose collaboration and friendship have made Coding Clinic advice and the
Official Coding Guidelines a reality.
Another sincere thanks to 3M for its generous permission for the author and
Central Office staff to use 3M’s ICD-10 Translation Tool. This tool enhanced our
understanding of the implications of the code set change.
Thanks are also in order for the coding professionals and instructors who
were early adopters of this handbook, and who provided many helpful
suggestions (and, the author is a tad ashamed to say, corrections) to the early
versions of the handbook. Their efforts made this work a better resource for
students. Special thanks in this regard are due to Minnette Terlep, Linda
Holtzman, Ann Zeisset, Lisa DeLiberto, Margaret Foley, Alicia Reinbolt, Noemi
Staniszewski, Pat Poli, and Anne Pavlik.
And thank you again to Channel Publishing, Inc., for continuing to supply
the Central Office team with its ICD-10-CM and ICD-10-PCS coding books.
Finally, Ms. Leon-Chisen wishes to acknowledge the tradition of excellence
in coding education established by Faye Brown through the ICD-9-CM Coding
Handbook. Ms. Brown’s work served as the foundation on which the present
handbook was built. The author humbly hopes this handbook can continue
educating generations of coding professionals as the field implements ICD-10-
CM and ICD-10-PCS.
How to Use This Handbook
As with the ICD-9-CM handbooks, this ICD-10 edition is designed as a versatile
resource:

Textbook for academic programs in health information technology and

administration
Text for in-service training programs
Self-instructional guide for individuals who would like to learn coding or
refresh their skills outside a formal program
Reference tool for general use in the workplace

The general and basic areas of information covered in chapters 1 through 11

are designed to meet the requirements of various basic courses on the use of
ICD-10-CM and ICD-10-PCS. They may also be used as a foundation for
moving on to the study of individual chapters of ICD-10-CM and ICD-10-PCS.
Chapters 12 through 33 of the handbook include advanced material for both
continuing education students and professionals in the field.
This handbook is designed to be used in conjunction with the ICD-10-CM
and ICD-10-PCS coding manuals (either in book or PDF format). The coding
manuals must be consulted throughout the learning process, and the material in
this text cannot be mastered without using them. The official versions are
available in PDF format from the Centers for Disease Control and Prevention
(CDC) National Center for Health Statistics (ICD-10-CM) and the Centers for
Medicare & Medicaid Services (ICD-10-PCS). Several publishers offer
unofficial printed versions. There may be minor variations between the way
material is displayed in this handbook and the way it is displayed in printed
versions.
The chapters in this handbook are not arranged in the same sequence as the
chapters in ICD-10-CM or ICD-10-PCS. The first two sections of the handbook
(chapters 1–13) provide discussions on the format and conventions followed in
ICD-10-CM and ICD-10-PCS, as well as basic coding guidelines and
introductory material on Z codes and External cause of morbidity codes. The
next eight sections (chapters 14–33) progress from the less-complicated ICD-10-
CM/PCS chapters to the more difficult. Faculty in academic and in-service
programs can rearrange this sequence to suit their particular course outlines.
Appendix A, Coding and Reimbursement, contains basic information on the
role of coding with reimbursement models for hospitals, physician practices, and
other health care settings.
Appendix B, Reporting of the Present on Admission Indicator, contains
information on the reporting of the Medicare requirement associated with the
hospital inpatient reporting of all ICD-10-CM diagnosis codes.
Appendix C, Case Summary Exercises, is designed for students who have
learned the basic coding principles and need additional practice applying the
principles to actual cases. The exercises are geared for students with beginning
to intermediate levels of knowledge. The case summaries are based on actual
health records of both inpatients and outpatients. The patients described often
have multiple conditions that may or may not relate to the current episode of
care. Some exercises include several episodes of care for a patient in various
settings.
Additional resources for educators are available for download on the AHA
Central Office website: www.ahacentraloffice.org. AHA offers materials
designed to supplement classroom work and exercises in this handbook.
Available materials include slide decks covering the key points of each chapter
and exercise test banks. Please visit www.ahacentraloffice.org and register under
“Educator Resources” to receive information on how to download these training
materials.
Students using the handbook edition without answers will need to ask their
instructors for the answers. After students have completed the exercises, they
can check their answers against the instructor’s edition, which lists the
appropriate codes for each exercise, with the codes for the principal diagnosis
and principal procedure sequenced first. Explanatory comments discuss why
certain codes are appropriate and others are not and why some conditions listed
in the case summaries are not coded at all. The comments also indicate how the
principal diagnosis and procedure codes were designated, and which symptoms
are inherent to certain conditions and so are not coded separately.
The ICD-10-CM Official Guidelines for Coding and Reporting and the
ICD-10-PCS Official Coding Guidelines, referenced throughout this handbook,
may be downloaded from the AHA Central Office website:
www.ahacentraloffice.org.
To use this handbook effectively, readers should work through the coding
examples provided throughout the text until they fully understand the coding
principles under discussion. Readers should be able to arrive at correct code
assignments by following the instructions provided and reviewing the pertinent
handbook material until it is fully understood. Exercises in the body of each
chapter should be completed as they come up in the discussion, rather than at the
end of the chapter or section. Most chapters provide a review exercise with
additional material that covers the entire chapter. There is also a final review
exercise toward the end of the book that offers additional coding practice.
Answers to all of these exercises are provided in the edition with answers.
The handbook follows three conventions:

In some examples, a hyphen is used at the end of a code to indicate that

additional characters are required but cannot be assigned in the
example because certain information needed for assignment of these
characters is not given. This is done to emphasize concepts and specific
guidelines without going too deeply into specific coding situations.
The underlining of codes in text examples indicates correct sequencing;
that is, the underlined code must be sequenced first in that particular
combination of codes. When no code is underlined, there is no implicit
reason why any of the codes in the series should be sequenced first. In
 actual coding, of course, other information in the health record may dictate
a different sequence. This underlining convention is used in the handbook
solely as a teaching device. It is not an element of the ICD-10-CM/PCS
coding system.
In the edition with answers, the underlining of words in exercise
questions indicates the appropriate term to be referenced in using the
alphabetic indexes. The underlining of codes in the answer column of
the exercises indicates correct code sequencing, as it does in the
examples in the main text.

Changes in Code Usage

Official coding guidelines approved by the four Cooperating Parties responsible
for administering the ICD-10-CM and ICD-10-PCS systems in the United States
(American Hospital Association, American Health Information Management
Association, Centers for Medicare & Medicaid Services, and National Center for
Health Statistics) are published on a yearly basis. The fiscal year 2019 (FY 2019)
updates to the ICD-10-CM and ICD-10-PCS code sets have been incorporated
into this edition of the handbook. The FY 2019 version of the ICD-10-PCS
guidelines and any changes to the ICD-10-CM guidelines that were available by
mid-June 2018 have been incorporated into this edition as well. However, the
complete 2019 updates to the ICD-10-CM guidelines were not available at press
time.
AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS advice published
through Second Quarter 2018 has been included in this edition of the handbook.
Further information on AHA Coding Clinic® may be found on the next two
pages.