The following provides an overview of the chapter specific guidelines. This overview will provide a brief
introduction. These guidelines will be further explored in this week's Live Classroom and Reading
Chapter 12 describes the organization of the conditions and codes included in chapter 12 of ICD-10-CM,
Diseases of the Skin and Subcutaneous Tissue (L00-L99). Pressure ulcer stages Codes from category L89,
Pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of
the ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by
stages 1-4, unspecified stage and unstageable. Assign as many codes from category L89 as needed to
identify all the pressure ulcers the patient has, if applicable
Unstageable pressure ulcers Assignment of the code for unstageable pressure ulcer (L89.--0)
should be based on the clinical documentation. These codes are used for pressure ulcers whose
stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated
with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but
not documented as due to trauma. This code should not be confused with the codes for
unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure
ulcer, assign the appropriate code for unspecified stage (L89.--9).
Documented pressure ulcer stage Assignment of the pressure ulcer stage code should be guided
by clinical documentation of the stage or documentation of the terms found in the Alphabetic
Index. For clinical terms describing the stage that are not found in the Alphabetic Index, and
there is no documentation of the stage, the provider should be queried. 4) Patients admitted
with pressure ulcers documented as healed No code is assigned if the documentation states that
the pressure ulcer is completely healed. 5) Patients admitted with pressure ulcers documented
as healing Pressure ulcers described as healing should be assigned the appropriate pressure
ulcer stage code based on the documentation in the medical record. If the documentation does
not provide information about the stage of the healing pressure ulcer, assign the appropriate
code for unspecified stage.
Patient admitted with pressure ulcer evolving into another stage during the admission. If a
patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two
separate codes should be assigned: one code for the site and stage of the ulcer on admission
and a second code for the same ulcer site and the highest stage reported during the stay.
Chapter 13 includes diseases of the musculoskeletal system and connective tissues (M00-M99). You will
be able to describe the classification of rheumatoid arthritis and osteoarthritis, describe the coding of
various types of deforming dorsopathies and define the two types of compartment syndrome.
Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone,
joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually
involved, such as osteoarthritis, there is a "multiple sites" code available. For categories where no
multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes
should be used to indicate the different sites involved.
For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular
necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may
be at the joint, the site designation will be the bone, not the joint.
Many musculoskeletal conditions are a result of previous injury or trauma to a site, or are
recurrent conditions. Bone, joint or muscle conditions that are the result of a healed injury are
usually found in chapter 13.
Recurrent bone, joint or muscle conditions are also usually found in chapter 13. Any
current, acute injury should be coded to the appropriate injury code from chapter 19.
Chronic or recurrent conditions should generally be coded with a code from chapter 13.
If it is difficult to determine from the documentation in the record which code is best to
describe a condition, query the provider.
Coding of Pathologic Fractures 7th character A is for use as long as the patient is receiving active
treatment for the fracture.
Examples of active treatment are: surgical treatment, emergency department
encounter, evaluation and continuing treatment by the same or a different physician.
While the patient may be seen by a new or different provider over the course of
treatment for a pathological fracture, assignment of the 7th character is based on
whether the patient is undergoing active treatment and not whether the provider is
seeing the patient for the first time.
7th character, D is to be used for encounters after the patient has completed active treatment.
The other 7th characters, listed under each subcategory in the Tabular List, are to be used for
subsequent encounters for routine care of fractures during the healing and recovery phase as
well as treatment of problems associated with the healing, such as malunions, nonunions, and
Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are
affected. Therefore, site is not a component of the codes under category M81, Osteoporosis
without current pathological fracture. The site codes under category M80, Osteoporosis with
current pathological fracture, identify the site of the fracture, not the osteoporosis.
Osteoporosis without pathological fracture Category M81, Osteoporosis without current
pathological fracture, is for use for patients with osteoporosis who do not currently
have a pathologic fracture due to the osteoporosis, even if they have had a fracture in
the past. For patients with a history of osteoporosis fractures, status code Z87.310,
Personal history of (healed) osteoporosis fracture, should follow the code from M81.
Osteoporosis with current pathological fracture Category M80, Osteoporosis with
current pathological fracture, is for patients who have a current pathologic fracture at
the time of an encounter. The codes under M80 identify the site of the fracture. A code
from category M80, not a traumatic fracture code, should be used for any patient with
known osteoporosis who suffers a fracture, even if the patient had a minor fall or
trauma, if that fall or trauma would not usually break a normal, healthy bone.
Chapter 19 includes codes that report: Injury, poisoning, and certain other consequences of external
Most categories in chapter 19 have a 7th character requirement for each applicable code. Most
categories in this chapter have three 7th character values (with the exception of fractures):
A, initial encounter,
D, subsequent encounter
Categories for traumatic fractures have additional 7th character values. While the patient may be seen
by a new or different provider over the course of treatment for an injury, assignment of the 7th
character is based on whether the patient is undergoing active treatment and not whether the provider
is seeing the patient for the first time.
For complication codes, active treatment refers to treatment for the condition described by the code,
even though it may be related to an earlier precipitating problem.
For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal
joint prosthesis, initial encounter, is used when active treatment is provided for the infection,
even though the condition relates to the prosthetic device, implant or graft that was placed at a
previous encounter. 7th character "A", initial encounter is used for each encounter where the
patient is receiving active treatment for the condition.
Examples of active treatment are: surgical treatment, emergency department
encounter, and evaluation and continuing treatment by the same or a different
7th character "D" subsequent encounter is used for encounters after the patient has completed
active treatment of the condition and is receiving routine care for the condition during the
healing or recovery phase.
Examples of subsequent care are: cast change or removal, an x-ray to check healing
status of fracture, removal of external or internal fixation device, medication
adjustment, other aftercare and follow up visits following treatment of the injury or
The aftercare Z codes should not be used for aftercare for conditions such as injuries or
poisonings, where 7th characters are provided to identify subsequent care.
For example, for aftercare of an injury, assign the acute injury code with the 7th character "D"
(subsequent encounter). 7th character "S", sequela, is for use for complications or conditions
that arise as a direct result of a condition, such as scar formation after a burn. The scars are
sequelae of the burn.
When using 7th character "S", it is necessary to use both the injury code that precipitated the
sequela and the code for the sequela itself. The "S" is added only to the injury code, not the
sequela code. The 7th character "S" identifies the injury responsible for the sequela. The specific
type of sequela (e.g. scar) is sequenced first, followed by the injury code.
See full guidelines for specific coding instructions for the coding of:
Burns and Corrosions
Chapter 20 includes codes for: External Causes of Morbidity (V00-Y99).
The external causes of morbidity codes should never be sequenced as the first listed or principal
External cause codes are intended to provide data for injury research and evaluation of injury
prevention strategies. These codes capture how the injury or health condition happened (cause), the
intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event
occurred the activity of the patient at the time of the event, and the person's status (e.g., civilian,
There is no national requirement for mandatory ICD-10-CM external cause code reporting. Unless a
provider is subject to a state-based external cause code-reporting mandate or these codes are required
by a particular payer, reporting of ICD-10-CM codes in Chapter 20, External Causes of Morbidity, is not
required. In the absence of a mandatory reporting requirement, providers are encouraged to voluntarily
report external cause codes, as they provide valuable data for injury research and evaluation of injury
External Cause: An external cause code may be used with any code in the range of A00.0-T88.9,
Z00-Z99, classification that is a health condition due to an external cause. Though they are most
applicable to injuries, they are also valid for use with such things as infections or diseases due to
an external source, and other health conditions, such as a heart attack that occurs during
strenuous physical activity.
Place of Occurrence: Codes from category Y92, Place of occurrence of the external cause, are
secondary codes for use after other external cause codes to identify the location of the patient
at the time of injury or other condition.
Activity: Assign a code from category Y93, Activity code, to describe the activity of the patient at
the time the injury or other health condition occurred.
External cause status: code from category Y99, External cause status, should be assigned
whenever any other external cause code is assigned for an encounter, including an Activity code,
except for the events noted below. Assign a code from category Y99, External cause status, to
indicate the work status of the person at the time the event occurred. The status code indicates
whether the event occurred during military activity, whether a non-military person was at work,
whether an individual including a student or volunteer was involved in a non-work activity at the
time of the causal event.
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