CodingStandards v2018 EN PDF

ICD-10-CA | CCI
Canadian Coding Standards

for Version 2018 ICD-10-CA and CCI
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ISBN 978-1-77109-675-1 (PDF)
© 2018 Canadian Institute for Health Information
How to cite this document:

Canadian Institute for Health Information. Canadian Coding Standards for Version
2018 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2018.
Cette publication est aussi disponible en français sous le titre Normes canadiennes
de codification pour la version 2018 de la CIM-10-CA et de la CCI.
ISBN 978-1-77109-676-8 (PDF)
Table of contents
Acknowledgements ...................................................................................................................12
Introduction ...............................................................................................................................13
Format of the coding standards .........................................................................................13
Amendments......................................................................................................................14
Data quality ........................................................................................................................15
Using the PDF version of the coding standards .................................................................17
History of the coding standards ..........................................................................................18
The basic structure and classification principles of the ICD ................................................19
General coding standards for ICD-10-CA ..................................................................................20
Main and Other Problem Definitions for NACRS ................................................................20
Coding of Main and Other Problems for NACRS ................................................................22
Diagnosis Typing Definitions for DAD ................................................................................25
Diagnosis Cluster ...............................................................................................................43
Diagnoses of Equal Importance .........................................................................................61
Specificity ..........................................................................................................................64
Using Diagnostic Test Results in Coding ...........................................................................65
Dagger/Asterisk Convention ..............................................................................................67
Acute and Chronic Conditions ............................................................................................71
Impending or Threatened Conditions .................................................................................72
Underlying Symptoms or Conditions ..................................................................................73
Unconfirmed Diagnosis ......................................................................................................77
Use Additional Code/Code Separately Instructions ............................................................84
Sequelae ...........................................................................................................................86
Admissions From Emergency Department .........................................................................88
Cancelled Interventions .....................................................................................................90
General coding standards for CCI .............................................................................................94
Selection of Interventions to Code for Ambulatory Care (Emergency, Clinic and Day
Surgery Visits) ...................................................................................................................94
Selection of Interventions to Code for Acute Inpatient Care .............................................102
Composite Codes in CCI .................................................................................................110
Multiple Codes in CCI ......................................................................................................111
Canadian Coding Standards for Version 2018 ICD-10-CA and CCI
Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction ....................117

Combined Diagnostic and Therapeutic Interventions .........................................................118
Endoscopic Interventions .................................................................................................121
Interventions to Manage Bleeding ....................................................................................127
Destruction or Excision of Aberrant/Ectopic Tissue ..........................................................129
Debulking of a Space-Occupying Lesion..........................................................................130
Abandoned Interventions .................................................................................................131
Failed Interventions..........................................................................................................133
Change of Plans During an Intervention...........................................................................135
Converted Interventions ...................................................................................................135
Revised Interventions ......................................................................................................136
Chapter I — Certain infectious and parasitic diseases ............................................................144
Infections .........................................................................................................................144
Drug-Resistant Microorganisms .......................................................................................146
Septicemia/Sepsis ...........................................................................................................151
Human Immunodeficiency Virus (HIV) Disease................................................................158
Chapter II — Neoplasms .........................................................................................................164
Primary and Secondary Neoplasms .................................................................................164
Multiple Independent Primary Neoplasms ........................................................................168
Acquired Absence of Breast and Lung Due to Primary Malignancy..................................170
Neoplasms Arising in Lymphoid, Hematopoietic and Related Tissue ...............................172
Neoplasms Extending Into Adjacent Tissue .....................................................................174
Neoplasms With Overlapping Boundaries (Contiguous Sites) ..........................................175
Admissions Following Diagnosis of Cancer ......................................................................176
Complications of Malignant Disease ................................................................................177
Recurrent Malignancies ...................................................................................................180
Interventions Relevant to Neoplasm Coding ....................................................................182
Sentinel Lymph Node Biopsy ...........................................................................................184
Brachytherapy..................................................................................................................186
Chapter III — Diseases of the blood and blood-forming organs and certain disorders
involving the immune mechanism ...........................................................................................189
Acute Blood Loss Anemia ................................................................................................189
Anemia of Chronic Disease..............................................................................................192
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Chapter IV — Endocrine, nutritional and metabolic diseases ..................................................196

Diabetes Mellitus .............................................................................................................196
Dehydration .....................................................................................................................211
Chapter VI — Diseases of the nervous system .......................................................................213
Cranioplasty and/or Duraplasty Concomitant With Intracranial Interventions ...................213
Hierarchy for Classification of Intracranial Lesion Resection ............................................216
Revision of Cerebrospinal Fluid (CSF) Shunt Systems (Ventricle, Brain Stem,
Spinal Canal) ...................................................................................................................218
Seizures...........................................................................................................................220
Neurological Deficits Following a Stroke ..........................................................................225
Neurologically Determined Death.....................................................................................227
Chapter IX — Diseases of the circulatory system....................................................................231
Hypertension and Associated Conditions .........................................................................231
Acute Coronary Syndrome (ACS) ....................................................................................233
Selection of Status Attribute for Percutaneous Coronary Intervention (PCI) .....................246
Thrombolytic Therapy ......................................................................................................248
Angina .............................................................................................................................252
Chronic Ischemic Heart Disease ......................................................................................254
Occlusion Following Coronary Artery Bypass Grafts (CABGs) .........................................256
Cardiac Arrest ..................................................................................................................258
Strokes: Hemorrhagic, Ischemic and Unspecified ............................................................262
Peripheral Vascular Disease ............................................................................................266
Aneurysms .......................................................................................................................268
Central Venous Catheters ................................................................................................270
Anticoagulation Therapy: Management and Adverse Effects ...........................................275
Chapter X — Diseases of the respiratory system ....................................................................283
Pneumonia ......................................................................................................................283
Pneumonia in Patients With Chronic Obstructive Pulmonary Disease (COPD) ................286
Asthma ............................................................................................................................288
Resection of Space-Occupying Lesions (Polyps) of Nose ................................................290
Septoplasty for Deviated Nasal Septum ...........................................................................292
Invasive Ventilation ..........................................................................................................295
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Chapter XI — Diseases of the digestive system ......................................................................300

Gastroenteritis and Diarrhea ............................................................................................300
Bleeding Esophageal Varices ..........................................................................................301
Gastrointestinal Bleeding .................................................................................................304
Selection of Attributes at Hernia Repair ...........................................................................306
Chapter XII — Diseases of the skin and subcutaneous tissue.................................................308

Cellulitis ...........................................................................................................................308
Chapter XIII — Diseases of the musculoskeletal system and connective tissue ......................310
Osteoarthritis ...................................................................................................................310
Arthrectomy and Arthroplasty...........................................................................................314
Fractures .........................................................................................................................315
Joint Fracture Reduction, Fixation and Fusion .................................................................320
Excision (of Lesion) of Bone, Soft Tissue and Skin ..........................................................321
Spinal Stenosis ................................................................................................................323
Chapter XIV — Diseases of the genitourinary system .............................................................325
Stages of Chronic Kidney Disease (CKD) ........................................................................325
Acute on Chronic Kidney Disease ....................................................................................326
Continuous Ambulatory Peritoneal Dialysis (CAPD) Peritonitis ........................................330
Menorrhagia as the Most Responsible Diagnosis (MRDx) ...............................................332
Chapter XV — Pregnancy, childbirth and the puerperium .......................................................333
Selection of the Sixth Digit in Obstetrical Coding .............................................................333
Sequencing Obstetrical Diagnosis Codes ........................................................................338
Intrauterine Death ............................................................................................................342
Pregnancy With Abortive Outcome ..................................................................................343
Continuing Pregnancy After Abortion/Selective Fetal Reduction in Multiple Gestation .....354
Complications Following Abortion and Ectopic and Molar Pregnancy ..............................358
Streptococcal Group B Infection/ Carrier in Pregnancy ....................................................359
Delivery in a Normal Case ...............................................................................................361
Complicated Pregnancy Versus Uncomplicated Pregnancy .............................................364
Delivery With History of Cesarean Section .......................................................................373
Multiple Gestation ............................................................................................................374
Maternal Care Related to the Fetus, Amniotic Cavity and Possible Delivery Problems ....376
Prolonged Pregnancy/Post-Dates Pregnancy ..................................................................379
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Table of contents
Premature Rupture of Membranes ...................................................................................381

Preterm Labor ..................................................................................................................382
Long Labor ......................................................................................................................383
Precipitate Labor..............................................................................................................385
Obstructed Labor .............................................................................................................386
Labor and Delivery Complicated by Fetal Stress..............................................................390
Postpartum Hemorrhage ..................................................................................................391
Complications of Anesthesia During Labor and Delivery ..................................................395
Interventions Associated With Delivery ............................................................................396
Dilation and Curettage .....................................................................................................403
Chapter XVI — Certain conditions originating in the perinatal period ......................................405
Low Birth Weight and/or Preterm Infant ...........................................................................406
Fetal Acidemia .................................................................................................................411
Neonatal Jaundice ...........................................................................................................413
Confirmed Sepsis and Risk of Sepsis in the Neonate ......................................................414
Birth Trauma ....................................................................................................................419
Perinatal Stroke ...............................................................................................................421
Chapter XVII — Congenital malformations, deformations and chromosomal abnormalities ....423
Congenital Anomaly Syndromes and Specific Manifestations ..........................................423
Chapter XVIII — Symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified ..........................................................................................................428
Systemic Inflammatory Response Syndrome (SIRS) .......................................................428
Vital Signs Absent (VSA) .................................................................................................433
Chapter XIX — Injury, poisonings and certain other consequences of external causes...........437
Adverse Reactions in Therapeutic Use Versus Poisonings ..............................................437
Allergic Reaction in Non-Therapeutic Use........................................................................447
Current Versus Old Injuries ..............................................................................................449
Early Complications of Trauma ........................................................................................454
Intracranial Injury NOS Versus Head Injury NOS .............................................................456
Skull Fracture and Intracranial Injury................................................................................457
Open Wounds ..................................................................................................................458
Fractures — Closed Versus Open ...................................................................................460
Treatment of Fractures ....................................................................................................461
7
Dislocations .....................................................................................................................461
Injury to Blood Vessels ....................................................................................................462
Significant Injuries ............................................................................................................463
Crush Injuries...................................................................................................................463
Bilateral Injuries ...............................................................................................................465
Burns and Corrosions ......................................................................................................467
Extent of Body Surface Area Involved in Burn Injury ........................................................470
Assignment of Most Responsible Diagnosis/Main Problem in Multiple Burns ...................471
Burns of Multiple Body Regions .......................................................................................472
Sequencing Multiple Injuries for Severity .........................................................................472
Code Assignment for Multiple Superficial Injuries or Multiple Open Wounds ....................475
Code Assignment for Multiple Types of Significant Injuries Involving a Single
Body Region ....................................................................................................................477
Code Assignment for Multiple Types of Significant Injuries Involving Multiple
Body Regions ..................................................................................................................479
Coding Nonspecific Multiple Injuries for Emergency Department Visits ............................481
Post-Intervention Conditions ............................................................................................481
Rejection/Failure of Transplanted Organs, Grafts and Flaps ............................................509
Complications of Devices, Implants or Grafts ...................................................................511
Misadventures During Surgical and Medical Care ............................................................518
Chapter XX — External causes of morbidity and mortality ......................................................534
External Cause Codes .....................................................................................................534
Place of Occurrence ........................................................................................................535
Type of Activity ................................................................................................................535
Chapter XXI — Factors influencing health status and contact with health services .................536
Pre-Treatment Assessment .............................................................................................536
Admission for Observation ...............................................................................................539
Admission for Follow-Up Examination ..............................................................................548
Admission for Convalescence ..........................................................................................553
Screening for Specific Diseases.......................................................................................556
Prophylactic Organ Removal ...........................................................................................560
Coding of NACRS Visits for Rehabilitative Services .........................................................561
Admission for Administration of Chemotherapy, Pharmacotherapy and
Radiation Therapy ...........................................................................................................562
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Table of contents
Admission for Insertion of a Vascular Access Device (VAD) ............................................570

Admission for Blood Transfusion......................................................................................571
Palliative Care..................................................................................................................572
Medical Assistance in Dying ............................................................................................580
Boarder Babies and Boarder Mothers ..............................................................................595
Homelessness .................................................................................................................596
Personal and Family History of Malignant Neoplasms .....................................................597
Personal History of Primary Malignant Neoplasms of Breast, Lung and Prostate.............600
Appendix A — Resources .......................................................................................................603

General coding standards for CCI ....................................................................................603
Definitions of flaps and grafts ....................................................................................603
Chapter I — Certain infectious and parasitic diseases .....................................................608
Drug-resistant microorganisms .................................................................................608
Chapter IV — Endocrine, nutritional and metabolic diseases ...........................................609
Diabetes mellitus.......................................................................................................609
Chapter IX — Diseases of the circulatory system ............................................................619
Acute coronary syndrome (ACS) and related interventions .......................................619
Strokes .....................................................................................................................624
Atrial fibrillation .........................................................................................................628
Chapter X — Diseases of the respiratory system .............................................................629
Pneumonia................................................................................................................629
Asthma .....................................................................................................................630
Adult respiratory distress syndrome ..........................................................................630
Chapter XI — Diseases of the digestive system...............................................................631
Diagnostic colonoscopic interventions.......................................................................631
Chapter XII — Diseases of the skin and subcutaneous tissue .........................................632
Cellulitis ....................................................................................................................632
Chapter XIII — Diseases of the musculoskeletal system and connective tissue...............632
Osteoarthritis ............................................................................................................632
Spinal stenosis ..........................................................................................................633
Chapter XIV — Diseases of the genitourinary system ......................................................633
Stages of chronic kidney disease (CKD) ...................................................................633
Pelvic relaxation ........................................................................................................634
Chapter XV — Pregnancy, childbirth and the puerperium ................................................636
9
Length of gestation ...................................................................................................636

Trimesters .................................................................................................................637
Chapter XVI — Certain conditions originating in the perinatal period ...............................637
Respiratory distress of newborn ................................................................................637
Neonatal jaundice .....................................................................................................638
Chapter XVIII — Symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified ...................................................................................................638
Systemic inflammatory response syndrome (SIRS) ..................................................638
Chapter XIX — Injury, poisonings and certain other consequences of external causes ...641
Crush injuries ............................................................................................................641
Opioid overdose ........................................................................................................642
Appendix B — Y83–Y84 Inclusion List ....................................................................................645

Appendix C — Table of changes — 2018 Canadian Coding Standards ..................................652
Appendix D — Mandatory attributes in CCI .............................................................................682
Appendix E — Tips for Coders ................................................................................................689
General coding standards for CCI ....................................................................................689
Endoscopic Retrograde Cholangiography With Sphincterotomy Alone or
Concomitant With Extraction .....................................................................................689
Interventions: Failed/Abandoned/Change of Plans....................................................691
Apheresis ..................................................................................................................693
Spinal Decompression ..............................................................................................694
Chapter I — Certain infectious and parasitic diseases .....................................................697
Infections: Interpretation of This Versus That ............................................................697
Urosepsis ..................................................................................................................700
Chapter IX — Diseases of the circulatory system ............................................................701
Thrombolytic Therapy ...............................................................................................701
Cardiac Arrest ...........................................................................................................703
I21 Acute Myocardial Infarction: Diagnosis Typing ....................................................704
Chapter XI — Diseases of the digestive system...............................................................706
Bariatric Surgery and Diagnosis Code Mismatch ......................................................706
Chapter XIII — Diseases of the musculoskeletal system and connective tissue...............708
Where Do Soft-Tissue Injuries Fit in the Classification? ............................................708
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Table of contents
Chapter XV — Pregnancy, childbirth and the puerperium ................................................710

Fetal Heart Rate Anomaly .........................................................................................710
Section 5 Intervention Codes Applicable to Stillbirths, Missed Abortion and
Termination of Pregnancy .........................................................................................711
Amniotic Fluid Embolism ...........................................................................................715
Assisted Reproductive Technology (ART) .................................................................716
Chapter XVI — Certain conditions originating in the perinatal period ...............................718
Spot the Error: Use of Codes From Chapter XVI — Certain conditions
originating in the perinatal period (P00–P96) ............................................................718
Sixth Digit at Z37 and Z38.........................................................................................719
Chapter XIX — Injury, poisonings and certain other consequences of external causes ...720
Selecting the Primary Code for a Post-Intervention Condition ...................................720
Ventilator-Associated Pneumonia Versus Postoperative Pneumonia ........................722
Post-Intervention Conditions — Residual Codes .......................................................724
The “Ifs” and “Thens” of Broken Devices ...................................................................726
Chapter XXI — Factors influencing health status and contact with health services ..........729
Admissions “Solely for a Specific Purpose . . .” .........................................................729
Appendix F1 — References to mandatory diagnosis type (3)/other problem in
directive statements ................................................................................................................732
Appendix F2 — References to optional diagnosis type (3)/other problem in
directive statements ................................................................................................................743
Appendix G — Text alternative for images ..............................................................................752
11
Acknowledgements
The Canadian Institute for Health Information (CIHI) wishes to acknowledge and thank the
National Coding Advisory Committee, representing their respective jurisdictions, for their
contribution to the Canadian Coding Standards for Version 2018 ICD-10-CA and CCI.
The continued support and contributions provided by the many individual reviewers from all
provinces and territories are also gratefully acknowledged.
We would also like to acknowledge the expertise provided by representatives from the following:
• Canadian Cardiovascular Society
• Canadian Diabetes Association (CDA)
• CIHI Classification Advisory Committee
• World Health Organization (WHO) Update and Revision Committee
• Society of Obstetricians and Gynecologists of Canada (SOGC)
12
Introduction
Introduction
The Canadian Coding Standards for Version 2018 ICD-10-CA and CCI is intended for use with
the 2018 version of the International Statistical Classification of Diseases and Related Health
Problems, 10th Revision, Canada (ICD-10-CA) and the Canadian Classification of Health
Interventions (CCI).
Format of the coding standards

Effective version 2018, the coding standards have a new look. These changes were made to
ensure that the document is accessible to all users. Also, text alternatives have been written for
all images and flow diagrams; the text alternatives are found in Appendix G.
Each standard contains

• Directive statements, which are in a shadow box; and
• Examples demonstrating how to apply the directive statements.
These standards apply to data submitted to the Discharge Abstract Database (DAD) and the
National Ambulatory Care Reporting System (NACRS). Where applicable, directive statements
and examples are preceded by an icon indicating whether the statement applies to the DAD
only, to NACRS only or to both the DAD and NACRS. Not all directives are easily assigned a
DAD or NACRS icon, but each has the potential to apply to either database.
The icons used are
D DAD only
N NACRS only
DN DAD and NACRS
The data elements included in the examples depend on the purpose of the example, the coding
standard in which the example appears and whether or not there is sufficient information to
provide each data element (e.g., diagnosis typing, prefix 5 and/or prefix 6, diagnosis cluster).
13
The diagnosis type for the DAD and the problem identification for NACRS are indicated in the
examples using the following:
(M) Most responsible diagnosis

(1) Diagnosis type (1)
(W) Diagnosis type (W)
(X) Diagnosis type (X)
(Y) Diagnosis type (Y)
MP Main problem diagnosis
OP Other problem diagnosis
Clinical and intervention information relevant to understanding the direction in the coding
standard is included whenever necessary. Exceptions to directives are listed where appropriate.
Each coding standard is understood best when read in its entirety. There may be more than
one directive statement within a directive box, and there may be more than one directive
box within a standard. These are designed to flow in a logical sequence to the greatest extent
possible. Each directive statement must be applied in the context of the entire standard in which
it is embedded.
Amendments
CIHI amends and develops new coding standards in consultation with the provinces and
territories. Some coding standards have been adapted from provincial documents and
incorporated into these national standards.
The word “amended” followed by the year appears under the title of a standard to indicate
years when
• New direction was provided in the standard;
• Wording changes were made to clarify the direction; and/or
• Examples were modified or new examples added.
14
Introduction
A hyperlink to Appendix C — Table of changes — 2018 Canadian Coding Standards also

appears under the title. The link reads “For description of change, see Appendix C.”
Coding standards are not designated as “amended” when changes are limited to reformatting
or adding a hyperlink.
Revisions to the coding standards are made on a regular basis to keep pace with changing
health care information needs.
Data quality
The coding standards are intended to supplement the classification rules inherent in ICD-10-CA
and CCI by providing additional information that could not be embedded into the classifications.
It is assumed that users of this document have had training in abstracting relevant information
from clinical records and in using ICD-10-CA and CCI.
The clinical record is the source for coding morbidity data. Reabstraction studies have identified
inadequate chart documentation as one cause of data quality concerns in the classification of
diagnoses, problems and interventions. From a data collection perspective, inadequate
documentation falls into two categories:
1. Deficiencies in the documentation

“Complete, clear, and accurate documentation is the foundation for complete and accurate
coding of all types of medical records.” 1 Deficiencies in the documentation result from
• Failure of the health care provider to record information;
• Lack of detail or specificity;
• Conflicting or inconsistent information;
• Illegible documents; and/or
• Missing documents.
Provincial/territorial hospital act legislation contains regulations that itemize the documentation
that must be included in the clinical record. Typically, the legislation designates the board of
directors as responsible for ensuring these requirements are met.
When the record does not contain sufficient information to assign a code, the coder
must consult with the responsible health care provider. The Canadian Coding Standards
cannot provide direction to compensate for deficiencies in the documentation. This becomes
particularly relevant when coding is outsourced.
15
2. Failure of health care facilities to provide the coder with appropriate documents from
the clinical record
To support data quality, health care facilities must ensure coders have access to the
documentation necessary for accurate code selection. As hospitals across Canada deal with
recruitment issues, shortened data submission timelines and the migration to the electronic
health record, processes are created that result in coders not having access to the pertinent
documentation. These include, but are not limited to, hybrid records and coders working
from remote locations.
CIHI suggests that facilities establish internal policies to specify the minimum set of
documents that must be made available to coders to support quality data collection but
recommends that source documentation (as noted below) pertaining to an episode of care
be reviewed during the data collection process.
The following table provides a list of documents for each type of case that CIHI recommends
be available for ICD-10-CA/CCI classification and data collection. While facilities may not
use the same terminology to identify the same component of the clinical record, coders will
know what record or document is required.
Source documents recommended to support quality

ICD-10-CA/CCI classification and data collection
Type of case Documentation requirements
Surgical • Discharge/case summary (for complex cases)
• Report of history and physical exam
• Progress notes
• Operation report (with postoperative diagnoses recorded)
• Anesthesia report (for operating room time data elements)
• Pathology report
• Consultation reports
• Diagnostic imaging reports (for specificity)
Medical • Discharge/case summary (final diagnoses must be recorded)

• Progress notes
• Interventional reports (e.g., cardiac catheterization, mechanical ventilation)
16
Introduction
Type of case Documentation requirements
Death • Discharge/case summary (final diagnoses must be recorded)

• Provisional autopsy report (when applicable)
• Progress notes
Obstetrical • Prenatal record

• Labor summary and delivery/operative record
• Anesthesia report
Newborn • Mother’s record or copy of delivery record

• Newborn physical exam
ED/outpatient visits • Emergency/outpatient record (final diagnoses must be recorded)

• Reports of diagnostic testing
Day surgery • Outpatient record (final diagnoses must be recorded)

• Operation report (with postoperative diagnoses recorded)
• Anesthesia report (for operating room time data elements)
• Pathology report
Using the PDF version of the coding standards

When used in electronic form, the portable document format (PDF) version of the coding
standards is easily searchable. To facilitate searching, this document has been published
using American spelling (with the exception of code titles, which are written as they appear in
the classifications). This is consistent with the alphabetical index for ICD-10-CA, which uses
American spelling, and the tabular version of ICD-10-CA, which is published using British
spelling (e.g., “haemorrhage” rather than “hemorrhage”). CCI is published using American
spelling throughout.
You can search the PDF using the following methods:

• Expand the table of contents to list the titles of the coding standards and click the name of
the standard’s title.
• Use the Find command to search by phrase, word or code.
You can copy portions of text from the PDF by using the select and snapshot tools.
You can move back and forth between coding standards you previously viewed by using the
Previous View and Next View icons. These icons are available under different
toolbars depending on your version of Adobe.
17
Hyperlinks have been inserted into the document to allow quick navigation to other related
coding standards.
The hyperlink “For description of change, see Appendix C” beneath a coding standard title will
take you to the appropriate section in Appendix C to review the description of the change for
that particular coding standard. You can return to the coding standard from Appendix C by
clicking the heading that identifies the name of the coding standard and chapter title.
History of the coding standards

The Canadian Coding Standards for ICD-10-CA and CCI was first introduced in 2001. The first
iteration was entitled ICD-10-CA and CCI Coding Guidelines, Volume 5 (volumes 1 through 4
are specific to the classifications themselves: ICD-10-CA volumes 1 and 2 and CCI volumes 3
and 4). Many of the diagnosis-related coding standards are derived from the instruction manual
that accompanies the International Statistical Classification of Diseases and Related Health
Problems (ICD-10) as published by the World Health Organization (WHO). These coding
standards are identified, where applicable, with references to the WHO source.
Prior to 2001, Canadian coders used the Coding Sourcebook, which supported the use of the
International Classification of Disease, 1975 Revision (ICD-9) and the Canadian Classification of
Diagnostic, Therapeutic, and Surgical Procedures (CCP). The Coding Sourcebook also included
information pertaining to the American clinical modification of ICD-9, the ICD-9-CM. Prior to the
implementation of ICD-10-CA and CCI, both ICD-9/CCP and ICD-9-CM were used across
Canada. Information from the Coding Sourcebook that was relevant to the new classifications
was brought forward into the Canadian Coding Standards for ICD-10-CA and CCI.
CIHI maintains the coding standards in consultation with the provinces and territories. Where
further clinical expertise is required, CIHI consults representatives from various organizations
and groups such as the
• Canadian Cardiovascular Society;
• Canadian Diabetes Association;
• CIHI Classification Advisory Committee;
• WHO Update and Revision Committee; and
• Society of Obstetricians and Gynaecologists of Canada.
Revisions to the coding standards are made on a regular basis to keep pace with changing
health care models, advancements in health care and technology, and health care information
needs. Prior to 2009, the coding standards were revised and published on an annual basis.
Errata identified after publication were communicated via bulletins. In 2009, the coding
18
Introduction
standards moved to a three-year update cycle to coincide with that of the ICD-10-CA and CCI
classifications. Errata identified after the publication of the 2009 and 2012 coding standards
were incorporated and published as a revised version of the coding standards. In 2018, the
format of the coding standards was revised to ensure that the document is accessible to all
users, and resources (e.g., content from retired education products and Tips for Coders) were
added as an appendix.
The basic structure and classification principles

of the ICD
The ICD is a variable-axis classification. Its main purpose is “to permit the systematic recording
analysis, interpretation and comparison of mortality and morbidity data collected in different
countries or areas and at different times.” 2 The classification is arranged to bring together
conditions that would be inconveniently arranged for epidemiological study were they to be
scattered, for instance, in a classification arranged primarily by anatomical site. These conditions
formulate the “special groups” chapters:
• Chapter I — Certain infectious and parasitic diseases (A00–B99)
• Chapter XV — Pregnancy, childbirth and the puerperium (O00–O99)
• Chapter XVI — Certain conditions originating in the perinatal period (P00–P96)
• Chapter XIX — Injury, poisoning and certain other consequences of external causes (S00–T98)
“The distinction between the ‘special groups’ chapters and the ‘body system’ chapters has
practical implications for understanding the structure of the classification, for coding to it and
for interpreting statistics based on it. It has to be remembered that, in general, conditions are
primarily classified to one of the special groups chapters. Where there is any doubt as to
where a condition should be classified, the special groups chapters should take priority.” 2
This principle is enforced in the excludes notes at the beginning of each chapter in the ICD.
References
1. MacDonald E. Better coding through improved documentation: Strategies for the current
environment. Journal of AHIMA. 1999.
2. World Health Organization. International Statistical Classification of Diseases and Related

Health Problems, Tenth Revision, Volume 2, 2nd Edition. 2004.
19
General coding standards for ICD-10-CA

Main and Other Problem Definitions for NACRS
For description of change, see Appendix C.
In effect 2002, amended 2007, 2008, 2009, 2018
Main problem
The main problem (MP) is the problem that is deemed to be the clinically significant reason for
the client’s visit and that requires evaluation and/or treatment or management. This can be a
diagnosis, condition, problem or circumstance.
The main problem is assigned by the health care provider at the end of the visit. This may be
the physician or another health care professional responsible for the client’s care (e.g., an allied
health professional).
When multiple problems are considered the main reason for providing ambulatory care services,
the main problem is the one responsible for the greatest use of resources.
For patients who have left without being seen, the main problem is the presenting complaint.
This can occur at any point in the patient’s visit.
Other problem
An ICD-10-CA code is assigned, mandatory, as an other problem (OP) when
• The condition or circumstance exists at the time of the client’s visit and is significant to the
client’s treatment or care;
- Determination of significance: requires monitoring and/or treatment.
• The direction is provided within another coding standard and/or within the classification itself.
- Other problems include codes from External Causes of Morbidity and Mortality (V01–Y98)
and Place of Occurrence (U98). See also the coding standards External Cause Codes
and Place of Occurrence.
It is optional to assign a code for a condition or circumstance when it does not meet the above
definition for mandatory other problem (OP) assignment.
CIHI recommends that any decision regarding optional other problem assignment be made at
the jurisdiction or facility level, based on data needs and in consultation with stakeholders
responsible for overseeing coding and data quality.
20
Jurisdiction-wide or facility-mandated direction ensures consistent capture of optional other

problem codes. Unless an other problem code is consistently captured by all coders at the
jurisdiction or facility level (i.e., not on an individual coder basis), it is not reliable or valid for use.
The assignment of optional other problem codes, which has not been mandated by CIHI or by a
jurisdiction or facility, creates unnecessary coder burden.
Note
Documentation from allied health professionals — such as nurses, crisis team workers and
physiotherapists — who are not the main service provider can be used for assignment of other problems.
Note
See data elements 44 and 45 in the National Ambulatory Care Reporting System (NACRS) Abstracting
Manual for additional main problem and other problem collection instructions.
N Example: A patient presents to the emergency department with a cough and fever and is
treated for pneumonia. The nurse records that he has had type 2 diabetes mellitus
for many years. He also has coronary artery disease (CAD).
Code NACRS Code title
J18.9 MP Pneumonia, unspecified
E11.52 OP Type 2 diabetes mellitus with certain circulatory complications
Rationale: E11.52 is assigned as an other problem because the coding standard

Diabetes Mellitus provides the direction to assign a code from E10–E14,
mandatory, whenever diabetes is documented. See also the coding
standard Use Additional Code/Code Separately Instructions.
N Example: A patient presents to the oncology clinic for a chemotherapy session for active left
main bronchus malignancy.
Z51.1 MP Chemotherapy session for neoplasm
C34.01 OP Malignant neoplasm of left main bronchus
Rationale: It is mandatory to assign an additional code for the malignant neoplasm as

an other problem. See also the coding standard Admission for Administration
of Chemotherapy, Pharmacotherapy and Radiation Therapy.
21
N Example: A patient presents to the emergency department with chest pain. After observation
and diagnostic testing, it is determined that the chest pain was non-cardiac in
nature. The emergency department discharge diagnosis is non-cardiac chest pain,
suspected GERD.
R07.4 MP Chest pain, unspecified
(Q) K21.9 OP Gastro-oesophageal reflux disease without oesophagitis (optional)
Rationale: Codes for suspected diagnoses may be assigned, optionally, as other

problems. Apply the prefix Q in such circumstances. See also the coding
standard Unconfirmed Diagnosis.
Coding of Main and Other Problems for NACRS

In effect 2002, amended 2008, 2009, 2018
Diagnoses must be supported by physician or primary care provider documentation to be

classified as a main problem (MP). The National Ambulatory Care Reporting System
(NACRS) recognizes that allied health professionals, such as nurses, crisis team workers and
physiotherapists, can be the main and/or only service providers. When a physician is not the
main service provider, documentation from allied health professionals may be used to select the
main problem. When a physician is the main service provider, documentation from allied health
professionals may be used for other problem code selection.
It is optional to assign a code as an other problem for a diagnosis listed only on a death
certificate, history and physical or pre-operative anesthetic consult, unless that diagnosis
meets the definition for mandatory other problem (OP) assignment.
Conditions documented in nurses’ notes, pathology reports, medication profiles, radiological

investigations, nuclear imaging and other similar investigations are valuable tools when they
clearly add specificity in identifying the appropriate diagnosis code for conditions documented in
the physician/primary care provider notes.
22
NACRS-only directive statements

N Determine the main problem from the documentation by identifying either
• The definitive (formulated) diagnostic statement;
• A symptom, sign or abnormal test result in the absence of a definitive diagnostic statement; or
• The specific reason for encounter (e.g., follow-up exam, treatment, observation for suspected condition
or pre-operative assessment).
N List the main problem as the first diagnosis code on the abstract.
N Always code to the greatest degree of specificity supported by the documentation.
See also the coding standards Diagnoses of Equal Importance, Specificity and
Unconfirmed Diagnosis.
Definitive (formulated) diagnostic statement

N Example: A woman presents with hematemesis that, on investigation, is found to be due
to an acute gastric ulcer (with hemorrhage). She is taking an NSAID for an
unrelated condition. The physician documents “NSAID related gastric bleed.”
Code NACRS Cluster Code title
K25.0 MP A Gastric ulcer, acute with haemorrhage
Y45.3 OP A Other nonsteroidal anti-inflammatory drugs [NSAID]

causing adverse effects in therapeutic use
Rationale: The external cause code is mandatory to assign as an other problem

when classifying an adverse effect in therapeutic use. See also the coding
standard Adverse Reactions in Therapeutic Use Versus Poisonings.

N Assign an external cause code from Chapter XX — External causes of morbidity and mortality (V01–Y98),
mandatory, as an other problem with any condition classifiable to Chapter XIX — Injury, poisoning and
certain other consequences of external causes.
N With any accident or poisoning classifiable to W00–Y34, excluding Y06 and Y07, assign a code from U98
Place of occurrence, mandatory, as an other problem.
23
See also the coding standards External Cause Codes and Place of Occurrence.
N Example: An interior decorator falls from a ladder while painting a client’s living room.
She sustains a closed fracture to her distal humerus.

S42.490 MP Fracture of unspecified part of lower part of humerus, closed
W11 OP Fall on and from ladder
U98.0 OP Place of occurrence, home
U99.2 OP Activity, while working for an income (optional)
Symptom, sign or abnormal test result

N Example: A man who recently argued with his wife presents to the emergency department
complaining of acute dizziness. Upon examination, the physician finds elevated
blood pressure readings and notes this as the cause of the dizziness. The patient
has not been diagnosed with hypertension. Follow-up is arranged for him with his
family physician and his social worker.

R03.0 MP Elevated blood-pressure reading, without diagnosis of hypertension
Specific reason for encounter

• Follow-up examinations: See also the coding standard Admission for Follow-Up Examination.
• Encounters for specific forms of treatment such as dialysis, radiation therapy or
adjustment of prosthesis, stoma appliances and pacemakers: Assign codes from
Chapter XXI — Factors influencing health status and contact with health services.
• Observation: See also the coding standard Admission for Observation.
• Pre-operative assessment: See also the coding standard Pre-Treatment Assessment.
24
Diagnosis Typing Definitions for DAD

In effect 2001, amended 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2012, 2015, 2018
Diagnosis typing applies to all data submitted to the Discharge Abstract Database (DAD).
The assignment of a diagnosis type to a condition is meant to signify the impact that the
condition had on the patient’s care as evidenced in the physician documentation. When the
primary responsibility for care has been designated to a certain allied health care provider
(such as a midwife or nurse practitioner), the documentation of this primary care provider is
used for code selection and determination of significance for diagnosis type assignment.
All diagnoses or conditions identified on the DAD abstract must be assigned a diagnosis type.
There are multiple diagnosis types:

• Most responsible diagnosis (type M)
• Comorbidity diagnoses (types 1 and 2)
• Secondary diagnoses (type 3)
• Admitting diagnoses (type 5)
• Proxy most responsible diagnosis (type 6)
• Service transfer diagnoses (types W, X and Y)
• External cause of injury codes (type 9)
• Diagnoses restricted to newborn abstracts only (type 0)
Diagnosis types (M), (1), (2), (6), (W), (X) and (Y) are considered significant diagnosis types.
DAD-only directive statement

Assign an ICD-10-CA code, mandatory, for any diagnosis/condition meeting the definition of a
D
significant/comorbid diagnosis type (M, 1, 2, 6, W, X and Y).
Definition of comorbidity
A comorbidity is defined as a condition that coexists in addition to the MRDx at the time of admission
or that develops subsequently and meets at least one of the three criteria for significance.
Note
For the purpose of submitting data to the Discharge Abstract Database (DAD), the term “comorbidity” refers
to diagnosis type (1) or (2) assignment.
25
Criteria for significance

The condition
1. Requires treatment beyond maintenance of the pre-existing condition;
2. Increases the length of stay (LOS) by at least 24 hours; and/or
3. Significantly affects the treatment received.
Determining when a condition meets the criteria for significance

Consider the following when determining whether a condition, documented by the physician
(or primary care provider) and relevant to the current episode of care, meets at least one of the
three criteria for significance.
• Review the source documents and look for evidence in the physician (or primary care
provider) documentation that the condition required one of the following:
- A consultation to assess a previously undiagnosed condition;
- A consultation to assess a previously diagnosed condition in which a new or amended
course of treatment is recommended and instituted (excludes a pre-operative
anesthetic assessment);
- A diagnostic or therapeutic intervention identified as mandatory for code assignment in the
coding standards Selection of Interventions to Code for Ambulatory Care and Selection of
Interventions to Code for Acute Inpatient Care; or
- A length of stay that was extended by at least 24 hours.
Note
Consultation does not have to be a formal consultation report/form — it may be documentation of a review
and assessment of the condition in the progress notes.
Note
Treatment may include transfer to another facility (e.g., another acute care inpatient facility, a day surgery
unit at another facility for an out-of-hospital [OOH] intervention) for a diagnostic or therapeutic intervention
identified as mandatory for code assignment in the coding standards.
26
Note
Documented evidence of a diagnostic investigation or an assessment, a confirmed diagnosis and a proposed
treatment plan that is not implemented per the patient’s decision to refuse treatment or due to a
contraindication do not preclude assignment of a significant diagnosis type.
• Keep the following in mind:

- Conditions documented in nurses’ notes, pathology reports, autopsy reports, medication
profiles, radiological investigations, nuclear imaging and other similar investigations are
valuable tools for identifying specificity in assigning the appropriate diagnosis code when
the diagnosis has been documented by the physician (or primary care provider). When
there is no physician (or primary care provider) documentation, conditions documented in
these reports may be captured, optionally, as a diagnosis type (3).
- Documentation of ongoing medication for treatment of a pre-existing condition does not
in itself denote significance, nor does a change in dosage of medication in and of itself
denote significance. There must be documentation of a change in the pre-existing
condition necessitating the need to change the medication dosage in order to meet the
criterion “requires treatment beyond maintenance of the pre-existing condition.”
Pre-existing conditions that do not qualify as MRDx or do not meet one of the criteria for
significance are assigned, optionally, as a diagnosis type (3).
- Diagnoses that are listed only on the front sheet, discharge summary, death certificate,
history and physical or pre-operative anesthetic consults qualify as a diagnosis type (3) —
secondary diagnosis unless there is physician (or primary care provider) documentation
elsewhere in the chart to support that the condition met at least one of the three criteria
for significance.
- Other coding standards provide direction to assign a significant diagnosis type for a certain
condition (under specific circumstances). For example, see also these coding standards:
o Drug-Resistant Microorganisms
o Acute Coronary Syndrome (ACS)
o Pneumonia in Patients With Chronic Obstructive Pulmonary Disease (COPD)
o Misadventures During Surgical and Medical Care
o Palliative Care
o Medical Assistance in Dying
27
Diagnosis type (M) — Most responsible diagnosis1

Diagnosis type (M) is the one diagnosis or condition that can be described as being
most responsible for the patient’s stay in hospital. If there is more than one such condition,
the one held most responsible for the greatest portion of the length of stay or greatest use of
resources (e.g., operating room time, investigative technology) is selected.
• If no interventions were performed, select the first-listed diagnosis as the most responsible
diagnosis (MRDx).
• If no definite diagnosis was made, select the main symptom, abnormal finding or problem as
the MRDx.
Diagnosis type (1) — Pre-admit comorbidity

A diagnosis type (1) represents a condition that existed prior to admission, has been assigned an
ICD-10-CA code and has been determined to meet at least one of the three criteria for significance.
Diagnosis type (2) — Post-admit comorbidity

A diagnosis type (2) represents a condition that arose post-admission, has been assigned an
ICD-10-CA code and has been determined to meet at least one of the three criteria for significance.
If a post-admit comorbidity qualifies as the MRDx, it must be recorded as both the MRDx and as
a diagnosis type (2).
Prefixes 5 and 6
Prefixes 5 and 6 describe the chronological relationship between a diagnosis type (2)
(post-admit comorbidity) and the first qualifying intervention occurring in
• The main operating room (OR) at the reporting facility; or
• The cardiac catheterization room at the reporting facility; or
• Another facility (out of hospital [OOH]) for selected cardiac interventions:
- 3.IP.10.^^ Xray, heart with coronary arteries;
- 1.IJ.50.^^ Dilation, coronary arteries; and/or
- 1.IJ.57.^^ Extraction, coronary arteries.
Note
For details related to the intervention location code and out-of-hospital (OOH) indicator, see Group 11 in the
Discharge Abstract Database (DAD) Abstracting Manual.
28
DAD-only directive statements

D Assign prefix 5, mandatory, to a diagnosis type (2) (post-admit comorbidity) that arose before the first
qualifying intervention.
D Assign prefix 6, mandatory, to a diagnosis type (2) (post-admit comorbidity) that arose during or after the
first qualifying intervention.
Exception
Prefixes 5 and 6 do not apply to obstetrical conditions classified in Chapter XV — Pregnancy, childbirth and
the puerperium (O00–O99).
Note
Prefixes 5 and 6 apply to acute care inpatients only.
Prefixes 5 and 6 take precedence over diagnosis prefixes Q (query diagnosis) and C (cause of death) or
facility-defined diagnosis prefixes.
29
Assigning prefixes 5 and 6 to a DAD inpatient abstract

The following flowchart describes the time frame of the post-admit comorbidity (diagnosis type 2)
to the first qualifying intervention episode.
NO
Is this a DAD acute Prefix 5 and 6
care inpatient abstract? do not apply
YES
Is there at least one post-admit NO

comorbidity (diagnosis type 2) on Prefix 5 and 6
abstract (excludes OBS codes do not apply
O00–O99)?
YES
Is there at least
one qualifying intervention
on the abstract (intervention performed NO
in main operating room [location 01] Prefix 5 and 6
or cardiac catheterization room do not apply
[location 08] or an OOH
intervention from 3.IP.10,
1.IJ.50 or 1.IJ.57)?
YES Did this post-admit YES

comorbidity arise before
Assign prefix 5
the first qualifying
intervention episode?
For each post-admit
comorbidity (diagnosis type 2)
on the abstract, establish
whether this condition arose
before or after the first
qualifying intervention episode
(the qualifying intervention
episode with the earliest start
date) and assign prefix 5 or
6 accordingly.
Did this post-admit YES
comorbidity arise during
Assign prefix 6
or after the first qualifying
intervention episode?
30
D Example: On the day of admission, a patient has a bronchoscopy performed in the endoscopy
suite for ongoing respiratory symptoms and abnormal radiological findings.
Following bronchoscopy, the patient develops cardiac dysrhythmia requiring
observation and treatment by cardiology service. On day 6, an open lung biopsy
is performed in the main OR, following which the patient develops persistent
post-operative atelectasis treated with physiotherapy and bronchodilators.
Prefix Code DAD Cluster Code title
5 I49.9 (2) A Cardiac arrhythmia, unspecified
— Y83.8 (9) A Other surgical procedures as the cause of abnormal

reaction of the patient, or of later complication, without
mention of misadventure at the time of the procedure
6 J98.10 (2) B Atelectasis
— Y83.8 (9) B Other surgical procedures as the cause of abnormal

Rationale: The first qualifying intervention in this example is the open lung biopsy
performed in the main OR. Prefix 5 is assigned to the post-admit
comorbidity that arose before the first qualifying intervention. Prefix 6
is assigned to the post-admit comorbidity that arose after the first
qualifying intervention.
D Example: A patient delivers by Cesarean section for obstructed labor due to breech presentation
of the baby. Prior to discharge, a Cesarean wound dehiscence is diagnosed.
Prefix Code DAD Code title
— O64.101 (M) Obstructed labour due to breech presentation, delivered,

with or without mention of antepartum condition
— O90.002 (2) Disruption of caesarean section wound, delivered, with

mention of postpartum complication
— Z37.000 (3) Single live birth, pregnancy resulting from both

spontaneous ovulation and conception
Rationale: Prefixes 5 and 6 do not apply to obstetrical codes.
31
Diagnosis type (3) — Secondary diagnosis

A diagnosis type (3) is a secondary diagnosis or condition for which a patient may or may
not have received treatment, that has been assigned an ICD-10-CA code and that does not
meet any of the three criteria for significance.
Diagnosis type (3) is also used for ICD-10-CA codes that are assigned to provide detail but that
in themselves do not represent a condition. Examples include the following:
• B95–B98 Bacterial, viral and other infectious agents

• Sequelae of . . . (B90–B94, E64, E68, G09, I69, O94, O97,T90–T98)
• Z22.30– Carrier of drug-resistant microorganism
• Z37 Outcome of delivery
• Z80–Z84 Family history of . . .
• Z85–Z88 Personal history of . . .
Note
Diagnosis type (3) is not allowed when the entry code is N — Newborn.
Direction pertaining to the assignment of diagnosis type (3) is found throughout the coding
standards. Direction may be specified as mandatory or optional.
CIHI recommends that any decision regarding optional diagnosis type (3) assignment be made
at the jurisdiction or facility level, based on data needs and in consultation with stakeholders
responsible for overseeing coding and data quality.
Jurisdiction-wide or facility-mandated direction ensures consistent capture of optional diagnosis

type (3) codes. Unless a diagnosis type (3) code is consistently captured by all coders at the
jurisdiction or facility level (i.e., not on an individual coder basis), it is not reliable or valid for use.
The assignment of optional diagnosis type (3) codes, which has not been mandated by CIHI or
by a jurisdiction or facility, creates unnecessary coder burden.
See Appendix F1 — References to mandatory diagnosis type (3)/other problem in directive

statements and Appendix F2 — References to optional diagnosis type (3)/other problem in
directive statements.
32
Diagnosis type (W), (X), (Y) — Service transfer diagnosis

A service transfer diagnosis, type (W), (X) or (Y), is an ICD-10-CA code associated with the first,
second or third service transfer, respectively. The use of this diagnosis type is determined at
the jurisdictional or facility level. Service transfer diagnoses are optional, with the exception of
service transfer to alternate level of care (ALC).
Note
When a diagnosis is recorded with a service transfer diagnosis type, it is equivalent to a diagnosis type (1);
therefore, it is not necessary to repeat it on the abstract as a diagnosis type (1).
When a diagnosis is recorded as a diagnosis type (2) and also qualifies as a service transfer diagnosis type
(W), (X) or (Y), facilities choosing to capture service transfer diagnoses must record the condition twice: first,
mandatory, as a diagnosis type (2) and second, optional, as a service transfer diagnosis type (W), (X) or (Y).
D Example: A patient is admitted with a cerebral infarction. He has a history of severe chronic
obstructive pulmonary disease (COPD). The neurologist deems the patient ready
for discharge on day 3 of his admission. However, he begins exhibiting signs of
a cold, and a chest X-ray reveals that he has pneumonia. His respiratory status
rapidly worsens. He is started on antibiotics and requires intubation and mechanical
ventilation. He is transferred to the intensive care unit (ICU) under the service of an
internist. He is discharged 10 days later.
Code DAD Code title
J44.0 (M) Chronic obstructive pulmonary disease with acute lower

respiratory infection
J18.9 (2) Pneumonia, unspecified
I63.9 (W) or (1) Cerebral infarction, unspecified
Rationale: The cerebral infarction meets the definition of diagnosis type (1) or service
transfer diagnosis (W). Therefore, for facilities that capture service transfer
diagnoses, I63.9 is service transfer diagnosis (W). Since a service transfer
diagnosis (W), (X), or (Y) is equivalent to diagnosis type (1) it is not
necessary to repeat I63.9 as a diagnosis type (1).
33
D Example: A patient is admitted with a non-ST elevation myocardial infarction (MI). The cardiologist
deems the patient ready for discharge on day 4 of his admission. However, he begins
exhibiting respiratory distress and is diagnosed with pneumonia. He is transferred to
respirology under the care of a respirologist. He is discharged three days later.
Code DAD Code title
I21.4 (M) Acute subendocardial myocardial infarction
R94.31 (3) Abnormal cardiovascular function studies (biomarkers or

ECG) suggestive of non ST segment elevation myocardial
infarction [NSTEMI]
J18.9 (2) Pneumonia, unspecified
J18.9 (W) Pneumonia, unspecified (optional)
Rationale: The pneumonia meets the criteria for diagnosis type (2). For those
facilities choosing to capture pneumonia as a service transfer diagnosis,
the code for pneumonia is repeated with a diagnosis type (W).
Diagnosis type (5) — Admitting diagnosis

Diagnosis type (5) can be used to code the admitting diagnosis when it differs from the MRDx
code. Its use is determined at the jurisdictional or facility level. Refer to the DAD Abstracting
Manual and facility policies to determine the jurisdictional or facility requirement for using this
diagnosis type.
Diagnosis type (6) — Proxy most responsible diagnosis

A diagnosis type (6) is assigned to a designated asterisk code in a dagger/asterisk convention
when the condition it represents fulfills the requirements stated in the definition for diagnosis
type (M) — MRDx. In morbidity coding, asterisk codes are manifestations of an underlying
condition and, according to the World Health Organization (WHO) rules, must be sequenced
following the code for the underlying cause. The underlying cause codes are identified with a
dagger symbol (†) in the ICD-10-CA classification. Diagnosis type (6) is used on the second
line of the diagnosis field of the abstract to indicate that the manifestation is the condition most
responsible for the patient’s stay in hospital. When the underlying condition meets the criteria
for MRDx, or when it would be difficult to delineate whether it is the underlying condition or the
manifestation that meets the criteria for MRDx, the asterisk code is assigned diagnosis type (3).
See also the coding standard Dagger/Asterisk Convention.
34
Note
Only one asterisk code is allowed as a diagnosis type (6).
D Example: A patient has advanced Crohn’s disease. He is on a maintenance dose of

medications for his regional enteritis. This time, he presents with pain, swelling
and inflammation of the lower back. He is admitted for treatment of sacroiliac joint
arthritis, a complication of the enteritis.
Code DAD Code title
K50.9† (M) Crohn’s disease, unspecified
M07.4* (6) Arthropathy in Crohn’s disease [regional enteritis]
Rationale: The arthropathy code is an asterisk code; thus it must be sequenced in

the second diagnosis location on the abstract. However, since the
arthropathy (and not the Crohn’s disease) meets the criteria for MRDx,
it is assigned diagnosis type (6). Note that K50.9 is not always a dagger
code. However, in this disease combination, the alphabetical index
directs that it be used as such with M07.4.
D Example: A patient with known systemic lupus erythematosus presents with hematuria and
fever. He is diagnosed with nephritis and admitted for treatment of his renal condition.
Code DAD Code title
M32.1† (M) Systemic lupus erythematosus with organ or system involvement
N08.5* (6) Glomerular disorders in systemic connective tissue disorders
Rationale: The glomerular disorder code is an asterisk code; thus it must be sequenced
in the second diagnosis location on the abstract. However, since the nephritis
(and not the systemic lupus erythematosus) meets the criteria for MRDx,
it is assigned diagnosis type (6).
35
D Example: A patient is admitted for meningococcal meningitis.
Code DAD Code title
A39.0† (M) Meningococcal meningitis
G01* (3) Meningitis in bacterial diseases classified elsewhere
Rationale: This patient has an infectious disorder involving the nervous system,
and a dagger/asterisk convention applies. However, since it would
be difficult to delineate whether it is the underlying condition or the
manifestation that meets the criteria for MRDx, the asterisk code is
assigned diagnosis type (3).
D Example: A patient is known to have type 1 diabetes mellitus with diabetic retinopathy.
He is admitted by an ophthalmologist for management of his retinopathy.
Code DAD Code title
E10.30† (M) Type 1 diabetes mellitus with background retinopathy
H36.0* (6) Diabetic retinopathy
Rationale: Retinopathy is an asterisk code; thus it must be sequenced in the second

diagnosis location on the abstract. However, since the retinopathy (and not the
diabetes mellitus) meets the criteria for MRDx, it is assigned diagnosis type (6).
Diagnosis type (7), (8) — Restricted to CIHI — DO NOT USE

Diagnosis type (9) — External cause of injury code
A diagnosis type (9) is an external cause of injury code (Chapter XX — External causes of morbidity
and mortality), place of occurrence code (U98.– Place of occurrence) or activity code (U99.– Activity).
Chapter XX codes are mandatory for use with codes in the range S00–T98 Injury, poisoning and
certain other consequences of external causes. Category U98 Place of occurrence is mandatory with
codes in the range W00–Y34, with the exception of Y06 and Y07; category U99 Activity is optional.
Diagnosis type (0) — Newborn

Diagnosis type (0) is restricted to newborn codes only (admit category N).
In a healthy infant for whom the MRDx is a code from category Z38 Liveborn infants according
to place of birth, any other codes entered on the newborn abstract must be diagnosis type (0).
36
Note
Diagnosis type (3) cannot be assigned to any code on a newborn’s abstract.
In an unhealthy infant for whom the MRDx is a code from the range P00–P96 or any other
code from another chapter within ICD-10-CA indicating a significant condition (i.e., any condition
that meets the criteria for significance), then Z38.– must be a diagnosis type (0). In this
circumstance, diagnosis type (0) can be used to record any additional insignificant conditions
that do not affect the newborn’s treatment or length of stay and do not satisfy the requirements
for determining when a condition meets the criteria for significance. Additional conditions that
meet the criteria for significance are assigned diagnosis type (1), (2), (W), (X) or (Y) as indicated
by the documentation in the chart.
Note
It is mandatory to assign a code from category Z38 Liveborn infants according to place of birth on a
newborn’s abstract.
A newborn is considered unhealthy and Z38.– is assigned diagnosis type (0) when a
documented condition in the newborn meets one of the criteria below.
• Required supervision and/or specific monitoring (e.g., admission to neonatal intensive care
unit [NICU]; excludes routine admission to NICU following Cesarean section);
• Put the baby’s health and/or life at risk;
• Prematurity (gestational age of the newborn less than 37 completed weeks);
• Low birth weight (less than 2,500 grams);
• Required a medical and/or surgical consultation;
• Required further investigation, for example, therapeutic or diagnostic interventions; and/or
• Requires further treatment or follow-up (beyond routine postnatal check-up) after discharge
(e.g., congenital malformations, deformations and chromosomal abnormalities).
Exception
Consultation for circumcision and/or the intervention does not qualify a newborn as unhealthy. Z41.2 Routine
and ritual circumcision, when assigned on the newborn abstract, is always a diagnosis type (0).
37
D Example: A newborn female is delivered vaginally at 34 weeks with birth weight of 2,400
grams. She is transferred to the NICU with a diagnosis of prematurity and request
for a cardiology consultation. Following consultation, she is diagnosed with a
patent ductus arteriosus (PDA), which spontaneously closes after five days.
She is discharged home at 21 days of age.
Code DAD Code title
P07.1 (M) Other low birth weight
P07.3 (1) Other preterm infants
Q25.0 (1) Patent ductus arteriosus
Z38.000 (0) Singleton, born in hospital, delivered vaginally, product of both

spontaneous (NOS) ovulation and conception
Rationale: This baby is unhealthy due to a low birth weight and PDA. See also the
coding standard Low Birth Weight and/or Preterm Infant.
D Example: A term infant is delivered by operative vaginal delivery using forceps. On the newborn
physical examination report, the physician notes that there is cephalhematoma.
Code DAD Code title
Z38.000 (M) Singleton, born in hospital, delivered vaginally, product of both

P12.0 (0) Cephalhaematoma due to birth injury
P03.2 (0) Fetus and newborn affected by forceps delivery
Rationale: The newborn is healthy, as there is no documentation indicating that the

cephalhematoma was complicated. If a code for cephalhematoma is
assigned, it must be a diagnosis type (0).
38
D Example: A newborn male is delivered vaginally at 40 weeks. On initial assessment, the

physician documents the infant as having left talipes equinovarus (club foot).
There are no consultations during the hospital stay, but the discharge note indicates
the mother is to make an appointment with an orthopedic surgeon for follow-up.
Code DAD Code title
Q66.0 (M) Talipes equinovarus

Rationale: This infant is considered an unhealthy newborn. The club foot is a

condition that will require subsequent follow-up and treatment.
D Example: A baby girl is born at term via spontaneous vaginal delivery with a birth weight of
3,928 grams. It is documented in the chart that the infant’s discharge was delayed
because the mother developed a postpartum fever and required further investigation
and treatment. The mother continued breastfeeding and caring for the baby.
Code DAD Code title

Rationale: This is a healthy infant even though there was a prolonged length of
stay. An additional code to describe the extended length of stay would
depend on physician documentation.
39
More examples of diagnosis typing for comorbid and

secondary conditions
D Example: A patient is admitted for inguinal hernia repair. The discharge summary states that he has
chronic atrial fibrillation and is on digoxin, propranolol and long-term Coumadin. The post-op
orders are to hold warfarin tonight, give warfarin 2.5 mg tomorrow morning and evening, and
check INR daily for three days. While in hospital, the patient has a cardiology consult, and his
digoxin and propranolol medications are adjusted. The discharge summary also states that
the patient was kept in the ICU for 24 hours to monitor his atrial fibrillation closely.
Code DAD Code title
K40.9 (M) Unilateral or unspecified inguinal hernia, without obstruction

or gangrene
I48.02 (1) Chronic atrial fibrillation
Rationale: Atrial fibrillation is a pre-admit comorbidity, as it met at least one of the

criteria for significance. Atrial fibrillation required treatment beyond
maintenance of the pre-existing condition; it warranted a consult,
amended course of treatment and admission to ICU.
D Example: A patient is admitted with a non-Q-wave MI. It states in the history and physical that he
has osteoarthritis and pain in his left knee. While recovering in hospital, an X-ray of his
left knee is done, but no treatment is undertaken and there is no further documentation.
Code DAD Code title
R94.38 (3) Other and unspecified abnormal results of cardiovascular function studies
M17.9 (3) Gonarthrosis, unspecified (optional)
Rationale: The physician has documented osteoarthritis in the history and physical.
A simple X-ray was taken to assess a previously diagnosed condition, but
there was no treatment beyond maintenance of this pre-existing condition.
There was also no additional documentation indicating the condition
prolonged the stay. If assigned, M17.9 is recorded as a diagnosis type (3).
A code from subcategory R94.3– as a diagnosis type (3) is mandatory with a
diagnosis from category I21. Since there is no documentation in this example
to support the selection of R94.30 or R94.31, the code R94.38 is assigned.
40
D Example: A patient is admitted with congestive heart failure (CHF) and an acute exacerbation
of COPD. Treatment and progress is documented in the discharge summary and
progress notes. He is treated with IV Lasix, oxygen and local pharmacotherapy
(Ventolin and Combivent). He recovers quickly. Hypokalemia is documented in
the physician’s progress notes, and the patient is kept in hospital for an additional
24 hours to deliver KCL boluses × 2. The patient is sent home on KCL elixir p.o.
Code DAD Code title
I50.0 (M) Congestive heart failure
J44.1 (1) Chronic obstructive pulmonary disease with acute

exacerbation, unspecified
E87.6 (2) Hypokalaemia
Rationale: J44.1 is a diagnosis type (1) because it was present prior to the patient’s
admission, and both the discharge summary and the progress notes confirm
its significance. E87.6 is a diagnosis type (2) because it was not present on
admission to hospital (post-admission comorbidity), and the progress notes
clearly reflect the increased length of stay for treatment and stabilization.
D Example: A patient is admitted with CHF and an acute exacerbation of COPD. She is treated
with IV Lasix, oxygen and local pharmacotherapy (Ventolin and Combivent).
Treatment for the CHF and COPD and the patient’s response are clearly
documented in the progress notes. She recovers quickly, but low potassium is noted
on a lab report, and an order for a KCL bolus is given. Following this, her potassium
level returns to normal. There is no mention of hypokalemia in the progress notes.
Code DAD Code title

J44.1 (1) Chronic obstructive pulmonary disease with acute

Rationale: Unless hypokalemia is documented by the physician, no code is assigned.
41
D Example: A patient is admitted with an upper gastrointestinal (GI) hemorrhage. On admission, the
physician documents that the hemoglobin is low. An upper GI endoscopy is performed.
An acute duodenal ulcer with perforation is diagnosed and repaired. During the episode
of care, the patient’s hemoglobin is monitored, and anemia is documented throughout
the stay. On day 3 of the admission, the physician recommends that the patient have a
blood transfusion. The patient refuses the blood transfusion and opts for “wait and see”
management. The final diagnosis is documented as acute duodenal ulcer with
hemorrhage and anemia due to acute blood loss.
Code DAD Code title

K26.2 (M) Duodenal ulcer, acute with both haemorrhage and perforation
D62 (1) Acute posthaemorrhagic anaemia
Rationale: D62 is a diagnosis type (1) because it was present on admission and the
physician’s documentation and proposed treatment plan (i.e., blood transfusion)
confirm its significance. Therefore, even though it is not treated, based on the
documentation, it is significant in the context of this episode of care.
D Example: A term patient with gestational diabetes presents in labor. Resources at the facility
are limited; therefore, arrangements are made to transfer the patient to the care of
an obstetrician at another facility. However, while waiting for the ambulance, after 90
minutes of labor, she delivers a baby boy, manually assisted without episiotomy.
She sustains a third-degree laceration of the perineum. She is transferred via
ambulance to the other facility for repair of the third-degree laceration.
Code DAD Code title

O24.801 (M) Diabetes mellitus arising in pregnancy (gestational), delivered,
O70.291 (1) Third degree perineal laceration during delivery, unspecified type,
delivered, with or without mention of antepartum condition
O62.301 (1) Precipitate labour, delivered, with or without mention of

antepartum condition
Z37.000 (3) Single live birth, pregnancy resulting from both spontaneous
ovulation and conception
Rationale: The third-degree perineal laceration was not repaired at the reporting facility
during this episode of care. However, the patient was transferred to another
facility for the repair. Therefore, the third-degree laceration qualifies as a
diagnosis type (1) because a therapeutic intervention identified as mandatory
for code assignment in the coding standards was performed.
42
Diagnosis Cluster
In effect 2012, amended 2015, 2018
A diagnosis cluster is a group of two or more ICD-10-CA codes that relate to one another.
Assigning the same diagnosis cluster character (uppercase alpha character A to Y) to each of
the codes in the cluster is the mechanism that links these codes together on the abstract.
DAD and NACRS directive statements
DN
Apply a diagnosis cluster, mandatory, when a code from the following categories is assigned:
• External causes related to complications of medical and surgical care (Y40–Y84); and
• Resistance to antibiotics (U82 and U83) and other antimicrobial drugs (U84).
DN Assign the same diagnosis cluster character (uppercase alpha character A to Y) to all codes within the same
diagnosis cluster.
Note
Ensure application of a diagnosis cluster is used only for adverse effects in therapeutic use (Y40–Y59),
post-intervention conditions (Y60–Y84) and infections from drug-resistant microorganisms (U82–U84).
Application of a diagnosis cluster in any other circumstance is not permitted.
Note
When there are two or more diagnosis clusters on the abstract, each must make use of a different uppercase
alpha character A to Y for the codes within the cluster.
Note
There is no limit to the number of codes assigned to the same diagnosis cluster.
Note
The diagnosis type for each code within a cluster is based on the diagnosis typing/problem definitions and/or
directions found in another coding standard.
43
Note
For more information about diagnosis clusters, see Group 10, Field 03 in the Discharge Abstract Database
(DAD) Abstracting Manual and data element 127 in the National Ambulatory Care Reporting System (NACRS)
Abstracting Manual.
Creating a diagnosis cluster for drug-resistant

microorganism infections
Note
The purpose of the diagnosis cluster for a drug-resistant microorganism infection is to link resistance to a
specific drug with the microorganism and the infection site with which the drug resistance is associated.
Create one diagnosis cluster for
• A single infection associated with a drug-resistant microorganism; or
• Two or more infections associated with the same drug-resistant microorganism.
Create two or more diagnosis clusters when there is more than one infection and each is associated with a
different drug-resistant microorganism.
The set of codes in the drug-resistant microorganism diagnosis cluster identifies the
• Type of drug resistance (U82–U84);
• Infectious organism; and
• Infection site or sites.
See also the coding standard Drug-Resistant Microorganisms.
44
DN Example: A patient presents to hospital with septic arthritis of the left shoulder that is MRSA
positive. Arthroscopy is performed to thoroughly irrigate and debride the shoulder.
Code DAD NACRS Cluster Code title
M00.01 (M) MP A Staphylococcal arthritis and polyarthritis,

shoulder region
B95.6 (3) OP A Staphylococcus aureus as the cause of diseases

classified to other chapters
U82.1 (1) OP A Resistance to methicillin
Rationale: Application of a diagnosis cluster is mandatory for drug-resistant

microorganism infections. The same diagnosis cluster character is
assigned to all codes describing the single drug-resistant microorganism
infection. Diagnosis cluster A links the drug resistance (methicillin) to
the related microorganism (staph aureus) and infection site (shoulder).
(This example demonstrates the use of one diagnosis cluster for a
single infection associated with a drug-resistant microorganism.)
DN Example: A patient is admitted with a urinary tract infection (UTI) and pneumonia, both of
which are due to staphylococcus aureus that is resistant to methicillin.
J15.2 (M) MP A Pneumonia due to Staphylococcus
N39.0 (1) OP A Urinary tract infection, site not specified


microorganism infections. The same diagnosis cluster character is
assigned to all codes describing the two infections that are associated
with the same drug resistance. Diagnosis cluster A links the drug
resistance (methicillin) to the related organism (staph aureus) and
infection sites (lung and urinary tract). (This example demonstrates the
use of one diagnosis cluster for two or more infections associated with
the same drug-resistant microorganism.)
45
Creating a diagnosis cluster for post-intervention conditions

Note
The purpose of the diagnosis cluster for a post-intervention condition is to link the external cause code
denoting the nature of the post-intervention condition with the condition(s) with which that complication of
surgical and medical care is associated.
The nature of the post-intervention condition pertains to the type of post-intervention condition, per the
external cause code that is assigned. Each post-intervention condition is
• A misadventure (Y60–Y69);
• An adverse incident associated with a medical device (Y70–Y82); or
• An abnormal reaction/later complication (Y83–Y84).
Note: Y83–Y84 includes both abnormal reactions and later complications.
• A single post-intervention condition; or
• Two or more post-intervention conditions of the same nature (misadventure, medical device
associated with adverse incident or abnormal reaction/later complication) that are related to the
same intervention episode.
Create two or more diagnosis clusters when
• There are two or more post-intervention conditions of the same nature and each is related to a different
intervention(s) within an intervention episode or different intervention episodes; and/or
• There are two or more post-intervention conditions of a different nature and each is related to the
same intervention episode.
The set of codes included in the post-intervention condition diagnosis cluster identifies the
• Nature of the complication of surgical and medical care (Y60–Y84);
• Related condition(s); and
• Additional code(s) for specificity (when required and available).
See also the coding standard Post-Intervention Conditions.
46
Note
It is mandatory to apply a diagnosis cluster each time a post-intervention condition is classified. This includes
when a post-intervention condition is captured
• During the episode of care;
• On readmission; and
• When the patient is transferred from another facility.
DN Example: A patient has a total hip replacement and is discharged. The next day, the patient
returns to the hospital with a dislocated left total hip replacement with no associated
trauma. A closed reduction is performed.
T84.031 (M) MP A Mechanical complication of hip prosthesis, instability
Y83.1 (9) OP A Surgical operation with implant of artificial internal

device as the cause of abnormal reaction of the patient,
or of later complication, without mention of misadventure
at the time of the procedure
Rationale: Application of a diagnosis cluster is mandatory for post-intervention

conditions. The same diagnosis cluster character is assigned to all codes
describing the single post-intervention condition. Diagnosis cluster A links
the external cause (abnormal reaction/later complication) to the related
condition (mechanical complication). (This example demonstrates the use
of one diagnosis cluster for a single post-intervention condition. It also
demonstrates the application of a diagnosis cluster when a post-intervention
condition is captured on readmission.)
47
DN Example: A patient has a carpal tunnel release and briefly exhibits mild confusion in the
recovery room, which quickly clears on its own.
G56.0 (M) MP — Carpal tunnel syndrome
R41.0 (3) OP A Disorientation, unspecified (optional)
Y83.8 (9) OP A Other surgical procedures as the cause of abnormal reaction

of the patient, or of later complication, without mention of
misadventure at the time of the procedure (optional)
Rationale: Application of a diagnosis cluster is mandatory for post-intervention conditions

regardless of diagnosis type assignment. The post-operative confusion does not
meet the criteria for significance in this case. If it is captured, it is assigned
diagnosis type (3). The same diagnosis cluster character is assigned to all codes
describing the single post-intervention condition. Diagnosis cluster A links the
external cause (abnormal reaction/later complication) to the related condition
(confusion). (This example demonstrates the use of one diagnosis cluster for a
single post-intervention condition. It also demonstrates that the diagnosis type
for each code within a cluster is based on the diagnosis typing/problem
definitions and/or direction found within another coding standard.)
DN Example: A patient is admitted for a revision arthroplasty due to metallosis, abrasion of the
metal components. The original surgery was 10 years ago.
T84.032 (M) MP A Mechanical complication of hip prosthesis, wear of articular

bearing surface
Y83.1 (9) OP A Surgical operation with implant of artificial internal device as

the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time of
the procedure
Rationale: Application of a diagnosis cluster is mandatory for post-intervention conditions

regardless of when the intervention took place. The same diagnosis cluster
character is assigned to all codes describing the single post-intervention
condition. Diagnosis cluster A links the external cause (abnormal reaction/later
complication) to the related condition (mechanical complication). (This example
demonstrates the use of one diagnosis cluster for a single post-intervention
condition. It also demonstrates the application of a diagnosis cluster when a
post-intervention condition is captured on readmission.)
48
D Example: The patient is admitted for a partial excision of the colon due to cancer. During the
intervention, an accidental tear to the spleen results in an unplanned splenectomy.
The patient also has ongoing issues with hypotension post-operatively.
Code DAD Cluster Code title
C18.9 (M) — Malignant neoplasm colon, unspecified
T81.2 (2) A Accidental puncture and laceration during a procedure, not

elsewhere classified
S36.091 (3) A Haematoma NOS, laceration NOS, injury to spleen NOS, with open
wound into cavity
Y60.0 (9) A Unintentional cut, puncture, perforation or haemorrhage, during

surgical operation
I95.9 (2) B Hypotension, unspecified
Y83.9 (9) B Surgical procedure, unspecified as the cause of abnormal

reaction of the patient, or of later complication, without mention
of misadventure at the time of the procedure

conditions. Since there are post-intervention conditions related to the
same intervention episode that are of different natures, two diagnosis
clusters are applied; each makes use of a different uppercase alpha
character. Diagnosis cluster A links the external cause (misadventure) to
the related condition (accidental laceration) and the additional code for
specificity (laceration of spleen). Diagnosis cluster B links the external
cause (abnormal reaction/later complication) to the related condition
(hypotension). (This example demonstrates the use of two or more
diagnosis clusters for post-intervention conditions of a different nature
[misadventure and abnormal reaction/later complication] that are related
to the same intervention episode.)
49
D Example: A patient undergoes a vaginal hysterectomy for uterovaginal prolapse. On the

second day following the intervention, she is diagnosed with urinary retention
and atelectasis requiring further treatment and monitoring. An indwelling urinary
catheter was inserted at the end of surgery, and the patient subsequently
develops catheter-related cystitis.
N81.4 (M) — Uterovaginal prolapse, unspecified
R33 (2) A Retention of urine
J98.10 (2) A Atelectasis
Y83.6 (9) A Removal of other organ (partial) (total) as the cause of abnormal
reaction of the patient, or of later complication, without mention of
misadventure at the time of the procedure
T83.5 (2) B Infection and inflammatory reaction due to prosthetic device, implant
and graft in urinary system
N30.0 (3) B Acute cystitis
Y84.6 (9) B Urinary catheterization as the cause of abnormal reaction of the

patient, or of later complication, without mention of misadventure at
the time of the procedure

conditions. Since there are post-intervention conditions related to
different interventions, two diagnosis clusters are applied; each makes
use of a different uppercase alpha character. Diagnosis cluster A links
the external cause (abnormal reaction/later complication) to the related
conditions (retention of urine and atelectasis) associated with the same
intervention episode (hysterectomy). Diagnosis cluster B links the
external cause (abnormal reaction/later complication) to the related
condition (cystitis) associated with a different intervention episode
(catheterization). (This example demonstrates the use of two or more
diagnosis clusters for two or more post-intervention conditions of the
same nature [abnormal reaction/later complication] that are related to
different intervention episodes [hysterectomy and catheterization].)
50
D Example: A patient with primary, bilateral osteoarthritis of the knee has a total knee
replacement in Hospital A and is transferred to Hospital B one day after surgery for
convalescence. On admission to Hospital B, the patient is diagnosed with anemia,
for which she is transfused with two units of washed red blood cells.
Z54.0 (M) — Convalescence following surgery
M17.0 (3) — Primary gonarthrosis, bilateral
D64.9 (1) A Anaemia, unspecified
Y83.1 (9) A Surgical operation with implant of artificial internal device as the
cause of abnormal reaction of the patient, or of later complication,
without mention of misadventure at the time of the procedure
Rationale: The same diagnosis cluster character is assigned to all codes describing
the single post-intervention condition. Diagnosis cluster A links the
condition (anemia). (This example demonstrates the use of one
diagnosis cluster for a single post-intervention condition. It also
demonstrates the application of a diagnosis cluster when a post-
intervention condition is present on transfer during an uninterrupted
continuous episode of care.)
51
D Example: A patient with known coronary atherosclerosis is admitted for a coronary artery
bypass graft. Two days after surgery the patient suffers a cerebral infarction,
which significantly affects the length of stay and qualifies as the MRDx.
I63.9 (M) A Cerebral infarction, unspecified
I63.9 (2) A Cerebral infarction, unspecified
Y83.2 (9) A Surgical operation with anastomosis, bypass or graft as the cause
of abnormal reaction of the patient, or of later complication,
I25.10 (1) — Atherosclerotic heart disease of native coronary artery

conditions. Since the cerebral infarction is a post-admit comorbidity
that also qualifies as the MRDx, it is captured twice on the abstract; as
MRDx and as diagnosis type (2). The same diagnosis cluster character
is assigned to all codes describing the single post-intervention condition.
Diagnosis cluster A links the external cause (abnormal reaction/later
complication) to the related condition (cerebral infarction). Since there
is only one cerebral infarction associated with a single intervention
episode, the external cause code is recorded once. The same diagnosis
cluster character is applied to all three codes, thereby indicating that the
cerebral infarction occurred following the intervention and became the
MRDx. (This example demonstrates the use of one diagnosis cluster for
a single post-intervention condition that is a post-admit comorbidity and
becomes the MRDx.)
52
D Example: A patient is admitted with sepsis due to hernia repair (without tissue) performed two
weeks ago. He is treated for five days for the infection and is ready to go home
when he coughs and suffers a wound dehiscence, for which he has to be taken to
the OR for closure. He remains in hospital for another 25 days.
T81.3 (M) A Disruption of operation wound, not elsewhere classified
T81.3 (2) A Disruption of operation wound, not elsewhere classified
T81.4 (1) A Infection following a procedure, not elsewhere classified
A41.9 (3) A Sepsis, unspecified
Y83.4 (9) A Other reconstructive surgery as the cause of abnormal reaction of

the patient, or of later complication, without mention of misadventure

conditions. Although one post-intervention condition is present on
admission and the other arises following admission, both the sepsis and
the wound dehiscence are of the same nature (abnormal reaction/later
complication) and are related to the same intervention episode (hernia
repair); thus only one diagnosis cluster is applied. The same diagnosis
cluster (A) is assigned to all codes describing the post-intervention
conditions. (This example demonstrates the use of one diagnosis
cluster for two or more post-intervention conditions of the same
nature [abnormal reaction/later complication] that relate to the same
intervention episode even when one is present on admission [pre-admit
comorbidity] and another arises following admission [post-admit
comorbidity]. It also demonstrates the application of a diagnosis
cluster for a post-admit comorbidity that becomes the MRDx.)
53
D Example: The patient is admitted for evaluation of deep, painful abscesses on the back of her
neck. She also has a fever and abdominal pain. Culture and sensitivity of the pus
taken from the boils show that it is MRSA. She is placed in isolation. Ultrasound of
the abdomen reveals appendicitis, and an appendectomy is performed. Surgical
drainage of the neck abscess is done during the same operative episode. Post-
appendectomy, the patient has an infection of the incision site, which is treated.
K35.8 (M) — Acute appendicitis, other and unspecified
L02.1 (1) A Cutaneous abscess, furuncle and carbuncle of neck
B95.6 (3) A Staphylococcus aureus as the cause of diseases classified to

other chapters
U82.1 (1) A Resistance to methicillin
T81.4 (2) B Infection following a procedure, not elsewhere classified
Y83.6 (9) B Removal of other organ (partial) (total) as the cause of abnormal
reaction of the patient, or of later complication, without mention of

microorganism infections and post-intervention conditions. Diagnosis
cluster A links the drug resistance (methicillin) to the related organism
(staphylococcus aureus) and infection site (cutaneous abscess).
Diagnosis cluster B links the external cause (abnormal reaction/later
complication) to the related condition (wound infection). (This example
demonstrates the use of separate diagnosis clusters for a single
infection associated with drug resistance and a single post-intervention
condition when neither of the conditions relates to one another.)
54
D Example: This patient previously had a partial colectomy with anastomosis performed for
colon cancer. The patient is readmitted with an infection of the abdominal incision,
which is positive for MRSA. The wound infection is successfully treated and the
patient is discharged home.
T81.4 (M) A Infection following a procedure, not elsewhere classified
B95.6 (3) A Staphylococcus aureus as the cause of diseases classified to

other chapters
Y83.2 (9) A Surgical operation with anastomosis, bypass or graft as the cause
of abnormal reaction of the patient, or of later complication,

microorganism infections and post-intervention conditions. Diagnosis
cluster A links the external cause (abnormal reaction/later complication)
to the related condition (MRSA wound infection). (This example
demonstrates the use of one diagnosis cluster for a single post-intervention
condition that involves an infection associated with drug resistance.)
55
D Example: The patient is admitted for removal and replacement of an infected knee prosthesis
that was implanted six months ago. Following the revision procedure, the patient
develops pneumonia and remains in hospital for six more days.
T84.54 (M) A Infection and inflammatory reaction due to knee prosthesis
J18.9 (2) B Pneumonia, unspecified
Y83.1 (9) B Surgical operation with implant of artificial internal device as the

conditions. Diagnosis cluster A links the external cause (abnormal
reaction/later complication) to the related condition (infection of knee
prosthesis) following the insertion of the knee joint prosthesis. Diagnosis
cluster B links the external cause (abnormal reaction/later complication) to
the related condition (pneumonia) following the revision of the knee joint
prosthesis. The two identical external cause codes (Y83.1) reflect that
there are two different intervention episodes with one or more related
post-intervention conditions. (This example demonstrates the use of two
or more diagnosis clusters for two or more post-intervention conditions of
the same nature [abnormal reaction/later complication] that are related
to different intervention episodes [insertion of knee prosthesis and
replacement of knee prosthesis] even when the external cause code
for the different episodes is the same.)
56
D Example: A trauma patient is admitted and taken emergently to the OR, where he undergoes
repair of a large laceration on the arm, partial resection with primary anastomosis
of the small bowel related to his injury and application of an external fixator to an
open fracture of the tibia (intervention episode 1). On day 3, the patient develops
respiratory failure. On day 10, he is taken back to the OR for tracheostomy
(intervention episode 2). The following day, he returns to the OR for control of
hemorrhage around the tracheostomy site (intervention episode 3). On day 13,
the patient develops post-operative renal failure.

J95.2 (2) A Acute pulmonary insufficiency following nonthoracic surgery
Y83.9 (9) A Surgical procedure, unspecified, as the cause of abnormal reaction

T81.0 (2) B Haemorrhage and haematoma complicating a procedure,

not elsewhere classified
Y83.3 (9) B Surgical operation with formation of external stoma as the cause of
abnormal reaction of the patient, or of later complication, without
N99.0 (2) C Postprocedural renal failure
N17.9 (3) C Acute renal failure, unspecified
Y83.9 (9) C Surgical procedure, unspecified, as the cause of abnormal reaction


conditions. Diagnosis cluster A links the external cause (abnormal
reaction/later complication) to the related condition (respiratory failure)
following the first intervention episode in which multiple types of
interventions were performed (Y83.9). Diagnosis cluster B links the
condition (hemorrhage around tracheostomy site), which is clearly
related to the tracheostomy intervention episode. In this example, since
it is unknown to which intervention episode the renal failure pertains
(or whether it is a cumulative effect), a third diagnosis cluster (C) is
necessary, as this post-intervention condition cannot be included in a
diagnosis cluster identifying a post-intervention condition that is related
to a given intervention episode.
57
Noteworthy is that the two identical external cause codes (Y83.9) in two
separate diagnosis clusters have different meanings. The first Y83.9
represents a single intervention episode during which there were
different types of interventions performed. The second Y83.9 represents
multiple intervention episodes where different types of interventions
were performed.
(This example demonstrates the use of multiple diagnosis clusters when

all of the post-intervention conditions are of the same nature [abnormal
reaction/later complication] and some are clearly related to different
intervention episodes [intervention episode 1 and intervention episode 2]
while for another the related intervention episode is unknown [unknown
whether related to intervention episode 1, 2 or 3 or a combination of these].)
Creating a diagnosis cluster for adverse effects in

therapeutic use
Note
The purpose of the diagnosis cluster for adverse effects in therapeutic use is to link one or more drugs,
medicaments or biological substances causing one or more adverse effects to the specific adverse effects
with which they are associated.
• A single adverse effect of a drug, medicament or biological substance in therapeutic use; or
• Two or more adverse effects resulting from the same drug, medicament or biological substance in
therapeutic use; or
• One or more adverse effects resulting from a combination of drugs, medicaments or biological substances in
therapeutic use.
Create two or more diagnosis clusters when there are two or more adverse effects that are the result of a
different drug, medicament or biological substance in therapeutic use.
The set of codes included in the adverse effect in therapeutic use diagnosis cluster identifies the
• Drug(s), medicament(s) or biological substance(s) causing the adverse effect (Y40–Y59); and
• Adverse effect(s).
See also the coding standard Adverse Reactions in Therapeutic Use Versus Poisonings.
58
D Example: A patient is admitted for treatment of chemotherapy-induced neutropenia. The patient

is receiving a combination of chemotherapy agents, as an outpatient, for treatment of
cancer of the left lower lobe of the lung.
D70.0 (M) A Neutropenia
Y43.3 (9) A Other antineoplastic drugs causing adverse effects in

therapeutic use
C34.31 (3) — Malignant neoplasm of lower lobe, left bronchus or lung
Rationale: Application of a diagnosis cluster is mandatory for adverse effects in

therapeutic use. The same diagnosis cluster character is assigned to all
codes describing the single adverse effect from one drug in therapeutic
use. Diagnosis cluster A links the drug causing the adverse effect
(antineoplastic drugs) to the related adverse effect (neutropenia).
(This example demonstrates the use of one diagnosis cluster for
a single adverse effect of a single drug in therapeutic use.)
N Example: A patient presents to hospital with hives and swelling of the face. The patient has been
taking Keflex to treat a UTI for the past 24 hours. The discharge diagnosis is drug
reaction. The patient is advised to stop the Keflex, and a new antibiotic is introduced.
L50.0 MP A Allergic urticaria
R22.0 OP A Localized swelling, mass and lump, head
Y40.1 OP A Cefalosporins and other ß-lactam antibiotics causing adverse

effects in therapeutic use

therapeutic use. Diagnosis cluster A links the drug causing the adverse
effect (cephalosporin antibiotics) to the related adverse effects (urticaria
and localized swelling). (This example demonstrates the use of one
diagnosis cluster for two or more adverse effects resulting from the
same drug in therapeutic use.)
59
D Example: The patient is admitted to hospital with ventricular tachycardia due to digoxin toxicity.
On day 3, the patient develops pneumonia and is started on amoxicillin. The patient
develops confusion that is documented as being due to the amoxicillin. The amoxicillin
is stopped, and a new antibiotic is introduced. The pneumonia extends the patient’s
stay in hospital by another eight days.
J18.9 (M) — Pneumonia, unspecified
J18.9 (2) — Pneumonia, unspecified
I47.2 (1) A Ventricular tachycardia
Y52.0 (9) A Cardiac-stimulant glycosides and drugs of similar action causing

adverse effects in therapeutic use
R41.0 (2) B Disorientation, unspecified
Y40.0 (9) B Penicillins causing adverse effects in therapeutic use

therapeutic use. Diagnosis cluster A links the one drug causing an
adverse effect (cardiac-stimulant glycosides) to the related adverse effect
(ventricular tachycardia). Diagnosis cluster B links a second drug causing
an adverse effect (penicillin) to the related adverse effect (confusion).
(This example demonstrates the use of two or more diagnosis clusters
when there are two or more adverse effects that are the result of different
drugs in therapeutic use.)
60
DN Example: The patient presents to hospital with spontaneous bruising on the skin. The patient
is on Coumadin therapy and has also been taking tetracycline to treat a UTI for the
past eight days. The discharge diagnosis is “enhanced anticoagulation effect” from
an interaction between these two drugs. The patient is advised to stop both drugs,
and a new antibiotic is introduced.
R23.3 (M) MP A Spontaneous ecchymoses
Y44.2 (9) OP A Anticoagulants causing adverse effects in therapeutic use
Y40.4 (9) OP A Tetracyclines causing adverse effects in therapeutic use

therapeutic use. Diagnosis cluster A links the combination of drugs
causing the adverse effect (anticoagulants and tetracyclines) to the
related adverse effect (spontaneous bruising [cutaneous hemorrhage]).
(This example demonstrates the use of one diagnosis cluster when there
are single or multiple adverse effects resulting from a combination of
drugs in therapeutic use.)
Diagnoses of Equal Importance1

In effect 2001, amended 2006
DAD and NACRS directive statement
DN
When two or more diagnoses of equal importance are listed with no clear indication in the health record
as to which one is the MRDx/main problem, select the condition for which a definitive (as opposed to
diagnostic) surgical or non-surgical procedure has been performed. If no surgery has been performed,
select the first-listed diagnosis as the MRDx/main problem.
61
D Example: A patient is discharged home with a diagnosis of bronchopneumonia treated with

antibiotics and upper gastrointestinal hemorrhage due to esophageal varices,
which were sclerosed, endoscopically, using a laser.
Code DAD Code title
I85.0 (M) Oesophageal varices with bleeding
J18.0 (1) Bronchopneumonia, unspecified
1.NA.13.BA-AG Control of bleeding, esophagus, using endoscopic per orifice

approach and laser
D Example: The patient has a five-day stay in hospital to further investigate and conservatively
manage her COPD with acute exacerbation and bowel obstruction.
Code DAD Code title
J44.1 (M) Chronic obstructive pulmonary disease with acute

K56.6 (1) Other and unspecified intestinal obstruction
Rationale: Both diagnoses are of equal importance. Neither was treated surgically.
COPD is selected as the MRDx because it is listed first.
62
D Example: The patient is admitted with a stroke and spends 20 days on neurology. He develops
urinary retention and is assessed by a urologist, who diagnoses benign prostatic
hyperplasia and recommends a resection of the prostate. While remaining on the
neurology service, the patient continues to receive physiotherapy and occupational
therapy for hemiplegia. He is also taken to the OR for a transurethral resection of the
prostate, which is carried out without incident.
Code DAD Code title
I64 (M) Stroke, not specified as haemorrhage or infarction
G81.99 (1) Hemiplegia of unspecified type of unspecified [unilateral] side
N40 (1) Hyperplasia of prostate
Rationale: Although the prostatic hyperplasia is the condition for which the patient
received surgical care, the stroke is still the MRDx. The stroke has
consumed more resources in terms of time and attention devoted to its
treatment. (There will not always be a direct match between the MRDx
and the principal intervention.)
N Example: An elderly female patient presents to the emergency department. She has a chest
X-ray performed and is transferred to the medical unit with the diagnoses of
pneumonia and CHF.
J18.9 MP Pneumonia, unspecified
I50.0 OP Congestive heart failure
Rationale: Pneumonia and CHF are of equal importance. As pneumonia is listed

first, it is selected as the main problem.
63
Specificity1

When one diagnosis describes a condition in general terms but a more descriptive term providing more
DN
precise information about the site or nature of the condition is reported among the other listed diagnoses,
select the most specific condition.
DN Example: The physician lists both cerebrovascular accident and cerebral hemorrhage
as diagnoses.
Code DAD NACRS Code title
I61.9 (M) MP Intracerebral haemorrhage, unspecified
Rationale: Intracerebral hemorrhage is a type of cerebrovascular accident and is

more specific; only a code for intracerebral hemorrhage is assigned.
D Example: The physician has noted that the patient developed a decubitus ulcer that is
delaying discharge (the ulcer was not present on admission). The nurse specialist
has documented the ulcer as stage 3.
Code DAD Code title
L89.2 (2) Stage III decubitus [pressure] ulcer
Rationale: Since the ulcer is documented in the physician’s notes, the nursing
documentation can be used to add specificity.
64
Using Diagnostic Test Results in Coding

DN
Use X-ray, pathology and other diagnostic results (excluding laboratory reports) when they clearly add
specificity in identifying the appropriate diagnosis code for conditions documented in the physician/primary
care provider notes.
DN Example: The patient tripped and fell in a grocery store; the physician records a closed
fracture of the neck of femur. The X-ray result shows a cervicotrochanteric fracture.
S72.010 (M) MP Fracture of base of femoral neck

(cervicotrochanteric), closed
W01 (9) OP Fall on same level from slipping, tripping

and stumbling
U98.5 (9) OP Place of occurrence, trade and service area
DN Example: The patient’s chart documentation shows that she was admitted for removal of a
skin lesion. The pathology report shows solar keratosis.
L57.0 (M) MP Actinic keratosis
DN Example: The physician has recorded the diagnosis of intracranial hemorrhage. The CT scan
confirmed subarachnoid hemorrhage.
I60.9 (M) MP Subarachnoid haemorrhage, unspecified
65
DN Example: The patient presents with signs and symptoms of a UTI and is started on a course
of treatment. The laboratory report shows Escherichia coli (E. coli). The final
diagnosis is recorded by the physician as UTI.
N39.0 (M) MP Urinary tract infection, site not specified
Rationale: Laboratory reports are not used to add specificity to a documented

condition. There must be physician documentation confirming the
causative organism of the UTI before B96.2 Escherichia coli [E. coli]
as the cause of diseases classified to other chapters can be assigned.
See also the coding standard Infections.

When a condition is suggested by diagnostic test results, assign a code only when the condition has been
DN
confirmed by physician/primary care provider documentation.
DN Example: Microbiology reports suggest a UTI, and medication reports indicate that the
patient received antibiotics. There is no documentation relating to this in the
physician notes.
Code
No code is assigned
Rationale: Clinical interpretation is required to confirm the diagnosis.
DN Example: A patient has lower abdominal pain. A CT scan reveals adhesions of the abdomen,
but there is no documentation in physician notes identifying the adhesions as the
cause of the pain.
R10.39 (M) MP Lower abdominal pain, unspecified
Rationale: Clinical interpretation is required to confirm the cause of the pain.
66
Dagger/Asterisk Convention2
In ICD-10-CA, the dagger symbol (†) is used to indicate a code that represents the etiology or
underlying cause of a disease. The asterisk symbol (*) is used to indicate a code that represents
the manifestation of a disease.

DN Assign an asterisk code whenever indicated in ICD-10-CA.

D Assign diagnosis type (6) or diagnosis type (3) to asterisk codes in accordance with the diagnosis typing
definitions (see also the coding standard Diagnosis Typing Definitions for DAD).
In the tabular portion of the classification, the dagger represents the different applications of the
convention stipulated by the WHO, as shown below:
(i) If the dagger symbol and asterisk code both appear in the code title, all terms classifiable to
that code are subject to dual classification and all have the same alternative code.
Example
A17.0† Tuberculous meningitis (G01*)

Tuberculosis of meninges (cerebral) (spinal)
Tuberculous leptomeningitis
(ii) If the dagger symbol appears in the code title but the asterisk code does not, all terms
classifiable to that code are subject to dual classification, but they have different asterisk
codes (which are listed for each term).
Example
A18.0† Tuberculosis of bones and joints
Tuberculosis of:
• hip (M01.1*)
• knee (M01.1*)
• vertebral column (M49.0*)
67
Tuberculosis:
• arthritis (M01.1*)
• mastoiditis (H75.0*)
• necrosis of bone (M90.0*)
• osteitis (M90.0*)
• osteomyelitis (M90.0*)
• synovitis (M68.0*)
• tenosynovitis (M68.0*)
(iii) If neither the dagger symbol nor the asterisk code appears in the title, the rubric as a whole
is not subject to dual classification, but individual inclusion terms may be; if so, these terms
will be marked with the dagger symbol and their asterisk codes will be given.
Example
A54.88 Other gonococcal infections
Blenorrhagic bubo
Gonococcal:
• brain abscess † (G07*)
• dermatosis † (L99.8*)
• endocarditis † (I39.8*)
• heart disease NOS † (I52.0*)
• keratoderma † (L86*)
• keratosis † (L86*)
• lymphadenitis
• meningitis † (G01*)
• myocarditis † (I41.0*)
• pericarditis † (I32.0*)
• perihepatitis † (K67.1*)
• peritonitis † (K67.1*)
• pneumonia † (J17.0*)
• skin infection † (L99.8*)
• specified site NEC
68
(iv) In some instances, the direction to use dual classification appears in the index only.
Example
Neuropathy, neuropathic
– peripheral (nerve) (see also Polyneuropathy) G62.9
– – autonomic G90.9
– – – in (due to)
– – – – gout M10.0† G99.1*
DN Example: A patient presents for management of herpes viral meningoencephalitis.
B00.4† (M) MP Herpesviral encephalitis
G05.1* (3) OP Encephalitis, myelitis and encephalomyelitis in viral

diseases classified elsewhere
Rationale: Since both the dagger symbol and asterisk code appear in the code title,
all inclusion terms are subject to dual classification and both codes are
assigned. In this case, the asterisk code applies to encephalitis. Since it
would be difficult to delineate whether it is the underlying condition or
the manifestation that meets the criteria for MRDx, the asterisk code is
DN Example: A patient is seen for meningococcal pericarditis.

A39.5† (M) MP Meningococcal heart disease
I32.0* (3) OP Pericarditis in bacterial diseases classified elsewhere
Rationale: The dagger symbol appears in the code title, making all terms
classifiable to A39.5 subject to dual classification, but the asterisk codes
vary depending on the condition. Since it would be difficult to delineate
whether it is the underlying condition or the manifestation that meets the
criteria for MRDx, the asterisk code is assigned diagnosis type (3).
69
DN Example: A patient is seen for balanitis due to an amebic infection.
A06.8† (M) MP Amoebic infection of other sites
N51.2* (3) OP Balanitis in diseases classified elsewhere
Rationale: Neither the dagger symbol nor the asterisk symbol appears in the code
title. Only the inclusion term “balanitis” is subject to dual classification, in
which case A06.8 becomes a dagger code and N51.2 is the corresponding
asterisk code. The dagger/asterisk convention does not apply to amebic
appendicitis. Since it would be difficult to delineate whether it is the
underlying condition or the manifestation that meets the criteria for
MRDx, the asterisk code is assigned diagnosis type (3).
DN Example: A patient has carcinoma of the lung and has developed anemia as a result of her
neoplastic disease. She is admitted for management of the anemia.
C34.99† (M) MP Malignant neoplasm bronchus or lung, unspecified,

unspecified side
D63.0* (6) OP Anaemia in neoplastic disease
Rationale: In this case, the alphabetical index directs the coder to D48.9 and
D63.0*. This indicates that the code to describe the patient’s neoplastic
disorder becomes a dagger code. D48.9 is assigned when the neoplasia
is unspecified. Since it is specified in this example, the more specific
neoplasia code is the dagger code. Note that the full range of codes
C00–D48 are identified as dagger codes following the code title at D63.0
in the tabular listing. D63.0 is an asterisk code, so it must be sequenced
in the second diagnosis location on the abstract. However, since it is the
condition that meets the criteria for MRDx (and not the malignancy of the
lung), it is assigned diagnosis type (6).
70
DN Example: The patient’s discharge diagnosis is hemolytic uremic syndrome encephalopathy.
Code Code title
D59.3 Haemolytic-uraemic syndrome
G93.4 Encephalopathy, unspecified
Rationale: There is no dagger/asterisk convention applied to this disorder.

Each condition is classified separately. Diagnosis type and sequence
will depend on circumstances documented in the record.
Acute and Chronic Conditions3

DN
When a condition is described as being both acute (or subacute) and chronic, and ICD-10-CA provides
separate categories or subcategories for each but not for the combination, assign a code for the
acute condition.
• Assign a code for the chronic condition, optional, as a diagnosis type (3)/other problem.
DN
When an appropriate combination code is provided for both the acute and chronic condition,
assign only the combination code.
Exception
It is mandatory to assign a code for chronic kidney disease when a patient has acute kidney injury and chronic
kidney disease. See also the coding standard Acute on Chronic Kidney Disease.
DN Example: A patient is admitted for a total cholecystectomy because of chronic cholecystitis.

The physician noted in the discharge summary that acute and chronic cholecystitis
were noted on the pathology report.
K81.0 (M) MP Acute cholecystitis
K81.1 (3) OP Chronic cholecystitis
71
DN Example: The patient is admitted to hospital with a diagnosis of acute exacerbation of COPD.
J44.1 (M) MP Chronic obstructive pulmonary disease with acute


A condition described as recurrent cannot be assumed to be chronic. Follow the alphabetical index for a
DN sub-term of “recurrent.” If no sub-term exists for “recurrent,” classify the condition to the NOS category.
Exception
When a patient is admitted for tonsillectomy with a diagnosis of “recurrent” tonsillitis, select the code for
chronic tonsillitis.
Impending or Threatened Conditions

DN
Assign a code for impending or threatened conditions only when indexed as such in ICD-10-CA.
DN Example: The patient has a stage 4 decubitus ulcer. Documentation within the physician’s
notes states “impending gangrene.”
L89.3 (M) MP Stage IV decubitus [pressure] ulcer
Rationale: In the case of impending gangrene of the leg that did not progress within
the episode of care due to prompt treatment, the coder must look for an
index entry such as “gangrene, impending.” If no index entry is found,
this case must be classified to the documented precursor condition.
72
DN Example: Threatened abortion.
O20.003 (M) MP Threatened abortion, antepartum condition

or complication
Underlying Symptoms or Conditions1

The purpose of this coding standard is to provide direction for code assignment when a patient
presents for investigation of a sign, symptom and/or abnormal finding for which there is no
documentation to support that the patient has a specific suspected condition that is being
investigated. When there is documentation that the patient is being investigated to rule out a
specific suspected condition, see the coding standard Admission for Observation.
See also the coding standard Unconfirmed Diagnosis.
DN
When a patient presents with a symptom or condition and, during that episode of care, the underlying
disease or disorder is identified, assign the underlying disease or disorder as the MRDx/main problem.
• Assign an additional code for the symptom or condition, optional, as a diagnosis type (3)/other problem
based on the facility’s data needs.
DN
When no definite diagnosis has been established by the end of the episode of care, code the information
that permits the greatest degree of specificity and knowledge about the condition that necessitated care
or investigation. This may be a sign, an abnormal test result or a symptom.
73
N Example: A patient presents to the emergency department with a seizure. There is no history
of a previous seizure documented. The CT scan taken reveals a large brain tumor.
The patient is then admitted for a stereotactic biopsy of the brain.
D43.2 MP Neoplasm of uncertain or unknown behaviour of brain, unspecified
R56.88 OP Other and unspecified convulsions (optional)
3.AN.20.VA Computerized tomography [CT], brain, without contrast
Rationale: The patient presents with a symptom (seizure) and the underlying
condition is found. The greatest specificity about the condition is that
it is a brain tumor. The type of neoplasm is not identified.
D Example: The above emergency patient is admitted for a stereotactic biopsy of the brain after
a CT scan reveals a large brain tumor. Physician documentation states “no previous
history of seizures.” A stereotactic burr hole biopsy of the brain reveals a benign
neoplasm, and the patient is scheduled for further surgery.
Code DAD Code title
D33.2 (M) Benign neoplasm of brain, unspecified
R56.88 (3) Other and unspecified convulsions (optional)
2.AN.71.SE Biopsy, brain, using burr hole approach

3.AN.94.ZC Imaging intervention NEC, brain, using stereotaxis
(without computer guidance)
74
DN Example: The patient presents with diarrhea and anemia. A colonoscopy is performed and a
single polyp is excised from the sigmoid colon. Final impression: “Single polyp
removed by snare and sent to pathology.” Pathology confirms a hyperplastic polyp.
K63.5 (M) MP Polyp of colon
A09.9 (3) OP Gastroenteritis and colitis of unspecified

origin (optional)
D64.9 (3) OP Anaemia, unspecified (optional)
Rationale: The patient presents with symptoms (diarrhea and anemia). A polyp
is found and excised. The final diagnosis is recorded as “polyp.”
Therefore, assign K63.5 as the MRDx/main problem.
DN Example: The patient presents with dyspepsia and for follow-up of diverticulosis.
An esophagogastroduodenoscopy (EGD) and colonoscopy are performed.
Biopsies are taken from the duodenum and stomach. Polyps are excised from the
descending colon and rectum. The pathology report demonstrates negative EGD
biopsies, a tubular adenoma from the colon and an inflammatory polyp of the
rectum. No diverticulosis is noted.

D12.4 (M) MP Benign neoplasm of descending colon
K62.1 (1) OP Rectal polyp
Z09.9 (3) OP Follow-up examination after unspecified treatment

for other conditions
R10.19 (1) OP Upper abdominal pain, unspecified
Rationale: The patient presents with a symptom (dyspepsia) and is also admitted
for concomitant follow-up of diverticulosis. A tubular adenoma and an
inflammatory polyp are identified and excised. Since a therapeutic
intervention was performed, D12.4 is assigned as the MRDx/main
problem and K62.1 is assigned as diagnosis type (1)/other problem.
Diverticulosis is not found; therefore, a code from category Z09 is assigned.

See also the coding standard Admission for Follow-Up Examination.
75
DN Example: The patient presents for an EGD and colonoscopy to investigate iron deficiency
anemia. During the colonoscopy, external hemorrhoids are noted. EGD
demonstrates a normal examination. Final impression is documented as
“No identifiable cause to explain the anemia. Patient is referred back to family
physician for further investigation planning.”
D50.9 (M) MP Iron deficiency anaemia, unspecified
K64.8 (3) OP Other specified haemorrhoids (optional)
Rationale: The patient presents with a sign (iron deficiency anemia) for
investigation. An underlying condition is not found. The greatest degree
of specificity about this case is the anemia. Therefore, a code for the
anemia (sign) is assigned as the MRDx/main problem. The external
hemorrhoids are noted during the examination and are an incidental
finding. A code for an incidental finding is optional.
N Example: A patient presents to the emergency department with right lower quadrant (RLQ)
abdominal pain. After thorough investigations are completed, the physician
documents that both an ovarian cyst and appendicitis are ruled out. The patient
is discharged with instructions to follow up with her family physician. The final
diagnosis is recorded by the physician as “right-sided lower abdominal pain.”
R10.30 MP Right lower quadrant pain
Rationale: The patient presents with a symptom (RLQ pain). An underlying

condition is not found. The greatest degree of specificity known about
this case at the end of the episode of care is RLQ pain. Therefore, a
code for the RLQ pain (symptom) is assigned as the main problem.

When a patient presents with a manifestation of an underlying disease or disorder that is known at the
DN
time of admission, and management is directed solely to the manifestation, assign the manifestation as the
MRDx/main problem.
• Assign a code for the underlying disease as a diagnosis type (3)/other problem.
76
DN Example: A 45-year-old patient presents with unstable angina. He has known coronary
atherosclerosis at the time of admission. During this current admission, symptomatic
treatment is directed toward the unstable angina only. The patient is to see his
physician to discuss surgical options.
I20.0 (M) MP Unstable angina
I25.19 (3) OP Atherosclerotic heart disease of unspecified type of

vessel, native or graft
D Example: A patient suffering from advanced colon cancer is admitted with bowel obstruction,
and an enteroenterostomy is performed.
Code DAD Code title

K56.6 (M) Other and unspecified intestinal obstruction
C18.9 (3) Malignant neoplasm colon, unspecified
Unconfirmed Diagnosis
In effect 2018
The purpose of this coding standard is to provide direction for code assignment when a final
diagnosis is recorded using terms that denote uncertainty. The assignment of a code for an
unconfirmed diagnosis is determined by the specific manner in which the physician/primary care
provider has documented the conclusions. The code assigned reflects the greatest degree of
knowledge and specificity.
Unconfirmed pertains to physician documentation of the final diagnosis that suggests any
degree of uncertainty. This includes terms such as “query,” “suspected,” “questionable,” “rule
out,” “possible,” “probable,” “likely”, “?” and “presumed.” When more than one possibility is
recorded, comparative or contrasting terminology such as “versus” may be used. Please note
that this is not an exhaustive list of terms that denote unconfirmed.
See also the coding standards Admission for Observation and Underlying Symptoms or Conditions.
77
Unconfirmed diagnosis

When a single unconfirmed diagnosis is recorded as the final diagnosis and there is no further information
DN
or clarification, assign a code for the unconfirmed diagnosis as if it were established.
• Apply the prefix Q in such circumstances.
When two (or more) unconfirmed diagnoses are recorded as the final diagnosis and there is no further
DN
information or clarification, assign the first-listed unconfirmed diagnosis as the MRDx/main problem.
Assignment of a code for the additional unconfirmed diagnosis is optional. If assigned, it is a diagnosis
type (3)/other problem.
• Apply the prefix Q in such circumstances.
When two (or more) diagnoses that are part of a combination code and/or set of codes in ICD-10-CA are
DN
recorded as the final diagnosis and one of the diagnoses is unconfirmed, assign the applicable combination
code and/or set of codes as if each of the diagnoses were established.
• Apply the prefix Q in such circumstances to the combination code and/or set of codes as applicable.
Exception
Neonatal sepsis. See also the coding standard Confirmed Sepsis and Risk of Sepsis in the Neonate.
Note
The prefix Q is applied when the health care provider has documented uncertainty in the diagnosis, not when
the coder is uncertain of the diagnosis.
Note
The prefix Q to identify unconfirmed diagnoses is used with diagnosis codes only; it is not used with external
cause codes. See Group 10, Field 01 in the Discharge Abstract Database (DAD) Abstracting Manual and data
element 43 in the National Ambulatory Care Reporting System (NACRS) Manual.
Note
Prefixes 5 and 6 take precedence over prefix Q. See also the coding standard Diagnosis Typing Definitions
for DAD.
78
DN Example: The final diagnosis is recorded by the physician as “Query peptic ulcer.”
(Q) K27.9 (M) MP Peptic ulcer, unspecified as acute or chronic,

without haemorrhage or perforation
Rationale: The physician has recorded the final diagnosis as unconfirmed.

This unconfirmed diagnosis represents the greatest degree of knowledge.
It is coded as if it was established and prefix Q is applied.
DN Example: A young woman presents with severe abdominal pain; the final diagnoses listed on
the chart are “? dysmenorrhea” and “? constipation.”

(Q) N94.6 (M) MP Dysmenorrhoea, unspecified
(Q) K59.0 (3) OP Constipation (optional)
Rationale: Two unconfirmed diagnoses are recorded as the final diagnosis.

These unconfirmed diagnoses represent the greatest degree of knowledge.
Dysmenorrhea is selected as the MRDx/MP, as it is the first-listed unconfirmed
diagnosis and there is no further information or clarification, and prefix Q is applied.
N Example: The patient is being investigated for tingling and numbness in her right hand.
The final diagnosis is recorded by the physician as “query carpal tunnel syndrome.”
The documentation states the patient has type 1 diabetes mellitus.
(Q) E10.40† MP Type 1 diabetes mellitus with mononeuropathy
(Q) G59.0* OP Diabetic mononeuropathy
Rationale: The carpal tunnel syndrome is unconfirmed. This unconfirmed diagnosis represents
the greatest degree of knowledge. Diabetes mellitus with carpal tunnel syndrome
is classified using two codes: a combination code for diabetes mellitus with
mononeuropathy and a separate code for carpal tunnel syndrome. The combination
code and the code for carpal tunnel syndrome are assigned as if the diagnosis were
established. Prefix Q is applied to both E10.40 and G59.0 (the set of codes that
includes a combination code), as both encompass the unconfirmed diagnosis.
79
DN Example: The final diagnosis is recorded by the physician as “presumed pneumonia.”

COPD is also recorded in the documentation.
(Q) J44.0 (M) MP Chronic obstructive pulmonary disease with acute

lower respiratory infection
(Q) J18.9 (1) OP Pneumonia, unspecified
Rationale: The acute lower respiratory infection (pneumonia) is unconfirmed.

This unconfirmed diagnosis represents the greatest degree of
knowledge. COPD with pneumonia is classified using two codes: a
combination code for COPD with acute lower respiratory infection and a
separate code for pneumonia. The combination code and the code for
pneumonia are assigned as if the pneumonia was established. Prefix Q
is applied to both J44.0 and J18.9 (the set of codes that includes a
combination code), as both encompass the unconfirmed diagnosis.
DN Example: The patient has a noted history of type 2 diabetes. The final diagnosis is recorded
as “likely lactic acidosis.”
(Q) E11.11 (M) MP Type 2 diabetes mellitus with lactic acidosis
Rationale: The lactic acidosis is unconfirmed. This unconfirmed diagnosis

represents the greatest degree of knowledge. Diabetes with lactic
acidosis is classified using a combination code. The combination code is
assigned as if the lactic acidosis was established. Prefix Q is applied as
the combination code encompasses the unconfirmed diagnosis.
Confirmed diagnosis with unconfirmed specificity

The physician or primary care provider may have established that a patient has a particular
diagnosis but may document uncertainty about some aspect of the diagnosis. For example, the
underlying cause or (sub)type of the condition may be recorded as questionable.
80
DN
When a confirmed diagnosis is recorded as the final diagnosis with unconfirmed specificity, assign only the
unspecified code for the diagnosis.
Note
Do not assign an additional code to reflect the unconfirmed specificity. Do not assign prefix Q.
The selection of the unspecified code for the diagnosis depends on the feature of the diagnosis
that is uncertain and the structure of ICD-10-CA. Sometimes, the unspecified code is selected at
the category level. Other times, the unspecified code is selected at the block or chapter level.
Category level
DN Example: The final diagnosis is recorded by the physician as “angina, ? Prinzmetal.”
I20.9 (M) MP Angina pectoris, unspecified
Rationale: The greatest degree of specificity is the angina; there is uncertainty

about the type. Both Prinzmetal angina (I20.1) and unspecified angina
(I20.9) fall within the same category (I20 Angina pectoris). The code for
unspecified angina from this category is assigned.
DN Example: The final diagnosis is recorded by the physician as “middle cerebral artery
infarction, probably cardioembolic.”
I63.5 (M) MP Cerebral infarction due to unspecified occlusion or

stenosis of cerebral arteries
Rationale: The greatest degree of specificity is the cerebral infarction; there is

uncertainty about the cause. Both cardioembolic middle cerebral artery
infarction (I63.4) and unspecified middle cerebral artery infarction (I63.5)
fall within the same category (I63 Cerebral infarction). The code for
unspecified middle cerebral artery infarction from this category is assigned.
81
Block level
DN Example: The final diagnosis is recorded by the physician as “iron deficiency anemia versus
vitamin B12 deficiency anemia.”
D53.9 (M) MP Nutritional anaemia, unspecified
Rationale: The greatest degree of specificity is the anemia. There is uncertainty about
the type. Iron deficiency anemia is classified to D50.9 and vitamin B12
deficiency anemia is classified to D51.9. These codes are from different
categories but fall within the same block: Nutritional anaemias (D50–D53).
The code for unspecified nutritional anemia from this block is assigned.
Chapter level
DN Example: A patient presents with anemia of unknown cause. She has impaired renal function,
and she also has gastritis that could account for the anemia as well. The final
diagnosis is “anemia NYD, possibly due to chronic renal disease, possibly due to
chronic bleeding from gastritis.”

D64.9 (M) MP Anaemia, unspecified
Rationale: The greatest degree of specificity is the anemia; there is uncertainty about
the cause. Anemia in chronic renal disease is classified to D63.8 and anemia
due to chronic loss of blood is classified to D50.0. These codes are from
different blocks within Chapter III — Diseases of the blood and blood-forming
organs and certain disorders involving the immune mechanism (D50–D89).
The code for unspecified anemia from this chapter is assigned.
82
Sign/symptom/abnormal finding with unconfirmed diagnosis
DN
When a sign, symptom or abnormal finding and an unconfirmed diagnosis are recorded as the final
diagnosis and there is no further information or clarification, assign the code representing the sign,
symptom or abnormal finding. Assignment of a code for the unconfirmed diagnosis is optional. If assigned,
it is a diagnosis type (3)/other problem and prefix Q is mandatory to apply.
DN Example: The final diagnosis is recorded as “Right lower abdominal pain. Query acute appendicitis.”

R10.30 (M) MP Right lower quadrant pain
(Q) K35.8 (3) OP Acute appendicitis, other and unspecified (optional)
Rationale: The physician has recorded the final diagnosis as a symptom followed by
an unconfirmed diagnosis. The code for the symptom, which is the greatest
degree of knowledge, is assigned.
DN Example: A young woman presents with severe abdominal pain and nausea. The final
diagnosis is recorded as “severe abdominal pain and nausea — query
dysmenorrhea, query constipation.”
R10.0 (M) MP Acute abdomen
R11.1 (1) OP Nausea only
(Q) N94.6 (3) OP Dysmenorrhoea, unspecified (optional)
(Q) K59.0 (3) OP Constipation (optional)
Rationale: The health care provider has recorded the final diagnosis as multiple
symptoms with multiple unconfirmed diagnoses. The codes for the
symptoms, which are the greatest degree of knowledge, are assigned.
83
N Example: A patient is seen in the clinic for investigation of a suspicious lesion of the left lung
that was noted on chest X-ray. Following a complete history and physical, the
patient is booked for a bronchoscopy. The final diagnosis is recorded as “abnormal
chest xray — ?lung ca.”
R91 MP Abnormal findings on diagnostic imaging of lung
(Q) C34.91 OP Malignant neoplasm left bronchus or lung, unspecified (optional)
Rationale: The health care provider has recorded the final diagnosis as an abnormal
finding followed by an unconfirmed diagnosis. The code for the abnormal
finding (abnormal test result), which is the greatest degree of knowledge,
is assigned.
Use Additional Code/Code Separately Instructions

DN
When a “use additional code” instruction is provided in ICD-10-CA, assign the additional code as
instructed, mandatory.
DN
When a “code separately” instruction is provided in ICD-10-CA, assign the additional code, mandatory,
when the condition meets the criteria for significance.
See also the coding standards Diagnosis Typing Definitions for DAD, Main and Other Problem
Definitions for NACRS and Dagger/Asterisk Convention.
Exception
The instruction to “use additional code (B95–B98) to identify infectious agent” is optional when
it is not one of the mandatory drug-resistant infectious organisms. See also the coding standard
Drug-Resistant Microorganisms.
84
DN Example: A patient presents for investigation of abnormal hematology tests. It is determined

that he has aplastic anemia due to occupational exposure to insecticides at the dairy
farm where he works.
D61.2 (M) MP Aplastic anaemia due to other external agents
X48 (9) OP Accidental poisoning by and exposure to pesticides
U98.7 (9) OP Place of occurrence, farm
Rationale: Follow the “use additional code” instruction to identify the external
cause code.
DN Example: A 70-year-old male patient is diagnosed with epididymitis due to E. coli.
N45.90 (M) MP Epididymitis
B96.2 (3) OP Escherichia coli [E. coli] as the cause of diseases

classified to other chapters (optional)
Rationale: Assignment of a code from B95–B98 is optional, unless the infection is

due to one of the mandatory drug-resistant microorganisms.
DN Example: A 54-year-old patient presents with a vitreous hemorrhage for a vitrectomy.

The physician notes that he has had type 2 diabetes mellitus, well controlled,
for many years.

H43.1 (M) MP Vitreous haemorrhage
E11.33† (3) OP Type 2 diabetes mellitus with other retinopathy
H36.0* (3) OP Diabetic retinopathy
Rationale: Vitreous hemorrhage meets the criteria for significance in this example;
therefore, the “code separately” instruction is followed at E11.33†.
85
DN Example: A patient presents to the emergency department with a cough and fever and is
admitted for treatment of pneumonia. She has had type 2 diabetes mellitus for
many years. She also has CAD and had an MI three years ago.
J18.9 (M) MP Pneumonia, unspecified
E11.52 (3) OP Type 2 diabetes mellitus with certain

circulatory complications
Rationale: Since neither the CAD nor the history of the MI meets the criteria for
significance during this visit, it is not mandatory to follow the “code
separately” direction.
Sequelae
A sequela (or late effect) of a disease is a current condition under investigation or treatment
that was caused by a previously occurring condition or injury. There is no universal time frame
in which a condition can be considered a sequela. The residual condition (sequela) may be
apparent early in the process, such as neurological deficits occurring following a cerebral
infarction. 4 A scar or cicatrix is a sequela of a third-degree burn that develops remote to the
burn incident itself.

When a patient presents with a sequela of a previously treated condition, assign a code for the current
DN
condition under investigation or treatment as a significant diagnosis type.
• Assign codes from categories titled “Sequelae of . . .” (B90–B94, E64, E68, G09, I69, O94, O97, T90–T98),
optional, as a diagnosis type (3)/other problem to identify the current problem as sequelae.
DN Example: Unequal leg length (acquired). Late effect of poliomyelitis.

M21.7 (M) MP Unequal limb length (acquired)
B91 (3) OP Sequelae of poliomyelitis (optional)
86
DN Example: Osteoarthritis of hip joint due to an old hip fracture from a motor vehicle accident
20 years ago.
M16.5 (M) MP Other post-traumatic coxarthrosis
T93.1 (3) OP Sequelae of fracture of femur (optional)
Y85.0 (9) OP Sequelae of motor-vehicle accident (optional)
DN Example: A patient is admitted for release of skin contracture and fibrosis, old burn of hand
(due to a hot oil spill two years ago).
L90.5 (M) MP Scar conditions and fibrosis of skin
T95.2 (3) OP Sequelae of burn, corrosion and frostbite of upper

limb (optional)
Y86 (9) OP Sequelae of other accidents (optional)
DN Example: A patient presents with pain of the knee joint due to an old injury of the knee.
M25.56 (M) MP Pain in joint, lower leg
T93.9 (3) OP Sequelae of unspecified injury of lower

limb (optional)
Y89.9 (9) OP Sequelae of unspecified external cause (optional)
Note
Coders are reminded to read and follow all notes at block headings and chapter headings, where guidance is
provided regarding time frames, that is, I69, O97 and T90–T98.
See also the coding standard Current Versus Old Injuries.
87
Admissions From Emergency Department

Patients often move from one setting to another as their condition is being treated.
Treatment that begins in the emergency department may end in the inpatient setting.
DN
Select the diagnosis or diagnoses for each level of care (e.g., ambulatory care, acute care inpatient) to
accurately reflect the circumstances for the treatment provided during that episode of care.
N Example: An 87-year-old man is seen in the emergency department for a fractured rib.
He had slipped and fallen down in the grocery store that morning.

S22.300 MP Fracture of rib, closed
W01 OP Fall on same level from slipping, tripping and stumbling
U98.5 OP Place of occurrence, trade and service area
D Example: The patient in the example above is subsequently admitted from the emergency
department for overnight care, as he lives alone. He is discharged the next morning
in the care of his daughter.
Code DAD Code title
Z60.2 (M) Living alone
S22.300 (3) Fracture of rib, closed
W01 (9) Fall on same level from slipping, tripping and stumbling
U98.5 (9) Place of occurrence, trade and service area
88

When a patient is admitted as an inpatient to complete treatment started in the emergency department,
D
assign the MRDx according to the diagnosis typing definitions (see also the coding standard Diagnosis
Typing Definitions for DAD).
• When definitive treatment for an injury or a condition occurs in the emergency department and no
reason is given for why the patient was subsequently admitted, assume that it was for continuation of
treatment of the presenting condition.
N Example: A patient with known CAD is brought to the emergency department complaining of
chest pain. ECG shows ST elevation; therefore, thrombolytics are administered.
Diagnosis on the emergency department record is STEMI.
R94.30 MP Electrocardiogram suggestive of ST segment elevation myocardial

infarction [STEMI]
1.ZZ.35.HA-1C Pharmacotherapy, total body, percutaneous approach

[intramuscular, intravenous, subcutaneous, intradermal]
using thrombolytic agent
D Example: The patient in the above example is subsequently admitted from the emergency
department for continued treatment and care. Final diagnosis on the inpatient
record is averted MI.
Code DAD Code title
I24.0 (M) Coronary thrombosis not resulting in myocardial infarction
R94.30 (3) Electrocardiogram suggestive of ST segment elevation myocardial

infarction [STEMI]
1.ZZ.35.HA-1C Pharmacotherapy, total body, percutaneous approach [intramuscular,

intravenous, subcutaneous, intradermal] using thrombolytic agent
Rationale: The patient’s MI was successfully averted with administration of the

thrombolytics. As there was evidence of elevated ST segments found on
the ECG, assign R94.30 on the inpatient abstract as a diagnosis type (3).
89
DN Example: A 4-year-old child is brought into the emergency department with an anterior
dislocation of the shoulder after falling from the jungle gym in the day care play area.
The patient is admitted following a closed reduction in the emergency department.
The child is discharged in the care of his mother the following morning.
S43.000 (M) MP Anterior dislocation of shoulder, closed
W09.08 (9) OP Fall involving other playground equipment
U98.28 (9) OP Place of occurrence, school and other institutions

and public areas
Cancelled Interventions
In effect 2001, amended 2007, 2008, 2009, 2012, 2015
A scheduled or planned intervention may sometimes be cancelled for reasons such as staffing,
another emergency case taking precedence or even contraindications such as the patient
developing flu-like symptoms.
DN
When a scheduled or planned intervention is cancelled, assign a code from category Z53 Persons
encountering health services for specific procedures, not carried out, mandatory.
DN
When a scheduled or planned intervention is cancelled due to administrative reasons, assign Z53.8
Procedure not carried out for other reasons as the MRDx/main problem.
DN
When a scheduled or planned intervention is cancelled due to a contraindication and the patient is
discharged without treatment for the contraindication, assign Z53.0 Procedure not carried out because of
contraindication as the MRDx/main problem.
DN
When a scheduled or planned intervention is cancelled due to a contraindication and the patient is treated
for the contraindication, assign
• The contraindication as the MRDx/main problem; and
• Z53.0 Procedure not carried out because of contraindication as a diagnosis type (3)/other
problem, mandatory.
90

D For an inpatient admission, when the contraindication meets the definition of a post-admit comorbidity,
assign a code for the contraindication as the MRDx and as a diagnosis type (2).
Note
It is optional to record “CANCELLED” in the intervention field of the abstract when a patient presents to a day
surgery unit, clinic or emergency department for a scheduled or planned intervention that does not occur.
Check with your provincial/territorial department/ministry of health for any policies that might apply to the
coding of cancelled cases submitted to the DAD or NACRS.
Note
There is no status attribute in CCI to identify a cancelled intervention, and it is incorrect to code such cases to
the planned intervention with status attribute A.
Note
For more information about cancelled interventions, see Group 11, Field 02 in the Discharge Abstract
Database (DAD) Abstracting Manual and data elements 35, 46 and 47 in the National Ambulatory Care
Reporting System (NACRS) Abstracting Manual.
See also the coding standard Abandoned Interventions.
DN Example: A patient arrives for a scheduled coronary angiogram. The procedure is cancelled
due to staffing problems (snowstorm).

Z53.8 (M) MP Procedure not carried out for other reasons
N Example: A patient with breast cancer arrives for her scheduled chemotherapy, and her
blood work identifies neutropenia. The chemotherapy is cancelled and the patient
is discharged home with no treatment for the neutropenia.
Z53.0 MP Procedure not carried out because of contraindication
91
D Example: A patient is admitted as an inpatient for elective hip replacement for osteoarthritis
(coxarthrosis) but develops acute chest pain prior to surgery. A cardiologist is called
to see the patient, and STEMI is documented. The patient is transferred to the
cardiac care unit on thrombolytic therapy. The elective surgery is cancelled and the
patient remains in hospital for treatment of MI. The final diagnosis is recorded as
acute anterior wall MI.
Code DAD Code title
I21.0 (M) Acute transmural myocardial infarction of anterior wall
I21.0 (2) Acute transmural myocardial infarction of anterior wall

infarction [STEMI]
Z53.0 (3) Procedure not carried out because of contraindication
Rationale: The scheduled intervention (hip replacement) was cancelled because

the patient suffered an MI (contraindication). The MI was treated;
therefore, it is assigned as the MRDx and a diagnosis type (2). Z53.0
is a mandatory type (3).
N Example: A patient with breast cancer arrives for her scheduled chemotherapy, and her blood
work identifies neutropenia. The chemotherapy is cancelled, and a red blood cell
blood transfusion is started to treat the neutropenia.

D70.0 MP Neutropenia
Z53.0 OP Procedure not carried out because of contraindication
Rationale: The scheduled intervention (chemotherapy) was cancelled because of

neutropenia (contraindication). The neutropenia was treated; therefore,
it is assigned as the main problem. Z53.0 is a mandatory other problem.
92
References


4. National Centre for Classification in Health. Australian Coding Standards for the
International Statistical Classification of Diseases and Related Health Problems, Tenth
Revision, Australian Modification (ICD-10-AM) and the Australian Classification of Health
Interventions (ACHI), 6th Edition. 2008.
93
General coding standards for CCI

Selection of Interventions to Code for
Ambulatory Care (Emergency, Clinic and Day
Surgery Visits)
This coding standard applies to day surgery cases submitted to the Discharge Abstract
Database (DAD) and all cases submitted to the National Ambulatory Care Reporting System
(NACRS). The DAD and NACRS icon DN refers to ambulatory cases submitted to the DAD
and NACRS.
Codes from all sections of CCI may be applicable in an ambulatory care setting.
Not every action carried out during an episode of care requires code assignment (see the
coding standard Multiple Codes in CCI). This standard identifies the minimum requirements
for ambulatory care submitted to the DAD and NACRS; however, provincial/territorial and local
standards may specify additional requirements.
Additionally, certain interventions that may not meet the criteria relating to intervention room,
anesthesia or operative approach must also be captured. These are listed in the table Additional
mandatory CCI codes for ambulatory care.
Clinic visits
Clinic visits may include audiology, dietetics, mental health, obstetrics, occupational therapy,
physiotherapy, recreational therapy, respiratory therapy, speech therapy and social work.
NACRS-only directive statement

N Assign a code from any section in CCI for each intervention performed during a clinic visit.
All other ambulatory care visits

Other ambulatory care visits include scheduled and non-scheduled emergency visits and
day surgery.
94
Any section in CCI
DN
Assign a code from any section in CCI for interventions that meet one or more of the following criteria:
• Specified as mandatory elsewhere in these standards; or
• Included in the table Additional mandatory CCI codes for ambulatory care.
Note
When applying the directive statements below, reference Appendix A — CCI Code Structure — Qualifier 1 —
Section — Approach/Technique in CCI as needed for more detail about operative approaches.
Section 1
DN
Assign a code for interventions classified in Section 1 of CCI that meet one or more of the following criteria:
• Classified to a generic intervention number of 50 or higher (excluding per orifice catheter interventions
for bladder drainage and IV insertion using percutaneous approach);
• Performed in an operating/intervention room (e.g., endoscopy room or cardiac catheterization room);
• Performed under anesthesia (any anesthesia, including local); and/or
• Performed using one of the following approaches:
− Open;
− Endoscopic; or
− Percutaneous transluminal/transarterial
95
Section 2

DN
• An inspection performed as the sole intervention at a given anatomical site using one of the
following approaches:
− Open;
− Endoscopic; or
− Percutaneous transluminal/transarterial;
• A biopsy performed as the sole intervention at a given anatomical site; and/or
• The sole intervention performed under anesthesia (any anesthesia, including local).
Section 3
DN Assign a code for interventions classified in Section 3.
Exception
It is optional to assign a code for the use of an operating microscope: 3.^^.94.ZA Imaging intervention NEC
using microscope.
Note
Per the direction in CCI, 3.^^.12.^^ Fluoroscopy excludes that with X-ray (see 3.^^.10.^^ Xray); when a
fluoroscopy is performed during the same intervention episode as an X-ray, assign a code from 3.^^.10.^^
Xray only.
Section 5
DN
Assign a code for interventions classified in Section 5 of CCI with a generic intervention number of 40
or higher.
96
Additional mandatory CCI codes for ambulatory care

CCI code Intervention
1.ZX.07.KS-KK Hyperthermy, multiple body sites, using extracorporeal blood warming device
1.AN.09.^^ Stimulation, brain
1.HZ.09.^^ Stimulation, heart NEC
1.ET.13.CA-HB Control of bleeding, nose, using per orifice approach and diathermy or thermal device
1.ET.13.CA-GX Control of bleeding, nose, when using per orifice approach and electrocautery
1.FJ.13.JA-GX Control of bleeding, tongue, when using electrocautery
1.FR.13.JA-GX Control of bleeding, tonsils and adenoids, when using electrocautery
1.FX.13.JA-GX Control of bleeding, oropharynx, when using electrocautery
1.LZ.19.HH-U7-^ Transfusion, circulatory system NEC, of stem cells
1.LZ.19.HH-U8-^ Transfusion, circulatory system NEC, of cord blood stem cells
1.LZ.20.^^ Apheresis, circulatory system NEC
1.^^.21.^^ Dialysis, any site
1.^^.26.^^ Brachytherapy, any site
1.^^.27.^^ Radiation, any site
1.GZ.30.JH Resuscitation, respiratory system NEC, using external manual compression technique
1.HZ.30.JN Resuscitation, heart NEC, by external manual compression with or without

concomitant ventilation
1.GZ.31.^^ Ventilation, respiratory system NEC
1.^^.35.H2-^^ Any pharmacotherapy when delivered via drug eluting balloon
1.^^.35.HZ-^^ Any pharmacotherapy delivered via drug eluting stent
1.^^.35.^^-1C Any infusion/injection of thrombolytic agent
1.^^.35.^^-M^ Pharmacotherapy using antineoplastic and immunomodulating agents
1.NF.35.^^ Pharmacotherapy (local), stomach (includes gastric lavage)
1.OT.35.^^ Pharmacotherapy (local), abdominal cavity
1.ZZ.35.^^ Pharmacotherapy, total body — mandatory only in certain circumstances; see the
coding standards Medical Assistance in Dying and Admission for Administration of
Chemotherapy, Pharmacotherapy and Radiation Therapy
1.HZ.37.JA-NN Installation of external appliance, heart NEC, of temporary (external) cardiac pacemaker
2.ZZ.02.PM Assessment (examination), total body for assistance in dying
97

2.HZ.08.^^ Test, heart NEC
2.AX.13.^^ Specimen collection (diagnostic), spinal canal and meninges
2.AN.24.^^ Electrophysiological measurement, brain
2.CZ.24.^^ Electrophysiological measurement, eye NEC
2.HZ.24.GP.^^ Electrophysiological measurement, heart NEC, percutaneous transluminal

[cardiac catheterization] insertion
2.CZ.25.^^ Potential (evoked) measurement, eye NEC
2.CZ.28.^^ Pressure measurement, eye NEC
2.NM.28.CA-PL Pressure measurement, large intestine, using per orifice approach with pressure
measuring device
2.HZ.29.GP-TS Other measurement NEC, heart NEC, using percutaneous transluminal approach and
balloon catheter
2.IJ.57.GQ Flow study, coronary arteries, using percutaneous transluminal arterial approach
2.CZ.58.^^ Function study, eye NEC
2.RF.58.LA-Z9 Function study, fallopian tube, using open approach and agent NEC
2.AN.59.^^ Other study, brain
2.M^.71.^^ Biopsy, lymph node(s), any site with extent attribute=SN (Sentinel node(s))
5.AB.02.^^ Amniocentesis
5.AB.03.^^ Obstetrical ultrasound examinations
5.AB.04.^^ Obstetrical Doppler studies
5.AB.05.^^ Other antepartum diagnostic imaging examination
5.AB.09.^^ Antepartum diagnostic interventions, biopsy
5.CA.20.^^ Pharmacotherapy (in preparation for), termination of pregnancy
5.CA.24.^^ Preparation by dilating cervix (for), termination of pregnancy
5.AC.24.CK-BD Preparation by dilating cervix (for), labour, using per orifice (ripening) by balloon catheter
5.AC.24.CK-W6 Preparation by dilating cervix (for), labour, using per orifice insertion of laminaria
5.LD.25.^^ Removal of device, cervix, during active labour
5.PC.25.^^ Removal of device, postpartum
5.AC.30.^^ Induction of labour
5.LD.31.^^ Augmentation of labour
7.SC.08.PM Other ministration, personal care for assistance in dying
98
In addition to the general coding standards for CCI, see also the following coding standards,
which provide direction for mandatory CCI code assignment:
Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction

Interventions Relevant to Neoplasm Coding
Sentinel Lymph Node Biopsy
Brachytherapy
Hierarchy for Classification of Intracranial Lesion Resection
Thrombolytic Therapy
Chronic Ischemic Heart Disease

Cardiac Arrest
Central Venous Catheters
Invasive Ventilation
Arthrectomy and Arthroplasty
Interventions Associated With Delivery
Vital Signs Absent (VSA)
Admission for Administration of Chemotherapy, Pharmacotherapy and Radiation Therapy
Medical Assistance in Dying
Example: The patient has an open reduction internal fixation of a bimalleolar fracture of the
left ankle. Fixation is performed using screws. Intraoperative fluoroscopy images
of the ankle demonstrate fixation of the fracture. Post-operative X-ray confirms
satisfactory reduction and internal fixation.
1.WA.74.LA-NW Fixation, ankle joint, open approach, using screw, plate

and screw fixation device alone
3.WA.10.VA Xray, ankle joint, without contrast (e.g. plain film) (with or
without fluoroscopy)
Rationale: 3.WA.12.^^ Fluoroscopy, ankle joint excludes “that with xray (see
3.WA.10.^^).” Both the fluoroscopy and X-ray were performed during the
same intervention episode; therefore, assign only the code for the X-ray.
99
Example: The patient is admitted with an injury of the right hand. An initial X-ray reveals a fracture
involving the mid-shaft of the fourth metacarpal. The physician reduces the fracture and
applies a cast. The right hand is X-rayed post-reduction to confirm alignment.
1.UF.73.JA Reduction, other metacarpal bones, using closed

(external) approach
3.UL.10.VA Xray, joints of fingers and hand NEC, without contrast

(e.g. plain film) (with or without fluoroscopy)
3.UL.10.VA Xray, joints of fingers and hand NEC, without contrast
(e.g. plain film) (with or without fluoroscopy)
Rationale: Assign a code for interventions classified to Section 3. Two X-rays

of the finger were performed (pre- and post-reduction); therefore,
3.UL.10.VA is assigned twice, even though it is the exact same code.
Example: The patient is admitted with epistaxis. The nose is packed, but the patient continues
to bleed from the left side of her nose. The packing is removed, and both sides
of her nose are decongested and anesthetized with topical Xylocaine as well as
cocaine. A posterior pack is done after examining the left nose for some time and
not being able to identify the actual site of bleeding. Using a #14 Foley catheter,
10 cc of water is placed in the balloon. The left anterior nose is packed with a
Vaseline gauze pack. Bleeding is eventually controlled.
No code assigned.
Rationale: The interventions performed do not meet any of the criteria for
assigning a code for interventions classified in Section 1. While the
standard indicates that a code must be assigned for interventions
performed under anesthesia (including local), this case presents a
unique but common circumstance. In the case of epistaxis, topical
(local) anesthetics, such as Xylocaine, are used as a means to control
the bleeding rather than to achieve anesthesia itself. For this reason,
the criterion “performed under anesthesia” does not apply in this case.
The table Additional mandatory CCI codes for ambulatory care directs
to assign a code when control of bleeding of the nose is performed
using diathermy/thermal device or electrocautery only; therefore, it is
not mandatory to assign a code for the packing, nasal balloon or use of
Xylocaine and cocaine.
100
Example: The patient is admitted for elective percutaneous coronary intervention (PCI)
for in-stent restenosis of the right coronary artery (RCA). Coronary angiogram is
performed, and the Pantera-Lux drug-eluting balloon is deployed at the site of the
two in-stent restenotic segments of the RCA. The intervention is performed in the
cardiac catheterization room.
1.IJ.50.GQ-BD Dilation, coronary arteries, percutaneous transluminal

approach [e.g. with angioplasty alone] using balloon or
cutting balloon dilator without stent insertion
Status: P
Extent: DG
3.IP.10.VX Xray, heart with coronary arteries of left heart structures, using
percutaneous transluminal arterial (retrograde) approach
Status: I
Location: U
1.IL.35.H2-M3 Pharmacotherapy (local), vessels of heart, elution from other
device, of plant alkaloids and other natural products
Rationale: A code for the dilation is mandatory for three reasons: 1) dilation is
classified to the generic intervention number 50; 2) it is performed in a
cardiac catheterization room; and 3) it is performed using a percutaneous
transluminal approach.
The coronary angiogram is classified to Section 3; therefore, it is
mandatory to assign.
The pharmacotherapy delivered via drug-eluting balloon is assigned
because it is included in the table Additional mandatory CCI codes for
ambulatory care.
Example: A young woman is brought to the emergency department following a witnessed

seizure at home. An electroencephalogram (EEG) is performed.
2.AN.24.JA-JA Electrophysiological measurement, brain,

using externally applied electrodes
Rationale: A code for EEG is assigned because it is included in the table

Additional mandatory CCI codes for ambulatory care.
101
Example: A young man is brought to the emergency department, where he undergoes

incisional drainage of a peritonsillar abscess and insertion of an intravenous line
for infusion of Clindamycin.
1.FR.52.LA Drainage, tonsils and adenoids, using open

(incisional) approach
Rationale: A code is assigned for the drainage because it meets two of the criteria:
1) drainage is classified to the generic intervention number 52; and 2)
the drainage was performed using an open approach. The infusion of
antibiotics is not coded because it does not meet the criteria for
interventions classified in Section 1 and is not listed in the table
Additional mandatory CCI codes for ambulatory care.
Selection of Interventions to Code for Acute

Inpatient Care
This coding standard applies to acute inpatient cases submitted to the DAD. The DAD icon D
in this coding standard refers to inpatient cases only. For day surgery cases submitted to the
DAD, see the coding standard Selection of Interventions to Code for Ambulatory Care, where the
DAD and NACRS icon N refers to ambulatory cases submitted to either the DAD or NACRS.
D
Not every action carried out during an episode of care requires code assignment (see the
coding standard Multiple Codes in CCI). This standard identifies the minimum requirements
for acute inpatient care submitted to the DAD; however, provincial/territorial and local standards
may specify additional requirements.
Interventions that are invasive to the patient and/or require significant resources must be
captured for inpatient cases. Generally, CCI interventions from Section 1 with a generic
intervention number of 50 or higher describe interventions that are invasive and/or require
significant resources. Interventions classified to a generic intervention number of 50 or higher
from Section 1 that do not meet any of the criteria in the directive statements below are
not required for acute inpatient care in the DAD. Conversely, interventions with a generic
intervention number below 50 from Section 1 that meet any of the criteria in the directive
statements below are required for acute inpatient care in the DAD.
102
Additionally, certain interventions that may not meet the criteria relating to intervention room,
presence of anesthetist or operative approach must also be captured. These are listed in the
table Additional mandatory CCI codes for acute inpatient care.
Any section in CCI

Assign a code from any section in CCI for interventions that meet one or more of the following criteria:
D
• Specified as mandatory elsewhere in these standards; or
• Included in the table Additional mandatory CCI codes for acute inpatient care.
Note
When applying the directive statements below, reference Appendix A — CCI Code Structure — Qualifier 1 —
Section — Approach/Technique in CCI as needed for more detail about operative approaches.
Section 1

Assign a code for interventions classified in Section 1 of CCI that would require one or more of the following:
D
• Performance in an operating/intervention room (e.g., endoscopy room or cardiac catheterization room);
• Performance in the presence of an anesthetist (i.e., an anesthetic record is on the chart); and/or
• Performance using the following approaches:
− Open;
− Endoscopic; or
− Percutaneous transluminal/transarterial.
103
Section 2

D
• An inspection performed as the sole intervention at a given anatomical site using one of the
following approaches:
− Open;
− Endoscopic; or
− Percutaneous transluminal/transarterial;
• A biopsy performed as the sole intervention at a given anatomical site; and/or
• The sole intervention performed in the presence of an anesthetist (i.e., an anesthetic record is on
the chart).
Section 3

D
• Performed in a cardiac catheterization room (even when performed with a therapeutic intervention at
the same anatomical site); and/or
• The sole intervention performed in the presence of an anesthetist (i.e., an anesthetic record is on
the chart).
Note
When diagnostic imaging studies are performed in conjunction with therapeutic interventions, it is optional
to assign a code for the diagnostic imaging intervention (excluding 3.IP.10.VX Xray, heart with coronary
arteries, of left heart structures using percutaneous transluminal arterial (retrograde) approach).
When diagnostic imaging studies are coded optionally, status attribute “I” may be available to signify
intraoperative. Facilities are free to define the use of this status attribute to meet internal reporting needs.
Note
It is mandatory to assign a code for coronary angiogram, 3.IP.10.VX, when performed with any therapeutic
intervention regardless of whether the coronary angiogram is diagnostic or intraoperative in nature.
The status and location attributes at 3.IP.10.^^ Xray, heart with coronary arteries are mandatory.
104
Example: Diagnosis: Acute inferior ST elevation myocardial infarction

Intervention: Primary angioplasty of RCA with stent insertion
The patient is taken immediately to the catheterization laboratory; on coronary

angiography (via the left femoral artery), he is found to have a culprit RCA lesion, which
is angioplastied and stented. A BMW wire is used to cross the occlusion. A 3.0 balloon
is used to pre-dilate the lesion. A Pronto catheter is used to aspirate the thrombus.
Further pre-dilation is carried out with a 2.5 balloon. A bare metal stent is deployed.
1.IJ.50.GU-OA Dilation, coronary arteries, percutaneous transluminal

approach with thrombectomy using balloon or cutting balloon
dilator with (endovascular) stent insertion
Status: N
Extent: DG
3.IP.10.VX Xray, heart with coronary arteries, of left heart structures using
Status: DX
Location: FY
Rationale: It is mandatory to assign 3.IP.10.VX when performed with a therapeutic

intervention. The status attribute is “DX” because the angiogram was
performed to assess (diagnose) the extent and location of coronary
artery disease prior to proceeding to the dilation procedure.
105
Example: The patient underwent angioplasty of the distal RCA two years previously. Recent
angiogram reveals restenosis, and the patient is admitted electively for PCI. An
angioplasty with stent insertion of the distal RCA is performed following coronary
angiogram via the femoral artery. A BMW wire is used to cross the occlusion. A 3.0
balloon is used to pre-dilate the lesion. A bare metal stent is deployed.
1.IJ.50.GQ-OA Dilation, coronary arteries, percutaneous transluminal

approach using balloon or cutting balloon dilator with
(endovascular) stent insertion
Status: P
Extent: DG
Status: I
Location: FY
Rationale: It is mandatory to assign 3.IP.10.VX when performed with a therapeutic

intervention. The status attribute is “I” because the intervention was
performed for visualization purposes during the dilation procedure;
the disease and the affected artery had already been diagnosed on a
previous diagnostic coronary angiogram.
Section 5

Assign a code for interventions classified in Section 5 of CCI with a generic intervention number of 40
D
or higher.
Additional mandatory CCI codes for acute inpatient care

1.^^.03.HA-KC Immobilization using percutaneous external fixator
1.AN.09.^^ Stimulation, brain
1.HZ.09.^^ Stimulation, heart NEC
1.LZ.19.HH-U7-^ Transfusion, circulatory system NEC of stem cells
1.LZ.19.HH-U8-^ Transfusion, circulatory system NEC of cord blood stem cells
1.WY.19.HH-^^ Transfusion, bone marrow
106

1.OA.21.HQ-BR Dialysis, liver, by hemofiltration
1.PZ.21.^^ Dialysis, urinary system NEC
1.^^.26.^^ Brachytherapy, any site
1.^^.27.^^ Radiation, any site
1.HZ.30.JN Resuscitation, heart NEC, by external manual compression with or without

concomitant ventilation
1.GZ.31.CA-^^ Ventilation, respiratory system NEC, invasive approach (excluding when an inherent part
1.GZ.31.CR-ND of the administration of a general anesthetic, and the patient is extubated prior to leaving
1.GZ.31.GP-ND the operating room)
1.HZ.34.^^ Compression, heart NEC
1.^^.35.H2-^^ Any pharmacotherapy when delivered via drug eluting balloon
1.^^.35.HZ-^^ Any pharmacotherapy delivered via drug eluting stent
1.^^.35.^^-1C Any infusion/injection of thrombolytic agent
1.^^.35.^^-M^ Pharmacotherapy using antineoplastic and immunomodulating agents
1.LZ.35.^^-C6 Pharmacotherapy (local), circulatory system NEC of parenteral nutrition
1.ZZ.35.^^ Pharmacotherapy, total body — mandatory only in certain circumstances; see the
coding standards Medical Assistance in Dying and Admission for Administration of
Chemotherapy, Pharmacotherapy and Radiation Therapy
1.LZ.37.^^ Installation of external appliance, circulatory system NEC
1.GV.52.^^ Drainage, pleura when it is the sole intervention performed at a single

intervention episode
1.OT.52.^^ Drainage, abdominal cavity when it is the sole intervention performed at a single
intervention episode
1.IS.53.^^ Implantation of internal device, vena cava (superior and inferior) — mandatory only in
certain circumstances; see the coding standard Central Venous Catheters
1.NF.53.^^ Implantation of internal device, stomach excluding 1.NF.53.CA-TS Implantation of

(gastric) tube using per orifice approach
1.NK.53.^^ Implantation of internal device, small intestine
1.^^.73.^^ Reduction, fracture or dislocation
1.GJ.77.^^ Bypass with exteriorization, trachea
2.AN.24.LA-JA Electrophysiological measurement, brain, using insertional electrodes [e.g. sphenoidal,

nasopharyngeal] by open approach
2.IJ.57.GQ Flow study, coronary arteries, using percutaneous transluminal arterial approach
107

2.RF.58.^^ Function study, fallopian tube
2.M^.71.^^ Biopsy, lymph node(s), any site with extent attribute=SN (Sentinel node(s))
5.AB.02.^^ Amniocentesis
5.AB.09.^^ Antepartum diagnostic interventions, biopsy
5.CA.20.^^ Pharmacotherapy (in preparation for), termination of pregnancy
5.CA.24.^^ Preparation by dilating cervix (for), termination of pregnancy
5.AC.24.CK-BD Preparation by dilating cervix (for), labour, using per orifice (ripening) by balloon catheter
5.AC.24.CK-W6 Preparation by dilating cervix (for), labour, using per orifice insertion of laminaria
5.LD.25.^^ Removal of device, cervix, during active labour
5.PC.25.^^ Removal of device, postpartum
5.AC.30.^^ Induction of labour
5.LD.31.^^ Augmentation of labour
In addition to the general coding standards for CCI, see also the following coding standards,
which provide direction for mandatory CCI code assignment:
Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction
Brachytherapy
Hierarchy for Classification of Intracranial Lesion Resection
Cardiac Arrest
Admission for Administration of Chemotherapy, Pharmacotherapy and Radiation Therapy
108
Example: Insertion of a urinary catheter performed on the nursing unit without anesthetic
No code assigned.
Rationale: Insertion of a urinary catheter is classified to a generic intervention number

of 50 or higher from Section 1: 1.PM.52.CA-TS Drainage, bladder, using
per orifice approach and drainage catheter. However, the intervention
performed in this example does not meet any of the criteria in the above
directive statements; therefore, it is not mandatory to assign.
Example: Injection of antihemorrhagic agent into burr hole to control bleeding of the meninges
of the brain
1.AA.13.SE-C2 Control of bleeding, meninges and dura mater of brain,

using injection of antihemorrhagic agent into burr hole
Rationale: Control of bleeding of the meninges of the brain is classified to a generic

intervention number below 50 from Section 1: 1.AA.13.^^ Control of bleeding,
meninges and dura mater of brain. However, the intervention in this example
was performed using an open approach; therefore, it is mandatory to assign.
CCI’s Appendix A — CCI Code Structure — Qualifier 1 — Section —
Approach/Technique confirms that burr hole is an open approach for
Section 1; SE is defined as “using open approach with burr hole technique.”
Example: A patient with a pathological fracture of the vertebra is admitted, and a

percutaneous vertebroplasty is performed in the diagnostic imaging (DI) room.
1.SC.80.HA-XX-N Repair, spinal vertebrae, using percutaneous approach

and (injection of) synthetic material (e.g. bone cement)
Rationale: A vertebroplasty is an intervention classified to Section 1. It is mandatory

to assign a code from Section 1 when an intervention classified there
requires performance in an operating/intervention room. The DI room is
considered an “intervention room” because the vertebroplasty was
performed in it; therefore, it is mandatory to assign 1.SC.80.HA-XX-N.
Example: Closed elbow reduction performed on the nursing unit
1.TM.73.JA Reduction, elbow joint, using closed (external) approach
Rationale: 1.^^.73.^^ Reduction, fracture or dislocation is included in the table

Additional mandatory CCI codes for acute inpatient care; therefore, it is
mandatory to assign 1.TM.73.JA.
109
Composite Codes in CCI

DN When available, use one CCI code to describe complex health interventions by selecting the
appropriate qualifiers.
When one CCI code is not available to describe complex health interventions, code additionally any
DN
associated concomitant interventions.
Every attempt has been made to reduce the need for multiple code assignment to describe a
complex health intervention. In most cases, it is possible to use a single code to definitively
describe, in generic terms, the intent and means of accomplishing an intervention. When an
intervention commonly or frequently involves a sequence of associated concomitant actions
to reach its goal, this will be described — wherever possible — by a single code. The qualifiers
provide options that describe the alternate techniques involved.
Example: A partial gastrectomy may be performed alone or with a vagotomy. When the
vagotomy is performed with the gastrectomy, a qualifier is selected to identify this.
A second code for the vagotomy is not recorded.
1.NF.87.GX Excision partial, stomach, endoscopic [laparoscopic]

approach with vagotomy and esophagogastric anastomosis
Rationale: Vagotomy would be a separate code only when it is performed alone.
An even more common example is the excision of (lesion of) an anatomical site with a
concomitant repair involving a graft or a flap to close the surgical defect. A qualifier is selected
to describe the concomitant repair.
Example: A patient with breast malignancy undergoes a simple total mastectomy. The defect
is repaired using a local flap.
1.YM.89.LA-XX-E Excision total, breast, using open approach and local flap
Location: U
Rationale: Both the mastectomy and the repair of the surgical defect using a flap
are assigned to 1.YM.89.LA-XX-E.
110
Multiple Codes in CCI

Multiple codes from different rubrics
DN
When more than one intervention is performed during the same intervention episode, assign multiple codes
from different rubrics when there is no composite code (qualifier) to cover this combination.
DN
When an intervention is performed using robotic assistance, assign 7.SF.14.ZX Robotic assisted
telemanipulation of tools, service, using system NEC, mandatory, as an additional code.
Note
Not every action carried out during an intervention needs to be coded. Many smaller actions that are carried
out during an intervention episode are an inherent part of an overall intervention and do not need to be
coded separately. Additionally, the closure of the operative site is included in the intervention code.
Example: Closed reduction fracture of right humerus and open reduction with screw fixation
of left humerus
1.TK.74.LA-NW Fixation, humerus, open approach, using plate, screw,

no tissue used
1.TK.73.JA Reduction, humerus, using closed [external] approach
Rationale: Different generic interventions were performed on bilateral sites: fixation

of the left humerus and closed reduction of the right humerus.
Therefore, multiple codes are assigned.
Example: Robotic-assisted supraglottic laryngectomy for carcinoma in situ of the supraglottis
1.GE.87.NZ Excision partial, larynx NEC, open approach [e.g. apron

flap incision] with horizontal technique no tissue used
7.SF.14.ZX Robotic assisted telemanipulation of tools, service, using
system NEC
Rationale: It is mandatory to assign 7.SF.14.ZX when an intervention is performed

using robotic assistance.
111
Note
In CCI, explanatory notes are provided to clarify what is classified to a rubric or code.
When these notes describe various components of a complex intervention that may or may not be performed
in a given case, additional codes for these components are not assigned. These notes are intended to
eliminate assigning multiple codes. They do not purport to describe the exact nature of all possible
interventions that may be correctly classified to the rubric or code.
Example: The patient previously had a total colectomy with rectal sparing and creation of
ileostomy. He presents to hospital for elective takedown of the ileostomy,
completion proctectomy, ileoanal J-pouch and defunctioning loop ileostomy.
1.NQ.84.LA-XX-G Construction or reconstruction, rectum, using open

approach with ileum (to construct pouch)
1.NK.77.EN Bypass with exteriorization, small intestine, endoscopic
[laparoscopic] approach, end enterostomy [e.g. terminal,
end or loop ileostomy]
Rationale: This note is at 1.NQ.84.^^: “Usually involves takedown of ileostomy to

construct a functional pseudo-rectum using distal ileum. This may involve
conversion of a Hartmann rectal closure by excising remaining rectal
and anal tissue [e.g. anorectal mucosectomy].” The note provides the
information that the takedown of the existing ileostomy is included in this
rubric; therefore, one code, 1.NQ.84.LA-XX-G, is required to capture the
creation of the pelvic pouch and the concomitant takedown of the ileostomy.
An additional code is required for the creation of the temporary ileostomy
because this is not implicit with construction of the ileoanal J-pouch.
Note
In CCI, the “code also” instruction means that the rubric does not include the interventions in the “code also”
instruction. When the intervention in the “code also” instruction is performed, an additional code is
mandatory when it meets the requirements for mandatory code selection specified in these standards.
While “code also” notes have been included throughout CCI, they do not cover every possible circumstance
where multiple codes are required.
112
Example: The patient is admitted for a lumpectomy and sampling of the sentinel axillary
lymph nodes.
1.YM.87.LA Excision partial, breast, using open approach with simple

apposition of tissue (e.g. suturing)
Location: U
2.MD.71.LA Biopsy, lymph node(s), axillary, using open approach

Extent: SN
Rationale: Sampling of the sentinel axillary lymph nodes is not included at rubric
1.YM.87.^^. The “code also” instruction directs to also assign a code
from 2.MD.71.^^ if a biopsy (sampling) of the sentinel axillary lymph
nodes is also performed. It is mandatory to assign 2.MD.71.^^ based
on the direction in the coding standard Sentinel Lymph Node Biopsy.
Example: A patient suffers a trauma resulting in bone loss to the anterior maxilla. The patient
is admitted for a repair of the maxilla using autograft from her mandible, allograft
and screws.
1.ED.80.LA-NW-Q Repair, maxilla, open approach using plate, screw device

(with/without wire/mesh) with combined sources of tissue
1.EE.58.LA-XX-A Procurement, mandible, using open approach of
(bone) autograft
Rationale: The procurement of bone from the mandible is not included at rubric
1.ED.80.^^. While no “code also” note is included in this rubric, another
code is required to cover this combination. See also the coding standard
Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction.
113
Multiple codes from the same rubric

As a general rule, multiple codes from the same rubric are not assigned for the same
intervention episode, unless the codes within a rubric identify separate operative approaches.
Multiple codes from the same rubric are not assigned to show different devices used at the
same operative site. A hierarchy for orthopedic devices is provided below; in all other cases,
select the qualifier that is most significant or important for the reporting facility.
Example: The patient has both an esophagogastroduodenoscopy (EGD) and ileoscopy.
2.NK.70.BA-BL Inspection, small intestine, using endoscopic per orifice

approach (or via stoma) and gastroscope
2.NK.70.BD-BK Inspection, small intestine, using retrograde (via
rectum) endoscopic per orifice approach and (double)
balloon enteroscope
Rationale: EGD and ileoscopy are distinct interventions because they require
different operative approaches and involve different sites that happen to
be classified to the same rubric; therefore, multiple codes are assigned.
Note
In many orthopedic procedures, the surgeon may use more than one device to stabilize the bone. Make the
code selection based on the following hierarchy of devices (from highest to lowest):
• Endoprosthesis
• Intramedullary nail
• Screws and plates
• Pins and nails
• Wire, staples and mesh
• No device
Make the code selection based on the following hierarchy of devices used to repair ligament or soft tissue
(from highest to lowest):
• Biodegradable binding devices (e.g., bioscrews and biodegradable anchors)
• Screw (and washer)
• Endobutton or staple
• Sutures, suture anchors
114
Example: The patient suffers a hip fracture and is admitted for repair. An intramedullary nail
and screws are used for fixation.
1.VA.74.LA-LQ Fixation, hip joint, open approach, using intramedullary

nail, fixation device alone
Rationale: The fixation was performed at one operative site; therefore, only one
code is assigned. Using the orthopedic hierarchy of devices, the code
identifying the fixation using intramedullary nail is selected.
DN
When the same generic intervention is performed on bilateral sites and there is no variation in any
component of the CCI code, assign
• A single code from the rubric; and
• The location attribute “B” (signifying bilateral), mandatory, when available.
Example: A woman has a bilateral total mastectomy using free flap for breast cancer.
1.YM.90.LA-XX-F Excision total with reconstruction, breast, with no

implanted device, using free flap
Location: B
Rationale: Exactly the same intervention was performed on both sides; therefore,
only one code is assigned, along with the mandatory location attribute
to identify bilateral reconstruction.
Note
When the location attribute “bilateral” is not available, a single code is still assigned.
Example: A patient has an open reduction with internal fixation using a combination of plates
and screws for bilateral maxilla fractures.
1.ED.74.LA-NW Fixation, maxilla, using plate, screw device (with/without

wire/mesh) no tissue used [device only]
Rationale: Exactly the same intervention was performed on both sides; therefore,
only one code is assigned. There is no location attribute available at
1.ED.74.^^ because the maxilla is a single bone.
115

When the same generic intervention is performed on bilateral sites and there is a variation in any
DN
component of the CCI code, assign
• Separate codes for each intervention from the same rubric; and
• The applicable location attribute to each code, mandatory, when available.
Example: A patient has bilateral inguinal hernias repaired at the same intervention episode.
Both are repaired laparoscopically through separate groin incisions; the left side
requires mesh in the repair and the right side uses simple suturing.
1.SY.80.DA-XX-N Repair, muscles of the chest and abdomen, endoscopic

[laparoscopic] approach, using synthetic tissue
[e.g. mesh, sponge]
Status: 0
Location: LW
1.SY.80.DA Repair, muscles of the chest and abdomen, endoscopic
[laparoscopic] approach, without tissue [e.g. suturing
or stapling]
Status: 0
Location: LW
Rationale: When interventions are performed on bilateral sites and there is a

variation in any component of the CCI code, multiple codes are
assigned to identify these as different interventions. In this example,
the variation is with the tissue qualifier — one side used synthetic tissue
(mesh) and the other used no tissue. The mandatory location attributes
identify that each repair was unilateral.
Example: Closed reduction fracture of right humerus and open reduction fracture of left humerus
1.TK.73.JA Reduction, humerus, using closed [external] approach

Location: R
1.TK.73.LA Reduction, humerus, using open approach
Location: L
Rationale: Reductions were performed on the left and right humeri with different
approaches; therefore, multiple codes are assigned to identify these as
different interventions. The mandatory location attributes identify that
each reduction was unilateral.
116
Procurement or Harvesting of Tissue for

Closure, Repair or Reconstruction

When a separate incision is made to obtain the tissue, assign the appropriate CCI code for procurement
DN
of tissue.
Procurements are coded to reflect the existence of a separate surgical defect (wound) that
usually requires its own post-surgical care and monitoring. If an incision is simply enlarged to
obtain the tissue, there is no need to code the procurement. A local flap (for advancement,
rotation and realignment) does not usually involve a separate incision for procurement of
the flap.
For clinical information, see Definitions of flaps and grafts in Appendix A.
Example: A fasciocutaneous free flap from the thigh is harvested to repair a serious
facial burn.
1.YF.80.LA-XX-F Repair, skin of face, using free flap [e.g. microvascular

free flap]
1.YV.58.LA-XX-F Procurement, skin of leg, of free flap using open approach
Example: A high tibial osteotomy with patellar tendon transfer
1.VQ.80.LA-KD Repair, tibia and fibula, using wire, mesh, staple,

no tissue used (for repair)
1.VS.80.LA-XX-E Repair, tendons of lower leg [around knee], using
apposition technique [tendon sutured to tendon] with tendon
transfer for realignment [e.g. advancement, transposition]
Rationale: Procurement is not coded because a separate incision at another site

on the body was not made.
Note
When the tissue qualifier is “E,” this usually means that you do not need a procurement code.
117
Exception
Whenever a segment of the intestine is harvested, a procurement code is assigned. This happens most
often for repairs and reconstructions of the urinary tract and the esophagus. Because creating a defect along
the gastrointestinal tract always requires careful post-surgical monitoring, the procurement of intestine must
be coded.
Combined Diagnostic and Therapeutic Interventions


When both a diagnostic intervention from Section 2 and a therapeutic intervention from Section 1 are
DN
performed at the same anatomical site, assign a code for the therapeutic intervention, mandatory. Assign
a code for the diagnostic intervention, optional, as required to meet facility reporting requirements.
Exception
In order to identify whether a therapeutic intervention was performed by sigmoidoscopy or
colonoscopy, assign an additional code, mandatory, for the inspection (see also the coding standard
Endoscopic Interventions).
Exception
Sentinel lymph node biopsy, 2.M^.71.^^ Biopsy, lymph node(s), any site, with extent attribute “SN”
(sentinel node(s)) is mandatory to assign whenever it is performed. See also the coding standard
Sentinel Lymph Node Biopsy.
Example: A frozen section of a biopsy of thyroid that was performed on this patient reveals
malignancy and a total thyroidectomy is performed.
1.FU.89.^^ Excision total, thyroid gland

Location: U
Rationale: When a biopsy and a therapeutic intervention are performed at the same
site during the same operative episode, a code for the biopsy is optional.
118
Example: The patient is brought into hospital for a lumpectomy of her left breast. A sentinel
node biopsy is performed followed by an axillary node dissection.
1.YM.87.^^ Excision partial, breast

Location: L
1.MD.89.LA Excision total, lymph node(s), axillary, using open approach
Extent: SN
Rationale: It is mandatory to assign 2.MD.71.^^ with extent attribute “SN” (sentinel

node(s)) whenever performed. See also the coding standard Sentinel
Lymph Node Biopsy.
Note
The intent of an excisional biopsy is therapeutic as well as diagnostic. The lesion has to be excised and a
diagnosis established by pathology. The therapeutic intervention takes precedence and a code from Section 2
is not assigned. An excisional biopsy is classified to a “partial excision” at the appropriate anatomical site.
Example: The patient is brought into hospital to investigate a suspicious lump in her right
breast. The surgeon performs an excisional biopsy of breast, which is sent to
pathology for examination.

Location: R
Example: A trauma victim is taken to the operating room for an explorative laparotomy.
A ruptured spleen is identified upon opening the abdominal cavity. A total
splenectomy is performed.
1.OB.89.LA Excision total, spleen, using open [abdominal] approach
Rationale: When the intervention was planned as a diagnostic one but was
subsequently changed to a therapeutic one, only the therapeutic
component of the procedure is coded.
119
Example: The patient is experiencing severe shortness of breath. A CT scan of the chest
reveals significant pleural effusion. A pleurocentesis is performed, and the fluid is
sent to pathology for analysis. Pathology reports a malignant pleural effusion.
1.GV.52.^^ Drainage, pleura
Rationale: Aspiration of fluids from a body cavity may have both diagnostic and
therapeutic value. Procedures such as pleurocentesis are coded to the
therapeutic intervention “drainage.” Note: 3.GY.20.VA Computerized
tomography [CT], thoracic cavity NEC, without contrast would be
assigned on the ambulatory care abstract.
DN
Classify incisional biopsies in Section 2 to the generic intervention “biopsy” at the appropriate anatomical
site. Incisional biopsies involve removing a tissue sample for diagnostic purposes only.
Example: The patient is being followed by a nephrologist for elevated creatinine and blood urea
nitrogen (BUN). He is now being admitted for a renal biopsy to rule out glomerulonephritis.
2.PC.71.^^ Biopsy, kidney
Example: The patient is admitted for investigation of a suspicious lung lesion. A right lung
biopsy is done by percutaneous needle aspiration.
2.GT.71.HA Biopsy, lung NEC, using percutaneous (needle) approach

Location: R
See also the coding standard Endoscopic Interventions.
120
Endoscopic Interventions
Endoscopic interventions are widely performed and may be either diagnostic or therapeutic in
their intent.
DN When the intent of an endoscopy is diagnostic only, classify the intervention to “inspection” of the
anatomical site.
DN
Select the anatomical site based on the furthest site inspected through the endoscope
Example: Esophagogastroduodenoscopy (EGD) done for screening

DN
When a biopsy and an inspection are performed at the same anatomical site, assign a code for the
biopsy only.
Example: Colonoscopy with biopsy of lesion in transverse colon

2.NM.71.BA-BJ Biopsy, large intestine, using endoscopic per orifice
approach (or via stoma) and colonoscope
DN
At 2.NM.70.^^ Inspection, large intestine and 2.NM.71.^^ Biopsy, large intestine, select the device
qualifier based on the intent of the intervention (sigmoidoscopy versus colonoscopy).
An endoscopic intervention of the lower gastrointestinal tract may be performed either via
colonoscope or sigmoidoscope.
A colonoscopy and a sigmoidoscopy are very different interventions in terms of risk,

complication, preparation and anesthetic.
121
The device qualifiers at both 2.NM.70.^^ Inspection, large intestine and 2.NM.71.^^ Biopsy,
large intestine are meant to distinguish a colonoscopy from a sigmoidoscopy.
For clinical information, see also Diagnostic colonoscopic interventions in Appendix A.
Note
In some facilities, a colonoscope may be used when the intent is to perform a sigmoidoscopy; however, the
device qualifier “sigmoidoscope” is selected because the codes reflect the intent of the intervention. When
the documentation is unclear as to the intent of the procedure, refer to the consent form to identify the
planned intervention to which the patient consented.
Example: The patient presents for a flexible sigmoidoscopy. The inspection is successful to
the descending colon, and no biopsies are taken.
2.NM.70.BA-BH Inspection, large intestine, using endoscopic per orifice

approach (or via stoma) and flexible sigmoidoscope
Rationale: A sigmoidoscopy is an inspection of the rectum, to the sigmoid colon,

up into the lower portion of the descending colon.
Example: The patient presents for a colonoscopy. At the time of inspection, the physician is
able to proceed only as far as the sigmoid colon due to an obstruction. It is biopsied
and the scope is withdrawn.

Rationale: This is considered a failed intervention because the expected outcome

was not entirely achieved upon termination of the procedure. Classify a
failed intervention in the same manner as one that is successful.
122
Example: The patient is booked for a colonoscopy. The endoscope is inserted and maneuvered
through the colon. The ileocecal valve is visualized, and the scope is withdrawn.
2.NM.70.BA-BJ Inspection, large intestine, using endoscopic per orifice

Rationale: The intent of this procedure was a colonoscopy. The scope was
inserted up to the ileocecal valve, but the terminal ileum was not
intubated. Visualization of the ileocecal valve in this case is the
landmark that tells the physician he has successfully reached the
end of the colon and that the colonoscopy has been completed.
DN
When an inspection goes beyond the site of the biopsy, assign codes for both the biopsy and the
inspection, sequencing the biopsy first.
Example: EGD with biopsy of stomach lesion

2.NF.71.BA Biopsy, stomach, using endoscopic per orifice approach
(or via stoma)
DN
When the colonoscope enters the terminal ileum during colonoscopy, assign
• 2.NK.70.^^ Inspection, small intestine; or
• 2.NK.71.^^ Biopsy, small intestine when a biopsy is performed.
Example: The physician documents that the colonoscope was passed through the colon and
that the terminal ileum was intubated.
2.NK.70.BA-BJ Inspection, small intestine, using endoscopic per orifice

Rationale: In this example, the inspection has gone beyond the large intestine (NM) and has
entered the small intestine (NK); therefore, the correct CCI anatomical site is NK.
123
Example: The patient is booked for a colonoscopy. The endoscopy report documents that a
colonoscope was inserted and a suspicious lesion was seen in the ascending colon;
it was biopsied. There is also documentation that the terminal ileum was intubated.
The scope was then withdrawn.


Rationale: When an inspection goes beyond the anatomical site of a biopsy,

assign codes for both the biopsy and the inspection, sequencing the
biopsy first.
Example: The colonoscope is advanced through the colon and into the terminal ileum.
Biopsies are taken of the rectum, colon and ileum.
2.NK.71.BA-BJ Biopsy, small intestine, using endoscopic per orifice


2.NQ.71.BA Biopsy, rectum, using endoscopic per orifice approach
Rationale: When separate anatomical sites are biopsied, a code for each site is
assigned; the deepest site is sequenced first.
124
Example: The patient has an EGD and a colonoscopy. The gastroscope is advanced to the
duodenum. The colonoscope is advanced into the terminal ileum, and the physician
notes findings of ileitis in the terminal ileum.


Rationale: Although two codes from the same rubric are not normally assigned,
in this example, two distinct interventions were performed.
DN
When both an inspection and a therapeutic intervention are performed at the same anatomical site,
assign a code for the therapeutic intervention only.
Exception
In order to identify whether a therapeutic intervention was performed by sigmoidoscopy or colonoscopy,
assign an additional code, mandatory, for the inspection.
Example: Cystoscopy with fulguration of bladder tumor
1.PM.59.BA-GX Destruction, bladder, endoscopic per orifice approach

using device NEC (for tissue ablation or lithotripsy)
Rationale: Inspection by cystoscopy is inherent in the device qualifier (BA)

at destruction, bladder; therefore, a code for cystoscopy is not
assigned separately.
125
Example: Colonoscopy with polypectomy of large intestine
1.NM.87.BA Excision partial, large intestine, endoscopic per orifice

approach, simple excisional technique
Location: U
2.NM.70-BA-BJ Inspection, large intestine, using endoscopic per orifice
Rationale: A code for the inspection is assigned along with the therapeutic
intervention to identify that a colonoscopy instead of a sigmoidoscopy
was performed.
Example: Colonoscopy to cecum with polypectomy of sigmoid colon and random biopsies of
ascending colon
1.NM.87.BA Excision partial, large intestine, endoscopic per orifice

approach, simple excisional technique
Location: U

Rationale: In this example, colonoscopy is inherent in the device qualifier (BJ) for the
biopsy code; therefore, a code for inspection is not assigned separately.

When separate anatomical sites are biopsied during one operative episode, assign a code for the biopsy of
DN
each anatomical site.
• Sequence the biopsy of the deepest site first.
Example: EGD with biopsy of stomach lesion and biopsy of a duodenal lesion
2.NK.71.BA-BL Biopsy, small intestine, using endoscopic per orifice

2.NF.71.BA Biopsy, stomach, using endoscopic per orifice approach
(or via stoma)
See also the coding standard Combined Diagnostic and Therapeutic Interventions.
126
Interventions to Manage Bleeding

See also the coding standards Selection of Interventions to Code for Acute Inpatient Care and
Selection of Interventions to Code for Ambulatory Care.
Interventions to manage bleeding can be classified to 1.^^.13.^^ Control of bleeding, 1.^^.51.^^

Occlusion, 1.^^.59.^^ Destruction or 1.^^.80.^^ Repair depending upon
• The anatomical site:
- For example, some organs are only ever repaired to manage bleeding. In order to not
duplicate categories in CCI, there are no repair (80) interventions available for the
tonsil/adenoid, thyroid, spleen and liver anatomical sites. The management of bleeding
of these organs is included in the intervention control of bleeding (13);
• The method used to manage the bleeding (e.g., vessel occlusion, local area destruction or
organ repair); and
• Whether or not the bleeding is a result of a damaged artery/vein or is within a solid organ.
Note
It is essential to follow the includes/excludes notes in CCI to determine the correct rubric for interventions to
manage bleeding.
Example: During his hospital admission, the patient requires control of an episode of
intractable epistaxis. This is accomplished by clipping the ethmoid artery via a
transantral open approach.
1.JX.51.LA-FF Occlusion, other vessels of head, neck and spine NEC,

open approach [e.g. transantral, Caldwell Luc] using clips
Extent: 0
Rationale: The excludes note at rubric 1.ET.13.^^ excludes ligation of the

ethmoidal artery and directs the coder to assign 1.JX.51.^^.
DN
When a solid organ is damaged and is bleeding from within, or when the bleeding is due to internal
pathology, assign 1.^^.13.^^ Control of bleeding, by anatomical site.
127
Example: A stabbing victim has surgery to control bleeding to an internal wound of the liver.
An open approach is used to apply fibrin glue to repair the damage and stem
the bleeding.
1.OA.13.LA-W3 Control of bleeding, liver, open approach using fibrin glue

Extent: 0
Example: The patient is admitted for uterine embolization for control of heavy uterine bleeding
due to fibroids. This is accomplished via uterine artery embolization with two coils.
1.RM.13.GQ-GE Control of bleeding, uterus and surrounding structures, using

percutaneous (transarterial) approach and [detachable] coils
Extent: 02
Example: During his hospital stay, the patient requires control of an episode of intractable
epistaxis. A transarterial embolization of the ethmoid artery is accomplished
using microspheres.
1.ET.13.GQ-W0 Control of bleeding, nose, using percutaneous [transarterial]

approach and other synthetic material [e.g. gelfoam,
microspheres, polystyrene, polyvinyl alcohol, contour particles]
Extent: 0
DN
When a blood vessel outside of an organ has been transected and is being repaired to control hemorrhage,
assign a code from 1.^^.80.^^ Repair of the blood vessel.
Example: A stabbing victim has surgery to control internal bleeding caused by a transected
hepatic artery, which is repaired with simple suturing through a laparotomy approach.
1.KE.80.LA Repair, abdominal arteries NEC, using open approach
DN
When an intervention to manage bleeding is done to a skin site via destruction of tissue, assign a code from
1.^^. 59.^^ Destruction, skin, by site. Omit the code when the management of bleeding is part of a more
invasive procedure.
128
Example: A patient with a bleeding laceration of the skin on his forehead has the bleeding
controlled via cauterization only, with light dressing applied.
1.YB.59.JA-GX Destruction, skin of forehead, using device NEC
Example: A patient with a bleeding laceration of the skin on the forehead has the bleeding
points cauterized prior to suturing of the laceration.
1.YB.80.LA Repair, skin of forehead, using apposition technique

[e.g. suturing, stapling]
Rationale: While both cauterization and sutures were performed to manage the
bleeding, the sutures are more invasive; therefore, only 1.YB.80.LA
is assigned.
Destruction or Excision of Aberrant/

Ectopic Tissue
In effect 2006

Classify the excision or destruction of aberrant (or ectopic) tissue of a gland or an organ to the anatomical
DN site of origin, even though the tissue is found outside the site of origin and at a distance from it.
The most common types of aberrant tissue found away from a gland or organ are adrenal,
endometrial and parathyroid. A location attribute indicating that the tissue is aberrant (AT)
may be selected to accompany the intervention code.
Example: Laparoscopic destruction by electrocautery of endometrial tissue found within the

pelvic cavity — on ovary and intestine
1.RM.59.DA-GX Destruction, uterus and surrounding structures,

endoscopic [laparoscopic] approach using device NEC
[e.g. electrocautery, rollerball diathermy]
Location: AT
Rationale: The destruction is of endometrial tissue even though it is found on the

ovary and intestine. No intervention is assigned to indicate surgery on
the ovaries or intestines.
129
Debulking of a Space-Occupying Lesion

In effect 2006
For various reasons, it is not always possible to completely excise a lesion. For example, in an
intracranial lesion, the neurological defect could be so severe as to outweigh the benefits of total
eradication of the neoplasm. A surgeon may, however, choose to excise or destroy the bulk of
the lesion to alleviate symptoms or to facilitate subsequent radiation or chemotherapy. When an
intramarginal excision or destruction of a lesion is performed, it is frequently termed a “debulking”
of a tumor. Excisional debulking procedures should not be confused with biopsy procedures,
where the intent is to remove a small piece of the tumor for diagnostic purposes only.
Debulking procedures of intracranial lesions may be performed using an ultrasonic aspirator.

Common names for this frequently used tool are “Cavitron” and “Cavitronic ultrasonic
aspirator (CUSA).”
Following this intralesional excision, chemotherapy may be used to further retard the growth of
(and shrink) the neoplasm. A planned second resection done to complete surgical management
of the lesion may be flagged with a status attribute “staged.” Because this is a completion
procedure, it would never be described as a revision. This holds true even if a person returns
for a neoplasm resection at the same site years later. In such a situation, the resection would
be coded without the use of an attribute at all.
If, however, a re-visitation to the original site of the resection is required to evacuate a hematoma
or to debride an abscess, the status attribute “revision” must be used to describe this (see also
the coding standard Revised Interventions).

Classify debulking procedures to the generic CCI intervention “destruction” or “partial excision,” by site,
DN according to the procedure performed.
Example: The surgeon performs a debulking of a tracheal tumor using laser via bronchoscopy.
1.GJ.59.BA-AG Destruction, trachea, using endoscopic per orifice

approach and laser
Example: The surgeon performs a craniotomy to debulk a cerebral neoplasm using a

CUSA device.
1.AN.87.SZ-AZ Excision partial, brain, craniotomy [or craniectomy] flap
technique for access, with ultrasonic aspirator [e.g. CUSA]
130
Abandoned Interventions
An abandoned intervention describes a situation in which a planned intervention classifiable to

Section 1 or Section 5 is begun but, due to usually unanticipated circumstances, cannot be
completed beyond an incision, inspection, biopsy or anesthetization.
DN
When a planned intervention from Section 1 or Section 5 cannot be completed beyond incision, inspection,
biopsy or anesthetization, assign a CCI code from one of the following:
• Incision (1.^^.70)
• Inspection (2.^^.70)
• Biopsy (2.^^.71)
• Anesthetization (1.^^.11)
DN
Immediately following, sequence the CCI code for the planned intervention from Section 1 or Section 5,
optional. If the code is assigned, it is mandatory to assign the status attribute “A.”
Note
When an intervention meets the criteria for “abandoned,” it is mandatory to assign the status attribute “A,”
when available, even when the status attribute is not activated as mandatory in Folio (i.e., the status attribute
box is not pink in Folio).
Note
An attribute for abandoned does not exist in Section 2 and Section 3. When a planned intervention from
Section 2 or Section 3 is attempted beyond anesthetization but the expected outcome is either poor or not
achieved entirely, code the intervention in the same manner as an intervention with successful results.
See also the coding standards Failed Interventions and Cancelled Interventions.
131
Example: The intended intervention was to excise the large intestine for a malignancy, but at
laparotomy it is discovered that the neoplasm is so extensive that removal is
impossible. The surgeon simply conducts an inspection and then closes the
abdomen without attempting the colon resection.
2.OT.70.^^ Inspection, abdominal cavity
1.NM.89.^^ Excision total, large intestine

Status: A
Note
An incision into the site may be coded for a limited number of anatomical sites (e.g., 1.OT.70.LA Incision NOS,
abdominal cavity using open approach).
Example: The patient is admitted to the day surgery unit for tonsillectomy. The patient is taken
to the operating room and given general anesthesia. The surgeon notes that he
cannot position the Boyle Davis gag to allow access to the tonsils because the
patient has a very large neck. The procedure is terminated and the patient is
discharged home.
1.ZZ.11.HA-P1 Anesthetization, total body, using percutaneous (needle)

approach and general anesthetic agent
1.FR.89.LA Excision total, tonsils and adenoids, tonsillectomy alone
using device NEC
Status: A
Example: The patient presents for bronchoscopy. Her throat is sprayed with Xylocaine, but
the physician is called off to an emergency before the procedure starts. The patient
is discharged home to have the procedure rebooked for another date.
No CCI code assigned.
Rationale: This example does not meet the definition of an abandoned intervention.
It also does not meet the definition of a failed intervention because the
bronchoscopy (a Section 2 intervention) was not attempted beyond
anesthetization. Therefore, the example meets the definition of a cancelled
intervention. The patient presented for a scheduled intervention that
did not occur due to administrative reasons. See the coding standard
Cancelled Interventions for direction related to diagnosis code assignment.
132
Failed Interventions
DN Classify a failed intervention in the same manner as one that is successful.
For the purposes of classification, an intervention is considered “failed” if, on termination of the
procedure, the expected outcome is either poor or not achieved entirely.
Example: A failed cholangiogram could mean that the common bile duct was explored but that
the dye could not pass, as expected, into the duct. As a result, the expected outcome
(viewing of the common bile duct using a dye) was not adequately achieved.
Code the cholangiogram.
3.OE.10.WZ Xray, bile ducts, following endoscopic (retrograde)

injection of contrast
Example: A failed elective coronary angioplasty could be one during which the balloon catheter
could not be advanced beyond the stenosis in the artery. The expected dilation of the
coronary artery could not be performed to the satisfaction of the surgeon.
Code the coronary angioplasty.
1.IJ.50.GQ-BD Dilation, coronary arteries, percutaneous transluminal

cutting balloon dilator without stent insertion
Status: P
Extent: DG
Assign also 3.IP.10.VX Xray, heart with coronary arteries, of left heart
structures using percutaneous transluminal arterial
(retrograde) approach
Status: UN
Location: U
133
Note
In such a scenario, the responsible physician will sometimes attempt to clear the plaque or thrombus
formation by injecting a thrombolytic agent directly into the coronary artery. This is classified to 1.IL.35.HA-1C
Pharmacotherapy (local), vessels of heart, percutaneous injection approach of thrombolytic agent. When a
drug is administered via a venous approach, it must be considered systemic pharmacotherapy. When the
drug is injected into an artery, it is always classified to local pharmacotherapy.
Example: The patient is prepped for an endoscopic retrograde cholangiopancreatography

(ERCP). The procedure is started and the ampulla appears inflamed, as though it
may have been traumatized. The pancreatic duct is easily opacified and seen to be
normal. Despite good positioning and trying various papillotomes, it is not possible to
get deep cannulation of the bile duct even using a wire. The procedure is aborted.
3.OG.10.WZ Xray, biliary ducts with pancreas, following endoscopic

(retrograde) injection of contrast [ERCP]
Example: Failed closed reduction of the shoulder joint is one in which the responsible
physician could not reduce the displaced bone to its normal anatomical location
despite efforts in that direction. Code the closed reduction, even though the
desired outcome was not achieved. The patient goes on to have an open reduction
and internal fixation at a later operative episode.
1.TA.73.JA Reduction, shoulder joint, using closed (external) approach
Exception
Failed trial of labor following previous Cesarean section (subcategory O66.4) and failed application of vacuum
extractor and forceps (subcategory O66.5) are captured by ICD-10-CA codes and do not lend themselves to
this coding standard. See also the coding standard Interventions Associated With Delivery.
See also the coding standard Abandoned Interventions.
134
Change of Plans During an Intervention

DN
When an intervention is performed that is different than the one originally intended, code only the
intervention that was actually performed.
The intended therapeutic intervention has no clinical significance and must not be recorded on
the abstract. Coding of therapeutic interventions reflects what was actually done.
Example: The patient is admitted with abdominal pain. Appendicitis is suspected, and the
patient is taken to the operating room for an appendectomy. At laparotomy, it is
clear that the patient has a ruptured ovarian cyst and a normal appendix.
Unilateral oophorectomy is performed.
1.RB.89.LA Excision total, ovary, using open approach

Location: U
Converted Interventions
DN
When an intervention begins as an endoscopic approach but is changed to an open approach, select the
qualifier to indicate open approach and assign the status attribute “C” (converted).
CCI allows for the capture of information regarding interventions that begin as endoscopic
procedures but, for some reason, must be changed to an open approach. The status attribute
“C” (converted) is currently available at the most common interventions where this may occur.
The intervention is coded with the appropriate qualifier designating the open approach, followed
by the use of the status attribute “C.”
135
Note
When an intervention meets the criteria for “converted,” it is mandatory to assign the status attribute “C,”
when available, even when the status attribute is not activated as mandatory in Folio (i.e., the status attribute
box is not pink in Folio).
Example: The patient is admitted for a laparoscopic cholecystectomy. Extensive adhesions

are encountered while attempting to perform the cholecystectomy, so the
intervention is switched to an open cholecystectomy.
1.OD.89.LA Excision total, gallbladder, open approach,

cholecystectomy alone without extraction (of calculi)
Status: C
Revised Interventions
Describing a therapeutic intervention as a revision in CCI requires the use of status attribute “R.”
Note
The status attribute “R” (revision) is currently activated as mandatory (i.e., the status attribute box is pink) at
the most common interventions where a revision intervention may occur. However, when the attribute box is
yellow, it is mandatory to assign the status attribute “R” whenever the criteria stated in the directive box
below are met.
DN
Assign the status attribute “R” when the current intervention is a complete or partial redo of an
intervention performed previously for any problem, whether expected (e.g., end of life of device) or
unexpected (e.g., complication).
136
Note
The following interventions are not classified as revisions:
• Re-insertion of stents, catheters and shunt systems (e.g. 1.^^.52.^^): The replacement of stents and
catheters is such a routine activity that it is considered a reasonable expectation, especially when in situ
long term.
• Management of any internal device (1.^^.54.^^): Devices such as cardiac pacemakers, lens prostheses,
chest tubes and penile prostheses will always involve going back to the site of the original implant. Hence it
is redundant to code these as revisions, and the attribute is unavailable at this generic intervention.
• Control of bleeding using local application of antihemorrhagic agent, packing, diathermy or thermal device,
electrocautery, or external manual compression or direct compression to the site (1.^^.13.^^ and not
requiring re-apposition by suture, staple, etc.).
• Management of operative wounds, for example, first repair of an incisional hernia, wound debridement or
scar revision.
• Implantation of internal device (1.^^.53.^^) when it is the initial (first) implantation of an internal device at
a site where an intervention was previously performed.
• A second resection at the same anatomical site: This is usually done to take care of additional diseased
tissue and must be considered a new resection each time it is performed.
• Any intervention on a surgically constructed site (i.e., anatomical sites OW — Surgically Constructed Sites
in Digestive and Biliary Tract, PV — Surgically Constructed Sites in Urinary Tract and KY — Artery With
Vein), as these are always, by nature, revisions in themselves; status attribute “R” is not available.
• Repeat diagnostic interventions such as biopsies performed to discover if any new pathology has returned
to a site or inspections with no further intervention (e.g., a post-operative exploratory laparoscopy) are
not revisions because they result in no real definitive change to the previous intervention at that
anatomical site.
137
D Example: Diagnosis: Loose left hip arthroplasty

Previous procedure: Total left hip replacement
Current intervention: Replacement of acetabular cup using a bone graft and cement
T84.030 (M) A Mechanical complication of hip prosthesis, loosening
Y83.1 (9) A Surgical operation with implant of artificial internal

device as the cause of abnormal reaction of the
patient, or of later complication, without mention of
1.SQ.53.LA-PM-Q Implantation of internal device, pelvis, prosthetic device,

single component [e.g. cup] using combined sources of
tissue [e.g. bone, graft, cement/paste]
Status: R
Location: L
Rationale: This example meets the criteria for revision because it is a partial redo of
an intervention performed previously. It is mandatory to assign the status
attribute “R.” The redo is for an unexpected reason.
D Example: Diagnosis: End of life of pacemaker

Previous procedure: Implantation of a dual chamber rate responsive pacemaker (DDD)
Current intervention: Total replacement of DDD, which includes replacement of
battery/generator pack and replacement of ventricular and atrial leads
Code DAD Code title

Z45.00 (M) Adjustment and management of cardiac pacemaker
1.HZ.53.GR-NK Implantation of internal device, heart NEC, percutaneous

transluminal [transvenous] approach or approach NOS, dual
chamber rate responsive pacemaker [DVI, DDD, DDDR modes]
Status: R
Extent: AV
Rationale: This example meets the criteria for revision because it is a complete redo
of an intervention performed previously. It is mandatory to assign the
status attribute “R” despite the fact that the status attribute box is yellow.
The redo is for an expected reason.
138
D Example: Diagnosis: Pain in the left knee. The patient had left knee repair with meniscectomy two
years ago and has now developed osteoarthritis requiring a total knee replacement.
Previous procedure: Knee repair with meniscectomy
Current intervention: Total replacement of the knee prosthesis, uncemented,
using a tri component prosthetic device
Code DAD Code title
M17.9 (M) Gonarthrosis, unspecified
1.VG.53.LA-PP Implantation of internal device, knee joint, uncemented,

tri component prosthetic device
Status: P
Location: L
Extent: 3
Rationale: This example does not meet the criteria for revision because it is not a
redo of a previous intervention for the meniscus problem. This is the first
implantation of a joint prosthesis.
DN Example: Diagnosis: Leaking left breast implant

Previous procedure: Insertion of bilateral silicone breast implants
Current intervention: Replacement of the left breast prosthesis with a new silicone
implant using open approach and no graft required

T85.4 (M) MP A Mechanical complication of breast prosthesis and implant
Y81.2 (9) OP A General- and plastic-surgery devices associated with

adverse incidents, prosthetic and other implants,
materials and accessory devices
1.YM.79.LA-PM Repair by increasing size, breast, open approach with

implantation of prosthesis without tissue
Status: R
status attribute “R.” The redo is for an unexpected reason.
139
DN Example: Diagnosis: Incisional hernia in upper abdominal region

Previous procedure: Cholecystectomy
Current intervention: Herniorrhaphy with mesh and autograft, open approach
K43.2 (M) MP Incisional hernia without obstruction or gangrene
1.SY.80.LA-XX-Q Repair, muscles of the chest and abdomen, open approach

using combined sources of tissue [e.g. mesh with autograft]
Status: 0
Location: UP
Rationale: This example does not meet the criteria for revision because it is a first-
time repair of an incisional hernia (i.e., it is not a recurrent incisional
hernia that was previously repaired).
DN Example: Diagnosis: Continued symptoms of nerve entrapment following left carpal tunnel
release performed two years previously
Previous procedure: Carpal tunnel release, left wrist
Current intervention: Carpal tunnel release, left wrist

G56.0 (M) MP Carpal tunnel syndrome
1.BN.72.LA Release, nerve(s) of forearm and wrist, using open approach

Status: R
status attribute “R” despite the fact that the status attribute box is yellow.
This redo is for an unexpected reason.
140
D Example: One year after fixation of the second and third metatarsal bones of the right foot,
the patient returns for surgery due to excessive pain and migration of the pins
(noted on X-ray). The surgeon elects to fuse the MTP joints because of malunion;
fixation is not a good option for this obese man. This time, wire is used and an iliac
crest bone graft is harvested.
M84.07 (M) — Malunion of fracture, ankle and foot
T84.15 (1) A Mechanical complication of internal fixation device of bones of foot
1.WJ.75.LA-KD-A Fusion, tarsometatarsal joints, other metatarsal bones and

other metatarsophalangeal joints [forefoot], using wire, staple,
with bone autograft
Status: R
1.SQ.58.LA-XX-A Procurement, pelvis, of [bone] autograft [e.g. iliac crest

bone graft] using open approach
Rationale: This example meets the criteria for revision because it is a complete
redo of a correction of the fracture, even though a different intervention is
done to accomplish this. It is mandatory to assign the status attribute “R”
despite the fact that the status attribute box is yellow. This redo is for an
unexpected reason.
141
A staged intervention versus revision of an intervention

Staged interventions involve a complex course of treatment planned right from the onset.
Revisions represent a problem requiring a complete or partial redo.

Apply the status attribute “S” to all (initial and subsequent) surgical interventions that are part of the
DN
complex course of treatment. Currently, capturing staged interventions is optional, but facilities may
elect to code this based on their data needs.
Note
At times it may be difficult to tell whether a second procedure is a revision or part of a planned series of steps
(stages) to reach the desired outcome. When in doubt, discuss the decision to use the staged or revision
attribute with the surgeon.
D Example: A child with a cleft face has had the major portion of her face repaired and is now
presenting for cleft palate repair.
Code DAD Code title
Q35.9 (M) Cleft palate, unspecified
1.FB.86.LA-XX-E Closure, fistula, hard palate, using local flap [e.g. levator veli
palatini sling reconstruction; VY advancement flap, vomer flap]
Status: S (optional)
142
D Example: A child who had her cleft palate repaired is admitted to undergo a reclosure of her
palate due to a palatal fistula.
T81.82 (M) A Persistent postoperative fistula
Y83.4 (9) A Other reconstructive surgery as the cause of abnormal reaction of

the patient, or of later complication, without mention of misadventure
1.FB.86.LA-XX-E Closure, fistula, hard palate, using local flap [e.g. levator veli
palatini sling reconstruction; VY advancement flap, vomer flap]
Status: R
Rationale: This is a revision procedure and not a staged procedure. The palatal fistula
is a complication of the original repair and was not planned. It is mandatory
to assign the status attribute “R” despite the fact that the status attribute
box is yellow.
143
Chapter I — Certain infectious and

parasitic diseases
Infections
See also the coding standards Using Diagnostic Test Results in Coding and
DN When coding an infection and the causative organism is not known, code the infection by site.
DN Example: The patient presents with abdominal pain, which is later shown to be due to a
urinary tract infection (UTI).
Code Code title

N39.0 Urinary tract infection, site not specified

When the causative organism is known, classify the case in one of the following three ways, as indicated
DN
by the classification:
• Use the dual classification (dagger/asterisk) with a code specifying the infectious organism followed by
the manifestation. Both codes must be used together to identify the infectious disease.
• Use a combination code.
• Use two codes, the first identifying the locally manifesting disease and the second identifying the
infectious organism. The infectious agent is classified to categories B95–B98. Assignment of codes from
categories B95–B98 is optional; if coded, they must be assigned diagnosis type (3)/other problem.
144
Chapter I — Certain infectious and parasitic diseases
Exception
It is mandatory to assign a code from B95–B98 Bacterial, viral and other infectious agents as a diagnosis type
(3)/other problem when the causative agent is one of the specific drug-resistant microorganisms. See also the
coding standard Drug-Resistant Microorganisms.
DN Example: The patient is diagnosed with a candidal infection of the vulva and vagina.
Code Code title
B37.3† Candidiasis of vulva and vagina
N77.1* Vaginitis, vulvitis and vulvovaginitis in infectious and parasitic diseases

classified elsewhere
Rationale: Candidiasis of vulva and vagina is classified using the dual

classification (dagger/asterisk).
DN Example: Final diagnosis: Clostridium difficile diarrhea resistant to multiple antibiotics.
Code Code title
A04.7 Enterocolitis due to Clostridium difficile
Rationale: Clostridium difficile diarrhea is classified using a combination code per

the classification. It is one of the most common causes of antibiotic-
associated diarrhea. Antibiotic-associated diarrhea is not the same as
an infection due to a specific drug-resistant microorganism; therefore,
do not assign U83.7 Resistance to multiple antibiotics.
DN Example: After laboratory investigation, the physician confirms acute cystitis due to E. coli.
N30.0 (M) MP Acute cystitis
B96.2 (3) OP Escherichia coli [E. coli] as the cause of diseases

Rationale: Acute cystitis due to E. coli is classified using two codes. One code
identifies the locally manifesting disease (cystitis) and one code
identifies the documented infectious organism (E. coli); however,
assignment of B96.2 is optional.
145
DN
When only the organism is known and the site is not specified, classify as infection by the organism of
unspecified site.
DN Example: The chart documentation states only “Staph infection.”
Code Code title
A49.0 Staphylococcal infection, unspecified site
Drug-Resistant Microorganisms
The presence of the drug-resistant microorganisms methicillin-resistant Staphylococcus aureus

(MRSA), carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum betalactamase
(ESBL) producing microorganisms and vancomycin-resistant enterococci (VRE) has been
increasing and is a patient safety concern in hospitals across the country. Once in a health
care environment, these drug-resistant microorganisms can be difficult to treat, can further
compromise a patient who is already unwell and can spread to other patients.
When a patient has a current infection due to MRSA, CRE, ESBL producing microorganisms or
VRE, it means that the drug-resistant microorganism has caused the infection. The correct code
assignment is described in the directive statements below.
For clinical information, see Drug-resistant microorganisms in Appendix A.
146
Infections due to MRSA, CRE, ESBL or VRE
DN
When there is a current infection that is clearly documented by the physician/primary care provider as
being due to MRSA, CRE, ESBL producing microorganisms or VRE, assign, mandatory, the appropriate code
combination to identify the
• Site of the infection, as a significant diagnosis type/main problem or other problem;
• Infectious microorganisms from categories B95–B98 Bacterial, viral and other infectious agents as a
diagnosis type (3)/other problem; and
• Specific drug-resistance as a comorbid diagnosis type (1) or type (2)/other problem:
− U82.1 Resistance to methicillin; or
− U82.20 Resistance to carbapenem; or
− U82.28 Resistance to other specified extended spectrum betalactam antibiotics; or
− U83.0 Resistance to vancomycin.
Note
Documentation by infection control staff stating that a patient has a current infection due to MRSA, CRE,
ESBL producing microorganisms or VRE may be used to meet the requirement for code assignment as
directed above.
Note
It is mandatory to apply the diagnosis cluster to the set of codes that describes a drug-resistant
microorganism infection. See also the coding standard Diagnosis Cluster.
147
D Example: This patient, who has primary, bilateral osteoarthritis of the hip, is admitted for a left
total hip replacement. Five days post-surgery, the physician documents that the
patient has an infected hip prosthesis with the presence of MRSA in the wound.
The patient is started on antibiotics and placed in isolation. A consult with the
infection control nurse results in initiation of the MRSA protocol.
M16.0 (M) — Primary coxarthrosis, bilateral
T84.53 (2) A Infection and inflammatory reaction due to

hip prosthesis
B95.6 (3) A Staphylococcus aureus as the cause of diseases


Rationale: The infection is clearly documented as being due to MRSA. It is mandatory

to assign the set of codes that describe an infection due to a specific drug-
resistant microorganism: the infection (T84.53), the specific microorganism
causing the infection (B95.6) and the specific drug resistance (U82.1).
DN Example: Final diagnosis: ESBL E. coli UTI

N39.0 (M) MP A Urinary tract infection, site not specified
B96.2 (3) OP A Escherichia coli [E. coli] as the cause of diseases

U82.28 (1) OP A Resistance to other specified extended spectrum

betalactam antibiotics
Rationale: The infection (UTI) is clearly documented as being due to ESBL E. coli.
It is mandatory to assign the set of codes that describe an infection due
to a specific drug-resistant microorganism: the infection (N39.0), the
specific microorganism causing the infection (B96.2) and the specific
drug resistance (U82.28).
148
D Example: The patient is admitted for treatment of infected stage II pressure ulcers. The ulcers
are documented as infected by VRE and MRSA.
L89.1 (M) A Stage II decubitus [pressure] ulcer
B95.6 (3) A Staphylococcus as the cause of diseases classified

to other chapters
U83.0 (1) A Resistance to vancomycin
B95.21 (3) A Enterococcus as the cause of diseases classified to

other chapters
Rationale: The infected pressure ulcers are clearly documented as being due to
VRE and MRSA. It is mandatory to assign the set of codes that describe
an infection due to a specific drug-resistant microorganism: the infection
(L89.1), the specific microorganisms causing the infection (B95.6 and
B95.21) and the specific drug resistance (U82.1 and U83.0).
DN Example: A patient is admitted with a diagnosis of pneumonia due to MRSA.
J15.2 (M) MP A Pneumonia due to Staphylococcus

Rationale: The infection is clearly documented as being due to MRSA. It is

mandatory to assign the set of codes that describe an infection due to a
specific drug-resistant microorganism: the infection (J15.2), the specific
microorganism causing the infection (B95.6) and the specific drug
resistance (U82.1).
149
Carriers of drug-resistant microorganisms

When a patient is a carrier of MRSA, CRE, ESBL producing microorganisms or VRE, it means
that the microorganism is present on or in the body without causing illness. Patients will have no
signs or symptoms of infection but will have a positive microbiology report for MRSA, CRE, ESBL
producing microorganisms or VRE. Documentation of a positive microbiology report for MRSA,
CRE, ESBL producing microorganisms or VRE without documentation of a current infection
due to these drug-resistant microorganisms is classified to Z22.30– Carrier of drug-resistant
microorganism. Many facilities have policies and procedures related to screening certain patients
for specific drug-resistant microorganisms. Knowing your facility’s policies and procedures related
to drug-resistant microorganisms will help with correct interpretation of the documentation.

Assign Z22.30– Carrier of drug-resistant microorganism, mandatory, as a diagnosis type (3)/other problem
DN
when there is documentation that the patient is a carrier of a specific drug-resistant microorganism.
Note
Documentation by nursing or infection control staff stating that a patient is a carrier of a specific drug-
resistant microorganism may be used to capture Z22.30– as a mandatory diagnosis type (3)/other problem.
DN Example: This patient presents with congestive heart failure. The physician documents
that the swab taken from the patient at the time of admission came back MRSA+.
There is no documentation indicating that the patient has a current infection.
As a precautionary measure, the patient is placed in isolation.

I50.0 (M) MP Congestive heart failure
Z22.300 (3) OP Carrier of drug-resistant staphylococcus
150
Septicemia/Sepsis
In effect 2001, amended 2005, 2006, 2008, 2009, 2012, 2015, 2018
A response to infection, sepsis can be a serious condition calling for immediate medical care.
If sepsis becomes severe, it can result in extensive tissue damage, organ failure or death.
Sepsis can be caused by a number of bacterial, fungal or viral infections that progress into the
bloodstream. While sepsis can develop from minor infections, such as the flu or a UTI, it is most
likely to develop in people who have serious wounds, extremely weakened immune systems
and open or exposed areas from catheters. 1
See also the coding standards Confirmed Sepsis and Risk of Sepsis in the Neonate, Systemic
Inflammatory Response Syndrome (SIRS) and Post-Intervention Conditions.

Assign a code for septicemia/sepsis only when the physician has documented the diagnosis. It cannot be
DN assumed or ruled out on the basis of laboratory values alone.
• When the underlying localized infection is documented, assign an additional code, mandatory, as a
significant diagnosis type.
• When septic shock is documented, also assign R57.2 Septic shock, mandatory
Exception
When sepsis and the underlying localized infection are classified using the dagger/asterisk coding convention,
the localized infection is assigned either diagnosis type (3) or (6).
151
D Example: The history and physical states that the patient was seen in the emergency
department on January 1 and sent home with a diagnosis of E. coli UTI. The patient
returns on January 3, complaining of feeling unwell. He is admitted to the intensive
care unit (ICU) with a diagnosis of sepsis.
Final diagnosis: E. coli sepsis due to UTI
Code DAD Code title
A41.50 (M) Sepsis due to Escherichia coli [E.coli]
N39.0 (1) Urinary tract infection, site not specified
B96.2 (3) Escherichia coli [E. coli] as the cause of diseases classified to other
chapters (optional)
Rationale: When the underlying localized infection is documented in cases of

generalized sepsis, codes identifying both sepsis and the localized
infection are assigned as significant diagnosis types.
D Example: The patient is being treated in ICU for Staphylococcus aureus septicemia due
to pneumonia.
Final diagnosis: Sepsis and pneumonia due to Staphylococcus aureus
Code DAD Code title

A41.0 (M) Sepsis due to Staphylococcus aureus
J15.2 (1) Pneumonia due to Staphylococcus
Rationale: Sepsis is documented, so A41.0 is assigned; it meets the definition

of MRDx.
152
D Example: A 35-year-old trauma patient is in ICU for several days and develops an E. coli
UTI that progresses to E. coli septicemia. He continues to deteriorate, with
signs of acute renal failure and hepatic failure, and goes into septic shock.
Despite aggressive treatment, the patient dies.
Code DAD Code title
A41.50 (2) Sepsis due to Escherichia coli [E.coli]
N17.9 (2) Acute renal failure, unspecified
K72.9 (2) Hepatic failure, unspecified
R57.2 (2) Septic shock
B96.2 (3) Escherichia coli [E. coli] as the cause of diseases classified to other
chapters (optional)
R65.1 (3) Systemic inflammatory response syndrome of infectious origin with

acute organ failure (optional)
Note
Sometimes physicians will use the term “sepsis” to describe a localized infection; therefore, care must be
taken in code assignment. When the term “sepsis” is used to mean a localized infection, search the lead term
“Infection” rather than “Sepsis.”
153
D Example: The patient undergoes an abdominal hysterectomy and is subsequently diagnosed

with fever two days following the surgery. The incision site is noted to be reddened,
and there is purulent drainage. The physician documents that the patient has
wound sepsis due to staph epidermidis.
T81.4 (2) A Infection following a procedure,

B95.7 (3) A Other staphylococcus as the cause of diseases

Y83.6 (9) A Removal of other organ (partial) (total) as the

cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the
time of the procedure
Rationale: The physician has used the term “sepsis” to describe a localized infection
(redness and purulent drainage). There is no documentation describing an
illness affecting the body as a whole; therefore, a code for septicemia/sepsis
is not assigned. As this is a post-intervention condition, it is mandatory to
assign the diagnosis cluster to all the codes assigned related to this
condition. See also the coding standard Post-Intervention Conditions.

When septicemia/sepsis is classified to one of the following:
DN
O03–O05 Pregnancy with abortive outcome (with a fourth character .0 or .5)
O07.3 Failed attempted abortion, complicated
O08.0– Genital tract and pelvic infection following abortion and ectopic and molar pregnancy
O75.3– Other infection during labour
O85.– Puerperal sepsis
O98.– Maternal infectious and parasitic diseases complicating pregnancy, childbirth and the
puerperium (with a fourth character of .2, .5 or .8)
T80.2 Infections following infusion, transfusions and therapeutic injection
T81.4 Infection following a procedure, not elsewhere classified
T88.0 Infection following immunization
T82–T85 Infections and inflammatory reaction due to prosthetic devices, implants and grafts
• Assign the appropriate code from the list above as a significant diagnosis type/main or other problem; and
• Assign an additional code, mandatory, to identify the type of sepsis as a diagnosis type (3)/other problem.
154
Note
Categories T82–T85 Infections and inflammatory reaction due to prosthetic devices, implants and grafts are
used only when an infected device, implant or graft is documented as causing the sepsis. Otherwise, T81.4
Infection following a procedure, not elsewhere classified is assigned. See also the coding standard Complications
of Devices, Implants and Grafts.
DN Example: The patient has an incomplete spontaneous abortion with candidal septicemia
diagnosed during the current episode of care.

O03.0 (M) MP Spontaneous abortion, incomplete, complicated by
genital tract and pelvic infection
B37.7 (3) OP Candidal sepsis
D Example: The patient develops post-operative E. coli septicemia following total colectomy
with stoma creation.

T81.4 (2) A Infection following a procedure,
A41.50 (3) A Sepsis due to Escherichia coli [E.coli]
Y83.3 (9) A Surgical operation with formation of external stoma

as the cause of abnormal reaction of the patient,
or of later complication, without mention of
D Example: The patient develops post-operative staphylococcal sepsis documented as due to a

prosthetic cardiac valve replacement.

T82.6 (2) A Infection and inflammatory reaction due to cardiac
valve prosthesis
A41.2 (3) A Sepsis due to unspecified staphylococcus
Y83.1 (9) A Implant of artificial internal device, as the cause

of abnormal reaction of the patient, or of later
complication, without mention of misadventure at
155
D Example: The patient is admitted for a total colectomy with ileostomy for colon cancer.
On post-operative day 2, he develops post-operative staphylococcus sepsis.
On post-operative day 4, he is transferred to the intensive care unit with
septic shock.
T81.4 (2) A Infection following a procedure, not

T81.1 (2) A Shock during or resulting from a procedure,

R57.2 (3) A Septic shock
Y83.3 (9) A Surgical operation with formation of external stoma

Rationale: Per the alphabetical index lookup for sepsis, postprocedural, post-
operative sepsis is classified to T81.4. Per the use additional code
note at T81.4, it is mandatory to assign an additional code to provide
specificity; therefore, A41.2 is assigned to identify the type of sepsis.
Per the directive statement, it is mandatory to also assign a code for

septic shock (R57.2). Post-operative septic shock is classified to
T81.1, per the alphabetical index lookup for shock, postoperative.
R57.2 is assigned to identify the type of shock per the use additional
code note at T81.1.
156
D Example: The patient is admitted to the intensive care unit with a diagnosis of central line–
associated E. coli sepsis and septic shock. He is treated with intravenous antibiotics
and is subsequently discharged home.

T82.701 (M) A Bloodstream infection and inflammatory reaction due
to central venous catheter
A41.50 (3) A Sepsis due to Escherichia coli [E.coli]
T82.8 (1) A Other specified complications of cardiac and

vascular prosthetic devices, implants and grafts
R57.2 (3) A Septic shock
Y84.8 (9) A Other medical procedures as the cause of abnormal

Rationale: Per the alphabetical index lookup, infection due to or resulting from an
infusion catheter specified as a central venous catheter, central line–
associated sepsis (or bloodstream infection) is classified to T82.701.
Per the use additional code note at T82.701, it is mandatory to assign
an additional code to provide specificity; therefore, A41.50 is assigned to
identify the type of sepsis.
Per the directive statement, it is mandatory to also assign a code for

septic shock (R57.2). Central line–associated septic shock is classified
to T82.8, per the alphabetical index lookup complication, infusion,
catheter, specified NEC. R57.2 is assigned to identify the type of
shock per the use additional code note at T82.8.
DN When more than one causative organism of septicemia/sepsis is documented, assign a code for each.
DN Example: The patient has septicemia documented as due to E. coli and

staphylococcus bacteria.
Code Code title

A41.50 Sepsis due to Escherichia coli [E.coli]
A41.2 Sepsis due to unspecified staphylococcus
157
Human Immunodeficiency Virus (HIV) Disease

In effect 2001, amended 2005, 2006, 2007, 2008, 2012, 2015
DN
When a patient with AIDS/HIV disease presents for management of one or more manifestations of
AIDS/HIV disease, assign
• B24 Human immunodeficiency virus [HIV] disease as the MRDx/main problem; and
• An additional code as a diagnosis type (1)/other problem in the second position for the manifestation
being treated.
DN
When AIDS or HIV disease is recorded as a diagnosis, assume that a documented condition, classified to the
code ranges below, is a manifestation of AIDS/HIV disease:
• Infectious and viral diseases: A00–B19, B25–B34, B99;
• Mycoses: B35–B49;
• Protozoal diseases: B58–B64;
• Neoplasms: C46.–, C81–C96; or
• Pneumonia (viral, bacterial and infectious): J12–J18. 2
Note
The above directives apply when AIDS or HIV disease is recorded; it does not apply when the diagnosis is
“HIV positive.”
AIDS manifestations are not limited to the code ranges above. The list above shows the manifestations that
are assumed if no connection is provided in the documentation. When a condition is documented as resulting
from HIV disease or AIDS, classify that condition as a manifestation.
Note
B24 Human immunodeficiency virus [HIV] disease cannot appear as the MRDx/main problem without an
additional code for at least one manifestation.
Note
B24 Human immunodeficiency virus [HIV] disease must not be recorded as a post-admit comorbidity
(diagnosis type (2)).
158
D Example: A patient who has AIDS is admitted for treatment of Kaposi’s sarcoma of the soft
palate. The patient also has lymphoma, which is not actively treated at this admission.
Code DAD Code title
B24 (M) Human immunodeficiency virus [HIV] disease
C46.2 (1) Kaposi’s sarcoma of palate
C85.9 (3) Non-Hodgkin lymphoma, unspecified
D Example: The patient is admitted due to severe AIDS-related dementia. The patient also has
Kaposi’s sarcoma of the skin, which is not treated during this admission.
Code DAD Code title
B24† (M) Human immunodeficiency virus [HIV] disease
F02.4* (6) Dementia in human immunodeficiency virus [HIV] disease
C46.0 (3) Kaposi’s sarcoma of skin
Rationale: Code F02.4* is the only asterisk code that may be sequenced in the
second position on the abstract after B24 Human immunodeficiency
virus [HIV] disease. As AIDS-related dementia is the focus of care in this
example, it is assigned a diagnosis type (6).
DN Example: A patient who has AIDS is treated for Pneumocystis jiroveci pneumonia (PJP).
B24 (M) MP Human immunodeficiency virus [HIV] disease
B59† (1) OP Pneumocystosis
J17.3* (3) OP Pneumonia in parasitic diseases
159
DN Example: A patient who has AIDS encounters the health care system for treatment of wasting
syndrome due to HIV.
B24 (M) MP Human immunodeficiency virus [HIV] disease
R64 (1) OP Cachexia

When the diagnosis is recorded as “HIV positive” with no documentation of AIDS or HIV disease and
DN
the patient
• Has an indicator disease listed in the chapter on AIDS in Case Definitions for Communicable Diseases
Under National Surveillance (see below), assign B24 Human immunodeficiency virus [HIV] disease.
• Does not have an indicator disease listed in the chapter on AIDS in Case Definitions for Communicable
Diseases Under National Surveillance (see below), assign Z21 Asymptomatic human immunodeficiency
virus [HIV] infection status.
National surveillance case definitions for acquired immunodeficiency

syndrome (AIDS): Indicator diseases for adults and adolescents age 15 and
older 3
Bacterial pneumonia, recurrent
Candidiasis, bronchi, trachea or lungs
Candidiasis, esophageal
Cervical cancer, invasive
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis chronic intestinal, >1 month duration
Cytomegalovirus diseases, other than in liver, spleen or nodes
Cytomegalovirus retinitis, with loss of vision
Encephalopathy, HIV-related dementia
Herpes simplex: chronic ulcer(s), >1 month duration, or bronchitis, pneumonitis or esophagitis
Histoplasmosis, disseminated or extrapulmonary
160
Isosporiasis, chronic intestinal >1 month duration

Kaposi’s sarcoma
Lymphoma, Burkitt’s or equivalent term
Lymphoma, immunoblastic or equivalent term
Lymphoma, primary in brain
Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary

Mycobacterium of other species or unidentified species
Mycobacterium tuberculosis, disseminated or extrapulmonary
Mycobacterium tuberculosis, pulmonary
Pneumocystis jiroveci pneumonia (formerly known as Pneumocystis carinii pneumonia)
Progressive multifocal leukoencephalopathy
Salmonella sepsis, recurrent

Toxoplasmosis of brain
Wasting syndrome due to HIV
Indicator diseases for pediatric cases only (younger than age 15)
Bacterial infections, multiple or recurrent, excluding recurrent bacterial pneumonia
Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia
D Example: A patient who has a diagnosis of “HIV positive” is admitted for treatment of
disseminated histoplasmosis.
Code DAD Code title

B39.3 (1) Disseminated histoplasmosis capsulati
Rationale: When a patient presents to hospital with one or more conditions from
the national surveillance case definitions for AIDS list (an indicator
disease) and the clinical documentation states only that the patient is
“HIV positive,” it is assumed the patient has HIV disease classifiable to
B24, not simply Z21 Asymptomatic human immunodeficiency virus [HIV]
infection status.
161
DN Example: A patient is admitted for treatment of staphylococcus pneumonia. The documentation

also states that the patient is “HIV positive.”
J15.2 (M) MP Pneumonia due to Staphylococcus
Z21 (3) OP Asymptomatic human immunodeficiency virus [HIV]

infection status
Rationale: In this example, the documentation states “HIV positive.”

Staphylococcus pneumonia is not recorded as recurrent; therefore,
documentation does not support that this patient has an indicator
disease for AIDS. Z21 Asymptomatic human immunodeficiency virus
[HIV] infection status is assigned for the diagnosis of “HIV positive.”
DN
Ensure that the following mutually exclusive codes are not assigned for the same episode of care:
• R75 Laboratory evidence of human immunodeficiency virus [HIV]
• Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
• B24 Human immunodeficiency virus [HIV] disease
Ensure that R75 is not assigned as the MRDx/main problem, as it relates to patients who have an
DN
inconclusive HIV test.
When patients are admitted and discharged on the same day for primary prophylactic chemotherapy for
DN HIV infection, select Z29.2 Other prophylactic chemotherapy as the MRDx/main problem along with Z21
Asymptomatic human immunodeficiency virus [HIV] infection status, mandatory, as an additional diagnosis
DN Example: An HIV-infected patient with no symptoms attends for anti-retroviral therapy on a

same-day basis.
Z29.2 (M) MP Other prophylactic chemotherapy
Z21 (3) OP Asymptomatic human immunodeficiency virus [HIV]

infection status
162
When a patient who has previously been identified as having AIDS presents with a condition that is
DN unrelated to the HIV disease, and that condition fulfils the criteria for MRDx/main problem, assign the
presenting condition as the MRDx/main problem for that admission.
D Example: The patient suffers a Colles fracture of the right arm due to a fall on ice on a
sidewalk. The patient also has active HIV disease. His fracture is treated, and he
is discharged two days later.
Code DAD Code title
S52.500 (M) Colles’ fracture, closed
W00 (9) Fall on same level involving ice and snow
U98.4 (9) Place of occurrence, street and highway
U99.9 (9) During unspecified activity (optional)
B24 (3) Human immunodeficiency virus [HIV] disease
References
1. Canadian Institute for Health Information. In Focus: A National Look at Sepsis. 2009.

3. Public Health Agency of Canada. Case Definitions for Diseases Under National
Surveillance. 2000.
163
Chapter II — Neoplasms
Primary and Secondary Neoplasms

When a patient is diagnosed with a primary neoplasm with metastasis, and treatment is directed toward
DN
both the primary and secondary sites equally, sequence the primary site before the secondary site.
DN
When metastasis is diagnosed during an episode of care, assign diagnosis type (1)/other problem for the
specified metastatic sites.
Note
Codes from the range C00–D48 are never assigned diagnosis type (2).
D Example: The patient is diagnosed with right lower lobe lung cancer with vertebral metastasis.
Chemotherapy is initiated for the primary lesion, and radiotherapy sessions are
given to treat the bony metastasis.
Code DAD Code title
C34.30 (M) Malignant neoplasm of lower lobe, right bronchus or lung
C79.5 (1) Secondary malignant neoplasm of bone and bone marrow
1.ZZ.35.HA-M0 Pharmacotherapy, total body, percutaneous approach

using antineoplastic agent NOS
1.SC.27.JA Radiation, spinal vertebrae, using external beam
164
D Example: The patient is admitted for modified radical mastectomy. The pathology report
shows infiltrating ductal carcinoma of the right breast. Three axillary lymph nodes
are positive for metastases.
Code DAD Code title
C50.90 (M) Malignant neoplasm of right breast, part unspecified
C77.3 (1) Secondary malignant neoplasm of axillary and upper limb

lymph nodes
Rationale: Metastasis to the axillary lymph nodes was diagnosed during the
episode of care and qualifies as a diagnosis type (1).
DN
When a patient is diagnosed with a secondary neoplasm, assign an additional code, mandatory, to identify
the primary site: a code from either
• Chapter II — Neoplasms; or
• Category Z85 Personal history of malignant neoplasm when the malignancy has been completely
eradicated or excised and there is no further treatment (including adjuvant therapy) being directed to
the primary site.
D Example: A patient with an inoperable malignant neoplasm of the sigmoid colon is admitted
for aspiration of malignant ascites with drainage tube. No treatment is directed
toward the colon cancer.
Code DAD Code title

C78.6 (M) Secondary malignant neoplasm of retroperitoneum and peritoneum
C18.7 (3) Malignant neoplasm of sigmoid colon
1.OT.52.HA-TS Drainage, abdominal cavity, using percutaneous (needle)

approach and leaving drainage tube in situ
165
DN Example: The patient presents to day surgery for bronchoscopy and left lung biopsy.
The morphology reveals metastatic carcinoma from the patient’s primary breast
malignancy. The patient had a radical mastectomy five years ago.
C78.01 (M) MP Secondary malignant neoplasm of left lung
Z85.39 (3) OP Personal history of malignant neoplasm of breast,

unspecified side
2.GT.71.BA Biopsy, lung NEC, using endoscopic per orifice approach

Location: L
N Example: A patient with metastatic right breast cancer treated with chemotherapy presents for
radiotherapy of liver metastases. The patient is on maintenance Herceptin therapy
for the breast cancer.

Z51.0 MP Radiotherapy session
C78.7 OP Secondary malignant neoplasm of liver and intrahepatic bile duct
C50.90 OP Malignant neoplasm of right breast, part unspecified
Rationale: It is mandatory to assign a code for the primary malignancy when a

patient is diagnosed with a secondary neoplasm. The primary site is
classified to C50.90 (not Z85.30) because the patient is still undergoing
adjuvant therapy (Herceptin), which is considered treatment directed at
the primary site.

When a primary site is specified and “carcinomatosis” is recorded as a final diagnosis
DN
• Without mention of the specific secondary sites, assign C79.9 Secondary malignant neoplasm,
unspecified site.
• With mention of the specific secondary sites, assign individual codes for the secondary sites.
DN
When the primary site is unspecified and “carcinomatosis” is recorded as a final diagnosis, assign two
codes: C80.9 Malignant neoplasm, primary site unspecified and C79.9 Secondary malignant neoplasm,
unspecified site.
166
D Example: The patient is diagnosed with primary malignancy of his sigmoid colon “with
carcinomatosis.” The metastatic sites are not documented.
Code DAD Code title
C18.7 (M) Malignant neoplasm of sigmoid colon
C79.9 (1) Secondary malignant neoplasm, unspecified site
Rationale: The primary site is known; therefore, a statement of “carcinomatosis”

refers to metastatic spread from the primary site. There is no mention of
the secondary sites, so C79.9 is assigned to identify metastatic cancer.
D Example: The patient is brought in complaining of severe abdominal pain. She is admitted by
the general surgeon. Exploratory laparotomy reveals extensive carcinomatosis.
Code DAD Code title
C80.9 (M) Malignant neoplasm, primary site unspecified
C79.9 (1) Secondary malignant neoplasm, unspecified site
Rationale: When a patient is diagnosed with a secondary neoplasm, it is mandatory

to identify the primary site. In this example, the primary site is unspecified;
therefore, C80.9 is assigned.
D Example: The patient is investigated during the admission, and the pathology report identifies
primary carcinoma of the pancreas with metastases to the right lung, bone and
brain. The final diagnosis is stated as “carcinomatosis.”
Code DAD Code title
C25.9 (M) Malignant neoplasm pancreas part unspecified
C78.00 (1) Secondary malignant neoplasm of right lung
C79.3 (1) Secondary malignant neoplasm of brain and cerebral meninges
C79.5 (1) Secondary malignant neoplasm of bone and bone marrow
Rationale: The primary and metastatic sites are known and specifically documented;
therefore, a code for each site is assigned.
167
Multiple Independent Primary Neoplasms


When a patient is diagnosed with multiple independent primaries, assign a code to identify the site of each
DN
primary neoplasm.
DN Example: The patient has an exploratory laparoscopy, in which her left ovary and colon are
biopsied. The pathology report reveals separate primary malignancies of the ovary
and the colon.
C56.0 (M) MP Malignant neoplasm of ovary, unilateral
C18.9 (1) OP Malignant neoplasm colon, unspecified

When a patient is diagnosed with documented separate primary invasive neoplasms in the same organ,
DN
but they are of non-contiguous sites, code each separate primary neoplasm.
DN Example: The patient has investigation and diagnosis of a transitional cell carcinoma of the
posterior wall of the bladder, as well as a separate non-contiguous transitional cell
carcinoma of the trigone of the bladder.

C67.4 (M) MP Malignant neoplasm of posterior wall of bladder
C67.0 (1) OP Malignant neoplasm of trigone of bladder
168
DN Example: The pathology report describes two malignant primary neoplasms of the right
breast. Both are in the 12 o’clock position, but they are non-contiguous (one is
superior to the other).
C50.80 (M) MP Overlapping malignant lesion of right breast
C50.80 (1) OP Overlapping malignant lesion of right breast
Rationale: The fourth character .8 has been selected because the 12 o’clock
position overlaps the outer and inner quadrants. This case is not one
of a contiguous neoplasm whose point of origin cannot be determined.
Even though the neoplasms fall to the same code, they are listed twice
to describe the circumstances of two separate primaries.

When a patient has separate primary invasive neoplasms and in situ neoplasia at separate, non-contiguous
DN
locations within the same organ, assign a code for each.
D Example: The patient is admitted for left mastectomy for carcinoma of the upper-outer
quadrant of the breast. The pathology report describes infiltrating duct carcinoma
and a non-contiguous carcinoma in situ in the 2 o’clock position.
Code DAD Code title

C50.41 (M) Malignant neoplasm of upper-outer quadrant of left breast
D05.11 (1) Intraductal carcinoma in situ of left breast
Rationale: Two codes are assigned: one for the infiltrating duct carcinoma and one
for the carcinoma in situ.
169
Acquired Absence of Breast and Lung Due to

Primary Malignancy
In effect 2015
The purpose of assigning Z90.1– Acquired absence of breast(s) in combination with a code
from Z85.3– Personal history of malignant neoplasm of breast is to assist in identifying patients
who have undergone previous total mastectomy for the treatment of primary malignancy.
Likewise, the purpose of assigning Z90.2– Acquired absence of lung [part of] in combination
with a code from Z85.11– Personal history of malignant neoplasm of bronchus and lung is to
assist in identifying patients who have undergone previous lobectomy/pneumonectomy for the
treatment of primary malignancy. These patients are now undergoing another excision (partial
or total) of the contralateral breast or lung (or the remainder of the lung) for a new primary
malignancy. The collection of this data makes it possible to analyze and report on these
patient types to study surgical treatment outcomes.

When a patient has a history of total mastectomy for the treatment of primary malignancy and is now
DN
undergoing partial or total excision of the contralateral breast (with/without reconstruction) for a new
primary breast malignancy, assign two additional codes, mandatory:
• Z90.1– Acquired absence of breast(s) as a diagnosis type (3)/other problem; and
• Z85.3– Personal history of malignant neoplasm of breast as a diagnosis type (3)/

other problem.
DN
When a patient has a history of lobectomy or pneumonectomy for the treatment of primary malignancy and
is now undergoing partial or total excision of either lung for a new primary lung malignancy, assign two
additional codes, mandatory:
• Z90.2– Acquired absence of lung [part of] as a diagnosis type (3)/other problem; and
• Z85.11– Personal history of malignant neoplasm bronchus and lung as a diagnosis type
(3)/other problem.
See also the coding standards Personal History of Primary Malignant Neoplasm of Breast,
Lung and Prostate and Recurrent Malignancies.
170
D Example: The patient is admitted for left simple mastectomy for invasive breast cancer. The
patient has a history of invasive right breast cancer treated with total mastectomy
12 years ago.
Code DAD Code title
C50.91 (M) Malignant neoplasm of left breast, part unspecified
Z90.10 (3) Acquired absence of right breast
Z85.30 (3) Personal history of malignant neoplasm of right breast
Rationale: The patient has a history of total mastectomy of the right breast and
is now undergoing total excision of the left breast for primary breast
cancer. It is mandatory to assign Z90.10 in combination with Z85.30 to
identify that this patient has previously undergone a total mastectomy for
the treatment of primary breast cancer.
D Example: The patient is admitted for right upper lobectomy for adenocarcinoma of the lung.
The patient has a history of left lower lobectomy for primary lung cancer five years ago.
Code DAD Code title

C34.10 (M) Malignant neoplasm of upper lobe, right bronchus or lung
Z90.21 (3) Acquired absence of left lung [part of]
Z85.111 (3) Personal history of malignant neoplasm of left bronchus and lung
Rationale: The patient has a history of left lower lobectomy and is now undergoing
excision on the contralateral lung (right upper lobectomy) for primary
lung cancer. It is mandatory to assign Z90.21 in combination with
Z85.111 to identify that this patient has previously undergone a
lobectomy for the treatment of primary lung cancer.
171
D Example: The patient is admitted for a completion pneumonectomy of the residual left lung for
a new primary squamous cell carcinoma. The patient has a history of left lobectomy
for primary lung cancer three years ago.
Code DAD Code title
C34.91 (M) Malignant neoplasm left bronchus or lung, unspecified
Z90.21 (3) Acquired absence of left lung [part of]
Z85.111 (3) Personal history of malignant neoplasm of left bronchus and lung
Rationale: The patient has a history of left lobectomy and is now undergoing
excision on the remainder of the same lung for primary lung cancer. It is
mandatory to assign Z90.21 in combination with Z85.111 to identify that
this patient has previously undergone a lobectomy for the treatment of
primary lung cancer and is now undergoing excision in the same lung for
a new primary lung cancer.
Neoplasms Arising in Lymphoid, Hematopoietic

and Related Tissue
DN
When there is documentation of more than one site of malignancy in lymphatic and hematopoietic
tissues (i.e., one in each system), code each site as a separate primary neoplasm.
DN Example: A patient admitted with multiple myeloma is also determined to have

developed leukemia.
C90.0 (M) MP Multiple myeloma
C95.9 (1) OP Leukaemia, unspecified
172
When a primary of the lymphoid hematopoietic or related tissues (categories C81–C96) is documented as
DN
having metastasized, do not assign a secondary malignancy neoplasm code.
Unlike solid tumors of other sites, neoplasms that arise in lymphatic and hematopoietic tissues
do not metastasize to secondary sites. The malignant cells circulate within the lymphatic or
hematopoietic circulation and may occur in other sites within these tissues, but they are
considered to be part of the primary disease rather than metastatic spread.
The physician documentation may describe the extent of these malignancies using terminology
such as “spread to” or “metastasis to”; however, these are included in the appropriate code
from C81–C96. 1
DN Example: A patient with multiple myeloma is stated to have metastatic spread to the pelvis
and spine.
Code Code title
C90.0 Multiple myeloma
DN Example: A patient with non-Hodgkin’s lymphoma is stated to have metastatic spread to the
inguinal nodes.
Code Code title
C85.9 Non-Hodgkin lymphoma, unspecified
DN When documentation indicates “leukemia in remission,” assign a code from categories C91–C95.
173
DN Example: The patient is stated to have leukemia in remission for six months.
Code Code title
C95.9 Leukaemia, unspecified
Rationale: Leukemia described as “in remission” cannot be specifically identified in

ICD-10-CA. “In remission” means that the disease activity has abated
but the condition is still present. Diagnosis type will depend on the
circumstances documented in the record.
Neoplasms Extending Into Adjacent Tissue

In effect 2002
Classify neoplasms to the point of origin when documented as “invading into” or “extending into”
DN adjacent sites.
DN Example: Pancreatic malignancy extending into the duodenum
Code Code title
C25.9 Malignant neoplasm pancreas part unspecified
174
Neoplasms With Overlapping Boundaries

(Contiguous Sites)
Classify a neoplasm that overlaps two or more contiguous sites within a three-character category and
DN
whose point of origin cannot be determined to the subcategory .8 (overlapping lesion), unless the
combination is specifically indexed elsewhere.
DN Example: The patient has a carcinoma of the tip and ventral surface of the tongue. No point of
origin is determined or documented.
Code Code title

C02.8 Overlapping malignant lesion of tongue
DN Example: The patient has a carcinoma of the tip of the tongue documented as “with invasion”
or “spreading to” the ventral surface of the tongue.
Code Code title

C02.1 Malignant neoplasm of border of tongue
Rationale: The point of origin is known and stated as the tip of the tongue.
DN Example: The patient has a malignant neoplasm that overlaps the junction of the esophagus
and stomach.
Code Code title
C16.0 Malignant neoplasm of cardia
Rationale: This site of overlap (of sites next to each other) is indexed separately.
175
Classify a neoplasm that overlaps two or more contiguous sites of separate three-character categories
DN
and whose point of origin cannot be determined to a distinct single code listed in ICD-10-CA at the
beginning of Chapter II — Neoplasms (C00–D48) at Note 5.
DN Example: The patient has a malignant neoplasm, which is stated as overlapping the pylorus
and duodenum.
Code Code title
C26.8 Overlapping malignant lesion of digestive system
Rationale: Malignant neoplasm of the pylorus is classified to C16.4, and malignant

neoplasm of the duodenum is classified to C17.0. Since the neoplasm
overlaps the two sites otherwise classified at different three-character
categories, and its point of origin cannot be determined, the code
for overlapping lesion of the digestive tract is assigned. Coders are
directed to the notes at the beginning of Chapter II — Neoplasms,
where they will find a list of applicable .8 categories.
Admissions Following Diagnosis of Cancer

When a patient is admitted for definitive surgery to remove tissue from the site of a neoplasm that was
DN
previously excised, assign a code for the primary malignancy as the MRDx/main problem. This is the case
even when the pathology report for the current episode is negative for malignancy.
176
DN Example: The patient has a skin lesion removed from her shoulder area as an outpatient.
The pathology report shows malignant melanoma. The patient returns for wider
excision. Pathology is negative for malignancy.
C43.6 (M) MP Malignant melanoma of upper limb, including shoulder
Rationale: Definitive surgery includes removal of a neoplasm and/or surrounding

tissue. As in this example, the physician most often documents the
diagnosis as malignancy in accordance with the initial biopsy or
excision. The coder should accept this diagnosis, even though the
pathology report shows no malignancy remaining, since the surgery
is part of the treatment plan for the malignant condition.
Complications of Malignant Disease

DN
When a patient is admitted for treatment of a specific complication of the malignancy, and no treatment is
directed toward the malignancy itself, assign the code for the complication as the MRDx/main problem.
• Assign the code for the malignancy, mandatory, as a diagnosis type (3)/other problem.
Exception
When the complication is captured as an asterisk code, assign the malignancy as the MRDx and the asterisk
code as a diagnosis type (6).
DN Example: Family members bring the patient to the emergency department. He is complaining
of lethargy, fever and generalized pain. The emergency department physician admits the
patient for treatment of his streptococcal septicemia. He has chronic myeloid leukemia.
A40.9 (M) MP Streptococcal sepsis, unspecified
C92.1 (3) OP Chronic myeloid leukaemia [CML], BCR/ABL-positive
177
D Example: The patient has primary adenocarcinoma of the lung and is admitted for
management of resulting anemia.
Code DAD Code title
C34.99† (M) Malignant neoplasm bronchus or lung, unspecified, unspecified side
D63.0* (6) Anaemia in neoplastic disease

When a patient is admitted for management of a side effect of cancer treatment, assign a code for the side
DN
effect as the MRDx/main problem.
• Assign the code for the malignancy, mandatory, as a diagnosis type (3)/other problem.
D Example: The patient is admitted for treatment of chemotherapy-induced neutropenia.

The patient is receiving a combination of chemotherapy agents as an outpatient
for treatment of cancer of the left lower lobe of the lung.
D70.0 (M) A Neutropenia

therapeutic use
C34.31 (3) — Malignant neoplasm of lower lobe, left bronchus

or lung
178
N Example: The patient is undergoing outpatient radiotherapy sessions for advanced carcinoma
of the prostate. He presents to the emergency department complaining of the
inability to urinate for the past 12 hours. The emergency department physician
orders blood tests, urinalysis, X-ray of the kidney with IV contrast and urinary
catheterization. The patient is transferred to the urology service with the admitting
diagnosis of urinary retention.

R33 MP Retention of urine
C61 OP Malignant neoplasm of prostate
3.PC.10.VC Xray, kidney, following intravenous injection of contrast (with or

Assign diagnosis type (2), post-admit comorbidity, to side effects of chemotherapy that arise during a
D
patient’s admission for diagnosis and initial treatment for cancer when the side effect condition satisfies
the criteria for post-admit comorbidity.
D Example: A patient newly diagnosed with acute lymphoblastic leukemia has his initial
chemotherapy treatment while in hospital. He experiences significant nausea and
vomiting requiring IV therapy.
C91.0 (M) — Acute lymphoblastic leukaemia [ALL]
R11.3 (2) A Nausea with vomiting

therapeutic use

using antineoplastic agent NOS
179
Recurrent Malignancies

Assign a code from categories C00–C75 when a primary malignancy, eradicated from the same organ or
DN
tissue, has recurred.
• Assign an additional code, mandatory, from category Z85 Personal history of malignant neoplasm as a
diagnosis type (3)/other problem to identify the primary site.
DN Example: The patient is diagnosed with infiltrating ductal carcinoma of the right breast and
undergoes a lumpectomy with removal of the entire lesion. A year later, she
comes in with a nodule in the same breast at the site of the previous lumpectomy.
Needle biopsy shows infiltrating ductal carcinoma. This is a recurrence of the
primary malignancy.
C50.90 (M) MP Malignant neoplasm of right breast, part unspecified
Z85.30 (3) OP Personal history of malignant neoplasm of

right breast
undergoes a mastectomy with removal of the entire breast. A year later, she comes
in with a nodule at the site of the previous mastectomy. Needle biopsy shows
infiltrating ductal carcinoma. The physician documentation and pathology report
state that there is recurrence of the infiltrating ductal carcinoma in the right chest
wall (after the mastectomy).


right breast
180
undergoes a lumpectomy with removal of the entire lesion. A year later, she comes
in with a nodule in the same breast at the site of the previous lumpectomy.
The physician documentation and pathology report state metastatic infiltrating
ductal carcinoma in skin of lumpectomy scar.
C79.2 (M) MP Secondary malignant neoplasm of skin

right breast
Rationale: This is not classified as a recurrent malignancy of the primary site

because it has metastasized to a different organ/tissue.
D Example: A patient with a primary malignant neoplasm of the brain undergoes a debulking
procedure. A year later, he returns to hospital for further debulking.
Code DAD Code title

C71.9 (M) Malignant neoplasm of brain unspecified
Rationale: A debulking procedure does not eradicate the lesion; malignant tissue
would have been left at the site and continued to grow. This is not a
recurrent malignancy and Z85.– is not assigned.
See also the coding standards Personal and Family History of Malignant Neoplasms and
Debulking of a Space-Occupying Lesion.
181

Generally speaking, in the Canadian Classification of Health Interventions (CCI), the therapeutic
interventions performed on body sites are hierarchical in nature; this means that the higher the
number in the third field (intervention), the more extensive or complex the intervention. The
destruction and excisional interventions are of particular relevance in neoplasm treatment.
DN When body tissue is destroyed, not removed, select a code from 1.^^.59.^^ Destruction.
1.^^.59.^^ Destruction includes ablation of tissue, often using extreme heat (laser, cautery),
extreme cold (cryoprobe) or chemicals (chemical cautery). No tissue is removed; it is just
destroyed. Sometimes, debulking of a neoplasm may be done in this way if none of the actual
body parts are being removed.
Example: A patient with malignant neoplasm of the large intestine has an endoscopic
debulking of the neoplasm using a laser device.
1.NM.59.BA-AG Destruction, large intestine, using endoscopic per orifice

approach and laser
When a neoplasm is excised locally with a margin of normal tissue, with or without grafting to the surgical
DN
defect, select a code from 1.^^.87.^^ Excision partial.
Example: Lumpectomy of the right breast
1.YM.87.LA Excision partial, breast, using open approach with simple

apposition (e.g. suturing)
Location: R
Note
There is no separate generic intervention for excisional biopsy in CCI. This intervention is classified as a partial
excision of the anatomical site involved.
182
Example: Lumpectomy of the left breast with autograft to fill in defect
1.YM.87.LA-XX-A Excision partial, breast, using open approach with

autograft (to close defect)
Location: L
When a neoplasm is excised by removing an entire body part (except amputations), with or without
DN grafting to the surgical defect, select a code from 1.^^.89.^^ Excision total.
Example: A patient with breast malignancy undergoes a bilateral simple total mastectomy with
grafting of defect.
1.YM.89.LA-XX-A Excision total, breast, using open approach and autograft

Location: B
For the three anatomical sites Eyelid (CX), Vulva (RW) and Breast (YM), select a code from 1.^^.88.^^
D
Excision partial with reconstruction when the intervention includes an excision that is not as extensive as
total or radical excision but includes reconstruction and/or prosthetic implants.
Example: A patient with malignant neoplasm of the eyelid has a partial excision of the eyelid
with a local flap reconstruction performed during the same episode.
1.CX.88.UD-XX-E Excision partial with reconstruction, eyelid NEC, full

thickness excision of major lesion, with local flap
When an excision of tissue includes removal of adjacent body structures, with or without complex repair
DN
of the wide surgical defect, select a code from 1.^^.91.^^ Excision radical.
183
Example: A patient with osteosarcoma of the humeral head is treated with a “limb-sparing”
radical excision of the humerus with prosthetic implants.
1.TK.91.LA-PM Excision radical, humerus, using endoprosthesis

[humeral head], no tissue used (for closure of defect)
Rationale: In CCI, a radical excision does not require a total excision of a body
part. It usually means that organs from multiple body systems are
involved in the excision. There may be partial or total excision of the
multiple sites. This intervention is often used for definitive surgical
treatment of large malignant neoplasms.
See also the coding standards Brachytherapy and Admission for Administration of
Chemotherapy, Pharmacotherapy and Radiation Therapy.

In effect 2015
Whenever a sentinel lymph node biopsy is performed, assign a code from 2.M^.71.^^ Biopsy, lymph
DN
node(s), any site with extent attribute of “SN” (Sentinel node(s)), mandatory.
DN Example: The patient is admitted for a lumpectomy of the right breast and sampling of the
sentinel axillary lymph nodes. The pathology report demonstrates adenocarcinoma
of the breast and negative lymph nodes.
1.YM.87.LA Excision partial, breast, using open approach, with simple

apposition (e.g. suturing)
Extent: SN
Rationale: It is mandatory to assign a code for a sentinel lymph node biopsy

whenever one is performed. Sampling of the sentinel axillary lymph
nodes is classified to 2.MD.71.^^.
184
DN Example: A patient with right breast cancer is brought into hospital for a right lumpectomy and
sentinel lymph node biopsy. Frozen section demonstrates that one of three nodes is
positive for metastatic disease. Partial dissection of axillary lymph nodes is performed.
C77.3 (1) OP Secondary malignant neoplasm of axillary and upper

limb lymph nodes

Location: R
1.MD.87.LA Excision partial, lymph node(s), axillary, using open approach
Extent: SN
Rationale: Codes for both the lymph node dissection (1.MD.87.^^) and lymph node
biopsy (2.MD.71.LA) are mandatory to assign.
D Example: The patient is brought into hospital for a total mastectomy of her left breast due to
cancer. A sentinel node biopsy is performed, and frozen section demonstrates
metastatic disease. An axillary lymph node dissection is performed.
Code DAD Code title
C50.91 (M) Malignant neoplasm of left breast, part unspecified
C77.3 (1) Secondary malignant neoplasm of axillary and upper limb

lymph nodes
1.YM.91.^^ Excision radical, breast

Location: L
Extent: SN

whenever one is performed. Total mastectomy with concomitant
dissection of axillary lymph nodes is classified to radical mastectomy
(1.YM.91.^^). When 1.YM.91.^^ or 1.YM.92.^^ is assigned, the removal
(dissection) of the axillary lymph nodes is an inherent part of a radical
mastectomy; therefore, an additional code is not assigned.
185
D Example: A patient is admitted for open perineal radical prostatectomy for a diagnosis
of adenocarcinoma. A biopsy of the pelvic lymph nodes is also performed.
The pathology report describes negative sentinel lymph node biopsy.
Code DAD Code title
C61 (M) Malignant neoplasm of prostate
1.QT.91.PB Excision radical, prostate using open perineal approach

2.MH.71.LA Biopsy, lymph node(s), pelvic using open approach
Extent: SN

whenever one is performed. See also the coding standard Using
Diagnostic Test Results in Coding.
Brachytherapy
DN
When a patient is admitted for brachytherapy, assign a code for the malignant disease as
the MRDx/main problem.
Assign separate intervention codes for the preparation for brachytherapy and the administration
DN of brachytherapy.
Admissions for brachytherapy should not be confused with admissions for radiation therapy.
Typically, two distinct phases are required to complete the process of brachytherapy. The first
phase involves inserting non-radioactive applicators or conduits (hollow needles, catheters,
stents, etc.) that receive or transmit the radioactive material into the body. The second phase
involves afterloading the radioactive material (seeds, pellets, wires, etc.) into the applicator or
conduit. These stages may occur during the same operative episode or during separate episodes.
186
DN Example: The patient has cancer of the prostate gland. He is admitted for percutaneous
transcatheter interstitial implantation of radioactive material. A brachytherapy
applicator is implanted during the same episode.
C61 (M) MP Malignant neoplasm of prostate
1.QT.26.HA Brachytherapy, prostate, using percutaneous (transcatheter or

transneedle) approach
1.QT.53.HA-EM Implantation of internal device, prostate, of brachytherapy
applicator using percutaneous approach
D Example: The patient is admitted for brachytherapy treatment of cancer of the uterus. The
hysteroscopic approach is used to insert the brachytherapy applicator in a separate
episode on day 1, and the sealed radiation source is afterloaded on day 2.
Code DAD Code title
C54.9 (M) Malignant neoplasm corpus uteri NOS
Intervention episode 1
1.RM.53.BA-EM Implantation of internal device, uterus and surrounding structures,
of brachytherapy applicator using endoscopic per orifice
(hysteroscopic) approach
1.RM.26.BA Brachytherapy, uterus and surrounding structures, using
endoscopic per orifice (hysteroscopic) approach
D Example: The patient is admitted to have brachytherapy catheters inserted for breast cancer
of the upper-outer quadrant of the right breast.
Code DAD Code title

C50.40 (M) Malignant neoplasm of upper-outer quadrant of right breast
1.YM.53.HA-EM Implantation of internal device, breast, of brachytherapy applicator

using percutaneous approach
187
N Example: The same patient as above presents to the chemotherapy clinic for brachytherapy
(i.e., afterloading of brachytherapy catheters) for breast cancer of the upper-outer
quadrant of the right breast.
C50.40 MP Malignant neoplasm of upper-outer quadrant of right breast
1.YM.26.HA Brachytherapy, breast, using percutaneous (transcatheter or

transneedle) approach
Other standards related to neoplasm coding

• Admission for Observation
• Admission for Follow-Up Examination
• Screening for Specific Diseases
• Prophylactic Organ Removal
• Admission for Administration of Chemotherapy, Pharmacotherapy and Radiation Therapy
• Personal and Family History of Malignant Neoplasms
• Personal History of Primary Malignant Neoplasms of Breast, Lung and Prostate
Reference
1. Fletcher J. ICD10-CA/CCI Classification Primer, 7th Edition. 2006.
188
Chapter III — Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
Chapter III — Diseases of the blood

and blood-forming organs and
certain disorders involving the
immune mechanism
Acute Blood Loss Anemia
In effect 2012
Acute blood loss is the sudden loss of blood. It can be due to many factors, including trauma
(such as a ruptured spleen), a ruptured blood vessel (such as a ruptured abdominal aortic
aneurysm), a postpartum hemorrhage, an acute gastrointestinal hemorrhage or blood loss
during a surgical intervention. Acute blood loss anemia is anemia resulting from or due to
an episode of acute loss of blood and is classified to D62 Acute posthaemorrhagic anaemia.
The physician can diagnose acute blood loss anemia based on hematological analysis.
The amount of blood loss that leads to a diagnosis of anemia depends on individual patient
characteristics. Other factors that are taken into consideration when establishing a diagnosis of
anemia, such as body mass index and the presence or absence of comorbidities, apply also to
acute blood loss anemia.
When anemia is documented as resulting from or due to an episode of acute blood loss or acute
DN
hemorrhage, assign D62 Acute posthaemorrhagic anaemia.
Note
When a link between an episode of acute blood loss and unspecified anemia is not established in the
documentation, do not assume it is anemia due to acute blood loss. For example, a diagnosis documented as
“postoperative anemia” is classified to D64.9 Anaemia, unspecified with the appropriate external cause code
and diagnosis cluster data element.
189
Note
Do not assume that the administration of blood or blood products following acute blood loss means the
patient has anemia. There must be documentation of “anemia” or “low hemoglobin.”
DN Example: The patient is admitted with an acute gastrointestinal tract bleed. An

esophagogastroduodenoscopy (EGD) confirms a Mallory-Weiss tear. The physician
documents in the progress notes that there was an abrupt fall in the patient’s
hemoglobin following the acute hemorrhage. During the admission, the patient
receives an intravenous bolus of saline and a transfusion to restore his volume and
hemoglobin level.

K22.6 (M) MP Gastro-oesophageal laceration-haemorrhage
syndrome
D62 (1) OP Acute posthaemorrhagic anaemia
Rationale: The patient experienced acute and significant blood loss. He was
then diagnosed with subsequent anemia. The physician has
documented the link between the abrupt fall in hemoglobin and the
episode of acute blood loss. Therefore, anemia is classified to D62
Acute posthaemorrhagic anaemia.
D Example: The patient has a long history of iron deficiency anemia related to chronic, bleeding
peptic ulcer. She is admitted for a blood transfusion.
Code DAD Code title
Z51.3 (M) Blood transfusion (without reported diagnosis)
D50.0 (3) Iron deficiency anaemia secondary to blood loss (chronic) (optional)
K27.4 (3) Peptic ulcer, chronic or unspecified with haemorrhage (optional)
Rationale: There is no documentation linking anemia to acute blood loss. The anemia
is linked to a chronic, bleeding peptic ulcer; therefore, it is classified to
D50.0. See also the coding standard Admission for Blood Transfusion.
190
D Example: The patient is admitted for a cholecystectomy for chronic cholecystitis with
cholelithiasis. “Postoperative anemia” is documented on the summary sheet.
The patient is given one unit of blood. Iron supplements are prescribed, and the
patient’s discharge is delayed until his hemoglobin begins to rise.
— K80.10 (M) — Calculus of gallbladder with

other cholecystitis
6 D64.9 (2) A Anaemia, unspecified
— Y83.6 (9) A Removal of other organ (partial) (total),

as the cause of abnormal reaction of the
patient, or of later complication, without
mention of misadventure at the time of
the procedure
Rationale: There is no documentation linking anemia to acute blood loss; therefore,

it is classified to D64.9.
D Example: The patient is admitted with primary osteoarthritis of the right knee for an elective
total knee replacement. The physician documents in the progress notes that the
patient’s preoperative hemoglobin is within normal limits but that her hemoglobin
is low postoperatively due to the blood loss that occurred during the procedure.
On postoperative day 3, the patient is given two units of blood.

— M17.1 (M) — Other primary gonarthrosis
6 D62 (2) A Acute posthaemorrhagic anaemia
— Y83.1 (9) A Surgical operation with implant of artificial

internal device, as the cause of abnormal
reaction of the patient, or of later
complication, without mention of
Rationale: The physician has documented the link between the abrupt fall in
hemoglobin and the episode of acute blood loss. Therefore, anemia is
classified to D62 Acute posthaemorrhagic anaemia.
191
D Example: The patient is admitted with primary osteoarthritis of the left hip for an elective total
hip replacement. The physician documents that two units of packed red cells are
transfused intraoperatively.
Code DAD Code title
M16.1 (M) Other primary coxarthrosis
Rationale: A diagnosis of anemia is not assumed based on administration of blood

or blood products alone; therefore, a code for anemia is not assigned for
this example.
Anemia of Chronic Disease

In effect 2012
Anemia of chronic disease is a multifactorial anemia resulting from an underlying chronic

condition that has an effect on the production and/or lifespan of red blood cells. Certain
conditions, such as chronic infections, inflammation and cancer, have been commonly linked to
anemia of chronic disease and as such are identified in ICD-10-CA by utilizing the dagger and
asterisk convention; examples of such chronic diseases are neoplastic disease, chronic kidney
disease, malaria and myxedema. Anemia of chronic disease is a manifestation of an underlying
chronic condition; therefore, it is an asterisk code in the classification.
The literature associates a number of underlying chronic conditions with anemia of chronic
disease. Sometimes the condition and the anemia of chronic disease are specifically linked
in the classification using the dagger/asterisk convention. Anemia of chronic disease can also
be found in the classification using an adjectival form of the disease; examples include
brickmaker’s, Egyptian, malarial, syphilitic and tuberculous, among others. It can also be found
by using the terms “anemia . . . in”; examples include anemia “in” chronic kidney disease and
anemia “in” neoplastic disease. Sometimes the underlying chronic condition and anemia of
chronic disease are not linked in the classification at all.
When the underlying chronic condition and the anemia of chronic disease are not specifically
linked in the classification, D63.8* Anaemia in other chronic diseases classified elsewhere is
assigned when the health care provider specifically and clearly establishes a connection
between the underlying chronic condition and “anemia of chronic disease.”
192

When documentation clearly establishes a connection between “anemia of chronic disease” and a chronic
DN condition that is not linked in the classification, assign
• A code for the underlying chronic condition; and
• D63.8* Anaemia in other chronic diseases classified elsewhere.
Note
When the connection between anemia and the chronic condition is not documented, classify the anemia to
D64.9 Anaemia, unspecified.
DN Example: The patient is admitted to treat his rheumatoid arthritis. The physician documents
that the patient has associated anemia of chronic disease. During this episode of
care, the patient receives a blood transfusion.
M06.9 (M) MP Rheumatoid arthritis, unspecified
D63.8* (3) OP Anaemia in other chronic diseases

Rationale: The physician has linked the anemia of chronic disease to rheumatoid
arthritis, so D63.8* is assigned.
DN Example: The patient is admitted to treat an acute exacerbation of his chronic obstructive lung
disease. The physician documents that the patient has anemia. During this episode
of care, the patient receives a blood transfusion.

D64.9 (1) OP Anaemia, unspecified
Rationale: D63.8* does not apply because anemia and chronic obstructive lung
disease are not linked in the classification and the physician has not
described it as “anemia of chronic disease.”
193
DN When the type of anemia is not specified in a patient with chronic kidney disease (N18.3–N18.9) or
neoplasia (C00–D48), follow the alphabetical index lookup by using the lead term “anemia” and the
secondary term “in” and assign
• The indexed dagger code for either the chronic kidney disease or neoplasia; and
• The code from category D63* Anaemia in chronic diseases classified elsewhere.
Note
Do not confuse anemia described as “chronic” with anemia “due to” or “of” chronic disease.
Note
When the type of anemia is specified (e.g., blood loss anemia or iron deficiency anemia) in a patient with
chronic kidney disease or neoplastic disease, the anemia is classified to the specific type of anemia. D63* is
not assigned.
When multiple types of anemia (such as anemia of chronic disease and iron deficiency anemia) are
documented, assign a code for each type of anemia.
DN Example: The patient is admitted with end-stage chronic kidney disease. During this episode
of care, he receives a blood transfusion for his documented anemia.

N18.5 (M) MP Chronic kidney disease, stage 5

Rationale: A specific type of anemia is not documented and the alphabetical

index links the anemia in chronic kidney disease; therefore, anemia is
classified to D63.8*.
194
D Example: The patient is admitted for treatment of his colon cancer. He also has anemia
documented as due to chronic blood loss, for which he receives two units of blood.
Code DAD Code title
C18.9 (M) Malignant neoplasm colon, unspecified
D50.0 (1) Iron deficiency anaemia secondary to blood loss (chronic)
Rationale: Anemia is specified as due to chronic blood loss; therefore, the anemia
is classified to D50.0.
DN Example: The patient is admitted with end-stage chronic kidney disease. During this episode
of care, he receives a blood transfusion for his documented “anemia of chronic
disease” and “iron deficiency anemia.”

N18.5 (M) MP Chronic kidney disease, stage 5

D50.9 (1) OP Iron deficiency anaemia, unspecified
Rationale: Anemia of chronic disease and a specific type of anemia are both
documented; therefore, the anemia is classified to D63.8* and D50.9.
195
Chapter IV — Endocrine, nutritional

and metabolic diseases
Diabetes Mellitus
Diabetes is a serious disease that, if not controlled, can be life-threatening. It is often associated
with long-term complications that can affect every system and part of the body. Diabetes can
contribute to eye disorders and blindness, heart disease, stroke, kidney failure, amputation
and nerve damage. It can also affect pregnancy and cause birth defects.
The code titles in block E10–E14 Diabetes mellitus in ICD-10-CA clearly state diabetes mellitus
with a complication. Therefore, a cause-and-effect relationship does not have to be specifically
documented to classify cases to these categories.
See also the coding standard Use Additional Code/Code Separately Instructions as well as
Diabetes mellitus in Appendix A for clinical information.
DN Assign a code for diabetes mellitus whenever the condition is documented.
Note
The intent is to assign a code for diabetes mellitus when it is noted on routine review of the record, not to
conduct an exhaustive search of all ancillary documentation for reference to diabetes.
196
Chapter IV — Endocrine, nutritional and metabolic diseases
N Example: The patient is seen in the emergency department for treatment of renal colic,
which is diagnosed as left ureteric stone. Type 2 diabetes mellitus is noted on the
emergency department sheet by the triage nurse. No further details regarding
diabetic complications or glycemic control are available in the chart.
N20.1 MP Calculus of ureter
E11.9 OP Type 2 diabetes mellitus without (mention of) complications
Rationale: Diabetes must be coded whenever it is documented. It is acceptable to

use nursing documentation to fulfill this mandatory coding requirement.
DN Example: A 68-year-old female patient is admitted with pneumonia. The history and physical
documents that the patient has type 2 diabetes mellitus with mononeuropathy.
E11.40† (3) OP Type 2 diabetes mellitus with mononeuropathy
G59.0* (3) OP Diabetic mononeuropathy
Rationale: It is mandatory to assign a code for diabetes mellitus when it is

documented. Since diabetes with mononeuropathy is a dagger/asterisk
combination, both codes are mandatory to assign. See also the coding
standard Dagger/Asterisk Convention.
N Example: The patient is seen in the emergency department for “kidney failure” without further
specification as to type or cause. The patient has type 2 diabetes mellitus.
N19 MP Unspecified kidney failure
E11.9 OP Type 2 diabetes mellitus without (mention of) complications
Rationale: Unspecified renal failure is not classified as a complication of diabetes

mellitus. The alphabetical index does not associate unspecified renal
failure and diabetes mellitus.
197
When there are complications of diabetes mellitus, assign a code from E10–E14 to describe each
DN
complication that meets the criteria for significance.
When multiple complications of diabetes mellitus affect separate body systems and none meet
DN the criteria for significance, assign the one code E1–.78 Type ~ diabetes mellitus with multiple
other complications.
D Example: A 51-year-old woman known to have type 2 diabetes mellitus is admitted to the
hospital for treatment of her diabetic nonproliferative retinopathy. She is also
seen by a nephrologist to evaluate signs of diabetic nephropathy noted by her
family physician. The nephrologist recommends and begins appropriate treatment.
She has no other known complications related to diabetes.
Code DAD Code title

E11.30† (M) Type 2 diabetes mellitus with background retinopathy
H36.0* (6) Diabetic retinopathy
E11.23† (1) Type 2 diabetes mellitus with established or advanced

kidney disease
N08.39* (3) Unspecified glomerular disorders in diabetes mellitus
Rationale: The diabetic retinopathy and nephropathy both meet the criteria for
significance; therefore, codes are assigned to describe each complication.
DN Example: A 45-year-old female patient with type 1 diabetes mellitus is admitted for treatment
of preproliferative diabetic retinopathy. She also has diabetic nephropathy and
mononeuropathy, for which she receives no treatment during this admission.
E10.31† (M) MP Type 1 diabetes mellitus with preproliferative

retinopathy
H36.0* (6) OP Diabetic retinopathy
Rationale: Since only the diabetic retinopathy is significant to this visit, only
E10.31† is assigned with the corresponding asterisk code.
198
DN Example: A patient with type 2 diabetes mellitus, known end-stage kidney disease (ESKD)
and congestive heart failure (CHF) presents to hospital. The patient presents with
increased shortness of breath, poor appetite and excessive thirst, symptoms of
the CHF and kidney disease. The final diagnosis is CHF and diabetic ESKD;
appropriate treatment is given.
I50.0 (M) MP Congestive heart failure

E11.23† (1) OP Type 2 diabetes mellitus with established or

advanced kidney disease
N08.35* (3) OP Glomerular disorders in diabetes mellitus, chronic

kidney disease, stage 5
Rationale: The CHF and kidney disease both meet the criteria for significance;
therefore, codes are assigned to describe each complication.
N Example: The patient is registered for his biweekly hemodialysis session. He has type
2 diabetes with ESKD. He also has diabetic maculopathy and sensorimotor
peripheral neuropathy.
Z49.1 MP Extracorporeal dialysis
E11.23† OP Type 2 diabetes mellitus with established or advanced

kidney disease
N08.35* OP Glomerular disorders in diabetes mellitus, chronic kidney disease,

stage 5
Rationale: Although this patient has multiple diabetic complications, only the kidney
disease meets the criteria for significance; thus a code for ESKD is the
only one required.
199
DN Example: A patient with type 2 diabetes mellitus is admitted to hospital due to acute
symptoms of known Crohn’s disease of the large intestine. The history and physical
documents that the patient has CHF and multi-infarct dementia. Neither of these
conditions is significant to the patient’s stay in hospital.
K50.1 (M) MP Crohn’s disease of large intestine

Rationale: E11.78 does not apply in this example because CHF and multi-infarct
dementia are complications affecting the same body system. Although
neither condition meets the criteria for significance, it is mandatory to
code diabetes mellitus whenever it is documented; E11.52 satisfies
this requirement.
DN Example: A patient with type 2 diabetes mellitus is admitted for treatment of a fractured wrist
due to a fall out of bed at home. The patient has a history of peripheral vascular
disease and cardiomyopathy.
S62.800 (M) MP Fracture of other and unspecified parts of wrist and

hand, closed
W06 (9) OP Fall involving bed
U98.0 (9) OP Place of occurrence, home

Rationale: E11.78 does not apply in this example because peripheral vascular
disease and cardiomyopathy are complications affecting the same body
system. Both are classified to separate fourth-character subcategories,
and although neither meets the criteria for significance, it is mandatory
to code diabetes mellitus whenever documented. To satisfy this
requirement, assign either E11.52 or E11.50†/I79.2*.
200
D Example: A patient with type 2 diabetes mellitus is admitted due to an acute exacerbation of
chronic obstructive pulmonary disease. It is documented that on admission the
patient’s diabetes mellitus is uncontrolled. The history documents that the patient
has peripheral vascular disease and retinopathy; however, these complications do
not impact the patient’s hospital stay.
Code DAD Code title
J44.1 (M) Chronic obstructive pulmonary disease with acute

E11.64 (1) Type 2 diabetes mellitus with poor control, so described
Rationale: Uncontrolled diabetes mellitus is always captured as a significant

diagnosis type. This patient has multiple complications of diabetes, but
only E11.64 meets the criteria for significance. It satisfies the mandatory
requirement to code diabetes mellitus, and E11.78 is not assigned.
N Example: The patient comes to the emergency department after slipping and falling on ice and
sustaining a closed bimalleolar fracture of her left ankle. She has type 2 diabetes with
known nephropathy and retinopathy.
S82.800 MP Bimalleolar fracture of ankle, closed
W00 OP Fall on same level involving ice and snow
U98.9 OP Unspecified place of occurrence
E11.78 OP Type 2 diabetes mellitus with multiple other complications
Rationale: The nephropathy and retinopathy are not significant to the emergency
visit; E11.78 is assigned to identify the diabetes mellitus.
When the type of diabetes mellitus is not evident from the documentation, seek clarification from the
DN
physician/primary care provider or assign E14.– Unspecified diabetes mellitus.
When diabetes mellitus is described as poorly controlled by the physician/primary care provider at
DN admission or at any time during the episode of care, assign E1–.64 Type ~ diabetes mellitus with poor
control, so described as a significant diagnosis type/main problem or other problem.
201
Note
E1–.64 Type ~ diabetes mellitus with poor control, so described identifies diabetes mellitus with poor control.
The code R73.8–2 Other evidence of elevated blood glucose level, greater than or equal to 14.0 mmol/L is
not required.
E1–.64 Type ~ diabetes mellitus with poor control, so described must not be assigned a diagnosis type (2).
Terminology that indicates poor control includes “out of control,” “uncontrolled,” “unstable,”
“inadequately controlled” or “that with secondary treatment failure.” Patients requiring stabilization
of poorly controlled diabetes include those who need to initiate insulin therapy because they are
experiencing secondary treatment failure to oral hypoglycemic agents. It should be noted that the
use of a sliding-scale insulin regimen does not imply uncontrolled diabetes.
D Example: A 54-year-old patient is admitted with CHF. He has had type 2 diabetes for many
years and is on oral hypoglycemic medication. Lately, his blood sugars have been
consistently on the high side. The physician notes that his diabetes is out of control,
and appropriate treatment is given.
Code DAD Code title
E11.52 (3) Type 2 diabetes mellitus with certain circulatory complications
D Example: A 62-year-old patient with type 2 diabetes is admitted for elective radical prostatectomy
for carcinoma of the prostate. Following surgery, he is sent to the intensive care unit
(ICU), and the physician’s notes state that his diabetes is out of control. The patient’s
insulin dosage is adjusted, and he is kept in ICU for two extra days.
Code DAD Code title

C61 (M) Malignant neoplasm of prostate
Rationale: Postoperatively, patients with diabetes may experience temporary poor

control of their diabetes. Diabetes is a chronic condition and must not be
assigned a diagnosis type (2).
202
Note
Diabetes mellitus with poor control is inherent with coma and acidosis associated with diabetes; as such,
the code E1–.64 Type ~ diabetes mellitus with poor control, so described is not assigned with codes E1–.0
Type ~ diabetes mellitus with coma or E1–.1– Type ~ diabetes mellitus with acidosis. There is an exclusion
note at E1–.64 Type ~ diabetes mellitus with poor control, so described providing this direction.
DN Example: A 56-year-old man is brought to the hospital by ambulance. His wife says that he
appears to be semi-conscious. His diabetes is documented as uncontrolled with blood
glucose of 46 mmol/L. The patient is admitted with dehydration and hyperosmolality.
With IV rehydration and other treatment, his condition improves significantly.
Final diagnosis: Hyperosmolar hyperglycemic nonketotic coma, type 2 diabetes mellitus
E11.0 (M) MP Type 2 diabetes mellitus with coma
E87.0 (1) OP Hyperosmolality and hypernatraemia
E86.0 (1) OP Dehydration
Note
It is important to be aware that coma (a state of unconsciousness) can be due to a number of problems,
including traumatic brain injury, stroke, brain tumor or infection such as encephalitis, as well as extremely high
or low blood sugar in diabetes mellitus. Use physician/primary care provider documentation to verify diabetes
mellitus as the cause of the coma prior to assigning a code from categories E10–E14 to record the coma.
203
DN Example: The patient is an 18-year-old who went swimming in the lake with some friends.
The lifeguard noticed that the young man was in trouble and immediately rushed in
and brought him to the beach, where he performed resuscitation. An ambulance was
called and transported the youth to hospital. Though resuscitation was successful,
the patient remains in a coma. History and physical examination report that the
patient has type 1 diabetes. He dies two days after admission.
Final diagnosis: Accidental drowning

T75.1 (M) MP Drowning and nonfatal submersion
W69 (9) OP Drowning and submersion while in natural water
U98.8 (9) OP Other specified place of occurrence
R40.29 (1) OP Coma, unspecified
E10.9 (3) OP Type 1 diabetes mellitus without

(mention of) complication
Rationale: This patient with type 1 diabetes was in a coma because of lack of blood
flow and oxygen to the brain during his near-drowning experience. There
was no documentation linking the coma to his type 1 diabetes mellitus.

Classify diabetic foot ulcer to E1–.70 Type ~ diabetes mellitus with foot ulcer or E1–.71 Type ~ diabetes
DN mellitus with foot ulcer with gangrene to identify the absence or presence of gangrene.
• Assign an additional code for abscess, cellulitis or osteomyelitis associated with the ulcer.
204
D Example: The patient has had type 2 diabetes for many years with multiple diabetes-related
complications. She is admitted with a diabetic (right) foot with ulcer and gangrene.
During her stay, she undergoes amputation of her second and third toes of her right
foot, with drainage of the associated abscess.
Final diagnosis: Diabetic foot abscess with gangrenous toes
Pathology report: Necrotic second and third toes with ulcer
Code DAD Code title
E11.71 (M) Type 2 diabetes mellitus with foot ulcer (angiopathic) (neuropathic)
with gangrene
L02.4 (1) Cutaneous abscess, furuncle and carbuncle of limb
Rationale: An additional code is assigned for the abscess. An additional code for
the ulcer is not assigned.

When assigning the mandatory asterisk code N08.3–* Glomerular disorders in diabetes mellitus, select the
DN
fifth character based on documentation of the stage of chronic kidney disease, not the glomerular filtration
rate (GFR).
DN When the stage of chronic kidney disease is not documented, assign N08.39* Unspecified glomerular
disorders in diabetes mellitus.
DN Example: Diagnosis: Type 2 diabetes with chronic kidney disease

Nephropathy stage 4
Code Code title
E11.23† Type 2 diabetes mellitus with established or advanced kidney disease
N08.34* Glomerular disorders in diabetes mellitus, chronic kidney disease, stage 4
205
DN Example: Diagnosis: Type 2 diabetes with chronic kidney disease with documented GFR of 35
Code Code title
N08.39* Unspecified glomerular disorders in diabetes mellitus
Rationale: Since the stage of the chronic kidney disease is not documented,
N08.39* is assigned despite documentation of the GFR.
DN Example: Diagnosis: Type 2 diabetes with end-stage kidney disease

Nephropathy stage 4
Code Code title
N08.35* Glomerular disorders in diabetes mellitus, chronic kidney disease, stage 5
Rationale: If the health care provider documents both a stage of chronic kidney
disease and ESKD, assign the code N08.35* for the ESKD. ESKD is
always classified as stage 5.
When a diagnostic statement of “borderline diabetes” is recorded, seek further information from the
DN physician/primary care provider to determine whether the patient has type 2 diabetes (E11.–) or
impaired glucose tolerance/pre-diabetes (R73.0).
For clinical information, see also Borderline diabetes in Appendix A.
Assign E1–.63 Type ~ diabetes mellitus with hypoglycaemia to identify a hypoglycemic episode in a patient
DN with diabetes.
206
Note
Ensure that code E1–.63 Type ~ diabetes mellitus with hypoglycaemia does not appear on the same abstract
with a code for hypoglycemia from the range E16.0–E16.2, as these codes are mutually exclusive.
D Example: A 51-year-old man with type 1 diabetes mellitus is brought to hospital, where the
physician notes that his diabetes is poorly controlled. The patient is admitted with
a glucometer reading of 14.1 mmol/L, and he is given insulin per the physician’s
orders. The next day, he has only a light breakfast and complains of feeling dizzy
and weak. The physician documents “hypoglycemia” in the progress notes and the
patient is treated appropriately.
Code DAD Code title

E10.64 (M) Type 1 diabetes mellitus with poor control, so described
E10.63 (2) Type 1 diabetes mellitus with hypoglycaemia
Rationale: It is possible to have a high blood sugar reading and hypoglycemia in

the same episode of care.
For clinical information, see also Hypoglycemia in diabetes mellitus in Appendix A.
Classify diabetes that is first diagnosed during pregnancy to O24.8– Diabetes mellitus arising in
DN pregnancy (gestational).
Sequence codes from Chapter XV — Pregnancy, childbirth and the puerperium before any applicable
DN diabetes code from E10–E14 Diabetes mellitus.
D Example: The patient presents at 39 weeks gestation. She was first diagnosed with diabetes
mellitus at the first prenatal visit (10 weeks gestation). She spontaneously delivers a
healthy baby girl.
Code DAD Code title
O24.801 (M) Diabetes mellitus arising in pregnancy (gestational), delivered with or

without mention of antepartum condition
207
D Example: A patient with type 1 diabetes mellitus, with nephropathy, is admitted at 39 weeks
gestation. She delivers a healthy baby girl. She is seen by a nephrologist for
evaluation and recommendations for treatment of her renal condition.
Code DAD Code title
O24.501 (M) Pre-existing type 1 diabetes mellitus in pregnancy, delivered, with or

E10.23† (1) Type 1 diabetes mellitus with established or advanced

kidney disease
N08.39* (3) Unspecified glomerular disorders in diabetes mellitus
DN Example: A patient with type 1 diabetes, who is pregnant, is brought to the hospital with a
history of nausea and vomiting for a few days. Blood sugars are tested during this
visit, and the physician diagnoses uncontrolled glucose levels and gravidarum
emesis with dehydration.
O21.103 (M) MP Hyperemesis gravidarum with metabolic disturbance,

antepartum condition or complication
O24.503 (1) OP Pre-existing type 1 diabetes mellitus in pregnancy,

antepartum condition or complication
E10.64 (1) OP Type 1 diabetes mellitus with poor control,

so described

When total or partial pancreatectomy causes diabetes mellitus, the resulting diabetes mellitus is classified to
DN
E89.1 Postprocedural hypoinsulinaemia for the episode of care during which the surgery was performed.
• For all subsequent encounters, any resulting diabetes mellitus is assigned to category E13 Other specified
diabetes mellitus.
208
First visit
D Example: A non-diabetic patient is admitted for a Whipple procedure, and part of her
pancreas is removed. She is monitored in ICU following surgery. She goes into
acute hyperglycemia and is put on insulin to control the hypoinsulinemia.
The final diagnosis is recorded as benign pancreatic tumor and acquired diabetes
mellitus with postoperative hyperglycemia.
D13.6 (M) — Benign neoplasm of pancreas
E89.1 (2) A Postprocedural hypoinsulinaemia
Y83.6 (9) A Removal of other organ (partial) (total) as the

Rationale: Following a pancreatectomy, loss of beta cells results in a decrease

in insulin production. This condition may sometimes be transient;
as such, for the current episode of care only, assign E89.1
Postprocedural hypoinsulinaemia.
209
Second visit
D Example: The patient is readmitted to hospital four days after discharge. She has developed a
Staphylococcus aureus wound infection. The physician notes state that the patient
has acquired diabetes and is on insulin as a result of the pancreatectomy.
T81.4 (M) A Infection following a procedure, not

B95.6 (3) A Staphylococcus aureus as the cause of diseases

Y83.6 (9) A Removal of other organ (partial) (total) as the cause

E13.9 (3) — Other specified diabetes mellitus without

Rationale: When the condition is established as diabetes mellitus in any

subsequent admissions, assign a code from category E13 Other
specified diabetes mellitus since this is neither type 1 nor type 2
diabetes mellitus. An external cause code is not assigned with E13.9
for diabetes resulting from pancreatectomy.
D When a patient develops steroid-induced diabetes after admission, assign a code from category E13
Other specified diabetes mellitus as a diagnosis type (2).
When lactic acidosis or a hypoglycemic event meets the criteria for a post-admit comorbidity, assign the
D
appropriate codes as a diagnosis type (2).
210
D Example: The patient is in hospital undergoing treatment for pemphigus. She is given high
doses of steroids. She develops steroid-induced diabetes and is put on oral
hypoglycemic medication.
L10.9 (M) — Pemphigus, unspecified
E13.9 (2) A Other specified diabetes mellitus without

Y42.0 (9) A Glucocorticoids and synthetic analogues causing

adverse effects in therapeutic use
D Example: A 36-year-old woman with type 1 diabetes mellitus is brought to hospital because
her diabetes is poorly controlled. The next day, she complains of feeling dizzy and
weak. The physician documents “hypoglycemia” in the progress notes, and the
patient is given orange juice.
Code DAD Code title

E10.63 (2) Type 1 diabetes mellitus with hypoglycaemia
Dehydration
DN
Assign a code for documented dehydration as a significant diagnosis type/main problem or other problem
when it is either
• A condition in its own right without any documented underlying cause; or
• Noted to be severe enough to warrant rehydration with intravenous (IV) fluids.
See also the coding standard Gastroenteritis and Diarrhea.
When there is a documented underlying cause and dehydration is managed by increased oral
intake of fluids alone, it must not be assigned a significant diagnosis type; if coded, assign a
diagnosis type (3).
211
Note
The presence of an IV does not in itself indicate rehydration. IV lines may be started for other purposes,
including administration of medications and stabilization of the patient.
DN Example: An elderly man who lives alone is found in a state of confusion and dehydration.
He improves significantly following aggressive IV fluid treatment and is sent home
with home care to visit three times a week.
E86.0 (M) MP Dehydration
R41.0 (3) OP Disorientation, unspecified (optional)
Rationale: Dehydration must be clearly documented before it can be coded.

Dehydration is a condition in its own right in this example and is treated
with IV fluids. Disorientation is a symptom of dehydration and, if coded,
must be assigned diagnosis type (3)/other problem.
D Example: A patient with type 1 diabetes mellitus is admitted to stabilize his condition.
His blood sugars have been spiraling and not staying in the acceptable range.
His family doctor refers him for an urgent admission. He is given insulin twice and
responds to this treatment nicely, with fasting and random blood sugar levels well
within the adequate range. The physician documents dehydration and prescribes
an increase in oral fluids.
Code DAD Code title
E86.0 (3) Dehydration (optional)
Rationale: Dehydration treated with an increase in oral intake of fluids does not
meet the criteria for significance and, if assigned, is an optional type
(3) diagnosis.
212
Chapter VI — Diseases of the nervous system
Chapter VI — Diseases of the

nervous system
Cranioplasty and/or Duraplasty Concomitant
With Intracranial Interventions
To gain access to the brain, the cranium and dura must be incised. While raising/closing
(reaffixing) a cranial bone flap and incising/re-approximating the dura following intracranial
resection are considered a routine part of any invasive intracranial intervention, there are two
occasions when it becomes necessary to assign an additional code for a concomitant cranial
and/or dural repair.
D When there is documentation of a cranial defect requiring a repair/reconstruction concomitant with an

intracranial intervention, assign an additional code, 1.EA.80.^^ Repair, cranium.
D When there is documentation of a dural graft used for the dural repair concomitant with an intracranial
intervention, assign an additional code, 1.AA.80.^^ Repair, meninges and dura mater of brain.
Note
Reaffixing (replacing) the cranial bone flap that was created to gain access to the brain with small
plates/screws or clamps is not classified as a “repair” of the cranium. The small plates/screws or
clamps are considered to be routine closure of the operative site and are not coded separately. Similarly,
re-approximating the dura with sutures is considered to be routine closure of the operative site and is not
coded separately.
See also the coding standard Debulking of a Space-Occupying Lesion.
213
Example: A 59-year-old man with a history of low-grade astrocytoma (subtotal resection eight
years ago) now presents with seizure activity due to the recurrence of the neoplasm.
A craniotomy is performed through the original craniotomy incision to remove the
recurrent astrocytoma. The dura is adhesive and tears during surgery. Following
removal of the tumor, a duraplasty using the patient’s own temporalis fascia is
performed. Finally, the cranial defect is repaired by performing a cranioplasty
using bone from the bone bank and plates and screws to secure the graft.
1.AN.87.SZ-GX Excision partial, brain, craniotomy [or craniectomy] flap

technique for access, with device NEC
1.AA.80.SZ-XX-A Repair, meninges and dura mater of brain, using autograft
[e.g. pericranium, fascia lata]
1.EA.80.LA-NW-K Repair, cranium, using plate, screw or clamp device
(with/without wire/mesh), with homograft
Rationale: There is documentation of a cranial defect requiring repair/reconstruction

and the dura required a repair using a graft; therefore, additional codes
for the cranioplasty and duraplasty are assigned.
Example: The patient is admitted for resection of frontal parietal extra-axial tumor. A high-speed
drill is used to create four burr holes. The cranial bone is cut temporally in order to
devascularize the dura before turning the bone flap. The bone flap is elevated.
The bone is obviously involved with the tumor. The bulk of the tumor is removed.
Following removal of the tumor, the dura is repaired using a synthetic dura substitute
that is sutured to the native dura with a running 4-0 Nurolon. Given that the bone
was involved with the tumor, there was a cranial defect that required reconstruction.
A large metal plate is placed over the defect and anchored to the skull using mini-
screws. The plate is covered with methylmethacrylate bone cement.
1.AN.87.SZ-GX Excision partial, brain, craniotomy [or craniectomy] flap

technique for access, with device NEC
1.EA.80.LA-NW-N Repair, cranium using plate, screw or clamp device
(with/without wire/mesh) with synthetic tissue [cement, paste]
1.AA.80.SZ-XX-N Repair, meninges and dura mater of brain, using synthetic
tissue substitute [Sialastic sheath]
Rationale: As bone was involved with the tumor, the resulting cranial defect
required a repair/reconstruction. The cranium was reconstructed using
a large metal plate and bone cement. The dura also required repair
using a graft; therefore, additional codes for both the cranioplasty
and duraplasty are assigned.
214
Example: The patient is admitted for resection of intra-axial tumor. One burr hole is drilled at the
keyhole, and two are drilled over the temporal region. These are then connected to
raise the craniotomy. The dura is dissected free. Following removal of the tumor,
the dura is closed using running 4-0 Nurolon. The cranial bone flap is replaced and
re-approximated using cranial clamps to secure the cranial bone flap back in place.
1.AN.87.SZ-GX Excision partial, brain, craniotomy [or craniectomy]

flap technique for access, with device NEC
Rationale: There was no documentation of a cranial defect requiring

repair/reconstruction, and the dura did not require a graft. Closing
(reaffixing) the cranial bone flap with clamps and incising/re-approximating
the dura with sutures following the intracranial resection is considered a
routine part of the surgery and no additional codes are assigned.
Example: A 73-year-old man is admitted for resection of a temporal tumor. A standard

craniotomy is made, and when the bone is removed the dura is intact. The dura is
incised over the lesion. The lesion is visible as a firm bump in the middle of the
craniotomy. The inner lining of the dura is very adherent to the lesion and it is
difficult to separate. The tumor is removed. Once hemostasis is confirmed, the
cadaver fascia lata is used to repair the dura where the tumor was removed.
The cadaver fascia lata is sutured with interrupted silk, and the cranial bone
flap is replaced using small plates/screws to secure it back in place.
1.AN.87.SZ-GX Excision partial, brain, craniotomy [or craniectomy]

flap technique for access, with device NEC
1.AA.80.SZ-XX-K Repair, meninges and dura mater of brain using homograft
[e.g. freeze dried donor dura]
Rationale: A duraplasty requiring a graft is not considered a routine part of an

intracranial intervention; therefore, an additional code for the duraplasty
is required. However, closure (reaffixing) of the cranial bone flap
created to gain access to the brain is considered a routine part of the
intracranial intervention; therefore, an additional code is not required.
215
Example: The patient is admitted for evacuation of right cerebellar intracerebellar hematoma.
A single burr hole is placed in the appropriate position and a craniotomy is fashioned
out of this. The bone flap is lifted and the dura is exposed and incised. A significant
amount of blood is found deep in the cerebellum. The blood is evacuated easily
with suction. The dura is closed with a Dura-Guard patch, and DuraGen is laid
over the patch. The bone flap is put back in place and secured with burr hole
covers and screws.
1.AN.52.SZ Drainage brain drainage alone [without catheter in situ]

open craniotomy flap technique.
1.AA.80.SZ-XX-L Repair, meninges and dura mater of brain, using xenograft
[e.g. bovine]
Rationale: There was no documentation of a cranial defect requiring

repair/reconstruction. Closing (reaffixing) the cranial bone flap with burr
hole covers and screws is considered a routine part of the surgery, so no
additional code for the cranioplasty is assigned. A duraplasty requiring a
graft is not considered a routine part of an intracranial intervention;
therefore, an additional code for the duraplasty is required.
Hierarchy for Classification of Intracranial

Lesion Resection
To avoid assigning multiple codes to describe the surgical management of intracranial

resections, a coding hierarchy has been factored into CCI that considers the severity of the
neurological defect and the complexity of the surgery in order to determine the single most
appropriate code for the type of resection. Necessary guidance for code selection is provided
in the inclusions, exclusions and notes at the excision codes.
DN Classify intracranial resections that overlap regions of the brain to one code (see flowchart below).
216
Start
Yes
Involves cranium
1.EA.92.^^
(skull base)?
No
Yes
Involves brain stem? 1.AP.87.^^
No
Involves ventricle Yes

1.AC.87.^^
of brain?
No
May be referred to
as a “posterior
fossa” resection Involves Yes
cerebellopontine 1.AK.87.^^
angle?
No
Yes
Involves
1.AJ.87.^^
cerebellum?
No
Involves (lobe of) Yes

1.AN.87.^^
brain?
No
Involves pituitary Yes

1.AF.87.^^
region primarily?
No
Involves pineal Yes

1.AG.87.^^
gland primarily?
No
Involves only Yes

meninges, dura 1.AA.87.^^
mater of brain?
End
217
Revision of Cerebrospinal Fluid (CSF) Shunt

Systems (Ventricle, Brain Stem, Spinal Canal)
Partial revision
When the replacement of a part of a cerebrospinal fluid (CSF) shunt system is documented as a revision,
DN
select one of the following codes, depending on the originating site of drainage (where the blockage lies):
1.AC.54.^^ Management of internal device, ventricles of brain

1.AP.54.^^ Management of internal device, brain stem
1.AX.54.^^ Management of internal device, spinal canal and meninges
The qualifier portion of the code identifies the region of the body in which the shunt terminates.
Example: The patient has a ventriculoperitoneal shunt because of hydrocephalus. He is

admitted on this occasion to have the valve changed.
1.AC.54.ME-SJ Management of internal device, ventricles of brain, open

approach, shunt system terminating in abdominal cavity
[e.g. ventriculoperitoneal, gallbladder]
218
Complete revision
When there is removal and concomitant reinstallation of an entire CSF shunt system, select one of the
DN
following code sets, depending on the originating site of drainage (where the blockage lies). The qualifier
portion of the code identifies the region of the body in which the shunt terminates.
1.AC.52.^^ Drainage, ventricles of brain

1.AC.55.^^ Removal of device, ventricles of brain
1.AP.52.^^ Drainage, brain stem

1.AP.55.^^ Removal of device, brain stem
1.AX.52.^^ Drainage, spinal canal and meninges

1.AX.55.^^ Removal of device, spinal canal and meninges
The insertion of the new system is sequenced as the principal intervention, followed by the removal of
the old system.
Example: The patient had a previous insertion of a syringopleural shunt for syringomyelia.
On this occasion, she is admitted for a complete removal and replacement of the
syringopleural shunt due to shunt failure.
1.AP.52.MQ-SJ Drainage, brain stem, using shunt system terminating in

thoracic cavity [e.g. syringopleural]
1.AP.55.SE-SJ Removal of device, brain stem, of shunt catheter system,
burr hole technique for access
As with any other indwelling catheterization for continuous drainage, there is no status attribute
in CCI to indicate “revision” at the drainage codes, as there is a reasonable expectation that
there may be a need to replace valves, unblock shunts and reposition catheters over the course
of its installation. It is quite common to replace any long-term indwelling catheter system in its
entirety, especially in a growing child.
219
Seizures
DN
When there is documentation of a recurrent seizure that is not associated with an acute medical illness or
psychoactive drug withdrawal, use the alphabetical index lead term “Epilepsy.”
DN
When there is documentation of a seizure provoked by
• Psychoactive drug withdrawal, use the alphabetical index lead term “Withdrawal.”
• Acute medical illness, assign a code for the medical illness.
DN
When there is documentation of “seizure disorder”
• Described as febrile, use the alphabetical index lead term and subterm “Seizure, febrile.”
• With no further specification, assign R56.80 Seizure disorder, so described.
Note
Examples of acute medical illnesses that may provoke a seizure are hyponatremia, hypomagnesemia,
hypocalcemia, hypoglycemia, nonketotic hyperglycemia, hypoxia, renal or hepatic failure and sepsis.
Note
A single, isolated (no history of previous seizure) or first-time seizure is not classified to epilepsy. See the
exclusion note at category G40 Epilepsy.
Note
Do not confuse intractable epilepsy (medication-resistant or refractory) with status epilepticus. Intractable
epilepsy means that the seizures are “poorly controlled” with the current anticonvulsant medication regime,
whereas status epilepticus refers to continuous seizure activity and is a life-threatening emergency.
The documentation must specifically state “status epilepticus” before a code from G41 Status epilepticus
is assigned.
Note
For assistance in determining the correct lead term for documentation of seizure or seizure disorder, see the
following flowchart.
220
Correct index search for seizure(s) and seizure disorder

Start
Diagnosis is recorded
as Seizure(s) or
Seizure Disorder
Was the
Use lead term and subterm
seizure due to any
Withdrawal,
alcohol or psychoactive Yes End
state
drug withdrawal?
(F10–F19)
No
Was the Use lead tem and subterm

seizure due to high fever Seizure,
Yes End
or referred to as a febrile febrile
seizure? (R56.0–)
No
Did any
Assign a code for the
acute medical illness
Yes acute medical illness End
provoke the
(+ R56.88 optional)
seizure?
No
Did the
Use lead term
dx refer to a single,
Yes Seizure End
isolated or first
(R56.88)
seizure?
No
Was there
Use lead term
a history of previous
Yes Epilepsy End
seizure(s) or recurrent
(G40.–)
seizures?
No
Use lead term and subterm

Disorder,
seizure
(R56.80)
End
221
N Example: A 65-year-old male patient is brought in by ambulance having suffered a seizure.

The physician describes a tonic-clonic seizure and notes that the patient has had three
such seizures in the past. The final diagnosis is recorded as tonic-clonic seizure.
G40.60 MP Grand mal seizures, unspecified (with or without petit mal), not stated
as intractable
Rationale: The patient has a history of seizures. The current seizure was not
caused by an acute medical illness or withdrawal from psychoactive
drugs; therefore, this case is classified as epilepsy. Based upon the
further detail of tonic-clonic seizure, G40.60 is assigned.
DN Example: A 5-year-old child is admitted following a seizure not associated with any fever.
The physician documents that the child has had at least two previous seizures and
records the final diagnosis as “Seizure Disorder.”

G40.90 (M) MP Epilepsy, unspecified, not stated as intractable
Rationale: A final diagnosis of seizure disorder with a history of previous seizures

is classified as epilepsy. R56.80 Seizure disorder, so described is not
assigned because there is documentation of previous seizures.
DN Example: A 4-year-old child is admitted following a febrile convulsion. The physician

documents that he has had a previous febrile convulsion. Final diagnosis is
recorded as “Febrile Convulsion.”
R56.09 (M) MP Febrile convulsions, unspecified
Rationale: The correct code is found by following the alphabetical index lookup
“Convulsions, febrile.”
222
N Example: This 57-year-old woman has a grand mal seizure in a shopping mall. She is taken
to the hospital by ambulance. History and physical reveals that she has no previous
history of seizures. Final diagnosis is recorded as grand mal seizure.
R56.88 MP Other and unspecified convulsions
Rationale: An isolated seizure, even when described using terminology such

as “grand mal,” “tonic-clonic” or “petit mal,” is assigned to R56.88.
The category G40 Epilepsy excludes an isolated (first) seizure.
N Example: The patient is a known alcoholic. He was enrolled in an alcohol rehab program but
quit. He went back to drinking heavily. His wife calls 911 when he begins convulsing
in the afternoon after having consumed several drinks. The emergency physician
notes that this patient has a history of alcoholic seizures, with multiple emergency
visits in the past. The emergency department record documents “Alcohol poisoning
and seizures.” The patient is admitted to the intensive care unit.
T51.0 MP Toxic effect of ethanol
G40.50 OP Special epileptic syndromes, not stated as intractable
X45 OP Accidental poisoning by and exposure to alcohol
Rationale: Recurrent seizures induced by alcohol, drugs, stress, sleep deprivation or

photosensitivity are classified as epilepsy. There is no documentation of
withdrawal to classify this as a withdrawal seizure. To assign the correct
code, use the alphabetical index lookup “Epilepsy, related to, alcohol.”
223
N Example: A 17-year-old male is brought to the emergency department following a seizure.

He consumed an excessive amount of alcoholic beverages throughout the evening.
History reveals no previous seizures. The diagnosis is recorded as seizure due to
alcohol poisoning.
T51.0 MP Toxic effect of ethanol
R56.88 OP Other and unspecified convulsions
X45 OP Accidental poisoning by and exposure to alcohol
Rationale: The seizure is an isolated event and assigned to R56.88.
N Example: A 3-day-old female is brought to the emergency department of Children’s

Hospital because she had a seizure. Tests are done, and the baby is treated with
anticonvulsive medication. She is released, and her parents are to take her to her
pediatrician for monitoring and follow-up.

P90 MP Convulsions of newborn
Rationale: The correct code is found by using the alphabetical index lookup
“Seizure, newborn.”
DN Example: A patient known to have epilepsy is admitted through the emergency department.
The admitting diagnosis is “status epilepticus.”
Code Code title
G41.9 Status epilepticus, unspecified
G40.90 Epilepsy, unspecified, not stated as intractable
Rationale: The “Use additional code” instruction at category G41 Status epilepticus
directs to assign a code to identify any underlying convulsions, seizures
or epileptic syndromes. Diagnosis typing definitions must be applied to
individual cases. No sequencing rules apply.
224
Neurological Deficits Following a Stroke


Code as comorbid conditions all neurological deficits documented by the physician, such as paralysis,
D
dysphagia, aphasia, urinary incontinence and fecal incontinence, when they affect the management and
treatment of the patient during the acute care phase of the stroke.
Criteria
R13.– Dysphagia must be assigned a diagnosis type (1) when the patient requires nasogastric tube/
enteral feeding or still requires treatment more than seven days after the stroke occurred.
R15 Fecal incontinence must be assigned a diagnosis type (1) when it is still present at discharge or
persists for at least seven days.
R32 Unspecified urinary incontinence must be assigned as a diagnosis type (1) when it is still present at
discharge or persists for at least seven days.
D For all other neurological deficits following a stroke, apply diagnosis types according to the diagnosis
typing definitions.
See also the coding standards Strokes: Hemorrhagic, Ischemic and Unspecified and Sequelae.
D Example: On admission, a patient experiences left-sided weakness. He is diagnosed as

having suffered an acute cerebral infarction, and tissue plasminogen activator
(TPA) is administered. On admission, he also has difficulty swallowing. On day 8
following the stroke, the patient is transferred to a facility closer to home for
continued stroke care with a nasogastric tube in place.
Code DAD Code title
I63.9 (M) Cerebral infarction, unspecified
R13.8 (1) Other and unspecified dysphagia
225
Hemiplegia
DN Assign a code from category G81 Hemiplegia as a most responsible diagnosis/main problem only when it is
reported without further specification or it is stated to be old or long-standing but of unspecified cause. 1
DN Assign a code from category G81 Hemiplegia as an additional code to identify types of hemiplegia
resulting from any cause.
DN Example: A patient is seen in day surgery for excision of multiple skin lesions of basal cell
carcinoma — lower leg. Examination reveals residual hemiparesis from a previous
stroke. No specific treatment is directed to the residual hemiparesis in this episode
of care.
C44.7 (M) MP Malignant neoplasm skin of lower limb, including hip
G81.99 (3) OP Hemiplegia of unspecified type of unspecified

[unilateral] side (optional)
I69.4 (3) OP Sequelae of stroke, not specified as haemorrhage

or infarction (optional)
D Example: A right-handed patient has suffered a CVA due to an embolism of a cerebral

artery. He has left-sided hemiplegia, which is a focus of this treatment, and he
receives physiotherapy.
Code DAD Code title
I63.4 (M) Cerebral infarction due to embolism of cerebral arteries
G81.91 (1) Hemiplegia of unspecified type of non-dominant side
226
Neurologically Determined Death

In effect 2018
Neurological determination of death is a clear and standardized process for determining the
death of an individual based on neurologic or brain-based criteria. Neurological determination
of death is one of the requirements for deceased organ donation. 2
“Brain death” is the most universal term used to describe neurological determination of death
and is based on the concept of complete and irreversible loss of brain function. Common terms
used in clinical practice to describe neurologically determined death include “brain death,”
“brain dead,” “neurological death,” “neurologically deceased” and “death by neurological
criteria.” Brain death is defined as “irreversible loss of the capacity for consciousness
combined with the irreversible loss of all brain stem functions, including the capacity to
breathe.” 3 A patient who is brain dead will not have the capacity to breathe, which means
he or she will be mechanically ventilated.
Brain death is determined according to accepted medical practice and is confirmed by a health
care provider.2 This would be a physician who is fully authorized to pronounce death in
accordance with an internal/facility-written policy and procedure on pronouncement of death as
a delegated medical function. This coding standard addresses how to classify documented
cases of neurologically determined death.
Assign G93.81 Neurologically determined death as a diagnosis type (3)/other problem, mandatory, when
DN
there is documentation of brain death by a designated physician.
Note
Documentation of brain death will often include the outcome of neurological assessments that are
completed to see if the patient meets the clinical criteria for neurological death. Some of these assessments
may test for the absence of gag and cough reflexes and the absence of respiratory effort based on an apnea
test. Assessments may also test the absence of bilateral motor responses (excluding spinal reflexes),
corneal responses and pupillary responses to light. 4 These assessments in and of themselves do not qualify
for the case to be classified to G93.81. There must be documentation of neurologically determined death
(brain death).
227
D Example: A patient attempts suicide by hanging himself. He is found at home. He is ultimately

resuscitated from this and admitted to the intensive care unit on life support.
Despite aggressive resuscitation, he proceeds to brain death. He is determined
neurologically dead and organ support is withdrawn. Brain death is determined
and is documented by the physician.
Code DAD Code title
T71 (M) Asphyxiation
X70 (9) Intentional self-harm by hanging, strangulation and suffocation
U98.0 (9) Place of occurrence, home
G93.81 (3) Neurologically determined death
Rationale: This patient was determined neurologically dead and brain death is
documented; therefore, G93.81 is assigned, mandatory, as a diagnosis
type (3).
D Example: A patient presents after collapsing while exercising. The CT scan reveals a
subarachnoid hemorrhage due to a ruptured aneurysm of the basilar artery.
While the patient is in the intensive care unit, it is determined that he is not a surgical
candidate and he progresses to meet the criteria for the neurological determination
of death. It is documented by the physician that the patient is brain dead.
Code DAD Code title
I60.4 (M) Subarachnoid haemorrhage from basilar artery
G93.81 (3) Neurologically determined death
Rationale: This patient was determined neurologically dead and this is documented;
therefore, G93.81 is assigned, mandatory, as a diagnosis type (3).
228
D Example: A patient presents with peritonitis and disseminated intravascular coagulation (DIC).
A discussion is held with the family regarding her small chance of survival, and
withdrawal of life support is recommended. The patient’s family agrees with the
physician’s recommendation. The patient is extubated, and vasopressors and
hemodynamic support are discontinued. The patient dies shortly thereafter.
Code DAD Code title
K65.9 (M) Peritonitis, unspecified
D65 (1) Disseminated intravascular coagulation [defibrination syndrome]
Rationale: There is no documentation of brain death; therefore, G93.81 is not

assigned. G93.81 is not meant as a flag for all deaths.
D Example: A patient presents with a devastating ischemic stroke in the left middle cerebral
artery territory and continues to have a poor neurological exam, including absent
pupillary reflexes and absent corneal reflexes. The family agrees that CPR should
not be provided. She develops worsening hypotension and is pronounced dead by
the attending physician.
Code DAD Code title

I63.5 (M) Cerebral infarction due to unspecified occlusion or stenosis of
cerebral arteries
Rationale: There is no documentation of brain death; therefore, G93.81 is not

assigned. G93.81 is not meant as a flag for all deaths.
229
N Example: A patient is brought to the emergency department by ambulance after collapsing at

home. Paramedics performed CPR en route to the hospital. In the emergency
department, an endotracheal tube is inserted and CPR is continued and is
ultimately successful. At this point it is determined that due to the long downtime,
the patient has suffered severe anoxic brain injury due to cardiac arrest. Brain
death is determined and documented by the physician.

I46.0 MP Cardiac arrest with successful resuscitation
G93.1 OP Anoxic brain damage, not elsewhere classified
G93.81 OP Neurologically determined death
Rationale: There is documentation on the emergency department record of brain death.

Therefore, G93.81 is assigned, mandatory, as an other problem (OP).
References
Health Problems (ICD-10), Tenth Revision, Volume 1. 2010
2. Canadian Council for Donation and Transplantation. Severe Brain Injury to Neurological
Determination of Death: A Canadian Forum. October 2003.
3. Shemie SD, Doig C, Dickens B, Byrne P, Wheelock B, Rocker G, Baker A, Seland TP, Guest
C, Cass D, Jefferson R, Young K, Teitelbaum J; Pediatric Reference Group; Neonatal
Reference Group. Severe brain injury to neurological determination of death: Canadian
Forum recommendations. Canadian Medical Association Journal. March 2006.
4. Trillium Gift of Life Network. Donation Resource Manual. March 2010.
230
Chapter IX — Diseases of the circulatory system
Chapter IX — Diseases of the

circulatory system
Hypertension and Associated Conditions
Hypertensive heart and hypertensive renal disease
Assign I11 Hypertensive heart disease, I12 Hypertensive renal disease or I13 Hypertensive heart and renal
DN disease only when the physician specifically documents a cause/effect relationship between the cardiac
or renal condition and the hypertension. A causal relationship must not be assumed.
Assign an additional code to identify any associated conditions that are due to hypertension
DN (such as congestive heart failure or chronic renal failure). Sequence I11, I12 or I13 first.
Note
Ensure that codes from categories I10–I13 are never recorded as a post-admit comorbidity — diagnosis type
(2) — on an inpatient abstract and are never used together on one abstract, as they are mutually exclusive.
D Example: An obese patient with long-standing hypertension complains of exertional

and non-exertional dyspnea, ankle edema and weight gain. A transthoracic
echocardiography (TTE) is performed. He is admitted in congestive heart failure.
Diagnosis: Hypertensive heart disease

Congestive heart failure
Code Code title

I11 Hypertensive heart disease
I50.0 Congestive heart failure
Rationale: When heart failure is caused by essential hypertension, physicians

commonly use terminology such as “due to hypertension” or “hypertensive”
to link the two. When diagnostic statements on the chart mention both
conditions independently, a causal relationship must not be assumed. Since
“hypertensive” is used in this example, a causal relationship is indicated.
231
DN Example: Chronic renal failure and hypertension
Code Code title
N18.9 Chronic kidney disease, unspecified
I10.0 Benign hypertension
Rationale: I12 Hypertensive renal disease is not assigned because a causal

relationship cannot be presumed.
DN Example: Diagnosis: Type 2 diabetes mellitus with chronic renal failure

Hypertension
Code Code title
N08.39* Unspecified glomerular disorders in diabetes mellitus
Rationale: I12 Hypertensive renal disease is not assigned because a causal

relationship cannot be assumed between the hypertension and kidney
disease. Classify each condition separately.
D Example: A patient is admitted for treatment of congestive heart failure and chronic renal
failure documented as secondary to long-standing pre-existing hypertension.
Treatment consists of aggressive diuresis and dialysis.
Code DAD Code title

I13 (M) Hypertensive heart and renal disease
I50.0 (1) Congestive heart failure
N18.9 (1) Chronic kidney disease, unspecified
Rationale: A cause-and-effect relationship has been documented between heart

failure and renal failure due to hypertension. Diagnosis type (1) is
assigned with I50.0 and N18.9 because treatment was directed toward
the congestive heart failure and kidney failure.
232
Hypertension with cerebrovascular disease
DN Sequence the code for cerebrovascular disease first when it is present with hypertension
DN Example: Occlusion of basilar artery with hypertension
Code Code title

I65.1 Occlusion and stenosis of basilar artery
Acute Coronary Syndrome (ACS)

For clinical information, see also Acute coronary syndrome (ACS) and related interventions
in Appendix A.
DN
When any code from category I21 Acute myocardial infarction or I22 Subsequent myocardial infarction or
the code I24.0 Coronary thrombosis not resulting in myocardial infarction is assigned, assign an additional
code from subcategory R94.3– Abnormal results of cardiovascular function studies, mandatory, as
diagnosis type (3)/other problem.
Note
For inpatient and day surgery abstracts, R94.30 and R94.31 are reserved for the purpose of adding ST
segment elevation myocardial infarction (STEMI) and non–ST segment elevation myocardial infarction
(NSTEMI) information to acute myocardial infarction (AMI) or aborted myocardial infarction. These codes are
to be used only when a code from category I21 Acute myocardial infarction or I22 Subsequent myocardial
infarction or the code I24.0 Coronary thrombosis not resulting in myocardial infarction is assigned. R94.30 and
R94.31 are not used with any other diagnosis.
For emergency department encounters, R94.30 and R94.31 may be used without a code from category I21
or I22 or without code I24.0; however, they must be used only for the purpose of indicating a discharge
diagnosis of STEMI or NSTEMI.
233
Note
Do not refer to the ECG or laboratory reports for assignment of R94.3–. Use the physician statement of
the ECG findings. If no such statement is found, use R94.38 Other and unspecified abnormal results of
cardiovascular function studies.
D Example: A 74-year-old female is seen in the emergency department and subsequently

admitted with chest discomfort, pain radiating down both arms and a general sense
of feeling unwell. Symptoms had been present for about three days before the
patient came to hospital. Upon admission to hospital, the physician notes that
the patient’s ECG is normal but her troponin and CK-MB are elevated.
Final diagnosis: Non-Q-wave myocardial infarction
Code DAD Code title

infarction [NSTEMI]
Rationale: R94.31 is assigned because the physician documented the diagnosis

as a myocardial infarction (MI) and there was documentation indicating
that there was no ST segment elevation (i.e., the ECG was normal) but
there were positive biomarkers.
234
D Example: The patient presents with episodes of syncope. An admission ECG documents ST
depression in leads V4 to V6 with non-specific ST changes in the high lateral leads.
His biomarkers are positive.
Impression: NSTEMI
Plan: NSTEMI management
His first troponin is 0.18. The second is 0.16, and the CK-MB is negative. This points
to a noncardiac cause of troponin leak. He has a computerized tomography (CT)
pulmonary angiogram study, which confirms pulmonary embolism. He is started on
heparin and warfarin.
Final diagnosis: Pulmonary embolism
Code DAD Code title

I26.9 (M) Pulmonary embolism without mention of acute cor pulmonale
Rationale: As the final diagnosis is not an MI, R94.3– is not assigned.
The diagnosis of STEMI or NSTEMI clinically represents the early picture of ACS on presentation.
The evolution or outcome of the condition may not be determined until after further investigation
or treatment.
In the emergency department setting, a diagnosis written as STEMI, for example, is classified to
R94.30 alone to reflect that the outcome is yet to be determined. However, when a physician
records the diagnosis in the emergency department in terms such as “acute MI,” it is interpreted
to mean that the outcome has been determined, and the appropriate code from I21 is assigned.
In the inpatient setting, the evolution or outcome of the condition is expected to be determined by
the time of discharge. The usual evolution of STEMI is Q-wave MI. Therefore, an MI documented
as STEMI is classified to the appropriate code from I21.0–I21.3 unless there is documentation
to support that the final outcome is a non-Q-wave MI or an averted MI. The usual evolution of
NSTEMI is non-Q-wave MI. Therefore, an MI documented as NSTEMI is classified to I21.4
unless there is documentation to support that the final outcome is a Q-wave MI.
235
N When the emergency department discharge diagnosis is documented as ST segment elevation myocardial
infarction (STEMI) or non–ST segment elevation myocardial infarction (NSTEMI), assign the appropriate
code from subcategory R94.3– Abnormal results of cardiovascular function studies as the main problem.
N When the emergency department discharge diagnosis is documented in terms of an acute myocardial
infarction, assign the appropriate code from category I21 Acute myocardial infarction as the main problem.
N Example: This patient presents to the emergency department with crushing chest pain and
associated jaw pain. The ECG initially shows depression in anterior and inferior
leads. Subsequent ECGs show that the patient developed right bundle branch block
and ST depression in anterolateral and inferior leads. The patient is transferred to
the coronary care unit (CCU) with a diagnosis of NSTEMI.
R94.31 MP Abnormal cardiovascular function studies (biomarkers or ECG)

suggestive of non ST segment elevation myocardial infarction
[NSTEMI]
Rationale: In the emergency department, the working diagnosis of NSTEMI represents

the greatest degree of specificity known at the time of transfer to the CCU.
N Example: The patient is received in the emergency department from Hospital A by air
ambulance with a diagnosis of STEMI. On examination, the patient is ashen and
there are no peripheral pulses. The patient is sent directly to the catheterization lab
with an emergency department discharge diagnosis of AMI.

I21.9 MP Acute myocardial infarction, unspecified
R94.30 OP Electrocardiogram suggestive of ST segment elevation myocardial

infarction [STEMI]
Rationale: Always assign codes to the greatest degree of specificity documented.

The documentation states that this patient was brought to hospital with
a diagnosis of STEMI, so R94.30 is assigned. I21.9 is selected as the
code for the main problem because the final outcome or type of MI has
not yet been established.
236
Classify a myocardial infarction with ST segment elevation to subcategory I21.0–I21.3 Acute transmural
D
myocardial infarction by site unless there is documentation to support that the final outcome was a non-
Q-wave myocardial infarction or aborted myocardial infarction.
D Example: A 61-year-old man is transferred in from another hospital with an acute inferior wall
STEMI, having failed thrombolytic therapy. The physician notes that ECGs done on
admission at the referring hospital showed ST segment elevation. The patient has
no previous history of coronary artery disease (CAD). Percutaneous coronary
intervention (PCI) is performed on day 1 to the right coronary artery.
Discharge diagnosis: ST segment elevation MI, inferior wall
Code DAD Code title

I21.1 (M) Acute transmural myocardial infarction of inferior wall

infarction [STEMI]
Rationale: I21.1 is assigned because the final diagnosis is documented as ST

segment elevation MI, inferior wall. There is no documentation to
support that the final outcome is a non-Q-wave MI or that the MI is
aborted. R94.30 is assigned to denote that the patient presented with
ST segment elevation.
237
D Example: A 54-year-old male presents with chest pain. The physician notes that his admitting
ECG shows ST segment elevation. He is admitted to the CCU with thrombolytic
therapy initiated immediately. His ECG appears normal following treatment, but
troponin levels are documented as elevated. Final diagnosis is documented as
non-Q-wave MI.
Code DAD Code title

infarction [STEMI]
Rationale: Although this case presented as STEMI, thrombolytic therapy

was successful in preventing this MI from evolving into a Q-wave MI;
therefore, a code from subcategory I21.0–I21.3 is not assigned. R94.30 is
assigned to denote that the patient presented with ST segment elevations.
Classify a myocardial infarction presenting with ST segment elevation but aborted or averted by
D
successful treatment to I24.0 Coronary thrombosis not resulting in myocardial infarction.
D Example: A 57-year-old male with known CAD presents with chest pain. The physician notes
that his admitting ECG shows ST segment elevation. A primary PCI is performed.
Final diagnosis is documented as aborted MI.
Code DAD Code title
I24.0 (M) Coronary thrombosis not resulting in myocardial infarction

infarction [STEMI]
I25.19 (1) Atherosclerotic heart disease of unspecified type of vessel, native

or graft
238
Classify a myocardial infarction without ST segment elevation to I21.4 Acute subendocardial myocardial
D
infarction unless there is documentation to support that the final outcome was a Q-wave
myocardial infarction.
D Example: A 45-year-old male presents with a clinical picture and subsequent ECG and
enzyme documentation of a small ACS event. NSTEMI is documented. Subsequent
coronary angiogram indicates triple-vessel CAD. Surgical consultation is obtained,
and a bypass procedure will be scheduled. Discharge medications include aspirin,
Plavix and ramipril.
Final diagnosis: Non–ST segment elevation myocardial infarction
Code DAD Code title


infarction [NSTEMI]
I25.10 (1) Atherosclerotic heart disease of native coronary artery
Rationale: I21.4 is assigned because the final diagnosis is documented as non–ST

segment elevation myocardial infarction. There is no documentation to
support that the final outcome is a Q-wave MI. R94.31 is assigned to
denote that the patient presented with non–ST segment elevation.
D Whenever a myocardial infarction is within the acute phase (i.e., within 28 days), assign a comorbid
diagnosis type (M), (1), (2), (W), (X) or (Y) as appropriate for the case.
239
DN
When a patient presents with any condition in the spectrum of acute coronary syndrome (ACS) and
undergoes emergent or urgent percutaneous coronary intervention (PCI) during the same admission,
assign a code for the ACS diagnosis as the MRDx/main problem. Assign an additional code for any
documented underlying coronary artery disease as a diagnosis type (1)/other problem. This applies to
in-hospital and out-of-hospital PCIs and to both the transferring and receiving hospitals.
When a patient who has a myocardial infarction that is still in the acute phase presents for elective
DN percutaneous coronary intervention, assign a code for the underlying coronary artery disease as the
MRDx/main problem and assign an additional code for the MI as a significant diagnosis
type/other problem.
Exception
When a patient is readmitted with a diagnosis classifiable to category I22 Subsequent myocardial infarction,
a code from category I21 Acute myocardial infarction may be assigned as an optional diagnosis type (3)/other
problem to indicate the site of the original MI.
D Example: The patient choked on some custard earlier this week. She then went on to develop
a cough and a fever. Chest X-ray confirms that she has aspiration pneumonia.
The physician notes in the discharge summary that she had an AMI two weeks ago.
Final diagnosis: Aspiration pneumonia
Code DAD Code title
J69.0 (M) Pneumonitis due to food and vomit
W79 (9) Inhalation and ingestion of food causing obstruction of

respiratory tract
U98.9 (9) Unspecified place of occurrence
I21.9 (1) Acute myocardial infarction, unspecified
R94.38 (3) Other and unspecified abnormal results of cardiovascular

function studies
Rationale: The MI was still within the acute phase, so it was assigned a comorbid diagnosis
type. Since a code from I21 was assigned, R94.38 Other and unspecified
abnormal results of cardiovascular function studies is mandatory.
240
D Example: The patient is received in transfer from Hospital A with a diagnosis of STEMI,
having failed thrombolytic therapy. He had been treated with tenecteplase (TNK),
but chest pain continued and he was referred to Hospital B for coronary
angiography and possible intervention.
Final diagnosis: Acute inferior wall ST segment elevation myocardial infarction

with failed thrombolytic therapy. Successful rescue PCI.
Code DAD Code title

infarction [STEMI]
Rationale: As this is not an elective PCI for Hospital B, I21.1 is assigned as the
MRDx. In the acute phase of an MI, a PCI is most often a life-saving
event. The focus of care is the MI and, secondarily, the underlying CAD.
Had there been documentation of underlying CAD, it would have been a
diagnosis type (1).
D Example: A 52-year-old male presents with chest pain and shortness of breath. The physician
documents possible ACS. The ECG is documented as showing no significant
ischemia and no acute infarction. Troponin levels are documented as negative
for infarction.
Final diagnosis on angiogram report: Non–ST segment elevation acute coronary
syndrome (non-STEACS) with diffuse coronary artery disease.
Code DAD Code title

I20.0 (M) Unstable angina
I25.19 (1) Atherosclerotic heart disease of unspecified type of vessel, native

or graft
Rationale: Note: For this example, non-STEACS = unstable angina because of the
normal ECG and the negative troponin. R94.3– is not assigned in this
case because the MRDx is not from category I21 or I22 and is not
code I24.0.
241
When a transmural (Q-wave) myocardial infarction is classifiable to more than one code in category I21,
D
assign I21.2 Acute transmural myocardial infarction of other sites.
Assign a code from category I22 Subsequent myocardial infarction to capture a repeat myocardial
D
infarction within the acute phase (i.e., within 28 days) of the initial infarction or an extension of the initial
infarct occurring within the 28-day period. Assign a diagnosis type according to the diagnosis typing
definitions.
DN When a code from category I22 Subsequent myocardial infarction is assigned, assign an additional code
from subcategory R94.3– Abnormal results of cardiovascular function studies, mandatory, as a diagnosis
See also the coding standard Diagnosis Typing Definitions for DAD.
DN Example: Acute Q-wave MI involving the anterolateral and inferolateral wall. Progress notes
state ECGs show ST segment elevation.
I21.2 (M) MP Acute transmural myocardial infarction of other sites
R94.30 (3) OP Electrocardiogram suggestive of ST segment

elevation myocardial infarction [STEMI]
242
D Example: A 63-year-old woman presents to the hospital by ambulance because of ongoing

chest pain since midnight. ECG shows non-specific ST-T wave changes. There
are no ST segment elevations. Her cardiac markers are abnormal, with troponin
peaking at 1.42. The patient has a known history of CAD and had a previous
angioplasty in 2001. She is admitted to the CCU.
Impression: NSTEMI
On her third day in the CCU, the patient starts to have severe chest pain. The
physician notes that a stat ECG taken during that time showed that she was having
ST segment elevations in 2, 3 and AVF, which did not settle down within 5 to 10
minutes. Therefore, the patient is immediately taken to the cardiac catheterization
lab for primary PCI for STEMI. Coronary angiograms show that the patient has a
95% stenosis of the proximal circumflex artery and a 75% stenosis of the distal
circumflex artery. She goes on to have primary angioplasty with deployment of two
stents to her circumflex artery.
Final diagnosis: Acute myocardial infarction
Code DAD Code title

I22.9 (M) Subsequent myocardial infarction of unspecified site

infarction [STEMI]
I21.4 (1) Acute subendocardial myocardial infarction
R94.31 (3) Abnormal cardiovascular function studies (biomarkers or ECG)

suggestive of non ST segment elevation myocardial
infarction [NSTEMI]
I22.9 (2) Subsequent myocardial infarction of unspecified site
Rationale: Both I21.4 and I22.9 are required. In this case, I22.9 meets the
definition of the MRDx. Since the subsequent MI occurred after
admission, it is also assigned a diagnosis type (2). An additional code
from subcategory R94.3– is mandatory for both I21.4 (i.e., R94.31,
to show that the original MI was NSTEMI) and I22.9 (i.e., R94.30 to
show that the subsequent MI was STEMI).
243
D Example: The patient is treated and discharged from hospital with an acute Q-wave MI of the
inferolateral wall. Two days following discharge, he is readmitted with an AMI of the
posterolateral and posteroseptal wall.
Code DAD Code title
I22.8 (M) Subsequent myocardial infarction of other sites

function studies
I21.1 (3) Acute transmural myocardial infarction of inferior wall (optional)

function studies
Rationale: I22.8 is assigned because the previous MI was less than 28 days old.
The fact that the patient had a recent MI is inherent in the code
I22.8. In the case of a readmission for a subsequent MI, it is optional to
assign a code from category I21 Acute myocardial infarction to indicate
the site of the original MI. If I21 is assigned, it is a diagnosis type
(3)/other problem, and a code from subcategory R94.3– must also be
assigned. In this case, since it is not documented whether the (initial or
subsequent) MIs were STEMI or NSTEMI, R94.38 is assigned.
Assign a code from category I23 Certain current complications following acute myocardial infarction
D
for specified complications that occur during the acute phase (i.e., within 28 days) of a
These complications usually occur within 2 to 7 days post-AMI. However, this does not preclude
the use of these codes when the condition is documented as a current complication following
AMI or when the MI is in the acute stage (i.e., within 28 days). When complications occur
simultaneously with the infarction, they are included in the AMI code.
244
D Example: The patient is admitted from the emergency department, where she received
thrombolytics, with a diagnosis of STEMI. She is admitted directly to the CCU.
Based on documented ST segment elevations noted on the ECG, she is diagnosed
with an inferior STEMI. Two days later, she suffers post-MI angina.
Diagnosis: Acute myocardial infarction of inferior wall

Post–myocardial infarction angina
Code DAD Code title


infarction [STEMI]
I23.82 (2) Postmyocardial infarction angina as current complication following

acute myocardial infarction

Assign I25.2 Old myocardial infarction (i.e., “history of MI”), optional, as a diagnosis type (3) only when both
D
of the following criteria apply:
• The previous myocardial infarction occurred more than 4 weeks (28 days) ago; and
• The patient is not currently receiving observation, evaluation or treatment for the previous
D Example: The patient is admitted for a hemicolectomy. The physician documents a past
history of MI based on ECG investigations. No treatment is directed toward the
healed infarct.
Code DAD Code title

I25.2 (3) Old myocardial infarction (optional)
245
Selection of Status Attribute for Percutaneous

Coronary Intervention (PCI)
The main purpose of the mandatory status attribute at rubric 1.IJ.50.^^ Dilation, coronary
arteries is to distinguish primary PCI for STEMI from other PCI.
DN When a percutaneous coronary intervention classifiable to rubric 1.IJ.50.^^ Dilation, coronary arteries is
performed, assign, mandatory, the status attribute (see flowchart below).
Note
Ensure status attribute N — Primary PCI for STEMI or D1 — Other PCI for STEMI is selected only with a
diagnosis of STEMI (i.e., R94.30 must be assigned on the abstract).
246
Start
PCI performed
Yes
Was the Select P—

PCI elective? Elective PCI
No
No
Was there a current Select OP—

ACS diagnosis? Other PCI
Yes
Yes
Yes
Is it a STEMI Was this a second Select OP—
(R94.30)? stage of a staged PCI? Other PCI
No No
No Yes
Select Did the patient Select D1—-
Is it a NSTEMI or UA
UN—Unknown receive thrombolytic Other PCI for
(R94.31 or I20.0)?
(I24.9) therapy prior to PCI? STEMI
Yes No
Yes
Was the Yes
Was this a
Select OP - PCI performed Select N—
second stage of a
Other PCI within 12hrs of Primary PCI
staged PCI?
presentation to the for STEMI
first hospital?
No
No
Select UR— Select D1—

Urgent PCI for Other PCI for
NSTEMI or UA STEMI
End End
247
Thrombolytics are serine proteases that convert plasminogen to plasmin, which in turn breaks down
the fibrinogen and fibrin in a clot to dissolve it. In other words, a thrombolytic is a clot “buster.” 1
Some examples of thrombolytic agents currently used (sometimes referred to as reperfusion

therapy) include streptokinase (Streptase®), alteplase or tissue plasminogen activator (TPA)
(Activase®), anistreplase (Eminase®), reteplase (Retavase®), urokinase or urokinase-type
plasminogen activator (UPA) (Abbokinase®) and tenecteplase (TNKase®). The intent is to
achieve a reperfusion by thrombolysis.
DN Assign a code for thrombolytic therapy, mandatory, whenever it is administered, regardless of the diagnosis.

N When thrombolytic therapy is administered in the emergency department or prior to arrival, such as
by a paramedic, assign a code for thrombolytic therapy, mandatory, on the National Ambulatory Care
Reporting System (NACRS) emergency department abstract.

Assign a code for thrombolytic therapy, mandatory, on the abstract of the first inpatient encounter of the
D
current, uninterrupted episode of care, even when administered
• Prior to arrival in the emergency department (such as by a paramedic); or
• In the emergency department of the same facility or transfer facility.
248
DN Classify administration of a thrombolytic agent by intravenous infusion to 1.ZZ.35.HA-1C

Pharmacotherapy, total body, percutaneous approach [intramuscular, intravenous, subcutaneous,
intradermal], using thrombolytic agent.
Classify administration of a thrombolytic agent by injection into an artery or by intra-arterial infusion to

DN 1.^^.35.^^ Pharmacotherapy (local), vessel, by site.
Note
The intent of assigning a code for thrombolytic therapy is to identify a specific patient population (i.e., those
who received thrombolytic therapy), not to capture the number of times thrombolytic therapy is administered.
Note
Apply the Intervention Pre-Admit Flag only when the diagnosis is ST-segment elevation myocardial infarction
(STEMI) to indicate when thrombolytic therapy was administered prior to admission during an encounter of
the current, uninterrupted episode of care. See Group 11, Field 20 in the Discharge Abstract Database (DAD)
Abstracting Manual for specific instructions for applying the flag for interventions initiated prior to admission.
Example: The patient is admitted with left hemiparesis, slurred speech and facial drooping.
He is diagnosed with a cerebral infarction. Intravenous streptokinase is
immediately administered.

[intramuscular, intravenous, subcutaneous, intradermal],
Note: The diagnosis is not STEMI and the thrombolytic agent is administered
after admission. Therefore, the Intervention Pre-Admit Flag does not apply.
249
Example: The patient is admitted from the emergency department with STEMI for possible
PCI. Two culprit arteries, LAD and Cx, are dilated and stented. Following PCI,
intracoronary thrombolytic injection is performed for a clot in the artery. The femoral
artery approach is used and coronary angiograms are taken.
1.IJ.50.GQ-OA Dilation, coronary arteries, percutaneous transluminal

cutting balloon dilator with (endovascular) stent insertion
Status: N
Extent: DF
1.IL.35.HA-1C Pharmacotherapy (local), vessels of heart, percutaneous
injection approach, of thrombolytic agent
Status: DX
Location: FY
Note: The diagnosis is STEMI. However, the thrombolytic therapy is administered
Example: The patient is admitted to Facility A with STEMI. Streptokinase is administered in the
emergency department, and the patient is admitted to the intensive care unit (ICU).
When a bed is available at Facility B (a tertiary facility), the patient is transferred.

Note: The diagnosis is STEMI and the thrombolytic therapy is administered prior
to admission. Therefore the Intervention Pre-Admit Flag does apply.
Rationale: Facility A would capture thrombolytic therapy on both the NACRS

emergency abstract (if it is a NACRS reporting facility) and the DAD
inpatient abstract. Facility B would not capture the administration of the
thrombolytic agent on its inpatient abstract.
Many facilities in Canada do not report to NACRS; therefore, to ensure

that thrombolytic therapy given prior to admission as an inpatient is not
lost, it must be captured on the abstract of the first inpatient encounter.
In this scenario, thrombolytic therapy would be captured on the DAD
inpatient abstract of Facility A; therefore, it is not necessary to report it
again on the DAD inpatient abstract of Facility B.
250
Example: The patient is brought to the emergency department at Facility A, where he is

diagnosed with STEMI and receives TNK. The patient is immediately transferred to
Facility B, where he is admitted directly to the CCU.

Note: The diagnosis is STEMI and the thrombolytic therapy is administered prior to
admission. Therefore, the Intervention Pre-Admit Flag does apply.
Rationale: Facility A would capture thrombolytic therapy on the NACRS emergency

abstract (if it is a NACRS reporting facility). Facility B must capture the
administration of the thrombolytic agent on its inpatient abstract.
Many facilities in Canada do not report to NACRS; therefore, to ensure

that thrombolytic therapy that is given prior to admission as an inpatient
is not lost, it must be captured on the abstract of the first inpatient
encounter. In this scenario, the first inpatient DAD abstract would be
generated at Facility B; therefore, thrombolytic therapy must be captured
on the DAD abstract of Facility B.
Example: The patient is admitted with an arteriovenous (AV) fistula thrombosis. The patient
undergoes a fistuloplasty and thrombolysis of the left brachiocephalic arteriovenous
fistula; 5 mg of TPA is given via each infusion catheter.
1.KY.80.LA Repair artery with vein using open approach

1.KV.35.HH-1C Pharmacotherapy (local), artery NEC, percutaneous
infusion approach, using thrombolytic agent
Note: The diagnosis is not STEMI and the thrombolytic agent is administered
Rationale: A code for the administration of thrombolytic therapy is mandatory to

assign. Intra-arterial infusion of a thrombolytic agent is classified by site.
251
A patient presenting with NSTEMI may be treated with antithrombotics (such as heparin) to
inhibit the coagulation process. Medical management following an MI may include platelet
aggregation inhibitors 2 (such as Plavix, ReoPro or Integrilin), ACE inhibitors and acetylsalicylic
acid (ASA) to prevent further atherothrombotic events. It is optional to capture pharmacotherapy
using antithrombotics or platelet aggregation inhibitors. The Intervention Pre-Admit Flag does
not apply to antithrombotics or platelet aggregation inhibitors.
Example: This 81-year-old gentleman is admitted with ACS. He has been having chest pain
on and off for several days leading up to his admission. He has ischemic-looking T
wave changes laterally in his ECG, associated with an elevation of his troponin T.
He is admitted to the ICU with a diagnosis of NSTEMI and treated in the usual
fashion with beta blockers, subcutaneous Lovenox, etc.
Note: Lovenox is in a class of antithrombotic agents known as low-molecular-

weight heparins.
1.ZZ.35.HA-C1 Pharmacotherapy, total body, percutaneous approach
using antithrombotic agent (optional)
Rationale: Since Lovenox is an antithrombotic, assignment of 1.ZZ.35.HA-C1 is

optional; it is mandatory to capture only thrombolytic therapy.
Angina
Angina pectoris (I20) is a clinical syndrome caused by myocardial ischemia; it is characterized

by precordial discomfort or pressure, typically precipitated by exertion and relieved by rest
or sublingual nitroglycerin. Unstable angina is characterized by a progressive increase in
anginal symptoms, new onset of rest or nocturnal angina, or onset of prolonged angina, and is
part of the spectrum of conditions in ACS.
See also the coding standards Chronic Ischemic Heart Disease and Acute Coronary Syndrome (ACS).
252
D Classify angina as a significant diagnosis type (M), (1) or (2) only when it is documented as occurring
during the current episode of care.
When a patient is admitted with angina that progresses to a myocardial infarction in the same episode of
D
care, assign a code for the myocardial infarction only.
When a coronary artery bypass graft (CABG) is performed, select I25.1– Atherosclerotic heart disease as
D
the MRDx.
D Example: A patient who is known to have coronary atherosclerosis presents to the emergency
department with unstable angina. She is subsequently admitted to undergo CABG.
The patient has had no previous bypass procedure.
Final diagnosis: CAD with unstable angina
Procedure: CABG (× 3)
Code DAD Code title

I25.10 (M) Atherosclerotic heart disease of native coronary artery
I20.0 (1) Unstable angina
Rationale: Since the unstable angina occurred during the current episode of care
and was present on admission, it is assigned a diagnosis type (1).
DN Example: The patient has had a long-standing history of CAD with exertional angina that has
been worsening in severity. He is admitted for elective PCI with stent insertion.
He experiences no episodes of angina during the current episode of care.
Final diagnosis: CAD with history of angina

I25.10 (M) MP Atherosclerotic heart disease of native
coronary artery
I20.88 (3) OP Other forms of angina pectoris (optional)
Rationale: Treatment was aimed at the underlying disease. While the patient had
angina prior to admission, there was no episode of angina during the current
episode of care. A history of angina with no documented episode occurring
during the patient’s stay in hospital describes a risk factor and may be
recorded at the facility’s discretion with a diagnosis type (3)/other problem.
253
DN Example: A patient with known CAD presents with unstable angina. He is stabilized
and transferred to another hospital for coronary angiogram and possible CABG.
I20.0 (M) MP Unstable angina
I25.10 (3) OP Atherosclerotic heart disease of native

coronary artery
Rationale: Treatment at the first hospital was aimed at the unstable angina only.

Chronic ischemic heart disease is also described as arteriosclerotic heart disease,

atherosclerotic heart disease (ASHD), CAD or coronary atherosclerosis; it is classified to I25.1–
Atherosclerotic heart disease. I25.0 Atherosclerotic cardiovascular disease, so described is
used only for atherosclerotic cardiovascular disease (ASCVD) when it is so documented by
the physician. In advanced disease, ASHD is often manifested by angina or an AMI.
See also the coding standards Angina and Acute Coronary Syndrome (ACS).
D When the patient is admitted with an acute myocardial infarction and undergoes coronary artery bypass
during the same admission, select a code from I25.1– Atherosclerotic heart disease as the MRDx and
assign diagnosis type (1) to the code for myocardial infarction.
254
D Example: This patient presents to the emergency department on August 17 with crushing
chest pain and associated jaw pain. ECG initially shows depression in anterior and
inferior leads. Subsequent ECGs show that the patient developed slight bundle
branch block and ST depression. Troponin 0.57, CK-MB 5.5. Diagnosed as
NSTEMI and admitted to CCU on ASA, Plavix, B-blocker and ACE-I. He is booked
for coronary angiography on August 18, which shows severe three-vessel CAD,
amenable to bypass. The patient has CABG on August 19. He is discharged on
August 27.
Code DAD Code title

I25.10 (M) Atherosclerotic heart disease of native coronary artery

[NSTEMI]
Rationale: In this case, the CAD meets the criteria for MRDx.
Related interventions
CABG is classified in CCI to the rubric 1.IJ.76.^^ Bypass, coronary arteries. The tissue used for
the bypass is captured as the qualifier. The saphenous vein is considered a free graft, whereas
the internal mammary artery is a pedicled graft. When both pedicled and free autografts are
used, the qualifier for combined grafts is selected.
Harvesting of the vessel used for the bypass (such as the saphenous vein or radial artery) is
coded whenever a separate incision is made to obtain it.
See also the coding standard Procurement or Harvesting of Tissue for Closure, Repair
or Reconstruction.
Note
A mandatory extent attribute is required to record the number of arteries bypassed.
D When cardiopulmonary bypass, endarterectomy or intraoperative cell saver is performed with coronary
artery bypass graft, assign an additional CCI code to capture these procedures.
255
Procedures such as hypothermia, cardioplegia, cardioversion, insertion of pacing wires and

chest tube insertions are an inherent part of the bypass surgery and do not need to be
coded separately.
Example: Internal mammary artery bypass graft of the left anterior ascending artery
and saphenous vein bypass graft of the proximal posterior descending artery.
Extracorporeal heart–lung bypass is used, and cardioplegia is achieved. Epicardial
pacing wires are placed and a chest tube is inserted.
1.IJ.76.LA-XX-Q Bypass, coronary arteries, open approach [sternotomy],

using combined sources of tissue [e.g. graft/pedicled flap]
Extent: 2
1.LZ.37.LA-GB Installation of external appliance, circulatory system
NEC, open (chest) approach, cardiopulmonary
bypass (intraoperative)
1.KR.58.LA Procurement, veins of leg NEC, using open approach
Rationale: Codes for extracorporeal bypass are mandatory, but codes for pacing
wires and chest tube insertion are not.
Occlusion Following Coronary Artery Bypass

Grafts (CABGs)
The success of CABG varies depending on whether the revascularization was performed using
saphenous vein graft or a pedicled artery. Saphenous vein grafts are prone to occlusive disease.
By 10 years after surgery, 50% have closed, mainly because of atherosclerosis. In contrast, the
internal mammary artery is less affected by atherosclerosis and has a 90% patency rate after
10 years.
Different processes can cause saphenous vein graft occlusion. These processes include
the following:
• Thrombosis accounts for graft failure within the first month but continues to occur as long
as one year after surgery. Graft thrombosis is classified in ICD-10-CA to T82.8 Other
complications of cardiac and vascular prosthetic devices, implants and grafts.
256
• Vein graft atherosclerosis may begin as early as the first year but is fully developed after
about five years. Saphenous vein graft atherosclerosis is classified to I25.11 Atherosclerotic
heart disease of autologous vein bypass graft. 3
CIHI has sought clinical advice for classification of occluded CABGs when documentation
is ambiguous.
DN
When coronary artery bypass graft occlusion is stated as being due to thrombosis OR when it occurs
within one month of surgery, assign T82.8 Other complications of cardiac and vascular prosthetic devices,
implants and grafts.
DN
When coronary artery bypass graft occlusion is stated as being due to atherosclerosis (or atheroma) OR
when it occurs one year or more after surgery, assign a code from I25.1– Atherosclerotic heart disease.
DN
When the cause of coronary artery bypass graft occlusion is not stated and occlusion occurs between one
month and one year after surgery, seek clarification from the physician.
D Example: The patient is admitted for occlusion of his previous saphenous vein CABG.
The graft surgery was done almost six years previously.
Code DAD Code title

I25.11 (M) Atherosclerotic heart disease of autologous vein bypass graft
D Example: The patient is readmitted two weeks following CABG due to a thrombus within the
newly placed graft.

T82.8 (M) A Other specified complications of cardiac and vascular
prosthetic devices, implants and grafts
I24.0 (3) A Coronary thrombosis not resulting in myocardial infarction
R94.38 (3) A Other and unspecified abnormal results of cardiovascular

function studies
Y83.2 (9) A Surgical operation with anastomosis, bypass or graft as

the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time
of the procedure
257
Cardiac Arrest
DN Assign I46.0 Cardiac arrest with successful resuscitation or I46.9 Cardiac arrest, unspecified when
cardiac arrest is documented by the physician and a resuscitative intervention is undertaken, regardless
of outcome.
DN
Assign, mandatory, codes to identify cardiac resuscitative interventions undertaken.
DN
When cardiac arrest occurs as an expected terminal event in hospital and no resuscitation is attempted,
code only the underlying condition.
Assign I46.1 Sudden cardiac death, so described only when specifically documented as such by the physician.
DN
Cardiac resuscitative interventions include

• Codes from rubric 1.HZ.30.^^ Resuscitation, heart NEC; and
• Codes from rubric 1.HZ.09.^^ Stimulation, heart NEC.
Note
Do not confuse a statement of vital signs absent (VSA) with cardiac arrest. Cardiac arrest must be clearly
documented as such before assigning I46.0 or I46.9. A diagnosis of cardiac arrest cannot be assumed on the
basis of administration of cardiocerebral resuscitation (CCR) or cardiopulmonary resuscitation (CPR) alone.
Note
CCR is chest compressions only, without artificial respiration.
See also the coding standard Vital Signs Absent (VSA).
N Example: An 80-year-old woman calls 911. When the paramedics arrive, she is found VSA.
At the hospital, the emergency department physician pronounces her dead and
documents “sudden cardiac death” on the emergency record.

I46.1 MP Sudden cardiac death, so described
258
D Example: A patient with AIDS with disseminated aspergillosis is terminally ill. There is a do
not resuscitate (DNR) order on the chart. The physician documents that the patient
arrested at 11:45 and was subsequently pronounced dead.
Code DAD Code title
B44.7 (1) Disseminated aspergillosis
Rationale: As the arrest is an expected terminal event, only the underlying

condition is coded.
D Example: This 58-year-old female presents to the emergency department with chest pain.
The physician notes that the ECG shows ST segment elevation. The patient is
admitted to the CCU with a diagnosis of AMI. The patient subsequently goes into
cardiac arrest. CPR is initiated but is unsuccessful. The patient is pronounced
expired at 17:10.
Code DAD Code title

I21.3 (M) Acute transmural myocardial infarction of unspecified site

infarction [STEMI]
I46.9 (2) Cardiac arrest, unspecified
1.HZ.30.JN Resuscitation, heart NEC, by external manual compression with or

without concomitant ventilation
1.GZ.31.CB-EP Ventilation, respiratory system NEC, non-invasive approach
manual hand assisted (e.g. ambu bag) (optional)
Extent: 0
Rationale: Cardiac arrest was documented and a cardiac resuscitation intervention

was undertaken; therefore, it is mandatory to assign a code for the
cardiac arrest, regardless of the outcome. It is also mandatory to assign
a code for the cardiac resuscitation intervention. Note: It is optional to
assign a code for non-invasive ventilation in acute inpatient care.
259
N Example: A 40-year-old man presents to the hospital with chest pain and has a documented
cardiac arrest in the emergency department. An endotracheal tube is inserted, and
CPR is initiated and is successful. The patient reverts to normal sinus rhythm.
I46.0 MP Cardiac arrest with successful resuscitation

1.GZ.31.CA-EP Ventilation, respiratory system NEC, using invasive per orifice approach
by (endotracheal) intubation manual hand assisted (e.g. ambu bag)
Extent: CN

cardiac arrest, regardless of the outcome. It is also mandatory to
assign codes for the cardiac resuscitation and invasive ventilation.
D Example: A 52-year-old lady who was admitted with pneumonia has a cardiac arrest after
admission. Code blue is called. CPR is started and the defibrillator is used.
Resuscitation efforts are subsequently stopped and the patient is declared dead
at 21:00.
Code DAD Code title

J18.9 (M) Pneumonia, unspecified
I46.9 (2) Cardiac arrest, unspecified
1.HZ.09.JA-FS Stimulation, heart NEC, external approach, using electrode

converter/defibrillator

a code for the cardiac resuscitation intervention.
260
N Example: A 55-year-old gentleman collapses at home while shoveling snow in his driveway.
His wife calls the ambulance, and the paramedics find the patient pulseless. CPR is
initiated and continued en route to the closest emergency department. The patient
is immediately taken to the trauma room with paramedics still performing CPR.
The physician examines the patient and pronounces him deceased.
Final diagnosis: Cardiac arrest.
I46.9 MP Cardiac arrest, unspecified

1.GZ.31.CB-EP Ventilation, respiratory system NEC, non-invasive approach

manual hand assisted (e.g. ambu bag)
Extent: 0

a code for the cardiac resuscitation intervention. Note: For ambulatory
care, it is mandatory to assign a code from 1.GZ.31.^^ Ventilation,
respiratory system NEC, including non-invasive ventilation. See also the
coding standard Selection of Interventions to Code for Ambulatory Care.
N Example: A 65-year-old male is brought to the emergency department by ambulance.

Paramedics performed CCR, which was stopped shortly after arrival. The
emergency department physician pronounces the death and documents the
diagnosis as VSA.
Note: CCR is chest compressions only, without artificial respiration.
R99 MP Other ill-defined and unspecified causes of mortality

Rationale: Cardiac arrest cannot be assumed on the basis of CCR. It is mandatory

to assign a code for the resuscitation intervention.
261
Strokes: Hemorrhagic, Ischemic and Unspecified

This standard addresses the classification of a stroke in the context of

• The initial episode of care in which an acute/current stroke is diagnosed; and
• An admission solely for rehabilitation immediately following an acute/current stroke.
From a classification perspective, per the ICD-10-CA alphabetical index lookup, documentation
of a stroke (meaning acute/current stroke diagnosis) is classified to one of four categories: I60,
I61, I63 or I64. Code assignment depends on whether the cause of the stroke is hemorrhagic,
ischemic or unknown.
Stroke (apoplectic) (brain) (paralytic) (CVA) I64

...
– hemorrhagic I61.9
– – subarachnoid (see also Hemorrhage, subarachnoid) I60.9
– ischemic (see also Infarction, cerebral) I63.9
It is important to note that some provinces/territories monitor stroke strategy performance by

collecting additional data using the Stroke Special Projects in the DAD and NACRS databases.
The Stroke Special Projects capture specific information on patients who have been diagnosed
with an acute/current stroke as well as other conditions (i.e., transient ischemic attack [TIA],
transient retinal artery occlusion, intracranial and intraspinal phlebitis and thrombophlebitis,
nonpyogenic thrombosis of intracranial venous system, retinal artery occlusion). These other
conditions — though from a classification perspective are not classified as hemorrhagic (I60,
I61), ischemic (I63) or unspecified (I64) stroke — are monitored as part of the stroke strategy.
Refer to DAD and NACRS Stroke Strategy Performance Improvement Projects (340, 640) and
DAD Alpha FIM® Project 740 in Appendix A for a table that lists the ICD-10-CA codes that are
included in the completion criteria for DAD and NACRS projects 340, 640 and 740.
Direction related to coding neurological deficits following a stroke and sequelae/late effects of a
stroke are found in the coding standards Neurological Deficits Following a Stroke and Sequelae.
For clinical information, see also Strokes in Appendix A.
262
Acute/current stroke
DN Assign, mandatory, the applicable code from category I60, I61, I63 or I64 for an acute/current stroke
diagnosed during the initial episode of care. This includes the emergency department visit, the acute care
hospitalization and any subsequent admission to another facility for rehabilitation to continue treating
the associated neurological deficits during the current, uninterrupted episode of care.

When a patient is admitted solely for rehabilitation immediately following an acute/current stroke diagnosis,
D
assign a code from category Z50.– Care involving use of rehabilitation procedures as the MRDx.
• Assign an additional code as a diagnosis type (3), mandatory, to identify the specific type of
acute/current stroke (i.e., I60, I61, I63, I64).
When there is documentation of a second stroke, re-infarction or re-stroke following admission, assign a
D
code from I60, I61, I63 or I64 as a diagnosis type (2).
Note
The diagnosis type assigned to the current stroke, classifiable to I60, I61, I63 or I64, depends on the
circumstances of the episode of care.
Note
When a hemorrhagic or ischemic stroke is described as progressing or evolving, an additional code is not
assigned. A stroke may continue to worsen or progress for several hours to a day or two as a steadily
enlarging area of brain tissue dies (stroke in evolution).
Note
An acute/current stroke complicating pregnancy is classified per the direction in the coding standard
Complicated Pregnancy Versus Uncomplicated Pregnancy.
263
Note
The term “perinatal stroke” collectively refers to a nontraumatic stroke that occurred before birth (fetal or
prenatal), during birth or within 28 days after birth. Refer to the coding standard Perinatal Stroke.
Note
Documentation of “history of a stroke” is classified to Z86.78 Personal history of other diseases of the
circulatory system only when there are no longer any neurological deficits present. Assignment of Z86.78 is
optional. If assigned, it is diagnosis type (3)/other problem. When neurological deficits are documented in the
context of “history of a stroke,” follow the direction in the coding standards Neurological Deficits Following a
Stroke and Sequelae.
Note
When any code from I60, I61, I63 or I64 is recorded on an abstract, the code G45.9 Transient cerebral ischemic
attack, unspecified is typically not recorded on the same abstract unless they occurred as separate events.
DN Example: A person is admitted through the emergency department with a cerebral infarction.

I63.9 (M) MP Cerebral infarction, unspecified
D Example: The same person is now transferred from acute care to rehabilitation to regain
activities of daily living (ADLs) and to improve speech. Deficits are dominant-sided
hemiplegia and aphasia.
Code DAD Code title
Z50.9 (M) Care involving use of rehabilitation procedure, unspecified
I63.9 (3) Cerebral infarction, unspecified (for cerebral infarction occurring two
weeks ago)
G81.90 (1) Hemiplegia of unspecified type of dominant side
R47.0 (1) Dysphasia and aphasia
Rationale: The sole purpose of this admission was for rehabilitation to treat the
neurological deficits following a stroke; therefore, Z50.9 is assigned as
the MRDx and I63.9 is assigned, mandatory, as diagnosis type (3).
264
D Example: The patient is admitted with a cerebral infarction due to an embolism. She is seen by a
cardiologist and found to have atrial fibrillation; anticoagulants are started. She receives
intense physiotherapy for left-sided hemiplegia (she is right-handed). On day 10 after
admission, she suffers a second stroke due to an embolism of the cerebral arteries.
Code DAD Code title
I63.4 (M) Cerebral infarction due to embolism of cerebral arteries
I48.90 (1) Atrial fibrillation, unspecified
G81.91 (1) Hemiplegia of unspecified type of non-dominant side
I63.4 (2) Cerebral infarction due to embolism of cerebral arteries
D Example: The patient presents to the emergency department after being found to have a
decreased level of consciousness with decreased movements of her left side.
A computed tomography (CT) scan of the head shows a very large right hemispheric
ischemic stroke. In the emergency department, a decision is agreed upon with the
family that a palliative course of action will be taken. The patient is admitted for
palliation. The patient does not regain consciousness and passes away two days later.
Code DAD Code title
Z51.5 (M) Palliative care
I63.9 (3) Cerebral infarction, unspecified
Rationale: The documentation indicates that the patient is admitted for the sole
purpose of receiving palliative care. It is mandatory to assign a code
for the palliative condition. In this case, I63.9 meets the definition of
a diagnosis type (3). See also the coding standard Palliative Care.
Once a stroke is suspected, a CT scan or magnetic resonance imaging (MRI) scan may be
performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a
critical distinction that guides therapy.
Emergency treatment of an ischemic stroke from a blood clot is aimed at dissolving the clot
using thrombolytic therapy. See also the coding standard Thrombolytic Therapy.
265
Endovascular treatment (EVT) is a relatively new treatment option for acute stroke care.
Examples include endovascular clot retrieval (thrombectomy) and endovascular dilation
with or without stenting of carotid artery or intracranial vessels.
When the cause of stroke is hemorrhage, an evacuation procedure may be carried out
(e.g., 1.AA.52.^^ Drainage, meninges and dura mater of brain).
Peripheral Vascular Disease

Peripheral vascular disease (PVD) (or peripheral arterial disease) is a non-specific term. This
phrase is used to describe narrowing and occlusion of the peripheral blood vessels and is often
used to describe atherosclerotic disease of the peripheral arteries. 4 Common manifestations of
advanced/occlusive atherosclerosis of the extremities may be ischemia of the limbs, ulcers and
gangrene. Peripheral atherosclerosis is a common complication of diabetes mellitus.
See also the coding standard Diabetes Mellitus.
DN
Classify a diagnostic statement of “peripheral vascular disease” to I70.2– Atherosclerosis of arteries of
extremities unless there is documentation to indicate anything else was intended.
Note
Atherosclerotic gangrene is an inclusion at I70.21 Atherosclerosis of arteries of extremities with gangrene.
DN Example: A 65-year-old patient presents to the hospital electively for arteriography of the
lower limbs. He has been experiencing dull cramping pain in his thigh, and he
noticed that his symptoms were precipitated by walking and were relieved by rest.
He has a history of hypertension and no history of diabetes. The physician
documents the diagnosis as “PVD.” The arteriogram demonstrates occlusions
within the left femoral artery system.
I70.20 (M) MP Atherosclerosis of arteries of extremities

without gangrene
266
Exception
PVD without gangrene in a patient with diabetes is classified to E10–E14 with fourth and fifth characters
.50 and the asterisk code I79.2* Peripheral angiopathy in diseases classified elsewhere.
PVD with gangrene in a patient with diabetes is classified to E10–E14 with fourth and fifth characters .51 and
the asterisk code I79.2* Peripheral angiopathy in diseases classified elsewhere.
Follow the alphabetical index lookup for “Angiopathy, peripheral, diabetic.”
DN Example: A patient with type 2 diabetes is admitted for treatment of PVD. He undergoes iliac
artery angioplasty and stenting.
E11.50† (M) MP Type 2 diabetes mellitus with peripheral angiopathy
I79.2* (6) OP Peripheral angiopathy in diseases

Percutaneous transluminal angioplasty (PTA) with or without stent insertion is classified
at “dilation” by site. Endarterectomy is sometimes done locally to improve outflow and is
classified at “extraction” by site.
Bypass grafting may also be performed for revascularization of a limb. When an artery is
bypassed, it is coded to the anatomical site in which it originated. The terminating site of the
graft is captured in the qualifier component of the code.
See also the coding standard Procurement or Harvesting of Tissue for Closure, Repair
or Reconstruction.
DN Example: Aorto-femoral bypass graft using saphenous vein — originates in the aorta
1.KA.76.MZ-XX-A Bypass, abdominal aorta, bypass terminating at lower

limb vessels [e.g. iliac, femoral, popliteal, tibial], using
autograft [e.g. saphenous vein]
1.KR.58.LA Procurement, veins of leg NEC, using open approach
Amputation (93) may be performed if attempts at revascularization fail. The intervention is

classified to “amputation” when the incision is made through a bone and to “disarticulation” when
the incision is made through a joint.
267
Debridement of bone performed at a previous amputation site is coded to amputation of the

same site with status attribute “R” for revision.
Aneurysms
An aneurysm is an abnormal local dilatation in the wall of a blood vessel causing an abnormal
widening or ballooning of a blood vessel, usually an artery, due to a defect, disease or injury.
Aneurysms may be treated surgically in one of six ways:

1. Resection with graft replacement — Excision, partial (87)
2. Repair (reinforcement of the aneurysm wall) — Repair (80)
3. Repair with graft insertion — Repair (80)
4. Bypass of the ballooning artery — Bypass (76)
5. Filipuncture or wiring — Destruction (59)
6. Clipping and using [detachable] coils — Occlusion (51)
When an aortic aneurysm is incised and a Dacron (or other) tubular or bifurcated graft is inserted into
D
the vessel and then covered with the residual sac of the aneurysm (aneurysmorrhaphy), assign the
appropriate CCI code by site indicating “repair with graft insertion.”
Example: The patient is admitted with an abdominal aortic aneurysm. It is repaired by opening
up the aneurysmal sac and sewing a prosthetic Dacron graft into position within the
aorta. The wall of the aneurysm is then sewn over the graft to protect it.
1.KA.80.LA-XX-N Repair, abdominal aorta, using open approach with

synthetic material [e.g. Teflon felt, Dacron, Nylon, Orlon]
When an aortic aneurysm is excised and the aortic segment is replaced with a tubular or bifurcated
D
Dacron (or other) graft (aneurysmectomy), assign the appropriate CCI code by site indicating “excision
partial of the aortic segment with graft replacement.”
268
Example: The patient comes to hospital for an elective repair of a thoracoabdominal aortic
aneurysm. The aneurysm is excised and a synthetic graft is inserted to replace the
excised portion of the thoracoabdominal aorta.
1.ID.87.LA-XX-N Excision partial, aorta NEC, using open approach with

synthetic material [e.g. Dacron patch]
D When aneurysms of cerebral and precerebral arteries are treated by clipping or clamping, select the CCI
generic intervention “occlusion” (51).
Clips are applied externally to the artery to clamp it. Coils are inserted internally into an artery to
occlude it. The mandatory extent attribute applies to the number of coils deployed during an
occlusion. When occlusion is performed using a technique/device other than coils, select “0.”
Example: A 45-year-old patient is admitted with epistaxis. Radiological studies show an

external carotid artery aneurysm. The patient is taken to the operating room for
clipping of the aneurysm.
1.JE.51.LA-FF Occlusion, carotid artery, open approach using clips

Extent: 0
269

In effect 2015
The purpose of this coding standard is to provide direction to assist with determining whether or
not a code from rubric 1.IS.53.^^ is assigned when a central venous catheter (CVC) is inserted.

Assign a code from rubric 1.IS.53.^^ Implantation of internal device, vena cava (superior and inferior),
DN
mandatory, when a central venous catheter is inserted for one or more of the following reasons:
• As a stand-alone therapeutic intervention
• Solely for the purpose of administering
− Bolus (large-volume, given rapidly) fluids;
− Chemotherapy (pharmacotherapy);
− Hemodialysis;
− Plasmapheresis; and/or
− Total parenteral nutrition (TPN)
• To gain vascular access during a resuscitative intervention
Note
Do not assign a code from rubric 1.IS.53.^^ Implantation of internal device, vena cava (superior and inferior)
when a CVC is inserted as a routine and inherent part of a surgical procedure, such as a coronary artery bypass
graft (CABG).
When trying to determine whether or not insertion of a CVC is a routine and inherent part of a surgical
procedure, consider the following:
• A CVC that is a routine and inherent part of a surgical procedure is usually inserted after intubation but prior
to the beginning of the surgery (review the anesthetic record for details).
• A CVC that is inserted in its own right is usually documented by the physician (listed as an intervention being
performed during the operative episode and described within the body of the operative report) with the
reason for the insertion (e.g., chemotherapy, dialysis, TPN).
270
Example: The patient has an eight-hour debulking craniotomy for a right parietal
glioblastoma. Following intubation, an internal jugular CVC is passed under sterile
technique using ultrasound guidance. Upon completion of the procedure, the
patient is transferred to the neurosurgical intensive care unit (NICU) with the CVC
in situ. The CVC is removed on post-operative day 2.
No code assigned from rubric 1.IS.53.^^.
Rationale: The CVC is a routine and inherent part of this surgical procedure.
Therefore, a code from rubric 1.IS.53.^^ is not assigned.
Example: The patient presents with a non-ST-elevation myocardial infarction (NSTEMI) and is
noted to have triple-vessel disease on cardiac catheterization. The patient is taken to
the operating room, where she is intubated and the anesthetist places the appropriate
intra-operative central venous line. The patient is put on cardiopulmonary bypass, and
cardioplegia is given. A five-vessel CABG is done through a midline sternotomy.
No code assigned from rubric 1.IS.53.^^.
Rationale: The CVC is a routine and inherent part of this surgical procedure.
Therefore, a code from rubric 1.IS.53.^^ is not assigned.
Example: A patient with breast cancer is admitted for insertion of a peripherally inserted
central catheter (PICC) line for administration of chemotherapy. Her oncology clinic
appointment for administration of chemotherapy is scheduled for the following week.
1.IS.53.GR-LF Implantation of internal device, vena cava (superior and

inferior), non-tunnelled central venous catheter using
percutaneous transluminal venous approach (e.g.
peripherally inserted central catheter [PICC])
Location: PI
Rationale: The CVC is not a routine and inherent part of a surgical procedure.
The PICC line is inserted solely for administration of chemotherapy;
therefore, 1.IS.53.GR-LF is assigned, mandatory.
271
Example: The patient is admitted with multiple trauma, including a head injury and an intra-
abdominal hemorrhage, following a motor vehicle crash. The patient is transferred
to the surgical intensive care unit (SICU) where a right internal jugular line is
inserted. Normal saline and medications are administered via the central line.

Location: JU
The internal jugular line is inserted solely for administration of fluids and
pharmacotherapy; therefore, 1.IS.53.GR-LF is assigned, mandatory.
Example: The patient is admitted with an acute kidney injury. The nephrologist determines that
hemodialysis is required immediately. A Hickman line is placed for hemodialysis.
1.IS.53.HN-LF Implantation of internal device, vena cava (superior

and inferior), tunnelled central venous catheter using
percutaneous tunnelling technique (e.g. Hickman,
Broviac, Groshong, Leonard)
Location: SC
1.PZ.21.HQ-BR Dialysis, urinary system NEC, hemodialysis
The Hickman line is inserted solely for hemodialysis; therefore,
1.IS.53.HN-LF is assigned, mandatory.
272
Example: The patient is admitted after being found unconscious at home. She is admitted
with multiple organ failure, altered level of consciousness, hemodynamic instability,
coagulopathy and acute renal failure. She has a bradycardic event with pulseless
electrical activity. A code is called. She receives cardiopulmonary resuscitation and
is intubated and ventilated, and a central venous line is implanted. She receives
aggressive fluid resuscitation and inotropic support with recommended doses of
epinephrine and vasopressin via the line.
1.GZ.31.CA-ND Ventilation, respiratory system NEC, invasive per orifice

approach by endotracheal intubation, positive pressure
(e.g. CPAP, BIPAP)
Extent: CN
1.HZ.30.JN Resuscitation, heart NEC, by external manual
compression with or without concomitant ventilation
Location: PI
Rationale: The CVC is not a routine and inherent part of a surgical procedure. It is
inserted to gain vascular access during the resuscitative intervention;
therefore, 1.IS.53.GR-LF is assigned, mandatory.
273
Example: The patient is admitted for a laparoscopic cholecystectomy that is converted to an

open cholecystectomy due to an acutely inflamed gallbladder and dense adhesions.
The liver is accidentally fractured, and the patient loses roughly 2 liters of blood.
At extubation, the blood pressure drops and the patient arrests. A code blue is
called. Cardiopulmonary resuscitation continues for roughly three minutes. He is
reintubated and ventilated. The anesthesiologist places a central line. He receives
multiple units of blood, fluids, platelets and fresh frozen plasma. He is transferred to
the intensive care unit (ICU).
1.OD.89.LA Excision total, gallbladder, open approach,

cholecystectomy alone, without extraction (of calculi)
Status: C

approach by endotracheal intubation, positive pressure
(e.g. CPAP, BIPAP)
Extent: CN
1.HZ.30.JN Resuscitation, heart NEC, by external manual
compression with or without concomitant ventilation
Location: PI
Rationale: The CVC is not a routine and inherent part of this surgical procedure.
It is inserted to gain vascular access during the resuscitative
intervention; therefore, 1.IS.53.GR-LF is assigned, mandatory.
274
Example: A patient with neuroblastoma is taken to the operating room for a bone marrow
biopsy, an incisional soft tissue biopsy of the palpable mass on his back and
insertion of a right internal jugular Port-a-Cath for chemotherapy.
1.IS.53.LA-LF Implantation of internal device, vena cava (superior and

inferior), totally implanted central venous catheter (with
injection port) [e.g. Port-a-cath] using open approach
Location: JU
2.SH.71.LA Biopsy, soft tissue of the back, using open
[incisional] approach
2.WY.71.HA Biopsy, bone marrow, using percutaneous
(needle) approach
Rationale: The CVC is not a routine and inherent part of this surgical procedure.
It is inserted solely for administration of chemotherapy; therefore,
1.IS.53.LA-LF is assigned, mandatory.
Anticoagulation Therapy: Management and

Adverse Effects
In effect 2015
The purpose of this coding standard is to address the classification of the following:
1. Admissions where there is clear physician documentation that a patient’s length of stay was
extended due to the need for management of anticoagulation therapy; and
2. Adverse effects of anticoagulants in therapeutic use.
Management of anticoagulation therapy
When there is physician documentation of an extended length of stay due to management of

D
anticoagulation therapy (as identified below), assign Z51.88 Other specific medical care NEC as a
significant diagnosis type (M), (1), (W), (X) or (Y).
275
Note
This direction applies to cases with clear physician documentation of an extended length of stay due to
management of anticoagulation therapy in the following circumstances only:
• Pre-operative reversal of anticoagulation therapy;
• Initiation of anticoagulation therapy; and
• Reinitiation of anticoagulation therapy
without documentation of adverse effects of anticoagulant therapy in therapeutic use.
D Example: The patient is admitted with a fractured hip due to a fall down the stairs at home.
She is on long-term warfarin therapy for pre-existing atrial fibrillation. The admission
note states that the surgery will not proceed until the effects of the anticoagulants
have been reversed and the international normalized ratio (INR) is at the desired
level. Due to the risk of severe bleeding during surgery, the physician delays the hip
repair to allow time to reverse the effects of the warfarin. Warfarin is stopped and
intravenous vitamin K and fresh frozen plasma are used to reverse her INR pre-
operatively. The patient’s INR levels are monitored until they reach an acceptable
level. Surgery proceeds on day 4 of admission.
Code DAD Code title

S72.090 (M) Unspecified fracture of neck of femur, closed
W10 (9) Fall on and from stairs and steps
Z51.88 (1) Other specified medical care NEC
Rationale: There is clear documentation of an extended length of stay due to

pre-operative reversal of anticoagulation therapy (management of
anticoagulation therapy); therefore, Z51.88 is assigned as a
diagnosis type (1). Z92.1 Personal history of long-term (current) use
of anticoagulants may be assigned, optionally, as diagnosis type (3),
276
D Example: The patient is admitted for bilateral pulmonary emboli. The patient is not on any
anticoagulation therapy prior to admission. The course in hospital is uneventful;
however, the patient is kept in hospital for 14 days due to the need to monitor and
regulate her INR levels after initiation of anticoagulation therapy.
Code DAD Code title
I26.9 (M) Pulmonary embolism without mention of acute cor pulmonale
Rationale: There is clear documentation of an extended length of stay due to the

initiation of anticoagulation therapy (management of anticoagulation
therapy); therefore, Z51.88 is assigned as a diagnosis type (1). Z92.1
Personal history of long-term (current) use of anticoagulants does
not apply.
D Example: The patient is admitted for treatment of uncontrolled type 2 diabetes mellitus.
The patient was taking warfarin 4 mg p.o. daily due to pre-existing atrial fibrillation;
however, she stopped taking it four days prior to admission. Her INR is 4.42 on
admission. During her stay in hospital, the patient is restarted on warfarin and
monitored closely until the INR becomes stable. The discharge summary states that
there were problems controlling her INR, which contributed to the length of stay.
Code DAD Code title

Rationale: There is clear documentation of an extended length of stay due to the

reinitiation of anticoagulation therapy (management of anticoagulation
therapy); therefore, Z51.88 is assigned as a diagnosis type (1). Z92.1
Personal history of long-term (current) use of anticoagulants may
be assigned, optionally, as diagnosis type (3), based on the facility’s
data needs.
277
D Example: The patient is admitted for left total knee replacement due to osteoarthritis. He has
a history of atrial fibrillation and was on Coumadin. Coumadin was stopped prior
to admission, and he was taken to the operating room on the day of admission.
Post-operatively, Coumadin was restarted and his INR was therapeutic on
discharge. INRs will initially be drawn twice a week and will be followed by his
family physician.
Code DAD Code title
Rationale: Z51.88 is not assigned because there is no physician documentation

of an extended length of stay due to management of anticoagulation
therapy (reinitiation of anticoagulation therapy). Z92.1 Personal
history of long-term (current) use of anticoagulants may be assigned,
optionally, as diagnosis type (3), based on the facility’s data needs.
Adverse effects of anticoagulants in therapeutic use
DN
When a patient on anticoagulation therapy is diagnosed with a hemorrhage/bleeding that is not
documented as due to any other external cause (e.g., trauma or poisoning), classify the hemorrhage as an
adverse effect of anticoagulants in therapeutic use.
When a patient on anticoagulation therapy is diagnosed with a condition representing a thromboembolic

DN event (e.g., cerebral infarction, pulmonary embolus) that is clearly documented as due to (associated with)
anticoagulation therapy, classify the thromboembolic event as an adverse effect of anticoagulants in
therapeutic use.
When a patient on anticoagulation therapy is not diagnosed with a hemorrhage/bleeding or

DN thromboembolic event but there is documentation of interference/impact on the therapeutic effect
of the anticoagulation therapy, classify the interference as “coagulopathy” due to adverse effect of
anticoagulants in therapeutic use.
• Assign D68.9 Coagulation defect, unspecified and Y44.2 Anticoagulants causing adverse effects in
therapeutic use.
278
Note
An example of physician documentation of interference/impact on the therapeutic effect of the
anticoagulation therapy that is classified to D68.9 and Y44.2 is “increased INR,” “supratherapeutic INR,”
“decreased INR,” “subtherapeutic INR” or “unstable/abnormal INR” without any diagnosis of hemorrhage or
thromboembolic event in a patient who is on anticoagulation therapy.
D Example: The patient presents with rectal bleeding. He has been on warfarin for atrial
fibrillation, which is stopped on the day of admission. He is given vitamin K to
reverse the effects of warfarin. The physician documents that his INR dropped to a
subtherapeutic level (1.1) and the bleeding gradually stopped. The patient is going to
remain off warfarin until he has planned surgery for skin lesions following discharge.
Final diagnosis: Rectal bleeding

K62.5 (M) A Haemorrhage of anus and rectum
Y44.2 (9) A Anticoagulants causing adverse effects in

therapeutic use
Rationale: The patient is on anticoagulant therapy. The hemorrhage is not

documented as due to any other external cause; therefore, it is
classified as an adverse effect of anticoagulants in therapeutic use.
The reaction/manifestation to the anticoagulants in therapeutic use is
the hemorrhage. K62.5 is assigned per the alphabetical index lookup:
lead term “Hemorrhage, hemorrhagic,” subterms “due to circulating
anticoagulants NEC,” “specified site (see Hemorrhage, by site).”
279
D Example: A patient with a mechanical mitral valve who is on anticoagulation therapy is admitted
with a subacute cerebrovascular accident (CVA) (infarct). The physician documents
that the CVA is due to subtherapeutic INR. Initially, the INR is difficult to titrate, but
with the use of dalteparin bridge a therapeutic level is reached prior to discharge.

I63.9 (M) A Cerebral infarction, unspecified
Y44.2 (9) A Anticoagulants causing adverse effects in therapeutic use
Rationale: The patient is on anticoagulation therapy. The cerebral infarction

(thromboembolic event) is clearly documented as due to the patient’s
subtherapeutic INR level. The reaction/manifestation to the anticoagulants
in therapeutic use is the cerebral infarction. I63.9 is assigned per the usual
alphabetical index lookup: lead term “Infarct, infarction (of),” subterm
“cerebral.” D68.9 is not assigned because there is a cerebral infarction
(thromboembolic event) as a result of the coagulopathy (subtherapeutic INR).
D Example: A patient with a history of atrial fibrillation on Coumadin is admitted with pneumonia
and is started on Avelox. The physician documents that the patient develops a
supratherapeutic INR secondary to drug interaction between Avelox and Coumadin.
The antibiotic is changed. The Coumadin is held for three days and then restarted.
INR levels are monitored until the patient is ready for discharge.

J18.9 (M) — Pneumonia, unspecified
D68.9 (2) A Coagulation defect, unspecified
Y44.2 (9) A Anticoagulants causing adverse effects in therapeutic use
Y41.8 (9) A Other specified systemic anti-infectives and antiparasitics

Rationale: There is clear documentation of a drug interaction between Coumadin

and Avelox. The interaction is documented as having interfered with the
therapeutic effect of the Coumadin (developed supratherapeutic INR
[without hemorrhage]). The reaction/manifestation to the anticoagulants
and antibiotics in therapeutic use is the supratherapeutic INR.
D68.9 is assigned because there is no hemorrhage as a result of the
coagulopathy (supratherapeutic INR). Only a code for the coagulopathy is
assigned. Search the alphabetical index lookup: lead term “Coagulopathy.”
280
DN Example: The patient presents to hospital with spontaneous bruising on the skin. The patient
is on Coumadin therapy and has also been taking tetracycline to treat a urinary
tract infection (UTI) for the past eight days. The discharge diagnosis is “enhanced
anticoagulation effect” from an interaction between these two drugs. The patient is
advised to stop both drugs, and a new antibiotic is introduced.
R23.3 (M) MP A Spontaneous ecchymoses
Y44.2 (9) OP A Anticoagulants causing adverse effects in therapeutic use
Y40.4 (9) OP A Tetracyclines causing adverse effects in therapeutic use
Rationale: The patient is on anticoagulation therapy. There is clear documentation of

a drug reaction between Coumadin and tetracycline. The drug interaction
is documented as having interfered with the therapeutic effect of the
Coumadin (enhanced therapeutic effect), which has resulted in
spontaneous bruising (cutaneous hemorrhage). The reaction/ manifestation
to the anticoagulants and antibiotics in therapeutic use is the spontaneous
bruising (cutaneous hemorrhage). R23.3 is assigned per the alphabetical
index look up: lead term “Hemorrhage, hemorrhagic,” subterms “due to
circulating anticoagulants NEC,” “specified site (see Hemorrhage, by site).”
D68.9 is not assigned because there is a hemorrhage as a result of the
coagulopathy (enhanced therapeutic effect).
N Example: The patient presents with increased INR. The INR has been up and down for the
last couple of months and is checked frequently. The patient is taking Warfarin.
There is no bleeding. Warfarin is held and the patient is to follow up in 24 hours.
Final diagnosis: Elevated INR
D68.9 MP A Coagulation defect, unspecified
Y44.2 OP A Anticoagulants causing adverse effects in

therapeutic use
Rationale: The patient is on anticoagulant therapy. The final diagnosis “elevated

INR” without documentation of hemorrhage/bleeding or thromboembolic
event is classified as coagulopathy (D68.9) due to adverse effect of
anticoagulants in therapeutic use.
281
References
1. Rivera-Bou, WL; TheHeart.org/Medscape. Thrombolytic therapy. Accessed November 22, 2016.
2. Anderson JL, et al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/non-ST-elevation myocardial infarction. Journal of the American College of
Cardiology. 2007.
3. Nwasokwa ON. Coronary artery bypass graft disease. Annals of Internal Medicine. 1995.
4. eMedicineHealth. Peripheral vascular disease. Accessed September 30, 2016.
282
Chapter X — Diseases of the respiratory system
Chapter X — Diseases of the

respiratory system
For clinical information, see also Adult respiratory distress syndrome in Appendix A.
Pneumonia
DN
When pneumonia is documented by the physician/primary care provider and a specific organism is
documented as the cause, select the code indicating pneumonia due to the organism.
DN
When pneumonia is documented by the physician/primary care provider, diagnostic imaging reports may
be used to select the most specific diagnosis code.
When pneumonia is documented by the physician/primary care provider and no additional specificity is
DN
provided to select a more specific code, assign J18.9 Pneumonia, unspecified.
For clinical information, see also Pneumonia in Appendix A.
See also the coding standards Pneumonia in Patients With Chronic Obstructive Pulmonary
Disease (COPD) and Using Diagnostic Test Results in Coding.
DN Example: An elderly patient is brought in from a retirement home with fever, chills and dyspnea.
X-ray demonstrates complete consolidation of the left lower lobe. Sputum cultures are
done, and the physician records the diagnosis as pneumococcal pneumonia.
J13 (M) MP Pneumonia due to Streptococcus pneumoniae
Rationale: Pneumonia due to a specific organism is recorded by the physician.
283
DN Example: A patient presents with a history of eight days of coughing and progressive
shortness of breath. X-ray shows infiltrate in the right middle lobe.
Final diagnosis: RML pneumonia
Rationale: Pneumonia is documented by the physician without further

specificity. The X-ray report does not support selecting a more
specific code; therefore, J18.9 is assigned.
Lobar pneumonia
DN
When pneumonia is documented by the physician/primary care provider without further specificity and
the diagnostic imaging reports describe the pneumonia using one of the terms “apical,” “basilar,”
“massive” or “complete consolidation involving entire lobe,” assign J18.1 Lobar pneumonia, unspecified.
Note
When pneumonia is documented using terms such as “RLL pneumonia,” it may simply mean that there is an
infiltrate or segment of pneumonia within the lower lobe of the lung. It cannot be assumed that terms such
as “RLL pneumonia” mean lobar pneumonia unless there is physician/primary care provider or diagnostic
imaging documentation to clearly indicate involvement of the entire lobe. The terms “apical,” “basilar” and
“massive” are subterms listed under the lead term “Pneumonia” in the alphabetical index and lead to J18.1
Lobar pneumonia, unspecified.
284
DN Example: A 28-year-old male presents with chest pain. His chest X-ray demonstrates that he
has developed complete consolidation of the left lower lobe and that there is also
consolidation and partial collapse of the right lower lobe.
Final diagnosis: Pneumonia
J18.1 (M) MP Lobar pneumonia, unspecified
Rationale: Pneumonia is documented as the final diagnosis. The X-ray provides

further specificity and demonstrates complete consolidation of the entire
left lower lobe.
DN Example: An elderly patient is brought in from a retirement home with fever, chills and dyspnea.
X-ray reveals complete consolidation of the left lower lobe. Sputum cultures show
heavy growth of pneumococcus. There is no physician documentation acknowledging
the culture and sensitivity (C & S) results.
Final diagnosis: Pneumonia
J18.1 (M) MP Lobar pneumonia, unspecified
Rationale: Pneumonia is documented by the physician. The sputum culture was

positive, but it was not confirmed by the physician as the causative
organism in the documentation. Therefore, J13 Pneumonia due to
Streptococcus pneumonia cannot be assigned. J18.1 is assigned
because the X-ray report described complete consolidation of the left
lower lobe, which provides further specificity.
Bronchopneumonia
DN
When pneumonia is documented by the physician/primary care provider without further specificity
and the diagnostic imaging reports describe the pneumonia using one of the terms “catarrhal,”
“confluent,” “diffuse,” “disseminated (focal),” “lobular (segmental)” or “patchy,” assign J18.0
Bronchopneumonia, unspecified.
285
Note
Bronchopneumonia is identified on diagnostic imaging reports by small patches of consolidation that may
appear throughout the lungs but does not involve an entire lobe. Terms such as “catarrhal,” “confluent,”
“diffuse,” “disseminated (focal),” “lobular” and “patchy” are subterms listed under the lead term
“Pneumonia” in the alphabetical index and lead to J18.0 Bronchopneumonia, unspecified.
DN Example: A 75-year-old woman presents to the emergency department with shortness of

breath. X-ray report mentions “There is a patchy area of increased density in the
left lower lobe, compatible with left lower lobe pneumonia.” The diagnosis on the
summary sheet is stated as left-sided pneumonia.

J18.0 (M) MP Bronchopneumonia, unspecified
Rationale: There is documentation of “patchy area of increased density . . .

compatible with left lower lobe pneumonia” in the X-ray report. The final
diagnosis is pneumonia. The term “patchy” described in the X-ray adds
specificity and, per the alphabetical index, the pneumonia is classified
to J18.0.
Pneumonia in Patients With Chronic

Obstructive Pulmonary Disease (COPD)
DN
When COPD is present with pneumonia or any other acute lower respiratory tract infection and it is the
major reason for hospitalization, assign J44.0 Chronic obstructive pulmonary disease with acute lower
respiratory infection.
• When the infection is a significant condition in its own right, such as pneumonia, acute bronchitis or
acute bronchiolitis, assign an additional code as a comorbid diagnosis type/other problem to specify the
type of infection.
• Sequence the code for COPD first.
286
Patients with COPD are generally considered to be at high risk for pneumonia. When a person
with COPD gets a cold, it can develop into bronchitis or pneumonia. The infection can damage
the bronchial linings, creating a safe haven for bacteria to grow.
DN Example: A 68-year-old man with severe COPD contracts the common cold. He is being
treated by his family physician for exacerbation of COPD. His condition worsens,
and he is brought into the emergency department. Chest X-ray reveals pneumonia.
He is subsequently admitted for treatment of COPD exacerbation and pneumonia.

J18.9 (1) OP Pneumonia, unspecified
N Example: A patient from a nursing home presents to the emergency department with
aspiration pneumonia. He has a long-standing history of COPD.
J69.0 MP Pneumonitis due to food and vomit
W80 OP Inhalation and ingestion of other objects causing obstruction of

respiratory tract
U98.1 OP Place of occurrence, residential institution
J44.9 OP Chronic obstructive pulmonary disease, unspecified
Rationale: Pneumonia due to aspiration is not classified as an acute infective

exacerbation of COPD (J44.0); therefore, the above directive statements
do not apply.
D Example: A woman with COPD is admitted and treated with antibiotics for pneumonia due to
streptococcal pneumoniae. She also receives oxygen and has her corticosteroidal
regimen adjusted to manage the obstructive airway changes.
Code DAD Code title

J13 (1) Pneumonia due to Streptococcus pneumoniae
287
D Example: A woman with COPD is admitted and treated with antibiotics for acute bronchitis.
Code DAD Code title

J20.9 (1) Acute bronchitis, unspecified
DN Example: Final diagnosis is recorded as acute exacerbation COPD. The physician also
documents that the patient has chronic bronchitis.

Rationale: J44.0 is not assigned in this example because it cannot be assumed that
the acute exacerbation in a patient with obstructive chronic bronchitis is
due to acute bronchitis. Follow the alphabetical index lookup “Bronchitis,
chronic, obstructive,” which leads to J44.8. This code is not assigned per
the excludes note “with acute exacerbation.”
Asthma
DN
Classify asthma with onset during childhood (typically up to 16 years old) to J45.0– Predominantly allergic
asthma unless otherwise specified by the physician.
Note
Ensure that asthma is not reported as a post-admit comorbidity — diagnosis type (2).
For clinical information, see also Asthma in Appendix A.
288
DN Example: A 14-year-old is brought to hospital suffering from an asthmatic attack. He is placed

on bronchodilators.
J45.00 (M) MP Predominantly allergic asthma without stated

status asthmaticus
DN Example: A 12-year-old is brought to hospital suffering from shortness of breath with wheezing.
She has no previous history of asthma. The final diagnosis is reactive airway disease.
J98.8 (M) MP Other specified respiratory disorders
Rationale: A final diagnosis of reactive airway disease is not classified to asthma.

The alphabetical index leads to J98.8.
DN Example: A 19-year-old man is brought to hospital suffering from shortness of breath with
wheezing. The young man has no previous history of asthma. The patient is placed
on bronchodilators. The diagnosis noted in the chart is asthma.
J45.90 (M) MP Asthma, unspecified, without stated

status asthmaticus
Status asthmaticus
Status asthmaticus is a severe asthma attack where there is profound and intractable
bronchospasm. It is a life-threatening condition with prolonged bronchiolar spasm that cannot
be reversed with medication.
Terms that denote status asthmaticus include

• Acute severe asthma;
• Severe acute asthma;
• Intractable asthma attack;
• Refractory asthma;
• Severe intractable wheezing; and
• Airway obstruction not relieved by bronchodilators.
289
Note
The diagnostic statements “acute asthma” and “severe asthma” do not qualify as status asthmaticus.
DN Example: An 18-year-old is brought to hospital suffering from a severe acute asthmatic attack.
He is placed on bronchodilators. It is noted in the chart that the young man has had
asthma since childhood.

J45.01 (M) MP Predominantly allergic asthma with stated
status asthmaticus
Rationale: In this example, asthma has been present since childhood and is
documented using one of the terms denoting status asthmaticus;
therefore, a code from category J45.0– is assigned with the fifth
character “1.”
Note
As long as asthma onset is documented as having begun during childhood, follow this coding standard.
It applies to an adult with chronic asthma that began in childhood who now presents for treatment of
asthmatic attacks.
Resection of Space-Occupying Lesions

(Polyps) of Nose
In effect 2002
Classify resections of space-occupying lesions according to the deepest anatomical site from which the
DN
lesion is removed. This may be different from the site in which the lesion originates.
290
Start
Does
Involves radical Yes Code to 1.FA.91.^^
the lesion extend into the Yes
nasopharyngectomy?
nasopharynx?
No
No
Code to 1.FA.87.^^
Does the
lesion extend into multiple Involves a radical
Yes Yes Code to 1.EY.91.^^
sinuses (but not as far as the pansinusectomy?
nasopharynx)?
No
No Code to 1.EY.87.^^
Does the
Involves total
lesion extend into one sinus Ethmoid sinus? Yes Yes Code to 1.EU.89.^^
exenteration?
only? Yes
No
No Code to 1.EU.87.^^
Sphenoid sinus? Yes Code to 1.EV.87.^^
No
No
Frontal sinus? Yes Code to 1.EX.87.^^
No
Involves radical
Maxillary sinus? Yes
antrectomy?
Does Yes
the lesion occupy
the nasal cavity (middle
meatus) only? Yes
End No
No
Code to Code to Code to
1.ET.87.^^ 1.EW.87.^^ 1.EW.91.^^
End
291
Septoplasty for Deviated Nasal Septum

Selection of the correct CCI code for surgical procedures that involve straightening of a deviated
nasal septum depends on whether the intervention is with or without excision, with or without
grafting and with or without additional interventions to reshape other aspects of the nose.
The flowchart below has been provided to assist in making the correct selection.
Classify interventions involving a septoplasty for correction of deviated nasal septum according to the
DN
anatomical site and the intent of the intervention.
292
Correction of deviated
nasal septum
(septoplasty)
Code to 1.ET.80.^^ Repair, nose

Is the septoplasty included Yes
as part of an intervention Septoplasty (repositioning/realignment of nasal cartilage [septum])
involving reshaping the with nasal tip/bone reshaping (e.g. rasping, osteotomy, bone
nasal bone(s)? fracturing) with/without turbinectormy.
No
Yes Code to 1.ES.80.^^ Repair, nasal cartilage

Does the septoplasty
involve resection of
May involve some resection of bones that articulate with
the septum with
the septum (e.g., ethmoid, vomer, maxillary crest),
(cartilage) graft?
with/without turbinectomy.
No
Code to 1.ES.87.LA Excision partial, nasal cartilage, using

open approach with simple apposition (suturing) for closure
Does the septoplasty Yes
involve resection of
Simple septoplasty involving trimming of septum with a swing to
the septum without
midline. May involve some resection of bones that articulate with
(cartilage) graft?
the septum (e.g., ethmoid, vomer, maxillary crest), with/without
turbinectomy. E.g. submucous resection (SMR) of septum.
No
Yes Code to 1.ET.73.^^ Reduction, nose

Does the septoplasty involve
manual reduction of the nasal
Involves reduction of nasal structures into proper alignment.
structures without resection or
graft?
May involve reducing turbinates.
No
End
293
Example: The patient has a major displacement of his septum with a dorsal nasal hump
deformity due to previous trauma. He is admitted for a reconstructive septoplasty by
a columellar incision nasal approach. During the procedure, the deflected cartilage
is excised, the nasal bone is readjusted and a rasp is used to reduce the hump.
The cartilage is replaced with a prosthetic implant. The septum is returned to its
original midline position.
1.ET.80.WK-PM Repair, nose, using columellar incision approach with

prosthetic implant
Rationale: Since reshaping the nasal bone by rasping (rhinoplasty) was performed
with the septoplasty to correct the deviation of the septum, a code from
1.ET.80.^^ Repair, nose is assigned.
Example: A 26-year-old female suffers from recurrent sinus infections due to a deviated
nasal septum and is now admitted for a septoplasty. During the procedure, a
wedge of cartilage is removed along with a small fragment from the maxillary crest.
The cartilage is morselized and replaced.
1.ES.80.LA-XX-A Repair, nasal cartilage, using autograft [e.g. cartilage, skin]
Rationale: Since the correction of the septal deviation involved resection of

cartilage with replacement of morselized cartilage (a graft) and did not
involve reshaping of the nasal bone, a code from 1.ES.80.^^ Repair,
nasal cartilage is assigned.
Example: A 45-year-old male has been suffering from sleep apnea, which is exacerbated
by a significant displacement of his septum. He is admitted for a septoplasty.
A submucous resection of the septum is performed. There is no documentation
indicating replacement of cartilage.
1.ES.87.LA Excision partial, nasal cartilage, using open approach

with simple apposition (suturing) for closure
Rationale: Since the correction of the septal deviation involved resection of cartilage
without a graft and did not involve reshaping of the nasal bone, a code
from 1.ES.87.^^ Excision partial, nasal cartilage is assigned.
294
Example: A 19-year-old male is accidentally hit by a hockey stick when playing hockey and
is brought to the emergency department. Upon examination, there is apparent
deformity of the septum; an X-ray confirms a nasal fracture. A manual reduction of
the fracture is performed.
1.ET.73.JA Reduction, nose, using manual [reduction] technique
3.ET.10.VA Xray, nose, without contrast (e.g. plain film) (with or

Rationale: Since the repair of the deviated nasal septum (septoplasty) was
performed by manual reduction without reshaping of the nasal bone
or resection of cartilage with/without a graft, a code from 1.ET.73.^^
Reduction, nose is assigned.
Assign a code from 1.GZ.31.^^ Ventilation, respiratory system NEC, mandatory, to describe
DN
invasive ventilation.
When a patient is extubated and subsequently requires another episode of the same invasive ventilation,
D
record at a minimum the one episode that reflects the longest duration (extent attribute).
DN When one invasive approach (such as endotracheal intubation) is changed to another invasive approach
(such as tracheostomy), assign multiple codes from 1.GZ.31.^^ Ventilation, respiratory system NEC to
describe each approach.
See also the coding standard Selection of Interventions to Code for Ambulatory Care.
295
Exception
When invasive ventilation is an inherent part of the administration of a general anesthetic and the patient is
extubated prior to leaving the operating room, 1.GZ.31.^^ Ventilation, respiratory system NEC is not assigned.
Note
The extent attribute is mandatory, regardless of duration, for all codes at 1.GZ.31.^^ Ventilation, respiratory
system NEC. Use “0” when the ventilation is non-invasive.
Note
Use the Intervention Pre-Admit Flag to indicate when invasive ventilation was started prior to admission
during an encounter of the current, uninterrupted episode of care. See Group 11, Field 20 in the Discharge
Abstract Database (DAD) Abstracting Manual for specific instructions for applying the flag for interventions
initiated prior to admission.
To calculate the number of hours (duration) of continuous invasive ventilation during a

hospitalization, begin the count from the time of the tracheal access (e.g., endotracheal
intubation or transtracheal jet). The duration ends with extubation or when the ventilator is
turned off. Disregard intermittent attempts at weaning from ventilation support; include these
periods in the total hours.
• When a patient is intubated prior to admission, begin counting the duration from the time
of admission.
• When a patient dies, is transferred or is discharged while intubated, calculate the duration
ending with the time of death, transfer or discharge.
• When one invasive approach is changed to another invasive approach, assign a code for
each approach and calculate the duration for each separately.
• When a patient is extubated and subsequently requires another episode of the same
invasive ventilation, calculate the duration for each episode separately. Do not add the
durations together, because the calculation of duration ends with extubation.
• When invasive ventilation extends beyond the time the patient leaves the operating room,
calculate the duration from the time of intubation in the operating room to the time of extubation.
296
Example: The patient is admitted with pneumonia and an acute exacerbation of COPD. Her
respirations are severely compromised. An endotracheal tube is inserted and she is
connected to synchronized intermittent mandatory ventilation (SIMV). On day 3,
she is extubated.

approach by (endotracheal) intubation, positive pressure
(e.g. CPAP, BIPAP, IPPV)
Extent: CN
Rationale: It is mandatory to code invasive ventilation regardless of duration

(extent). The patient was successfully extubated prior to 96 hours of
continuous invasive ventilation; therefore, the extent attribute “CN —
Continuous but less than 96 hours of invasive ventilation” applies.
Example: A patient is taken to the operating room for repair of an incisional abdominal hernia.
General anesthetic is administered, and intubation and ventilation is begun.
The patient is extubated at completion of the procedure and is transferred to
the recovery room before being transferred back to the nursing unit.
Rationale: The intubation and ventilation is an inherent part of the administration of

the general anesthetic and is included in the capture of the anesthetic
technique on the abstract. 1.GZ.31.^^ Ventilation, respiratory system
NEC is not assigned.
Example: The patient is admitted for a coronary artery bypass graft. General anesthetic is
administered, and he is intubated and ventilated. He is transferred to the recovery
room and then to the surgical intensive care unit. He is extubated the next day and
transferred to the nursing unit to continue his recovery.

Extent: CN
Rationale: It is mandatory to code invasive ventilation regardless of duration (extent).

When invasive ventilation is an inherent part of the administration of a
general anesthetic, it is not coded. However, when the invasive ventilation
extends beyond the operating room, it is coded. In this example, the patient
was ventilated for less than 96 hours from the time of intubation in the
operating room to the time of extubation; therefore, the extent attribute
“CN — Continuous but less than 96 hours of invasive ventilation” applies.
297
Example: A patient is ventilated via endotracheal tube (ETT) using positive pressure for
10 days and then extubated. Two days later, the patient develops complications
and is re-intubated and ventilated using the same ventilation (positive pressure).
The patient is subsequently transferred to another facility the same day.

Extent: EX
(e.g. CPAP, BIPAP, IPPV) (optional)
Extent: CN
Rationale: When a patient receives the same invasive ventilation more than once
(i.e., he or she is extubated and re-intubated), it is mandatory to record
only the occurrence received for the longest duration (extent). It is optional
to record the same CCI code to describe invasive ventilation of a shorter
duration. The duration is calculated separately for each episode because
the patient was extubated and re-intubated (do not add times together).
Example: A patient is intubated and ventilated via ETT using positive pressure for two days. Due to
complications, the patient is taken to the operating room to have an open tracheostomy
for long-term ventilation. The patient remains in hospital for an additional 10 days.
1.GZ.31.CR-ND Ventilation, respiratory system NEC, invasive per orifice

with incision approach for intubation through tracheostomy,
positive pressure (e.g. CPAP, BIPAP, IPPV)
Extent: EX
1.GJ.77.LA Bypass with exteriorization, trachea, using open
approach (e.g. collar incision)
Status: 0
Extent: CN
Rationale: Different invasive approaches were used for ventilation; therefore, separate
codes from 1.GZ.31.^^ Ventilation, respiratory system NEC are assigned to
describe each approach. The extent attribute reflects the duration of each.
298
Example: The patient sustains significant trauma and multiple facial fractures in a motor
vehicle accident (MVA). At the time of presentation, respirations are six per minute
and shallow. An attempt to intubate is unsuccessful. Pressurized oxygen is
administered via a large bore needle inserted into the cricothyroid membrane.
A short time later, endotracheal intubation is achieved and she is connected to
continuous mandatory ventilation (CMV). She remains ventilated until she is
stabilized for transfer to the provincial trauma center. She is airlifted on post-MVA
day 8.

Extent: EX
1.GZ.31.GP-ND Ventilation, respiratory system NEC, invasive percutaneous
transluminal approach (e.g. transtracheal jet) through
needle, positive pressure (e.g. CPAP, BIPAP, IPPV)
Extent: CN
Rationale: Different invasive approaches were used for ventilation; therefore,

separate codes from 1.GZ.31.^^ Ventilation, respiratory system NEC
are assigned to describe each approach. The extent attribute reflects
the duration of each.
299
Chapter XI — Diseases of the

digestive system
Gastroenteritis and Diarrhea
Most cases of gastroenteritis are infectious, even in industrialized countries; thus ICD-10-CA
classifies gastroenteritis NOS as infectious (A09.9 Gastroenteritis and colitis of unspecified origin).
DN
Assign gastroenteritis as the MRDx/main problem in admissions for treatment of gastroenteritis
and dehydration.
Assign a code for any associated dehydration as a significant pre-admit comorbidity/other problem
DN only when the electrolyte imbalance is severe enough to warrant treatment with intravenous fluids and
the physician clearly documents that these fluids are intended to treat the dehydration.
See also the coding standard Dehydration.
DN Example: A 4-year-old child is seen with infectious gastroenteritis and dehydration.

The entire family is affected: mom, dad and three older siblings. She needs input/
output monitoring and is prescribed increased oral fluids. No intravenous fluids
are administered.

A09.0 (M) MP Other and unspecified gastroenteritis and colitis of
infectious origin
300
Chapter XI — Diseases of the digestive system
D Example: A 74-year-old woman is admitted to hospital from a nursing home after three days
of gastroenteritis. She is quite dehydrated on admission and receives intravenous
fluids for two days, with close monitoring of her input/output status. Stool culture
returns negative for organisms.
Code DAD Code title
A09.9 (M) Gastroenteritis and colitis of unspecified origin
E86.0 (1) Dehydration
Rationale: Unspecified gastroenteritis is classified to A09.9 Gastroenteritis and

colitis of unspecified origin.
DN Example: A 20-year-old man is seen for gastroenteritis. The final diagnosis is “non-
infectious gastroenteritis.”
K52.9 (M) MP Noninfective gastroenteritis and colitis, unspecified
Rationale: Gastroenteritis must be documented as noninfectious to assign K52.9.
Bleeding Esophageal Varices

DN
Follow the dagger/asterisk convention when coding bleeding esophageal varices associated with liver
disorders classified to K70.– Alcoholic liver disease, K71.– Toxic liver disease and K74.– Fibrosis and
cirrhosis of liver.
301
D Example: A patient with known alcoholic cirrhosis of the liver is admitted with hematemesis.
Endoscopy shows bleeding esophageal varices. He is treated with sclerotherapy.
Code DAD Code title
K70.3† (M) Alcoholic cirrhosis of liver
I98.3* (6) Oesophageal varices with bleeding in diseases classified elsewhere
1.NA.13.BA-X7 Control of bleeding, esophagus, using endoscopic per orifice

approach and chemical agent [e.g. ethanolamine, morrhuate
sodium, polidocanol, sclerosants, tetradecyl sulfate]
DN Example: A patient has chronic persistent hepatitis, which has resulted in fibrosis of the liver.
She presents with an upper gastrointestinal bleed. Endoscopy shows bleeding
esophageal varices.
K74.0† (M) MP Hepatic fibrosis
I98.3* (6) OP Oesophageal varices with bleeding in diseases

K73.0 (3) OP Chronic persistent hepatitis, not elsewhere classified
Rationale: While chronic persistent hepatitis (K73.0) in this case did lead to the
formation of fibrosis of the liver (K74.0) causing bleeding esophageal
varices (I98.3*), only codes from categories K70, K71 and K74 are
designated with the dagger symbol at I98.3*. Therefore, the pair K74.0†
with I98.3* is sequenced first, and K73.0 is assigned optionally.
DN Select the asterisk code I98.3* Oesophageal varices with bleeding in diseases classified elsewhere when
the physician records bleeding esophageal varices as a preoperative diagnosis but active bleeding is not
evident at endoscopy.
302
DN Example: A patient with known alcoholic cirrhosis of the liver presents for urgent endoscopy
and banding of varices following an episode of upper gastrointestinal bleeding.
The physician documents “bleeding esophageal varices.” Endoscopy shows
esophageal varices, but no active bleeding is noted. Several varices are banded.
K70.3† (M) MP Alcoholic cirrhosis of liver
I98.3* (6) OP Oesophageal varices with bleeding in diseases

1.NA.13.BA-FA Control of bleeding, esophagus, using endoscopic per orifice

approach and banding (varices)
In endoscopic therapy, the health care provider may directly inject the varices with a clotting
agent, or he or she may place a rubber band around the bleeding veins. This procedure is used
in acute bleeding episodes and as prophylactic (preventive) therapy.
Prophylactic endoscopic sclerotherapy (injection of varices with sclerosant) is done regularly,

usually every one to three weeks, until varices are obliterated, then at three- to six-month
intervals to maintain obliteration.
Select code 1.NA.13.BA-X7 Control of bleeding, esophagus, using endoscopic per orifice
approach and chemical agent [e.g. ethanolamine, morrhuate sodium, polidocanol, sclerosants,
tetradecyl sulfate].
Endoscopic sclerotherapy (injection of varices with sclerosant) is also used to control acute
hemorrhage from the esophageal varices.
Select code 1.NA.13.BA-X7 Control of bleeding, esophagus, using endoscopic per orifice
approach and chemical agent [e.g. ethanolamine, morrhuate sodium, polidocanol, sclerosants,
tetradecyl sulfate].
Esophageal variceal rubber band ligation controls active bleeding and eradicates varices as
effectively as sclerotherapy.
Select code 1.NA.13.BA-FA Control of bleeding, esophagus, using endoscopic per orifice
approach and banding (varices).
303
Sengstaken-Blakemore double balloon tube or Linton single balloon tube tamponade

gastric balloon placement needs X-ray confirmation. Acute bleeding may be treated by a balloon
tamponade — a tube that is inserted through the nose into the stomach and inflated with air to
produce pressure against the bleeding veins.
Select code 1.NA.13.BA-BD Control of bleeding, esophagus, using endoscopic per orifice
approach and balloon (or Sengstaken) tube tamponade.
Transjugular intrahepatic portosystemic shunt (TIPS) or distal splenorenal shunt (DSRS)

consists of a catheter that is extended through a vein into the liver, where it connects the portal
system to the systemic venous system and decreases portal venous pressure.
Select code 1.KQ.76.^^ Bypass, abdominal veins NEC.
Gastrointestinal Bleeding
DN
When hemorrhage or bleeding is not clearly expressed in the title of the code for the underlying cause,
assign an additional code:
• K92.0 Haematemesis
• K92.1 Melaena
• K92.2 Gastrointestinal haemorrhage, unspecified
DN Example: The patient’s final diagnosis is noted as “acute gastritis with hemorrhage.”

K29.0 (M) MP Acute haemorrhagic gastritis
DN Example: The patient is diagnosed with melena due to diverticulitis of the large bowel.
Colonoscopy is carried out, and she is treated with antibiotics and ferrous gluconate.

K57.3 (M) MP Diverticular disease of large intestine without
perforation or abscess
K92.1 (3) OP Melaena
304
DN
When a patient presents for investigations following an episode of gastrointestinal bleeding and no active
hemorrhage is manifest on endoscopy, select an ICD-10-CA combination code indicating “with bleeding”
or “with hemorrhage” in the disease/condition.
Alternatively, if there aren’t any such combination codes, code the underlying condition
DN and an additional code to indicate the presence of bleeding (K92.0, K92.1 or K92.2).
DN Example: The patient presents for urgent colonoscopy following an episode of lower
gastrointestinal bleeding. The physician documents “ulcerative colitis.”
Endoscopy report indicates no active bleeding, but ulcerated lesions are
noted with prominent vessels.

K51.9 (M) MP Ulcerative colitis, unspecified
K92.2 (3) OP Gastrointestinal haemorrhage, unspecified
When a patient is admitted for investigation or treatment of hemorrhage and has documented episodes
D
of gastrointestinal (GI) bleeding while in hospital, do not assign diagnosis type (2) to the ICD-10-CA code
indicating GI bleeding.
D Example: The patient is admitted through the emergency department following an episode of
hematemesis. His wife reports that he threw up about half a cup of bright red blood.
During his stay, he has another episode of hematemesis. Several diagnostic tests
and investigations are carried out, and the final diagnosis on the chart is recorded
as Mallory-Weiss syndrome.
Code DAD Code title
K22.6 (M) Gastro-oesophageal laceration-haemorrhage syndrome
305
Selection of Attributes at Hernia Repair

DN When the diagnosis does not reflect a hernia classifiable to categories K40–K43 and K45–K46, select
“0” — Not Applicable, for the mandatory location attribute at 1.SY.80.^^ Repair, muscles of the chest
and abdomen.
The location attribute at 1.SY.80.^^ Repair, muscles of the chest and abdomen is mandatory
because it is the only way to identify the intervention as a hernia repair. The location attribute
for ventral and incisional hernias will vary depending on the location of the hernia.
D Example: The patient is admitted by the trauma team. He sustained a penetrating wound to
the abdominal wall during a fight at a youth center. The victim was attacked with a
knife. Internal organs are not injured. The patient is taken to the operating room
where the defect in the abdominal wall is closed with sutures.
Code DAD Code title
S31.190 (M) Open wound of unspecified site of abdominal wall, uncomplicated
X99 (9) Assault by sharp object
U98.28 (9) Place of occurrence, school and other institutions and public areas
1.SY.80.LA Repair, muscles of the chest and abdomen, open approach,

without tissue [e.g. suturing or stapling]
Status: 0
Location: 0
Rationale: This was not a hernia repair, as the MRDx is an injury code; therefore,
location attribute is “0.”
306
DN Example: The patient is admitted for suture repair of an incisional hernia at the site of a
previous cholecystectomy.
K43.2 (M) MP Incisional hernia without obstruction or gangrene
1.SY.80.LA Repair, muscles of the chest and abdomen, open approach,

without tissue [e.g. suturing or stapling]
Status: 0
Location: UP
Rationale: Location attribute is mandatory when the diagnosis is hernia classifiable

to K40–K43 and K45–K46. A cholecystectomy incision is located in the
upper abdominal region.
307
Chapter XII — Diseases of the skin and

subcutaneous tissue
Cellulitis
DN Classify an open wound with associated cellulitis to a “complicated” open wound.
DN
When the course of treatment involves intravenous antibiotics, sequence cellulitis as the MRDx/main
problem and record the soft tissue injury as an additional diagnosis/other problem.
DN
When the course of treatment involves only oral antibiotics, sequence the soft tissue injury as the
MRDx/main problem and the cellulitis as a comorbid condition/other problem.
Assign an additional code, optional, as a diagnosis type (3)/other problem from the range B95–B98
DN Bacterial, viral and other infectious agents when a causative agent is identified.
For clinical information, see also Cellulitis in Appendix A.
Exception
It is mandatory to assign a code from B95–B98 Bacterial, viral and other infectious agents as a diagnosis type
(3)/other problem when the causative agent is one of the specific drug-resistant microorganism infections.
See also the coding standard Drug-Resistant Microorganisms.
See also the coding standard Open Wounds.
308
Chapter XII — Diseases of the skin and subcutaneous tissue
N Example: The patient lacerated her left index finger at home while using a kitchen knife
about three days prior to this visit. She presents to the emergency department with
cellulitis. She is given a prescription for oral antibiotics.
S61.01 MP Open wound of finger(s) without damage to nail, complicated
L03.00 OP Cellulitis of finger
W26.0 OP Contact with knife, sword or dagger
D Example: Approximately 36 hours ago, a woman received a dog bite to her right hand when
she intervened in an altercation between two dogs. She now presents with cellulitis
spreading up her arm and is admitted to hospital for a course of intravenous antibiotics.
Code DAD Code title

L03.10 (M) Cellulitis of upper limb
S61.91 (3) Open wound of wrist and hand part, part unspecified, complicated
W54 (9) Bitten or struck by dog
U98.9 (9) Unspecified place of occurrence
N Example: On a hiking trip in the woods, a young man fell down a ravine two days ago,
sustaining minor lacerations to his lower leg. He presents to the emergency
department with cellulitis and is treated with a wound debridement, topical
dressing and a course of oral antibiotics.

S81.91 MP Open wound of lower leg, part unspecified, complicated
L03.11 OP Cellulitis of lower limb
W17 OP Other fall from one level to another
U98.8 OP Other specified place of occurrence
309
Chapter XIII — Diseases of the

musculoskeletal system and
connective tissue
Osteoarthritis
DN
Classify arthrosis as primary when the physician/primary care provider documents that the arthrosis
• Is idiopathic; or
• Has “no known underlying cause”; or
• Is bilateral disease at the same anatomical site if not identified as secondary or post-traumatic.
DN
Classify arthrosis as secondary when the physician/primary care provider documents that the arthrosis
• Is secondary; or
• Is known to be caused by another condition.
DN
Classify arthrosis as post-traumatic when the physician/primary care provider documents a connection
between the arthrosis and a previous injury.
DN
Classify arthrosis as unspecified when the physician/primary care provider does not document the condition
as bilateral, primary, secondary or post-traumatic according to the above (e.g., the documentation is
osteoarthrosis with no further specification).
D Example: A 53-year-old man with idiopathic osteoarthritis (OA) of the left knee is admitted
electively for a total knee replacement.
Code DAD Code title

M17.1 (M) Other primary gonarthrosis
310
Chapter XIII — Diseases of the musculoskeletal system and connective tissue
D Example: A 22-year-old man is admitted for a left total knee replacement due to OA
documented as secondary to Ehlers-Danlos syndrome.
Code DAD Code title
M17.5 (M) Other secondary gonarthrosis
Q79.6 (3) Ehlers-Danlos syndrome
D Example: A 75-year-old man is admitted electively for a left total knee replacement due to left
knee OA, documented as secondary to a sports injury in the remote past.
Code DAD Code title
M17.3 (M) Other post-traumatic gonarthrosis
T93.9 (3) Sequelae of unspecified injury of lower limb (optional)
Y86 (9) Sequelae of other accidents (optional)
D Example: A 75-year-old woman is admitted electively for a total knee replacement.

The diagnosis is recorded as “OA right knee.”
Code DAD Code title
Rationale: All that is documented is “OA right knee”; therefore, assign unspecified
arthrosis. Primary arthrosis cannot be assumed just because there is no
documentation of a known cause.
D Example: A 75-year-old woman with OA of both hips is scheduled for a right hip arthroplasty.
She is admitted now for the right hip intervention. The left hip will be replaced in
six months.
Code DAD Code title
M16.0 (M) Primary coxarthrosis, bilateral
Rationale: Bilateral disease not specified as due to any other cause is presumed to
be primary disease.
311
DN
When a patient who has had a previous unilateral joint replacement for osteoarthritis (OA) is admitted for
treatment of the contralateral joint due to OA of the same type (primary, secondary, post-traumatic),
select the appropriate code to indicate bilateral disease.
Clinical input has indicated that even though a joint has been replaced, the patient has not been
cured and is still considered to have bilateral disease on subsequent admissions. Bilateral
disease not specified as due to any other cause is presumed to be primary disease.
For clinical information, see also Osteoarthritis in Appendix A.
D Example: A 53-year-old man with primary OA of both knees is admitted electively for
arthroscopic debridement of the left knee. The OA in the right knee was treated
five years ago with a total knee replacement.
Code DAD Code title
M17.0 (M) Primary gonarthrosis, bilateral
Z96.61 (3) Presence of artificial knee (optional)
D Example: A 64-year-old man with primary OA of both hips had his left hip replaced a year ago.
He is now admitted electively for a right hip arthroplasty.
Code DAD Code title
M16.0 (M) Primary coxarthrosis, bilateral
Z96.60 (3) Presence of artificial hip (optional)
312
Cortisone, a steroid, may be injected into the joint to relieve severe inflammation and swelling.
Select code 1.^^.35.^^ Pharmacotherapy (local).
Viscosupplementation is a procedure in which a clear gel-like substance is injected into the

knee. This substance lubricates the cartilage (much like oil lubricates an engine), reducing pain
and allowing greater movement of the knee.
Select code 1.^^.35.^^ Pharmacotherapy (local).
Surgical treatment for OA ranges from debridement (select code 1.^^.87.^^ Excision partial) to
replacement of a joint with one or more prosthetic components (select code 1.^^.53.^^ Implantation).
See also the coding standards Selection of Interventions to Code for Ambulatory Care and
Selection of Interventions to Code for Acute Inpatient Care.
313

In effect 2001
DN
Assign a code for arthrectomy as a separate intervention only when it is not part of an arthroplasty or
joint repair.
Start
Is the
arthrectomy
Code to
concomitant with joint
Implantation, joint,
replacement or resurfacing (using Yes End
by site
antibiotic cement spacer or
1.^^.53.^^
prosthesis)?
No
Is the
arthrectomy concomitant with a Code to Repair,
joint release, loose body extraction, Yes joint, by site End
ligament repair, excision or 1.^^.80.^^
other arthroplasty?
No
Code to Excision
partial, joint,
by site
1.^^.87.^^
End
314
Fractures
Pathological fractures
Pathological fractures, also known as “compression” or “spontaneous” fractures, occur in bones
and joints weakened by pre-existing disease.
DN
When there is no known traumatic injury to account for a fracture or when the physician clearly states
that the fracture is the result of an underlying disease (such as neoplasm, osteoporosis, Paget’s disease,
endocrine disorder or genetic disorder like osteogenesis imperfecta), classify the fracture as pathological.
DN
When a combination category is not available or when a dagger/asterisk convention is not applicable,
assign separate codes for the pathological fracture and the underlying disease that precipitated
the fracture.
• Sequence the code for the pathological fracture first, followed by the code for the underlying disease
as a mandatory diagnosis type (3)/other problem.
DN Example: The patient is diagnosed with a pathological fracture of the femur due to
Paget’s disease.

M84.45 (M) MP Pathological fracture, not elsewhere classified,
pelvic region and thigh
M88.8 (3) OP Paget’s disease of other bones
DN Apply the dagger/asterisk convention when coding a fracture in neoplastic disease.
315
D Example: The patient was diagnosed with osteosarcoma of the leg two years ago. He is now
admitted with a pathological fracture of the left tibia. He is treated with internal
fixation of the tibia.
Code DAD Code title
C40.2† (M) Malignant neoplasm long bones of lower limb
M90.7* (6) Fracture of bone in neoplastic disease
DN Example: The patient is brought to hospital in acute distress due to collapsed vertebrae.
She has known bone metastases. She had left breast cancer, which was treated
three years ago with mastectomy.
C79.5† (M) MP Secondary malignant neoplasm of bone and

bone marrow
M49.5* (6) OP Collapsed vertebra in diseases classified elsewhere
Z85.31 (3) OP Personal history of malignant neoplasm of left breast

Assign a code from the combination category M80 Osteoporosis with pathological fracture for fractures
DN
documented as due to osteoporosis.
DN
When a fracture is documented as traumatic and occurs in a patient with osteoporosis, assign a code from
Chapter XIX — Injury, poisoning and certain other consequences of external causes.
• Assign an additional code from category M81 Osteoporosis without pathological fracture to identify the
existing osteoporosis.
316
An osteoporotic pathological fracture is uniquely identified with a single code under the category
M80 Osteoporosis with pathological fracture. The codes in this category explicitly state the
causal relationship between the disease and the fracture.
DN Example: An 80-year-old man presents with a fractured hip due to osteoporosis with no known
significant trauma.
M80.95 (M) MP Unspecified osteoporosis with pathological fracture,

pelvic region and thigh
DN Example: A 70-year-old woman with known osteoporosis slips and falls down several stairs
in her home. X-rays demonstrate a fracture of L1.

S32.000 (M) MP Fracture of lumbar vertebra, L1 level, closed
W10 (9) OP Fall on and from stairs and steps
M81.9 (3) OP Osteoporosis, unspecified
Rationale: Even though the patient has osteoporosis, a significant traumatic event
was documented.
Stress fractures
Stress fractures, also known as “fatigue” or “march” fractures, occur most commonly in
metatarsals, hips, heels and fibula/tibia. Long-distance runners, military personnel, people
with cavus foot and those wearing shoes without proper shock absorption are most susceptible.
This type of fracture occurs when overexertion causes a crack in otherwise healthy bone; it
frequently is not diagnosed until after callus formation at the site of the fracture.
DN
When a stress fracture occurs in the vertebrae, assign M48.4– Fatigue fracture of vertebra.
For any other site, assign M84.3– Stress fracture, not elsewhere classified.
317
DN Example: A 45-year-old woman is admitted. On X-ray, it is discovered that she has a stress
fracture located in the lumbar region of the vertebrae.
M48.46 (M) MP Fatigue fracture of vertebra, lumbar region
DN Example: A 25-year-old long-distance runner is admitted. On X-ray, it is discovered that he

has a stress fracture located in his right fibula.
M84.36 (M) MP Stress fracture, not elsewhere classified, lower leg
Assign stress fractures in osteoporotic bone to category M80 Osteoporosis with pathological fracture
DN
(do not assign M84.3– Stress fracture, not elsewhere classified).
DN Example: A 65-year-old woman with osteoporosis of the vertebrae is found, on X-ray, to have
stress fractures of T11–T12.

M80.98 (M) MP Unspecified osteoporosis with pathological fracture,
other site
318
Fractures
Start
Is fracture a Yes
Yes Assign P13.– Birth injury
birth injury? to skeleton
No
No
Assign M96.6.– Fracture of

Is this a Yes
Yes bone following insertion of
periprosthetic
orthopaedic implant, joint
fracture?
prosthesis, or bone plate
No
No
While inserting
Yes orthopedic prosthetic Yes
Yes
Is fracture Yes Assign T81.88 + a code from
implant or fixative device
traumatically induced? Chapter XIX: fracture by site
or during another
intervention?
No
No
No
No Assign code from Chapter XIX:
fracture by site
Is fracture Yes Caused by Yes Yes

Yes
Yes Yes Assign M49.5* Collapsed
pathological (due to underlying neoplasm
Of vertebrae? vertebrae in diseases
underlying disease (code range
process)? C00–D48)?
No
No
No
No
Assign M90.7* Fracture of
bone in neoplastic disease
No
No Yes
Caused by Yes
Assign M80.– Osteoporosis
underlying
with pathological fracture
osteoporosis?
No
No
Assign M84.4 Pathological

fracture NEC
Is fracture due to Yes

Yes Yes
Yes
Assign M48.4 Fatigue fracture
stress (overexertion) Of vertebrae?
of vertebrae
alone?
No
No
Assign M84.3 Stress

End
fracture NEC
Note
* These codes are manifestation codes and require the use of an additional code for the underlying disease (dagger code).
319
Joint Fracture Reduction, Fixation and Fusion

DN
When an intervention is performed to amend a fracture and the fracture involves a portion of a bone that
forms a joint, assign a CCI code where the anatomical site indicates a joint.
Start
Is the joint
Yes
reduced into place Code to
only? (Does not matter if Reduction, joint by End
closed or open reduction site—1.^^.73.^^
is done.)
No
Is a fixation device Yes Yes

Is this done to fuse Code to Fusion
inserted into the joint (with
the joint? (This often joint by site— End
or without a concomitant
involves a bone graft.) 1.^^.75.^^
joint reduction)?
No
No
Fracture through
joint repaired
Code to Fixation
without fixation
joint by site—
device— Code to
1.^^.74.^^
Repair, joint by
site— 1.^^.80.^^
End End
Note
This coding standard applies to all joints, including the spinal vertebrae.
320
Excision (of Lesion) of Bone, Soft Tissue and Skin

DN
When a lesion excision involves removal of soft tissue and bone, assign a CCI code with a generic
intervention indicating radical excision of bone.
When an intervention involves skin and soft tissue, assign a CCI code indicating the anatomical site of
DN
soft tissue.
When the intent of a soft tissue excision of lesion is minor debridement only, assign a CCI code with a
DN
generic intervention indicating destruction of soft tissue.
When the intent of a soft tissue excision of lesion is removal of the lesion, assign a CCI code with a generic
DN
intervention indicating partial excision of soft tissue.
In CCI, an excision confined to muscle alone is presumed to be a removal of a previously

placed and nonviable muscle flap and is classified to partial excision of muscle by site.
Any other excision of a muscle lesion is presumed to involve other soft tissues (such as the
skin, subcutaneous tissues, fascia and tendon) and is classified accordingly.
321
Excision (of lesion) of bone, soft tissue and skin

Start
Code to radical excision of bone, by

site:
Cranium 1.EA.92.^^
Lesion excised involves bone with Yes Humerus 1.TK.91.^^
other soft tissues? Radius/Ulna 1.TV.91.^^
Pelvis 1.SQ.91.^^
Femur 1.VC.91.^^
Tibia/Fibula 1.VQ.91.^^
No
Code to partial excision of bone, by site:
Cranium 1.EA.87.^^ Zygoma 1.EB.87.^^
Maxilla 1.ED.87.^^ Mandible 1.EE.87.^^
Scapula 1.SN.87.^^ Clavicle 1.SM.87.^^
Yes Rib 1.SL.87.^^ Humerus 1.TK.87.^^
Lesion excised involves bone alone? Radius/Ulna 1.TV.87.^^ Carpal 1.UC.87.^^
Metacarpal 1.UF.87.^^ Phalanx (Finger) 1.UJ.87.^^
Sacrum/Coccyx 1.SF.87.^^ Pubis 1.SW.87.^^
Pelvis 1.SQ.87.^^ Femur 1.VC.87.^^
Tibia/Fibula 1.VQ.87.^^ Tarsal 1.WE.87.^^
No Metatarsal 1.WJ.87.^^ Phalanx (Toe) 1.WL.87.^^
Code to destruction of soft tissue (e.g.

amputation stump), by site:
Lesion excised involves soft tissues Yes Yes
Arm 1.TX.59.^^
(e.g. muscle, tendon) with or without skin Is this a minor debridement only?
Wrist/Hand 1.UY.59.^^
involvement?
Leg 1.VX.59.^^
Foot/Ankle 1.WV.59.^^
No
Code to partial excision of muscle, by site:

Head/Neck 1.EP.87.^^
Yes
Is a non-viable (necrotic) muscle flap Abdomen/Chest 1.SY.87.^^
being excised? Back 1.SG.87.^^
Arm 1.TQ.87.^^
Leg 1.VD.87.^^
No No
Code to partial excision of soft tissue, by site:

Head/Neck 1.EQ.87.^^
Abdomen/Chest 1.SZ.87.^^
Back 1.SH.87.^^
Arm 1.TX.87.^^
Wrist/Hand 1.UY.87.^^
Leg 1.VX.87.^^
Ankle/Foot 1.WV.87.^^
Code to repair of skin, by site:

Scalp 1.YA.80.^^ Forehead 1.YB.80.^^
Yes Yes Ear 1.YC.80.^^ Nose 1.YD.80.^^
Lesion excised involves only skin and Is debridement followed by a skin Eyelid 1.CX.80.^^ Lip 1.YE.80.^^
is a minor debridement? graft/flap? Face 1.YF.80.^^ Neck 1.YG.80.^^
Axilla 1.YR.80.^^ Trunk 1.YS.80.^^
Arm 1.YT.80.^^ Hand 1.YU.80.^^
Leg 1.YV.80.^^ Skin NEC 1.YZ.80.^^
No No
Code to dressing of skin, by site

Code to partial excision of skin, by site: Scalp 1.YA.14.^^ Forehead 1.YB.14.^^
Scalp 1.YA.87.^^ Forehead 1.YB.87.^^ Is debridement followed by Ear 1.YC.14.^^ Nose 1.YD.14.^^
Ear 1.YC.87.^^ Nose 1.YD.87.^^ Yes
temporary skin coverage Eyelid 1.CX.14.^^ Lip 1.YE.14.^^
Eyelid 1.CX.87.^^ Lip 1.YE.87.^^ (e.g. Dermagraft, cadaver allograft Face 1.YF.14.^^ Neck 1.YG.14.^^
Face 1.YF.87.^^ Neck 1.YG.87.^^ or xenograft)? Axilla 1.YR.14.^^ Trunk 1.YS.14.^^
Axilla 1.YR.87.^^ Trunk 1.YS.87.^^ Arm 1.YT.14.^^ Hand 1.YU.14.^^
Arm 1.YT.87.^^ Hand 1.YU.87.^^ Leg 1.YV.14.^^ Skin NEC 1.YZ.14.^^
Leg 1.YV.87.^^ Skin NEC 1.YZ.87.^^ No
Code to destruction of skin by site:

Scalp 1.YA.59.^^ Forehead 1.YB.59.^^
Ear 1.YC.59.^^ Nose 1.YD.59.^^
End Eyelid 1.CX.59.^^ Lip 1.YE.59.^^
Face 1.YF.59.^^ Neck 1.YG.59.^^
Axilla 1.YR.59.^^ Trunk 1.YS.59.^^
Arm 1.YT.59.^^ Hand 1.YU.59.^^
Leg 1.YV.59.^^ Skin NEC 1.YZ.59.^^
322
Spinal Stenosis
In effect 2008

When the diagnosis is recorded as spinal or foraminal stenosis and the underlying cause is documented,
DN
assign a code for the underlying cause; do not assign M48.0– Spinal stenosis.
DN
When the final diagnosis is recorded as spinal or foraminal stenosis and the underlying cause is not
documented, assign M48.0– Spinal stenosis.
DN
Assign an additional code from the category G55* Nerve root and plexus compressions in diseases classified
elsewhere for any documented radiculopathy, including these terms:
• Neuritis
• Radiculitis
• Sciatica
• Nerve root compression
DN Assign an additional code G99.2* Myelopathy in diseases classified elsewhere for documented myelopathy.
DN
Do not use category M99 Biomechanical lesions, not elsewhere classified for entry into the DAD or NACRS.
See the note in ICD-10-CA at category M99 Biomechanical lesions, not elsewhere classified.
For clinical information, see also Spinal stenosis in Appendix A.
DN Example: The patient is diagnosed with spinal stenosis resulting from degeneration of the
lumbar facet joints. He also has signs of radiculopathy in his lower limbs.
M47.26 (M) MP Other spondylosis with radiculopathy, lumbar region
G55.2* (3) OP Nerve root and plexus compressions in spondylosis
Rationale: The patient’s spinal stenosis was identified as being due to the
degeneration of the facet joints (spondylosis). As the underlying cause
was documented, the code M48.0– Spinal stenosis is not required.
323
D Example: The patient is admitted for a foraminotomy to decompress his documented

lumbosacral spinal stenosis. He also has documented sciatica. Final diagnosis is
foraminal stenosis with sciatica.
Code DAD Code title
M48.07 (M) Spinal stenosis, lumbosacral region
G55.3* (3) Nerve root and plexus compressions in other dorsopathies
Rationale: There was no physician documentation to identify the underlying cause

of the patient’s foraminal stenosis. In the presence of spinal stenosis,
sciatica is classified to radiculopathy.
Note
When an underlying cause for the spinal stenosis is not documented, it is recommended that the physician be
queried for clarification.
324
Chapter XIV — Diseases of the genitourinary system
Chapter XIV — Diseases of the

genitourinary system
See also the coding standard Hypertension and Associated Conditions.
For clinical information, see also Stages of chronic kidney disease (CKD) and Pelvic relaxation in
Appendix A.
Stages of Chronic Kidney Disease (CKD)

In effect 2009
DN
When assigning a code from category N18 Chronic kidney disease, base the diagnosis code selection on
clinical documentation of the stage of the disease, not the glomerular filtration rate (GFR).
• When the stage of chronic kidney disease (CKD) is not documented, assign N18.9 Chronic kidney
disease, unspecified.
Note
The stages of CKD are based on a clinical diagnosis that includes monitoring the GFR over several months.
Classification of CKD is, therefore, based on the clinical diagnosis of the stage of the disease and not a specific
GFR value.
DN Example: A patient with advanced stage 3 CKD is admitted with worsening symptoms.
Her GFR is noted to be 17 mL/min.

N18.3 (M) OP Chronic kidney disease, stage 3
Rationale: N18.3 is assigned based on documentation of stage 3. While the GFR

of 17 mL/min is a value included under N18.4 Chronic kidney disease,
stage 4, the stage as documented (stage 3) is used for code assignment.
325
DN Example: A patient is admitted with signs and symptoms of worsening kidney disease.
The physician records the final diagnosis as “chronic renal failure.”
N18.9 (M) MP Chronic kidney disease, unspecified
Acute on Chronic Kidney Disease

In effect 2015
When acute kidney injury (meaning “acute renal failure” rather than a traumatic injury to the
kidney) and chronic kidney disease (meaning “chronic renal failure” rather than a specific
chronic condition of the kidney) occur together, they may be described as one clinical concept:
acute on chronic renal failure (AoCRF). However, acute kidney injury and chronic kidney
disease are two distinct and separate conditions that are classified separately.
DN
When “acute kidney injury” (acute renal failure) and “chronic kidney disease” (chronic renal failure) are
documented and a code for acute kidney injury is assigned, assign a code for chronic kidney disease
(N18.– or N08.3–*), mandatory, regardless of significance.
Note
Ensure that the “use additional code” instructions are followed at
• Category N18 Chronic kidney disease — “use additional code to identify underlying disease”; and
• The blocks Glomerular diseases (N00–N08) and Renal tubulo-interstitial diseases (N10–N16) — “use
additional code to identify associated chronic kidney disease (N18.–).”
See also the coding standard Use Additional Code/Code Separately Instructions.
Note
The Canadian enhancement at N08.3–* Glomerular disorders in diabetes mellitus (E10–E14† with common
fourth character .2) satisfies the requirement to assign a code for chronic kidney disease in a patient who has
acute on chronic kidney disease with diabetes mellitus. Therefore, when N08.3–* is assigned, a code from
category N18 is not required.
326
D Example: The patient is diagnosed with acute tubular necrosis (ATN) following an abdominal
aortic aneurysm (bypass) repair. The patient is on hemodialysis for end-stage renal
disease. The patient is seen by a nephrologist, and his hemodialysis treatments are
adjusted until his creatinine returns to baseline.
6 N99.0 (2) A Postprocedural renal failure
— N17.0 (3) A Acute renal failure with tubular necrosis
— Y83.2 (9) A Surgical operation with anastomosis,

bypass or graft, as the cause of abnormal
— N18.5 (1) — Chronic kidney disease, stage 5
Rationale: Acute renal failure (ATN) and end-stage renal disease (chronic kidney
disease) are documented. The codes for post-operative acute renal
failure — N99.0, N17.0 and Y83.2 — are assigned; as well, N18.5 is
assigned for the chronic kidney disease, mandatory, regardless
of significance.
327
D Example: The patient is admitted via the emergency department because she is feeling
unwell. She has type 2 diabetes mellitus with chronic kidney disease and is on
metformin. She has a sudden spike in her creatinine level. Her antidiabetic
medication is changed and she is started on dialysis. Her creatinine returns to
baseline. The dialysis is discontinued. She is discharged with a final diagnosis of
acute on chronic renal failure due to metformin.
N17.9 (M) A Acute renal failure, unspecified
Y42.3 (9) A Insulin and oral hypoglycaemic [antidiabetic] drugs,

E11.23† (3) — Type 2 diabetes mellitus with established or

N08.39* (3) — Unspecified glomerular disorders in diabetes mellitus
Rationale: Acute renal failure and chronic kidney disease are documented. The
codes for acute renal failure as an adverse effect in therapeutic use —
N17.9 and Y42.3 — are assigned. The codes for chronic kidney disease
with diabetes mellitus — E11.23 and N08.39 — are assigned,
mandatory, regardless of significance.
N08.39 satisfies the requirement to assign a code for chronic kidney

disease; therefore, a code from category N18 is not required.
328
D Example: A patient with chronic diffuse sclerosing glomerulonephritis and stage 5 renal failure
is admitted for an abdominal aortic aneurysm (bypass) repair. Her creatinine spikes
above baseline post-operatively. She is seen in consultation by a nephrologist who
diagnoses her with acute postprocedural renal failure. He recommends a specific
treatment plan.
6 N99.0 (2) A Postprocedural renal failure
— N17.9 (3) A Acute renal failure, unspecified
— Y83.2 (9) A Surgical operation with anastomosis, bypass

or graft, as the cause of abnormal reaction
of the patient, or of later complication,
without mention of misadventure at the
— N18.5 (3) — Chronic kidney disease, stage 5
Rationale: Acute renal failure and stage 5 renal failure (chronic kidney disease) are
documented. The codes for post-operative acute renal failure — N99.0,
N17.9 and Y83.2 — are assigned; as well, N18.5 is assigned for the
chronic kidney disease, mandatory, regardless of significance.
329
D Example: A patient with chronic renal failure secondary to chronic diffuse membranous
glomerulonephritis presents with edema, elevated blood pressure and a spike
above baseline of his creatinine level. He is admitted and started on diuretics,
and his fluid intake and output are monitored.
Final diagnosis: Acute on chronic renal failure
Code DAD Code title
N17.9 M Acute renal failure, unspecified
N18.9 3 Chronic kidney disease, unspecified
N03.2 3 Chronic nephritic syndrome, diffuse membranous glomerulonephritis
Rationale: Acute renal failure and chronic renal failure (chronic kidney disease) are
documented. The code for acute renal failure, N17.9, is assigned. N18.9
is assigned for the chronic kidney disease, mandatory, regardless of
significance; as well, N03.2 is assigned for the underlying cause per the
“use additional code to identify underlying disease” note at category N18.
Continuous Ambulatory Peritoneal Dialysis

(CAPD) Peritonitis
DN
When peritonitis follows a dialysis procedure and is not attributable to the dialysis catheter (device),
classify the infection to T80.2 Infection following infusion, transfusion and therapeutic injection.
DN
When the physician documents a causal relationship indicating peritonitis due to a dialysis catheter,
classify the peritonitis to T85.7 Infection and inflammatory reaction due to other internal prosthetic
device, implants and grafts.
Assign an additional code from category K65 Peritonitis, mandatory, as a diagnosis type (3)/other problem
DN
to specify the infection.
See also the coding standards Drug-Resistant Microorganisms, Post-Intervention Conditions

and Complications of Devices, Implants or Grafts.
330
An exit site infection at the site of the dialysis catheter for continuous ambulatory peritoneal
dialysis (CAPD) may not be presumed to be the cause of peritonitis and does not always
result in peritonitis. Physician documentation specifying a causal relationship between the two
conditions is required to substantiate coding both conditions. The cause of peritonitis may be
the introduction of bacteria into the peritoneum by the dialysis procedure, but it is not always
related to an exit site infection; it is usually related to a breach in the patient’s sterile technique.
It is true, however, that if the patient has a chronic exit site infection, he or she will be more
prone to episodes of peritonitis caused by the same organism. Pneumococcus and
staphylococcus are the most common organisms.
DN Example: A patient on peritoneal dialysis has acute peritonitis (CAPD peritonitis). There is no
documentation of an infection relating to the catheter.
T80.2 (M) MP A Infections following infusion, transfusion and

therapeutic injection
K65.0 (3) OP A Acute peritonitis
Y84.1 (9) OP A Kidney dialysis as the cause of abnormal

misadventure at the time of procedure
DN Example: A patient has peritonitis due to a peritoneal dialysis catheter exit site infection.
The physician orders skin and peritoneal fluid cultures (positive for staphylococcus)
to confirm the causative agent of the peritonitis.

T85.7 (M) MP A Infection and inflammatory reaction due to
other internal prosthetic devices, implants
and grafts
K65.9 (3) OP A Peritonitis, unspecified
B95.8 (3) OP A Unspecified staphylococcus as the

cause of diseases classified to other
chapters (optional)
Y84.1 (9) OP A Kidney dialysis as the cause of abnormal

misadventure at the time of procedure
331
Menorrhagia as the Most Responsible

Diagnosis (MRDx)
In effect 2006
Menorrhagia (uterine bleeding) can be related to a variety of causes (such as hormonal); in the
great majority of cases, the cause is unknown or not fully explained. Menorrhagia can be the
main reason a hysterectomy is performed.
Fibroids may produce no symptoms even when they are large. Symptoms depend on the
number of fibroids, their size and their location in the uterus, as well as their status (whether
they are growing or degenerating). Symptoms may include heavy or prolonged menstrual
bleeding or bleeding between periods, pain, pressure or heaviness in the pelvic area during
or between periods, need to urinate more frequently and swelling in the abdomen.
The Society of Obstetricians and Gynaecologists of Canada (SOGC) indicates that fibroids
in and of themselves are not a reason for hysterectomy or embolization. The percentage of
symptomatic fibroids is very low, and fibroids are often just an incidental finding on pathology.
When it has been documented that the fibroid is the cause of the excessive uterine bleeding or
pain, then the fibroid would be the most responsible diagnosis.
When a patient presents for a hysterectomy due to menorrhagia, select the MRDx based on the final
D
diagnosis as stated by the attending physician. Do not assume that diagnoses listed on the pathology
report are the underlying cause of the menorrhagia. These diagnoses may be incidental findings.
D Example: A patient presents with menorrhagia, and a hysterectomy is performed. The pathology
report shows uterine fibroids. The physician documents menorrhagia as the final
diagnosis on the front sheet.
Code DAD Code title

N92.0 (M) Excessive and frequent menstruation with regular cycle
D25.9 (3) Leiomyoma of uterus, unspecified
Rationale: The leiomyomas (fibroids) were identified on the pathology report only
and were not included in the final diagnosis recorded by the physician.
It is optional to code and assign diagnosis type (3).
332
Chapter XV — Pregnancy, childbirth and the puerperium
Chapter XV — Pregnancy, childbirth

and the puerperium
For clinical information, see also Length of gestation and Trimesters in Appendix A.
See also the coding standard Diabetes Mellitus.
Recognizing that women typically give birth as inpatients, all of the directive statements and
examples are shown for Discharge Abstract Database (DAD) abstracts. Obstetric cases with
abortive outcomes have been identified as applicable to the DAD and the National Ambulatory
Care Reporting System (NACRS).
Selection of the Sixth Digit in Obstetrical Coding

The sixth digit that is applied to all codes in the range O10–O99 identifies the period (antepartum,
intrapartum or postpartum) in which the patient is receiving care and whether or not the delivery
occurs within that episode of care.
D Select the sixth digit “1” — Delivered with or without mention of antepartum condition — when delivery
occurs during the current episode of care and the condition occurred prior to or during delivery of
the baby.
D Example: The patient is admitted at 38 weeks gestation with gestational diabetes.

She delivers a healthy baby boy and is discharged home.
Code DAD Code title
O24.801 (M) Diabetes mellitus arising in pregnancy (gestational), delivered,

333
Select the sixth digit “2” — Delivered with mention of postpartum condition — when the delivery
D
occurred during the current episode of care and the condition occurred after delivery of the baby.
D Example: The patient is admitted at 39 weeks gestation. She delivers a healthy baby boy via
spontaneous vaginal delivery. There is postpartum hemorrhage due to retained
placenta. She is discharged home on postpartum day 4.
Code DAD Code title
O72.002 (M) Third-stage haemorrhage, delivered, with mention of

postpartum complication
Select the sixth digit “3” — Antepartum condition or complication — when the patient is admitted for
D
management of an antepartum condition. The patient does not deliver during the current episode of care
and is still pregnant on discharge.
D Example: A patient at 14 weeks gestation presents to hospital with hyperemesis gravidarum.

She is discharged home, undelivered.
Code DAD Code title
O21.003 (M) Mild hyperemesis gravidarum, antepartum condition or complication
Select the sixth digit “4” — Postpartum condition or complication — when the patient is admitted for
D
management of a postpartum condition or complication following delivery. The delivery occurred during
a previous episode of care or outside the hospital, and the mother is now admitted for observation
or care.
334
The postpartum period is six weeks from delivery unless specified otherwise in the
documentation. In other words, if physician documentation states that a condition is a
postpartum problem and it is more than six weeks after delivery, the condition is still classified
as postpartum.
D Example: This patient delivered a healthy baby boy via spontaneous vaginal delivery, with
episiotomy, at 38 weeks gestation. She was discharged home on postpartum day 2.
She now presents for readmission with dehiscence of the episiotomy.
Code DAD Code title
O90.104 (M) Disruption of perineal obstetric wound, postpartum condition

or complication
Select the sixth digit “9” — Unspecified as to episode of care or not applicable — only when the outcome
DN
of the pregnancy is abortive. In these cases, assign the code from O10–O99 as an additional code to
describe any obstetrical condition present with an abortion.
D Example: A patient presents requesting a medical abortion because of known fetal anomalies.
Ultrasound identified spina bifida with hydrocephalus.
Code DAD Code title
O04.9 (M) Medical abortion, complete or unspecified, without complication
O35.039 (1) Maternal care for (suspected) fetal spina bifida with hydrocephalus,
unspecified as to episode of care, or not applicable
Allowable sixth-digit combinations

Multiple coding is commonly used with obstetrical cases because a patient often has more than
one condition that affects the obstetrical experience. Different sixth digits may be used on the
obstetric codes when a patient delivers and has both an antepartum or intrapartum condition
and a postpartum condition. However, certain combinations of sixth digits are illogical for the
same episode of care.
335

Assign only the following combinations of sixth digits on an abstract:
D
Sixth digit Assign Never assign
1 Alone or with “2” With “3,” “4” or “9”
2 Alone or with “1” With “3,” “4” or “9”
3 Alone With any other sixth digit
Note
Certain obstetric conditions occur at only one point within an obstetric period. For example, placenta previa
occurs only in the antepartum period (sixth digits 1, 3 or 9 only would apply). Other obstetric conditions,
such as hypertension, may be present at any time throughout the pregnancy and persist into the puerperium
(any sixth digit may apply).
Coders are reminded to read all inclusion and exclusion notes carefully. In some circumstances, ICD-10-CA has
separate categories for conditions that occur either antepartum or postpartum (e.g., phlebothrombosis).
The following are examples of the correct usage of the sixth digits “1” and “2.”
D Example: The patient is admitted in labor. Twins are delivered. She develops subsequent
postpartum hemorrhage on the second day followed by deep phlebothrombosis.
Code DAD Code title
O30.001 (M) Twin pregnancy, delivered, with or without mention of antepartum

condition
O72.202 (2) Delayed and secondary postpartum haemorrhage, delivered with

mention of postpartum complication
O87.102 (2) Deep phlebothrombosis in the puerperium, delivered with mention of

Z37.200 (3) Twins, both liveborn, pregnancy resulting from both spontaneous
336
D Example: The patient delivers by Cesarean section due to obstructed labor due to breech
presentation of the baby. Prior to discharge, Cesarean wound dehiscence
is diagnosed.
Code DAD Code title
O64.101 (M) Obstructed labour due to breech presentation, delivered, with or

O90.002 (2) Disruption of caesarean section wound, delivered, with mention of

The sixth digit “3” — Antepartum condition or complication — must only be used alone.
D Example: The patient is at 30 weeks gestation. She is admitted with gestational diabetes.
She is monitored for three days and discharged home in good condition, undelivered.
Code DAD Code title

O24.803 (M) Diabetes mellitus arising in pregnancy (gestational), antepartum
condition or complication
The sixth digit “4” — Postpartum condition or complication — must only be used alone.
D Example: The patient delivered a healthy baby boy two weeks ago. She was discharged
home postpartum day 2. She is breastfeeding. She now presents with an abscess
of the right breast.
Code DAD Code title
O91.104 (M) Abscess of breast associated with childbirth, postpartum condition

or complication
The sixth digit “9” — Unspecified as to episode of care or not applicable — must only be
used alone.
337
DN Example: A patient was diagnosed with ovarian cancer at eight weeks gestation. She
underwent a series of radiotherapy sessions to shrink the tumor. Following
discussion with her radiation oncologist regarding the possible risk the radiation
presented to her fetus, the patient opted to have a medical termination of the
pregnancy. She now presents for a medical abortion.
O04.9 (M) MP Medical abortion, complete or unspecified,

without complication
O35.609 (1) OP Maternal care for (suspected) damage to fetus

by radiation, unspecified as to episode of care,
or not applicable
See also the coding standard Pregnancy With Abortive Outcome.
Sequencing Obstetrical Diagnosis Codes

When selecting the MRDx in obstetrical cases, the diagnosis typing definition for most responsible
diagnosis applies (see also the coding standard Diagnosis Typing Definitions for DAD). The following
directives are provided to assist in applying the MRDx definition in certain obstetrical cases.
When an episode of care includes non-instrumental, spontaneous vaginal delivery of an infant but the
D
mother was admitted for an antepartum condition that required treatment for five days or more before
the birth, sequence the antepartum condition as the MRDx.
An antepartum condition that prolongs the stay prior to delivery by at least five days is
considered to consume greater resources than the delivery itself when the delivery is a
routine vaginal delivery.
338
D Example: The patient is admitted with gestational hypertension. She is treated with bed
rest and delivers a baby boy, manually assisted without episiotomy, on day 6 of
admission. She has a first-degree laceration of the perineum, which is repaired.
Code DAD Code title

O13.001 (M) Gestational [pregnancy-induced] hypertension, delivered, with or
O70.001 (1) First degree perineal laceration during delivery, delivered, with or
5.MD.50.AA Manually assisted vaginal delivery (vertex), without episiotomy

5.PC.80.JP Surgical repair, postpartum, of current obstetric laceration of pelvic
floor, perineum, lower vagina or vulva
Rationale: O13.001 is selected as the MRDx, as it is most responsible for the

patient’s length of stay.
D Example: The patient is admitted at term with pregnancy-induced hypertension. Labor is

induced by intravenous oxytocin. She delivers a baby boy, manually assisted
without episiotomy. A first-degree laceration of the perineum is repaired.
Code DAD Code title

O70.001 (1) First degree perineal laceration during delivery, delivered, with
or without mention of antepartum condition

5.PC.80.JP Surgical repair, postpartum, of current obstetric laceration of pelvic
floor, perineum, lower vagina or vulva
5.AC.30.HA-I2 Induction of labour, using percutaneous injection of oxytocic agent
Rationale: Even though the antepartum condition in this example did not require a
lengthy pre-delivery stay of five days or more, it can still be the MRDx.
In this case, an induction was performed for the antepartum condition.
The perineal tear was minor and consumed minimal resources.
339
In cases within the expected length of stay where a Cesarean section or instrumentation (i.e., forceps or
D
vacuum) has been used, assign the diagnosis stating the indication for the intervention as the MRDx.
In cases where there is failed vacuum and/or forceps leading to subsequent Cesarean section, assign the
D
underlying maternal or fetal condition that was the indication for the forceps or vacuum as the MRDx.
When a case is within an expected length of stay for an instrumental delivery, it is presumed
that no other condition contributed to a greater consumption of resources than the condition that
indicated the delivery method.
D Example: A primigravida patient is admitted with gestational diabetes. On day 1 of her admission,
she goes into labor. After seven hours of labor, it is determined that she cannot deliver
vaginally because of cephalopelvic disproportion. She is taken to the labor and delivery
operative suite and delivers a healthy baby girl by Cesarean section.
Code DAD Code title
O65.401 (M) Obstructed labour due to fetopelvic disproportion, unspecified,

O24.801 (1) Diabetes mellitus arising in pregnancy (gestational), delivered,

5.MD.60.AA Cesarean section delivery, lower segment transverse incision,

without instrumentation
Status: PB
340
D Example: A primigravida patient is admitted with gestational hypertension and treated with bed
rest. On day 7, she goes into spontaneous labor. After eight hours of labor, it is
determined that she cannot deliver vaginally because of cephalopelvic disproportion.
Signs of fetal distress (heart rate anomaly) are noted, and the mother’s blood
pressure continues to rise. She is taken to the labor and delivery operative suite and
delivers a healthy baby girl by Cesarean section.
Code DAD Code title
O13.001 — Gestational [pregnancy-induced] hypertension, delivered, with or

O65.401 — Obstructed labour due to fetopelvic disproportion, unspecified,

O68.001 — Labour and delivery complicated by fetal heart rate anomaly,


Status: PB
Rationale: As will be true in many obstetrical cases, this patient’s circumstances are
unique and the above directives do not relate to her case. Selection of
MRDx must be determined on the basis of the documentation of this case.
341
D Example: The mother is fully dilated and the fetus is noted to be in left occipitotransverse
position, station +1. Forceps are used in an attempt to rotate and deliver the fetal
head. After the third contraction, and with no further fetal descent, it is decided to
abandon the forceps and move to a primary lower uterine segment Cesarean section.
Code DAD Code title
O64.001 (M) Obstructed labour due to incomplete rotation of fetal head, delivered,
O66.501 (1) Failed application of vacuum extractor and forceps, unspecified,

5.MD.60.JW Cesarean section delivery, lower segment transverse incision,

with use of forceps
Status: PB
Rationale: The Cesarean section is performed to address the obstructed labor due to
malposition; therefore, O64.001 is selected as the MRDx. The indication
for the Cesarean section does not become failed application of vacuum
extractor and forceps. Forceps traction delivery is not captured separately;
it is captured in the qualifier of the Cesarean section.
Intrauterine Death
D Classify late intrauterine fetal death — when the fetal demise occurs at or after 20 completed weeks of
gestation — to O36.4– Maternal care for intrauterine death.
DN Classify early intrauterine fetal death — when the fetal demise occurs before 20 completed weeks of
gestation — with retention of the fetus to O02.1 Missed abortion.
342
D Example: The patient noticed decreased fetal movement at 23 weeks gestation. On examination,
no fetal heart rate could be detected. She now presents at 25 weeks gestation,
in labor. She delivers a dead male fetus.
Code DAD Code title
O36.421 — Maternal care for intrauterine death, second trimester, delivered, with
Z37.100 (3) Single stillbirth, pregnancy resulting from both spontaneous ovulation
and conception
D Example: An ultrasound examination diagnoses fetal demise at 19 weeks. The patient is sent
home to await labor. Labor begins 10 days later, and she delivers a macerated male
fetus weighing 150 grams.
Code Code title
O02.1 Missed abortion
Rationale: Gestational age is determined at the time of fetal death.
Pregnancy With Abortive Outcome

See also the coding standard Continuing Pregnancy After Abortion/Selective Fetal Reduction in
Multiple Gestation.
O03–O08 Pregnancy with abortive outcome

The primary axis is the type of abortion, with the fourth character indicating any associated complication(s).
DN Example: Spontaneous abortion, incomplete, without complication, treated by dilation and curettage
O03.4 (M) MP Spontaneous abortion, incomplete, without complication
5.PC.91.GA Interventions to uterus (following delivery or abortion),

dilation and curettage
343
O04 Medical abortion

This is a broad category encompassing the diagnosis codes for both surgical and pharmacologically
induced abortions; the diagnosis code does not indicate the method used to terminate the pregnancy.
DN
Classify all medical abortions (intended terminations of pregnancy), regardless of gestational age, fetal
weight or outcome of the fetus (i.e., products of conception, stillborn or liveborn), to category O04
Medical abortion.
• When applicable, assign an additional code, mandatory, as a significant diagnosis type (1)/other
problem from
− Category O35 Maternal care for known or suspected fetal abnormality and damage to identify any
fetal reason for the medical abortion (e.g., anencephalic fetus); and/or
− Chapter XV — Pregnancy, childbirth and the puerperium (O10–O99) to identify any maternal
medical illness as the reason for the medical abortion (e.g., maternal toxoplasmosis).
Note
An encounter for extraction/expulsion where fetal demise occurred before 20 weeks gestation is classified as
a missed abortion, even when extraction/expulsion of the fetus occurs after 20 weeks.
Note
When a multiple pregnancy continues following a medical abortion, follow the direction in the coding
standard Continuing Pregnancy After Abortion/Selective Fetal Reduction in Multiple Gestation.
DN Example: Medical abortion for unwanted pregnancy treated with a suction curettage at 10 weeks

5.CA.89.GC Surgical termination of pregnancy, vaginal approach, aspiration

and curettage
Rationale: Neither a fetal nor a maternal reason for medical abortion was
documented; therefore, the case is classified to O04.9 only.
344
Medical abortion at or after 20 weeks resulting in a stillborn

A termination performed later in gestation is classified as a medical abortion on the mother’s
abstract as described above. A stillborn abstract is created per provincial/territorial direction.
Note
See Section 3: Additional Abstracting Information: Stillborn Abstracting in the Discharge Abstract Database
(DAD) Abstracting Manual for the criteria for completing a stillborn abstract.
DN
When a medical abortion is performed at or after 20 weeks gestation and it results in a stillborn, assign P96.4
Termination of pregnancy, affecting fetus and newborn as the MRDx/main problem on the stillborn abstract.
• When applicable, assign additional code(s), mandatory, as diagnosis type (3)/other problem to describe
any associated congenital anomaly
Note
When a medical abortion occurs at or after 20 weeks gestation, do not assign a code from category Z37
Outcome of delivery for a stillbirth on the mother’s abstract. Direction for classifying a medical abortion at
or after 20 weeks gestation resulting in a livebirth is addressed in the following section: Medical abortion
resulting in a liveborn.
345
Mother’s abstract
DN Example: An expectant mother presents at 26 weeks gestation. During her last prenatal visit,
an ultrasound and amniocentesis were ordered. The results of the amniocentesis
demonstrated that the fetus has trisomy 21. She has decided that she does not
wish to carry this pregnancy to term. She is admitted for a medical termination
of the pregnancy by vaginal insertion of prostaglandin.

O35.109 (1) OP Maternal care for (suspected) chromosomal

abnormality in fetus, unspecified as to episode of
care, or not applicable
5.CA.88.CK-I2 Pharmacological termination of pregnancy, per orifice

approach, oxytocins
Rationale: A medical abortion was performed and the reason for the medical
abortion was documented; therefore, the case is classified to O04.9
and a code for the fetal anomaly is assigned. The intent was to
terminate the pregnancy; therefore, a delivery code from rubric
5.MD.50.^^ to 5.MD.60.^^ is not assigned.
DN Stillborn’s abstract
P96.4 (M) MP Termination of pregnancy, affecting fetus
and newborn
Q90.9 (3) OP Down’s syndrome, unspecified
Rationale: A medical abortion was performed and the reason for the medical
abortion was documented; therefore, the case is classified to P96.4
and a code for the fetal anomaly is assigned.
346
Mother’s abstract
DN Example: A patient is admitted at 21 weeks for an unplanned pregnancy that she wishes to
terminate. Dilation and evacuation is performed. The physician documents the
diagnosis as “delivery of a stillborn.”

5.CA.89.GD Surgical termination of pregnancy, vaginal approach, dilation and

evacuation [D & E]
Rationale: A medical abortion was performed; therefore, this case is classified to

O04.9. Even though the physician documented “delivery of a stillborn,”
the intent was to terminate the pregnancy; therefore, a delivery code
from rubric 5.MD.50.^^ to 5.MD.60.^^ is not assigned.
DN Stillborn’s abstract

and newborn
Rationale: A medical abortion was performed; therefore, the case is classified

to P96.4.
347
Medical abortion resulting in a liveborn

When a medical abortion performed at or after 20 weeks gestation results in a liveborn, assign
D
• On the mother’s abstract, a code from
− Category O04 Medical abortion as the MRDx/main problem; and
− Category Z37 Outcome of delivery as a diagnosis type (3)/other problem to indicate that the abortion
resulted in a liveborn; and
− Category O35 Maternal care for known or suspected fetal abnormality and damage to identify any
fetal reason for the medical abortion (e.g., anencephalic fetus); and/or
− Chapter XV — Pregnancy, childbirth and the puerperium (O10–O99) to identify any maternal medical
illness as the reason for the medical abortion (e.g., maternal toxoplasmosis).
• On the newborn’s abstract
− P96.4 Termination of pregnancy, affecting fetus and newborn as the MRDx/main problem; and
− A code from category Z38 Liveborn infants according to place of birth as a diagnosis type (0); and
− When applicable, a code to describe any associated congenital anomaly, mandatory, as a significant
348
Mother’s abstract
DN Example: A patient presents at 20 weeks gestation requesting a therapeutic abortion. She is

started on misoprostol intravenously. The fetus is successfully expelled. A heart
beat and respirations are detected at birth.

Z37.000 (3) OP Single live birth, pregnancy resulting from both

5.CA.88.HA-A2 Pharmacological termination of pregnancy, percutaneous

approach [e.g. intravenous, injection into intraamniotic or
extraamniotic sac], antacid treatment
Rationale: The medical abortion resulted in a liveborn; therefore, the case is

classified to O04.9, and Z37.000 is assigned to show that the result was
a liveborn. The intent was to terminate the pregnancy; therefore, a
delivery code from rubric 5.MD.50.^^ to 5.MD.60.^^ is not assigned.
Newborn’s abstract
DN The outcome of the intended termination was delivery of a liveborn fetus.

and newborn
Z38.000 (0) OP Singleton, delivered vaginally, product of both

Rationale: The medical abortion resulted in a liveborn; therefore, the case is

classified to P96.4, and Z38.000 is assigned to show that the result
was a liveborn.
349
Mother’s abstract
DN Example: A medical abortion is performed at 23 weeks gestation for fetal anencephaly.

Labor is induced with intravenous Syntocinon. The fetus is born alive and survives
for one hour.

O35.009 (1) OP Maternal care for (suspected) fetal anencephaly,

unspecified as to episode of care, or not applicable
Z37.000 (3) OP Single live birth, pregnancy resulting from both

5.CA.88.HA-I2 Pharmacological termination of pregnancy, percutaneous

extraamniotic sac], oxytocins
Rationale: The medical abortion resulted in a liveborn. Therefore, the case is classified
to O04.9, and Z37.000 is assigned to show that the result was a liveborn.
The reason for the medical abortion was documented, so a code for the fetal
anomaly is assigned. The intent was to terminate the pregnancy; therefore,
a delivery code from rubric 5.MD.50.^^ to 5.MD.60.^^ is not assigned.
DN The outcome of the intended termination was delivery of a liveborn fetus with anencephaly.

and newborn
Q00.0 (1) OP Anencephaly
Z38.000 (0) OP Singleton, born in hospital, delivered vaginally,

product of both spontaneous (NOS) ovulation
and conception
Rationale: The medical abortion resulted in a liveborn. Therefore, the case is

classified to P96.4, and Z38.000 is assigned to show that the result
was a liveborn. The reason for the medical abortion was documented,
so a code for the fetal anomaly is assigned.
350
Note
A liveborn resulting from a medical abortion prior to 20 weeks is considered pre-viable for the purposes of
classification; therefore, a code from category Z37 Outcome of delivery is not assigned on the mother’s
abstract and a newborn abstract is not created.
Vital Statistics Act requirements for registration of a liveborn are not the same as those for classification of a
newborn in the DAD. Consequently, liveborn registrations for Vital Statistics will not always match newborn
data submitted to the DAD.
Mother’s abstract
DN Example: A patient presents at 19 weeks gestation for a therapeutic abortion. She is started
on misoprostol intravenously. The fetus is expelled. A heart beat is detected. The
fetus expires seven minutes later.

5.CA.88.HA-A2 Pharmacological termination of pregnancy, percutaneous

extraamniotic sac], antacid treatment
Rationale: A medical abortion prior to 20 weeks is considered pre-viable for the

purposes of classification; therefore, a code from category Z37 is
not assigned on the mother’s abstract and a newborn abstract is
not created.
O05 Other abortion
DN Assign O05.– Other abortion for self-inflicted abortion or abortion following amniocentesis or trauma.
351
DN Example: A patient at 18 weeks gestation is driving her car when she is hit broadside by a
man who runs a stop sign. She sustains a fractured (ischium) pelvis and
subsequently goes on to spontaneously deliver a dead fetus.
S32.800 (M) MP Fracture of other and unspecified parts of lumbar

spine and pelvis, closed
V43.5 (9) OP Car occupant injured in collision with car, pick-up

truck or van, driver of car, traffic accident
O05.9 (1) OP Other abortion, complete or unspecified,

O07 Failed attempted abortion
DN
When an intervention intended to terminate a pregnancy does not result in termination of the pregnancy,
assign O07 Failed attempted abortion. To use this category, there must be a live fetus within the uterus at
the time of discharge.
• Assign O07.4 Failed attempted abortion, without complication when no complication occurs within the
same episode of care as the failed abortion.
• Assign O07.3 Failed attempted abortion, complicated when a complication occurs within the same
episode of care as the failed abortion.
Note
When a complication follows a failed abortion, a code from category O08 Complications following abortion
and ectopic and molar pregnancy is not assigned. The patient is pregnant at the time of discharge, so the
codes for complication following abortion do not apply for this episode of care or any subsequent episode
of care.
A readmission for a complication following a failed attempted abortion is classified to a code from O10–O99
because the patient is pregnant.
See also the coding standard Complications Following Abortion and Ectopic and Molar Pregnancy.
352
D Example: The patient is admitted at 19 weeks gestation for a medical abortion. Prostin gel
is inserted to initiate labor, but no labor ensues. The patient declines any further
intervention and is discharged home.
Code DAD Code title
O07.4 (M) Failed attempted abortion, without complication

approach, oxytocins
DN Example: The patient is admitted at 19 weeks gestation for a medical abortion. Prostin gel is
inserted to initiate labor, but no labor ensues. The patient is taken to the operating room
for a dilation and curettage (D & C). Blood is noted on the pad in the recovery room.
After examination, it is determined that the patient is still pregnant, and she is taken
back to the operating room for a second D & C.

5.CA.89.GA Surgical termination of pregnancy, vaginal approach, dilation and

curettage [D & C]
approach, oxytocins
5.CA.89.GA Surgical termination of pregnancy, vaginal approach, dilation and
curettage [D & C]
Rationale: This was not a “failed abortion” because the patient was not pregnant at
the time of discharge. Neither a fetal nor a maternal reason for medical
abortion was documented; therefore, the case is classified to O04.9 only.
The expected outcome for the first D & C performed during this episode
of care was unsuccessful; however, because a failed intervention is
classified in the same manner as one that is successful, an intervention
code is assigned for both the unsuccessful and the successful D & Cs.
See also the coding standard Failed Interventions. A diagnosis code is
not assigned to show that the first D & C was unsuccessful.
353
Continuing Pregnancy After Abortion/Selective

Fetal Reduction in Multiple Gestation
When there is loss of one fetus or more, whether spontaneous or due to an intervention, the
case is classified to category O31 Complications specific to multiple gestation and not to
O00–O08 Pregnancy with abortive outcome.

When a multiple pregnancy continues after an abortion/selective fetal reduction (any condition in O00–O08)
DN
of one fetus or more, classify this to O31.11– Continuing pregnancy after spontaneous abortion of one fetus
or more or O31.12– Continuing pregnancy after selective fetal reduction of one fetus or more.
DN When a fetal anomaly or other condition is the reason for selective fetal reduction, assign an additional code
as a comorbid diagnosis type for the fetal anomaly/other condition on both the selective fetal reduction and
obstetrics delivered episodes.
DN Assign an additional code from O30 Multiple gestation, mandatory, as a comorbid diagnosis type
• On the abortive encounter, to describe the number of fetuses existing prior to the abortive outcome of
one or more fetuses; and
• On the delivery encounter, to describe the number of live fetuses remaining in the pregnancy,
when applicable (i.e., when there is more than one fetus at the time of delivery).
See also the coding standard Multiple Gestation.
D Example: The patient presents with a twin pregnancy at 18 weeks gestation. She has some mild
cramping and intermittent spotting. Despite bed rest, she spontaneously aborts one fetus.
Code DAD Code title
O31.113 (M) Continuing pregnancy after spontaneous abortion of one fetus or

more, antepartum condition or complication
O30.003 (1) Twin pregnancy, antepartum condition or complication
Rationale: Continuing pregnancy after spontaneous abortion of one or more

fetuses is classified to O31.11– rather than O03 Spontaneous abortion.
The patient remains pregnant; therefore, this is an antepartum condition
rather than an abortive outcome.
354
D Example: The same patient is now at 37 weeks, 2 days gestation, presenting in labor.
She delivers a healthy female baby at 05:45.
Code DAD Code title
O31.111 (M) Continuing pregnancy after spontaneous abortion of one fetus or

more, delivered, with or without mention of antepartum condition
Rationale: O30 Multiple gestation is not assigned because only a singleton

fetus remains.
DN Example: A patient with a quadruplet multiple gestation pregnancy, assisted by in vitro

fertilization, presents at 12 weeks for selective fetal reduction to a twin pregnancy,
via ligation of the umbilical cords. The patient tolerates the procedure well and is
discharged, retaining the reduced fetuses.

O31.123 (M) MP Continuing pregnancy after selective fetal reduction
of one fetus or more, antepartum condition
or complication
O30.203 (1) OP Quadruplet pregnancy, antepartum condition

or complication
5.CA.90.FM Selective fetal reduction, using vascular occlusion

Extent: 2
Rationale: Selective fetal reduction is classified to O31.12– rather than O04

Medical abortion. The patient presented with quadruplet multiple
gestation, so a code from category O30 Multiple gestation must be
used to show the presenting status of the pregnancy. The fourth digit is
selected to describe the number of fetuses existing prior to the selective
fetal reduction.
355
D Example: The same patient (who had selective fetal reduction at 12 weeks gestation)
now presents at 38 weeks gestation with severe preeclampsia necessitating
an emergency primary Cesarean section. She delivers healthy twin newborns.
The previously reduced, retained fetuses are delivered as well.
Code DAD Code title
O14.101 (M) Severe pre-eclampsia, delivered, with or without mention of

O31.121 (1) Continuing pregnancy after selective fetal reduction of one fetus or
O30.001 (1) Twin pregnancy, delivered, with or without mention of

Z37.201 (3) Twins, both liveborn, pregnancy resulting from assisted reproductive
technology (ART)

Status: PB
Rationale: O31.121 Continuing pregnancy after selective fetal reduction of one

fetus or more covers the abortive outcome for these two fetuses. If
another condition warrants assignment as MRDx, the code from
O31.12– Continuing pregnancy after selective fetal reduction of one
fetus or more does not have to be the MRDx.
356
D Example: The patient is admitted at 19 weeks gestation for selective fetal reduction of one
fetus of a twin pregnancy, due to fetus-to-fetus transfusion syndrome. The selective
fetal reduction is accomplished via ligation of the umbilical cord.
Code DAD Code title
O31.123 (M) Continuing pregnancy after selective fetal reduction of one fetus or
more, antepartum condition or complication
O43.013 (1) Fetus to fetus transfusion syndromes, antepartum condition

or complication
O30.003 (1) Twin pregnancy, antepartum condition or complication
5.CA.90.FM Selective fetal reduction, using vascular occlusion

Extent: 1
Rationale: Selective fetal reduction is classified to O31.12– rather than to O04

Medical abortion.
D Example: The same patient (who had selective fetal reduction of one fetus at 19 weeks
gestation) is now admitted at 38 weeks gestation in labor. She delivers a healthy
newborn girl and the dead fetus.
Code DAD Code title

O31.121 (M) Continuing pregnancy after selective fetal reduction of one fetus or
O43.011 (1) Fetus to fetus transfusion syndromes, delivered, with or without

mention of antepartum condition
Rationale: The delivery of the dead fetus is taken into consideration with the code
O31.121. This is not a stillbirth, nor is it retained products of conception.
357
Complications Following Abortion and Ectopic

and Molar Pregnancy
ICD-10-CA makes a distinction between an episode of care in which the abortion or ectopic and
molar pregnancy and any resulting complications are treated together (code from O00–O05 is
MRDx/main problem) and an episode of care for a complication of the abortion or ectopic and
molar pregnancy treated previously (category O08 is the MRDx/main problem). The inclusion
terms provided at the subcategories of O08 should be referenced when assigning the fourth-
character subcategories of O03–O05.
When the episode of care is solely for the treatment of a complication, the abortion itself having been
DN
performed and completed in a previous episode of care, assign a code from category O08 Complications
following abortion and ectopic and molar pregnancy as the MRDx/main problem.
N Example: The patient had a spontaneous abortion and underwent a D & C in the first episode
of care. She is brought to the emergency department two days after discharge
because she has developed a fever. She is treated with antibiotics for endometritis.

O08.02 MP Genital tract and pelvic infection following spontaneous abortion
Rationale: No other code is required because the abortion was performed during
a previous episode of care.
DN When the abortion and a complication occur during the same episode of care, select a code from O00–O05
as the MRDx/main problem.
• Assign an additional code, mandatory, from category O08 Complications following abortion and ectopic
and molar pregnancy to identify associated complications with a code from O00–O02 or to provide
further details with a code from O03–O05, per the “use additional code” instruction.
358
DN Example: Ruptured tubal pregnancy with shock (initial episode of care)
O00.1 (M) MP Tubal pregnancy
O08.30 (1) OP Shock following ectopic pregnancy
Rationale: The complication (shock) and the ruptured tubal pregnancy occurred
during the same episode of care. O00.1 is assigned as the MRDx/main
problem, and O08.30 is assigned to further specify the associated
complication, per the “use additional code” instruction.
DN Example: Incomplete spontaneous abortion with perforation of uterus (initial episode of care)
O03.3 (M) MP Spontaneous abortion, incomplete, with other and

unspecified complications
O08.62 (3) OP Damage to pelvic organs and tissues following

spontaneous abortion
Rationale: The complication (perforation of uterus) and the spontaneous abortion

occurred during the same episode of care. O03.3 (other and unspecified
complication) is assigned as the MRDx/main problem, and O08.62 is
assigned to further specify the associated complication, per the “use
additional code” instruction.
Streptococcal Group B Infection/

Carrier in Pregnancy
Infections due to group B streptococcus (GBS) in pregnant women are quite rare. Often,
a low vaginal swab will identify GBS; however, the woman will have no symptoms and will
simply be a carrier of the bacteria. Prophylactic antibiotic treatment may be given following
premature rupture of membranes or during labor to ensure that the organism is not passed onto
the baby during birth.
359

Assign O23.90– Other and unspecified genitourinary tract infection in pregnancy only when there is
D
documented evidence of an active infection.
• When there is active infection, assign B95.1 Streptococcus, Group B, as the cause of diseases classified to
other chapters, optional, as a diagnosis type (3) to identify the organism.
Assign Z22.38 Carrier of other specified bacterial diseases, optional, as a diagnosis type (3) to identify GBS
D
carrier state.
D When antibiotics are given for prophylaxis in a GBS carrier patient, assign Z29.2 Other prophylactic
chemotherapy, optional, as a diagnosis type (3).
D Example: The patient has a vaginal swab that is positive for GBS. On presentation, she has
no symptoms. It is decided that no prophylactic treatment is necessary.
Code DAD Code title

Z22.38 (3) Carrier of other specified bacterial diseases (optional)
D Example: The vaginal swab comes back positive for GBS. There is no documentation indicating an
active infection. The patient receives a course of antibiotics as a prophylactic measure.
Code DAD Code title

Z22.38 (3) Carrier of other specified bacterial diseases (optional)
Z29.2 (3) Other prophylactic chemotherapy (optional)
D Example: A patient presents with a genitourinary tract infection due to GBS. She has a
Cesarean section delivery of a female infant. There are no other documented
complications of pregnancy or delivery.
Code DAD Code title

O23.901 (M) Other and unspecified genitourinary tract infection in pregnancy,
B95.1 (3) Streptococcus, group B, as the cause of diseases classified to other

chapters (optional)
360
Delivery in a Normal Case


Assign a code from category Z37 Outcome of delivery, mandatory, for all deliveries.
D
• Select a code from subcategory Z37.0– Single live birth as the MRDx when a single, spontaneous vaginal
delivery without any conditions complicating the pregnancy, childbirth or puerperium occurs.
• When any other code from Chapter XV — Pregnancy, childbirth and the puerperium applies to the case,
assign the appropriate code from category Z37, mandatory, as a diagnosis type (3).
The following terms, when used in the absence of any other documentation to suggest
otherwise, indicate a spontaneous delivery without complication:
• Spontaneous vertex delivery
• Left occiput anterior (LOA)
• Right occiput anterior (ROA)
• Single term liveborn
• Healthy mother delivered
• Occiput transverse position during labor that spontaneously rotates to OA at delivery
• Occiput posterior position during labor that spontaneously rotates to OA at delivery
• No fetal manipulation or instrumentation (e.g., forceps)
• Periurethral, first-degree or second-degree unsutured perineal lacerations
• Chorioamnionitis or funisitis as an incidental placental pathological finding only, without
documentation of a diagnosis of fever or other symptoms of infection
• Nuchal cord (loose) or other cord entanglement, without mention of compression
or intervention
Note
For the purposes of the classification, “slipping the cord over the head/body” of the infant or other simple
manipulation of the cord during a delivery is not classified as an intervention.
361
The following presentations/positions are regarded as abnormal and are not considered normal
cases. Code the listed condition when it requires care during pregnancy or is present during
labor or at delivery:
• Breech presentation
• Brow presentation
• Compound presentation (nuchal arm/hand)
• Cord presentation
• Deep transverse arrest
• Face presentation
• Persistent occipitoposterior position (face-to-pubes, direct OP)
• Persistent occipitotransverse position
• Prolapsed arm
• Transverse/oblique lie
• Unstable lie
See also the coding standards Maternal Care Related to the Fetus, Amniotic Cavity and
Possible Delivery Problems, Obstructed Labor and Interventions Associated With Delivery.
D Example: The patient vaginally delivers a healthy newborn male, left OP presentation,
without complication.
Code DAD Code title
Z37.000 (M) Single live birth, pregnancy resulting from both spontaneous
Rationale: There is no mention of persistent OP, direct OP (face-to-pubes), fetal

manipulation or instrumentation; therefore, spontaneous rotation of
the fetal head to an OA position occurred prior to delivery.
362
D Example: The patient vaginally delivers a healthy female baby in the breech position.
An obstetrician is in attendance.
Code DAD Code title
O32.101 (M) Maternal care for breech presentation, delivered, with or without
5.MD.56.AA Breech delivery, spontaneous breech delivery, without episiotomy,

with spontaneous delivery of head
Rationale: Breech presentation is an abnormal presentation and is never

considered to be a normal case. There is no mention of any special
maneuvers or instrumentation to indicate that labor was obstructed;
therefore, this is classified to O32.101.
Note
Certain obstetrical interventions do not preclude the use of a code from subcategory Z37.0– Single live birth
as the MRDx (e.g., induction for convenience, artificial rupture of membranes and/or episiotomy). In a case
where a Cesarean section is requested by a mother who has not had a previous Cesarean section, and it is
done in the absence of any indications, a code from subcategory Z37.0– may still be used as the MRDx.
D Example: A primigravida patient does not want a vaginal delivery, so she requests an elective
Cesarean section. She has no complications of her pregnancy or delivery.
The obstetrician performs a low-segment section with no forceps.
Code DAD Code title

Status: PC
363
D Example: The patient had a Cesarean section delivery of her first child. The obstetrician has
noted that she is a candidate for vaginal birth after Cesarean (VBAC), but the
patient does not want a vaginal delivery and has requested an elective Cesarean
section. She has no complications of her pregnancy or delivery. The obstetrician
performs a low-segment section with no forceps.
Code DAD Code title
O34.201 (M) Uterine scar due to previous Caesarean section, delivered,


Status: RC
Complicated Pregnancy Versus

Uncomplicated Pregnancy
The purpose of this coding standard is to provide direction on determining whether or not a
condition, when present during pregnancy, is classified as complicating the pregnancy when
the classification is ambiguous and/or direction is not found within another coding standard.
Codes from Chapter XV — Pregnancy, childbirth and the puerperium (O00–O99) are assigned
for conditions related to or aggravated by the pregnancy; that is, conditions that “complicate”
the pregnancy.
The coding standard also provides direction on when to assign Z33 Pregnancy state, incidental.
Note
This coding standard does not address conditions arising in the postpartum period.
364
Complicated pregnancy
As noted in the antepartum and intrapartum guidelines published by the Society of Obstetricians
and Gynaecologists of Canada (SOGC), assisted reproductive technology and certain conditions,
such as (pre-existing and gestational) diabetes mellitus and hypertension, are associated with an
increased risk of adverse fetal outcome.
Advanced maternal age is not a condition complicating pregnancy per se. It is a risk factor —
for both mothers and babies — because it is associated with a higher probability of developing
pregnancy and labor complications; of requiring medical or surgical assistance during labor and
delivery; and of resulting in adverse birth outcomes and birth defects. Maternal age is recorded on
the abstract, and the appropriate codes are assigned for the conditions complicating the pregnancy.
A condition is classified as complicating the pregnancy when it is associated with an increased risk of
adverse fetal outcome. The following conditions, when documented as currently present or existing
during the antepartum or delivery episode of care, are always considered to complicate the pregnancy:
• Hypertensive disorders of pregnancy (O10–O16)
• Pre-existing diabetes mellitus or gestational diabetes (O24.–)
• Anemia (O99.0–)
• Hyperthyroidism (O99.2–)
• Vascular disease, such as cerebrovascular accident (CVA) or disease with potential clot
formation (O22.– or O88.– or O99.4–)
• Renal disease, such as acute kidney injury, chronic kidney disease or compromised kidney
function (O26.8– or O99.8–)
• Morbid obesity, so described (O99.2–)
• Cardiac disease, such as acute myocardial infarction, cardiomyopathy and coronary artery
disease (O99.4–)
• ST segment elevation myocardial infarction (STEMI) (R94.30) and non-ST segment elevation
myocardial infarction (NSTEMI) (R94.31) (O99.8–)
365
Note
For emergency department encounters, R94.30 and R94.31 may be used without a code from category I21 or
I22 or without code I24.0; however, R94.30 and R94.31 must be used only for the purpose of indicating an
emergency department discharge diagnosis documented as STEMI or NSTEMI. That is, when all that is
documented on an emergency department record is the working diagnosis STEMI or NSTEMI, O99.8– Other
specified diseases and conditions complicating pregnancy, childbirth and the puerperium is assigned as the
main problem and R94.30 or R94.31 is assigned as an other problem.
For inpatient and day surgery abstracts, R94.30 and R94.31 are reserved for the purpose of adding STEMI and
NSTEMI information to acute myocardial infarction (AMI) or aborted myocardial infarction. These codes are
to be used only when a code from category I21 Acute myocardial infarction or I22 Subsequent myocardial
infarction or the code I24.0 Coronary thrombosis not resulting in myocardial infarction is assigned. R94.30 and
R94.31 are not used with any other diagnosis.
For inpatient and day surgery cases, O99.4– Diseases of the circulatory system complicating pregnancy,
childbirth and the puerperium is assigned as a significant diagnosis and I21.– Acute myocardial infarction or
I22.– Subsequent myocardial infarction or I24.0 Coronary thrombosis not resulting in myocardial infarction
and R94.30 or R94.31 are assigned as diagnosis type (3). O99.8– Other specified diseases and conditions
complicating pregnancy, childbirth and the puerperium is not assigned.
See also the coding standard Acute Coronary Syndrome.
A non-obstetrical condition, not listed above, is classified as complicating the pregnancy when
the condition is present and significant (see the coding standard Diagnosis Typing Definitions
for DAD) during the antepartum or delivery episode of care and there is concern for maternal or
fetal well-being, as indicated by at least one of the following criteria:
• Requires admission to an obstetrical unit
• Requires the supervision of an obstetrician and/or neonatologist
• Requires an obstetrical and/or neonatology consultation or evaluation for the condition,
except when initial assessment determines there is no concern for the pregnancy and/or no
further obstetrical follow-up is required
• Requires continuous fetal evaluation and/or monitoring
• Requires a transfer to another facility for obstetrical and/or neonatal care
366
When a condition complicates the pregnancy, as described above, classify the condition to a code from
DN
Chapter XV — Pregnancy, childbirth and the puerperium (O00–O99) and assign a significant diagnosis
type/main or other problem.
D Example: A patient is admitted in labor at 38 weeks gestation. She delivers a healthy newborn
male, vaginally, left occiput posterior presentation, without complication. It is noted in the
progress notes that the patient has pre-existing hypertension, controlled by labetalol.
Code DAD Code title
O10.001 (M) Pre-existing essential hypertension complicating pregnancy,

childbirth and the puerperium, delivered, with or without mention of
Rationale: Hypertension is one of the conditions always considered to complicate the

pregnancy, as described above. Thus hypertension is classified to a code
from Chapter XV and is assigned a significant diagnosis type. In this case,
the hypertension is the only significant condition, so it qualifies as the MRDx.
D Example: A 30-year old G1P2 is admitted at 37 + 5 weeks gestation for query labor. It is noted
in the history and physical that the patient has type 1 diabetes mellitus and is on
insulin. After 24 hours, no cervical changes or further contractions are noted.
Discharge diagnosis is false labor.
Code DAD Code title
O47.103 (M) False labour at or after 37 completed weeks of gestation, antepartum

O24.503 (1) Pre-existing type 1 diabetes mellitus in pregnancy, antepartum

Rationale: It is mandatory to assign a code for diabetes mellitus whenever it is documented.

Diabetes mellitus is one of the conditions always considered to complicate the
pregnancy, as described above. Thus diabetes mellitus is classified to a code
from Chapter XV and is assigned a significant diagnosis type.
367
D Example: A patient is admitted at 36 weeks gestation with renal colic. Ultrasound shows
bilateral hydronephrosis with 1.5 cm calculus in lower pole of the left kidney.
On day 2 of admission, she passes the stone and is discharged.
Code DAD Code title
O26.803 (M) Other specified pregnancy-related conditions, antepartum condition

or complication
N13.2 (3) Hydronephrosis with renal and ureteral calculus

obstruction (optional)
Rationale: Renal disease is one of the conditions always considered to complicate the
pregnancy, as described above. Thus renal disease is classified to a code
from Chapter XV and is assigned a significant diagnosis type. An additional
code to identify the specific renal condition is assigned, optionally.
D Example: A primigravida patient is admitted at 37 weeks gestation for intravenous oxytocin

induction of labor for gestational hypertension. She has a seizure following
admission. A computerized tomography (CT) scan confirms a cerebral infarction
with occlusion of the middle cerebral artery. She is taken to the operating room for
an emergency Cesarean section and delivers a healthy female.
Code DAD Code title

O99.401 (2) Diseases of the circulatory system complicating pregnancy,

childbirth and the puerperium, delivered, with or without mention of
I63.5 (3) Cerebral infarction due to unspecified occlusion or stenosis of

cerebral arteries

Status: PM
368
Rationale: A cerebrovascular accident (stroke) is one of the conditions always

considered to complicate the pregnancy, as described above. Thus a
stroke is classified to a code from Chapter XV and is assigned a
significant diagnosis type. An additional code to identify the specific
(i.e., hemorrhagic, ischemic, unspecified) type of stroke is assigned,
mandatory, per the “use additional code to identify specific condition”
instruction at category O99.
DN
When a condition that complicates the pregnancy is classified to a code from O99 Other maternal diseases
classifiable elsewhere but complicating pregnancy, childbirth and the puerperium, assign an additional code,
mandatory, as a diagnosis type (3)/other problem, to identify the specific condition, per the “use additional
code” instruction.
When two or more conditions that complicate the pregnancy are classified to different subcategories from
DN
O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the
puerperium, assign the code from the appropriate subcategory (O99.0–O99.8) for each complication, to the
greatest level of specificity.
• Do not assign O99.8– as a flag to identify cases with multiple complications classifiable to O99.0–O99.7.
D Example: A 38-year-old at 11 weeks gestation is found to be anemic. She is admitted for a

work-up. The final diagnosis is “iron deficiency anemia requiring transfusion.”
Code DAD Code title
O99.003 (M) Anaemia complicating pregnancy, childbirth and the puerperium,

antepartum condition of complication
D50.9 (3) Iron deficiency anaemia, unspecified
Rationale: Anemia is one of the conditions always considered to complicate the

pregnancy, as described above. Thus anemia is classified to a code
from Chapter XV and is assigned a significant diagnosis type. An
additional code to identify the specific type of anemia is assigned,
mandatory, per the “use additional code to identify specific condition”
instruction at category O99.
369
D Example: A patient with gastroenteritis and dehydration is admitted for IV fluid rehydration.
She is 36 weeks gestation on admission. During this episode of care, electronic
fetal monitoring is done. It is documented in the discharge summary that the patient
is advised to see her obstetrician in a week for follow-up.
Code DAD Code title
O98.803 (M) Other maternal infectious and parasitic diseases complicating

pregnancy, childbirth and the puerperium, antepartum condition
or complication
A09.9 (3) Gastroenteritis and colitis of unspecified origin
O99.203 (1) Endocrine, nutritional and metabolic diseases complicating

pregnancy, childbirth and the puerperium, antepartum condition
or complication
E86.0 (3) Dehydration
Rationale: Gastroenteritis and dehydration are not conditions associated with

an increased risk of adverse fetal outcome. However, there is
documentation of fetal monitoring and follow-up with an obstetrician,
which is evidence of concern for maternal/fetal well-being. Therefore,
the gastroenteritis and dehydration meet the criteria to classify both
conditions to a code from Chapter XV, and both are assigned a
significant diagnosis type. Additional codes to identify the specific
conditions are assigned, mandatory, per the “use additional code to
identify specific condition” instruction at categories O98 and O99.
Uncomplicated pregnancy
A condition is not classified as complicating the pregnancy when there is no associated risk
of adverse fetal outcome and/or there is no concern for maternal or fetal well-being; that is,
the condition does not meet any of the criteria for “complicated,” as described above
(see Complicated pregnancy).
See also the coding standard Delivery in a Normal Case.
370
DN
When a condition does not complicate the pregnancy, as described above, classify the condition to the
regular code.
When a code from Chapter XV is not assigned during the antepartum episode of care, assign Z33
DN Pregnant state, incidental, mandatory, as a diagnosis type (3)/other problem.
N Example: A patient presents to the emergency department at 26 weeks gestation with redness,
itching and mucopurulent discharge of her left eye. She is seen in consultation by an
ophthalmologist. The final diagnosis is documented as “conjunctivitis.” She is
discharged home with a prescription for antibiotic eye drops.
H10.9 MP Conjunctivitis, unspecified
Z33 OP Pregnant state, incidental
Rationale: Conjunctivitis is not a condition associated with an increased risk of

adverse fetal outcome, nor is there any documentation to support
concern for maternal or fetal well-being. The conjunctivitis is classified
to the regular code. Z33 is assigned, mandatory, because a code from
Chapter XV does not apply.
D Example: A patient presents with right lower quadrant abdominal pain. She is 32 weeks gestation.
She is admitted for further investigation. An ultrasound is done and an obstetrician is
consulted. The obstetrician documents “pain is not obstetrical in nature.” The patient is
discharged without a follow-up appointment, and the final diagnosis is “abdominal pain.”
Code DAD Code title
R10.30 (M) Right lower quadrant pain
Z33 (3) Pregnant state, incidental
Rationale: An obstetrician was consulted; however, the documentation supports

the initial assessment, which determined that there was no concern for
the pregnancy and that no further obstetrical follow-up was required.
The abdominal pain is classified to the regular code. Z33 is assigned,
mandatory, because a code from Chapter XV does not apply.
371
N Example: A patient presents to the emergency department at 34 weeks gestation with a sore
throat. It is noted on the chart that she has gestational diabetes mellitus. She is
seen in consultation by an otolaryngologist. The final diagnosis is documented as
“acute pharyngitis.” She is discharged home with a prescription for antibiotics.
J02.9 MP Acute pharyngitis, unspecified
O24.803 OP Diabetes mellitus arising in pregnancy (gestational), antepartum

Rationale: Pharyngitis is not a condition associated with an increased risk of

adverse fetal outcome, nor is there any documentation to support
concern for maternal or fetal well-being. Therefore, the acute pharyngitis
is classified to the regular code. The patient also has gestational
diabetes. It is mandatory to assign a code for diabetes mellitus
whenever it is documented. Since diabetes mellitus is one of the
conditions always considered to complicate a pregnancy, as described
above, the diabetes mellitus is classified to a code from Chapter XV.
D Example: A patient at 28 weeks gestation falls down the stairs at home and sustains a right
Colles’ fracture. She is admitted for an open reduction and internal fixation of
the fracture.
Code DAD Code title

S52.500 (M) Colles’ fracture, closed
W10 (9) Fall on and from stairs and steps
Z33 (3) Pregnant state, incidental
Rationale: Non-obstetrical trauma is classified to a code from Chapter XIX, per

the exclusion note at the beginning of Chapter XV. Z33 is assigned,
mandatory, because a code from Chapter XV does not apply.
372
Delivery With History of Cesarean Section


When a delivery occurs during an episode of care and there is documentation of a previous Cesarean
D
section, assign one of the following codes, mandatory:
• O75.701 Vaginal delivery following previous caesarean section, delivered, with or without mention of
• O66.401 Failed trial of labour following previous caesarean, delivered, with or without mention of
• O34.201 Uterine scar due to previous Caesarean section, delivered, with or without mention of
D Ensure that the above codes never appear together on the same abstract, as they are mutually exclusive.
Exception
In cases of multiple gestation, O75.701 and O66.401 may appear together on the same abstract when one
baby is born vaginally and another is born via Cesarean section due to an unexpected complication.
When a patient who is booked for a repeat Cesarean section is admitted early in labor and proceeds
D
immediately to Cesarean section, assign O34.201 Uterine scar due to previous Caesarean section,
delivered, with or without mention of antepartum condition.
373
D Example: The patient had a previous Cesarean section. In this current pregnancy, the fetus
is found to be in breech presentation; therefore, the mother is booked for a repeat
Cesarean section. She presents in early labor prior to the planned date and
proceeds immediately to Cesarean section.
Code DAD Code title
O34.201 (M) Uterine scar due to previous Caesarean section, delivered, with or
O32.101 (1) Maternal care for breech presentation, delivered, with or without
Rationale: Uterine scar and breech presentation are both indications for
the planned repeat Cesarean section; therefore, either qualifies
as the MRDx.
Multiple Gestation
In effect 2008
Whenever there is multiple gestation, even when there are no other problems with the pregnancy or
D
delivery, assign a code from category O30 Multiple gestation, mandatory.
Exception
A code from O30 Multiple gestation is optional for cases classifiable to O00–O08 Pregnancy with
abortive outcome.
374
D Example: Normal spontaneous vaginal delivery of twins at 38 weeks gestation
Code DAD Code title
O30.001 (M) Twin pregnancy, delivered, with or without mention of

Rationale: Multiple gestation is always considered to be high risk or to have the

potential to complicate pregnancy or delivery. These cases are not
considered normal deliveries.
D Example: A 19-year-old primigravida with known twin pregnancy is admitted for a planned
Cesarean section due to frank breech presentation of one twin.
Code DAD Code title

O32.501 (M) Maternal care for multiple gestation with malpresentation of one fetus
or more, delivered with or without mention of antepartum condition
O30.001 (1) Twin pregnancy, delivered, with or without mention of

Rationale: Even in cases where a complication specific to multiple gestation has

been coded, an additional code from category O30 is assigned.
375
Maternal Care Related to the Fetus, Amniotic

Cavity and Possible Delivery Problems

Select a code from the range O32–O34 when
D
• The condition is noted prior to the onset of labor and a planned Cesarean section is performed;
• Interventions to correct a potentially obstructing factor (rotation, version) are performed prior to the
onset of labor; or
• A malpresentation or malposition delivers via a spontaneous vaginal delivery (e.g., without any fetal
manipulation or instrumentation) even if the malpresentation or malposition is not noted until after the
onset of labor.
D When labor has begun, but medical intervention is required due to malpresentation/malposition,
disproportion or abnormality of maternal pelvic organs, assign a code from the range O64–O66 to
classify as obstructed labor.
See also the coding standards Delivery in a Normal Case and Obstructed Labor.
D Example: A 26-year-old primigravida with known twin pregnancy is admitted for Cesarean
section due to breech presentation of one twin. She undergoes a lower-segment
Cesarean section with successful delivery of twin boys.
Code DAD Code title

O32.501 (M) Maternal care for multiple gestation with malpresentation of one fetus or
O30.001 (1) Twin pregnancy, delivered with or without mention of

Rationale: This mother was admitted for a planned Cesarean section and did not
go into labor; hence code selection is from O32–O34 and not from
O64–O66.
376
D Example: A 26-year-old primigravida with known twin pregnancy is admitted in early labor.
She progresses well until almost fully dilated, when it becomes apparent that twin
A is in breech presentation. She undergoes a lower-segment Cesarean section with
successful delivery of twin boys.
Code DAD Code title
O64.101 (M) Obstructed labour due to breech presentation, delivered with or

O30.001 (1) Twin pregnancy, delivered with or without mention of

D Example: A 27-year-old multigravida is admitted for Cesarean section due to past history of
two previous sections. A single live male is delivered.
Code DAD Code title
O34.201 (M) Uterine scar due to previous Caesarean section, delivered, with or
D Example: A 27-year-old G2P1 is admitted in active labor at 6 cm dilation. This patient has a
history of a previous Cesarean section but wishes for a trial of labor in hopes of
delivering vaginally. After several hours of labor, persistent OP is diagnosed and a
Cesarean section is carried out.
Code DAD Code title
O64.001 (M) Obstructed labour due to incomplete rotation of fetal head, delivered,
O66.401 (1) Failed trial of labour following previous caesarean, delivered, with or
377
D Example: A 27-year-old multigravida is admitted in active labor at 6 cm dilation. This patient

has a history of a previous Cesarean section but wishes for a trial of labor. After two
more hours of labor, she successfully delivers a female fetus vaginally.
Code DAD Code title
O75.701 (M) Vaginal delivery following previous caesarean section, delivered,

D Example: The patient presents to hospital in early labor. Fetal position is noted to be right OP.
At full dilation, the position is noted to be direct OP. The mother is placed in stirrups
in lithotomy position and encouraged to push. Spontaneous vaginal delivery occurs
from a direct OP position.
Final diagnosis: POP, prolonged 1st and 2nd stage of labor
Code DAD Code title
O32.801 (M) Maternal care for other malpresentation of fetus, delivered, with or
O63.001 (1) Prolonged first stage (of labour), delivered, with or without mention of
O63.101 (1) Prolonged second stage (of labour), delivered, with or without
Rationale: It is possible for a spontaneous vaginal delivery to occur from a direct

OP position; however, this is not considered a normal delivery. There
is no fetal manipulation or instrumentation to indicate obstruction;
therefore, the correct code is O32.801.
378
Prolonged Pregnancy/Post-Dates Pregnancy

In effect 2012
For clinical information, see also Length of gestation in Appendix A.
D When pregnancy has reached 42 completed weeks (42 + 0), assign a code from category O48
Prolonged pregnancy.
D Example: The patient delivers a healthy newborn. The gestational age on the delivery record
is recorded as 42 completed weeks.
Code DAD Code title
O48.001 (M) Prolonged pregnancy, delivered, with or without mention of

Rationale: A documented gestation of 42 completed weeks is indicative of

“prolonged pregnancy”; therefore, O48.001 is assigned.
D When pregnancy has reached 41 completed weeks (41 + 0) and “post-dates” or “post-term” is
documented as the indication for induction of labor, assign a code from category O48
Prolonged pregnancy.
Note
According to the definition, when the pregnancy has not reached 41 completed weeks, it is not post-term or
post-dates; therefore, when the diagnosis is stated as “post-dates” or “post-term” and the gestation has not
reached 41 completed weeks, the chart should be returned to the physician for verification of the diagnosis.
When this is not possible, classify the case as documented.
379
D Example: The patient is admitted for induction of labor. The delivery record documents the
gestational age as 41 + 2, and the reason for induction is documented as “post-dates.”
Code DAD Code title

Rationale: The gestation is more than 41 completed weeks and is documented as

the reason for induction; therefore, O48.001 is assigned.
D Example: The patient is admitted at 41 + 2 weeks gestation and spontaneously delivers a

healthy newborn with no complications.
Code DAD Code title
Rationale: Although the gestation was more than 41 completed weeks, it was not
an indication for an intervention.
D Example: The patient is admitted for induction of labor. The delivery record documents the
gestational age as 40 + 2, and the reason for induction is documented as “post-dates.”
Code DAD Code title

Rationale: This case should be referred to the physician for clarification of the
diagnosis. When this is not possible, classify the case as documented.
380
Premature Rupture of Membranes

Assign a code from category O42 Premature rupture of membranes when there is spontaneous rupture
D
of the amniotic sac more than one hour prior to the onset of labor. Select codes within the category O42
according to the length of time between rupture of the membranes and the onset of labor with a second axis
of term or preterm gestational age at the time of rupture.
Note
To determine the onset of labor, use the time that is documented on the delivery record.
See also the coding standard Interventions Associated With Delivery.
D Example: The patient presents to hospital at 35 weeks gestation with spontaneous rupture
of membranes. She is not having any contractions or tightenings. Labor begins
six hours after her premature rupture of membranes. She delivers a healthy baby
boy two hours after her labor begins.
Code DAD Code title
O42.011 (M) Premature rupture of membranes, onset of labour within 24 hours,

preterm, delivered, with or without mention of antepartum condition
O60.101 (1) Preterm spontaneous labour with preterm delivery, with or without

381
When delivery occurs more than 24 hours after premature rupture of membranes, assign as an additional
D
code O75.601 Delayed delivery after spontaneous or unspecified rupture of membranes, delivered with or
without mention of antepartum condition.
D Example: A 24-year-old primigravida at 39 weeks gestation is admitted at 02:00 with

documented rupture of membranes at 19:00 on the night before admission. She is
observed for several hours as, due to the shortage of available staff, induction
cannot be started until 18:00. Time of onset of labor is documented as 19:30, and a
healthy male infant is delivered at 22:00. Membranes were ruptured for a total of
24.5 hours prior to the onset of labor.
Code DAD Code title

O42.121 (M) Premature rupture of membranes, onset of labour after 24 hours, full
term, delivered with or without mention of antepartum condition
O75.601 (1) Delayed delivery after spontaneous or unspecified rupture

of membranes, delivered with or without mention of

Preterm Labor
When labor occurs before 37 completed weeks of pregnancy, assign a code from category O60
D
Preterm labour and delivery. Labor can be spontaneous or induced and can be followed by vaginal
or surgical delivery.
See also the coding standards Pregnancy With Abortive Outcome and Premature Rupture
of Membranes.
382
D Example: The patient presents in spontaneous labor. She delivers a healthy baby girl at
36 weeks gestation.
Code DAD Code title
O60.101 (M) Preterm spontaneous labour with preterm delivery, with or without
Long Labor

Assign a code from category O63 Prolonged labour when the length of time of a given stage of labor
D
meets the following criteria:
O63.0– Prolonged first stage

• More than 18 hours for primipara
• More than 12 hours for multipara
O63.1– Prolonged second stage

• More than 2 hours for primipara
• More than 3 hours for primipara who has received an epidural anesthetic
• More than 1 hour for multipara
• More than 2 hours for multipara who has received an epidural anesthetic
O63.2– Delayed delivery of second twin, triplet, etc.

• Time lapse of more than 15 minutes between births
383
Note
To calculate the duration of labor, use the times as recorded on the delivery record.
D Example: A primipara patient presents to hospital in labor. After 20 hours of labor, her
obstetrician recommends proceeding to Cesarean section because her cervix
remains at 6 cm dilation. She delivers a healthy baby girl by Cesarean section.
Code DAD Code title
O63.001 (M) Prolonged first stage (of labour), delivered, with or without mention of
O62.101 (1) Secondary uterine inertia, delivered, with or without mention of

Rationale: There was arrest of the active phase of labor (i.e., dilation reached 6 cm
and then stopped); therefore, this is classified to secondary uterine
inertia. Both conditions are present; therefore, both codes are assigned.
Sequencing does not matter in this case; either one can be MRDx.
D Example: A multipara patient presents to hospital in active labor, and an epidural anesthetic
is administered. Upon examination, her cervix is 10 cm dilated and 100% effaced.
She pushes for two hours and five minutes. Her obstetrician applies a vacuum.
A healthy baby girl is delivered vaginally, assisted by low vacuum traction.
Code DAD Code title
O63.101 (M) Prolonged second stage (of labour), delivered, with or without
Rationale: Once the patient is 10 cm dilated, she is in the second stage.
384
D Example: A primipara patient presents in labor at 38 weeks with a twin gestation. Following one
hour of pushing, she successfully delivers a healthy baby boy (twin A). She continues
to push and, 18 minutes later, her obstetrician applies a vacuum to facilitate the
delivery of a healthy baby girl (twin B).
Code DAD Code title

O63.201 (M) Delayed delivery of second twin, triplet, etc., delivered, with or without
O30.001 (1) Twin pregnancy, delivered, with or without mention of antepartum condition
Z37.200 (3) Twins, both liveborn, pregnancy resulting from both spontaneous ovulation
and conception
Precipitate Labor
Assign O62.3– Precipitate labour when the total duration of labor is less than or equal to three hours or
D
the physician documents rapid delivery or rapid second stage.
Note
To calculate the duration of labor, use the times as recorded on the delivery record.
D Example: This 26-year-old female, gravida 4, is admitted at 41 + 2 weeks gestation for

induction of labor due to post-dates. Induction with IV Syntocinon is started at 13:15
on the day of admission. Labor starts at 14:00, and she is fully dilated at 15:32.
She begins pushing at 15:39 and delivers a live male infant at 16:13.
Code DAD Code title

O62.301 (1) Precipitate labour, delivered, with or without mention of antepartum condition
Z37.000 (3) Single live birth, pregnancy resulting from both spontaneous ovulation
and conception
385
Obstructed Labor

Classify labor as obstructed when abnormalities occur that prevent a spontaneous vaginal delivery.
D
• Ensure there is documentation that the patient is in labor before assigning a code from the
range O64–O66.
• Code obstructed labor when the physician states that labor was obstructed or when the
alphabetical index leads to an obstructed labor code (e.g., shoulder dystocia, persistent
occipitotransverse position).
• Look for documentation of obstructed labor when an unplanned Cesarean section is performed for
maternal indications.
Note
Failure to progress NOS is not necessarily an indication that labor is obstructed. It is an inclusion term at
O62.2– Abnormalities of forces of labour, other uterine inertia.
See also the coding standards Maternal Care Related to the Fetus, Amniotic Cavity and
Possible Delivery Problems and Delivery in a Normal Case.
D Example: Pregnancy at term delivered with obstructed labor due to transverse lie
Code DAD Code title
O64.801 (M) Obstructed labour due to other malposition and malpresentation,

386
D Example: A female infant is delivered vaginally with significant shoulder dystocia lasting for
one minute. Apgars are 7 and 9.
Code DAD Code title
O66.001 (M) Obstructed labour due to shoulder dystocia, delivered, with or without
Rationale: The alphabetical index for shoulder dystocia leads to an obstructed

labor code; therefore, O66.001 is assigned.
D Example: Pregnancy at term delivered with obstructed labor due to breech presentation.
An unplanned Cesarean section is performed.
Code DAD Code title

D Example: The patient is booked for Cesarean section due to breech presentation. She
presents in spontaneous labor prior to the booked date and proceeds immediately
to Cesarean section.
Code DAD Code title
Rationale: Cesarean section was planned prior to the onset of labor; therefore,
maternal care for known or suspected breech presentation is selected.
387
D Example: The patient is admitted for induction of labor due to post-dates. She is induced with
IV oxytocin and labor begins. Shortly after labor begins, it is discovered that the fetus
is in breech presentation. The physician gives the mother the option of proceeding
with labor or having a Cesarean section. The mother opts for Cesarean section.
Code DAD Code title

O48.001 (1) Prolonged pregnancy, delivered, with or without mention of

Rationale: Breech presentation was not known prior to the onset of labor, and the
Cesarean section was unplanned; therefore, obstructed labor due to
breech presentation is selected.
D When maternal care is administered for a potentially obstructing factor prior to commencement of labor,
assign a code from the range O31–O34.
D Example: A patient is known to have a breech presentation (diagnosed on ultrasound). She is

admitted for Cesarean section (planned). She never goes into labor.
Code DAD Code title

Note
An obstructed labor may sometimes end in a vaginal delivery.
388

When an obstructing factor is resolved by version and/or rotation at the time of delivery
D
or by certain other maneuvers (e.g., Rubin, Wood’s) and the result is a vaginal delivery, assign a code
• From the range O64–O66; and
• For the intervention leading to the resolution of the obstruction.
Note
Maternal positioning classified to rubric 5.MD.16.^^ Maternal positions for delivery (assistance) (e.g.,
McRoberts) may alleviate some obstructions; however, it is not mandatory to assign a code for these
interventions. See also the coding standard Selection of Interventions to Code for Acute Inpatient Care.
D Example: The patient is admitted in active labor at 37 weeks gestation. Labor is obstructed
due to breech presentation. The physician successfully performs an external
cephalic version, and the infant is born vaginally in cephalic presentation.
Code DAD Code title

O64.101 (M) Obstructed labour due to breech presentation, delivered, with
5.LD.40.JA Version during labour, by external cephalic version
389
D Example: Shoulder dystocia is noted during delivery. McRoberts with suprapubic pressure
is performed followed by corkscrew maneuver (internal rotation of shoulder),
which results in delivery of the posterior arm. The rest of the body follows.
Code DAD Code title
O66.001 (M) Obstructed labour due to shoulder dystocia, delivered, with or without
5.MD.40.LH Version and/or rotation at time of delivery, corkscrew maneuver
Rationale: O66.001 is assigned because the alphabetical index for shoulder dystocia
leads to an obstructed labor code. 5.MD.40.LH is assigned for the
corkscrew maneuver, as it is mandatory per the direction in the coding
standard Selection of Interventions to Code for Acute Inpatient Care.
Although McRoberts (with suprapubic pressure) is also performed to
resolve the obstruction, McRoberts (with or without suprapubic pressure)
is classified to 5.MD.16.LL and is optional to assign.
Labor and Delivery Complicated by Fetal Stress

The codes in category O68 Labour and delivery complicated by fetal stress [distress] identify
the presence of possible indicators that the fetus may be in danger of developing asphyxia or acidemia.
Delivery interventions may be based on the presence of these indicators. Fortunately, despite the
pre-delivery concerns, the delivery most often results in a completely normal infant. Codes in the range
O68.0– to O68.2– may be assigned on the mother’s abstract even when the fetus is delivered with
no substantial evidence of asphyxia or acidemia. O68.3– Labour and delivery complicated by evidence
of fetal asphyxia, however, cannot be assigned without lab evidence that the condition is present.
When a diagnosis of fetal acidemia or fetal asphyxia has been substantiated by a documented abnormal
D
acid–base balance (pH value for fetal acidemia as shown at category P20.– Fetal acidaemia),
assign O68.3– Labour and delivery complicated by evidence of fetal asphyxia.
390
Note
When signs of fetal asphyxia are present prior to commencement of labor, assign a code from O36.3–
Maternal care for signs of fetal asphyxia.
See also the coding standard Fetal Acidemia.
D Example: The patient is admitted in active labor at 37 weeks gestation. During labor, a
non-reassuring fetal heart rate is identified. Fetal scalp sampling indicates an
arterial pH of 6.7. The obstetrician recommends an emergency Cesarean
section for fetal distress.
Code DAD Code title
O68.301 (M) Labour and delivery complicated by evidence of fetal asphyxia,

Postpartum Hemorrhage
“Postpartum hemorrhage describes an event rather than a diagnosis, and when encountered,
its etiology must be determined.” 1 Classification of postpartum hemorrhage (PPH) in ICD-10-CA
is based on its etiology (cause). Blood loss that is the result of uterine atony or retained
products during or following delivery is classified to category O72 Postpartum haemorrhage.
Blood loss occurring in the postpartum period due to causes other than the aforementioned,
such as injury (e.g., tear of the uterine artery during Cesarean section, sulcus tear during
vaginal delivery), is not classified to category O72 Postpartum haemorrhage.
Preventive measures (to avoid excessive postpartum blood loss) are part of the routine
management of the third stage of labor and are not an indication that postpartum hemorrhage
has occurred. These measures include administration of oxytocin and/or uterine massage to
assist with contraction of the uterus.
391
Treatment measures (to control excessive blood loss) are an indication that postpartum
hemorrhage has occurred. These measures include speculum examination, removal of clots,
introduction of intrauterine Foley catheter, manual revision of uterus and administration
of Hemabate.
When treatment measures are performed and there is no diagnosis of postpartum hemorrhage,
the chart should be referred back to the physician for documentation.

Assign a code from category O72 Postpartum haemorrhage when at least one of the following criteria
D
is met:
• Blood loss is excessive:
− Vaginal delivery with >500 cc/ml blood loss during third stage of labor, in immediate postpartum
period or after 24 hours following delivery.
− Cesarean delivery with >1,000 cc/ml blood loss.
• Documentation indicates uterine atony following delivery, regardless of the amount of blood
loss recorded.
• Physician documents postpartum hemorrhage, regardless of measures taken and/or the amount of
blood loss recorded.
Selection of the code from category O72 Postpartum haemorrhage is based on etiology and
time frame.
Etiology Time frame Code
Retained, trapped or adherent During the third stage of labor O72.0– Third-stage haemorrhage
placenta with excessive bleeding
Any time other than during the O72.2– Delayed and secondary
third stage of labor (regardless of postpartum haemorrhage
time frame)
Uterine atony or unknown/not During the first 24 hours following O72.1– Other immediate
documented (i.e., PPH NOS), the delivery postpartum haemorrhage
regardless of the amount of
blood loss recorded Between 24 hours and 6 weeks O72.2– Delayed and secondary
following delivery postpartum haemorrhage
392
Note
Retained, trapped or adherent placenta without excessive bleeding or physician documentation of
hemorrhage that occurs anytime during or after the third stage of labor is classified to O73.– Retained
placenta and membranes, without haemorrhage.
Note
Hemorrhage or excessive blood loss during the delivery process or immediately following the delivery
that is secondary to an injury, including perineal lacerations, is classified as intrapartum hemorrhage,
since the injury occurred prior to or during the delivery of the infant. It is classified to O67.8– Other
intrapartum haemorrhage.
D Example: The patient starts to hemorrhage during the third stage of labor due to retained
placenta. She is taken to the operating room, where a manual removal of retained
placenta is performed under general anesthetic.
Code Code title
O72.002 Third-stage haemorrhage, delivered, with mention of postpartum complication
Rationale: A postpartum hemorrhage documented as due to retained placenta

occurred during the third stage of labor; therefore, O72.002 is assigned.
D Example: The patient delivers a healthy male baby by Cesarean section. The obstetrician
documents that there is brisk bleeding and that the uterus appears atonic. Bimanual
compression is performed and the patient is given 40 units of Syntocinon in 1 liter of
Ringer lactate × 2 as well as an intramuscular dose of Hemabate. The estimated
blood loss is recorded as 900 cc.
Code Code title
O72.102 Other immediate postpartum haemorrhage, delivered, with mention of

Rationale: Uterine atony is documented; therefore, O72.102 is assigned regardless

of the amount of blood loss.
393
D Example: Approximately four hours following vaginal delivery, the patient starts to bleed very
actively from her vagina. She is taken to the operating room for manual exploration
of the uterus. Portions of placental and decidual tissue are found and removed.
The estimated blood loss recorded is 600 cc.
Code Code title
O72.202 Delayed and secondary postpartum haemorrhage, delivered, with mention of

Rationale: Excessive bleeding due to retained portions of placenta not

occurring during the third stage of labor is classified to delayed
and secondary hemorrhage.
D Example: The patient delivered a healthy baby boy two weeks ago. She presents to hospital
today with vaginal bleeding. She is taken to the operating room, where a D & C is
performed. Retained products of conception are removed.
Code DAD Code title

O73.104 (M) Retained portions of placenta and membranes, without
haemorrhage, postpartum condition or complication
Rationale: Retained products of conception without excessive bleeding or

physician documentation of hemorrhage is classified to O73.1–
Retained portions of placenta and membranes, without haemorrhage.
D Example: The patient delivers a healthy baby by vaginal delivery. The obstetrician documents
estimated blood loss to be “approximately 500 cc.” There are no complications
during the delivery.
Code DAD Code title
Rationale: Blood loss is not greater than 500 cc; therefore, this is not a postpartum
hemorrhage. A code from O72 Postpartum haemorrhage is not assigned.
394
D Example: The patient delivers a female infant via forceps secondary to arrest in the second
stage of labor. During the delivery, a right mediolateral episiotomy is performed.
The physician documents that the delivery was complicated by significant second-
degree vaginal lacerations. The subsequent repair was complicated. Estimated blood
loss was 1,000 cc, which in large part was due to the complicated vaginal lacerations.
Code DAD Code title
O70.101 (1) Second degree perineal laceration during delivery, delivered, with or
O67.801 (1) Other intrapartum haemorrhage, delivered, with or without mention of

Rationale: The amount of blood loss is documented as 1,000 cc, which justifies
classifying this blood loss as a hemorrhage. The physician has
documented the blood loss as due to the injury (second-degree
vaginal lacerations); therefore, a code from category O72 Postpartum
haemorrhage is not assigned. The hemorrhage is classified to O67.801
based on the following alphabetical index lookup: “hemorrhage,
complicating delivery, due to, trauma.”
Complications of Anesthesia During Labor

and Delivery
Assign a code to classify complications arising from the administration of a general or local anesthetic,
D
analgesic or other sedation during pregnancy or the puerperium on the basis of the stage of the
pregnancy at the time of the administration of the agent.
D Example: The patient receives an epidural anesthetic during labor and delivery. Within 24 hours,
she complains of a headache. A diagnosis of post-epidural headache is made.
Code Code title
O74.502 Spinal and epidural anesthesia-induced headache during labour and delivery,
delivered, with mention of postpartum complication
395

Assign an intervention code from the range 5.MD.50.^^ to 5.MD.60.^^, inclusive, for every delivery,
D
including each delivery in a multiple gestation.
Exception
When the deliveries in a multiple gestation result in assignment of the same CCI code, assign the code
only once.
D Example: The patient spontaneously delivers a healthy female baby at 04:15. The physician
has not yet arrived; however, nursing staff are in attendance.
Code DAD Code title
Example: A 24-year-old mother delivers this tiny, preterm fetus in her bed without any health
care personnel present.
5.MD.51.ZZ Unassisted spontaneous vaginal delivery, using

approach/technique NOS
Example: Twin gestation at 36 weeks delivered by planned repeat lower-segment

Cesarean section
5.MD.60.AA Cesarean section delivery, lower segment transverse

incision, without instrumentation
Status: RA
396
Example: A woman with a twin gestation is admitted fully dilated. The first twin is in vertex
presentation and is successfully delivered with low forceps over a mediolateral
episiotomy. The second twin is in breech presentation and requires a partial
breech extraction.
5.MD.53.KL Forceps traction and rotation delivery, low forceps

(e.g. Pajot maneuver), with episiotomy
(including midline or mediolateral)
5.MD.56.PA Breech delivery, partial breech extraction [assisted
breech delivery], with spontaneous delivery of head,
with episiotomy
Rationale: The episiotomy is done only once. However, as it was done prior to
the delivery of the first twin, both intervention codes selected should be
with episiotomy. This allows for retrieval of all deliveries done with an
episiotomy regardless of whether or not they were multiple births.
Induction and augmentation of labor

When cervical ripening is performed by balloon catheter or insertion of Laminaria, assign, mandatory,
D
• 5.AC.24.CK-BD Preparation by dilating cervix (for), labour, using per orifice (ripening) by balloon
catheter; and/or
• 5.AC.24.CK-W6 Preparation by dilating cervix (for), labour, using per orifice insertion of laminaria.
When active labor does not begin spontaneously and requires initiation by artificial methods, assign a code,
D
mandatory, from the rubric 5.AC.30.^^ Induction of labour. Code all methods that apply, including those
that were initiated or performed prior to admission.
When an intervention is required to ensure that labor continues to progress, whether active labor began
D
spontaneously or was induced, assign a code, mandatory, from the rubric 5.LD.31.^^ Augmentation of
labour. Code all methods that apply.
Exception
When an intravenous (IV) oxytocic agent is used to induce labor, any subsequent administration of an IV
oxytocic agent is a continuation of the induction and is not considered to be augmentation. This direction
applies regardless of whether the IV oxytocic agent was administered continuously or was stopped and
restarted after labor began.
397
Note
To determine the onset of labor, use the time that is documented on the delivery record. This time is
understood to be the start of active labor; the patient may be experiencing some contractions prior to this
time (latent labor).
Note
Apply the Intervention Pre-Admit Flag to capture that induction of labor (5.AC.30.^^) or cervical ripening by
balloon catheter (5.AC.24.CK-BD) and/or cervical ripening by insertion of Laminaria (5.AC.24.CK-W6) was
performed prior to admission. See Group 11, Field 20 in the DAD Abstracting Manual for specific instructions
for applying the flag for interventions initiated prior to admission.
Example: The patient presents to hospital at 42 weeks gestation with no signs of labor.
The decision is made to induce her by performing an artificial rupture of
membranes. She goes into labor and delivers a healthy baby girl.
5.AC.30.AP Induction of labour, using artificial rupture of membranes
Example: The patient presents for outpatient antepartum assessment at 40 weeks gestation.
Her pregnancy has been complicated by mild pregnancy-induced hypertension,
and the physician opts to proceed with induction of labor at this time. Her cervix is
unfavorable; therefore, Prepidil is inserted into the cervix and the patient is sent
home. She presents to hospital later that day in labor and delivers via spontaneous
vaginal delivery.
5.AC.30.CK-I2 Induction of labour, using per orifice (intra

cervical/vaginal) administration of oxytocic agent
Note: Apply Intervention Pre-Admit Flag.
Rationale: It is mandatory to record induction of labor that is initiated or performed

prior to admission. Using the Intervention Pre-Admit Flag identifies that
the induction was performed prior to admission.
398
Example: The patient is given Prepidil on an outpatient basis to begin labor induction for post-
dates. The patient is told to return when labor begins or in 12 hours if labor has not
begun. The patient does not go into labor; therefore, she is admitted and IV
Syntocinon induction is begun. She goes into labor and delivers a healthy baby boy.
5.AC.30.HA-I2 Induction of labour, using percutaneous injection of

oxytocic agent
5.AC.30.CK-I2 Induction of labour, using per orifice (intra
cervical/vaginal) administration of oxytocic agent
Note: Apply Intervention Pre-Admit Flag.
Rationale: Methods to induce labor are sometimes initiated on an outpatient basis.

It is mandatory to code all methods used for induction, including those
that are initiated or performed prior to admission. In this case one
method is performed prior to admission and one after admission;
each method is coded separately. Using the Intervention Pre-Admit
Flag identifies that one method was performed prior to admission.
Note: This is not a failed induction.
Example: The patient presents to hospital in spontaneous labor on May 13 and delivers a
healthy baby girl. The admission note mentions that the patient had previously been
admitted as an inpatient for oxytocin induction due to proteinuria and edema but
was discharged home following a diagnosis of failed induction of labor.
Note: The pre-admission induction of labor is not captured on the subsequent

admission for delivery.
Rationale: The pre-admission induction of labor was documented as failed;

therefore, this patient’s labor was spontaneous, not induced.
The purpose of capturing pre-admission induction is to assist in
distinguishing induced labor from spontaneous labor. Capturing the
pre-admission induction on the delivery admission would tell the
incorrect story of induced labor for this patient.
399
Example: The patient presents at 37 + 3 weeks gestation for a planned induction of labor
for essential hypertension. IV oxytocin is started at a high dose, per protocol.
She responds well to the oxytocin and it is stopped once active labor is achieved.
She reaches 6 cm dilation and contractions become irregular. Oxytocin is restarted.
Contractions remain irregular. Artificial rupture of membranes (AROM) is
performed. She progresses to 9 cm dilation and with involuntary pushing she
subsequently delivers a healthy male infant.
5.AC.30.HA-I2 Induction of labour, using percutaneous injection of

oxytocic agent
5.LD.31.AP Augmentation of labour, using artificial rupture of membranes
Rationale: Intravenous oxytocin is given to induce labor. It is restarted after labor

ensues due to failure to progress. The oxytocin is a continuation of the
induction and is not considered augmentation. Therefore, only
5.AC.30.HA-I2 is assigned for the oxytocin administered during this
episode of care. 5.LD.31.AP is also assigned for the augmentation
using AROM.
D When an induction of labor procedure is performed and no labor begins, and the patient is either
discharged or has a Cesarean section, assign a code from O61 Failed induction of labour.
When there is a failed induction and the patient proceeds to Cesarean section, sequence the indication
D
for the induction before O61 Failed induction of labour.
Multiple attempts at induction during a single admission that eventually result in labor and
vaginal delivery are not classified as failed induction.
400
D Example: A primigravida patient with preeclampsia is admitted for induction of labor. She is
given prostaglandin gel intravaginally and IV oxytocin. After five hours, no labor has
ensued and, due to increasing concerns of rising blood pressure in the mother, she
is taken to the operating room for a Cesarean section. The patient has no previous
history of hypertension.
Code DAD Code title
O14.901 (M) Pre-eclampsia, unspecified, delivered, with or without mention of

O61.001 (1) Failed medical induction of labour, delivered, with or without mention
of antepartum condition

Status: PB
5.AC.30.CK-I2 Induction of labour, using per orifice (intra cervical/vaginal)

administration of oxytocic agent
Rationale: The Cesarean section is performed because of increasing concerns of

rising blood pressure; therefore, preeclampsia is selected as the MRDx.
The indication for the Cesarean section does not become failed medical
induction of labor.
401
D Example: A primigravida patient with preeclampsia is admitted for induction of labor. She is
given prostaglandin gel intravaginally and IV oxytocin. Labor begins, but after eight
hours she is not fully dilated and her blood pressure is continuing to rise. She is
taken to the operating room for emergency Cesarean section. The patient has no
previous history of hypertension.
Code DAD Code title
O14.901 (M) Pre-eclampsia, unspecified, delivered, with or without mention of


Status: PB
5.AC.30.CK-I2 Induction of labour, using per orifice (intra cervical/vaginal)

administration of oxytocic agent
Rationale: Even though this patient was delivered by Cesarean section, induction did
result in labor; thus this is not considered a failed induction.
Labor that has been induced, either surgically or medically, can at times require further
augmentation — the same as labor that begins naturally. When this is the case, the codes for
induction of labor and augmentation of labor may be used together on the same abstract.
Example: The patient presents to hospital at 42 weeks gestation with no sign of labor.
The decision is made to induce her by performing an artificial rupture of membranes.
At 5 cm dilation, her contractions slow and a Syntocinon drip is started.
5.AC.30.AP Induction of labour, using artificial rupture of membranes

5.LD.31.HA-I2 Augmentation of labour, using injection of oxytocic agent
402
Postpartum interventions
D Assign a code from the block 5.PB.^^ to 5.PD.^^ Postpartum interventions when an intervention unique to
obstetrics is performed from during the third stage of labor until 42 days after delivery.
The third stage of labor includes the time from delivery of the fetus to delivery of the placenta.
The postpartum period includes the time from the third stage of labor to 42 days after delivery.
Repairs of obstetrical lacerations are included in postpartum interventions, as are D & C procedures.
Example: During delivery of a healthy baby boy, the patient sustains a third-degree perineal
laceration. The delivery physician repairs the obstetrical laceration in the labor and
delivery unit before the patient is transferred to the obstetrical nursing unit.
5.PC.80.JQ Surgical repair, postpartum, of current obstetric

laceration of rectum and sphincter ani
Dilation and Curettage

In effect 2001
The D & C intervention is the only intervention in CCI that is found in more than one section and
in more than one rubric within Section 5.
DN Assign the CCI code for dilation and curettage of the uterus based on the gravid status of the uterus.
See also the section Postpartum interventions in the coding standard Interventions Associated
With Delivery.
403
Start
Is patient
currently pregnant – Yes Assign a code from
fetus alive 5.CA.89.^^ Surgical
at initiation of termination of pregnancy
intervention?
No
Is reason for Yes Assign a code from

D&C related to 5.PC.91.^^ Interventions to
delivery or abortion? uterus (following delivery)
No
Assign 1.RM.87.^^
Excision partial, uterus and
surrounding structures
End
Reference
1. Cunningham FG, Leveno KJ, Bloom SL, et al. Chapter 35 — Obstetrical hemorrhage.
In: Williams Obstetrics. 23rd ed. 2010.
404
Chapter XVI — Certain conditions originating in the perinatal period
Chapter XVI — Certain conditions

originating in the perinatal period
For the purposes of ICD-10-CA code assignment, the perinatal period is defined as
commencing at 20 completed weeks of gestation and ending 28 completed days after birth.
Conditions that occur in the perinatal period or are documented as having their origin in the
perinatal period (even though death or morbidity occurs later) are intended to be classified to
Chapter XVI. Codes from this chapter take priority over code assignment from another chapter,
regardless of the patient’s age. However, there are some exceptions, such as the following:
• Certain infectious diseases acquired in utero or during birth are not classified to P35–P39
Infections specific to the perinatal period. These include
- Congenital gonococcal infection (A54.–);
- Congenital syphilis (A50.–);
- Human immunodeficiency virus (HIV) disease (B24); and
- Laboratory evidence of human immunodeficiency virus (HIV) (R75).
• Certain infectious diseases acquired after birth and within the perinatal period are not
classified to P35–P39 Infections specific to the perinatal period. These include
- Infections and parasitic diseases (A00–B99) (e.g., late-onset neonatal sepsis; see also the
coding standard Confirmed Sepsis and Risk of Sepsis in the Neonate); and
- Influenza (J09–J11).
• Certain conditions that may be diagnosed in the perinatal period are classified elsewhere.
These include
- Congenital malformations, deformations and chromosomal abnormalities (Q00–Q99);
- Endocrine, nutritional and metabolic diseases (E00–E90);
- Injury, poisoning and certain other consequences of external causes (S00–T98);
- Neoplasms (C00–D48);
- Tetanus neonatorum (A33); and
- Whooping cough (A37.–).
Note
The above list is not exhaustive. Coders are reminded to read and follow all notes at code, category, block and
chapter headings, where guidance is provided regarding code assignment.
405
Low Birth Weight and/or Preterm Infant

Low birth weight may result from a preterm birth (less than 37 weeks of gestation) or occur in a
term birth. Low birth weight increases the risk of infant death, physical and cognitive disabilities
and chronic health problems later in life.
Similarly, preterm birth, regardless of birth weight, is a major determinant of neonatal mortality and
morbidity and has long-term adverse consequences for health. Children who are born prematurely
have higher rates of cerebral palsy, sensory deficits, learning disabilities and respiratory illnesses
than children who are born at term. The morbidity associated with preterm birth often extends to
later life, resulting in enormous physical, psychological and economic costs. 1
See also Diagnosis type (0) — Newborn in the coding standard Diagnosis Typing Definitions
for DAD.

When birth weight is less than 2500 grams, assign, mandatory, as a significant diagnosis type, either
D
• P07.0 Extremely low birth weight for birth weight 999 grams or less; or
• P07.1 Other low birth weight for birth weight 1000–2499 grams.
D When fetal malnutrition is documented, assign, mandatory, as a significant diagnosis type P05.2 Fetal
malnutrition without mention of light or small for gestational age.
D When intrauterine growth restriction (i.e., light or small for gestational age) is documented, assign,
mandatory, as a significant diagnosis type a code from category P05.9– Slow fetal growth, unspecified.
When the gestational age of the newborn is less than 37 completed weeks, assign, mandatory, as a
D
significant diagnosis type, either
• P07.2 Extreme immaturity; or
• P07.3 Other preterm infants.
Note
This standard does not imply that low birth weight or prematurity must be selected as the MRDx.
When a serious condition other than low birth weight or prematurity qualifies as the MRDx, that condition
is selected as such.
406
Notes
• Use the gestational age recorded on the newborn’s physical exam at birth record as the first source
documentation. When the gestational age by physical assessment is not documented on the physical exam
at birth record or the discharge/delivery summary, default to the gestational age by dates recorded on the
labor and delivery record.
• Assignment of P07.2 Extreme immaturity and P07.3 Other preterm infants must align with the gestational
age data element on the DAD abstract. According to the Discharge Abstract Database (DAD) Abstracting
Manual, the gestational age of the newborn or neonate is based on the physical assessment at the time of
birth, per the Algorithm for the Estimation of Gestational Age, Canadian Perinatal Surveillance System, 2010.
See Group 18, Field 06 in the Discharge Abstract Database (DAD) Abstracting Manual.
• The gestational age recorded on the newborn’s abstract may not match the gestational age on the mother’s
abstract, since the former reflects a physical assessment of the newborn while the latter reflects the weeks
of pregnancy in the mother.
• Ensure P07.2 Extreme immaturity is assigned on a newborn or neonate abstract when the value recorded in
the gestational age data element is less than 28.
• Ensure P07.3 Other preterm infants is assigned on a newborn or neonate abstract when the value recorded
in the gestational age data element is between 28 and 37.
Sequencing low birth weight, fetal malnutrition, poor fetal

growth and/or prematurity
Use the following table to determine the sequence of codes for low birth weight, fetal
malnutrition, poor fetal growth and/or prematurity.
Weight 1000 to
Associated conditions Weight ≤999 grams 2499 grams Weight ≥2500 grams
Term infant ≥37 completed weeks gestation
Fetal malnutrition n/a P07.1 —P05.2

P05.2
Intrauterine growth restriction n/a P07.1 —P05.9–

P05.9–
Nil n/a P07.1 n/a
Preterm infant ≥28 completed weeks but <37 completed weeks gestation
Fetal malnutrition P07.0 P07.1 P05.2

P05.2 P05.2 P07.3
P07.3 P07.3
407
Weight 1000 to
Associated conditions Weight ≤999 grams 2499 grams Weight ≥2500 grams
Intrauterine growth restriction P07.0 P07.1 P05.9–

P05.9– P05.9– P07.3
P07.3 P07.3
Nil P07.0 P07.1 P07.3

P07.3 P07.3
Extremely preterm infant <28 completed weeks gestation
Fetal malnutrition P07.0 P07.1 P05.2

P05.2 P05.2 P07.2
P07.2 P07.2
Intrauterine growth restriction P07.0 P07.1 P05.9–

P05.9– P05.9– P07.2
P07.2 P07.2
Nil P07.0 P07.1 P07.2

P07.2 P07.2
D Example: A baby is born by Cesarean section at 33 weeks gestation with birth weight 1710
grams. The baby requires endotracheal intubation and is transferred to the intensive
care unit. The discharge summary states that the newborn has respiratory failure
secondary to respiratory distress syndrome.
Code DAD Code title

P22.0 (M) Respiratory distress syndrome of newborn (RDS)
P07.1 (1) Other low birth weight
Z38.010 (0) Singleton, born in hospital, delivered by caesarean, product of both

Rationale: Low birth weight is sequenced before a code for prematurity. Since
there is another condition that qualifies as the MRDx, both low birth
weight and prematurity are assigned diagnosis type (1).
408
D Example: An infant is delivered vaginally at 38 weeks gestation with evidence of symmetrical

growth restriction. Birth weight is 2400 grams.
Code DAD Code title
P05.90 (1) Symmetric intrauterine growth restriction [IUGR]

D Example: An infant is delivered by Cesarean section at 28 weeks gestation weighing 950 grams.
Along with the prematurity, there is evidence of fetal growth restriction.
Code DAD Code title
P07.0 (M) Extremely low birth weight
P05.99 (1) Unspecified intrauterine growth restriction [IUGR]

D Example: An infant is delivered by Cesarean section at 28 weeks gestation weighing 1700 grams.
Code DAD Code title


Rationale: Low birth weight is sequenced before a code for prematurity. Since
there is no other condition that qualifies as the MRDx, low birth weight
becomes the MRDx.
409
Mother’s abstract
D Example: An obstetrical patient is admitted in active labor at 37 weeks gestation. She

vaginally delivers a healthy newborn with a weight of 3110 grams. The discharge
summary mentions that the newborn was assessed at physical examination as
being closer to 36 weeks gestational age.
Code DAD Code title
Rationale: The mother’s record reflects a term delivery. Even though there is
documentation of the gestational age of the newborn that reflects
prematurity, do not assign O60.101 Preterm spontaneous labour with
preterm delivery, with or without mention of antepartum condition.
D Example: The discharge summary of the newborn states that the baby was delivered,
weighing 3110 grams, to a primigravida patient at 37 weeks gestation. The
gestational age recorded on the newborn’s physical examination is 36 weeks.
Code DAD Code title

P07.3 (M) Other preterm infants

Rationale: The gestational age is documented as 36 weeks on the newborn’s

physical examination. P07.3 is mandatory to assign as a significant
diagnosis type. Use the gestational age documented on the newborn’s
physical exam at birth as the first source document when determining
code assignment. In some circumstances, the mother’s record will be
coded as a term delivery and the baby’s record will be coded as a
preterm delivery.
410
Fetal Acidemia
An arterial blood pH value of less than or equal to 7.00 and/or a base deficit greater than or
equal to 12 mmol/L is indicative of fetal acidemia.
D When pH and/or base deficit values indicative of fetal acidemia (acidosis) are documented on the chart,
assign a code from P20.– Fetal acidaemia.
When a documented diagnosis of fetal asphyxia is substantiated by the pH and/or base deficit values,
D
assign a code from P20.– Fetal acidaemia.
When neonatal findings indicative of neonatal harm (such as hypoxic ischemic encephalopathy [HIE]
D
and/or organ failure) are documented, give priority to the condition and sequence it before the code
for acidemia.
When a documented diagnosis of fetal asphyxia is not substantiated by the pH and/or base deficit values,
D
assign P96.9 Condition originating in the perinatal period, unspecified.
D Example: Electronic fetal monitoring during active labor shows late decelerations. The infant is
delivered by emergency Cesarean section due to late decelerations during active
labor. Umbilical cord blood gases show arterial pH of 6.5. The diagnosis is
documented as asphyxia.
Code DAD Code title
P20.2 (M) Fetal acidaemia first noted at birth
Z38.010 (0) Singleton, delivered by caesarean, product of both spontaneous

(NOS) ovulation and conception
Rationale: The umbilical cord blood pH met the values for fetal acidemia; therefore,
P20.2 is assigned.
411
D Example: The mom presents in labor and fetal heart rate tracing is initially reassuring. Several
hours into labor, the fetal heart rate becomes non-reassuring with loss of variability
and decelerations. It is therefore decided to perform an emergency Cesarean
section. The infant initially experiences breathing problems requiring resuscitation
by the neonatology team. Apgar scores are 2 and 5 at one and five minutes,
respectively. Arterial cord blood pH is 7.15. Final diagnosis is documented as
perinatal asphyxia and severe metabolic acidosis.
Code DAD Code title

P96.9 (M) Condition originating in the perinatal period, unspecified
Z38.010 (0) Singleton, delivered by caesarean, product of both spontaneous

(NOS) ovulation and conception
Rationale: Fetal asphyxia is not substantiated by an arterial cord blood pH value of

≤7.0; therefore, P96.9 is assigned.
D Example: A male infant is delivered vaginally with an absent heartbeat. Apgar score at
one minute and at five minutes is 0. The fetal heart tracing had been reassuring
throughout the entire course of labor. Extensive resuscitation ensues for 40 minutes,
and the baby is eventually revived. Blood gases performed on umbilical cord blood
reveal a pH of 5.0 and a base excess of -21. Throughout the day, the neurological
status of the child is not reassuring and he begins having seizures. Kidney function
is also non-reassuring. A Foley catheter is placed, and there is only 1 cc of urine
output over the entire course of the day. Final diagnosis is documented as hypoxic
ischemic encephalopathy (HIE), anuria.
Code DAD Code title
P91.6 (M) Hypoxic ischaemic encephalopathy of newborn
P20.2 (1) Fetal acidaemia first noted at birth
P96.0 (1) Congenital renal failure
Z38.000 (0) Singleton, delivered vaginally, product of both spontaneous (NOS)

Rationale: HIE is indicative of neonatal harm and qualifies as the MRDx. HIE is
manifested by convulsions; therefore, the convulsions are not coded
separately. Fetal acidemia is substantiated by umbilical cord blood pH
values; therefore, P20.2 is assigned.
412
Neonatal Jaundice
Classify neonatal jaundice as the MRDx or significant diagnosis type only when there is documented
D
evidence of jaundice and/or elevated bilirubin with associated treatment by phototherapy or
exchange transfusion.
D Example: A term infant is delivered vaginally. The physician documents “jaundice” and
phototherapy is administered.
Code DAD Code title
P59.9 (M) Neonatal jaundice, unspecified

D Example: A preterm infant is delivered at 35 weeks by Cesarean section. Birth weight is 2000
grams. The infant has hyperbilirubinemia that is treated with phototherapy.
Code DAD Code title
P59.0 (1) Neonatal jaundice associated with preterm delivery

413
D Example: A term infant is delivered vaginally. The physician documents mild jaundice.
No other abnormalities are noted. Phototherapy is not administered.
Code DAD Code title

P59.9 (0) Neonatal jaundice, unspecified (optional)
Rationale: Jaundice that is documented but not actively treated (no phototherapy
was administered) may be coded as a type (0) diagnosis only. Coding
jaundice in this instance is optional.
Confirmed Sepsis and Risk of Sepsis in

the Neonate
The neonatal period is the first 28 days of life. Neonatal sepsis is defined as an invasive
bacterial infection occurring in the neonatal period. Neonatal sepsis can be divided into two
groups: early-onset sepsis and late-onset sepsis.
• Early-onset neonatal sepsis (newborn sepsis) arises in a newborn and is acquired in utero or
during birth. Newborn sepsis is clinically apparent within 6 hours of birth in more than 50% of
cases; the majority present within the first 72 hours of life. Newborn sepsis is classified to
P36.– Bacterial sepsis of newborn.
• Late-onset neonatal sepsis presents after 72 hours of age and includes nosocomial-
acquired infections. Late-onset neonatal sepsis is classified to a code from Chapter I —
Certain infectious and parasitic diseases, unless there is documentation to support that
the sepsis was acquired in utero or during birth.
Risk factors for invasive neonatal infection include

• Preterm labor;
• Premature rupture of membranes;
• Signs of maternal infection;
• Multiple birth with delay in delivery of subsequent infant(s);
• Prolonged rupture of membranes;
414
• Maternal carriage of group B streptococcus infection; and

• Previous baby with invasive group B streptococcal disease.
Neonates who have one or more of the above risk factors may require additional resources,
such as observation in a special care nursery and/or prophylactic antibiotic treatment
(generally for two or three days) until sepsis can be definitively ruled out.
Confirmed sepsis

When sepsis has been confirmed in a neonate, assign
D
• A code from category P36.– Bacterial sepsis of newborn when the sepsis arises within the first 72 hours
following birth; or
• A code from Chapter I – Certain infectious and parasitic diseases, when the sepsis arises after the first 72
hours following birth, unless there is physician documentation to indicate that the sepsis was acquired in
utero or during birth.
Assign an additional code, optional, as a diagnosis type (0), from block P00–P04 Fetus and newborn affected
D
by maternal factors and by complications of pregnancy, labour and delivery if the infection is a result of a
maternal condition.
When the diagnosis is documented by the physician as “probable sepsis,” “presumed sepsis” “clinical
D
sepsis” or “culture-negative sepsis” at the time of discharge, code the condition as confirmed sepsis.
Note
When any of the following descriptors for sepsis — “? sepsis,” “questionable sepsis,” “query sepsis,” “possible
sepsis” or “rule out sepsis” — are documented on a neonatal record, return the record to the responsible
physician/primary care provider for clarification prior to code assignment; these statements cannot be coded
as sepsis.
The above stated requirement to return the record to the physician/primary care provider for clarification is
an exception to the coding standard Unconfirmed Diagnosis. In the case of neonatal sepsis, seek clarification
to determine whether the case should be classified as confirmed or probable sepsis versus a case of
observation for a suspected condition.
415
D Example: The mom has prolonged rupture of membranes with chorioamnionitis. The infant is
delivered vaginally at term and admitted to the neonatal intensive care unit (NICU)
for observation. Blood cultures are drawn and antibiotics are started. Blood
cultures come back positive for streptococcus. Diagnosis is documented as
streptococcal septicemia.
Code DAD Code title
P36.1 (M) Sepsis of newborn due to other and unspecified streptococci
P02.7 (0) Fetus and newborn affected by chorioamnionitis

Rationale: The diagnosis of streptococcal septicemia is identified within the first

72 hours following birth. Therefore, it is appropriate to assign P36.1 as
the MRDx.
D Example: A 20-day-old neonate is admitted to hospital with sepsis and acute pyelonephritis
due to E. coli. Intravenous antibiotics are initiated and the patient is admitted to
the NICU.
Code DAD Code title

A41.50 (M) Sepsis due to Escherichia coli [E.coli]
N10 (1) Acute tubulo-interstitial nephritis
B96.2 (3) Escherichia coli [E. coli] as the cause of diseases classified to
other chapters
Rationale: The diagnosis of sepsis in a neonate is identified more than 72 hours

following birth and there is no physician/primary care provider
documentation to indicate the sepsis was acquired in utero or
during birth; therefore, A41.50 is assigned.
416
D Example: The infant is delivered vaginally at 37 weeks. The mom had premature rupture of
membranes for greater than 24 hours prior to the delivery. The baby has a fever and is
therefore admitted to NICU for two days for probable sepsis. He is started on a
course of antibiotics for seven days. The result of a blood culture is negative.
Discharge diagnosis: Probable sepsis
Code DAD Code title
P36.9 (M) Bacterial sepsis of newborn, unspecified
P01.1 (0) Fetus and newborn affected by premature rupture of membranes

Rationale: A prefix “Q” is not applied to the sepsis code in this case, as the
diagnosis of “probable” in neonatal sepsis is an indication that the
diagnosis was made by the physician/primary care provider on the basis
of clinical findings only. A diagnosis of probable sepsis is classified as
confirmed sepsis. Lab results are not used to either confirm or rule out
neonatal sepsis.
Ruled-out sepsis

When neonatal sepsis is suspected but ruled out, classify the case as follows:
D
• When the neonate is observed only and prophylactic antibiotic treatment for sepsis is not initiated,
assign Z03.8 Observation for other suspected diseases and conditions as a significant diagnosis type
(M, 1, 2, W, X or Y).
• When the neonate is given prophylactic antibiotic treatment, assign Z29.2 Other prophylactic
chemotherapy as a significant diagnosis type (M, 1, 2, W, X or Y).
Note
Z03.8 Observation for other suspected diseases and conditions is for use in limited circumstances on records
of otherwise healthy newborns who are at risk for an abnormal condition, such as sepsis, but for whom it is
determined, after examination and observation, that there is no need for further treatment or medical care.
417
D Example: The infant is delivered vaginally at 38 weeks. The mom is noted to be group B
streptococcus positive. The baby is observed in NICU for “possible sepsis,” as
documented by the neonatologist. Blood cultures are negative, and the infant is
discharged with his mom.
Code DAD Code title
Z03.8 (M) Observation for other suspected diseases and conditions

D Example: The infant is delivered vaginally at 37 weeks. The mom had premature rupture of
membranes. The physician documents “observe for sepsis.” Blood is drawn for
culture, and the baby is given prophylactic antibiotics. Blood culture results are
negative, and the infant is discharged with her mom.
Code DAD Code title
Z29.2 (M) Other prophylactic chemotherapy

Rationale: When antibiotics are given, assign Z29.2.
D Example: The infant is delivered vaginally at 39 weeks after prolonged rupture of membranes.
The infant is sent to the normal nursery, antibiotic therapy is not instituted, there is
no documentation of suspected sepsis and the infant is discharged home on day 2.
Code DAD Code title

Rationale: Z03.8 is not assigned based on the presence of risk factors alone.
In this example, no additional resources were utilized to either confirm
or rule out sepsis.
418
Birth Trauma
In effect 2007
The process of birth is a blend of compression, contractions, torques and traction. When fetal
size, presentation or neurologic immaturity complicates this event, such intrapartum forces may
lead to tissue damage, edema, hemorrhage or fracture in the neonate. The use of obstetric
instrumentation may further amplify the effects of such forces or may induce injury on their own. 2
Most birth traumas are self-limiting and have a favorable outcome. Risk factors include
• Large-for-dates infants, especially ones larger than 4500 grams;
• Instrumental delivery, especially with mid-cavity forceps or vacuum;
• Vaginal breech delivery; and
• Abnormal or excessive traction during delivery.

When the following birth injuries occur, assign the appropriate code from block P10–P15 Birth Trauma as
D
the MRDx or a diagnosis type (1):
• Intracranial laceration and hemorrhage
• Cerebral edema
• Cranial and spinal nerve injury
• Peripheral nerve injury
• Cephalhematoma that becomes infected or is severe enough to cause anemia, shock, hemolytic
jaundice requiring phototherapy, meningitis or osteomyelitis
• Subgaleal hematoma (epicranial subaponeurotic hemorrhage)
• Superficial abrasion and laceration that requires sutures or becomes infected
• Fracture, including of the skull, long bones or clavicle
• Dislocation
• Intra-abdominal injury
• Sternomastoid injury
D Assign an additional code, optional, as a diagnosis type (0) from block P00–P04 Fetus and newborn affected
by maternal factors and by complications of pregnancy, labour and delivery to describe the maternal factor
or intervention causing the birth trauma.
419
Note
The following birth injuries are not considered significant comorbidities and, if coded, must be assigned a
diagnosis type (0) unless documentation supports that they have become complicated or require observation
in a special care unit:
• Cephalhematoma NOS — rarely becomes complicated
• Chignon (artificial caput) due to vacuum — is of no consequence and resolves spontaneously within a
few hours
• Caput succedaneum — does not usually become complicated and resolves within the first few days
• Superficial abrasions and lacerations — are usually of no consequence
• Monitoring injuries — have a low incidence of hemorrhage, infection or abscess
• Subcutaneous fat necrosis — is of no consequence and requires no treatment
• Subconjunctival hemorrhage — is of no consequence and requires no treatment
D Example: A term male infant is delivered vaginally. There is significant shoulder dystocia
resulting in fracture of the clavicle during delivery.
Code DAD Code title

P13.4 (M) Fracture of clavicle due to birth injury
P03.1 (0) Fetus and newborn affected by other malpresentation, malposition

and disproportion during labour and delivery

Rationale: Fractures are always considered a significant birth injury; therefore,

fractured clavicle is selected as the MRDx.
D Example: A term infant is delivered by operative vaginal delivery using forceps. On the newborn’s
physical examination report, the physician notes that there is cephalhematoma.
Code DAD Code title

P12.0 (0) Cephalhaematoma due to birth injury
P03.2 (0) Fetus and newborn affected by forceps delivery
Rationale: There is no indication that the cephalhematoma is complicated;

therefore, if captured, it is assigned a diagnosis type (0).
420
Perinatal Stroke
In effect 2018
The purpose of this coding standard is to provide direction on how to classify a diagnosis of
“stroke” in the perinatal period.
For the purposes of ICD-10-CA code assignment, the perinatal period is defined as commencing
at 20 completed weeks of gestation and ending 28 completed days after birth. See the introduction
at the beginning of Chapter XVI — Certain conditions originating in the perinatal period.
The term “perinatal stroke” collectively refers to a nontraumatic stroke that occurred before birth
(fetal or prenatal), during birth or within 28 days after birth. Confirmation of a perinatal stroke
requires a computerized tomography (CT) or magnetic resonance imaging (MRI) scan.
The most common types of perinatal stroke are

1. Neonatal hemorrhagic stroke (NHS);
2. Neonatal arterial ischemic stroke (NAIS); and
3. Neonatal cerebral sinovenous thrombosis (nCSVT) (i.e., ischemic stroke).
From an ICD-10-CA classification perspective, a perinatal stroke equates to a nontraumatic

stroke that originated in the perinatal period and is classified to Chapter XVI — Certain
conditions originating in the perinatal period (P00–P96).
DN
Classify a hemorrhagic stroke originating in the perinatal period to a code from category P52.–
Intracranial nontraumatic haemorrhage of fetus and newborn.
DN Classify an ischemic stroke originating in the perinatal period to P91.0 Neonatal cerebral ischaemia.
Note
A diagnosis of a stroke occurring in childhood (i.e., a stroke that did not originate in the perinatal period)
is classified per the direction in the coding standard Strokes: Hemorrhagic, Ischemic and Unspecified.
421
D Example: A 1-day-old term infant born via normal vaginal delivery shows symptoms of a stroke.
CT scan confirms left basal ganglia hemorrhages. Final diagnosis: Perinatal stroke.
Code DAD Code title
P52.4 (M) Intracerebral (nontraumatic) haemorrhage of fetus and newborn
Rationale: A perinatal stroke is confirmed, and additional specificity from the CT

scan describes the stroke as being due to hemorrhage; therefore, P52.4
is assigned.
D Example: A term infant born by via normal vaginal delivery is having generalized seizures. A
CT scan of the head is performed to assess intracranial status. The CT scan reveals
an infarction in the left temporoparietal lobe. The final diagnosis is recorded by the
physician as “cerebral infarction.”
Code DAD Code title
P91.0 (M) Neonatal cerebral ischaemia
Rationale: The physician’s documentation supports that a cerebral infarction

originated in the perinatal period; therefore, P91.0 is assigned.
References
1. Beck S, Wojdyla D, Say L, et al. The worldwide incidence of preterm birth: A systematic
review of maternal mortality and morbidity. Bulletin of the World Health Organization. 2010
2. Medscape. Birth trauma. 2015.
422
Chapter XVII — Congenital malformations, deformations and chromosomal abnormalities
Chapter XVII — Congenital

malformations, deformations and
chromosomal abnormalities
Congenital Anomaly Syndromes and
Specific Manifestations
In effect 2009
The causes of congenital anomalies are

• Chromosomal abnormalities (such as Down’s syndrome);
• Genetic inheritance (such as cystic fibrosis);
• Environmental (exogenous) factors (such as fetal alcohol syndrome);
• Multiple factors; and
• Unknown causes.
For the purposes of classification in ICD-10-CA, anomalies are generally classified according to
their manifestations on structure, function or body metabolism. However, unless a specific code
is provided elsewhere, separate categories are provided for anomalies where the cause is
specified as chromosomal (Q99) or exogenous (Q86). Codes for congenital anomalies are
found in Chapter XVII — Congenital malformations, deformations and chromosomal
abnormalities (Q00–Q99), categories within Chapter IV — Endocrine, nutritional and metabolic
diseases (E00–E90) and categories within Chapter III — Diseases of the blood and blood-
forming organs and certain disorders involving the immune mechanism (D50–D89). 1
DN
When a patient is diagnosed with multiple congenital anomalies described as a syndrome that cannot be
classified to a more specific code (see flowchart below), assign Q87.8 Other specified congenital
malformation syndromes, not elsewhere classified.
• Assign additional codes from Q00–Q85.9 or other appropriate chapter to provide further specificity,
− Mandatory, when the anomalies meet the criteria for significance; or
− Optional, when the anomalies do not meet the criteria for significance.
423
Primary code selection for ICD-10-CA classification of multiple

congenital anomalies
There are multiple anomalies
Assign code for each

Yes End
anomaly
Anomalies are
Each anomaly
specified No
is specified
as syndrome
Assign Q89.7 to describe
No End
multiple anomalies NOS
Yes
A specific Assign code from

code for syndrome Q00–Q99 or other
is indexed, including Yes appropriate End
alternate or chapter for
synonymous syndrome
terms
No
Anomalies Assign code from

are specified as Yes Q90–Q99 for
chromosomal syndrome
No
Anomalies are Assign code from

specified as due to Yes Q86–Q86.8 for
exogenous cause syndrome
No
Assign code from

Syndrome affects
Yes Q00–Q85.9 for
single body system
syndrome
No
Syndrome
Syndrome affects predominantly
Assign code from
multiple specified involves skeletal
Yes Yes Q87.0–Q87.5
body systems changes classifiable
for syndrome
to Q87.0–Q87.5
No
No
Assign Q89.9 to describe Assign Q87.8 to describe

congenital anomaly syndrome affecting body Assign additional codes
syndrome NOS * See note systems not predominantly from Q00–Q85.9 or other
on next page. skeletal chapters to add specificity
End End
424
Note
Congenital anomaly syndrome NOS will rarely be seen in hospital documentation.
DN Example: The discharge diagnosis is Costello syndrome. The physician describes the patient
as having the typical distinctive features of low-set ears, thick earlobes and lips, and
cutis laxa of the hands and feet. The patient is also known to have a congenital
heart defect.

Q87.8 (M) MP Other specified congenital malformation syndromes,
Q24.9 (3) OP Congenital malformation of heart, unspecified
Q17.4 (3) OP Misplaced ear
Q18.6 (3) OP Macrocheilia
Q17.8 (3) OP Other specified congenital malformations of ear
Q82.8 (3) OP Other specified congenital malformations of skin
Rationale: Research indicates that this syndrome is a genetic disorder affecting

multiple systems. As there is not a more specific code for the syndrome,
it is classified to Q87.8. In this example, additional codes are added
optionally to provide specificity regarding the manifestations.
425
D Example: A newborn is discharged with a final diagnosis of uniparental disomy 16. This baby
has a number of congenital manifestations: ventricular septal defect (VSD),
micrognathia, abnormal elbow, camptodactyly, micropenis, right-sided cryptorchidism
and hypospadias. The baby was born at 34 weeks. He also has intrauterine growth
restriction (IUGR), weighing 1,200 grams on admission. The baby is discharged after
a stay of several weeks.
Code DAD Code title
Q99.8 (M) Other specified chromosome abnormalities
P05.99 (1) Unspecified intrauterine growth restriction [IUGR]
P07.1 (1) Other low birth weight
Q21.0 (0) Ventricular septal defect
K07.09 (0) Anomaly of jaw size, unspecified
Q68.8 (0) Other specified congenital musculoskeletal deformities
Q68.1 (0) Congenital deformity of hand
Q55.60 (0) Hypoplasia of penis
Q53.1 (0) Undescended testicle, unilateral
Q54.9 (0) Hypospadias, unspecified

Rationale: These multiple anomalies are described as due to a chromosomal

anomaly that can be classified to Q99.–. The code Q87.8 is not
assigned in this case.
426
DN Example: The diagnosis is KBG (Hermann-Pallister) syndrome. The physician documents

this as a rare genetic disorder. The child has the typical facial dysmorphism,
macrodontia of the upper central incisors and costovertebral skeletal anomalies.

Q87.0 (M) MP Congenital malformation syndromes predominantly
affecting facial appearance
K00.2 (3) OP Abnormalities of size and form of teeth
Q76.4 (3) OP Other congenital malformations of spine,

not associated with scoliosis
Rationale: References in the literature describe the condition as predominantly

affecting facial appearance; therefore, this condition can be classified to a
more specific code. Other manifestations may be coded separately and
assigned diagnosis type (3)/other problem.

When a patient presents solely for management of a specific manifestation of a congenital anomaly
DN syndrome, assign a code for the manifestation as the MRDx/main problem.
• Assign an additional code, optional, as a diagnosis type (3)/other problem to describe the syndrome.
D Example: A young male patient with Goldenhar syndrome and cleft palate is admitted for a
revision of the cleft palate repair.
Code DAD Code title

Q35.9 (M) Cleft palate, unspecified
Q87.0 (3) Congenital malformation syndromes predominantly affecting

facial appearance
Rationale: In the classification, there is a specific code to identify the Goldenhar

syndrome. However, the cleft palate is the condition described as the
reason for the patient’s stay in hospital and is the MRDx.
Reference
1. Health Canada. Congenital Anomalies in Canada: A Perinatal Health Report, 2002. 2002.
427
Chapter XVIII — Symptoms, signs and

abnormal clinical and laboratory
findings, not elsewhere classified
Systemic Inflammatory Response Syndrome (SIRS)
ICD-10-CA provides a separate category, R65 Systemic inflammatory response syndrome

[SIRS], to classify SIRS.
Underlying causes include infection, trauma (such as burns) and other insult
(e.g., pancreatitis, ischemia).
SIRS of an infectious origin progresses through six stages of severity: infection → SIRS →
sepsis → severe sepsis → multiple organ dysfunction syndrome (MODS) → septic shock.
The term “sepsis” means SIRS due to infectious origin; therefore, SIRS is inherent in the term
“sepsis” and R65.0 Systemic inflammatory response syndrome of infectious origin without organ
failure does not have to be assigned separately.
The term “severe sepsis” describes a patient who has progressed to at least one acute organ
failure as a result of the systemic inflammatory response to infection. In such cases, additional
codes to describe each documented acute organ failure associated with sepsis are assigned
rather than R65.1 Systemic inflammatory response syndrome of infectious origin with organ
failure. However, a patient with “severe sepsis” may progress very quickly to septic shock and
ultimately death; in these cases, sufficient documentation may not be available to assign
separate codes for each acute organ failure. A diagnosis of “severe sepsis” without further
specification is classified to R65.1, and a code to identify the type of sepsis is also assigned.
For clinical information, see also Systemic inflammatory response syndrome in Appendix A.
See also the coding standard Septicemia/Sepsis.
428
Chapter XVIII — Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
DN
When SIRS of an infectious origin is present without organ failure, assign
• A code identifying the type of sepsis; and
• R65.0 Systemic inflammatory response syndrome of infectious origin without organ failure, optional,
as a diagnosis type (3)/other problem.
DN
When the diagnosis is stated as “severe sepsis” and there is no documentation of the specified acute organ
failure, assign
• A code identifying the type of sepsis; and
• R65.1 Systemic inflammatory response syndrome of infectious origin with acute organ failure,
mandatory, as a diagnosis type (1) or (2)/other problem.
DN When septic shock is documented, assign R57.2 Septic shock, mandatory, as an additional code.
Note
When the acute organ failure is specified in a diagnosis of “severe sepsis,” the combination of codes assigned
(a code for sepsis plus a code for the associated acute organ failure) equates to the code R65.1 Systemic
inflammatory response syndrome of infectious origin with acute organ failure.
Notes
• Codes from category R65 Systemic inflammatory response syndrome [SIRS] are never assigned the
MRDx/main problem.
• R65.0 Systemic inflammatory response syndrome of infectious origin without organ failure is allowed only
as a diagnosis type (3)/other problem because SIRS is inherent in a diagnosis of sepsis.
• R65.1 Systemic inflammatory response syndrome of infectious origin with organ failure is assigned either
a diagnosis type (1), (2) or (3)/other problem, depending on the circumstances of the case.
• R65.2 Systemic inflammatory response syndrome of noninfectious origin without organ failure and
R65.3 Systemic inflammatory response syndrome of noninfectious origin with organ failure is assigned
either a diagnosis type (1) or (2)/other problem because SIRS of a noninfectious origin is recognized as
a separate condition in these cases.
• R65.9 Systemic inflammatory response syndrome, unspecified is not expected to appear on an abstract of an
inpatient or ambulatory care case because the underlying cause (infectious origin or non-infectious origin)
should be documented.
429
DN Example: The patient is diagnosed with SIRS due to E. coli and Staphylococcus aureus sepsis.
A41.50 (M) MP Sepsis due to Escherichia coli [E.coli]
A41.0 (1) OP Sepsis due to Staphylococcus aureus
R65.0 (3) OP Systemic inflammatory response syndrome of

infectious origin without organ failure (optional)
Rationale: R65.0 is optional because a diagnosis of sepsis (without organ failure)

includes SIRS.
DN Example: The patient presents to hospital with high fever and hypoxia.
Final diagnosis: Severe sepsis
A41.9 (M) MP Sepsis, unspecified
R65.1 (1) OP Systemic inflammatory response syndrome of

infectious origin with acute organ failure
Rationale: R65.1 is assigned diagnosis type (1) because “severe sepsis” is

documented and there is no documentation of the specific acute organ
failure. Had the individual organ failure been known, individual codes
to identify each specified organ failure would have been assigned as
comorbidities and R65.1 would have been an optional diagnosis type
(3). A41.9 is assigned in this case because the type of sepsis is not
specified in the documentation.
430
D Example: An 85-year-old woman presents to the emergency department with increasing shortness
of breath, productive cough and progressive weakness. She acutely deteriorates in the
emergency department and is emergently admitted to the intensive care unit (ICU) with a
diagnosis of sepsis due to Haemophilus influenzae, pneumonia and respiratory failure. In the
ICU, she is intubated, mechanically ventilated and started on broad-spectrum antibiotics.
Code DAD Code title

A41.3 (M) Sepsis due to Haemophilus influenzae
J14 (1) Pneumonia due to Haemophilus influenzae
J96.09 (1) Acute respiratory failure, type unspecified

Rationale: As the acute organ failure is specified and meets the criteria for
significance, R65.1 is optional.
D Example: A 35-year-old trauma patient is in ICU for several days and develops an E. coli
urinary tract infection that progresses to E. coli septicemia. He continues to
deteriorate with signs of acute renal failure and hepatic failure and goes into septic
shock. Despite aggressive treatment, the patient dies.
Code DAD Code title

A41.50 (2) Sepsis due to Escherichia coli [E.coli]
K72.9 (2) Hepatic failure, unspecified
R57.2 (2) Septic shock
B96.2 (3) Escherichia coli [E. coli] as the cause of diseases classified to
other chapters

Rationale: As the acute organ failure is specified and meets the criteria for
significance, R65.1 is optional. Septic shock indicates the last stage of
severity in the continuum of sepsis and is classified to R57.2. See also
the coding standard Septicemia/Sepsis.
431
Whereas a diagnosis of sepsis (without organ failure) includes SIRS, the diagnosis of SIRS
of a noninfectious origin identifies a separate condition in the patient. Therefore, SIRS of
a noninfectious origin always requires two codes: one for the cause and one for the
systemic response.
DN
When SIRS of a noninfectious origin is present without organ failure, assign
• A code identifying the cause (such as trauma, burn or pancreatitis); and
• R65.2 Systemic inflammatory response syndrome of noninfectious origin without organ failure,
mandatory, as diagnosis type (1) or (2)/other problem.
DN When SIRS of a noninfectious origin is present with associated acute organ failure, assign
• A code identifying the cause (such as trauma, burn or pancreatitis); and
• R65.3 Systemic inflammatory response syndrome of noninfectious origin with acute organ failure,
mandatory, as diagnosis type (1) or (2)/other problem.
DN Assign additional codes identifying the specific acute organ failure(s) according to diagnosis typing or
main/other problem definitions.
D Example: A 45-year-old woman is admitted to internal medicine with acute pancreatitis.

She is transferred to the ICU four days later with signs of systemic reaction.
The ICU physician documents SIRS; however, timely treatment prevents the
patient from progressing to associated acute organ failure.
Code DAD Code title
K85.9 (M) Acute pancreatitis, unspecified
R65.2 (2) Systemic inflammatory response syndrome of noninfectious origin

without organ failure
Rationale: R65.2 is assigned diagnosis type (2) because SIRS of a noninfectious

origin in this example meets the definition of a post-admit comorbidity.
432
D Example: A 52-year-old man is admitted to the burn ICU; his trunk was severely burned when
his house burned down. He has 25% body surface area involved in the burn, with
15% of the body surface area having third-degree burns. The patient was sleeping in
the basement at the time of the fire. A week after admission, the patient shows signs of
SIRS with acute renal failure. The patient is started on dialysis.
Code DAD Code title
T21.3 (M) Burn of third degree of trunk
T31.22 (1) Burns involving 20–29% of body surface with 10–19% third
degree burns
X00 (9) Exposure to uncontrolled fire in building or structure
R65.3 (2) Systemic inflammatory response syndrome of noninfectious origin

with acute organ failure
Rationale: R65.3 is assigned diagnosis type (2) because SIRS of a noninfectious

origin in this example meets the definition of a post-admit comorbidity.

In effect 2009
“Vital signs absent (VSA)” denotes that an individual is demonstrating no evidence of life, that is,
he or she has no respirations, no pulse and no blood pressure, and the pupils are fixed and
dilated (on neurological assessment). VSA is not a diagnosis per se, and cardiac arrest is not
assumed to be the diagnosis. Do not confuse a statement of VSA with cardiac arrest.
DN When vital signs absent (VSA) is the only documentation provided by the physician, without an underlying
cause, assign R99 Other ill-defined and unspecified causes of mortality.
DN Assign, mandatory, codes to identify cardiac resuscitative intervention(s) undertaken.
433
Cardiac resuscitative interventions include

• Codes from rubric 1.HZ.30.^^ Resuscitation, heart NEC; and
• Codes from rubric 1.HZ.09.^^ Stimulation, heart NEC.
Notes
• On an inpatient chart, it is not expected that VSA would be documented without an underlying cause;
therefore, it is not expected that the code R99 Other ill-defined and unspecified causes of mortality would
be assigned on a DAD abstract.
• Cardiac arrest must be clearly documented as such before assigning a code from I46.0 Cardiac arrest
with successful resuscitation or I46.9 Cardiac arrest, unspecified. A diagnosis of cardiac arrest cannot be
assumed on the basis of administration of cardiocerebral resuscitation (CCR)/cardiopulmonary
resuscitation (CPR) alone.
• CCR is chest compressions only, without artificial respiration.
See also the coding standard Cardiac Arrest.
N Example: A 45-year-old obese woman has a non-witnessed collapse. Upon arrival at the
scene, paramedics take over doing CPR, which was initiated by a bystander;
CPR is continued by emergency staff on arrival at the hospital. The doctor
assesses the patient after 10 minutes of CPR and documents the patient as VSA.

1.GZ.31.CB-EP Ventilation, respiratory system NEC, non-invasive approach,
Extent: 0
Rationale: The physician documented that this patient was VSA. No underlying
cause was documented.
434
N Example: A previously healthy 45-year-old man is driving to work when, witnesses report,
his car swerves suddenly for no apparent reason and veers off the highway.
Paramedics arrive at the scene and begin CPR. Upon arrival at the emergency
department, the patient is diagnosed as VSA. The patient sustained no visible
injuries as a result of the motor vehicle crash.


1.GZ.31.CB-EP Ventilation, respiratory system NEC, non-invasive approach,

Extent: 0
Rationale: The physician documented that this patient was VSA. No underlying
cause was documented.
N Example: This 16-year-old boy is the front seat passenger in a car involved in a non-collision motor
vehicle crash. The driver is pronounced expired at the scene. The patient is VSA, but
paramedics begin CCR at the scene. CCR is discontinued upon arrival at the emergency
department. The physician documents that the patient is VSA. The following obvious
injuries are documented: open fracture of base of skull, flail chest and open fracture of the
shaft of the right femur. The coroner is notified. The patient will have a complete autopsy.

S02.101 MP Fracture of base of skull, open
S22.500 OP Flail chest, closed
S72.301 OP Fracture of shaft of femur, open
V48.6 OP Car occupant injured in noncollision transport accident, passenger,

traffic accident

Rationale: The physician documented that this patient was VSA. The patient
suffered major trauma as a result of a motor vehicle crash. Codes are
assigned for the documented injuries. No code is assigned for VSA.
435
D Example: This 87-year-old woman is admitted to hospital for end-stage renal failure. On
routine nursing rounds, the patient is found VSA. The attending physician is paged
and arrives 30 minutes later to pronounce the patient expired.
Code DAD Code title
N18.5 (M) Chronic kidney disease, stage 5
Rationale: In this example, the underlying cause is known; therefore, R99 is

not assigned.
436
Chapter XIX — Injury, poisonings and certain other consequences of external causes
Chapter XIX — Injury, poisonings

and certain other consequences
of external causes
Adverse Reactions in Therapeutic Use
Versus Poisonings
DN Classify an “adverse effect in therapeutic use” or a “poisoning” based on the criteria in the table below.
DN
Classify all poisonings as accidental unless there is clear documentation of intentional self-harm or
undetermined intent.
DN
Classify poisonings from illicit drug use as accidental unless there is clear documentation of intentional
self-harm or undetermined intent.
DN When multiple drugs are involved in a poisoning, assign a code for each documented drug.
DN
When a compound drug (such as Tylenol #3, which is acetaminophen, codeine and caffeine) is involved in
a poisoning, assign a code for each drug separately.
Note
It is mandatory to apply the diagnosis cluster to the set of codes that describes
• An adverse effect in therapeutic use (Y40–Y59); or
• An accidental overdose of drug or wrong drug given in error (X40–X44) that is a misadventure during
surgical and medical care (Y60–Y69).
See also the coding standard Diagnosis Cluster.
437
Notes
• Only one code is required for multiple drugs classified to the same ICD-10-CA code.
• When a drug is documented using the brand name, use a Canadian drug reference to find the generic
name(s) or active ingredients to further search the Table of Drugs and Chemicals.
• When the generic name(s) or active ingredients cannot be found in the Table of Drugs and Chemicals,
assign a code from the general drug category to which the drug belongs (e.g., antibiotic, diuretic, analgesic
or narcotic).
Adverse effect in therapeutic use Poisoning
An adverse reaction may occur when a substance A poisoning may occur when a substance (drug,
(drug, medicament or biological agent) is taken or medicament or biological agent) is taken incorrectly.
administered correctly in therapeutic use.
Incorrect use includes the following:
Correct administration of a substance in therapeutic
• Wrong drug given or taken
use includes the following:
• Wrong dosage of a drug
• Correct substance given or taken
• Self-prescribed drug taken in combination with a
• Correct dosage of a drug given or taken (includes prescribed drug
prescribed and self-prescribed)
• Self-prescribed drug not taken as recommended
• Two or more prescribed drugs taken in combination
• Any drug taken in combination with alcohol
• Two or more self-prescribed drugs taken
as recommended The following terms are used to describe a poisoning:
Generally, the following terms are used to describe • Drug overdose

adverse effects in therapeutic use. When these terms • Accidental ingestion
are used, but it is clear that a substance was used
• Intentional self-harm
incorrectly, classify as a poisoning.
• Suicide attempt
• Allergic reaction (Note: In the case of an allergic
reaction to a substance not in therapeutic use,
Instructions for coding
see the coding standard Allergic Reaction in
Locate the poisoning codes from Chapter XIX and the
Non-Therapeutic Use)
external cause code (Accidental, Intentional Self-Harm
• Accumulative effect (toxicity) or Undetermined Intent) from the Table of Drugs
• Hypersensitivity and Chemicals.
• Iatrogenic reaction Sequence the poisoning code first, followed by the

• Idiosyncratic reaction manifestation code (when applicable), the external
cause code and the place of occurrence code.
• Interaction between two medications
• Paradoxical reaction Note: When a poisoning is also a misadventure during
surgical and medical care (such as an accidental
• Synergistic reaction
overdose of a drug or a wrong drug given in error within
the health care setting), in addition to assigning the
external cause code from X40–X44, assign an external
cause code from category Y60–Y69 Misadventures to
patients during surgical and medical care.
438
Adverse effect in therapeutic use Poisoning
Instructions for coding Note: No codes are assigned when there is no harm to
Assign a code to describe the reaction/ the patient from an overdose of a drug or wrong drug
manifestation. Sequence the reaction/ given in error within the health care setting.
manifestation code first, followed by an external cause
code (Y40–Y59) taken from the Table of Drugs and Note: Do not apply the diagnosis cluster when
Chemicals under the column Adverse Effect in classifying a poisoning unless the poisoning is also a
Therapeutic Use. misadventure during surgical and medical care and a
code from Y60–Y69 is assigned.
Apply the diagnosis cluster, mandatory.
Note: The diagnosis type assigned for the manifestation
When the specific reaction/manifestation is not resulting from a poisoning is based on the diagnosis
documented, select the applicable code, either typing definitions.
• T80.6 Other serum reactions; or

• T80.9 Unspecified complication following infusion,
transfusion and therapeutic injection; or
• T88.7 Unspecified adverse effect of drug
or medicament.
See also the coding standards Allergic Reaction in Non-Therapeutic Use and Misadventures
During Surgical and Medical Care, as well as Opioid overdose in Appendix A.
N Example: The patient presents to the emergency department with a rash. The physician
documents that the patient had a CT scan two days ago with injection of contrast dye.
Final diagnosis: Allergic reaction to contrast dye

L27.0 MP A Generalized skin eruption due to drugs
and medicaments
Y57.5 OP A Xray contrast media causing adverse effect in

therapeutic use
Rationale: This manifestation occurred from a substance taken correctly in

therapeutic use; therefore, it is classified following the instruction
in the above table for adverse effect in therapeutic use.
439
N Example: The patient is diagnosed with gastritis due to aspirin. Documentation indicates that
the patient takes aspirin once daily.

K29.7 MP A Gastritis, unspecified
Y45.1 OP A Salicylates causing adverse effects in therapeutic use
Rationale: A manifestation occurring from a self-prescribed drug taken as directed

is classified as an adverse effect in therapeutic use.
N Example: The patient is newly diagnosed with cervical spondylosis. His physician prescribes
“Painfree” (a nonsteroidal anti-inflammatory drug) 25 mg tablet to be taken once
daily. The patient presents at emergency the following day complaining of nausea
and vomiting that started 30 minutes after taking the first dose. The emergency
physician notes the reaction and changes his medication.

R11.3 MP A Nausea with vomiting
Y45.3 OP A Other nonsteroidal anti-inflammatory drugs [NSAID]

Rationale: This manifestation occurred from a substance taken correctly in

therapeutic use; therefore, it is classified following the instruction in
the above table for adverse effect in therapeutic use.
DN Example: Digoxin toxicity — patient experiences ventricular tachycardia

I47.2 (M) MP A Ventricular tachycardia
Y52.0 (9) OP A Cardiac-stimulant glycosides and drugs

of similar action causing adverse effects
in therapeutic use
Rationale: Although physicians often record “digoxin toxicity” as a diagnosis, there is

usually additional documentation indicating the specific manifestation of
the toxicity. Classify the case to the more specific condition (see also the
coding standard Specificity). When more specific documentation is not
provided, assign T88.7 Unspecified adverse effect of drug or medicament.
440
D Example: Following infusion of blood products while in the intensive care unit (ICU), the
patient develops symptoms that are documented as a mild transfusion reaction.
T80.9 (3) A Unspecified complication following infusion,

transfusion and therapeutic injection
Y44.6 (9) A Natural blood and blood products causing adverse

Rationale: “Mild transfusion reaction” is an example of an adverse effect in

therapeutic use in which the specific reaction/manifestation is not
documented; therefore, T80.9 is assigned.
DN Example: Hematemesis due to taking Coumadin (prescribed) and aspirin (self-prescribed)

in combination.
T45.5 (M) MP Poisoning by anticoagulants
T39.0 (1) OP Poisoning by salicylates
K92.0 (3) OP Haematemesis
X44 (9) OP Accidental poisoning by and exposure to other

and unspecified drugs, medicaments and
biological substances
X40 (9) OP Accidental poisoning by and exposure to nonopioid

analgesics, antipyretics and antirheumatics
U98.9 (9) OP Unspecified place of occurrence
Rationale: Any combination of a prescribed drug taken with a self-prescribed drug

is classified as a poisoning.
441
DN Example: The patient presents after her husband notes her to be quite drowsy. On review,
it is noted that she took her regular prescribed dose of Ativan and consumed three
glasses of wine.
Final diagnosis: Toxic effect from Ativan and alcohol consumption
T42.4 (M) MP Poisoning by benzodiazepines
T51.0 (1) OP Toxic effect of ethanol
R40.0 (3) OP Somnolence
X41 (9) OP Accidental poisoning by and exposure to

antiepileptic, sedative-hypnotic, antiparkinsonism
and psychotropic drugs, not elsewhere classified
X45 (9) OP Accidental poisoning by and exposure to alcohol
Rationale: When a condition is the result of an interaction between alcohol and any
drug, it is classified as a poisoning.
DN Example: A mother finds her 8-year-old son playing at home with candy-coated ibuprofen
tablets. A count of the tablets shows that 10 are missing. He admits to swallowing
the “candy.” He is taken to the emergency department, where his chief complaint is
stomach ache.
Final diagnosis: Ibuprofen ingestion
T39.3 (M) MP Poisoning by other nonsteroidal anti-inflammatory

drugs [NSAID]
R10.19 (3) OP Upper abdominal pain, unspecified

Rationale: A manifestation occurring from accidental ingestion is classified as

a poisoning.
442
DN Example: The patient is in a coma due to attempted suicide by drug overdose from a
combination of heroin, Xanax, Valium and acetaminophen. He was found at home.
The patient is admitted to the ICU for close monitoring of his level of consciousness;
a central venous line is inserted for dialysis.
T40.1 (M) MP Poisoning by heroin
T42.4 (1) OP Poisoning by benzodiazepines
T39.1 (1) OP Poisoning by 4-Aminophenol derivatives
X62 (9) OP Intentional self-poisoning by and exposure to

narcotics and psychodysleptics [hallucinogens],
X61 (9) OP Intentional self-poisoning by and exposure to

antiepileptic, sedative-hypnotic, antiparkinsonism
and psychotropic drugs, not elsewhere classified
X60 (9) OP Intentional self-poisoning by and exposure

to nonopioid analgesics, antipyretics
and antirheumatics
Rationale: When multiple drugs are classified to separate categories, a code must
be assigned for each. The generic names for Xanax and Valium, as
listed in the Compendium of Pharmaceuticals and Specialties (CPS),
are alprazolam and diazepam, respectively, and both are classified in
the Table of Drugs and Chemicals to T42.4.
443
DN Example: Drug overdose from Pamprin
T39.1 (M) MP Poisoning by 4-Aminophenol derivatives
T45.0 (1) OP Poisoning by antiallergic and antiemetic drugs
T50.2 (1) OP Poisoning by carbonic-anhydrase inhibitors,

benzothiadiazides and other diuretics

X44 (9) OP Accidental poisoning by and exposure to other

Rationale: Pamprin is a compound drug consisting of acetaminophen,

pyrilamine maleate and pamabrom; therefore, each is coded separately.
Since pamabrom is a diuretic and the generic name is not listed in the
Table of Drugs and Chemicals, it is classified to the diuretic category.
Pyrilamine and pamabrom are classified to the same external cause
code; therefore, X44 is assigned only once.
D Example: The patient presents in labor. An epidural is administered to the patient. When it is
noted that the epidural is not working, it is discovered that penicillin G had been
administered into the epidural space rather than the usual anesthetic mixture
(incorrect IV bag). No treatment is given to the patient, other than close observation
for signs and/or symptoms of an allergic reaction, which do not occur. The patient
delivered a healthy newborn.
Code DAD Code title
Rationale: There was no harm to the patient from the wrong drug being given;
therefore, no codes are assigned. See also the coding standard
Misadventures During Surgical and Medical Care.
444
DN Example: The patient is brought to hospital via ambulance after snorting fentanyl. The patient
is unconscious. The final diagnosis is documented as “fentanyl overdose.”
T40.40 (M) MP Poisoning by fentanyl and derivatives
X42 (9) OP Accidental poisoning by and exposure to

narcotics and psychodysleptics [hallucinogens],
Rationale: Fentanyl overdose is classified as a poisoning. Therefore, T40.40 is

taken from the first column of the Table of Drugs and Chemicals,
followed by the code for the manifestation. X42 is the external cause
code, as taken from the Table of Drugs and Chemicals under the
Accidental Poisoning column. Poisonings from illicit drug use are
classified as accidental unless otherwise specified.
DN Example: The patient is admitted to hospital for confusion due to oxycodone that he takes, as
prescribed, for ongoing back pain.
R41.0 (M) MP A Disorientation, unspecified
Y45.04 (9) OP A Oxycodone causing adverse effects in

therapeutic use
Rationale: The confusion is a manifestation of a substance taken correctly in

therapeutic use. Therefore, R41.0 is assigned as the MRDx. Y45.04 is
the external cause code taken from the Table of Drugs and Chemicals
under the Adverse Effect in Therapeutic Use column to identify that
R41.0 is due to the oxycodone taken, as prescribed, in therapeutic use.
445
D Example: The patient is admitted with shingles and placed on acyclovir. Unfortunately, there
is a transcription error in the medication orders, and a double dose of acyclovir is
given. Creatinine level subsequently rises to more than 400. The patient is seen
by the nephrology service and is diagnosed with acyclovir-induced crystal acute
tubular necrosis. After six days of intravenous hydration and discontinuation of the
acyclovir, renal function returns to normal and the patient is discharged home.
T37.5 (2) A Poisoning by antiviral drugs
N14.1 (3) A Nephropathy induced by other drugs, medicaments

and biological substances
X44 (9) A Accidental poisoning by and exposure to other

Y63.8 (9) A Failure in dosage during surgical and medical care
U98.20 (9) A Place of occurrence, hospital
Rationale: When there is harm to the patient as the result of wrong dosage during
care, it is classified as a poisoning and a misadventure. Application of a
diagnosis cluster is mandatory for misadventures. Note that while there
is an exclusion at Y63 for accidental overdose of drug or wrong drug
given in error (X40–X44), this does not preclude using these two
external codes on the same abstract. One indicates that there was an
accidental poisoning and the other indicates that there was a
misadventure. See also the coding standard Misadventures During
Surgical and Medical Care.
Noncompliance with therapy
DN
Classify conditions resulting from noncompliance with therapy to a code describing the manifestation
followed by Z91.1 Personal history of noncompliance with medical treatment and regimen, optional, as a
When a condition is documented as being due to noncompliance with therapy or self-directed

discontinuance of a drug, it is neither a poisoning nor an adverse effect.
446
DN Example: A 17-year-old patient, who has had asthma for several years, develops status
asthmaticus due to his failure to comply with his medication regimen.
J45.01 (M) MP Predominantly allergic asthma with stated

status asthmaticus
Z91.1 (3) OP Personal history of noncompliance with medical

treatment and regimen
Allergic Reaction in Non-Therapeutic Use

In effect 2009
DN
When a manifestation is documented as due to an allergy or allergic reaction to a substance (excluding
substances in therapeutic use or allergy to food), search the alphabetical index for the manifestation.
DN When the index
• Provides the subterm “allergy” or “allergic,” assign the applicable code from A00–R99.
• Does not provide the subterm “allergy” or “allergic,” assign
− T78.4 Allergy, unspecified; and
− An additional code identifying the manifestation as a diagnosis type (3)/other problem; and
− An external cause code (either X58 Exposure to other specified factors, when the causative agent is
known, or X59.9 Exposure to unspecified factor causing other and unspecified injury, when the
causative agent is unknown).
Note
Do not search the Table of Drugs and Chemicals to locate an external cause code when classifying an allergic
reaction to a substance not used in therapeutic use. External cause codes found in the Table of Drugs and
Chemicals are used only to describe an adverse effect in therapeutic use or a poisoning. See also the coding
447
N Example: The patient presents to the emergency department and is diagnosed with allergic
contact dermatitis after exposure to poison ivy.
L23.7 MP Allergic contact dermatitis due to plants, except food
Rationale: Searching the alphabetical index as follows leads to the correct code:
Dermatitis
– due to
– – plants NEC (contact) L25.5
– – – allergic L23.7
An external cause code is not necessary.
(Note: Contact with poison ivy is classified as an allergic contact dermatitis.)
DN Example: The patient presents with localized swelling of the face. The final diagnosis is
documented as an allergic reaction.

T78.4 (M) MP Allergy, unspecified
R22.0 (3) OP Localized swelling, mass and lump, head
X59.9 (9) OP Exposure to unspecified factor causing other

and unspecified injury
Rationale: The manifestation is specified as swelling; however, the alphabetical

index search does not provide a descriptor subterm for “allergic”;
therefore, T78.4 Allergy, unspecified is assigned. If T78.4 were not
assigned for this example, it would not be identified as an allergic
reaction. X59.9 is assigned because the causative agent of the allergic
reaction is unknown.
448
N Example: The patient presents with lymph edema of her eyelids after applying a hair dye color
treatment at home.
Final diagnosis: Hair dye allergy
T78.4 MP Allergy, unspecified
H02.8 OP Other specified disorders of eyelid
X58 OP Exposure to other specified factors
Rationale: In this example, the causative agent is identified as hair dye. Even
though “Dye NEC” can be found by searching the Table of Drugs and
Chemicals, this is not an allergic reaction resulting from an adverse
effect of a substance in therapeutic use; therefore, do not search the
Table of Drugs and Chemicals for the external cause code. Note: If
T78.4 were not assigned for this example, it would not be identified as
an allergic reaction.
Current Versus Old Injuries

Code assignment is based on physician documentation, which establishes how the coder
searches the alphabetical index and determines when to apply the notes in the tabular listing.
For some injuries, there are occurrences when the classification requires the coder to make a
choice between classifying the injury as a current injury (Chapter XIX — Injury, poisoning and
certain other consequences of external causes [S00–T98]) or an old injury (body system
chapter, such as Chapter XIII — Diseases of the musculoskeletal system and connective
tissue [M00–M99]).
This is an example from the alphabetical index:

Tear, torn (traumatic) (see also Wound, open) T14.1
– meniscus (knee) (current injury) S83.2–
– – nontraumatic (degenerative) M23.3–
– – old (anterior horn) (lateral) (medial) (posterior horn) M23.2–
449
This is an example from the tabular listing:

G56 Mononeuropathies of upper limb
Excludes: current traumatic nerve disorder — see nerve injury by body region

When an injury is documented as being related to a traumatic event and the classification provides a
DN
choice of a condition being classified as current or old, select a code from either the body system chapter
or Chapter XIX based on the time frames indicated below:
• A current injury is one that occurred within one year (365 days) before the date of the visit. Select a
code from Chapter XIX.
• An old injury is one that occurred more than one year (365 days) before the date of the visit. Select a
code from the body system chapter.
• When the date of injury is not specified (e.g., patient cannot remember the date, physician does not
state an approximate date or injury is documented as “long ago”) classify as an old injury. Select a code
from the body system chapter.
First visit
N Example: The patient falls while skiing on a commercial ski hill, twisting his knee. A week later,
he presents to the emergency department because of continued pain and swelling.
He is diagnosed with a tear of his medial meniscus and is discharged to await
surgical booking.
S83.20 MP Tear of medial meniscus of knee, current
W02.01 OP Fall involving skis
U98.3 OP Place of occurrence, sports and athletics area
Rationale: The injury is related to a traumatic event and, when searching the
alphabetical index (lead term “Tear,” subterm “meniscus”), the
classification provides a choice between a current injury (S83.2–) and
an old injury (M23.2–). Since there is documentation of the injury having
occurred within one year, the tear of the meniscus is classified as a
current injury.
450
Second visit
DN Example: The patient from the above example returns to the hospital for meniscectomy.
It is now 21 days since the original injury.

S83.20 (M) MP Tear of medial meniscus of knee, current
W02.01 (9) OP Fall involving skis
U98.3 (9) OP Place of occurrence, sports and athletics area
current injury.
DN Example: Six months ago, the patient fell while skiing on a commercial ski hill, twisting her
knee. At that time, she was seen in emergency and diagnosed with a partial tear of
the medial meniscus. She was discharged with instructions to rest and ice the injured
area. She now complains of pain in her knee with certain activity and is admitted for
meniscectomy. The final diagnosis is torn posterior horn, medial meniscus.
S83.20 (M) MP Tear of medial meniscus of knee, current
W02.01 (9) OP Fall involving skis
current injury.
451
DN Example: The patient presents to hospital with right femoral nerve dysfunction. He was struck
in the inguinal area with a hockey puck two months previously when playing a game
in a hockey arena. The physician states that the patient obviously had an injury to
his femoral nerve at the time he was struck by the hockey puck, as he has had
numbness in the distribution of the nerve plus slight weakness of the quadriceps
muscle ever since. The final diagnosis is femoral nerve dysfunction.

S74.18 (M) MP Other and unspecified injury of femoral nerve at hip
and thigh level
W21.03 (9) OP Striking against or struck by hockey puck
alphabetical index, there is no subterm for “nerve” under the lead term
“Dysfunction.” The alphabetical index lookup “Disorder,” subterms
“nerve,” “femoral” leads to G57.2 Lesion of femoral nerve. Referring to
the tabular listing, the category G57 Mononeuropathies of lower limb
“excludes current traumatic nerve disorder,” and the coder is directed
to “see nerve injury by body region.” Since there is documentation
of the injury having occurred within one year, the exclusion at G57 is
applicable; therefore, the diagnosis of nerve dysfunction is classified
as a current injury.
DN Example: This patient had a twisting and hyperflexion injury to her knee just more than a year
ago. She initially had significant pain; this improved over time until a few months
ago. She is admitted for surgery, which identifies a left knee lateral meniscal tear.
Meniscectomy is performed.
M23.26 (M) MP Derangement of other and unspecified lateral

meniscus due to old tear or injury
alphabetical index (lead term “Tear,” subterm “meniscus”), the classification
provides a choice between a current injury (S83.2–) and an old injury
(M23.2–). Since there is documentation of the injury having occurred more
than one year ago, the tear of the meniscus is classified as an old injury.
452
Note
Pay careful attention when injuries are not related to a traumatic event. For example, conditions described as
“repetitive,” “degenerative” and/or “from overuse” are unrelated to a traumatic event and thus must not be
classified as traumatic injuries (either current or old).
DN Example: The patient is admitted for knee arthroscopy. The lateral compartment is evaluated,
and a small tear in the lateral meniscus is found. This is identified as a degenerative
horizontal tear.
M23.36 (M) MP Other derangement of other and unspecified

lateral meniscus
Rationale: The tear is a nontraumatic injury, as it is documented as degenerative.

When searching the alphabetical index (lead term “Tear,” subterm
“meniscus”), the classification provides the subterm “nontraumatic
(degenerative).” Following this alphabetical index lookup, assign M23.36.
DN
When a patient presents with a condition that is a sequela/late effect resulting from a previous injury, assign
a code for the current condition under investigation or treatment.
• Assign a code from T90–T98 Sequelae of injuries, of poisoning and of other consequences of external
causes, optional, as a diagnosis type (3)/other problem to identify the current condition as a sequela of
an injury.
453
DN Example: This patient suffers a stab wound to the palm of her left hand while cooking at
home. She has loss of sensation in the ring and middle fingers. The procedure
performed is neurolysis of common digital nerve.
Final diagnosis: Scarring of nerves of left hand
G56.8 (M) MP Other mononeuropathies of upper limb
T92.4 (3) OP Sequelae of injury of nerve of upper limb (optional)
Rationale: Scarring of the nerves in this example is a sequela of the stab wound.
The alphabetical index (lead term “Scar, scarring”) does not provide a
subterm for “nerve,” and L90.5 is specific to “scarring of the skin.” Since
L90.5 is not appropriate for this case, the coder must try different
applicable lead terms to search the alphabetical index. Searching the
lead term “Disorder,” subterms “nerve,” “specified NEC,” “upper limb”
leads to G56.8. On review of the tabular listing, while category G56
Mononeuropathies of upper limb “excludes: current traumatic nerve
disorder — see nerve injury by body region,” this exclusion is
not applicable because the diagnosis “scarring of the nerve” is not
describing a current or old injury but rather a sequela of an injury.
See also the coding standards Sequelae and Admission for Follow-up Examination.
Early Complications of Trauma

DN When a trauma complication, such as a hemorrhage or infection, follows medical/surgical procedures

intended to repair the injured site, assign the appropriate code from the range of categories T80–T88
Complications of surgical and medical care, not elsewhere classified.
454
DN Example: The patient is seen at the hospital with a dehiscence of the surgically repaired open
wound of his forearm.
T81.3 (M) MP A Disruption of operation wound, not

Y83.8 (9) OP A Other surgical procedures as the cause of

abnormal reaction of the patient, or of later
complication, without mention of misadventure
Rationale: The complication occurred following medical/surgical treatment and

is therefore classified to T80–T88 Complications of surgical and
medical care.
Note
In a patient with multiple traumas, shock may be assumed to be due to the trauma. Assign T79.4 Traumatic
shock unless the physician clearly states another cause.
D Example: A patient with severe multiple injuries experiences shock from the administration
of anesthetic for interventions to repair the injuries.

T88.2 (2) A Shock due to anaesthesia
Y48.4 (9) A Anaesthetic, unspecified causing adverse effects in

therapeutic use
455
Intracranial Injury NOS Versus Head Injury NOS

For the purpose of the ICD-10-CA classification, a final diagnosis of “head injury” is classified as
an intracranial injury (brain injury) when any of the following is documented within the encounter:
• Altered state of awareness

• Altered cognition
• Altered mentation
• Altered state of consciousness
• Glasgow Coma Scale score of 3 to 12
DN
When the final diagnosis is recorded as “head injury” and further documentation indicates a brain injury
per the above criteria, assign a code from category S06 Intracranial Injury.
DN
When the final diagnosis is recorded as “head injury” without further specification, assign S09.9
Unspecified injury of head.
See also the coding standard Specificity.
DN Example: The patient is injured in a fall from a horse. The final diagnosis is recorded as “head
injury.” The history identifies that she was unconscious for 10 minutes immediately
after the head injury.

S06.0 (M) MP Concussion
V80.0 (9) OP Animal-rider or occupant of animal-drawn vehicle

injured by fall from or being thrown from animal or
animal-drawn vehicle in noncollision accident
Rationale: As the documentation (loss of consciousness) provides further

specificity, the final diagnosis of “head injury” is classified to category
S06 Intracranial Injury and not S09.9 Unspecified injury of head.
456
DN Example: A 15-year-old girl walking down the sidewalk while talking on her cell phone strikes
her head on a post. She complains of a headache. The final diagnosis is recorded
as “minor head injury.” There is no documented Glasgow Coma Scale score.
S09.9 (M) MP Unspecified injury of head
W22.08 (9) OP Striking against or struck by other objects

in non-sports
U98.4 (9) OP Place of occurrence, street and highway
Rationale: When there is no documented evidence to indicate a brain injury

(per the criteria above), do not classify the diagnosis as an intracranial
brain injury. A headache or sore head in the absence of other signs
of neurological impairment is not classified as a brain injury.
Skull Fracture and Intracranial Injury1

In effect 2001
DN
For fractures of the skull associated with an intracranial injury, sequence the intracranial injury first,
followed by an additional code for the fracture.
DN Example: The patient has a traumatic subarachnoid hemorrhage with closed fracture of base
of skull. He suffers a brief loss of consciousness but has no other injuries.
S06.6 (M) MP Traumatic subarachnoid haemorrhage
S02.100 (1) OP Fracture of base of skull, closed
457
Open Wounds
Open wounds include animal bites, cuts, lacerations, avulsions of skin and subcutaneous tissue,
and puncture wounds with or without penetrating foreign body. They do not include traumatic
amputations or avulsions that involve deeper tissue, such as a muscle.
See also the coding standard Code Assignment for Multiple Superficial Injuries or Multiple
Open Wounds.
DN
Classify an open wound communicating with a fracture to the open fracture. Do not assign an additional
code for the open wound.
DN Example: The patient suffers a large open wound of the thigh; a fracture of the shaft of the
femur is visible in the wound.
Code Code title
S72.301 Fracture of shaft of femur, open

Classify an open wound as “complicated” when it includes any of the following:
DN
• Delayed healing
• Delayed treatment
• Foreign body
• Major infection (except that following treatment)
458
DN Example: The patient has an open wound to his forearm due to being struck in the arm by
a hockey stick while playing street hockey in his driveway. He delayed seeking
treatment, and a significant infection has set in.

S51.91 (M) MP Open wound of forearm, part
unspecified, complicated
W21.02 (9) OP Striking against or struck by hockey stick
Rationale: Both an infection and delayed treatment are present in this case.
DN
Once a wound has been definitively treated (cleansed and sutured), classify a subsequent infection at
the site to T81.4 Infection following a procedure, not elsewhere classified. Do so regardless of the cause
of infection.
See also the coding standards Early Complications of Trauma and Post-Intervention Conditions.
DN Example: A patient presents for treatment of a wound infection. He had suffered an open
wound of his arm that was treated by cleansing and suturing one day previously

T81.4 (M) MP A Infection following a procedure,

Rationale: Primary closure of a wound is not performed if the physician believes

that the level of contamination from the injury is likely to result in an
infection. This is a judgment call that is affected by many factors,
including the length of time between injury and treatment. Since the
patient’s open wound was definitively treated (cleansed and sutured)
and the patient now presents with a wound infection, this is classified as
an infection following a procedure.
459
Fractures — Closed Versus Open

DN Classify a fracture not documented as closed or open as closed.
DN Example: Documentation of injury says only “fracture humerus.”
Code Code title
S42.390 Fracture of unspecified part of humerus, closed
DN Classify separately any open wound in the vicinity of a closed fracture
An open fracture involves an open wound extending down into and exposing the fracture site,
or a broken bone end extending through the skin surface. When an open wound occurs at the
vicinity of a fracture without exposed bone, the fracture is considered closed.
DN Example: The patient sustains a closed fracture of the shaft of the femur, as well as a surface
laceration of the thigh.
Code Code title
S72.300 Fracture of shaft of femur, closed
S71.10 Open wound of thigh, uncomplicated
460
Treatment of Fractures
In effect 2001
When a fracture site involves a joint, select the appropriate intervention code from the joint site,
DN
not from the bone site.
See also the coding standard Joint Fracture Reduction, Fixation and Fusion.
Example: Fixation of an intertrochanteric fracture of the femur with an intramedullary

nail — open approach
1.VC.74.LA-LQ Fixation, femur, open approach using intramedullary nail,

no tissue used
Example: Fixation of a fracture of the neck of femur with an intramedullary nail —
open approach
1.VA.74.LA-LQ Fixation, hip joint, open approach using intramedullary

nail, fixation device alone
Dislocations
In effect 2001
DN Classify dislocations not indicated as closed or open as closed.
DN Classify a “fracture dislocation” of a site as a fracture.
DN Classify simple dislocation of vertebrae as follows:
• S13.1 Dislocation of cervical vertebra
• S23.1 Dislocation of thoracic vertebra
• S33.1 Dislocation of lumbar vertebra
DN For any multiple dislocations of a single type of vertebra, use the code only once.
461
DN Example: Dislocation of second and third cervical vertebrae
Code Code title
S13.1 Dislocation of cervical vertebra
Injury to Blood Vessels

In effect 2001
DN
When there is an injury to blood vessels due to a fracture, open wound or other injury, assign an
additional code to indicate the injury to the blood vessel.
See also the coding standard Sequencing Multiple Injuries for Severity.
DN Example: The patient sustains a closed fracture of shaft of femur with rupture of the common
femoral artery.
Code Code title

S75.0 Injury of femoral artery
Rationale: Sequencing will depend on the circumstances documented in the chart.
462
Significant Injuries
DN For classification purposes, consider the following types of injuries to be significant:
• Fractures
• Dislocations
• Amputations
• Second- and third-degree burns
• First-degree burns meeting the criteria for a significant diagnosis type or main/other problem
• Frostbite, superficial or with tissue necrosis
• Injuries to nerves, blood vessels, muscles/tendons and internal organs
D Assign a diagnosis type (M), (1), (2), (W), (X) or (Y) to significant injuries.
This list is not intended to indicate a hierarchy of severity. See also the coding standard
Sequencing Multiple Injuries for Severity.
Crush Injuries
In effect 2006

Assign all significant injuries associated with a crush injury as comorbid conditions or a
DN
main/other problem.
• Assign an additional code, optional, as a diagnosis type (3)/other problem, to identify the crush injury.
When multiple body regions are involved in a crush injury, select the crush injury code from the
category T04 Crushing injuries involving multiple body regions.
DN
When crush syndrome is documented with compromised renal function, assign T79.5 Traumatic anuria as
a comorbid diagnosis type or main/other problem.
463
See also the coding standard Code Assignment for Multiple Types of Significant Injuries
Involving Multiple Body Regions.
DN Example: The patient has his hand crushed between two heavy objects in a hotel kitchen,
sustaining open fractures of his second and third metacarpals.
S62.491 (M) MP Multiple fractures unspecified site of other

metacarpal bones, open
S67.8 (3) OP Crushing injury of other and unspecified parts of

wrist and hand
W23 (9) OP Caught, crushed, jammed or pinched in or

between objects
DN Example: The patient sustains a closed Grade IV injury to his liver and a shattered spleen
due to a crush injury to his abdomen when he is crushed against a wall by a van as
it backs up.
S36.130 (M) MP Parenchymal liver disruption involving 25 to 75%

hepatic lobe, or 1 to three segments (Grade IV)
without open wound into cavity
S36.040 (1) OP Hilar vascular laceration resulting in completely

shattered spleen (Grade V), without open wound
into cavity
S38.1 (3) OP Crushing injury of other and unspecified parts of

abdomen, lower back and pelvis
V03.0 (9) OP Pedestrian injured in collision with car, pick-up truck

or van, nontraffic accident
464
DN Example: The patient is a passenger crushed in a train derailment accident; he sustains an

open fracture of the shaft of the humerus, open fracture of three ribs, contusion of
the heart with open thoracic wound, closed contusion of the liver and spleen, and
closed fracture of the ilium.
S26.801 (M) MP Contusion and haematoma of heart with open wound

into thoracic cavity
S42.301 (1) OP Fracture of shaft of humerus NOS, open
S22.401 (1) OP Multiple fractures of 2–4 ribs, open
S36.150 (1) OP Liver haematoma NOS, laceration NOS, injury to

liver NOS, without open wound into cavity
S36.090 (1) OP Haematoma NOS, laceration NOS, injury to spleen

NOS, without open wound into cavity
S32.300 (1) OP Fracture of ilium, closed
T04.7 (3) OP Crushing injuries of thorax with abdomen, lower back

and pelvis with limb(s)
T06.8 (3) OP Other specified injuries involving multiple

body regions
V81.7 (9) OP Occupant of railway train or railway vehicle injured in

derailment without antecedent collision
Bilateral Injuries
DN
When identical significant injuries occur bilaterally, classify the injuries using the same
ICD-10-CA code twice.
Exception
Do not code identical burns of bilateral sites twice; the category T31 Burns classified according to extent of
body surface involved encompasses this aspect.
465
DN Example: The patient has lacerations to his quadriceps muscles of both thighs because a
sharp ceremonial sword fell from a museum display into his lap.
S76.10 (M) MP Laceration of quadriceps muscle and tendon
S76.10 (1) OP Laceration of quadriceps muscle and tendon
W26.0 (9) OP Contact with knife, sword or dagger
U98.28 (9) OP Place of occurrence, school and other institutions

and public areas
DN Example: Closed fracture of shaft of femur, right and left
Code Code title

Assign also
• External cause code; and
• Place of occurrence code.
DN
Classify bilateral fractures to bones of which there is only one in the body (e.g., mandible or maxilla)
to one code indicating multiple fractures.
DN Example: Fracture of ramus (mandible), left side and right side
Code Code title
S02.670 Multiple mandibular fracture sites, closed
466
Burns and Corrosions

The term “burn” covers thermal burns, friction burns and scalds by non-caustic liquids and
vapors. Also included are burns caused by electrical heating appliances, electricity, flame, hot
objects, lightning and radiation. Corrosions are burns caused by caustic substances like acids or
alkalis. Sunburns are classified in L55.
In ICD-10-CA, burns and corrosions are described as occurring in “degrees.” This terminology
relates to the thickness of the burn. A first-degree burn is redness of the skin (erythema) only; it
is also called a superficial burn. A second-degree burn involves epidermal loss and blistering; it
is also called a partial thickness burn. Third-degree burns involve full thickness skin loss and/or
deep necrosis of any underlying tissue.
Burns and corrosions of the external body surface are specified by site in categories T20–T25.
Inclusion terms at each category level will help to ensure accurate code selection. Burns confined
to the eye and internal organs are classified in block T26–T28.
Category T29 classifies burns and corrosions of multiple body regions; T30 is used to classify
burns and corrosions of body region, unspecified. T31 and T32 are used to capture the extent of
the body surface area involved in the burn or corrosion.
DN Classify burns of varying degrees at one site to the deepest degree at that site.
DN Example: First-, second- and third-degree burns of the chest wall
Code Code title
T21.3 Burn of third degree of trunk
Assign also
• Extent of the body surface involved;
467
DN Classify an evolving burn to the greatest degree to which it progresses.
Sometimes, a burn initially stated to be a second-degree burn may evolve; within a few days,
the physician will change his documentation to say that the burn is a third-degree one. Code this
burn to the degree it has evolved to, that is, to the third degree.
DN Example: The patient presents with second-degree burns to the left arm (10% body surface
area) due to scalding with boiling water from a cooking pot while at home.
Documentation reveals the burn evolved to third-degree burn.
T22.3 (M) MP Burn of third degree of shoulder and upper limb,

except wrist and hand
T31.12 (1) OP Burns involving 10–19% body surface with 10–19%

third degree burns
X12 (9) OP Contact with other hot fluids
DN Classify burns described as “non-healing” or “necrotic” as current burns.
DN
When a patient presents for burn treatment that includes grafting or debridement, classify the burn as a
current burn.
DN
When a patient presents for a complication of a burn that has healed, assign a code for the subsequent
problem resulting from the burn, such as scar contractures.
When a patient presents for reconstructive surgery for a healed burn, assign Z42.–
DN
Follow-up care involving plastic surgery.
When a patient presents for change of burn dressings, assign as the MRDx/main problem Z48.0 Attention to
DN
surgical dressings and sutures.
• Assign an additional code, optional, as a diagnosis type (3)/other problem, to identify the burn itself.
See also the coding standards Current Versus Old Injuries and Admission for Follow-up Examination.
468
DN Example: A patient suffered multiple burns to his body in a house fire seven months
previously. He now presents for Z-plasty of a scar contracture of his right wrist.
He also still has an area of non-healing, third-degree burn with necrosis of his
left buttock, which accounts for less than 1% of body surface.
L90.5 (M) MP Scar conditions and fibrosis of skin
T95.2 (3) OP Sequelae of burn, corrosion and frostbite of upper

limb (optional)
T21.3 (1) OP Burn of third degree of trunk
T31.01 (1) OP Burns involving less than 10% of body surface with
less than 10% third degree burns
X00 (9) OP Exposure to uncontrolled fire in building or structure
DN
When failure or rejection of a xenograft or homograft occurs at a treated burn site, assign a code from
category T86.84 Failure and rejection of soft tissue (skin, muscle, fascia, tendon, mucosa) graft/flap.
When rejection or failure of a patient’s own grafted tissue (autograft) to a burn site occurs, assign T85.8
DN
Other complications of internal prosthetic devices, implants and grafts, not elsewhere classified.
469
Extent of Body Surface Area Involved

in Burn Injury

When a code from T20–T25 or T29 is assigned, assign a mandatory additional code, as a comorbid
DN diagnosis type/other problem, from the category
• T31 Burns classified according to extent of body surface involved; or

• T32 Corrosions classified according to extent of body surface involved.
DN
Ensure that the diagnosis type for T31.– or T32.– matches the diagnosis type of the code for the burn or
corrosion in terms of pre-admit/post-admit comorbidity or other problem.
DN
Select only one code from within the categories T31 and T32.
Categories T31 and T32 may both apply to a single case, but only one code from each category
may be used.
DN Example: First- (5% body surface affected [BSA]), second- (10% BSA) and third- (15% BSA)
degree burns of the trunk

T21.3 (M) MP Burn of third degree of trunk
T31.32 (1) OP Burns involving 30–39% of body surface with

10–19% third degree burns
Assign also
Rationale: T31.32 is mandatory with T21.3. Diagnosis type for T31.32 is assigned
a pre-admit comorbidity type. If the burn was a post-admit comorbidity,
T31.32 would also be assigned a post-admit comorbidity diagnosis type.
Only one code can be selected from T31.–.
Note
Burn diagrams that describe the patient’s total injury may help coders to select the appropriate code from
these categories.
470
Assignment of Most Responsible

Diagnosis/Main Problem in Multiple Burns
In the presence of multiple burns of several sites, select the burn site of the most severe degree as the
DN
MRDx/main problem.
In the case of burns of multiple sites of the same degree, select the site with the larger body surface as
DN
All parameters remaining the same, select burns requiring grafting over burns not requiring grafting as
DN
DN Example: Second-degree burns of forearm and palm of hand and first-degree burn of face

T22.2 (M) MP Burn of second degree of shoulder and upper limb,
except wrist and hand
T23.2 (1) OP Burn of second degree of wrist and hand
T20.1 (1) OP Burn of first degree of head and neck
Assign also
• Extent of body surface involved;

Rationale: Burn of the forearm is selected as the MRDx/main problem over the
first-degree burn of the face due to greater severity; it is selected over
the burn of the palm of hand due to larger body surface area.
471
Burns of Multiple Body Regions

In effect 2001
DN
When documentation of specific sites of burns is provided, assign separate codes for each burn site.
Assign T29.– Burns and corrosions of multiple body regions as a comorbid diagnosis type/other problem
DN
only when specific documentation of sites is not provided.
Assign T29.– Burns and corrosions of multiple body regions, optional, as a diagnosis type (3)/other
DN
problem, to facilitate data retrieval.
DN Example: Third-degree burn of left thigh and foot

T24.3 (M) MP Burn of third degree of hip and lower limb, except
ankle and foot
T25.3 (1) OP Burn of third degree of ankle and foot
T29.3 (3) OP Burns of multiple regions, at least one burn of third

degree mentioned
Assign also
• Extent of body surface involved;
Sequencing Multiple Injuries for Severity

DN When there are multiple injuries, sequence the most severe (or life-threatening) first.
See also the coding standard Diagnoses of Equal Importance.
472
D Example: The patient is admitted following a motor vehicle accident with third-degree burns of
his head and neck (body surface area 11%) requiring extensive skin grafting, along
with a lacerated muscle of the wrist requiring debridement and suturing, and
traumatic amputation of two fingers.
Code DAD Code title
T20.3 (M) Burn of third degree of head and neck
T31.12 (1) Total body surface involved in burn (any degree) 10–19%,
percentage that was third degree, 10–19%
S66.90 (1) Laceration of unspecified muscle and tendon at wrist and hand level
S68.2 (1) Traumatic amputation of two or more fingers alone (complete) (partial)
Assign also
• External cause code.
Rationale: Third-degree burns would be considered the most severe and life-threatening.
DN
When superficial (skin) injuries occur concomitantly with more severe injuries of the same body region,
code only the more severe injuries.
DN Example: The patient presents with a fracture of the olecranon process. There are also
multiple bruises and abrasions in the area.
S52.000 (M) MP Fracture of olecranon process of ulna, closed
Assign also

473
DN Classify significant injuries to the greatest level of specificity possible, even if this requires selecting more
than one code from the same category.
See also the coding standards Significant Injuries and Specificity.
Exception
Do not assign the same diagnosis code more than once to capture multiple fractures located at the same site
of a bone (e.g., fracture of shaft in two places) or for multiple/bilateral fractures of bones of which there is
only one in the body (e.g., bilateral fractures of mandible). See also the coding standard Bilateral Injuries.
DN Example: The patient is admitted following open fracture of bones of his hand, specified as
neck of first metacarpal and proximal phalanx of the thumb, and a closed fracture of
the shaft of his third metacarpal.
S62.221 (M) MP Fracture of head and neck of first metacarpal

bone, open
S62.501 (1) OP Fracture of proximal phalanx, open
S62.310 (1) OP Fracture of shaft of other metacarpal bone, closed
Assign also
Rationale: The sites of each fracture are specified and therefore coded to the
greatest level of specificity, even though the codes are from the same
three-character category.
474
Code Assignment for Multiple Superficial

Injuries or Multiple Open Wounds
DN
Use combination categories to describe multiple and/or bilateral superficial injuries or open wounds of
the same body region or multiple body regions.
Unlike significant injuries, multiple injuries classified in the categories listed in the tables below
do not need to be classified individually. They may be captured individually to meet facility or
provincial/territorial data reporting requirements.
Use just one code to identify multiple open wounds.
Choose from the following:

S01.7– of head
S11.7– of neck
S21.7– of thorax
S31.7– of lower back and pelvis
S41.7– of shoulder and upper arm
S51.7– of forearm
S61.7– of wrist and hand
S71.7– of hip and thigh
S81.7– of lower leg
S91.7– of ankle and foot
T01.– of multiple body regions (see fourth character for body site combinations)
475
DN Example: The patient sustains lacerations to his thumb, palm and middle finger following a
construction site accident where his hand is caught in machinery.
S61.70 (M) MP Multiple open wounds of wrist and hand,

uncomplicated
W31 (9) OP Contact with other and unspecified machinery
U98.6 (9) OP Place of occurrence, industrial and construction area
Rationale: The multiple open wounds are all classifiable to the category S61.
Since these are not significant injuries, they can be captured using the
combination code S61.70.
Use just one code to identify multiple superficial injuries.
Choose from the following:

S00.7– of head
S10.7– of neck
S20.7– of thorax
S30.7– of lower back and pelvis
S40.7– of shoulder and upper arm
S50.7– of forearm
S60.7– of wrist and hand
S70.7– of hip and thigh
S80.7– of lower leg
S90.7– of ankle and foot
T00.– of multiple body regions (see fourth character for body site combinations)
476
Code Assignment for Multiple Types of Significant

Injuries Involving a Single Body Region
DN
When there are two or more significant types of injuries involving a single body region, classify each injury
to the greatest level of specificity indicated in the documentation and sequence in order of severity.
See also the coding standard Significant Injuries.
The following codes can be used as a flag to identify cases with multiple significant injuries. If
used, they must be assigned diagnosis type (3):
S09.7 (3) Multiple injuries of head
Injuries classified to more than one of the categories (S02–S09.2)
S19.7 (3) Multiple injuries of neck
Injuries classified to more than one of the categories (S12–S18)
S29.7 (3) Multiple injuries of thorax
Injuries classified to more than one of the categories (S22–S29.0)
S36.7 (3) Multiple injuries of intra-abdominal organs
Injuries classified to more than one of the categories (S36.0–S36.9)
S37.7 (3) Multiple injuries of pelvic organs
Injuries classified to more than one of the categories (S37.0–S37.9)
S39.7 (3) Multiple injuries of intra-abdominal with pelvic organs
S49.7 (3) Multiple injuries of shoulder and upper arm
S59.7 (3) Multiple injuries of forearm

S69.7 (3) Multiple injuries of wrist and hand
477
S79.7 (3) Multiple injuries of hip and thigh

S89.7 (3) Multiple injuries of lower leg
S99.7 (3) Multiple injuries of ankle and foot
More than one type of significant injury occurring in the same body region is considered
“multiple” injuries of that body region.
DN Example: The patient is admitted following a snowmobile accident where he was the driver.
He sustains an open trochanteric fracture of the femur, a non-contiguous laceration
of the gluteus maximus, and injury to several blood vessels and the sciatic nerve at
the thigh level.
S72.191 (M) MP Unspecified trochanteric fracture, open
S74.00 (1) OP Laceration of sciatic nerve at hip and thigh level
S76.00 (1) OP Laceration of muscle and tendon of hip
S75.7 (1) OP Injury of multiple blood vessels at hip and thigh level
S79.7 (3) OP Multiple injuries of hip and thigh
V86.50 (9) OP Driver of snowmobile injured in nontraffic

land accident
Rationale: These injuries are all considered significant for assignment of the
multiple injuries code for a single body region. Since the documentation
does not provide further specification of the blood vessel injuries, S75.7
is assigned.
Ensure that the S–9.7 Multiple injuries of . . . codes are not assigned to identify multiple injuries when one
DN
significant injury occurs with one or more superficial wounds.
478
DN Example: The patient is admitted following a construction site accident where his hand is
injured in machinery. He sustains a closed fracture of the distal phalanx of his index
finger and lacerations of his thumb, palm and middle finger.
S62.610 (M) MP Fracture of distal phalanx of finger, closed
S61.70 (3) OP Multiple open wounds of wrist and

hand, uncomplicated
W31 (9) OP Contact with other and unspecified machinery
U98.6 (9) OP Place of occurrence, industrial and construction area
Rationale: The multiple superficial injuries are captured using the combination code
S61.70 (see also the coding standard Code Assignment for Multiple
Superficial Injuries or Multiple Open Wounds). However, S69.7 Multiple
injuries of wrist and hand is not assigned, since there is only one type of
significant injury in this case.
Code Assignment for Multiple Types of Significant

Injuries Involving Multiple Body Regions
DN
Whenever there are two or more significant types of injuries involving multiple body regions, classify
each injury to the greatest level of specificity indicated in the documentation and sequence injuries in
order of severity.
See also the coding standards Significant Injuries and Sequencing Multiple Injuries for Severity.
T06.8 Other specified injuries involving multiple body regions can be used as a flag to identify
cases with multiple significant injuries involving multiple body regions. If used, it must be
When T06.8 is assigned, a code from S–9.7 Multiple injuries of . . . is not required.
479
DN Example: The driver of a snowmobile injured in a traffic accident sustains multiple injuries to
multiple body regions: a Le Fort 3 fractured maxilla, subdural hematoma with a
65-minute loss of consciousness, open wound of abdomen with contusion of the
pancreas, laceration of duodenum and bile duct, closed fracture of C6 vertebra,
and open fractures of upper end of humerus and of clavicle.
S06.5 (M) MP Traumatic subdural haemorrhage
S36.201 (1) OP Haematoma of pancreas (without pancreatic duct

injury), with open wound into cavity
S36.421 (1) OP Laceration of duodenum with bile duct or

duodenopancreatic complex injury, with open
wound into cavity
S02.431 (1) OP Fracture of malar and maxillary bones, LeFort 3,

unilateral, open
S12.210 (1) OP Fracture of C5–C7 vertebra, closed
S42.281 (1) OP Fracture of other part of upper end of humerus, open
S42.011 (1) OP Fracture of shaft of clavicle, open
T06.8 (3) OP Other specified injuries involving multiple

body regions
V86.00 (9) OP Driver of snowmobile injured in traffic accident
Note
The code T06.8 may be assigned on any abstract where multiple codes begin with the letter “S” and the
second character changes, because the second characters refer to the different body regions. For instance,
S06 + S44 = multiple types of significant injury involving multiple body regions.
Neither superficial injuries (third character = “0”) nor open wounds (third character = “1”) are considered
significant types of injury for the purposes of assigning this multiple injury code. However, certain open
wounds or superficial injuries could qualify as comorbid conditions.
480
Coding Nonspecific Multiple Injuries for

Emergency Department Visits
N When documentation does not permit assignment of specific injury codes for significant injuries, assign a
multiple injury code as the main problem for emergency department visit abstraction.
See also the coding standard Sequencing Multiple Injuries for Severity.
N Example: A passenger of a car is injured when a bus strikes the vehicle she is riding in.
She sustains severe multiple injuries to several body regions. She is transferred
to a trauma center before the diagnostic work-up is completed.

T06.8 MP Other specified injuries involving multiple body regions
V44.6 OP Car occupant, passenger, injured in collision with heavy transport

vehicle or bus, traffic accident
Post-Intervention Conditions
Post-intervention condition code assignment

The code assignment for a post-intervention condition consists of
• A primary code that, when following the alphabetical index, classifies the condition or
symptom to one of the following:
- A code from T80–T88 Complications of surgical and medical care, not elsewhere
classified (T-code);
- A post-procedural disorder code found in most body system chapters (PP-code); or
- The regular code (the usual code in the classification);
• An additional code to provide specificity, mandatory when available; and
• An external cause code to identify the nature of the post-intervention condition, mandatory.
481
Note
It is mandatory to apply a diagnosis cluster to the set of codes that describes a post-intervention condition.
See also the coding standard Diagnosis Cluster.
Note
Diagnosis typing/problem definitions apply to post-intervention conditions. When a post-intervention
condition does not meet the criteria for significance, it is optional to assign codes; however, when codes are
assigned, the following directive statements apply.
DN
Classify a condition or symptom as a post-intervention condition when
• A condition or symptom that is not attributable to another cause arises during an uninterrupted,
continuous episode of care within 30 days following an intervention (including transfers from one facility
to another); or
• A cause/effect relationship is documented, regardless of timeline.
DN Assign a minimum of two codes:
• Either a T-code, PP-code or regular code upon following the alphabetical index; and
• One external cause code from either
− Y60–Y69 Misadventures to patients during surgical and medical care; or
− Y70–Y82 Medical devices associated with adverse incidents in diagnostic and therapeutic use; or
− Y83–Y84 Surgical and other medical procedures as the cause of abnormal reaction of the patient,
or of later complication, without mention of misadventure at the time of the procedure.
Note
The 30-day timeline does not apply when a patient has been discharged. This is considered an interruption in
care (no longer a continuous episode of care).
On readmission, a condition must be clearly documented as post-procedural to be classified as a post-

intervention condition.
482
Note
The 30-day timeline includes direct transfers between the same level of care at different facilities (such as
acute to acute) and different levels of care at the same or different facilities (such as ambulatory care to
acute). A direct transfer constitutes an uninterrupted, continuous episode of care, and the 30-day timeline
rule still applies.
D Example: The patient is admitted with a diagnosis of pneumonia. The history mentions that the
patient had a radical hysterectomy eight days ago.
Code DAD Code title
Rationale: The pneumonia is not classified as a post-intervention condition

because there is no clear documentation by the physician that a
cause/effect relationship exists between the pneumonia and the
previous intervention. Once a patient has been discharged, the 30-day
timeline is no longer in effect.
Note
When it is clear from the chart documentation that a condition or symptom occurring in the post-intervention
period of 30 days is attributable to another cause, it is not classified as a post-intervention condition.
This includes
• A condition that represents a worsening of the very condition being treated;
• An exacerbation of a pre-existing condition; and
• A condition that is due to another cause, for example
− A condition that is the result of an accident; or
− An adverse effect of a drug, medicament or biological agent in therapeutic use.
483
D Example: The patient is admitted with congestive heart failure (CHF) and subsequently has a
cardiac catheterization performed during the admission. Five days later, while still
an inpatient, the patient experiences acute respiratory failure. The physician
documents that the respiratory failure is due to CHF.
Code DAD Code title
J96.09 (2) Acute respiratory failure, type unspecified
Rationale: The respiratory failure has been documented as due to CHF; therefore, it is
not classified as a post-intervention condition. It is due to another cause.
D Example: A patient with known atrial fibrillation is admitted for coronary artery bypass surgery.
On postoperative day 2, he has an episode of atrial fibrillation and is monitored in
the cardiac care unit.
Code DAD Code title

I48.90 (1) Atrial fibrillation, unspecified
Rationale: Atrial fibrillation was a known condition prior to surgery; therefore, it is

not classified as a post-intervention condition. It is an exacerbation of a
pre-existing condition and is assigned diagnosis type (1).
D Example: On postoperative day 1, the patient gets out of the hospital bed without assistance
and falls, resulting in a fractured hip.
Code DAD Code title
S72.090 (2) Unspecified fracture of neck of femur, closed
W06 (9) Fall involving bed
U98.20 (9) Place of occurrence, hospital
Rationale: Although the injury occurred within 30 days following an intervention,

the fracture is due to another cause (a fall); therefore, it is not classified
as a post-intervention condition.
484
N Example: The patient presents to the emergency department after a fall at home onto her
colostomy bag. Blood from the blunt trauma to the stoma is present in the
colostomy bag.
K91.40 MP Haemorrhage from colostomy stoma
W19 OP Unspecified fall
Rationale: A condition resulting from an accident is not classified as a post-

intervention condition because it is due to another cause (an accident).
Hemorrhage from colostomy is classified to K91.40 per the alphabetical
index. Assigning an external cause code for the accident distinguishes a
colostomy hemorrhage that is the result of an accident from one that is a
post-intervention condition (cause/effect with the stoma itself).
D Example: The patient trips and falls while at a private physiotherapy clinic and suffers a
fracture of the femur at the lower end, where a bone plate and screws were in situ
following a previous fracture repair. The final diagnosis is periprosthetic fracture.
Code DAD Code title

M96.68 (M) Fracture of bone following insertion of other and unspecified
orthopaedic implant
S72.490 (3) Unspecified fracture of lower (distal) end of femur, closed
W01 (9) Fall on same level from slipping, tripping and stumbling
U98.28 (9) Place of occurrence, school and other institutions and public areas
Rationale: A condition resulting from an accident is not classified as a post-

intervention condition because it is due to another cause (an accident).
A periprosthetic fracture is classified to M96.6– per the classification.
Assigning an external cause code for the accident distinguishes a
periprosthetic fracture that is the result of an accident from one that
is a post-intervention condition (cause/effect with the implant itself).
485
D Example: The patient had a previous fracture of the left femoral neck with fixation using
screws. In the nursing home, the patient experiences hip pain, and an X-ray
confirms a displaced fracture of the femoral neck. The patient is admitted for
hemiarthroplasty for management of this periprosthetic fracture.
M96.68 (M) A Fracture of bone following insertion of other and

unspecified orthopaedic implant
S72.090 (3) A Unspecified fracture of neck of femur, closed

Rationale: A periprosthetic fracture is classified to M96.6– per the classification.

This condition is classified as a post-intervention condition (cause/effect
with the implant itself), as it was not associated with an accident
(external cause). M96.68 does not identify the site of the fracture;
therefore, S72.090 is assigned to add this specificity.
Note
Complications of postoperative wounds (such as wound hemorrhage, wound dehiscence and wound
infection) are always classified as post-intervention conditions because the relationship to the intervention is
inherent in the diagnosis. There may be contributing factors; however, a wound complication cannot be said
to be attributable to another cause (such as an accident).
486
DN Example: A patient who had a knee replacement eight days ago presents to the hospital with bleeding
from the operative wound after bumping his knee. The diagnosis is wound hematoma.

T81.0 (M) MP A Haemorrhage and haematoma complicating a
procedure, not elsewhere classified

Rationale: Wound hematoma is classified as a post-intervention condition because

a relationship to the intervention is inherent in the diagnosis. Assignment
of an additional external cause code (W22.08) is not required in spite of
the contributing external factors.
Note
When a condition arises following an intervention to administer a substance, the condition can be related
to the substance that was administered or it can be related to the act of administering the substance.
A condition that is related to the substance that was administered is an adverse effect in therapeutic use and
is classified according to the standard Adverse Reactions in Therapeutic Use Versus Poisonings. A condition
that is related to the act of administering the substance is a post-intervention condition.
D Example: Following infusion of blood products while in ICU, the patient develops symptoms
that are documented as a mild transfusion reaction.

T80.9 (3) A Unspecified complication following infusion,
Y44.6 (9) A Natural blood and blood products causing adverse

Rationale: “Transfusion reaction” relates to the substance (blood product) that

was administered and not to the act of administering the substance
(transfusing); therefore, this is classified as an adverse effect in
therapeutic use and not a post-intervention condition. Transfusion
reaction without further specification is assigned to T80.9. Assigning
an external cause code for the substance causing the adverse effect
distinguishes a complication following transfusion that is the result of
the substance from one that is a result of the intervention.
487
D Example: The patient is seen in consultation for transfusion-related phlebitis of the forearm.
T80.1 (2) A Vascular complications following infusion,

I80.8 (3) A Phlebitis and thrombophlebitis of other sites

reaction of the patient, or of later complication,
without mention of misadventure at the time of
the procedure
Rationale: The phlebitis is related to the act of administering the substance and not
to the substance that was administered; therefore, it is classified as a
post-intervention condition.
Note
When a condition can reasonably be assumed to be unrelated to a particular intervention or to any
intervention at all, it is not classified as a post-intervention condition. For example,
• It can reasonably be assumed that pneumonia would be unrelated to a diagnostic imaging intervention.
• It can reasonably be assumed that acquiring a communicable disease would be unrelated to any
intervention at all.
488
D Example: The patient is admitted with advanced breast cancer with metastases to lung, brain
and bone. Additional diagnoses on admission include pulmonary embolism and
MRSA cellulitis of chest wall. The patient’s course in hospital is complicated by
non–ST elevation myocardial infarction (MI) and CHF; these complications initially
improve, but the patient subsequently deteriorates and expires on day 25. Multiple
diagnostic imaging interventions, including ultrasound and magnetic resonance
imaging (MRI), and palliative radiotherapy to the breast and lumbar spine were
performed prior to the presentation of the MI and CHF.
Code DAD Code title


[NSTEMI]
I50.0 (2) Congestive heart failure
Rationale: Based on what we know about MI and CHF, the interventions that
were performed and this patient’s overall condition, it is reasonable to
assume that the MI and CHF are unrelated to the diagnostic imaging
interventions or radiation therapy. Additionally, there is no mention in
the documentation of such a relationship. Therefore, these conditions
are not classified as post-intervention conditions.
Note
When post-intervention conditions related to obstetrical cases are classified to Chapter XV — Pregnancy,
childbirth and the puerperium (O00–O99), the directives pertaining to post-intervention conditions do
not apply.
489
D Example: The patient delivers by Cesarean section for obstructed labor due to breech
presentation of the baby. Prior to discharge, Cesarean wound dehiscence
is diagnosed.
Code DAD Code title

O90.002 (2) Disruption of caesarean section wound, delivered, with mention of

Rationale: Cesarean wound dehiscence is classified to Chapter XV — Pregnancy,

childbirth and the puerperium (O00–O99). The directives for post-
intervention conditions do not apply.
D Example: The patient is admitted with a diagnosis of complete spontaneous abortion attributed
to recent amniocentesis.
Code DAD Code title
O05.9 (M) Other abortion, complete or unspecified, without complication
Rationale: Abortion following amniocentesis is classified to Chapter XV —

Pregnancy, childbirth and the puerperium (O00–O99). The directives
for post-intervention conditions do not apply.
490
D Example: A patient at 28 weeks gestation is admitted with a fracture of the humerus following
a motor vehicle accident. Following open reduction internal fixation, there is
disruption of the wound that prolongs the stay.
T81.3 (2) A Disruption of operation wound, not


patient, or of later complication, without mention
Rationale: While this is an obstetrical patient, disruption of an operation

wound from an open reduction internal fixation is not classified to
Chapter XV — Pregnancy, childbirth and the puerperium (O00–O99);
it is classified to T80–T88 Complications of surgical and medical care,
not elsewhere classified, and the directives for post-intervention
conditions apply.
D Example: A patient with postpartum hemorrhage due to retained products one day following
delivery is taken to the operating room for a dilation and curettage (D & C), during
which there is a tear to the cervix that is repaired with a suture.
T81.2 (2) A Accidental puncture and laceration during a

S37.611 (3) A Laceration of uterus, with open wound into cavity
Y60.0 (9) A Unintentional cut, puncture, perforation or

haemorrhage during surgical operation
Rationale: While this is an obstetrical patient, tear of the cervix during D & C
following delivery is not classified to Chapter XV — Pregnancy,
childbirth and the puerperium (O00–O99); it is classified to T80–T88
Complications of surgical and medical care, not elsewhere classified,
and the directives for post-intervention conditions apply.
491
Searching the alphabetical index for the primary code for a

post-intervention condition
Searching the alphabetical index
Step 1: Locate the lead term.
a. Misadventure — Condition or circumstance meets the criteria for a misadventure.

Search the lead term “Misadventure” and the applicable subterm and assign the code per the
classification. See also the coding standard Misadventures During Surgical and Medical Care. END
b. Select interventions Group A — Condition is related to (associated with) one of the

following interventions:
• Artificial fertilization (N98)
• Immunization (includes vaccination) (T88.0, T88.1)
• Infusion, transfusion, therapeutic injection (includes dialysis, extracorporeal circulation
and perfusion) (T80)
Search the lead term “Complication, complications (from) (of)” and a subterm denoting the specific
intervention and assign the code per the classification. END
c. All others — Search the specific condition or symptom. GO TO STEP 2.
Step 2: Look for a subterm denoting “post-procedural.”
a. No post-procedural subterm — There is no post-procedural subterm. GO TO STEP 3.
b. Single subterm — When a single subterm denoting post-procedural exists, assign the code per the
classification. END
c. Two or more subterms — When there are two or more post-procedural subterms,
• One leading to a code specific to one of the select interventions listed in Group B at Step 3a; and
• One leading to a code from category T81 Complications of procedures, not elsewhere classified,
assign the code specific to the select intervention in Group B when the condition is attributed (due to)
or clearly related to/associated with the outcome of the intervention; otherwise, assign the code from
category T81 Complications of procedures, not elsewhere classified. END
Step 3: Assign a regular code or a code for a select intervention.
a. Select interventions Group B — Condition is attributed (due to) or clearly related to/associated with
the outcome of one of the following select interventions:
• Amputation (T87.3–, T87.4–, T87.5–, T87.6–)
– The condition is directly related to the amputation stump itself.
492
• Device, implant or graft (T82–T85)

– The condition is directly related to the in situ device, implant or graft itself.
• Lumbar puncture (G97.1)
– The condition is directly related to the effects of cerebrospinal fluid loss.
• Mastoidectomy (H95.0, H95.1)
– The condition is directly related to the post-mastoidectomy cavity.
• Reattached extremity/body part (T87.0–, T87.1–, T87.2–)
– The condition is directly related to the reattached limb itself.
• Stoma (J95.0–, K91.4–, K91.6–, N99.5–)
– The condition is directly related to the established (healed) stoma.
Search the lead term “Complication, complications (from) (of)” and a specific subterm for the
select intervention and assign the code per the classification. END
b. All others — Assign the regular code per the classification. END
Example: Surgical sponge left in operative wound
Misadventure (prophylactic) (therapeutic) (see also Complications) T88.9

– during
– – procedure (surgical or medical) T81.9
– – – foreign body accidentally left in body cavity or operation wound T81.5–
Rationale: The condition meets the criteria of a misadventure; thus search the lead
term “Misadventure” and the applicable subterm and select T81.5–.
Example: Deltoid bursitis following administration of vaccine
Complication, complications (from) (of)

– vaccination T88.1
Rationale: The condition is related to one of the Group A select interventions

(Step 1b); thus search the lead term “Complication, complications
(from) (of)” and a subterm denoting the specific intervention and
select T88.1.
493
Example: Wound infection following mastectomy six weeks previously
Infection
– postoperative wound T81.4 (select this T-code)
Rationale: There is a single subterm denoting post-procedural; thus T81.4

is selected.
Example: Abdominopelvic abscess three days following surgery
Abscess (embolic) (infective) (metastatic) (multiple) (pyogenic) (septic) L02.9

– abdominopelvic K65.0
– postoperative (any site) T81.4 (select the T-code)
Rationale: There is a single subterm denoting post-procedural; therefore, T81.4 is

selected. Note that the post-procedural subterm takes precedence over
the regular code that specifies the site of the abscess.
Example: Extensive pelvic adhesions following radical oophorectomy two years ago
Adhesions, adhesive (postinfective)

– pelvic (peritoneal)
– – female N73.6
– – – postprocedural N99.4 (select this PP-code)
– postoperative
– – pelvic peritoneal (female) (male) N99.4 (select this PP-code)
Rationale: There are two subterms denoting post-procedural, but since each
leads to the same code, it is equivalent to a single subterm; thus
N99.4 is selected.
Example: Postoperative pleural effusion occurring on day 2 following hepatectomy
Effusion
– pleura, pleurisy, pleuritic, pleuropericardial J90 (select the regular code)
Rationale: There is no subterm denoting post-procedural and the intervention is

not one of the identified Group B select interventions (Step 3a);
therefore, select J90.
494
Example: Postoperative pleural effusion occurring on day 2 following coronary artery bypass
graft (CABG)
Effusion
– pleura, pleurisy, pleuritic, pleuropericardial J90 (select the regular code)
Rationale: There is no subterm denoting post-procedural. The intervention is one of

the Group B select interventions (Step 3a); however, the pleural effusion
is not directly related to the in situ graft itself; therefore, select J90.
Example: Streptococcal sepsis diagnosed three days following formation of

tracheostomy stoma
Sepsis (generalized) (see also Infection) A41.9

– due to device, implant or graft (see also Complications, by site and type, infection
or inflammation) T85.7
– postprocedural T81.4 (select the T-code)
– Streptococcus, streptococcal A40.9
– tracheostomy stoma J95.01
– – site of current (healing) surgical wound T81.4
Rationale: There are two or more post-procedural subterms in the index lookups:
1. Sepsis — postprocedural (T81.4); and
2. Sepsis — tracheostomy stoma (J95.01).
Since sepsis is not directly related to the outcome of tracheostomy (an

established [healed] stoma), T81.4 is selected.
Example: Vertigo following lumbar puncture
Vertigo R42
Complication, complications (from) (of)
– lumbar puncture G97.1 (select G97.1)
Rationale: There is no subterm denoting post-procedural under the lead term

“vertigo.” Since the condition is directly related to the outcome of the
Group B select intervention lumbar puncture (effects of cerebrospinal fluid
loss), search using the lead term “Complication, complications (from) (of)”
and a specific subterm for the select intervention.
495
Note
Do not classify a post-intervention condition arising in a neonate to Chapter XVI — Certain conditions
originating in the perinatal period (P00–P96). Post-intervention conditions in a neonate are classified in
the same manner as other post-intervention conditions.
D Example: A newborn with congenital diaphragmatic hernia has hernia repair with simple
closure at eight days of age. Five days following surgery, the baby develops pleural
effusion that requires a thoracentesis.
J90 (2) A Pleural effusion, not elsewhere classified
Y83.4 (9) A Other reconstructive surgery as the cause of

Rationale: The pleural effusion arose during an uninterrupted, continuous episode

of care within the 30-day timeline; therefore, it is classified as a post-
intervention condition. There is no subterm denoting post-procedural for
pleural effusion, and hernia repair is not a select intervention; therefore,
the regular code is selected. The subterm for fetus or newborn (P28.8)
is not selected, as the pleural effusion is not considered a naturally
occurring respiratory condition originating in the perinatal period.
496
D Example: A patient is diagnosed with streptococcal sepsis three days following left-side
oophorectomy for ovarian malignancy.
T81.4 (2) A Infection following a procedure, not elsewhere

classified
A40.9 (3) A Streptococcal sepsis, unspecified
Y83.6 (9) A Removal of other organ (partial) (total), as the cause

Rationale: Streptococcal sepsis arose during an uninterrupted continuous episode

of care within the 30-day timeline and is not attributable to another
cause; therefore, it is classified as a post-intervention condition. In the
alphabetical index, a single subterm denoting post-procedural exists
under the lead term “Sepsis”; therefore, T81.4 is assigned. An additional
code, A40.9, is mandatory to further specify the type of infection.
D Example: The patient is admitted for a mechanical valve replacement. As the incision is being
closed, she arrests on the operating table. An open cardiac massage is performed
but is unsuccessful, and the patient dies in the operating room.

I46.9 (2) A Cardiac arrest, unspecified

device, as the cause of abnormal reaction of the
Rationale: Cardiac arrest is classified as a post-intervention condition because it

occurred during an uninterrupted, continuous episode of care within the
30-day timeline and is not attributable to another cause. On searching
the alphabetical index for cardiac arrest, there is no subterm denoting
post-procedural, and the cardiac arrest is not directly related to the in
situ device; therefore, the regular code I46.9 is assigned.
497
DN Example: A patient has an abdominal hysterectomy and is discharged home. She returns to
hospital with a wound infection.
T81.4 (M) MP A Infection following a procedure,

Y83.6 (9) OP A Removal of other organ (partial) (total), as the

cause of abnormal reaction of the patient, or of
later complication, without mention of misadventure
Rationale: Wound infection is classified as a post-intervention condition

because a relationship to the intervention is inherent in the diagnosis.
The alphabetical index leads to T81.4.
DN Example: The patient presents to hospital for lysis of extensive pelvic adhesions due to
previous radical oophorectomy.
N99.4 (M) MP A Postprocedural pelvic peritoneal adhesions
Y83.6 (9) OP A Removal of other organ (partial) (total), as the

cause of abnormal reaction of the patient, or of
later complication, without mention of misadventure
Rationale: The pelvic adhesions are classified as a post-intervention condition

because there is a documented cause/effect relationship. A single
subterm denoting post-procedural exists under the lead term
“Adhesions”; therefore, N99.4 is assigned.
498
N Example: The patient has a tonsillectomy and is discharged without any apparent problems.
She returns to the hospital the next day complaining of significant pain.
The physician prescribes ibuprofen for the “postoperative pain” and advises
the patient to return if there are any further problems.
R52.0 MP A Acute pain
Y83.6 OP A Removal of other organ (partial) (total), as the

time of the procedure.
Rationale: On readmission, cause/effect must be clearly documented. In this example,

the physician has described the pain as postoperative, thereby establishing
the relationship. This example also illustrates that a symptom that meets
the definition equally qualifies as a post-intervention condition. On
searching the alphabetical index for pain, there is a single subterm
denoting post-procedural; therefore, R52.0 is assigned.
D Example: The patient has a relatively uneventful postoperative course following single-lung
transplantation for primary pulmonary hypertension; however, on postoperative
day 32 of the admission, she develops pleural effusion requiring thoracentesis. CT
scans are suspicious for fungal lung infection, but no definite infectious cause is
documented. The discharge summary reads, in part, “post-transplant pleural
effusion of undetermined cause.”
J90 (2) A Pleural effusion, not elsewhere classified
Y83.0 (9) A Surgical operation with transplant of whole organ

or tissue as the cause of abnormal reaction of the
Rationale: Although the pleural effusion arose after 30 days, it is documented as

having a cause/effect relationship and, therefore, is classified as a post-
intervention condition. On searching the alphabetical index for pleural
effusion, there is no subterm denoting post-procedural, and transplant is
not a select intervention; therefore, the regular code J90 is assigned.
499
D Example: On day 5 following surgery for pinning of a fracture of the femur, this elderly patient
is transferred from Hospital A to Hospital B to be closer to family. On postoperative
day 10 in Hospital B, the patient develops atelectasis requiring fiber optic
bronchoscopy to aspirate secretions.

Rationale: The atelectasis is classified as a post-intervention condition at Hospital B

because it arose within 30 days of the intervention during an uninterrupted,
continuous inpatient episode of care and is not attributable to another
cause. On searching the alphabetical index for atelectasis, there is no
subterm denoting post-procedural, and the atelectasis is not directly related
to the in situ device itself; therefore, the regular code J98.10 is assigned.
DN Example: The patient has an inguinal hernia repair and develops nausea and vomiting
following surgery, which settles quickly on its own.

R11.3 (3) OP A Nausea with vomiting
Y83.4 (9) OP A Other reconstructive surgery as the cause of

Rationale: Although nausea and vomiting do not meet the criteria for significance in
this example, when codes are assigned to describe a post-intervention
condition, the directive statements related to post-intervention condition
code assignment apply.
500
D Example: Two days following elective surgery for graft replacement of an abdominal aortic
aneurysm, the patient develops respiratory failure requiring ventilator support.
J95.2 (2) A Acute pulmonary insufficiency following

nonthoracic surgery
Y83.2 (9) A Surgical operation with anastomosis, bypass or graft

Rationale: Per the alphabetical index, respiratory failure following surgery is

classified to a code in category J95 based on whether it is acute or
chronic and, if it is acute, whether the surgery was thoracic surgery
or nonthoracic surgery. The documentation does not specify acute
respiratory failure; however, it was of abrupt onset and in need of
decisive, prompt treatment, as compared with respiratory failure that
persists or recurs over a long period of time with little or no change,
which is considered chronic. Repair of an abdominal aortic aneurysm
is nonthoracic surgery, so J95.2 is selected. While the code title says
“acute pulmonary insufficiency,” respiratory failure is included here per
the exclusion at J96 and the alphabetical index lookup.
Residual codes
Always follow the alphabetical index to locate the appropriate code. Residual codes (.8 codes)
in the body system chapters and the injury chapter are used primarily to classify unique
conditions that exist only as a result of an intervention and thus are not classifiable elsewhere.
It is important that only conditions classified to these codes per the alphabetical index or tabular
listing be assigned to these codes.
Note
When a condition does not have a subterm denoting post-procedural, do not default to a residual T-code
(e.g., T81.88 Other complications of procedures, not elsewhere classified) or residual PP-code (e.g., K91.8 Other
postprocedural disorders of digestive system, not elsewhere classified). In these circumstances, assign the regular
code, unless the condition is directly related to a select intervention identified in the section Searching the
alphabetical index for the primary code for a post-intervention condition.
501
Note
Since residual categories primarily capture conditions that are not classifiable elsewhere, an additional code is
typically not assigned. See also the section Assignment of additional codes for specificity in this standard.
DN Example: The patient presents to hospital for management of afferent loop syndrome.
K91.8 (M) MP A Other postprocedural disorders of digestive

system, not elsewhere classified
Y83.9 (9) OP A Surgical procedure, unspecified, as the cause

Rationale: Afferent loop syndrome is a unique post-intervention condition that is

specifically indexed and classified to a residual (.8) code. It is found in
the alphabetical index as follows:
Syndrome (see also Disease)

– afferent loop NEC K91.8
An additional code to identify the nature of this post-procedural disorder

is not assigned, as there is no other place in the classification where
afferent loop syndrome is classified. This unique condition is classified
to K91.8.
502
D Example: A patient in ICU develops ventilator-associated pneumonia four days after being
intubated and started on mechanical ventilation.
J95.88 (2) A Other postprocedural respiratory disorders
J18.9 (3) A Pneumonia, unspecified

the procedure
Rationale: Ventilator-associated pneumonia is not a unique post-intervention

condition, but it is specifically indexed and classified to a residual (.8)
code. It is found in the alphabetical index as follows:
Pneumonia
– ventilator-associated (VAP) J95.88
There is a “use additional code” instruction at J95.88 to identify the

specific type of pneumonia, and J18.9 is assigned.
Assignment of additional codes for specificity
When a post-intervention condition is classified to a code that does not fully describe the condition, assign
DN
an additional code (when available), mandatory, as a diagnosis type (3)/other problem to provide more
detail regarding the nature of the condition.
Note
The following do not qualify as additional codes for specificity:
• Symptoms associated with the post-intervention condition;
• Situations where codes or clinical concepts are mutually exclusive; and
• Any additional or subsequent post-intervention condition(s). Additional and subsequent post-intervention

conditions are conditions in and of themselves and are subject to diagnosis typing/problem definitions.
See also the coding standard Underlying Symptoms or Conditions.
503
Note
An additional code is assigned when required and when available whether or not a “use additional code”
instruction exists at the code.
D Example: A patient seen in the cardiology clinic is started on antibiotics for symptoms
related to subacute infective endocarditis. On referral to hospital for admission,
the patient’s condition is described as prosthetic valve endocarditis.
T82.6 (M) A Infection and inflammatory reaction due to cardiac

valve prosthesis
I33.0 (3) A Acute and subacute infective endocarditis

Rationale: The alphabetical index leads to T82.6 for infection due to or resulting
from a heart valve prosthesis. This code does not identify the type of
infection associated with the prosthesis; therefore, I33.0 is assigned to
add this specificity.
DN Example: Post–spinal tap headache treated with blood patch

G97.1 (2) OP A Other reaction to spinal and lumbar puncture
R51 (3) OP A Headache
Y84.4 (9) OP A Aspiration of fluid as the cause of abnormal

the procedure
Rationale: The alphabetical index leads to G97.1, which does not specify the
type of reaction to the spinal tap; therefore, R51 is assigned to add
this specificity.
504
DN Example: A patient presents for treatment of a wound infection. He had suffered an open
wound of his arm that was treated by cleansing and suturing one day previously.
T81.4 (M) MP A Infection following a procedure, not


Rationale: T81.4 does not specify the type of infection; however, an additional code
is not available to describe a wound infection.
D Example: A patient is readmitted for closed reduction of a dislocated left total hip replacement
with no preceding trauma.

T84.031 (M) A Mechanical complication of hip prosthesis, instability

Rationale: The alphabetical index leads to T84.031 for dislocation, hip, prosthesis.
While the code title identifies the mechanical complication as instability,
it is not specific to dislocation. However, adding a code from category
S73.0 Dislocation of hip is not appropriate because these codes relate
to mutually exclusive concepts. One code (T84.031) is for a problem
with the components of the artificial hip (prosthesis) and the other
(S73.0–) is for a problem with the bones that make up the natural hip.
505
Assignment of external cause code
When more than one post-intervention condition of the same nature is related (attributable) to the same
DN
intervention episode, assign the external cause code only once.
When there are post-intervention conditions associated with separate intervention episodes, assign an
DN external cause code for each episode, even when it means repeating the external cause code.
Note
A post-intervention condition “of the same nature” pertains to the external cause code. The post-intervention
conditions are
• All misadventures (Y60–Y69);
• All adverse incidents associated with medical devices (Y70–Y82); or
• All abnormal reactions/later complications (Y83–Y84). Note that Y83–Y84 includes both abnormal
reactions and later complications.
D Example: The patient is admitted for an abdominal hysterectomy. On postoperative day 2,

she experiences urinary retention and atelectasis requiring further treatment
and monitoring.
Y83.6 (9) A Removal of other organ (partial) (total), as the

Rationale: A single external cause code is assigned because both conditions are
of the same nature (abnormal reactions) and are related to the same
intervention episode.
506
D Example: The patient is admitted for removal and replacement of an infected knee prosthesis
that was implanted six months ago. Following the revision procedure, the patient
develops deep vein thrombosis, which prolongs the stay by more than one week.
T84.54 (M) A Infection and inflammatory reaction due to

knee prosthesis

T81.7 (2) B Vascular complications following a procedure, not

I80.2 (3) B Phlebitis and thrombophlebitis of other deep vessels

of lower extremities
Y83.1 (9) B Surgical operation with implant of artificial internal

Rationale: These post-intervention conditions are related to separate intervention

episodes. An external cause code is assigned for each intervention
episode, even though it is the same Y83 code (both the original
intervention and the revision are classified to implant of a device).
Repeating the identical external cause code indicates that there were
multiple intervention episodes of this type (implant of device) that
resulted in a post-intervention condition.
DN
When different types of interventions are performed during the same intervention episode and it is
unclear to which intervention the post-intervention condition is related (attributable), select the (.9)
unspecified subcategory for the external cause code.
507
D Example: The patient undergoes an abdominal hysterectomy with anterior and posterior (A & P)
repair. On postoperative day 2, she experiences urinary retention and atelectasis
requiring treatment and monitoring.
Y83.9 (9) A Surgical procedure, unspecified as the cause

Rationale: It is unclear from the documentation whether the urinary retention and
atelectasis are related to the A & P repair (Y83.4) or to the hysterectomy
(Y83.6); therefore, the unspecified code Y83.9 is assigned.
See also Y83–Y84 Inclusion List in Appendix B and the following coding standards:
• Diagnosis Cluster
• Complications of Devices, Implants or Grafts
• Early Complications of Trauma
• Misadventures During Surgical and Medical Care
• Occlusion Following Coronary Artery Bypass Grafts (CABGs)
• Rejection/Failure of Transplanted Organs, Grafts and Flaps
508
Rejection/Failure of Transplanted Organs,

Grafts and Flaps
When the source of an organ or tissue is another person (homograft) or animal (xenograft) and a
DN
complication of the organ, graft or flap is failure or absolute rejection, assign a code from the category
T86 Failure and rejection of transplanted organs and tissues.
DN
Do not use category T86 when the original source of the graft or flap is the patient’s own
body (autograft).
Note
For rejection/failure and complications of grafts for treatment of burns, see also the coding standard
Burns and Corrosions.
D Example: The patient is admitted with kidney transplant (homograft) rejection.
T86.100 (M) A Kidney transplant rejection
Y83.0 (9) A Surgical operation with transplant of whole organ as

the cause of abnormal reaction of the patient, or later
509
DN Example: The patient is seen in hospital for management of necrosis of a myocutaneous

breast flap.
T85.8 (M) MP A Other complications of internal prosthetic devices,

implants and grafts, not elsewhere classified
R02 (3) OP A Gangrene, not elsewhere classified
Y83.2 (9) OP A Surgical operation with anastomosis, bypass or

graft, as the cause of abnormal reaction of the
Rationale: Category T86 is not used when a flap is sourced from the patient’s
own body.
DN
When a condition is documented as affecting the transplanted organ or tissue but it cannot be classified
as either failure or rejection, assign a code for the condition and assign an additional code from category
Z94 Transplanted organ and tissue status, optional, as a diagnosis type (3)/other problem.
When it is unclear from the documentation whether the condition is a result of failure/rejection or a
DN
disease process, seek clarification from the physician.
Certain conditions, such as pre-existing chronic hepatitis C virus infection, may affect the
transplanted organ and not be a result of the transplant itself. Other conditions, such as cancer
arising in a transplanted organ or tissue, may be due to long-term immunosuppression of the
patient. These are not classified as failure or rejection of the transplanted organ.
DN Example: The patient had a liver transplant due to damage from chronic hepatitis C virus
infection two years ago. He has developed hepatitis C infection damage in his
transplanted liver.
Code Code title
B18.2 Chronic viral hepatitis C
Z94.4 Liver transplant status (optional)
510
DN Example: The patient develops renal cell carcinoma in a transplanted kidney five
years post-transplant.
Code Code title
C64 Malignant neoplasm of kidney, except renal pelvis
Z94.0 Kidney transplant status (optional)
Complications of Devices, Implants or Grafts

Internal devices, implants and grafts used for diagnostic and therapeutic purposes may
themselves fail to perform as intended or may produce undesirable effects. When a problem
with the product or a problem that is caused by the product is the result of intrinsic (internal)
forces, it is considered a post-intervention condition. When a problem with the product or a
problem that is caused by the product is the result of extrinsic (external) forces (V01–X59
Accidents), it is not considered a post-intervention condition. This coding standard addresses
the code assignment for a variety of circumstances that are encountered for patients with
internal devices, implants and grafts and is organized by circumstances involving intrinsic
(internal) forces and those involving extrinsic (external) forces (V01–X59 Accidents).
See also the coding standards Occlusion Following Coronary Artery Bypass Grafts (CABGs),
Rejection/Failure of Transplanted Organs, Grafts and Flaps and Post-Intervention Conditions.
There are three major categories in which to classify complications of internal devices:
Mechanical complications Infection/inflammation Other complications
Breakdown (mechanical) Assign an additional code to identify Embolism

Broken (device) (e.g. fractured) any documented septicemia, Fibrosis
Displacement mandatory. See also the coding Hemorrhage
Leakage standard Septicemia/Sepsis. Pain
Malfunction Stenosis
Assign an additional code,
Malposition Stricture
optional, to identify the organism,
Obstruction Thrombosis
as applicable.
Perforation
Assign an additional code,
Protrusion
mandatory, to identify the
Retention (retained)*
specific complication.
511
Notes
• * An intact device that was intended (expected) to be left in the body (e.g., an intrauterine device [IUD])
that is described as retained is classified as a mechanical complication. It is not classified as a foreign body.
• * An intact device that was not intended (expected) to be left in the body (such as a guidewire) that is
retained following a procedure is classified to T81.5– Foreign body accidentally left in body cavity or
operation wound following a procedure. See the coding standard Misadventures During Surgical and
Medical Care.
Intrinsic forces: Complications excluding malfunction

and breakage
Complications involving intrinsic (internal) forces are ones that arise from within; that is, they
are not attributable to an external force. Extrinsic (external) forces include events classified to
V01–X59 Accidents. Events due to extrinsic forces and malfunction and breakage due to
intrinsic forces are addressed separately.

When a complication of an internal device, implant or graft (excluding malfunction and breakage) is
DN
attributed to intrinsic forces, assign
• A code from categories T82–T85 for the specific complication:
− T82.– Complications of cardiac and vascular prosthetic devices, implants and grafts;
− T83.– Complications of genitourinary prosthetic devices, implants and grafts;
− T84.– Complications of internal orthopaedic devices, implants and grafts; or
− T85.– Complications of other internal devices, implants and grafts;
And
• An external cause code from the range Y83–Y84 Surgical and other medical procedures as the cause of
abnormal reaction of the patient, or of later complication, without mention of misadventure at the time
of the procedure.
512
D Example: The patient is admitted for revision of his total hip replacement prosthesis due
to loosening and displacement of the hardware.
T84.030 (M) A Mechanical complication of hip prosthesis, loosening

Rationale: Loosening and displacement are considered a “mechanical

complication.” Y83.1 is assigned, as the loosening and displacement
of the device is not documented as being related to malfunction or
breakage or associated with an extrinsic force (V01–X59 Accidents).
D Example: The patient develops staphylococcal septicemia, documented as due to infection

from a PICC line.
T82.701 (M) A Bloodstream infection and inflammatory reaction due

to central venous catheter

the procedure
Rationale: When an infective process is attributable to a device, a code for

“infection and inflammatory reaction” is assigned. Y84.8 is assigned,
as the infective process is not related to malfunction or breakage
or associated with an extrinsic force (V01–X59 Accidents).
513
DN Example: The patient has pain in his right hip due to a hip prosthesis. No dislocation or
displacement is identified on X-rays.
T84.8 (M) MP A Other complications of internal orthopaedic

prosthetic devices, implants and grafts
M25.55 (3) OP A Pain in joint, pelvic region and thigh

Rationale: Pain that is directly attributable to a device, implant or graft is

assigned to “other complications.” Y83.1 is assigned, as the pain is
not related to malfunction or breakage or associated with an extrinsic
force (V01–X59 Accidents).
DN Example: The patient presents for removal of retained IUD.

T83.3 (M) MP A Mechanical complication of intrauterine
contraceptive device
Y84.8 (9) OP A Other medical procedures as the cause of

Rationale: A medical device intended (expected) to be in the body that is described

as retained is classified as a mechanical complication. It is not classified
as a foreign body. Y84.8 is assigned in this case, as the mechanical
complication is not related to malfunction or breakage or associated
with an extrinsic force (V01–X59 Accidents).
514
Intrinsic forces: Malfunction or breakage

Complications involving intrinsic (internal) forces are ones that arise from within; that is, they
are not attributable to an external force. Extrinsic (external) forces include events classified to
V01–X59 Accidents and are addressed in another directive box below.

When an internal device unexpectedly malfunctions or breaks, and the malfunction/breakdown is attributed
DN to an intrinsic force, assign
• A code for mechanical complication from the applicable category T82–T85; and
• An external cause code from the range Y70–Y82 Medical devices associated with adverse incidents in
diagnostic and therapeutic use.
Note
External cause codes from the range Y70–Y82 Medical devices associated with adverse incidents in diagnostic
and therapeutic use are assigned exclusively for unexpected malfunctioning or breakage of a device.
D Example: The patient presents for urgent replacement of pacemaker lead due to fracture of
the right ventricular lead.

T82.1 (M) A Mechanical complication of cardiac electronic device
Y71.2 (9) A Cardiovascular devices associated with adverse

incidents, prosthetic and other implants, materials
and accessory devices
Rationale: A broken device (fractured lead) is classified as a mechanical

complication. When a broken (or malfunctioning) device is not
associated with an extrinsic force (V01–X59 Accidents), the external
cause code is selected from Y70–Y82.
515
DN Example: This 85-year-old gentleman has an implanted defibrillator to control ventricular

tachycardia that goes off while he is walking home. It continues to go off more than
six times prior to admission. The doctor’s final diagnosis is ventricular tachycardia
due to malfunctioning defibrillator. The malfunctioning defibrillator is replaced.
T82.1 (M) MP A Mechanical complication of cardiac

electronic device
Y71.2 (9) OP A Cardiovascular devices associated with adverse

incidents, prosthetic and other implants, materials
and accessory devices.
I47.2 (1) OP — Ventricular tachycardia
Rationale: The defibrillator failed to perform properly (malfunctioned). When a

malfunctioning (or broken) device is not associated with an extrinsic
force (V01–X59 Accidents), the external cause code is selected
from Y70–Y82.
Extrinsic forces: Mechanical complication

Complications involving extrinsic (external) forces are ones that include events classified to
V01–X59 Accidents.
DN
When a mechanical complication (of any type) of an internal device is attributed to an extrinsic
force, assign
• A code for mechanical complication from the applicable category T82–T85; and
• An external cause code from the range V01–X59 Accidents.
Note
Do not classify a mechanical complication of a device that is attributed to an extrinsic force as a post-
intervention condition. This includes not assigning a diagnosis cluster.
516
DN Example: The patient falls off her chair at home and dislocates her hip prosthesis.
T84.031 (M) MP — Mechanical complication of hip

prosthesis, instability
W07 (9) OP — Fall involving chair
U98.0 (9) OP — Place of occurrence, home
Rationale: The mechanical complication of the hip prosthesis was the result of
an extrinsic force (fall). The external cause code describing the
extrinsic force (V01–X59 Accidents) is assigned (W07). As this is
not a post-intervention condition, no diagnosis cluster is assigned.
DN Example: In the nursing home, the patient trips on his urinary catheter line and accidentally
pulls out the catheter, which results in a laceration to the urethra.

T83.0 (M) MP — Mechanical complication of urinary
(indwelling) catheter
S37.311 (3) OP — Laceration of urethra, with open wound into cavity
W49 (9) OP — Exposure to other and unspecified inanimate

mechanical forces
U98.1 (9) OP — Place of occurrence, residential institution
Rationale: The laceration of the urethra by the catheter is a mechanical

complication (all injuries caused by a device are mechanical
complications). The external cause code describing the extrinsic force
(inanimate mechanical force) is assigned (W49). As this is not a post-
intervention condition, no diagnosis cluster is assigned.
517
DN Example: During his hospital admission, a patient intentionally pulls out his inflated Foley
catheter, which results in an injury to the urethra causing bleeding and clots.
Following his injury, the patient is monitored for urethral bleeding for three days.
T83.0 (2) MP — Mechanical complication of urinary

(indwelling) catheter
S37.391 (3) OP — Injury NOS of urethra, with open wound into cavity
W49 (9) OP — Exposure to other and unspecified inanimate

mechanical forces
U98.20 (9) OP — Place of occurrence, hospital
Rationale: The injury to the urethra by the catheter is a mechanical complication (all
injuries caused by a device are mechanical complications).The external
cause code describing the extrinsic force (inanimate mechanical force)
is assigned (W49). As this is not a post-intervention condition,
no diagnosis cluster is assigned.
Misadventures During Surgical and

Medical Care
This coding standard addresses the assignment of an external cause code from the range
Y60–Y69 Misadventures to patients during surgical and medical care.
An injury or an adverse event that causes harm during the provision of surgical and medical
care is classified as a misadventure in ICD-10-CA and identified using external cause codes
from the range Y60–Y69 Misadventures to patients during surgical and medical care.
When an adverse event occurs but there is no associated harm, no codes are assigned. CIHI’s
clinical administrative databases are not incident reporting systems that collect data on the
occurrence of any and all events related to patient safety. To submit codes to CIHI’s clinical
administrative databases, there must be an injury or harm from an adverse event.
518
This coding standard addresses

• Applying the definition for misadventure;
• Basic code assignment for misadventures; and
• Particular requirements related to three specific types of misadventures — hemorrhage,
puncture/laceration/perforation and foreign body.
See also the coding standards Post-Intervention Conditions and Adverse Reactions in
Therapeutic Use Versus Poisonings.
Misadventure code assignment

Code assignment for a misadventure consists of all of the following:
• A primary code from one of seven specific categories or blocks
- N98 Complications associated with artificial fertilization; or
- T20–T32 Burns and corrosions; or
- T36–T50 Poisoning by drugs, medicaments and biological substances; or
- T66 Unspecified effects of radiation or a code for the specific effect; or
- T80 Complications following infusion, transfusion and therapeutic injection; or
- T81 Complications of procedures, not elsewhere classified; or
- T88 Other complications of surgical and medical care, not elsewhere classified
(Locate the correct primary code by searching the alphabetical index lead term
“Misadventure” and the applicable subterm.)
• An additional code for specificity when applicable.
• An external cause code from the misadventures block Y60–Y69.
DN Misadventure code assignment, as described above, applies only when there is documentation of
• An injury during the provision of care; or
• Harm that resulted from an adverse event during the provision of care.
Note
No codes are assigned when there is no harm to the patient from an adverse event.
519
Note
Direction for when to assign a significant diagnosis type/main or other problem specific to the following types of
misadventures is located within subsections of this standard. Refer to these when applicable.
• Intraoperative hemorrhage;
• Puncture/laceration/perforation during a procedure; and
• Foreign body accidentally left following a procedure.
Note
A misadventure may be apparent at the time of the provision of care, or it may be identified following the
provision of care.
D Example: The patient is admitted for right oophorectomy; after the patient leaves the
operating room, it becomes apparent that a left oophorectomy was inadvertently
performed. This is confirmed on diagnostic imaging, and the physician progress
notes outline the discussion with the patient. The patient returns to the operating
room and a right oophorectomy is performed.

T88.8 (2) A Other specified complications of surgical and
medical care, not elsewhere classified
Y65.5 (9) A Performance of inappropriate operation during

surgical and medical care
Rationale: Code assignment for a misadventure applies (i.e., harm resulted from
an adverse event during the provision of care). The performance of an
incorrect operation resulted in harm (normal ovary removed, diseased
ovary remains).
520
D Example: The patient presents in labor. An epidural is administered to the patient. When it is noted
that the epidural is not working, it is discovered that penicillin G was administered into
the epidural space rather than the usual anesthetic mixture (incorrect IV bag). No
treatment is given to the patient, other than close observation for signs and/or symptoms
of an allergic reaction, which do not occur. The patient delivered a healthy newborn.
Code DAD Code title

Rationale: An adverse event is documented (wrong drug given) but there is no harm
to the patient; therefore, no codes are assigned. See also the coding
D Example: The patient is admitted with shingles and placed on acyclovir. There is a
transcription error in the medication orders, and a double dose of acyclovir is given.
Creatinine level subsequently rises to more than 400. The patient is seen by the
nephrology service and is diagnosed with acyclovir-induced crystal acute tubular
necrosis. After six days of intravenous hydration and discontinuation of the
acyclovir, renal function returns to normal and the patient is discharged home.

T37.5 (2) A Poisoning by antiviral drugs
N14.1 (3) A Nephropathy induced by other drugs, medicaments and

Y63.8 (9) A Failure in dosage during other surgical and medical care
X44 (9) A Accidental poisoning by and exposure to other and

unspecified drugs, medicaments and biological substances
U98.20 (9) A Place of occurrence, hospital
Rationale: An adverse event (poisoning — double dose of a drug) that resulted

in harm (acyclovir-induced crystal acute tubular necrosis) occurred
during the provision of medical care; therefore, code assignment for a
misadventure applies. Note that while there is an exclusion at Y63 for
accidental overdose of drug or wrong drug given in error (X40–X44), this
does not preclude using these two external codes on the same abstract.
One describes that there was an accidental poisoning, and the other
describes that there was a misadventure.
521
N Example: The patient experiences a burn to the chest wall as a result of radiation therapy for
lung cancer. The documentation reveals that the exposure time was inadvertently
prolonged. Cold compresses are applied to relieve the patient’s discomfort.
T21.0 OP A Burn of unspecified degree of trunk
T31.00 OP A Burns involving less than 10% of body surface with

0% or unspecified third degree burns
Y63.2 OP A Overdose of radiation given during therapy
Rationale: Code assignment for a misadventure applies (i.e., harm resulted from an
adverse event during the provision of care). A burn is documented as
being due to prolonged exposure time.
D Example: The patient experiences a burn to the chest wall as a result of radiation therapy for
lung cancer during the current episode of care.
T21.0 (2) A Burn of unspecified degree of trunk
T31.00 (2) A Burns involving less than 10% of body surface with
0% or unspecified third degree burns
Y65.8 (9) A Other specified misadventures during surgical and

medical care
Rationale: Code assignment for a misadventure applies (i.e., injury during

the provision of care). A burn is documented as resulting from
radiation therapy.
522
DN Example: The patient is admitted in acute renal failure and is put on fluid restriction; however,
intravenous fluids are given to the patient in error, which leads to fluid overload.
T80.8 (2) OP A Other complications following infusion, transfusion

and therapeutic injection
E87.7 (3) OP A Fluid overload
Y65.8 (9) OP A Other specified misadventures during surgical and

medical care
Rationale: In this example, code assignment for a misadventure applies (i.e., harm
resulted from an adverse event during the provision of care). Fluid overload
(harm to the patient) is documented as being due to accidental
administration of fluids.
D Example: Three days following mitral valve replacement, the patient develops fluid overload.
Management of this condition prolongs the stay.

E87.7 (2) A Fluid overload

Rationale: In this example, fluid overload is not classified as a misadventure

because there is no documentation that the fluid overload was the result
of any adverse event during the provision of care. Therefore, the fluid
overload is classified as an abnormal reaction/later complication (Y83.1).
523
DN Example: The patient sustains multiple rib fractures associated with chest compressions
during cardiopulmonary resuscitation.
T81.88 (2) OP A Other complications of procedures, not

S22.490 (3) OP A Multiple fractures of unspecified number of

ribs, closed

medical care
Rationale: Code assignment for a misadventure applies (i.e., injury during the
provision of care). The rib fractures are documented as being due to the
performance of cardiopulmonary resuscitation.
DN Example: The patient has laparoscopic oophorectomy for an ovarian cyst. Postoperatively,
she reports an area of numbness along her left lateral thigh, which the surgeon
diagnoses as postoperative sensory neurapraxia secondary to position compression
at the time of her surgery.
T81.88 (2) OP A Other complications of procedures, not

S74.28 (3) OP A Other and unspecified injury of cutaneous sensory

nerve at hip and thigh level

medical care
provision of care). The nerve injury is documented as being due to
position compression at the time of surgery.
524
D Example: Following hip replacement surgery, this patient has femoral palsy that is documented
as being secondary to a retractor used during the surgery. The femoral palsy affects
the recovery period and extends the length of stay.
T81.88 (2) A Other complications of procedures, not

S74.18 (3) A Other and unspecified injury of femoral nerve at hip

and thigh level
Y65.8 (9) A Other specified misadventures during surgical and

medical care
provision of care). The nerve injury is documented as being secondary
to a retractor used during surgery.
D Example: The patient presents for laparoscopic oophorectomy due to a left hemorrhagic
ovarian cyst. During insertion of the camera, an old clot is seen within the lumen of
the trocar. The camera and trocar are removed and the trocar is passed off the
field. The clot appears to be the result of a poorly cleaned trocar. A new trocar is
inserted and the abdomen inspected. An incident report is filed and antibiotics
initiated due to concern for potential infection from the contaminated port.
Code DAD Code title
N83.2 (M) Other and unspecified ovarian cysts
Rationale: Misadventure code assignment does not apply because no harm

to the patient is documented from the adverse event (use of a
contaminated instrument).
Intraoperative hemorrhage
While a hemorrhage that occurs intraoperatively is considered a misadventure (Y60–Y69), the
hemorrhage must meet select criteria to assign a significant diagnosis type. A hemorrhage that
occurs postoperatively is not a misadventure; it is classified as a later complication (Y83–Y84).
525
DN When intraoperative blood loss/hemorrhage meets one of the criteria for significance described
below, assign
• T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified as a significant
diagnosis type/main or other problem; and
• An external cause code from category Y60 Unintentional cut, puncture, perforation or haemorrhage
during surgical and medical care.
Note
Blood loss/hemorrhage occurring intraoperatively meets the criteria for significance when it
• Is described by the physician as substantial, massive, torrential or difficult to control, or using similar
terminology; or
• Requires consultation by another surgeon/specialty; or
• Requires an intervention for control of bleeding; or
• Requires postoperative monitoring and/or investigation impacting length of stay.
Note
Do not assign T81.0 Haemorrhage and haematoma complicating a procedure, not elsewhere classified and an
external cause code from category Y60 Unintentional cut, puncture, perforation or haemorrhage during surgical
and medical care when
• Documentation does not indicate there is an intraoperative hemorrhage, regardless of amount of blood loss
documented; and
• Intraoperative blood loss is a direct result of disease or trauma (e.g., bleeding ulcers, bleeding varices or
ruptured aneurysm).
Note
Do not assume that administration of blood or blood products during surgery or that anemia following
surgery is an indication that a hemorrhage has occurred. Blood or blood products are often given during
surgery to prevent anemia or after surgery to treat anemia in patients where significant blood loss is
expected. See also the coding standard Acute Blood Loss Anemia.
526
D Example: The patient is admitted to hospital for an abdominal hysterectomy. During the
intervention, a hemorrhage occurs that is documented on the operative report as being
substantial and with an estimated blood loss of 800 cc. The hemorrhage is controlled
and the patient stabilized; the intervention is completed without further incident.
T81.0 (2) A Haemorrhage and haematoma complicating a


Rationale: The hemorrhage occurred intraoperatively and the physician describes

the hemorrhage as “substantial”; therefore, T81.0 meets the criteria for
significance and is assigned a significant diagnosis type.
D Example: The patient sustains a traumatic abdominal aortic disruption with significant blood
loss as a result of a single gunshot wound to the abdomen following a hunting
accident. The aorta is repaired with a tube graft, and the patient receives 20 units
of packed red blood cells during the intervention. Despite aggressive resuscitation,
the patient continues to have significant hemorrhage from the abdomen and dies.
Code DAD Code title

S35.0 (M) Injury of abdominal aorta
W33 (9) Rifle, shotgun and larger firearm discharge
U98.9 (9) Other specified place of occurrence
Rationale: The intraoperative blood loss is a direct result of the traumatic aortic
injury; therefore, do not assign T81.0.
Puncture/laceration/perforation during a procedure

While any puncture/laceration/perforation during a procedure is considered a misadventure
(Y60–Y69), the puncture/laceration/perforation must meet select criteria to assign a significant
diagnosis type.
527
DN
When a puncture/laceration/perforation during a procedure meets one of the criteria for significance
described below assign
• T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified as a significant
diagnosis type/main or other problem; and
• An external cause code from category Y60 Unintentional cut, puncture, perforation or haemorrhage
during surgical and medical care.
Note
An accidental puncture/laceration/perforation during a procedure meets the criteria for significance when it
• Requires consultation by another surgeon/specialty; or
• Requires a return to the operating room; or
• Requires repair or removal of the damaged organ, which would not have otherwise been
repaired/removed; or
• Is a dissection during cardiac catheterization/angioplasty that requires stenting for repair; or
• Is a reason for readmission to hospital; or
• Requires postoperative monitoring and/or investigation impacting length of stay; or
• Requires an additional different intervention.
Note
For the purposes of assigning an additional code to identify the site of the laceration/puncture/perforation
from Chapter XIX — Injury, poisoning and certain other consequences of external causes (S00–T98), select the
sixth character “with open wound into cavity.”
See also the coding standards Post-Intervention Conditions and Assignment of Additional Codes for Specificity.
Note
Do not assign T81.2 when a laceration occurs to a diseased organ that is being removed as part of the original
planned surgery.
528
DN Example: The patient has a cholecystectomy during which a tear in the gallbladder occurs
with spillage of gallstones. Routine removal with cleanup of gallstones is done.
Nil Do not code the tear to the gallbladder. It is being removed as part of
the surgery.
D Example: A 54-year-old patient is admitted for cancer of the sigmoid colon. During colectomy,
laceration of the splenic capsule is noted and a splenectomy is required.
C18.7 (M) — Malignant neoplasm of sigmoid colon
T81.2 (2) A Accidental puncture and laceration during a

S36.091 (3) A Haematoma NOS, laceration NOS, injury to spleen

NOS, with open wound into cavity

Rationale: The splenic laceration meets the criteria for significance because it
required removal of an organ that would not have otherwise been
removed; therefore, T81.2 is assigned a significant diagnosis type.
The sixth character “with open wound” is selected for the additional
code S36.091.
529
DN Example: The patient presents for lysis of abdominal adhesions. During the procedure, an
intraoperative laceration to the kidney occurs, requiring an intraoperative consult to
ensure viability of the organ. The kidney is subsequently repaired with suturing.
K66.0 (M) MP — Peritoneal adhesions
T81.2 (2) OP A Accidental puncture and laceration during a

S37.011 (3) OP A Laceration of kidney (without urinary

extravasation), with open wound into cavity
Y60.0 (9) OP A Unintentional cut, puncture, perforation or

Rationale: T81.2 meets the criteria for significance because the laceration was
repaired. Even if it had not been repaired, it would have met the criteria
for significance because there was an intraoperative consult. The sixth
character “with open wound” is selected for the additional code S37.011.
DN Example: The patient sustains an intraoperative laceration to the bowel during laparoscopic
tubal ligation. The surgeon places two sutures in the bowel for repair with no further
consequences or monitoring.
Z30.2 (M) MP — Sterilization

S36.511 (3) OP A Laceration of colon, with open wound into cavity

Rationale: T81.2 meets the criteria for significance because the laceration was
repaired. The sixth character “with open wound” is selected for the
additional code S36.511.
530
DN Example: During colonoscopy in day surgery, a polypectomy of the large intestine is

performed, and an inadvertent puncture is made in the large intestine. Four clips are
applied, and India ink is used to mark the area. The physician documents that the
patient will be admitted as an inpatient overnight because of the perforation to the
bowel. Pathology report reveals benign neoplasm of large intestine.
D12.6 (M) MP — Benign neoplasm of colon, unspecified

S36.511 (3) OP A Laceration of colon, with open wound into cavity

haemorrhage during endoscopic examination
Rationale: T81.2 meets the criteria for significance on the day surgery abstract
because the puncture was repaired. Even if it had not been repaired,
it would have met the criteria for significance because it required
postoperative monitoring impacting the length of stay. The sixth
character “with open wound” is selected for the additional code S36.511.
Foreign body accidentally left following a procedure

A foreign body that is accidentally left following a procedure must meet select criteria to be
assigned a significant diagnosis type.

When an intact device not intended to remain in the body is inadvertently left behind following a procedure
DN and one of the criteria for significance as described below is met, assign
• A code from subcategory T81.5– Foreign body accidentally left in body cavity or operation wound
following a procedure as a significant diagnosis type/main or other problem; and
• An external cause code from category Y61 Foreign object accidentally left in body during surgical or
medical care.
531
Note
A foreign body accidentally left following a procedure meets the criteria for significance when it
• Requires a return to the operating room for its removal; or
• Is a reason for readmission to hospital; or
• Requires an additional intervention for its removal; or
• Requires postoperative monitoring and/or investigation impacting length of stay.
Note
When an intact device that was intended (expected) to be left in the body (such as an IUD) is described as
retained, it is classified as a mechanical complication. See the coding standard Complications of Devices,
Implants or Grafts.
DN Example: The patient has a left hip replacement performed. The operative report documents
that after closure of the wound and while the patient is still in the operating room,
one small surgical sponge is noted to be missing in the sponge count. Intraoperative
X-ray confirms a sponge marker within the acetabulum; therefore, the patient is fully
reprepped and draped, and the incision is reopened to remove the sponge.
T81.57 (2) OP A Foreign body accidentally left in body cavity or

operation wound following a procedure, without
mention of any complication
Y61.0 (9) OP A Foreign object accidentally left in body during

surgical operation
Rationale: The sponge was inadvertently left behind following the procedure and
it meets one of the criteria for significance. It required an additional
intervention for its removal. T81.57 is selected, as no complication
subsequent to the foreign body has been documented.
532
DN Example: The patient has a central line insertion, and the guidewire used to introduce the
catheter is inadvertently left behind in the superior vena cava. Under ultrasound
guidance, the guidewire is removed using a gooseneck snare inserted into the
internal jugular vein by the radiologist.
T81.57 (2) OP A Foreign body accidentally left in body cavity or

operation wound following a procedure without
mention of any complication
Y61.6 (9) OP A Foreign object accidentally left in body during

aspiration, puncture and other catheterization
Rationale: The guidewire was inadvertently left behind following the procedure and
it meets one of the criteria for significance. An additional intervention
was required for its removal. T81.57 is selected, as no complication
subsequent to the foreign body has been documented.
Reference
533
Chapter XX — External causes of

morbidity and mortality
External Cause Codes
In effect 2001
See also Y83–Y84 Inclusion List in Appendix B.
DN
Assign an external cause code from V01–Y98, mandatory, as a diagnosis type (9)/other problem with any
condition classifiable to S00–T98.
DN Example:

S88.1 (M) MP Traumatic amputation at level between knee
and ankle
W58 (9) OP Bitten or struck by crocodile or alligator
DN
When an external cause can be attributed to any condition classifiable to chapters I to XVIII, assign an
additional code from V01–Y98 as a diagnosis type (9)/other problem.
DN Example:

K29.0 (M) MP A Acute haemorrhagic gastritis
Y45.3 (9) OP A Other nonsteroidal anti-inflammatory drugs

[NSAID] causing adverse effects in therapeutic use
534
Chapter XX — External causes of morbidity and mortality
Place of Occurrence
DN For any accident or poisoning classifiable to W00–Y34, excluding Y06 and Y07, assign a code from U98.–
Place of occurrence, mandatory, as a diagnosis type (9)/other problem.
DN Example: A 4-year-old child ingests approximately 10 candy-coated ibuprofen tablets at home.

T39.3 (M) MP Poisoning by other nonsteroidal anti-inflammatory
drugs [NSAID]

Type of Activity
DN With any external cause code from V01–Y98, assign a code from U99.– Activity, optional, as a diagnosis
type (9) /other problem to indicate the activity of the injured person at the time the event occurred.
DN Example: The patient falls off a ladder at work and sustains a fracture to his distal humerus.

S42.490 (M) MP Fracture of unspecified part of lower end of
humerus, closed
W11 (9) OP Fall on and from ladder
U99.2 (9) OP While working for an income (optional)
535
Chapter XXI — Factors influencing

health status and contact with
health services
Pre-Treatment Assessment

Assign Z01.8 Other specified special examination to describe an encounter for a pre-treatment assessment.
DN
DN
When a significant condition diagnosed during the pre-treatment assessment requires further treatment
or investigation, assign a code for the significant condition as the MRDx/main problem.
• Assign Z01.8 Other specified special examination, mandatory, as a diagnosis type (3)/other problem.
Assign an additional code to describe the underlying reason for the assessment, optional, as diagnosis type
DN
(3)/other problem.
N Example: A woman visits the pre-admission clinic for a pre-treatment assessment for carpal
tunnel release, which is scheduled for two weeks from now.
Z01.8 MP Other specified special examinations
G56.0 OP Carpal tunnel syndrome (optional)
2.ZZ.02.ZZ Assessment (examination), total body, general NEC

(e.g. multiple reasons)
Status: P1
536
Chapter XXI — Factors influencing health status and contact with health services
First visit
N Example: A patient visits the oncology clinic for a pre-chemotherapy assessment for
treatment of breast cancer.

Z01.8 MP Other specified special examinations
C50.99 OP Malignant neoplasm of breast, part unspecified, unspecified

side (optional)

Status: P1
Interim visit
N Example: The same patient attends the cancer clinic for an interim assessment during the
course of her chemotherapy treatment following mastectomy. She is scheduled to
receive her fifth chemotherapy treatment the next day. There is no documentation
of the outcome of the assessment.

Z51.88 MP Other specified medical care NEC

side (optional)

Status: N1
Rationale: This is not a pre-treatment assessment; therefore, Z01.8 is not

assigned. It is also not a follow-up visit. This is an interim assessment.
As the patient has no condition necessitating a change in the treatment
plan, assign Z51.88. (If a condition was found, assign a code for the
condition as the main problem.)
537
DN Example: A morbidly obese patient is seen in the day surgery unit for esophagogastroduodenoscopy
as a pre-treatment assessment of her gastrointestinal tract prior to undergoing gastric
bypass surgery; there are no unexpected findings.
Z01.8 (M) MP Other specified special examinations
E66.8 (3) OP Other obesity (optional)
2.NK.70.BA-BL Inspection, small intestine, using endoscopic per orifice approach

(or via stoma) and gastroscope
DN Example: A patient presents for coronary angiography via the femoral artery as a pre-treatment
assessment prior to undergoing lung transplant due to emphysema. The X-ray reveals
that the patient has severe three-vessel coronary artery disease (CAD), amenable
to bypass.
I25.10 (M) MP Atherosclerotic heart disease of native

coronary artery
Z01.8 (3) OP Other specified special examinations (mandatory)
J43.9 (3) OP Emphysema, unspecified (optional)
Status: DX
Location: FY
Rationale: When a condition is found during a pre-treatment assessment, the

condition is coded as the MRDx/main problem. The underlying reason for
the encounter is coded as a mandatory diagnosis type (3)/other problem.
538
Admission for Observation

The purpose of this coding standard is to provide direction for code assignment when a patient
presents for investigation of a sign, symptom and/or abnormal finding (e.g., positive screening test)
for which there is documentation to support that the patient is being investigated to rule out a specific
suspected condition. When there is no documentation that the patient is being investigated to rule
out a specific suspected condition, see the coding standard Underlying Symptoms or Conditions.
Codes from Z03 are assigned as the MRDx/main problem when a patient is investigated for
a suspected condition and is considered to have no disease/problem. These patients will
have a sign, symptom and/or abnormal finding (e.g., positive screening test); however, after
investigation, it will have been determined that the condition for which they are being examined
has been ruled out and there is no documentation to support that further investigation is required.
See also the coding standards Screening for Specific Diseases and Unconfirmed Diagnosis.

Assign a code from category Z03 Medical observation and evaluation for suspected diseases and conditions as
DN
the MRDx/main problem when a patient with a sign, symptom and/or abnormal finding is investigated for a
suspected condition and all of the following criteria are met:
• The suspected condition is ruled out/not found; and
• There is no documentation to support that further investigation is required; and
• Another underlying condition is not identified.
Assign an additional code for the sign, symptom or abnormal finding, optional, as a diagnosis type (3)/other
problem based on the facility’s data needs.
DN When a patient is investigated for a suspected condition and the suspected condition is found, assign a code
for the identified underlying condition as the MRDx/main problem.
Assign an additional code for the sign, symptom or abnormal finding, optional, as a diagnosis type (3)/other
problem based on the facility’s data needs.
DN When a patient is investigated for a suspected condition and the suspected condition is not found and there
is documentation to support that further investigation is required, assign a code for the sign, symptom or
abnormal finding as the MRDx/main problem.
DN When a patient is investigated for a suspected condition and an underlying condition that is not the
suspected condition is identified, assign a code for the underlying condition as the MRDx/main problem.
539
Note
Do not assign codes from category Z03 Medical observation and evaluation for suspected diseases and
conditions as a diagnosis type (3)/other problem.
Note
Repeat screening is not synonymous with further investigations required. Therefore, the fact that the patient
is scheduled to return for a repeat screening test (such as a prostate-specific antigen [PSA] test in six months
or a mammogram in one year) following observation does not limit the use of a code from category Z03.
Note
A fecal immunochemical test (FIT) and fecal occult blood test (FOBT) are screening tests for colorectal cancer.
Therefore, a patient with a positive result who is admitted for an endoscopy is considered to be under
observation for suspected colorectal cancer. There is no requirement for colorectal cancer to be documented
as a suspected condition that is being ruled out.
DN Example: The patient presents with an elevated PSA test and undergoes biopsy of the prostate
for suspected prostate malignancy. After investigation, no evidence of neoplasm or
other pathology is detected, and no further action is required at this time.
Z03.1 (M) MP Observation for suspected malignant neoplasm
Rationale: The patient is seen for investigation of an abnormal finding (elevated

PSA) to rule out malignancy. The suspected condition (malignancy) is
ruled out, there is no documentation to support that further investigation
is required and another underlying condition is not identified. Therefore,
Z03 is assigned as the MRDx/main problem.
540
DN Example: The patient presents for colonoscopic examination due to a positive FIT. The final
diagnosis is recorded as “normal examination; patient will be seen again in 3–5 years.”
Rationale: The patient is seen for investigation of an abnormal finding (positive

screening FIT). A patient with a positive FIT (or FOBT) who is admitted
for a colonoscopy is considered to be under observation for suspected
colorectal cancer. The suspected condition (malignancy) is ruled out,
there is no documentation to support that further investigation is required
and another underlying condition is not identified. Therefore, Z03 is
assigned as the MRDx/main problem.
A repeat screening colonoscopy in 3 to 5 years is not synonymous with
further investigation required and does not limit the use of Z03.
D Example: The patient presents for observation of obstructive sleep apnea due to increased
snoring. Sleep apnea is ruled out.
Code DAD Code title
Rationale: The patient is seen for investigation of a symptom (snoring) for a

specific suspected condition (sleep apnea). Sleep apnea is ruled out,
there is no documentation to support that further investigation is
required and another underlying condition is not identified. Therefore,
Z03 is assigned as the MRDx.
541
DN Example: The patient presents for a colonoscopy due to rectal bleeding. The physician
documents “rule out malignancy.” The physician notes diverticulosis in the colon
during examination. Post-operative diagnosis is recorded as “normal colonoscopy to
terminal ileum.”
Rationale: The patient presents with a symptom (rectal bleeding) to rule out
malignancy. The suspected condition (malignancy) is ruled out, and the
physician documents the final diagnosis as “normal colonoscopy.”
Therefore, Z03 is assigned as the MRDx/main problem. The
diverticulosis is noted during the examination and is an incidental
DN Example: The patient presents for a colonoscopy due to rectal bleeding. The physician notes
diverticulosis in the colon during examination. Post-operative diagnosis is recorded
as “normal colonoscopy to terminal ileum.”

K62.5 (M) MP Haemorrhage of anus and rectum
Rationale: The patient presents with a symptom (rectal bleeding). There is no

documentation of a suspected condition; therefore, the directives for this
coding standard do not apply. See the coding standard Underlying
Symptoms or Conditions.
The diverticulosis is noted during the examination and is an incidental
542
DN Example: The patient has been having gross hematuria. He presents for a biopsy of the
bladder for suspected bladder malignancy. A cystoscopic biopsy is performed.
The pathology results come back positive for adenocarcinoma of the bladder.
C67.9 (M) MP Malignant neoplasm of bladder, unspecified
Rationale: The patient presents for investigation of a symptom (gross hematuria)

for suspected bladder malignancy. The suspected condition is found.
Therefore, assign a code for the identified underlying condition
(malignancy) as the MRDx/main problem. Z03 is not assigned because
the suspected condition is confirmed.
DN Example: The patient presents for colonoscopy to rule out malignancy due to ongoing rectal
bleeding, melena and weight loss. Investigation of the colon demonstrates a normal
examination. The physician documents that the patient will be brought back in a few
weeks for an EGD to further investigate the cause of the symptoms.

K62.5 (M) MP Haemorrhage of anus and rectum
K92.1 (1) OP Melaena
R63.4 (1) OP Abnormal weight loss
Rationale: The patient is seen for investigation of signs and symptoms (rectal
bleeding, melena and weight loss) for suspected malignancy. The
examination is normal and the documentation supports that further
investigation is required. When there is documentation to support that
further investigation is required, codes for the signs and symptoms
are assigned. Z03 is not assigned because the three criteria have
not been met.
543
DN Example: The patient presents for colonoscopic examination due to a positive FIT. During
colonoscopy, a polyp is found in the sigmoid colon and removed. Diverticulosis is
noted during examination. Pathology confirms a tubular adenoma.
D12.5 (M) MP Benign neoplasm of sigmoid colon
Rationale: The patient presents with an abnormal finding (positive screening FIT).
A patient with a positive FIT who is admitted for a colonoscopy is
considered to be under observation for suspected colorectal cancer.
The suspected condition is not found. Other conditions are identified.
When an underlying condition that is not the suspected condition is
identified, assign a code for the underlying condition as the MRDx/main
problem when it meets the criteria for significance.
The diverticulosis is noted during the examination and is an incidental
finding. A code for an incidental finding is optional. Z03 is not assigned
because the three criteria have not been met.
DN Example: The patient presents for colonoscopic examination due to a positive FIT. The final
diagnosis is recorded as “first-degree bleeding internal hemorrhoids.”
K64.0 (M) MP First degree haemorrhoids
Rationale: The patient is seen for investigation of an abnormal finding (positive

screening FIT). A patient with a positive FIT who is admitted for a
colonoscopy is considered to be under observation for suspected
colorectal cancer. The suspected condition (malignancy) is not found
and the final diagnosis is recorded as “first-degree bleeding internal
hemorrhoids” (another condition is found and is identified as the final
diagnosis). Z03 is not assigned because the three criteria have not
been met.
544
DN Example: The patient presents for endoscopic examination due to “RUQ pain, rectal
bleeding and a family history of colorectal cancer.” The physician documents “R/O
malignancy.” An EGD is performed and gastric biopsies reveal chronic gastritis.
During colonoscopy, a polyp is removed from the rectum. The polyp is confirmed
on pathology to be a tubular adenoma. Final diagnosis is recorded as “gastritis and
rectal polyp.”

D12.8 (M) MP Benign neoplasm of rectum
K29.5 (1) OP Chronic gastritis, unspecified
Rationale: The patient presents with signs and symptoms to rule out malignancy.
The final diagnosis is recorded as “gastritis and rectal polyp.” The
suspected condition is not found. Other underlying conditions are
identified. When an underlying condition that is not the suspected
condition is identified, assign a code for the underlying condition as the
MRDx/main problem when it meets the criteria for significance. Z03 is
not assigned because the three criteria have not been met.
Since the polyp is excised (definitive therapeutic intervention), D12.8

is the MRDx/main problem. See also the coding standard Diagnoses of
Equal Importance.
N Example: A mother finds her child next to an empty pill bottle. She is uncertain how many
tablets were in the bottle. After observation in the emergency department, it is
determined that the child has not swallowed any pills.
Z03.6 MP Observation for suspected toxic effect from ingested substance
Rationale: Poisoning was suspected because evidence (an empty pill bottle) was
found beside the child. At the end of the episode of care, poisoning is
ruled out. There is no documentation to support that further investigation
is required and no other underlying condition is found. Therefore, a code
from Z03 is assigned as the main problem.
545
D Example: A newborn, delivered vaginally, is monitored in the special care nursery for
investigation because the mother used morphine during most of her pregnancy.
The outcome of the investigation is negative, but the stay is extended by two days
due to additional monitoring in the special care nursery.
Code DAD Code title


Rationale: This is an otherwise healthy newborn who is kept in hospital for an

extended period of time for observation to rule out a suspected condition.
The suspected condition is implied (addiction) as there is a risk (mother
used morphine). After examination and observation, the suspected
condition is ruled out and it is determined that there is no need for further
treatment or medical care. Z03.8 Observation for other suspected
diseases and conditions is assigned as the MRDx in this circumstance.
Admission for observation following accident or alleged

assault or abuse

When the purpose of the encounter is for examination and observation after an accident, alleged rape,
DN sexual assault or physical abuse and, following examination/observation,
• An injury classifiable to categories S00–T19 is documented, assign a code for the specified injury as the
MRDx/main problem.
• No injury is documented, assign a code from category Z04 Examination and observation for other reasons
N Example: A patient involved in a motor vehicle accident is brought to the emergency department
for examination and observation. Following X-rays, it is determined that the patient
suffered no injuries. She is discharged.
Z04.1 MP Examination and observation following transport accident
Rationale: No external cause code is assigned, as there were no injuries.
546
N Example: A young woman presents to the emergency department after waking up in bed
without her clothes. She has no memory of what occurred the night before because
of alcohol intoxication. She is concerned that she was sexually assaulted and is
requesting an examination. Following examination, there is no physical evidence of
any sexual assault and no documented injuries.
Final diagnosis: Sexual assault, rape kit completed

Z04.4 MP Examination and observation following alleged rape and seduction
Rationale: The purpose of this ambulatory visit was examination following an

alleged rape. When there are no documented injuries, Z04.4 is assigned
as the main problem.
DN Example: A patient presents to hospital for examination following an attack. She was walking
home from the cinema when she was grabbed around the neck from behind. She
became unconscious and does not recall the subsequent events. She awoke from
this attack partially clothed. Upon examination, she is found to have a torn hymen
and perineal bruising, indicating that a sexual assault occurred. She also has
significant bruising around her neck.

S31.400 (M) MP Open wound of vagina and vulva, uncomplicated
S30.28 (1) OP Contusion of other external genital organs
S10.9 (1) OP Superficial injury of neck, part unspecified
Y05 (9) OP Sexual assault by bodily force
Rationale: Z04.4 is not assigned as the MRDx/main problem in this example

because specified injuries were found. The external cause code
identifies that the injuries occurred as a result of a sexual assault.
547
Admission for Follow-Up Examination

“Follow-up” is a term used to describe an episode of care for routine investigations following
treatment for a disease, condition or injury. In these circumstances, the patient is exhibiting no
signs or symptoms related to the previous disease, condition or injury; the episode of care
is strictly to assess post-treatment status. Periodic examinations to determine if there is
recurrence of a previously treated condition are examples of follow-up.
Documentation of follow-up is classified in ICD-10-CA according to the purpose and outcome of

the examination.
DN
When the purpose of the examination is to assess the status of a previously treated condition or injury
(a personal history classifiable to categories Z85–Z88) and the outcome indicates no need for further
treatment, select the appropriate code from one of the following as the MRDx/main problem:
• Z08 Follow-up examination after treatment for malignant neoplasm; or
• Z09 Follow-up examination after treatment for conditions other than malignant neoplasms.
− In either case, assign an additional code indicating a personal history of the condition, optional, as a
diagnosis type (3)/other problem, unless identified as mandatory elsewhere in the coding standards.
DN
When the examination reveals that the original condition has recurred or identifies another related
condition, assign
• A code for the condition as the MRDx/main problem; and
• An additional code from Z08 or Z09, mandatory, as a diagnosis type (3)/other problem.
See also the coding standards Personal History of Primary Malignant Neoplasms of Breast, Lung
and Prostate, Personal and Family History of Malignant Neoplasm and Recurrent Malignancies.
548
DN Example: A male patient is admitted for a cystoscopy for follow-up of bladder cancer that was
previously treated by radiation therapy. There is no recurrence of the malignancy.
Trabeculation of bladder is noted.
Z08.1 (M) MP Follow-up examination after radiotherapy for

malignant neoplasm
Z85.5 (3) OP Personal history of malignant neoplasm of urinary

tract (optional)
N32.8 (3) OP Other specified disorders of bladder (optional)
2.PM.70.BA Inspection, bladder, using endoscopic per orifice approach
Rationale: Trabeculation of the bladder is neither a recurrence nor a related condition.

It is optional to code; if coded, it is a diagnosis type (3)/other problem.
DN Example: A patient is admitted for a cystoscopy for follow-up of bladder cancer that was
previously treated by radiation therapy. Carcinoma of the bladder is detected.

C67.9 (M) MP Malignant neoplasm of bladder, unspecified
Z08.1 (3) OP Follow-up examination after radiotherapy for

malignant neoplasm

urinary tract
2.PM.70.BA Inspection, bladder, using endoscopic per orifice approach
Rationale: The examination revealed a recurrence of bladder carcinoma; therefore,

it is mandatory to assign a code for the bladder cancer, an additional code
for the follow-up examination and also Z85.5 to denote a personal history
of bladder cancer, per the coding standard Recurrent Malignancies.
549
DN Example: A 45-year-old patient with a history of kidney stones presents to hospital. Four years
ago, she underwent extracorporeal shock wave lithotripsy (ESWL) and has been
stone-free since. A stone analysis done at that time showed them to be made of
calcium oxalate. She is on magnesium supplement prophylaxis to prevent the
formation of any more stones. At this visit to the stone clinic, she has no complaints.
Her 24-hour urine tests and abdominal ultrasound are negative.
The patient will continue to be under surveillance in the stone clinic and is asked to
continue her magnesium supplement. She will be seen again in 12 months.
Z09.8 (M) MP Follow-up examination after other treatment for

other conditions
Z87.4 (3) OP Personal history of diseases of the genitourinary

system (optional)
First visit
N Example: A construction worker presents to the emergency department with a foreign body in
his right eye. A small metallic piece is removed from his right cornea using an
external approach. The client is instructed to return for follow-up in a week.
T15.0 MP Foreign body in cornea
W44 OP Foreign body entering into or through eye or natural orifice
U98.6 OP Place of occurrence, industrial and construction area
Second visit
N Example: The construction worker returns to the emergency department. During this visit, it is
found that his right cornea has completely healed, and the client is discharged
home with no further instructions.

Z09.8 MP Follow-up examination after other treatment for other conditions
Z87.8 OP Personal history of other specified conditions
550
DN Example: A 72-year-old gentleman presents with increasing anemia. The patient has a history
of a right hemicolectomy for colon cancer that was performed one year previously.
He undergoes colonoscopy that is documented as normal. The patient is scheduled
to be seen in follow-up for an esophagogastroduodenoscopy (EGD) to further
evaluate the anemia.
D64.9 (M) MP Anaemia, unspecified
Z85.0 (3) OP Personal history of malignant neoplasm of digestive

organs (optional)
Rationale: This is not a routine investigation for follow-up. This patient has a sign
(anemia) that is being investigated. A follow-up exam does not include
patients who are exhibiting a sign or symptom.

When the sole purpose of the encounter is to receive a specific intervention or service, select the
DN
appropriate code from one of the following as the MRDx/main problem:
Z39.2 Routine postpartum follow-up
Z42 Follow-up care involving plastic surgery
Z47 Other orthopaedic follow-up care
Z48 Other surgical follow-up care
• Assign an additional code, optional, as a diagnosis type (3)/other problem to describe the underlying
disease or injury for which specific follow-up care is required.
Note
Categories Z40–Z54 Persons encountering health services for specific procedures and health care are
intended to indicate a reason for care. They may be used for patients who have already been treated for
a disease or injury but who are receiving follow-up or prophylactic care; convalescent care; or care to
consolidate the treatment in order to deal with residual states, ensure that the condition has not recurred
or prevent recurrence. 1
Category Z48 Other surgical follow-up care is used to describe encounters solely for the purpose of receiving
a specific intervention related to previous treatment. This includes dressing changes and wound checks,
which may include reassurance that healing is progressing as expected.
551
N Example: A woman presents to the emergency department for a dressing change (medicated)
on the weekend. She had a mastectomy for breast cancer the week before and is
scheduled the following week for chemotherapy.
Z48.0 MP Attention to surgical dressings and sutures

side (optional)
1.YS.14.JA-H1 Dressing, skin of abdomen and trunk, using medicated

dressing (optional)
N Example: A young man presents to the fracture clinic for removal of a cast that was put on six
weeks ago after a non-displaced fracture of the ankle due to a fall on ice.

Z47.8 MP Other specified orthopaedic follow-up care
1.WA.38.JA-FQ Management of external appliance, ankle joint, of cast
N Example: A patient presents to the emergency department after recent surgery because the
wound is red and draining. The doctor assesses the wound and tells the patient to
continue with her antibiotics, as prescribed by the surgeon. Final diagnosis is
recorded as “postoperative concern.”

Z48.8 MP Other specified surgical follow-up care
Rationale: The patient underwent surgery and required reassessment to ensure

the wound was healing as expected; no condition or complication
was found.
552
Admission for Convalescence

Convalescence is the stage of recovery following an attack of disease, a surgical operation

or an injury. For classification purposes, it describes the intermediate recovery phase after
treatment until a patient is ready to be discharged home/place of residence. It includes
maintenance of homeostasis, wound management, routine postoperative monitoring,
physiotherapy, and prevention and early detection of complications. Often patients are
transferred from one hospital to another to complete this phase of care to allow them to be
closer to home or to manage beds within a health region. These patients are given the routine
daily care they would normally receive if all of their care occurred in the original facility. In some
circumstances, an admission from day surgery to inpatient care may constitute an admission
for convalescence.
Z54 Convalescence does not include

• Care provided to manage the original condition;
• Care provided to treat a complication;
• Patients who are admitted solely for rehabilitation; and
• Patients who have been discharged and who return for specific care (such as attention to
drainage devices, dressing changes or examinations for reassurance).
See also the coding standards Admission for Follow-up Examination and Acute Coronary
Syndrome (ACS).

When a patient is transferred from one hospital to another or admitted from day surgery to inpatient care
D
solely for the purpose of receiving care in the recovery phase following treatment of an illness or injury or
following a surgical intervention, assign a code from category Z54 Convalescence as the MRDx.
• Assign an additional code, mandatory, as a diagnosis type (3) to indicate the condition for which
convalescence is required.
553
Exception
The above directive statement does not apply to jurisdictions (British Columbia, Yukon, the Northwest
Territories and Nunavut) that submit one acute inpatient abstract to the Discharge Abstract Database (DAD)
for a patient who is admitted to an inpatient bed directly from the day surgery unit of the reporting facility.
See Section 3: Additional Abstracting Information: Day Surgery Abstracting, Patients Admitted Directly
From Day Surgery to Acute Care in the Discharge Abstract Database (DAD) Abstracting Manual for
further instructions.
D Example: The physician documents that the patient is being admitted for convalescence
following surgery to treat a fracture of the femur after falling out of bed at home.
The patient is transferred from Hospital A to Hospital B to be closer to family.
The patient is discharged home on day 3.
Code DAD Code title
Z54.0 (M) Convalescence following surgery
S72.900 (3) Fracture of femur, part unspecified, closed
W06 (9) Fall involving bed
Inpatient admission to Hospital B
D Example: The patient is admitted to Hospital A with ST elevation myocardial infarction.

The patient is immediately transferred to day surgery in Hospital B for primary
percutaneous coronary intervention (PCI), after which he is admitted as an inpatient
to Hospital B with a diagnosis of STEMI.
Code DAD Code title

infarction [STEMI]
Rationale: This case is not classified to convalescence (or to follow-up surgical

care), as the care the patient is receiving is still being directed toward
the acute condition.
554
Return admission to Hospital A
D Example: The same patient is transferred back to Hospital A for continued treatment following
the myocardial infarction and PCI.
Code DAD Code title

infarction [STEMI]
Rationale: The purpose of the transfer is to receive continuing care directed toward
the condition itself. The patient is not being transferred solely for the
purpose of convalescence; therefore, Z54 is not assigned.
Admission following day surgery
D Example: The patient is admitted to day surgery for elective coronary angiography. Over the
last several months, he has noted that his angina has been increasing in frequency
and duration. The patient is known to have CAD. During the intervention, it is noted
that the patient has a 90% stenosis of the left anterior descending (native) artery
that is amenable to coronary angioplasty. A PCI with stent insertion is performed.
The patient is then admitted overnight as an inpatient for observation.
Diagnosis: Unstable angina, coronary artery disease
Code DAD Code title
Z54.0 (M) Convalescence following surgery
I20.0 (3) Unstable angina
Rationale: The reason for admission is to monitor the patient for any complications
following the surgical intervention rather than to receive continuing care
for CAD. When the sole purpose of the admission is for postoperative
monitoring, this is included at category Z54.
Note: This example does not apply to B.C., Yukon, the Northwest
Territories or Nunavut.
555
When a patient presents solely for the purposes of receiving routine care following delivery outside the
D
hospital, assign Z39.0 Postpartum care and examination immediately after delivery as the MRDx.
D Example: A patient is transferred from another facility for postpartum care following a
Cesarean section. She receives routine obstetrical care and is discharged home
two days later.
Code DAD Code title
Z39.0 (M) Care and examination immediately after delivery
Rationale: Z39.0 includes routine postpartum care in uncomplicated cases.
Screening for Specific Diseases

Screening is performed to enable early detection/diagnosis of a disease, such as cancer, by

testing a person who does not yet have recognized symptoms or obvious signs of the condition.
Screening does not include examination of individuals who have previously been treated
for a condition. Ideally, screening detects a condition before it becomes serious and when it is
usually easily treatable or preventable.
Some examples of screening programs include

• Mammography to detect breast cancer for women who, because of age and/or family history,
have risk factors;
• Pap tests for all women who are or have ever been sexually active;
• Prostate-specific antigen (PSA) tests to detect prostate cancer because of age and/or
family history;
• Fecal occult blood tests (FOBTs) or fecal immunochemical tests (FITs), colonoscopy or
sigmoidoscopy, or double contrast barium enema to detect colon cancer for all persons older
than age 50 and persons younger than 50 who have risk factors (such as family history); and
• Tuberculin skin tests to detect tuberculosis for certain populations, such as health care
workers, correctional institution workers and immigrants.
556
Note
For direction on code assignment when the episode of care is to further investigate a positive screening test,
see the coding standard Admission for Observation.

When a patient undergoes a screening examination and no sign of disease is found, assign a code from
DN
category Z11, Z12 or Z13 as the MRDx/main problem.
DN
When the condition or a sign of the condition for which the patient is screened is found, assign a code
• For the condition or sign as the MRDx/main problem; and
• From Z11, Z12 or Z13, mandatory, as a diagnosis type (3)/other problem.
Assign an additional code, optional, as a diagnosis type (3)/other problem to identify any circumstances
DN
indicating the reason for the screening test (such as family history).
DN
Assign an additional code, optional, as a diagnosis type (3)/other problem, to identify any incidental findings
noted at the time of the exam.
N Example: A 52-year-old female patient with no signs or symptoms of breast disease comes to
the breast clinic for a mammogram. No abnormalities are found.
Z12.3 MP Special screening examination for neoplasm of breast
N Example: A 60-year-old female patient with no signs or symptoms of breast disease comes
to the breast clinic for a mammogram. A suspicious area is found in the upper-outer
quadrant; the patient will be booked for a breast biopsy.

R92 MP Abnormal findings on diagnostic imaging of breast
Z12.3 OP Special screening examination for neoplasm of breast
Rationale: The screening revealed a sign of the condition; therefore, R92 is the
main problem. Z12.3 is mandatory to show that the condition was
discovered on screening.
557
N Example: A 60-year-old female patient detects a lump in her right breast on self-examination.
She is referred for mammography by her family physician. The mammogram
confirms a lesion in her breast.
N63 MP Unspecified lump in breast
Rationale: As the patient presented with a sign of breast cancer, the mammogram
in this case does not qualify as a screening test.
DN Example: A patient with no known complaint is admitted as a day surgery patient for a screening
colonoscopy due to a family history of colon cancer. No abnormalities are detected.

Z12.1 (M) MP Special screening examination for neoplasm of
intestinal tract
Z80.0 (3) OP Family history of malignant neoplasm of digestive

organs (optional)
DN Example: A patient with no known complaint is admitted as a day surgery patient for a
screening colonoscopy due to a family history of colon cancer. Internal hemorrhoids
are noted.

intestinal tract

organs (optional)
K64.8 (3) OP Other specified haemorrhoids (optional)
558
DN Example: A patient with no known complaint presents for a screening colonoscopy due to a
family history of colon cancer. Upon examination, a lesion is noted and biopsied,
which is shown to be adenocarcinoma of the sigmoid colon.
C18.7 (M) MP Malignant neoplasm of sigmoid colon
Z12.1 (3) OP Special screening examination for neoplasm of

intestinal tract

organs (optional)
Rationale: The screening revealed malignancy; therefore, C18.7 is the MRDx/

main problem and Z12.1 is mandatory to show that the condition was
discovered on screening.
DN Example: A patient with a positive family history for colon cancer undergoes a screening
colonoscopy. An adenomatous polyp is found in the sigmoid colon. Polypectomy
is performed.
D12.5 (M) MP Benign neoplasm of sigmoid colon
Z12.1 (3) OP Special screening examination for neoplasm of

intestinal tract

organs (optional)
Rationale: The screening revealed neoplastic disease; therefore, D12.5 is the

MRDx/main problem and Z12.1 is mandatory to show that the condition
was discovered on screening.
Note: The patient is being screened for neoplastic disease (malignant
or benign), which is found. Adenomatous polyps in the colon have the
potential to be malignant; therefore, this is not an incidental finding.
559
Prophylactic Organ Removal

DN Select a code from the category Z40 Prophylactic surgery when a patient is admitted for surgical removal
of non-diseased organs or tissue related to risk of or treatment for malignancy.
D Example: A patient is admitted for prophylactic bilateral orchidectomy due to advanced cancer
of the prostate.
Code DAD Code title

Z40.08 (M) Prophylactic removal of other organ
C61 (3) Malignant neoplasm of prostate
1.QM.89.^^ Excision total, testis

Location: B
Rationale: This patient is being admitted for bilateral orchidectomy to reduce the
risk of metastases; therefore, Z40.08 is assigned.
D Example: A patient with a personal history of breast cancer (left breast, no residual disease)
elects to have a right total simple mastectomy to remove the non-diseased breast.
Code DAD Code title

Z40.00 (M) Prophylactic removal of breast
Z85.31 (3) Personal history of malignant neoplasm of left breast
1.YM.89.^^ Excision total, breast

Location: R
Rationale: This patient is being admitted for surgical removal of non-diseased

breast tissue due to the risk of malignancy; therefore, Z40.00 is
assigned. It is mandatory to assign a code from Z85 in this example.
See also the coding standards Personal and Family History of Malignant Neoplasms and
Personal History of Primary Malignant Neoplasms of Breast, Lung and Prostate.
560
Coding of NACRS Visits for Rehabilitative Services

N Assign a code from category Z50 Care involving use of rehabilitation procedures as the main problem
when rehabilitation is a reason for the NACRS visit.
N When a person is referred solely for physical therapy (care involving use of rehabilitation procedures),
assign Z50.1 Other physical therapy as the main problem.
N Assign an additional code, optional, as an other problem to identify the underlying disorder.
These codes apply to patients who have already been treated for a disease or injury who are
receiving care involving rehabilitation procedures.
See also the coding standard Selection of Interventions to Code for Ambulatory Care.
N Example: A woman with multiple sclerosis visits the rehabilitation clinic for physiotherapy.

Z50.1 MP Other physical therapy
G35 OP Multiple sclerosis (optional)
1.ZX.12.JA Therapy, multiple body sites, using other technique NEC
N Example: A patient with a history of recent stroke with ongoing aphasia attends the
rehabilitation clinic for a scheduled speech therapy session.
Z50.5 MP Speech therapy
R47.0 OP Dysphasia and aphasia
I69.4 OP Sequelae of stroke, not specified as haemorrhage or

infarction (optional)
6.RA.30.BR Therapy, voice, for breath control
561
Admission for Administration of Chemotherapy,

Pharmacotherapy and Radiation Therapy
DN
When a patient previously diagnosed with a malignancy has an encounter solely for the administration of
radiation therapy, assign
• Z51.0 Radiotherapy session as the MRDx/main problem; or
• Z51.0 Radiotherapy session as a diagnosis type (1)/other problem when a post-admit condition arises
during the episode of care and that condition meets the criteria for MRDx/main problem.
DN
When a patient previously diagnosed with a malignancy has an encounter solely for the administration of
chemotherapy to treat the malignancy or neoplasm-related conditions, assign
• Z51.1 Chemotherapy session for neoplasm as the MRDx/main problem; or
• Z51.1 Chemotherapy session for neoplasm as a diagnosis type (1)/other problem when a post-
admit condition arises during the episode of care and that condition meets the criteria for
MRDx/main problem.
DN
Assign an additional code to identify the malignant condition, mandatory, as a diagnosis type (3)/other
problem for radiation therapy visits and chemotherapy visits.
DN
Assign a CCI code, mandatory, for any radiation therapy or chemotherapy interventions to treat the
malignancy or neoplasm-related conditions.
See also the coding standards Selection of Interventions to Code for Ambulatory Care and
Selection of Interventions to Code for Acute Inpatient Care.
CCI codes for systemic chemotherapy for neoplastic disease (e.g., drugs where the
agent component of the qualifier begins with “M”) are classified within rubric 1.ZZ.35.^^
Pharmacotherapy, total body. For example, the antineoplastic drug vincristine administered
by injection is classified to 1.ZZ.35.HA-M3. These procedures need be assigned only once.
562
Note
Z51.0 Radiotherapy session and Z51.1 Chemotherapy session for neoplasm must not be assigned as a
diagnosis type (2) or diagnosis type (3).
Chemotherapy and radiation therapy are interventions; therefore, a CCI code is assigned. Z51.0 Radiotherapy
session and Z51.1 Chemotherapy session for neoplasm are diagnosis codes and are assigned only when the
patient is admitted solely for administration of radiation therapy or chemotherapy, respectively.
Note
Admissions for brachytherapy should not be confused with admissions for radiation therapy. See also the
coding standard Brachytherapy.
When a patient presents for a radiation therapy or chemotherapy intervention and it is cancelled
due to contraindication, see also the coding standard Cancelled Interventions.
DN Example: Encounter for IV vincristine chemotherapy session for active left main
bronchus malignancy

Z51.1 (M) MP Chemotherapy session for neoplasm
C34.01 (3) OP Malignant neoplasm of left main bronchus

antineoplastic and immunomodulating agents, using plant
alkaloid and other natural product
Rationale: The patient is admitted solely for administration of chemotherapy.

Therefore, Z51.1 is assigned as the MRDx/main problem. An additional
code to identify the malignancy is assigned as a diagnosis type (3)/other
problem, mandatory. It is mandatory to assign a CCI code for the
chemotherapy to treat the malignancy or neoplasm-related conditions.
563
DN Example: A patient with malignant neoplasm of the breast presents solely for administration of the
drug pamidronate for the treatment of her generalized bone loss due to malignancy.
Z51.1 (M) MP Chemotherapy session for neoplasm
M85.80 (3) OP Other specified disorders of bone density and

structure, multiple sites
C50.99 (3) OP Malignant neoplasm of breast, part unspecified,

unspecified side
1.ZZ.35.HA-N5 Pharmacotherapy, total body, percutaneous approach [intramuscular,

intravenous, subcutaneous, intradermal], musculoskeletal system
agents, using drug for treatment of bone disease
Rationale: The patient is admitted solely for administration of chemotherapy.

The chemotherapy is directed at the bone loss. The bone loss in this
case is a neoplasm-related condition; therefore, Z51.1 (not Z51.2) is
assigned as the MRDx/main problem. An additional code to identify
the malignancy is assigned as a diagnosis type (3)/other problem,
mandatory. It is mandatory to assign a CCI code for the chemotherapy
to treat the malignancy or neoplasm-related conditions.
DN Example: Encounter for radiation therapy session for carcinoma of the left lower lobe of lung.
Z51.0 (M) MP Radiotherapy session
C34.31 (3) OP Malignant neoplasm of lower lobe, left bronchus

or lung
1.GT.27.JA Radiation, lung NEC, using external beam
Rationale: The patient is admitted solely for administration of radiation therapy.

Therefore, Z51.0 is assigned as the MRDx/main problem. An additional
code to identify the malignancy is assigned as a diagnosis type (3)/other
problem, mandatory. It is mandatory to assign a CCI code for the
radiation therapy.
564
D Example: A patient with recurrent Hodgkin’s lymphoma who previously underwent

dexamethasone, high-dose cytarabine and cisplatin (DHAP) chemotherapy for stem cell
mobilization and harvesting is now admitted for BiCNU (carmustine), etoposide, ara-C
(cytarabine), melphalan (BEAM) chemotherapy and autologous stem cell reinfusion.
Code DAD Code title
C81.9 (M) Hodgkin lymphoma, unspecified
1.LZ.19.HH-U7-A Transfusion, circulatory system NEC of stem cells using

autologous transfusion

antineoplastic and immunomodulating agents, using plant
alkaloid and other natural product
antineoplastic and immunomodulating agents, using
antimetabolite
antineoplastic and immunomodulating agents, using
alkylating agent.
Rationale: The MRDx is C81.9 because the patient is not admitted solely for
administration of chemotherapy. Chemotherapy is an intervention.
Therefore, a CCI code is assigned for each chemotherapy agent
administered to treat the malignancy. A code from category Z51
Other medical care is not assigned.
565
D Example: A patient with acute myeloblastic leukemia (AML) is admitted for post-remission
mitoxantrone, etoposide and cytarabine (MEC) consolidation therapy. During the
admission the patient develops febrile neutropenia with severe enterocolitis, and
blood cultures are positive for coagulase-negative staphylococcus. General surgery
service is consulted and recommends conservative management with intravenous
(IV) antibiotics, bowel rest, total parenteral nutrition (TPN) and vigilant observation,
which significantly prolongs the patient’s length of stay.

A04.8 (M) — Other specified bacterial intestinal infections
B95.7 (3) — Other staphylococcus as the cause of diseases

Z51.1 (1) — Chemotherapy session for neoplasm
A04.8 (2) A Other specified bacterial intestinal infections
D70.0 (2) A Neutropenia
Y43.3 (9) A Other antineoplastic drugs causing adverse effect in

therapeutic use
C92.0 (3) — Acute myeloblastic leukaemia (AML)

antineoplastic and immunomodulating agents, using cytotoxic
antibiotic and related substance

antineoplastic and immunomodulating agents, using plant alkaloid
and other natural product

antineoplastic and immunomodulating agents, using antimetabolite
1.LZ.35.HH-C6 Pharmacotherapy (local), circulatory system NEC, percutaneous

infusion approach of parenteral nutrition
566
Rationale: The patient is admitted solely for administration of chemotherapy for a

malignancy. During the admission, complications arise that meet the
criteria for MRDx. Therefore, Z51.1 Chemotherapy session for neoplasm
is assigned as a diagnosis type (1); mandatory CCI codes for MEC
consolidation therapy (chemotherapy) and TPN are assigned.
DN
When a patient previously diagnosed with a non-malignant condition has an encounter solely for the
administration of chemotherapy, assign
• Z51.2 Other chemotherapy as the MRDx/main problem; or
• Z51.2 Other chemotherapy as a diagnosis type (1)/other problem when a post-admit condition arises
during the episode of care and meets the criteria for MRDx/main problem.
DN
Assign an additional code to identify the disease/condition, mandatory, as a diagnosis type
(3)/other problem.
Assign a CCI code, mandatory, for any chemotherapy interventions classified to 1.^^.35.^^-M^
DN
Pharmacotherapy using antineoplastic and immunomodulating agents.
N Assign a CCI code, mandatory, for any chemotherapy interventions performed during a clinic visit.
Note
Z51.2 Other chemotherapy must not be assigned as a diagnosis type (2) or diagnosis type (3). Z51.2 Other
chemotherapy is assigned only when the patient is admitted solely for administration of chemotherapy to
treat a condition other than a malignant neoplasm or neoplasm-related condition.
567
N Example: A patient with bursitis of the elbow is seen in the emergency department for
administration of IV indomethacin therapy to treat that condition.
Z51.2 MP Other chemotherapy
M70.3 OP Other bursitis of elbow
Rationale: The patient is admitted solely for the administration of IV indomethacin

therapy to treat a condition other than a malignant neoplasm or
neoplasm-related condition. Therefore, Z51.2 Other chemotherapy is
assigned as the main problem. An additional code to identify the
condition (M70.3) is assigned, mandatory, as an other problem.
N Example: A patient with AIDS is seen in ambulatory care solely for administration of
antiretroviral pharmacotherapy.

Z51.2 MP Other chemotherapy
B24 OP Human immunodeficiency virus [HIV] disease
Rationale: The patient is admitted solely for the administration of antiretroviral

pharmacotherapy to treat a condition other than a malignant neoplasm
or neoplasm-related condition. Therefore, Z51.2 Other chemotherapy is
assigned as the main problem. An additional code to identify the
condition (B24) is assigned, mandatory, as an other problem.
When chemotherapy or radiation therapy is given during the admission in which the definitive surgical
D
treatment occurs, code the malignancy as the MRDx.
568
Note
When chemotherapy or radiation therapy is administered during the episode of care in which the malignancy
is diagnosed or during which the definitive surgery occurs, a code from category Z51 Other medical care is not
assigned. A code from category Z51 Other medical care is assigned only when the patient is admitted solely
for administration of chemotherapy or radiation therapy. Chemotherapy and/or radiation therapy is captured
with a CCI intervention code.
D Example: A patient with cancer of the right lower lobe of the lung is admitted for lobectomy. He
is started on intravenous chemotherapy before discharge.
Code DAD Code title
C34.30 (M) Malignant neoplasm of lower lobe, right bronchus or lung
1.GR.89.QB Excision total, lobe of lung, using open thoracic approach

Location: RH

[intramuscular, intravenous, subcutaneous, intradermal] using
antineoplastic agent NOS
Rationale: The patient is admitted for a surgical intervention (lobectomy).

Therefore, the malignancy is captured as the MRDx. During the
admission, the patient also receives intravenous chemotherapy to treat
the malignancy or neoplasm-related condition and a CCI code is
assigned for the chemotherapy, mandatory.
569
Admission for Insertion of a Vascular Access

Device (VAD)
When a patient is admitted solely for insertion of a vascular access device (VAD) for treatment of an existing
DN
condition, assign Z51.4 Preparatory care for subsequent treatment, not elsewhere classified as the
MRDx/main problem.
Classify any encounter that is solely for adjustment or removal (without replacement) of an implanted
DN VAD to Z45.2 Adjustment and management of vascular access device as the MRDx/main problem.
Assign an additional code to identify the disease/condition, mandatory, as a diagnosis type

DN (3)/other problem.
Exception
Insertion of a VAD for the purpose of hemodialysis is classified to Z49.0 Preparatory care for dialysis.
Note
When there is a change to or removal of a VAD due to a complication, do not assign Z51.4 Preparatory care
for subsequent treatment, not elsewhere classified. Select an appropriate code from Chapter XIX —
Injury, poisoning and certain other consequences of external causes. See also the coding standards
Post-Intervention Conditions and Complications of Devices, Implants or Grafts.
570
DN Example: A patient presents for insertion of a PICC line for future administration of
antineoplastic agents to treat leukemia.
Z51.4 (M) MP Preparatory care for subsequent treatment,

C95.9 (3) OP Leukaemia, unspecified
1.IS.53.GR-LF Implantation of internal device, vena cava (superior and inferior)

non-tunnelled central venous catheter using percutaneous
transluminal venous approach
Location: PI
DN Example: A patient presents for removal of a Broviac catheter after completing chemotherapy
for carcinoma of the lung. No further treatment is planned.

Z45.2 (M) MP Adjustment and management of vascular
access device
Z85.119 (3) OP Personal history of malignant neoplasm of bronchus

and lung, unspecified side
1.IS.55.GR-LF Removal of device, vena cava (superior and inferior), of central

venous catheter using percutaneous transluminal approach
Admission for Blood Transfusion


When a patient is admitted solely for the purpose of a blood transfusion session, assign
DN
• Z51.3 Blood transfusion (without reported diagnosis) as the MRDx/main problem; and
• An additional code to identify the disease/condition, optional, as a diagnosis type (3)/other problem.
571
DN Example: A patient with thalassemia major is admitted every six weeks for a blood transfusion.
Z51.3 (M) MP Blood transfusion (without reported diagnosis)
D56.9 (3) OP Thalassaemia, unspecified
Rationale: The patient is admitted solely for the purpose of a blood transfusion;
therefore, Z51.3 is assigned as the MRDx/main problem.
D Example: A patient with leukemia is admitted for further assessment of the disease. During
hospitalization, she receives a blood transfusion as part of her treatment.
Code DAD Code title
C95.9 (M) Leukaemia, unspecified
Rationale: As the patient was not admitted solely to receive a blood transfusion,
Z51.3 is not assigned.
Palliative Care
Palliative care is part of the continuum of patient care, not necessarily a formal
organizational designation.
Documentation to support coding palliative care may include

• Palliative care consultation with initiation of a palliative care treatment plan; or
• Physician documentation such as “palliative patient,” “palliative situation,” “end-of-life care,”
“comfort care,” “supportive care” or “compassionate care.”
Palliative patients typically fall into one of the following three categories:
Known palliative patient admitted for the sole purpose of palliative care
• No life-sustaining/curative treatment is given for reversible or irreversible (palliative) conditions.
572
Known palliative patient admitted for treatment of one or more reversible conditions
• Life-sustaining/curative treatment is given for reversible conditions (such as pneumonia,
blood clot, sepsis, electrolyte imbalance or dehydration), but not for irreversible conditions.
• It is assumed that palliative care is part of the treatment plan and qualifies as a significant
diagnosis type.
• These patients are often expected to go home; however, they may deteriorate, and the focus
of care may change to that described in the first category above.
Patient not known to be palliative prior to arrival at the facility

• These patients initially receive investigation and/or treatment but are subsequently changed
to a palliative care plan.
Notes
• Palliative care does not have to be provided in a designated palliative care bed/unit or be managed by a
palliative care team.
• Do not resuscitate (DNR) orders alone do not constitute palliative care; there must be documentation of
palliative care. While DNR orders are part of a palliative care plan, they may also be present in non–palliative
care cases.
• “Pain control” alone does not constitute palliative care. While pain control is part of a palliative care plan,
it may also be provided to patients who are not receiving palliative care.
• Acute conditions (such as pneumonia or dehydration) may be treated as part of the palliative care
treatment plan.
• Medical assistance in dying is not the same as palliative care. See also the coding standard Medical
Assistance in Dying.
DN Assign Z51.5 Palliative care as a significant diagnosis type/main or other problem whenever there is
physician documentation of palliative care.
DN Assign additional code(s), mandatory, to describe the palliative condition(s).
DN When palliative care is documented as a known component of the patient’s care plan prior to arrival at
the facility, assign prefix 8, mandatory.
573
Note
Prefix 8 is restricted for use with Z51.5 Palliative care.
For more information about prefix 8, see Group 10, Field 02 in the Discharge Abstract Database (DAD)
Abstracting Manual and data element 43 in the National Ambulatory Care Reporting System (NACRS)
Abstracting Manual.
N Example: A patient known to be on a palliative care plan with end-stage lung cancer is seen
in the emergency department following a questionable fall at home. The emergency
department physician documents the final diagnosis as pneumonia/pleural effusion.
The patient’s condition deteriorates and she develops respiratory arrest and expires
in the emergency department two hours after presentation to hospital.
Prefix Code NACRS Code title
— J18.9 MP Pneumonia, unspecified
— J90 OP Pleural effusion, not elsewhere classified
8 Z51.5 OP Palliative care
— C34.99 OP Malignant neoplasm bronchus or lung, unspecified,

unspecified side
Rationale: Palliative care is documented as a known component of the patient’s

care plan prior to arrival at the facility; therefore, Z51.5 is assigned with
prefix 8, mandatory.
N Example: A patient with advanced adenocarcinoma of the right upper lung is admitted to the
day surgery unit to have a PICC line put in for palliative chemotherapy.
— Z51.4 MP Preparatory care for subsequent treatment, not

— C34.10 OP Malignant neoplasm of upper lobe, right bronchus

or lung
Rationale: Palliative care is a known component of the patient’s care plan prior to
arrival at the facility; therefore, Z51.5 is assigned with prefix 8, mandatory.
574
N Example: A patient with multiple myeloma falls from his bed at home and sustains a
fracture of the humerus. The documentation indicates that the patient is on a
palliative care plan.
— S42.300 MP Fracture of shaft of humerus NOS, closed
— W06 OP Fall involving bed
— U98.0 OP Place of occurrence, home
— C90.0 OP Multiple myeloma
Rationale: Palliative care is a known component of the patient’s care plan prior to
arrival at the facility; therefore, Z51.5 is assigned with prefix 8, mandatory.
D When a known palliative patient is admitted to the hospital for the sole purpose of receiving palliative
care, assign
• Z51.5 Palliative care as the MRDx; and
• Additional code(s), mandatory, to describe the palliative condition(s).
D When a known palliative care patient is admitted for treatment of reversible condition(s), assign
• Z51.5 as a diagnosis type (1), (W), (X) or (Y); and
• The reversible condition as the MRDx, unless palliative care subsequently consumes the majority of the
length of stay; and
• Additional code(s), mandatory, to describe the palliative condition(s).
D When a patient is not known to be palliative at the time of admission and subsequently changes to a
palliative care plan, assign
• The condition that is investigated or treated as the MRDx, unless palliative care subsequently
consumes the majority of the length of stay (at least 24 hours in a short-stay admission).
Note
Z51.5 Palliative care must not be assigned a diagnosis type (2) or diagnosis type (3).
575
Note
Do not assign palliative care as the MRDx on an obstetrical or newborn abstract. When palliative care is
documented in these cases, assign Z51.5 Palliative care as a diagnosis type (1).
D Example: A patient is admitted to hospital for end-of-life care because of amyotrophic lateral
sclerosis. On admission, an IV is started to maintain hydration. Pain control is monitored
and medication adjusted as necessary. The patient dies three days after admission.

8 Z51.5 (M) Palliative care
— G12.20 (3) Amyotrophic lateral sclerosis
Rationale: The documentation indicates that the patient is admitted for the sole purpose
of receiving palliative care. The palliative condition is mandatory to assign
and, in this case, G12.20 meets the definition of diagnosis type (3). Prefix 8 is
assigned with Z51.5 in this case because palliative care is documented as a
known component of the patient’s care plan prior to arrival at the facility.
D Example: A 68-year-old patient, who is on the Palliative Care Registry due to end-stage
chronic obstructive pulmonary disease (COPD), is admitted with pneumonia.
The patient is admitted to a palliative care bed, and all documentation describes
treatment for the pneumonia. The patient’s condition improves during the
admission, and he is discharged home in a satisfactory condition.

— J44.0 (M) Chronic obstructive pulmonary disease with acute
— J18.9 (1) Pneumonia, unspecified
8 Z51.5 (1) Palliative care
Rationale: The documentation indicates that the patient is admitted for treatment of
pneumonia in COPD, which is classified in the usual manner. Z51.5 is
assigned diagnosis type (1) because it is assumed that palliative care is
part of the treatment plan for a known palliative care patient, and it is
assigned a significant diagnosis type. Prefix 8 is assigned with Z51.5 in
this case because palliative care is documented as a known component
of the patient’s care plan prior to arrival at the facility.
576
D Example: A known palliative care patient presents for treatment of dehydration. The patient has
cancer of the lung with advanced secondary malignancy of the brain. She is admitted to
the medical ward to receive hydration therapy and discharged home the following day.

— E86.0 (M) Dehydration
8 Z51.5 (1) Palliative care
— C34.99 (3) Malignant neoplasm bronchus or lung, unspecified,

unspecified side
— C79.3 (3) Secondary malignant neoplasm of brain and

cerebral meninges
Rationale: The documentation indicates that this palliative care patient is admitted
for the purpose of receiving treatment for dehydration. In the case of a
known palliative care patient, it is assumed that palliative care is part of the
treatment plan, and Z51.5 is assigned a significant diagnosis type. Prefix 8
is assigned with Z51.5 in this case because palliative care is documented
as a known component of the patient’s care plan prior to arrival at the
facility. C34.99 and C79.3 are mandatory to assign to identify the palliative
condition; in this example, they meet the definition of diagnosis type (3).
D Example: A patient with ovarian cancer is receiving palliative care through a community
program. She is admitted to hospital on January 4 for IV antibiotics to treat
pneumonia. She deteriorates on January 6, and the family is consulted. A decision
is made to give comfort measures only. She dies peacefully on January 10.

— J18.9 (1) Pneumonia, unspecified
— C56.9 (3) Malignant neoplasm of ovary, not specified whether

unilateral or bilateral
Rationale: The documentation indicates that the patient is admitted for management
of an acute reversible condition; however, her condition deteriorated, and
palliative care is responsible for the greatest length of stay. C56.9 is
mandatory to assign to identify the palliative condition; in this example,
it meets the definition of diagnosis type (3). Prefix 8 is assigned with Z51.5
in this case because palliative care is documented as a known component
577
D Example: A patient is admitted for investigation of gastric symptoms. The following day,
gastroscopy and biopsy reveal linitis plastica. The physician discusses the
prognosis (incurable cancer) with the patient. A DNR order is written, a palliative
care consultation is initiated and the treatment plan is changed to palliative care.
The patient dies in hospital 20 days following orders of palliative care.
Code DAD Code title
Z51.5 (M) Palliative care
C16.9 (1) or (W) Malignant neoplasm stomach unspecified
Rationale: This patient was diagnosed during the admission with an irreversible
condition, and palliative care became the treatment plan consuming the
greatest length of stay and resources. Prefix 8 is not assigned in this
case because palliative care is not documented as a known component
D Example: A patient is admitted on January 1 for treatment of congestive heart failure (CHF).
The patient is given medication for the CHF. By January 8, the CHF is worsening
and the physician discusses the poor prognosis with the patient and family. The
patient agrees to comfort care, and all aggressive treatment measures are stopped.
The patient wishes to die at home and is therefore discharged home on January 10
with palliative care measures in place.
Code DAD Code title
Z51.5 (1) or (W) Palliative care
Rationale: Z51.5 Palliative care did not meet the definition of MRDx, as it did not
consume the greatest length of stay and resources. Diagnosis type (1)
or (W) is assigned because there was a change in the treatment plan.
Prefix 8 is not assigned in this case because palliative care is not
documented as a known component of the patient’s care plan prior to
arrival at the facility.
578
D Example: An 84-year-old gentleman is found unresponsive at home on June 8 at 16:45.

The ambulance is called, and the patient is intubated and ventilated. Upon admission
to hospital, further examination and investigation reveal that the patient suffered a
hemorrhagic cerebrovascular accident. The physician discusses the diagnosis and
poor prognosis with the family. The physician recommends that the treatment plan
be changed to palliative care because nothing further can be done for the patient.
The family agrees to the palliative care treatment plan. The patient is extubated at
19:00 and transferred to a palliative care room, where he is kept comfortable with
administration of IV morphine and scopolamine. He dies on June 9 at 08:45.
Code DAD Code title
I61.9 (M) Intracerebral haemorrhage, unspecified
Z51.5 (1) or (W) Palliative care
Rationale: Palliative care is documented following admission, and it constitutes a

treatment change; therefore, Z51.5 qualifies as a diagnosis type (1) or
(W). When palliative care is initiated after admission, it must account for
the majority of the stay and for at least 24 hours to qualify as the MRDx.
It is not the MRDx in this case because the patient was in hospital for
less than 24 hours. Prefix 8 is not assigned in this case because
palliative care is not documented as a known component of the
patient’s care plan prior to arrival at the facility.
D Example: A 50-year-old woman with known non–small cell cancer of the right lung is admitted
on June 17 with a diagnosis of pneumonia. The physician writes that her prognosis
is poor. The patient dies on June 19.
Code DAD Code title
C34.90 (3) Malignant neoplasm of right bronchus or lung unspecified
Rationale: Palliative care cannot be assumed based on the diagnosis of cancer

alone. Z51.5 is assigned only when there is documentation of
palliative care.
579

In effect 2018
Medical assistance in dying (MAID) was decriminalized in Canada with the enactment of
legislation (Bill C-14) in June 2016.
The legislation makes it legal for “a competent adult who clearly consents to the termination of
life” and who “has a grievous and irremediable medical condition (including an illness, disease
or disability) that causes enduring suffering that is intolerable and whose death has become
reasonably foreseeable” to request medical assistance in dying. 2
MAID data can be used to inform future health policy, evaluate the responses of Canada’s
health systems to this new health care service, enable health research on patient trajectories at
the end of life and support a better understanding of patient and provider experiences with the
provision of this new health care service.
The purpose of this coding standard is to provide direction on the classification of MAID using
ICD-10-CA and CCI codes. It addresses code assignment for a variety of circumstances that
are encountered for patients who request MAID.
Medical assistance in dying and palliative care

MAID is not the same as palliative care. Palliative care is part of the continuum of end-of-life
care and is the provision of “comfort care,” “supportive care” or “compassionate care” when it is
determined that it is futile to continue life-sustaining or curative treatment for a patient with an
irreversible or terminal condition. MAID, however, is assisting the patient to end his or her life
because the condition cannot be alleviated by means acceptable to the patient.
Z51.5 Palliative care is not assigned to flag a MAID case. Z51.5 Palliative care is assigned only
when palliative care is a known component of the patient’s care plan prior to arrival at the facility
or when it is a component of the care plan during the episode of care.
See also the coding standard Palliative Care.
580
MAID consultation
Typically, at least one consultation occurs during an encounter for MAID. The consultation may
be to discuss the initial request for MAID or it may be a repeat consultation to further discuss the
process and/or to confirm the decision to proceed with MAID. A CCI code is assigned for each
MAID-related consultation performed during an episode of care. The applicable status attribute
is applied to denote whether it is the initial or a repeat consultation.
Note
The initial consultation may be performed at another facility prior to the current episode of care. When it is
known this occurred, any MAID-related consultation performed following the initial consultation is a repeat
consultation, regardless of when and where the initial consultation was performed.
DN Assign 2.ZZ.02.PM Assessment (examination), total body for assistance in dying, mandatory, for each
consultation that occurs during the episode of care.
Apply, mandatory, the applicable status attribute:
U Initial consultation; or
V Repeat consultation.
Note
When the consultation occurs during an episode of care and MAID is not performed during that episode of
care, a code for the underlying condition for which MAID was requested is assigned as a significant diagnosis
type with prefix J.
Z51.81 Assistance in dying is assigned only when MAID is performed during that episode of care.
581
D Example: A patient with cancer of the esophagus, who is on a palliative care plan at home,
is admitted to the palliative care unit. He requests MAID on the day following his
admission. In the presence of family, the physician discusses the treatment options
available and goes over the MAID process and procedure. On day 11, prior to
performing the MAID intervention, the physician, in the presence of family, confirms
that the patient wants to proceed with MAID. The patient shares with the physician
that he has changed his mind; he prefers to let nature take its course. The patient
expires peacefully three days later.

J C15.9 (1) Malignant lesion oesophagus unspecified
— Z53.2 (3) Procedure not carried out because of patient's

Mandatory decision for other and unspecified reasons
Status: U Initial consultation
Status: V Repeat consultation
Rationale: The patient requested MAID after admission; however, he changed his
mind. Z51.81 is not assigned because MAID was not performed during
this episode of care. Z51.5 is assigned as the MRDx because palliative
care consumes the majority of the length of stay. Z53.2 is assigned as a
diagnosis type (3), mandatory, to denote that the patient requested MAID
but changed his mind. (See the coding standard Cancelled Interventions.)
C15.9 is assigned as a diagnosis type (1) and prefix J is assigned to
denote that cancer of the esophagus is the underlying condition that led
the patient to request MAID. 2.ZZ.02.PM is assigned twice, once for the
initial consultation and once for the repeat consultation.
582
D Example: A patient with terminal glioblastoma multiforme, who is on a palliative care plan at
home, is admitted for further investigations to evaluate his status. He requests
MAID on day 4 of his admission. In the presence of family, the physician discusses
the treatment options available and goes over the MAID process and procedure.
On day 6, the nurse finds the patient unresponsive. The physician is called and
pronounces the patient expired.
J C71.9 (1) Malignant neoplasm of brain unspecified
Rationale: The patient requested MAID after admission; however, he expired prior
to MAID being performed. Z51.81 is not assigned because MAID was
not performed during this episode of care. Z51.5 is assigned as the
MRDx, and C71.9 is assigned as a diagnosis type (1) and prefix J is
assigned to denote that glioblastoma multiforme is the underlying
condition that led the patient to request MAID. 2.ZZ.02.PM is assigned
once for the initial consultation.
583
N Example: A patient with ovarian cancer and multiple metastases (lung, ascites, liver and
brain) is transferred from Hospital A to the Hospital B clinic for MAID. The
physician goes over the procedure with the patient and confirms that she wants
to proceed with MAID. Midazolam, lidocaine, propofol and cisatracurium are
administered intravenously.
— Z51.81 (MP) Assistance in dying
J C56.9 (OP) Malignant neoplasm of ovary, not specified whether

unilateral or bilateral
J C78.09 (OP) Secondary malignant neoplasm of lung,

unspecified side
J C78.6 (OP) Secondary malignant neoplasm of retroperitoneum

and peritoneum
J C78.7 (OP) Secondary malignant neoplasm of liver and

intrahepatic bile duct
J C79.3 (OP) Secondary malignant neoplasm of brain and

cerebral meninges
1.ZZ.35.HA-P7 Pharmacotherapy, total body, percutaneous approach
nervous system agents, using hypnotic and sedative agent
nervous system agents, using anesthetic agent
1.ZZ.35.HA-N3 Pharmacotherapy, total body, percutaneous approach
musculoskeletal system agents, using muscle relaxant
Mode: DI Administered by health care provider
584
Rationale: The patient is admitted for planned MAID; therefore, Z51.81 is assigned
as the main problem. C56.9, C78.09, C78.6, C78.7 and C79.3 are
assigned as other problems and prefix J is assigned to denote that
ovarian cancer with multiple metastases is the underlying condition
that led the patient to request MAID. A CCI code is assigned for each
pharmaceutical agent administered to facilitate death with 7.SC.08.PM.
7.SC.08.PM is assigned to denote that the MAID intervention was
performed during this episode of care. Note: 1.ZZ.35.HA-P1 is assigned
once for lidocaine and propofol because these two agents are classified
to the same agent qualifier (P1). 2.ZZ.02.PM is assigned for the
consultation. The initial consultation was performed at Hospital A;
therefore, status attribute V is applied to 2.ZZ.02.PM to denote that this
is a repeat consultation.
Planned admission for medical assistance in dying

When a patient requests MAID, there is a legislated waiting period before the MAID can be
performed. This waiting period may be spent at home or at a facility that does not perform
MAID. When the waiting period is over, the patient may be admitted for planned performance
of MAID. The following directive statements apply in this circumstance.
DN
Assign Z51.81 Assistance in dying as the MRDx/main problem when a patient has an encounter for planned
medical assistance in dying and it results in death.
• Assign an additional code to identify each condition for which MAID was requested, mandatory, as a
• Assign prefix J, mandatory, to each code denoting the underlying condition.
Note
Do not apply prefix J to Z51.81.
Prefix J is assigned to identify the underlying condition(s) for which MAID was requested or performed. See
Group 10, Field 01 in the Discharge Abstract Database (DAD) Abstracting Manual and data element 43 in the
National Ambulatory Care Reporting System (NACRS) Abstracting Manual.
585

Assign a code from rubric 1.ZZ.35.^^ Pharmacotherapy, total body, mandatory, for each agent administered
DN for MAID; and
DN Assign 7.SC.08.PM Other ministration, personal care for assistance in dying, mandatory.
• Apply, mandatory, the applicable mode attribute:
DI Administered by health care provider; or
SD Administered by self (patient).
Note
When the specific pharmaceutical agents administered to perform MAID are not noted in the documentation
(i.e., a MAID cocktail was administered or nothing is documented about the agents administered), assign the
following code:
1.ZZ.35.HA-T9 Pharmacotherapy, total body, percutaneous approach [intramuscular, intravenous,

subcutaneous, intradermal], various systemic agents, using pharmacological agent NEC
Note
Anesthetization is inherent in the MAID intervention. When anesthesia such as propofol is administered
during a MAID intervention, it is used as a means to perform MAID rather than to achieve anesthesia. It is
mandatory to record the intervention episode start date when a MAID intervention is performed, and it is
mandatory to record anesthetic technique when an intervention episode start date is recorded. Therefore,
enter anesthetic technique 8 — No anaesthetic or pre-admission interventions on the abstract when a MAID
intervention is performed. See Group 11, Field 12 in the Discharge Abstract Database (DAD) Abstracting
Manual and data element 53 in the National Ambulatory Care Reporting System (NACRS) Abstracting Manual.
586
D Example: A patient with end-stage chronic obstructive pulmonary disease (COPD) is admitted
from home for planned MAID. In the presence of family, the physician goes over the
procedure with the patient and confirms that she wants to proceed with MAID.
Midazolam, lidocaine, propofol and cisatracurium are administered intravenously.
— Z51.81 (M) Assistance in dying
J J44.9 (1) Chronic obstructive pulmonary disease, unspecified
as the MRDx. J44.9 is assigned as a diagnosis type (1) and prefix J is
assigned to denote that end-stage COPD is the underlying condition that
led the patient to request MAID. A CCI code is assigned for each
pharmaceutical agent administered to facilitate death with 7.SC.08.PM.
7.SC.08.PM is assigned to denote that the MAID intervention was
performed during this episode of care. Note: 1.ZZ.35.HA-P1 is assigned
once for lidocaine and propofol because these two agents are classified to
the same agent qualifier (P1). 2.ZZ.02.PM is assigned for the consultation.
587
N Example: A patient with previously diagnosed cancer of the esophagus is admitted from home
to the clinic for MAID. He is on a palliative care plan at home while he waits for
MAID. The physician goes over the procedure with the patient and confirms that he
wants to proceed with MAID. Midazolam, lidocaine, propofol and cisatracurium are
administered intravenously.
— Z51.81 (MP) Assistance in dying
J C15.9 (OP) Malignant lesion oesophagus unspecified
8 Z51.5 (OP) Palliative care
as the main problem. C15.9 is assigned as an other problem and prefix
J is assigned to denote that esophageal cancer is the underlying
condition that led the patient to request MAID. Z51.5 with prefix 8 is
assigned because the patient is on a known palliative care plan prior to
588
arrival at the facility. A CCI code is assigned for each pharmaceutical

agent administered to facilitate death with 7.SC.08.PM. 7.SC.08.PM is
assigned to denote that the MAID intervention was performed during this
episode of care. Note: 1.ZZ.35.HA-P1 is assigned once for lidocaine
and propofol because these two agents are classified to the same agent
qualifier (P1). 2.ZZ.02.PM is assigned for the consultation.
Medical assistance in dying performed during episode of care

When a patient requests MAID during an episode of care, the legislated waiting period may be
spent in an acute care inpatient bed or in a palliative care bed. This extends the length of stay.
The following directive statements apply in this circumstance.

Assign a code to identify each condition for which MAID was requested, mandatory, as a significant
D diagnosis type.
• Assign prefix J, mandatory, to each code denoting the underlying condition.
Note
Do not apply prefix J to Z51.81.
Prefix J is assigned to identify the underlying condition(s) for which MAID was requested or performed. See
Group 10, Field 01 in the Discharge Abstract Database (DAD) Abstracting Manual and data element 43 in the
National Ambulatory Care Reporting System (NACRS) Abstracting Manual.
Assign Z51.81 Assistance in dying as a diagnosis type (1) when MAID is performed during the
episode of care and it results in death.
Note
Z51.81 Assistance in dying must not be assigned as a diagnosis type (2) or a diagnosis type (3).
589

Assign a code from rubric 1.ZZ.35.^^ Pharmacotherapy, total body, mandatory, for each agent administered
D
for MAID; and
D Assign 7.SC.08.PM Other ministration, personal care for assistance in dying, mandatory.
• Apply, mandatory, the applicable mode attribute:
DI Administered by health care provider; or
SD Administered by self (patient).
Note
When the specific pharmaceutical agents administered to perform MAID are not noted in the documentation
(i.e., a MAID cocktail was administered or nothing is documented about the agents administered), assign the
following code:
1.ZZ.35.HA-T9 Pharmacotherapy, total body, percutaneous approach [intramuscular, intravenous,

subcutaneous, intradermal], various systemic agents, using pharmacological agent NEC
Note
Anesthetization is inherent in the MAID intervention. When anesthesia such as propofol is administered
during a MAID intervention, it is used as a means to perform MAID rather than to achieve anesthesia. It is
mandatory to record the intervention episode start date when a MAID intervention is performed, and it is
mandatory to record anesthetic technique when an intervention episode start date is recorded. Therefore,
enter anesthetic technique 8 — No anaesthetic or pre-admission interventions on the abstract when a MAID
intervention is performed. See Group 11, Field 12 in the Discharge Abstract Database (DAD) Abstracting
Manual and data element 53 in the National Ambulatory Care Reporting System (NACRS) Abstracting Manual.
590
D Example: The patient is admitted, immobile and in uncontrollable pain, with multiple sclerosis.
He is on subcutaneous morphine for pain. He also has congestive heart failure. He
requests MAID on day 3 of his 13-day length of stay. In the presence of family, the
physician discusses the treatment options available and goes over the MAID process
and procedure. On day 13, prior to performing the MAID intervention, the physician,
in the presence of family, confirms that the patient wants to proceed with MAID.
Midazolam, lidocaine, propofol and rocuronium are administered intravenously.

J G35 (M) Multiple sclerosis
— Z51.81 (1) Assistance in dying
— I50.0 (3) Congestive heart failure





591
Rationale: The patient requested MAID after admission and MAID was performed
during this episode of care. Therefore, Z51.81 is assigned as a
diagnosis type (1). G35 is assigned as the MRDx and prefix J is
assigned to denote that multiple sclerosis is the underlying condition
that led the patient to request MAID. I50.0 is assigned as a diagnosis
type (3), optionally. While the congestive heart failure may have been
a contributing factor in the patient’s request for MAID, it was not the
underlying condition that led the patient to request MAID, and there is
no documentation to support that the congestive heart failure otherwise
met the criteria for significance.
A CCI code is assigned for each pharmaceutical agent administered to

facilitate death with 7.SC.08.PM. 7.SC.08.PM is assigned to denote
that the MAID intervention was performed during this episode of care.
Note: 1.ZZ.35.HA-P1 is assigned once for lidocaine and propofol
because these two agents are classified to the same agent qualifier
(P1). 2.ZZ.02.PM is assigned twice, once for the initial consultation
and once for the repeat consultation.
592
D Example: A patient is admitted with amyotrophic lateral sclerosis (ALS). He also has type 2
diabetes mellitus with end-stage kidney disease. He is seen by a nephrologist who
recommends the patient be started on hemodialysis. The patient refuses dialysis. On
day 15, the patient requests MAID. He would like to proceed with MAID before his ALS
progresses any further. On day 17, the patient is transferred to palliative care. On day
20, the patient asks to see the physician again about his request for MAID. On day 27,
in the presence of family, the physician confirms the patient wants to proceed with
MAID. Midazolam, lidocaine, propofol and rocuronium are administered intravenously.

J G12.20 (M) Amyotrophic lateral sclerosis
— Z51.81 (1) Assistance in dying
— E11.23 (1) Type 2 diabetes mellitus with established or

— N08.35 (3) Glomerular disorders in diabetes mellitus, chronic

kidney disease, stage 5
— Z51.5 (1) Palliative care





593

Rationale: The patient requested MAID after admission and MAID was performed
during this episode of care. Therefore, Z51.81 is assigned as a
diagnosis type (1). G12.20 is assigned as the MRDx and prefix J is
assigned to denote that ALS is the underlying condition that led the
patient to request MAID. E11.23 is assigned as a diagnosis type (1)
and N08.35 is assigned as a diagnosis type (3) because the patient
was seen in consultation by a nephrologist. While the type 2 diabetes
mellitus and end-stage kidney disease may have been contributing
factors in the patient’s request for MAID, the ALS was the underlying
condition that led the patient to request MAID.
A CCI code is assigned for each pharmaceutical agent administered to

facilitate death with 7.SC.08.PM. 7.SC.08.PM is assigned to denote
that the MAID intervention was performed during this episode of care.
Note: 1.ZZ.35.HA-P1 is assigned once for lidocaine and propofol
because these two agents are classified to the same agent qualifier
(P1). 2.ZZ.02.PM is assigned three times, once for the initial
consultation and twice for the two repeat consultations.
Note
See the coding standard Adverse Reactions in Therapeutic Use Versus Poisoning for direction on classifying an
adverse effect in therapeutic use resulting from administration of agents to perform MAID. Do not apply
prefix J to the codes that denote the adverse effect in therapeutic use.
Apply the diagnosis cluster to the set of codes that denote the adverse effect in therapeutic use, per the
direction in the coding standard. Do not apply the diagnosis cluster to Z51.81 Assistance in dying or to the
code(s) for the underlying condition(s) for which MAID was requested or performed.
594
Boarder Babies and Boarder Mothers


When a mother is admitted for early postpartum care and her healthy newborn is also admitted as a
D
“boarder baby,” assign one of the following codes as the MRDx on the infant’s abstract:
• Z76.2 Health supervision and care of other healthy infant and child when supervision and care for the
healthy infant is carried out by the nursing staff.
• Z76.3 Healthy person accompanying sick person when the mother provides all care for the infant herself.
Infant’s abstract
D Example: A healthy male infant is admitted with his mother, who requires early postpartum
care. The infant receives care and supervision from the nursing staff.
Code DAD Code title
Z76.2 (M) Health supervision and care of other healthy infant and child
Infant’s abstract
D Example: A healthy male infant is admitted with his mother, who requires early postpartum
care. The infant rooms with his mother, who provides all care for the infant.
Code DAD Code title
Z76.3 (M) Healthy person accompanying sick person
D When a baby is ill and a mother is admitted in order to provide care and supervision for her sick infant,
assign Z76.3 Healthy person accompanying sick person as the MRDx on the mother’s abstract.
595
Mother’s abstract
D Example: Due to distance and family circumstances, the healthy mother of a sick infant is
admitted to care for her breastfeeding baby.
Code DAD Code title
Z76.3 (M) Healthy person accompanying sick person
Z39.1 (3) Care and examination of lactating mother (optional)
Rationale: This code is applicable to any healthy person whose only reason to be
in hospital is to accompany a sick person. In this case, it applies to a
healthy mother. In this case, Z39.1 may be added as an optional
diagnosis type (3) to describe the breastfeeding component.
Homelessness
In effect 2018
“Whether as a cause or a consequence of ill health, homelessness has emerged as a

fundamental health issue for Canadians. Homelessness affects a significant number of
Canadians of all ages and is associated with a high burden of illness, yet the health care system
may not adequately meet the needs of homeless people.” 3 Tracking health care usage by
homeless individuals is important to understanding initiatives aimed at reducing homelessness.
The Canadian Observatory on Homelessness explains that “homelessness encompasses a

range of physical living situations,” including living on the streets or in places not intended for
human habitation (e.g., sidewalks, parks, cars); staying in overnight shelters; and staying in
temporary accommodations (e.g., motels, rooming houses, with friends/family, couch surfing,
temporary housing for immigrants and refugees during settlement). 4
Assign Z59.0 Homelessness as a diagnosis type (3)/other problem, mandatory, for patients who are
DN
homeless on admission.
596
Documentation of homelessness is not limited to physician documentation. The intent is

to assign a code for homelessness when it is noted on routine review of the record, not to
conduct an exhaustive search of all ancillary documentation for reference to homelessness.
Homelessness on admission may be documented at any point during the patient’s episode
of care.
DN Example: A 60-year-old patient is admitted with bronchitis. Documentation indicates that this
patient resides in a men’s shelter.
J40 (M) MP Bronchitis, not specified as acute or chronic
Z59.0 (3) OP Homelessness
Rationale: As there is documentation of homelessness on admission, it is

mandatory to assign Z59.0.
Note
For more information on homeless/transient patients, see Group 03, fields 03 and 06 in the Discharge
Abstract Database (DAD) Abstracting Manual and data elements 04 and 06 in the National Ambulatory Care
Reporting System (NACRS) Abstracting Manual.
Personal and Family History of

Malignant Neoplasms

Use the following criteria to determine when to assign a code from Z85 Personal history of
DN malignant neoplasm.
• The malignancy has been completely eradicated or excised and no further treatment (including adjuvant
therapy) is being directed to the primary site.
Note
Codes from the category Z80 Family history of malignant neoplasm and Z85 Personal history of malignant
neoplasm are never recorded as the MRDx/main problem.
597
Note
Z85 Personal history of malignant neoplasm is mandatory only in certain circumstances.
See the following coding standards:
• Acquired Absence of Breast and Lung Due to Primary Malignancy

• Personal History of Primary Malignant Neoplasm of Breast, Lung and Prostate
• Primary and Secondary Neoplasms
• Recurrent Malignancies
N Example: A woman presents to the emergency department for a dressing change (medicated)
on the weekend. She had a mastectomy for breast cancer the week before and is
scheduled for chemotherapy.
Z48.0 MP Attention to surgical dressings and sutures

side (optional)
1.YS.14.JA-H1 Dressing, skin of abdomen and trunk, using medicated dressing (optional)
Rationale: Z85.– is not assigned because the patient is still undergoing treatment.
See also the coding standard Admission for Follow-up Examination.
DN Example: A patient who had a radical prostatectomy five years ago presents for management
of bone metastases.
C79.5 (M) MP Secondary malignant neoplasm of bone and

bone marrow
Z85.4 (3) OP Personal history of malignant neoplasm of genital

organs (mandatory)
Rationale: When a patient is diagnosed with a secondary malignancy it is

mandatory to assign an additional code to identify the primary site.
Z85.4 is selected because the patient has completed treatment directed
toward the primary site. See also the coding standard Primary and
Secondary Neoplasms.
598
DN
Assign a code from Z80 Family history of malignant neoplasm, optional, as diagnosis type (3)/other
problem to denote a reason for an examination or prophylactic surgery.
D Example: The patient has an extremely strong maternal family history of breast malignancy.
She is admitted for prophylactic bilateral simple total mastectomies.
Code DAD Code title
Z40.00 (M) Prophylactic removal of breast
Z80.3 (3) Family history of malignant neoplasm of breast (optional)
1.YM.89.^^ Excision total, breast (approach coded with qualifiers)

Location: B
DN Example: The patient has a strong family history of colon cancer. She is admitted for an
elective colonoscopy to screen for the disease. No disease is found at this time.

intestinal tract
Z80.0 (3) OP Family history of malignant neoplasm of

digestive organs (optional)
2.NM.70.BA-BJ Inspection, large intestine, using endoscopic per orifice approach

(or via stoma) and colonoscope
See also the coding standards Prophylactic Organ Removal and Screening for Specific Diseases.
599
Personal History of Primary Malignant

Neoplasms of Breast, Lung and Prostate
In effect 2015

Assign a code from Z85.11– Personal history of malignant neoplasm of bronchus and lung or Z85.3–
DN Personal history of malignant neoplasm of breast or Z85.4 Personal history of malignant neoplasm of
genital organs, mandatory, as a diagnosis type (3)/other problem when all of the following criteria are met:
• There is a history of primary malignancy of the breast, lung or prostate; and

• The previous malignancy has been completely excised or eradicated; and
• There is no further treatment (including adjuvant therapy) directed to the primary site; and
• The current episode of care relates to a follow-up examination, prophylactic organ removal or
reconstructive surgery.
Note
Codes from the category Z85 Personal history of malignant neoplasm are never recorded as the
MRDx/main problem.
See also the coding standards Acquired Absence of Breast and Lung Due to Primary Malignancy,
Admission for Follow-up Examination, Personal and Family History of Malignant Neoplasms,
Prophylactic Organ Removal, Recurrent Malignancies and Primary and Secondary Malignant Neoplasms.
DN Example: A patient with a personal history of primary breast cancer, left breast (no residual disease),
elects to have a right total simple mastectomy to remove the non-diseased breast.
Z40.00 (M) MP Prophylactic removal of breast

right breast
Rationale: It is mandatory to assign a code from Z85 Personal history of malignant

neoplasm for this example as all four criteria are met. The patient has a
history of primary malignancy of the breast; the previous malignancy has
been completely excised; there is no further treatment directed to the primary
site; and the current episode of care relates to prophylactic organ removal.
600
DN Example: The patient had an excision of the left upper lobe of lung for primary malignancy
two years ago. The patient is seen for a follow-up bronchoscopy; the examination
is negative.
Z08.0 (M) MP Follow-up examination after surgery for

malignant neoplasm
Z85.111 (3) OP Personal history of malignant neoplasm of left

bronchus and lung
Rationale: It is mandatory to assign a code from Z85 Personal history of

malignant neoplasm for this example as all four criteria are met.
The patient has a history of primary malignancy of the lung; the
previous malignancy has been completely excised; there is no further
treatment directed to the primary site; and the current episode of care
relates to a follow-up examination.
DN Example: The patient completed radiotherapy of the prostate for primary malignancy six
months ago. The patient is seen for a follow-up endoscopic examination of the
prostate; the exam is negative.
Z08.1 (M) MP Follow-up examination after radiotherapy for

malignant neoplasm

genital organs

neoplasm for this example as all four criteria are met. The patient
has a history of primary malignancy of the prostate; the previous
malignancy has been completely eradicated; there is no further
treatment directed to the primary site; and the current episode of
care relates to a follow-up examination.
601
DN Example: A patient with a history of previous total mastectomy of left breast for primary breast
cancer presents for left breast reconstruction with breast implant.
Z42.1 (M) MP Follow-up care involving plastic surgery of breast
Z85.31 (3) OP Personal history of malignant neoplasm of left breast

neoplasm for this example as all four criteria are met. The patient has
a history of primary malignancy of the breast; the previous malignancy
has been completely excised; there is no further treatment directed
to the primary site; and the current episode of care relates to
DN Example: A patient with a history of right breast cancer treated with total mastectomy one year
ago is admitted for prophylactic removal of the left breast due to risk of malignancy.
The patient will continue to receive tamoxifen therapy for the right breast cancer for
another six months.
Z40.00 (M) MP Prophylactic removal of breast
C50.90 (3) OP Malignant neoplasm of right breast, part unspecified
Rationale: All of the criteria have not been met. The patient is receiving adjuvant
therapy (tamoxifen) for the right breast cancer; therefore, the code
Z85.30 Personal history of malignant neoplasm of right breast is
not assigned.
References
1. World Health Organization. International Statistical Classification of Diseases and
Related Health Problems (ICD-10), Tenth Revision, Volume 1. 2010.
2. Department of Justice, Government of Canada. About the proposed legislation. Accessed

August 3, 2017.
3. The Homeless Hub. Health. Accessed June 1, 2017.
4. Canadian Observatory on Homelessness. Canadian Definition of Homelessness. 2012.
602
Appendix A — Resources
Definitions of flaps and grafts
When direct closure of a wound is not possible, there are several options available to the
surgeon to repair a defect, whether surgically or traumatically created. Although some clinicians
use the terms “flap” and “graft” interchangeably, the classification clearly distinguishes between
the two. The following definitions of terms commonly used to describe a flap or a graft of skin
and soft tissue have been prepared to help with selection of the correct CCI qualifier, to obtain
national coding consistency.
Skin and soft tissue terminology

Dermis
The dermis is the layer of skin below the epidermis. It is made up of dense vascular connective
tissue and consists of two layers: the papillary layer or stratum papillare and the reticular layer
or stratum reticulare.
Epidermis
The epidermis is the outermost, nonvascular, layer of the skin. It is made up of five layers,
beginning with the deepest layer and moving to the surface: basal layer or stratum basale;
spinous layer or stratum spinosum; granular layer or stratum granulosum; clear layer or stratum
lucidum; and horny layer or stratum corneum.
Skin
The skin is the body’s largest organ. It is the body’s outer, protective covering. It is composed
of the dermis and the epidermis. In CCI, the skin is classified to anatomy site (Y) Skin and
Subcutaneous Tissue and Breast.
Soft tissue
Soft tissue is the tissue that connects and supports other body structures. It includes connective
tissue — tendons, ligaments, fascia, fibrous tissue and fat — and muscles, nerves and blood
vessels. In CCI, soft tissue is classified to the alphabetical character that denotes the specific
anatomy site. An example is (EQ) Soft Tissue of Head and Neck.
603
Subcutaneous tissue
Subcutaneous tissue is the layer below the dermis. It is composed of adipose cells, loose
connective tissue and larger blood vessels and nerves. It is also known as the hypodermis.
Interventions
Tissue qualifier
The tissue qualifier is a component of the CCI code. It is one character, positioned in field six
of the CCI code. When an intervention may commonly involve a sequence of associated
concomitant actions in order to reach its goal, this will be described — when possible — by a
single code. For example, qualifiers provide options that describe the excision of (a lesion of) an
anatomy site with a concomitant repair involving a graft or a flap to close the surgical defect.
The qualifier selected describes the concomitant repair.
Excision
In CCI, an excision is classified to Excision partial (87), Excision partial with reconstruction (88),
Excision total (89), Excision total with reconstruction (90), Excision radical (91) or Excision
radical with reconstruction (92). The “deepest site” rule applies to excisions. An excision of a
lesion of the skin that extends into the soft tissue is classified to excision of soft tissue of the
anatomy site. An example is 1.EQ.87.^^ Excision partial, soft tissue of head and neck.
Wide excision
A wide excision, also known as a wide local excision, is removal of the lesion along with a
margin of normal-appearing tissue that surrounds the lesion. In CCI, a wide excision is classified
to Excision partial (87).
Wedge excision
A wedge excision is removal of a triangular-shaped piece of tissue, which includes the lesion as
well as a small amount of normal-appearing tissue that surrounds the lesion. In CCI, a wedge
excision is classified to Excision partial (87).
Procurement
Procurement is retrieval of tissue from one (donor) site to repair a defect at another (local or
distant recipient) site. It is also known as “harvesting.” In CCI, procurement is classified to
Procurement (58).
604
Flaps
Advancement flap
An advancement flap is a local flap that is moved to the site of the defect using a sliding
technique. The CCI tissue qualifier for an advancement flap is “E.”
Flap
A flap is tissue procured that includes the blood and nerve supply. It is usually cut on three
sides, leaving the fourth side attached to the blood and nerve supply of the procurement site.
When it is completely excised from the procurement site, microvascular anastomosis is required
to attach it to the recipient site.
Free flap
A free flap is tissue that is raised on its vascular pedicle, procured from one site and reattached
at a distant site. These flaps include vessels — at least one vein and one artery — to maintain
a blood supply and must be joined at the recipient site by microvascular anastomosis to allow
revascularization. A free flap may also be referred to as composite free flap, fasciocutaneous
flap, fibular flap, interpositional intestinal flap, island flap or random flap. The CCI tissue qualifier
for a free flap is “F.”
Island flap
An island flap is also known as a free flap. An island flap (vascular pedicle) includes vessels —
at least one vein and one artery — and is procured from one site and reattached using
microvascular anastomosis at a distant site. The CCI tissue qualifier for an island flap is “F.”
Local flap
A local flap is tissue that is procured in the immediate vicinity of the defect where the “repair” is
needed. When direct closure of a wound is impossible due to its size or shape a local flap may
be used. It is usually cut on three sides, leaving the fourth side attached to the blood and nerve
supply of the donor site to maintain blood and nerve supply to the recipient site. Examples of
local flaps include a V-Y advancement flap, a transposition flap, a Z-plasty and a rotation flap.
The most frequent types of tissue used for local flaps are skin, mucosa and omentum. The CCI
tissue qualifier for a local flap is “E.”
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Musculocutaneous or myocutaneous flap
A musculocutaneous or myocutaneous flap is tissue composed of skin and muscle. Blood

and nerve supply of the donor site are maintained to the recipient site. An example of a
musculocutaneous or myocutaneous flap is a pedicled flap. The CCI tissue qualifier for a
musculocutaneous or myocutaneous flap is “G.”
Pedicled (distant or regional) flap
A pedicled flap is tissue that is procured from a site, usually distant from the defect, which
remains attached to the donor site to maintain blood and nerve supply to the recipient site.
It is prepared like a local flap but it is not procured in the immediate vicinity where the repair
is needed. It elevated and often split and/or “tunnelled” in order to reach the recipient. The
pedicled flap remains attached at its base (pedicle) carrying its own blood supply. When the
flap has been set into the recipient defect site and the new blood and nerve supply have been
well-established, the pedicle may be divided. This usually takes about three weeks. A pedicled
flap may also be referred to as a composite flap, a myocutaneous flap, a regional flap, a muscle
rotation flap, a muscle transposition flap, a latissimus dorsi myocutaneous flap (LDM) or a trans
rectus abdominis muscle flap (TRAM). The CCI tissue qualifier for a pedicled flap is “G.”
Rotation flap
A rotation flap is a type of local flap. The width or length and the mobility of the flap are
increased by using curved incisions and counter-incisions. The tissue is rotated and stretched to
repair the defect. The CCI tissue qualifier for a rotation flap is “E.”
Transposition flap
A transposition flap is a type of local flap. The tissue is stretched and repositioned to repair the
defect. The CCI tissue qualifier for a transposition flap is “E.”
V-Y advancement flap
A V-Y advancement flap is a type of local flap. The length of the flap is increased by making an
incision shaped like a “V.” The tissue is then stretched and sutured into the defect in the shape
of a “Y.” The CCI tissue qualifier for a V-Y advancement flap is “E.”
Z-plasty
A Z-plasty is a transposition local flap that combines components of an advancement flap and a
rotation flap. Two triangular flaps are created by the “Z” incision and are transposed or rotated
so that the apex of each flap fits into the defect at the base of the opposite flap. This technique
redistributes the tension on the wound and results in a less noticeable scar. The scar is broken
up into smaller units, camouflaging a wound that crosses relaxed skin tension lines or Langer
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lines that correspond to collagen fibers within the dermis. For example, a Z-plasty is often used
to repair a linear wound that crosses the vermillion border or the medial canthus. The CCI tissue
qualifier for a Z-plasty is “E.”
Grafts
Autograft
An autograft is tissue, without vascular supply, procured from and used to repair a defect in the
patient’s own body. An autograft may be described as a full-thickness or split-thickness skin, fat,
fascia, cartilage, bone or nerve graft. It may also be called autologous tissue in the source
documentation. The CCI tissue qualifier for an autograft is “A.”
Full thickness
A full-thickness graft is procurement of the epidermis and the full depth of the dermis. The CCI
tissue qualifier for a full-thickness autograft is “A.”
Graft
A graft is tissue procured that does not include the blood and nerve supply. It includes the
epidermis and some or all of the dermis.
Homograft
A homograft is an organ or tissue procured from another human being that is used promptly
after procurement or after preservation in a tissue bank. A homograft may also be referred to as
allograft, allogeneic organ or homologous tissue.
Split thickness
A split-thickness graft is procurement of the epidermis and some of the dermis. It is described
as “thin,” “intermediate” or “thick” depending on the thickness of the dermis procured. The CCI
tissue qualifier for a split-thickness autograft is “B.”
Synthetic tissue graft
A synthetic tissue graft is man-made material that is used to replace tissue and often also
encourages tissue regeneration or healing. It includes materials such as bone paste and Marlex
mesh. Synthetic tissue may be used to reinforce repairs such as that of a hernia.
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Xenograft
A xenograft is an organ or tissue procured from an animal source (e.g., porcine valves, bovine
bone tissue). A xenograft may also be referred to as heterograft, heterologous graft or
heteroplastic graft.

parasitic diseases
Drug-resistant microorganisms
What is methicillin resistant Staphylococcus aureus (MRSA)?
Staphylococcus aureus, often referred to simply as “staph,” is a bacterium commonly found on
the skin of healthy people. Occasionally, staph can get into the body and cause an infection.
This infection can be minor (such as pimples, boils, and other skin conditions) or serious (such
as blood infections or pneumonia). Methicillin is an antibiotic commonly used to treat staph
infections. Although methicillin is very effective in treating most staph infections, some staph
bacteria have developed resistance to methicillin and can no longer be killed by this antibiotic.
These resistant bacteria are called methicillin-resistant Staphylococcus aureus, or MRSA.
They can be found on the skin, in the nose, and in blood and urine.
MRSA infection usually develops in hospital patients who are elderly or very sick, or who have
an open wound (such as a bedsore) or a tube (such as a urinary catheter) going into their body.
Although MRSA is resistant to many antibiotics and often difficult to treat, a few antibiotics can
still successfully cure MRSA infections.
What is vancomycin-resistant enterococcus (VRE)?

Enterococcus is a common, gram-positive bacterium. The most common infections caused
by enterococci are urinary tract infections, wound infections, bacteremia, endocarditis and
meningitis. Enterococci also frequently colonize open wounds and skin ulcers.
Vancomycin is the antibiotic used for the treatment of serious infections caused by enterococci.
Like with MRSA, patients can be either “colonized” or “infected” with vancomycin-resistant
enterococci (VRE) and both are sources for nosocomial infection. The most frequent sites for
colonization are in the stool, perineum, anus, axilla, umbilicus, wounds, Foley catheters and
colostomy sites.
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VRE can be spread directly by patient-to-patient contact or indirectly via hands of personnel,
contaminated environmental surfaces or patient care equipment. Treatment of VRE infection is
difficult due to a very limited range of antibiotics available. Those people found to be harmlessly
colonized by VRE need no special treatment and over a period of time these people become
spontaneously clear of VRE.
What is the difference between colonization and infection?

Colonization means that MRSA or VRE is present on or in the body without causing illness.
Patients will have no signs or symptoms of infection caused by the organism. A microbiology
report may indicate the presence of MRSA or VRE, but the patient will not have an actual
infection, however, they are carriers. Treatment of carriers without symptoms of infection is not
usually necessary, but they may sometimes be treated with special antibiotic ointments to the
nose and/or washing with special antibacterial preparations.
On the other hand, if a patient has a MRSA or VRE infection it means that MRSA or VRE is
making the person sick.
What is decolonization?
Decolonization is the elimination of MRSA carrier state through use of infection control
measures and/or antibiotics. This decreases the risk of transmission to high-risk individuals
(immunocompromised or otherwise highly susceptible persons) or to others in an
outbreak situation.
Chapter IV — Endocrine, nutritional and

metabolic diseases
Diabetes mellitus
Diabetes mellitus is a chronic disease in which the body does not make, or does not properly
use, insulin. Insulin is the hormone that helps the body use the energy from sugar, starches
and other foods. Glucose is a form of sugar produced when the body digests carbohydrates
(sugars and starches). Glucose is the body’s major fuel for the energy it needs. When insulin
is absent or ineffective, the blood glucose (blood sugar) level increases and the patient
becomes hyperglycemic.
ICD-10-CA alphabetical index lead term “diabetes, diabetic” provides look-ups for complications
and conditions associated with diabetes mellitus or considered to be diabetes-related.
Combination codes are typically located in the alphabetical index under secondary terms such
as “with,” “due to” and “in” diabetes. In the tabular listing, conditions with diabetes are referred to
as “complications.”
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Therefore, the cause-and-effect relationship does not have to be specifically documented to

classify cases to a diabetes mellitus with complication code.
Two major coding conventions apply when classifying diabetes mellitus: the dagger and asterisk
convention and the “code separately” instruction.
The dual axis is used to classify diabetes mellitus and the specific complication of or condition
associated with diabetes mellitus. The dagger code denotes that the etiology or underlying
cause is diabetes mellitus and the asterisk code denotes the manifestation or specific
complication of or condition associated with diabetes mellitus.
The conditions listed under the “code separately” instruction are typically the focus of the
episode of care when a patient with diabetes mellitus presents with one of the listed conditions.
These conditions are not subject to the asterisk code sequencing rules and are allowed as the
most responsible diagnosis (MRDx) or main problem when appropriate.
Diabetes mellitus is classified to the block E10 to E14 in ICD-10-CA. The first axis (three-
character category level) identifies the type of diabetes.
Type 1 diabetes mellitus (E10.–)

The cause of type 1 diabetes is unknown. It is the result of an autoimmune process in which
the body’s immune system attacks and destroys the insulin producing cells of the pancreas.
The failure of the beta cells to produce insulin prevents glucose from entering the cells of the
body to provide fuel. When glucose cannot enter the cells, it builds up in the blood and the
body’s cells literally starve to death. People with type 1 diabetes must take daily insulin
injections and regularly monitor their blood sugar levels.
Type 1 diabetes can cause different problems, but there are three key complications:
1. Hypoglycemia (low blood sugar; sometimes called an insulin reaction) occurs when blood
sugar drops too low.
2. Hyperglycemia (high blood sugar) occurs when blood sugar is too high, and can be a sign
that diabetes is not well controlled.
3. Ketoacidosis (diabetic coma) is loss of consciousness due to untreated or under-treated diabetes.
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Type 2 diabetes mellitus (E11.–)

Type 2 diabetes mellitus, which is related to insulin resistance (lack of the ability of the body
to respond to insulin appropriately), is the most common form of diabetes. In type 2 diabetes,
either the body does not produce enough insulin or the cells ignore the insulin. When glucose
builds up in the blood instead of going into cells, it can cause the cells to be starved for energy.
Over time, high blood glucose levels may result in hyperglycemia and other complications such
as accelerated atherosclerosis, neuropathy, nephropathy and retinopathy.
“Although most type 2 diabetics are treated with diet, exercise and oral drugs, some patients
intermittently or persistently require insulin to control hyperglycemia and prevent non-ketotic
hyperglycemic-hyperosmolar coma (NKHHC).” 1 Treatment by insulin is not an indicator of
the type of diabetes. Type 2 diabetes is considered as insulin requiring diabetes if the
patient needs insulin therapy, while type 1 diabetes mellitus is considered as insulin
dependent diabetes.
Other specified diabetes mellitus (E13.–)

Other specified types, previously called secondary diabetes, are caused by other illness or
medications that result in destruction of pancreatic beta cells or development of peripheral
insulin resistance. The most common are diseases of the pancreas that destroy the pancreatic
beta cells (e.g., hemochromatosis, pancreatitis, cystic fibrosis, pancreatic cancer), hormonal
syndromes that interfere with insulin secretion (e.g., pheochromocytoma) or cause peripheral
insulin resistance (e.g., acromegaly, Cushing syndrome, pheochromocytoma), and diabetes
induced by drugs (e.g., phenytoin, glucocorticosteroids, estrogens). 2 Genetic research has
provided new insights into the pathogenesis of MODY (maturity-onset diabetes of young), which
was formerly included as a form of type 2 diabetes. A review of the literature shows that other
specified types of diabetes may account for 1% to 2% of all diagnosed cases of diabetes.
Just as patients with type 2 diabetes do not become type 1 diabetics, or vice versa, patients with
a type of diabetes classifiable to E13.– do not become type 1 or type 2 diabetics.
Diabetes mellitus in pregnancy (O24.5–O24.8)

This pregnancy-related form of diabetes occurs when high levels of hormones cause cells
to become less sensitive to insulin. Gestational diabetes occurs in about 2%–5% of all
pregnancies, and disappears when pregnancy is over. Women who have had gestational
diabetes are at increased risk for later developing type 2 diabetes mellitus.
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Borderline diabetes — A misnomer

According to Diabetes Canada, “borderline” diabetes doesn’t exist, although the term seems
to be used quite frequently. In general, it appears to be a common expression meaning that
a person has mild diabetes, or perhaps that the treatment is only diet and exercise.
Another misunderstanding about being “borderline” may be the assumption that blood
glucose levels are just slightly elevated in a diabetic. 3
Impaired glucose tolerance (IGT) [R73.0 Abnormal Glucose Tolerance Test]

A diagnostic statement of IGT indicates a prediabetic state, which is associated with insulin
resistance and closely related to type 2 diabetes. It occurs when the blood glucose level is
higher than normal, but not high enough to be classified as diabetes. IGT is detected through
the same oral glucose tolerance test that is used to detect diabetes. People with IGT have a 1 in
3 chance of developing type 2 diabetes within 10 years, but this can be minimized through
healthy eating and physical activity.
Complications of diabetes
Diabetic complications can be classified broadly as micro-vascular or macro-vascular disease.
Microvascular complications include neuropathy, nephropathy and vision disorders (e.g.,
retinopathy, glaucoma, cataract and corneal disease). Macrovascular complications include
conditions such as heart disease and stroke.
Common microvascular complications of diabetes mellitus

Diabetic nephropathy
Diabetic nephropathy is kidney damage, usually due to changes in small blood vessels leading
to the filtering system of the kidney or to the smaller blood vessels within the filtering system
itself, caused by a persistently high blood sugar level from diabetes. The damaged nephrons
allow proteins that normally would stay in the blood to pass into the urine.
Diabetic nephropathy is the most common cause of kidney failure. There are no symptoms
in the early stages of diabetic nephropathy. A small amount of protein in the urine
(microalbuminuria) is the first sign of kidney damage. As damage to the kidneys progresses,
larger amounts of protein spill into the urine (macro-albuminuria) and blood pressure rises.
When damage to the blood vessels continues over time, kidney failure develops.
End-stage kidney disease is complete (or nearly total) and permanent kidney failure. The body
begins to fill up with waste products and excess water. This condition — uremia — if left
untreated can lead to seizures or coma and ultimately death. 4
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Related intervention
The treatment for end-stage kidney disease is either kidney transplant or dialysis. Dialysis is a
way of detoxifying the blood with an artificial kidney (dialyzer). Dialysis is classified to 1.PZ.21.^^
Dialysis, urinary system NEC. The qualifier denotes the type of dialysis performed: hemodialysis
versus peritoneal dialysis. It is mandatory to assign a CCI code for dialysis whenever it is performed
during an episode of care, regardless of who performs it or in which location it is performed.
Diabetic retinopathy
Retinopathy is the non-inflammatory impairment of the retina. Diabetic retinopathy occurs

when the small blood vessels in the retina become swollen, often leaking fluid, or when new
tiny blood vessels grow that block the retina. Diabetic retinopathy is a common cause of
blindness in adults.
Additionally, new tiny blood vessels may form across the retina (neo-vascularization). These
blood vessels are extremely fragile and may break and bleed easily, resulting in the formation
of fibrous (scar) tissue around them. This causes the vision to be obscured and may ultimately
cause retinal detachment (where scar tissue pulls the retina away from where it should be).
This often causes the sudden loss of sight in one eye.
Related intervention
The treatment for retinopathy is usually a form of laser treatment called pan-retinal laser
photocoagulation, which is normally done under local anesthetic. In this form of laser treatment,
bursts of a laser beam directed at the retina can destroy the new, abnormal blood vessels and
prevent the retina detaching. It has been shown to reduce severe visual loss significantly if
treatment is undertaken early. In CCI, this is coded to 1.CN.59.LA-AG Destruction, retina,
using laser.
Diabetic neuropathy
Diabetic neuropathy is the loss of the function of peripheral nerves in people with diabetes.
There are many theories as to why patients with diabetes develop this condition. It may be
due to the nerves having increased levels of glucose (sugar), which leads to dysfunction of the
normal pathways that utilize the glucose for energy. Another possibility is that the blood supply
to the nerves is compromised, which causes them not to function properly.
The symptoms of diabetic neuropathy can include increased but abnormal sensations such as
pain or burning, or decreased sensation like numbness. Diabetic neuropathy typically affects
the longest nerves first, and so it is most common in the feet. Loss of pain and/or temperature
sensation can predispose the patient with diabetes to foot ulcers — they can bump their foot
and not even realize there is an open wound until the wound has already become infected.
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Many other nerves can be affected in patients with diabetes. The nerves that make the eyes
move may be affected so a diabetic may develop double vision. The optic nerve can be affected
with subsequent loss of vision.
The autonomic nervous system can over-function or under-function. This can cause patients
with diabetes to have too much or too little sweating, incontinence or retention of urine, diarrhea
or constipation, sexual problems (including erectile dysfunction), problems with the pupils
reacting to light changes and even fainting spells.
Peripheral circulatory complications
Diabetic vascular disease refers to hardening of the arteries throughout the body because
of diabetes. Peripheral arterial disease (PAD) is hardening and narrowing of the arteries
(atherosclerosis) that supply blood to the arms, legs and other parts of the body. It results
in reduced blood flow to those parts of the body. The arteries in the legs are most often
affected. As an artery is narrowed by atherosclerosis, the leg muscles do not get enough
blood, especially during increased activity when more blood is required. The main symptom of
peripheral arterial disease in the leg is a tight or squeezing pain in the calf, foot, thigh or buttock
that occurs during exercise (such as walking up a hill or a flight of stairs, running, or simply
walking a few steps). This pain is called intermittent claudication.
PAD treatment may consist of a minimally invasive procedure called angioplasty and stenting
[1.KG.50.^^ Dilation, arteries of leg NEC]. In an angioplasty, a long, thin, flexible tube called a
catheter is inserted into a tiny incision above an artery in the leg and is guided through the
arteries to the blocked area. Once there, a special balloon attached to the catheter is inflated
and deflated several times. The balloon pushes the plaque in the artery against the artery
walls, widening the vessel. A tiny mesh-metal tube called a stent may then be placed into the
narrowed area of the artery to keep it open. The stent remains permanently in the artery.
Bypass surgery creates a detour around any narrowed or blocked sections of the artery
[1.KG.76.^^ Bypass, arteries of leg NEC]. The blood then flows, bypassing the blocked part of the
artery. Sometimes the blockage itself can be removed with a procedure called an endarterectomy
[1.KG.57.^^ Extraction, arteries of leg NEC]. Amputations [generic intervention 93] of the lower
extremity may also be performed in patients with advanced multiple diabetic complications.
Macrovascular complications of diabetes mellitus

Chronic hyperglycemia or persistent high glucose levels allow glucose to react with certain
components of the blood. When this happens, the by-products of these reactions tend to
attach themselves on the wall of the major blood vessels. The lumen (space) of the blood
vessel narrows down and this decreases the blood flow to the various organs. Since larger
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blood vessels are involved these complications are referred to as macro-vascular complications.
The common macro-vascular complications are cardiac and cardiovascular complications
and cerebral vascular diseases.
Diabetic cataracts
Cataracts in a patient with diabetes are not assumed to be “diabetic” unless specified as such.
Diabetic cataracts occur at a younger age and progress more rapidly to a mature opacity.
Young people with type 1 diabetes occasionally develop snowflake or metabolic cataracts.
Poor control of the diabetes may be a predisposing factor. True diabetic cataracts are characterized
by bilateral white punctate or snowflake anterior and posterior subcapsular opacities of the lens.
This condition is usually preceded by a sudden and progressive myopia. It is due to an
increased accumulation of sorbitol, fructose and glucose in the lens. These opacities may
lessen or resolve with improved glycemic control.
E10.35† Type 1 diabetes mellitus with diabetic cataract is only assigned when the physician
documents this type of cataract. It may be recorded as “diabetic cataract” or “cataract due
to diabetes.”
Diabetes mellitus and hyperglycemia

In simple terms, “diabetes control” means keeping blood glucose levels within — or close to — the
normal range. Glucose is the major source of energy for the body’s cells. When glucose can’t be
transferred into cells from the bloodstream, glucose builds up in the blood. Hyperglycemia is the
medical term for having too much sugar in the blood. Patients with diabetes are hyperglycemic
when their blood glucose is not well controlled. Hence, a positive glucose tolerance test
(R73.0 Abnormal glucose tolerance test) or unspecified hyperglycemia (R73.9 Hyperglycaemia,
unspecified) must not be coded on cases being classified to the range E10–E14. Marked
hyperglycemia may lead to a coma, a critical situation requiring immediate hospitalization.
Hyperglycemia in hospitalized people with diabetes contributes to increased mortality and

morbidity by increasing the susceptibility to infection and lengthening hospital stays.
Hypoglycemia in diabetes mellitus

Hypoglycemia, as defined by Diabetes Canada, is when blood glucose levels drop too low.
Symptoms may include sweating, trembling, hunger, dizziness, moodiness, confusion and
blurred vision. A low blood glucose level can occur when the blood glucose drops below a
certain level (usually less than 4 mmol/L). Not eating enough food, missing or delaying a meal,
exercising without taking the necessary precautions, taking too much insulin or drinking alcohol
causes hypoglycemia. Severe low blood glucose may cause confusion, disorientation
and/or seizures.
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Hypoglycemia can also be called insulin shock or insulin reaction. Severe hypoglycemia is
dangerous. Very low blood sugar seriously affects the brain’s ability to reason or use good
judgment. If the blood sugar levels continue to plummet to a dangerously low level, the brain is
seriously impaired and consciousness is usually lost. Permanent brain changes and death can
result if emergency treatment for advanced hypoglycemia is not given.
Coma in diabetes mellitus

Diabetic coma — Hypoglycemia
When blood sugars become too low a loss of consciousness can result. This can advance to
coma. Hypoglycemia starves the brain of glucose energy and this lack of energy can cause
symptoms ranging from headache and mild confusion to loss of consciousness, seizure and
coma. Severe hypoglycemia is dangerous. Very low blood sugar seriously affects the brain’s
ability to reason or use good judgment.
Diabetic coma — Hyperglycemia — Associated with diabetic ketoacidosis (DKA) or

diabetic hyperosmolar syndrome (DHS)
Diabetic coma is a life-threatening condition. Either diabetic ketoacidosis or diabetic

hyperosmolar syndrome can lead to diabetic coma. If blood sugar levels become too high,
this can also result in a loss of consciousness. In some cases, this can advance to coma.
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, metabolic acidosis and

increased circulating total body ketone concentration caused by the buildup of by-products of fat
metabolism. DKA occurs mainly in those who have type 1 diabetes mellitus. Sometimes, it can
occur in those who have type 2 diabetes mellitus.
Hyperosmolar hyperglycemic nonketotic coma (HHNC) is characterized by hyperglycemia,

hyperosmolarity and an absence of significant ketosis. HHNC most commonly develops in
patients with diabetes who have some concomitant illness that leads to a reduced fluid intake
for example an infection like pneumonia and urinary tract infection (UTI).
When a patient with diabetes presents with hyperglycemia hyperosmolality that has not
advanced to coma it must be classified to E1–.64 Type ~ diabetes mellitus with poor control, so
described. When not documented as diabetes mellitus with poor control (or similar terminology),
the chart must be sent back to the physician to document the appropriate terminology to support
the clinical picture. When hyperosmolality and dehydration are documented, assign E87.0
Hyperosmolality and hypernatraemia and E86.0 Dehydration and apply the appropriate
diagnosis type per the diagnosis typing definitions.
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Diabetes mellitus and multiple complications

Diabetic ulcers
Neuropathy and peripheral artery disease occur very commonly in the patient with diabetes and
are often encountered together. These two entities are mainly responsible for ulcers in patients
with diabetes. A diabetic foot ulcer is an open sore that most commonly occurs on the bottom of
the foot. People who use insulin are at a higher risk of developing a foot ulcer, as are patients
with diabetes-related kidney, eye and heart disease. Being overweight and using alcohol and
tobacco also play a role in the development of foot ulcers.
Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation,
foot deformities, irritation (such as friction or pressure), and trauma. Vascular disease can
complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an
infection. Elevations in blood glucose can reduce the body’s ability to fight off a potential
infection and also slow the healing process.
A diabetic foot ulcer may be documented as neuropathic, ischemic or neuro-ischemic.1
A diabetic foot is an infection, ulceration and/or destruction of deep tissues associated with
neurological abnormalities and various degrees of peripheral vascular disease in the lower limb.
It is a syndrome in which the patient has several pathological processes with tissue ischemia
that may ultimately lead to tissue breakdown. There may be associated ulceration and gangrene
and the patient has a higher risk for amputation. 5
Due to the interrelatedness of the many diabetic complications and associated factors, diabetic
foot is classified to subcategory E1–.7– Type ~ diabetes mellitus with multiple complications.
The specific code is selected based on whether the foot ulcer is with or without gangrene.
Decubitus ulcers, otherwise known as pressure ulcers or bedsores, are skin ulcers that develop
on areas of the body where the blood supply has been reduced because of prolonged pressure.
Diabetes is not the cause of decubitus ulcers but rather a risk factor that may cause the problem
to worsen and healing to become difficult. Therefore, when associated with diabetes mellitus,
per the “use additional code” instruction at category L89 Decubitus [pressure] ulcer and
pressure area, a code from E1–.68 Type ~ diabetes mellitus with other specified complication,
not elsewhere classified is assigned to classify any associated diabetes mellitus.
Glycemic control in patients with diabetes has a direct impact on progression of the angiopathy
and tissue perfusion. Therefore, healing of any ulcer is dependent on diabetic complications
present in the patient.
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Diabetes mellitus in pregnancy

Dr. Ian Blumer, in his book Diabetes for Canadians for Dummies, states “Gestational diabetes is
defined as diabetes diagnosed during pregnancy. The great majority of the time it resolves as
soon as the baby is born.” Changing hormones and weight gain are part of a healthy pregnancy.
But both changes make it hard for the body to keep up with its need for insulin.
Causes of gestational diabetes
• The body needs more energy than usual during pregnancy so more insulin is required
to move glucose into the cells to provide energy.
• The placenta produces other hormones during pregnancy and some of these hormones can
block the action of insulin in the body, causing “insulin resistance” to develop.
• Though insulin requirement is greater in all women during pregnancy, for some, the pancreas
is not able to produce enough insulin for the body’s needs, so high levels of glucose remain
in the blood stream and this is called gestational diabetes.
• It usually takes many weeks before the amount of insulin produced is not enough,
so gestational diabetes does not appear until the middle of pregnancy.
Other problems in pregnancy associated with diabetes mellitus
Most women with gestational diabetes can safely have a full-term pregnancy and have
a normal labor, but there may be some pregnancy-associated problems due to the diabetes.
• Pregnancy induced hypertension (PIH) also known as preeclampsia — high blood pressure
caused by pregnancy is fairly common when a mother has diabetes. It usually goes away
soon after the birth of the baby.
• Infections, such as bladder infections are also fairly common during pregnancy, but are more
common when the mother has diabetes.
• If the mother’s blood sugar is not well controlled during the pregnancy there is an increased
risk of miscarriage or still birth.
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Acute coronary syndrome (ACS) and related interventions
Acute coronary syndrome is a spectrum of conditions which includes:
• ST elevation myocardial infarction [STEMI]
• Non-ST elevation myocardial infarction [NSTEMI]
• Unstable angina
This schema is not intended to provide direction for code assignment in cases where the
documentation is lacking. When documentation is lacking, the coder must seek clarification
from the physician or assign a code from the appropriate “unspecified” category. The typical
flow of events is a patient presenting with symptoms of acute coronary syndrome leads to a
working diagnosis of one of the following:
619
ST-segment elevation myocardial infarction [STEMI]

When the ECG shows ST elevation, a diagnosis of myocardial infarction (MI) is virtually inevitable.
However, prompt treatment (e.g., percutaneous coronary intervention [PCI] or thrombolytic
therapy) can alter the final outcome or type of MI. A patient presenting with an ECG with
documented ST-segment elevation (STEMI) can have one of the following potential outcomes:
• Evolution to Q-wave [transmural] myocardial infarction
• Evolution to non-Q-wave [subendocardial] myocardial infarction
• Aborted or averted myocardial infarction
Non-ST-segment elevation myocardial infarction [NSTEMI]

When there is no ST elevation on the ECG, while Q-waves can develop, typically the potential
outcomes include
• Evolution to a less-damaging non Q-wave [subendocardial] myocardial infarction
• A final diagnosis of unstable angina
Sometimes the final diagnosis is referred to as non-ST-elevation acute coronary syndrome

(NonSTEACS or NSTEACS). When NonSTEACS or NSTEACS is the final diagnosis, the
documentation must be reviewed for further confirmation to determine if the patient has had
an NSTEMI or unstable angina.
In NSTEMI, myocardial infarction is confirmed by the presence of cardiac biomarkers such as

troponin or CK-MB. Cardiac biomarkers are enzymes, proteins or hormones found in the blood
that confirm necrosis to myocardial cells has occurred.
NSTEMI is a myocardial infarction identified by either elevated cardiac biomarkers or ECG changes
without ST-segment elevation. The ECG findings may include changes such as ST depression or
T-wave inversion or the ECG may be normal. The high sensitivity of the newer biomarkers enables
detection of small areas of myocardial necrosis that may not show up on ECG. 6
Acute coronary syndrome spectrum

The lack of blood supply to the heart results in a continuum of acute events ranging from
myocardial ischemia to injury to infarction. The most common cause of this diminished blood
flow is coronary atherosclerosis — plaque formation within the coronary arteries.
Myocardial ischemia appears at the onset, and the subendocardial region is the first to be
affected, since this layer of the heart is farthest from the blood supply. When ischemia is severe
it results in injury to the myocardial cells. Subendocardial injury is manifested on ECG by ST-
segment depression, and transmural injury is manifested by ST-segment elevation. Myocardial
infarction describes necrosis or death of myocardial cells. A myocardial infarction can be either
nontransmural (partial thickness) or transmural (full thickness).
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Elevation of biomarkers is expected in both types of infarction. In the absence of elevated

biomarkers, ST- and T-wave abnormalities are interpreted as due to ischemia or injury rather
than infarction.
Diagnosis is non-Q-wave or Q-wave infarction

Non-Q-wave infarction is thought to result from persistence of thrombus with greater plaque
disruption than in unstable angina. However, occlusion is usually short-lived (less than an hour),
and the distal myocardial territory is usually supplied by collaterals; therefore, necrosis is
confined to the subendocardium.
Q-wave infarction is believed to develop as a result of larger plaque fissures, when spontaneous
thrombolysis, resolution of vasoconstriction and presence of collateral circulation are absent.
The result is fixed, persistent and complete thrombotic occlusion, with abrupt cessation of
myocardial perfusion lasting more than an hour and resulting in transmural necrosis.6
Diagnosis is unstable angina

Stable angina refers to chest discomfort that is predictable and has a stable course. Angina
becomes unstable when there is a change in frequency and when it occurs during increasingly
less physical activity, lasts longer or becomes more severe in nature. In the clinical spectrum of
coronary artery disease, the syndrome of unstable angina falls between stable angina and acute
myocardial infarction.6 Unstable angina corresponds to an acute change in the morphology of a
high-risk plaque, with overlying thrombus formation that only partially occludes the vessel and
hence results in no more than intermittent ischemia. The thrombus may be quickly broken down
by spontaneous lysis; therefore, the symptoms can disappear as quickly as they appear.
Diagnosis is aborted myocardial infarction

An aborted or averted myocardial infarction is diagnosed when myocardial ischemia does not
result in significant myocardial necrosis. When a patient presents with ST-segment elevation on
an ECG, rapid and effective reperfusion improves the likelihood of successful myocardial
salvage or preservation and the myocardial infarction is aborted or averted. 7
Diagnosis is non-cardiac or non-ischemic

Conditions such as pulmonary embolism or pericarditis may initially present with symptoms
similar to ACS including slightly elevated biomarkers. Investigations may include
echocardiography or CT scan to confirm the diagnosis. Final diagnosis may be cardiac
(e.g., pericarditis) or non-cardiac (e.g., esophagitis, pulmonary embolism).
621
ICD-10-CA codes
While effective with v2018, NSTEMI is an inclusion term at I21.4 Acute subendocardial
myocardial infarction to capture when the documentation supports that the NSTEMI evolved to
a non-Q-wave myocardial infarction, the international version of the ICD does not include the
terminology STEMI. In order to maintain international comparability, ICD-10-CA has retained the
integrity of category I21 Acute myocardial infarction and category I22 Subsequent myocardial
infarction. Effective April 1, 2007 category R94.3 Abnormal results of cardiovascular function
studies was expanded to 5 characters to capture working diagnoses of STEMI or NSTEMI.
Codes from I21 Acute myocardial infarction are used to capture final diagnoses recorded as
STEMI or NSTEMI.
R94.30 Electrocardiogram suggestive of ST segment elevation myocardial infarction [STEMI]
R94.31 Abnormal cardiovascular function studies (biomarkers or ECG) suggestive of non ST

segment elevation myocardial infarction [NSTEMI]
ST depression
T waves
R94.38 Other and unspecified abnormal results of cardiovascular function studies

Abnormal:
• electrocardiogram [ECG] [EKG] not elsewhere classified
• electrophysiological intracardiac studies
• phonocardiogram
• vectorcardiogram
Percutaneous coronary intervention (PCI)
A PCI is an intervention performed on the coronary arteries via a percutaneous approach but
usually refers to a coronary angioplasty, previously described as a percutaneous transluminal
coronary angioplasty (PTCA). PCI is the treatment of choice in treating ST-segment elevation
myocardial infarctions when immediate access to cardiac catheterization laboratories is
possible. 8 When immediate access is not possible, or PCI is not indicated, thrombolytic therapy
has become the standard of care. 9
At 1.IJ.50.^^ Dilation, coronary arteries, a mandatory status attribute exists to distinguish PCI
that are considered primary/direct from those that are not. A primary PCI is one performed as
the first intervention for STEMI within 12 hours of presentation to hospital with no thrombolytic
therapy prior to PCI.
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Thrombectomy devices (e.g., Pronto extraction catheter, Export aspiration catheter,

Rescue catheter) may be used in cases of acute myocardial infarction where a large thrombus
burden exists. The aspiration catheters are designed to reduce the thrombus before proceeding
to angioplasty.
Atherectomy devices (e.g., Rotablator, rotational atherectomy catheter, laser) may be used for
extraction of plaque from a coronary artery. These devices either remove plaque or pulverize it
before proceeding to angioplasty.
When a thrombectomy or atherectomy is performed concomitantly with a dilation, select the

appropriate code from the rubric 1.IJ.50.^^ Dilation, coronary arteries. When a thrombectomy is
performed “without” a dilation, select the appropriate code from rubric 1.IJ.57.^^ Extraction,
coronary arteries.
It is expected that codes from rubric 1.IJ.57.^^ Extraction, coronary arteries will be used rarely
as most times dilation is performed with atherectomy and thrombectomy.
Drug-eluting stents (DES) may be used for the treatment of symptomatic ischemic disease in
discrete de novo lesions. Common coatings for these stents include paclitaxel (e.g., Taxus
stent), sirolimus (e.g., Cypher stent), zotarolimus (e.g., Endeavor stent), or everolimus (e.g.,
Xience stent). Drug-eluting balloons (DEB) may be used for the prevention and/or treatment of
in-stent restenosis. The most common DEB currently in use is the Pantera Lux which is coated
with paclitaxel.
When a drug-eluting stent or balloon is employed in a PCI intervention, an additional code from
rubric 1.IL.35.^^ Pharmacotherapy, (local) vessels of heart is assigned, mandatory as per
direction in these standards.
Thrombolytic therapy
Thrombolytic therapy has become the standard of care for treating STEMI patients when
immediate access to PCI is not available. Thrombolytic therapy — also called thrombolysis,
fibrinolysis or lytics — involves the administration of clot-busting drugs to dissolve thrombus in
the affected coronary artery or arteries and restore blood flow to the heart muscle. Thrombolytic
therapy reduces mortality and limits infarction size in patients with acute myocardial infarction
associated with ST-segment elevation.
Patients without ST-segment elevation generally have temporary, incomplete or partial

occlusions and do not benefit from thrombolytic therapy.
Thrombolytic agents include anistreplase, streptokinase, urokinase, tissue plasminogen

activator (TPA), alteplase, reteplase, tenecteplase and TNKase (TNK).
623
Strokes
A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.
A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply
oxygen and nutrients, and to remove waste products, brain cells quickly begin to die. Depending
on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of
memory and reasoning ability, coma or death. A stroke is also sometimes called a brain infarct
or a cerebrovascular accident (CVA) lasting more than 24 hours. A transient ischemic attack
(TIA), by contrast, is defined arbitrarily as a similar neurological deficit lasting less than
24 hours. In the past, the defined time limit for a TIA was one hour but the time limit was
expanded for practical purposes. 10
A stroke involves either an ischemic or a hemorrhagic event, which causes damage to the brain.
Cerebral thrombosis and cerebral embolism are caused by blood clots that block an artery
supplying the brain, either in the brain itself or in the neck. Subarachnoid hemorrhage and
intracerebral hemorrhage occur when a blood vessel bursts around or in the brain.
Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself,
blocking the flow of blood through the affected vessel. Clots most often form due to “hardening”
(atherosclerosis) of brain arteries.
Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks
free. If it becomes lodged in an artery supplying the brain, either in the brain or in the neck,
it can cause a stroke.
Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage
affects arteries at the brain’s surface, just below the protective arachnoid membrane.
Comorbid conditions and life style choices predispose patients undergoing any kind of surgery
to a stroke event. It is impossible to determine which factor caused the event. Researchers have
identified five risk factors for stroke following coronary artery bypass graft. They are age; history
of hypertension, diabetes and previous stroke; and the presence of carotid bruit.
Studies have shown that stroke complicates the postoperative course in 1% to 6% of patients
undergoing coronary revascularization. This may be due to a predisposition (risk factors) or it
may be due to a piece of plaque that becomes loose before or after surgery, traveling to the
brain and precipitating the stroke. Because these patients are almost always at risk for a stroke
anyway, the most that can be said with any certainty is that the stroke is a postoperative event.
Since you can never know if this is a complication of the surgical procedure or a natural
progression (possibly expedited) of a disease process culminating in a sudden acute event,
a postoperative stroke is not classified to I97.8 Other postprocedural disorders of circulatory
system, not elsewhere classified.
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DAD and NACRS Stroke Strategy Performance Improvement Projects (340,

640) and DAD Alpha FIM® Project 740
The Stroke Special Projects capture specific information on patients who have been diagnosed
with an acute/current stroke, as well as other conditions (cited below) that — while from an ICD-
10-CA classification perspective are not classified as hemorrhagic (I60, I61), ischemic (I63) or
unspecified (I64) stroke — are monitored as part of the stroke strategy. Note: In the obstetrical
population, a hemorrhagic, ischemic or unspecified stroke is classified to O99.4– and it is
mandatory to assign an additional code — one of I60.–, I61.–, I63.– or I64 — as diagnosis type
(3)/other problem to specify the type of acute/current stroke that complicated the pregnancy,
childbirth or puerperium.
These other conditions include the following:

• Transient ischemic attack (TIA) (also referred to as a mini-stroke) (G45.0, G45.1, G45.2,
G45.3, G45.8, G45.9) and transient retinal artery occlusion (H34.0). Note: In the
obstetrical population, a TIA is classified to O99.30– and it is mandatory to assign an
additional code — one of G45.0, G45.1, G45.2, G45.3, G45.8, G45.9 — as diagnosis type
(3)/other problem to specify that the condition complicating the pregnancy, childbirth or
puerperium is a TIA. In the obstetrical population, a transient retinal artery occlusion is
classified to O99.80– and it is mandatory to assign the additional code H34.0 as a diagnosis
type (3)/other problem to specify that the condition complicating pregnancy, childbirth or
puerperium is a transient retinal artery occlusion.
• Intracranial and intraspinal phlebitis and thrombophlebitis (G08). Note: In the obstetrical
population, this condition is classified to O22.5– Cerebral venous thrombosis in pregnancy or
O87.3– Cerebral venous thrombosis in the puerperium, as applicable.
• Nonpyogenic thrombosis of intracranial venous system (I67.6). Note: In the obstetrical
population, this condition is classified to O99.40– and it is mandatory to assign the additional
code I67.6 as diagnosis type (3)/other problem to specify that the condition complicating
the pregnancy, childbirth or puerperium is nonpyogenic thrombosis of intracranial
venous system.
• Central retinal artery occlusion (also referred to as ocular or eye stroke) (H34.1). Note: In
the obstetrical population, this condition is classified to O99.80– and it is mandatory to assign
the additional code H34.1 as diagnosis type (3)/other problem to specify that the condition
complicating the pregnancy, childbirth or puerperium is a central retinal artery occlusion.
For complete and the most up-to-date information and to find out if your province/territory
participates in the Stroke Special Projects (340, 640 and 740) refer to the Special Projects Data
Collection Instructions available via the DAD/NACRS Abstracting Manual link in the DAD and
NACRS applications.
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The table below summarizes the codes included in the completion criteria for Stroke Special
Projects 340, 640 and 740. Of note, Project 740 does not include H34.0 or H34.1 in its project
completion criteria.
ICD-10-CA codes included in DAD and NACRS Stroke Strategy Performance

Improvement Projects and DAD Alpha FIM® Project 740
Hemorrhagic stroke
Code Code description

I60.0 Subarachnoid haemorrhage from carotid siphon and bifurcation
I60.1 Subarachnoid haemorrhage from middle cerebral artery
I60.2 Subarachnoid haemorrhage from anterior communicating artery
I60.3 Subarachnoid haemorrhage from posterior communicating artery
I60.4 Subarachnoid haemorrhage from basilar artery
I60.5 Subarachnoid haemorrhage from vertebral artery
I60.6 Subarachnoid haemorrhage from other intracranial arteries
I60.7 Subarachnoid haemorrhage from intracranial artery, unspecified
I60.8 Other subarachnoid haemorrhage
I60.9 Subarachnoid haemorrhage, unspecified
I61.0 Intracerebral haemorrhage in hemisphere, subcortical
I61.1 Intracerebral haemorrhage in hemisphere, cortical
I61.2 Intracerebral haemorrhage in hemisphere, unspecified
I61.3 Intracerebral haemorrhage in brain stem
I61.4 Intracerebral haemorrhage in cerebellum
I61.5 Intracerebral haemorrhage, intraventricular
I61.6 Intracerebral haemorrhage, multiple localized
I61.8 Other intracerebral haemorrhage
I61.9 Intracerebral haemorrhage, unspecified
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Ischemic stroke
I63.0 Cerebral infarction due to thrombosis of precerebral arteries
I63.1 Cerebral infarction due to embolism of precerebral arteries
I63.2 Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
I63.3 Cerebral infarction due to thrombosis of cerebral arteries
I63.4 Cerebral infarction due to embolism of cerebral arteries
I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I63.8 Other cerebral infarction
I63.9 Cerebral infarction, unspecified
Unspecified stroke
I64 Stroke, not specified as haemorrhage or infarction
Transient ischemic attack
G45.0 Vertebro-basilar artery syndrome
G45.1 Carotid artery syndrome (hemispheric)
G45.2 Multiple and bilateral precerebral artery syndromes
G45.3 Amaurosis fugax
G45.8 Other transient cerebral ischaemic attacks and related syndromes
G45.9 Transient cerebral ischaemic attack, unspecified
Transient retinal artery occlusion

H34.0 Transient retinal artery occlusion
Note: H34.0 is excluded from Project 740 completion criteria
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Thrombosis of intracranial venous system

G08 Intracranial phlebitis and thrombophlebitis
O22.5– Cerebral venous thrombosis in pregnancy
O87.3– Cerebral venous thrombosis in puerperium
I67.6 Nonpyogenic thrombosis of intracranial venous system

(Excludes: when causing infarction see I63.6)
Central retinal artery occlusion
H34.1 Central retinal artery occlusion

Note: H34.0 is excluded from Project 740 completion criteria
Atrial fibrillation
Atrial fibrillation is an abnormally fast and highly irregular heartbeat and is classified as a
functional disturbance when it occurs following cardiac surgery. Atrial fibrillation and flutter are
abnormal heart rhythms in which the atria, or upper chambers of the heart, are contracting out
of synchronization with the ventricles, or lower chambers of the heart. In atrial fibrillation, the
atria “quiver” chaotically and the ventricles beat irregularly. In atrial flutter, the atria beat
regularly and faster than the ventricles.
There are two main types of atrial fibrillation: paroxysmal and persistent. Paroxysmal atrial
fibrillation is recurrent, typically lasts less than 48 hours and converts spontaneously to normal
sinus rhythm. Persistent atrial fibrillation can last for more than a week and requires treatment
such as electrical cardioversion and/or catheter ablation to convert back to normal sinus rhythm.
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In most cases, the cause of atrial fibrillation and flutter can be found, but sometimes the cause
is not documented. Causes of these heartbeat abnormalities include
• Cardiomyopathy
• Valvular disorders
• Hyperthyroidism
• Hypertension
• Stress and anxiety
• Caffeine
• Alcohol
• Tobacco
• Diet pills
• Some prescription and over-the-counter medications
• Open-heart surgery

Pneumonia
Pneumonia, per The Merck Manual, is an acute inflammation of the lungs caused by infection;
the most common causes of infection are pathogens in the air we breathe such as bacteria,
viruses and fungi. Pneumonia can affect anyone, but the two age groups at highest risk are
children and seniors.
There are four main kinds or categories of pneumonia as determined by both the type of
pathogen that causes it and where the infection is acquired.
When the pneumonia is acquired outside of hospital or other health care facility, it is called
community-acquired pneumonia (CAP); this is the most common type of pneumonia. CAP
includes lobar pneumonia and bronchopneumonia, which are most often caused by the bacteria
Streptococcus pneumoniae; other pathogens such as viruses or fungi may also be the cause.
Hospital-acquired pneumonia (HAP), including ventilator-acquired and post-operative

pneumonia, develops in patients during a hospital stay for an unrelated illness. It usually
develops 48 hours after admission and is a severe type of pneumonia because the bacteria
causing it tend to be more resistant to antibiotics, and also because the people who get it are
already compromised due to age and other health conditions.
629
Aspiration pneumonia is another prevalent type of pneumonia. It occurs when large volumes of
upper airway or gastric secretions, such as food, drink, vomit or saliva, enter into the lungs,
causing infection.
Health care–acquired pneumonia (HCAP) is a bacterial type of infection of the lungs acquired
most often by seniors or people living in nursing homes or other long-term care facilities. Like
HAP, HCAP is an acute and severe type of pneumonia because the bacteria causing it tend to
be resistant to antibiotics.
Asthma
Asthma is a disease in which inflammation of the airways causes airflow into and out of the
lungs to sometimes be restricted. When an asthma attack occurs, the muscles of the bronchial
tree become tight and the lining of the air passages swells, reducing airflow and producing the
characteristic wheezing sound. Mucus production is increased.
Most people with asthma have periodic wheezing attacks separated by symptom-free periods.
Some asthmatics have chronic shortness of breath with episodes of increased shortness of
breath. Asthma attacks can last minutes to days, and can become dangerous if the airflow
becomes severely restricted.
Adult respiratory distress syndrome

Adult respiratory distress syndrome (ARDS) is a group of conditions or symptoms that
collectively indicate or characterize a disease process.
ARDS is a life-threatening condition that occurs when there is severe fluid buildup in both lungs.
The fluid buildup prevents adequate oxygen-carbon dioxide transfer within the pulmonary alveoli.
ARDS is the end result of a variety of severe injuries to the lungs, characterized by sudden onset
of severe shortness of breath, tachycardia, and profound hypoxia and pulmonary edema.
Sepsis and the systemic inflammatory response are the most common predisposing factors
associated with development of ARDS. A (non-inclusive) list of common causes of ARDS
includes septic shock, traumatic shock, diffuse viral pneumonia, oxygen therapy toxicity, inhaled
toxins and irritants, narcotic overdose, hypersensitivity reaction and aspiration pneumonia.
The pathogenesis of ARDS begins with mediators, for example, platelet activating factor, into
the blood that result in leukocyte aggregation in the lungs. Stimulating neutrophils release
oxygen-free radicals, lysosomal enzymes and products of arachidonic acid that damage the
lung capillaries and alveolar epithelium. This allows fluid to leak from the blood. Further
chemical damage by neutrophils destroy alveolar living cells. The result is accumulation of
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serum, fibrin and dead cell debris in the alveoli. Hyaline membranes form inside the alveoli.
Once hyaline membranes have formed, no surfactant is present and alveoli tend to collapse.
Atelectasis and edema make the lungs stiff and non-compliant.
Injured cells promote inflammation and fibrosis, and alter bronchomotor tone and vasoreactivity.

Diagnostic colonoscopic interventions
A sigmoidoscopy, colonoscopy and ileoscopy are all endoscopic examinations of the lower
gastrointestinal tract.
A sigmoidoscopy is an endoscopic examination of the lower portion of the large intestine; its
aim is to examine the rectum to the sigmoid up to the lower portion of the descending colon up
to the splenic flexure. Very occasionally, the transverse colon may be visualized.
A colonoscopy is an endoscopic examination of the entire large intestine from the distal
rectum to the cecum. The goal of a complete inspection is to reach the cecum, and the
anatomic landmarks that help the physician to determine if this has been achieved
include visualization of the appendiceal orifice and the ileocecal valve.
An ileoscopy is an endoscopic examination of the terminal ileum (anatomic site 2.NK.^^) and
may be accomplished using a colonoscope. This is considered a retrograde approach. The
instrument tip first passes through the rectum, then through the colon and eventually reaches
the area where the cecum (large intestine) and terminal ileum (small intestine) connect. The
ileocecal valve separates the small from the large intestine. In order to inspect the terminal
ileum, the ileocecal valve must be intubated. Anytime the terminal ileum is intubated during
an endoscopy, it is for the purpose of inspecting the small intestine.
The ileum can also be examined by a double balloon enteroscopy. A double balloon
enteroscopy, also known as push-and-pull enteroscopy is an advanced endoscopic technique
to inspect the entire small bowel. The double balloon enteroscope can be inserted either orally,
antegrade approach, or it can be passed in retrograde fashion, through the rectum, into the
colon and finally into the ileum to inspect the end of the small bowel. To complete a double
balloon enteroscopy, doctors use a scope fitted with two balloons to navigate the entire small
bowel. When inflated with air, the balloons can expand sections of the small intestine to allow
the camera a closer examination.
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Chapter XII — Diseases of the skin and

subcutaneous tissue
Cellulitis
Cellulitis is a relatively deep infection, generally resulting from a break in the skin. It involves
subcutaneous spaces in addition to the dermis. Some cases of cellulitis appear on areas of
trauma, where the skin has broken open, such as the skin near ulcers or surgical wounds. Many
times, however, cellulitis occurs where there has been no break in the skin at all. The patient
presents with pain, redness, warmth and systemic symptoms such as fever. The affected area
appears red and is warm to the touch. Lymphatic drainage is damaged by cellulitis, which
renders the area predisposed to subsequent infections.
Cellulitis is typically treated with a course of oral or intravenous (IV) antibiotics as well
as wound management involving debridement, any re-apposition and topical dressing.
Chapter XIII — Diseases of the musculoskeletal

system and connective tissue
Osteoarthritis
Osteoarthritis (OA) is often called “wear and tear” of the joints. OA causes certain parts of the
joints to weaken and break down. Cartilage, the tough elastic material that cushions the ends of
the bones, begins to crack and get holes in it. Bits of cartilage can break off into the joint space
and irritate soft tissues, such as muscles, and cause problems with movement. Much of the pain
of OA is a result of muscles and the other tissues that help joints move (such as tendons and
ligaments) being forced to work in ways for which they were not designed, as a result of
damage to the cartilage. Cartilage itself does not have nerve cells, and therefore cannot sense
pain, but the muscles, tendons, ligaments and bones do. After many years of cartilage erosion,
bones may actually rub together. This grinding of bone against bone adds further to the pain.
Bones can also thicken and form growths, called spurs or osteophytes, which rub together.
Also, when cartilage is weak or damaged, the surrounding bones place extra force on it, and
this may cause excessive blood flow (hyperemia) that can cause pain, especially at night.
Damage due to OA progresses slowly over time and may result in several problems. OA commonly
affects weight-bearing joints such as hips, knees, feet and spine. However, non–weight bearing
joints such as finger joints and the joint at the base of the thumb may be affected as well. It usually
does not affect other joints, except when they have been injured or been put under unusual stress.
632
No one knows for sure what causes OA, although scientists are well on their way to
understanding the events that lead to the breakdown of cartilage. Researchers now think
that there are several factors that may increase the risk for getting OA. Key risk factors include
heredity, excess weight, injury and/or joint damage from another type of arthritis.
Osteoarthritis resulting from a known cause such as a congenital/developmental problem,

metabolic disease, endocrine disease, calcium deposition disease, neuropathic condition,
other bone and joint conditions, acute and chronic (repetitive) trauma is classified as
secondary osteoarthritis.
Spinal stenosis
Spinal stenosis is defined as any developmental or acquired narrowing of the spinal (neural) canal,
or nerve root canals (intervertebral foramina) that results in compression of neural elements. 11
Spinal or foraminal stenosis is a term used when the underlying condition has become so
severe that the spinal canal’s dimensions have been reduced to the point that the patient
develops symptoms which range from pain to extremity dysfunction. In myelopathy, the patient
will typically have organ dysfunction. Some common causes of spinal stenosis include neoplasms,
intervertebral disc disorders such as displacement or disc degeneration, and spondylosis.
Chapter XIV — Diseases of the

genitourinary system
Stages of chronic kidney disease (CKD)
Chronic kidney disease is defined according to the presence or absence of kidney damage and
level of kidney function irrespective of the underlying disease. The stages of CKD are defined
by physicians based on the level of kidney function as evidenced by the glomerular filtration
rate (GFR).
In a clinical setting, patients are diagnosed with chronic kidney disease if they meet either
of the following criteria:
• Kidney damage for three months or more, as defined by structural or functional abnormalities
of the kidney, with or without decreased GFR, manifest by either
- Pathological abnormalities; or
- Markers of kidney damage, including abnormalities in the composition of the blood or
urine, or abnormalities in imaging tests; or
- GFR <60 mL/min/1.73 m2 for three months or more, with or without kidney damage.
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Recent professional guidelines classify the severity of chronic kidney disease in five stages, with
stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness
with poor life expectancy if untreated. Stage 5 CKD, also called end-stage chronic kidney
disease or established kidney disease, is synonymous with the now-outdated terms “end-stage
renal disease” (ESRD) or “end-stage renal failure” (ESRF).
Stage Description GFR (mL/min/1.73 m2)

1 Kidney damage with normal or increased GFR ≥90
2 Kidney damage with mild decreased GFR 60 to 89
3 Moderate decreased GFR 30 to 59
4 Severe decreased GFR 15 to 29
5 End-stage kidney disease <15
Adverse outcomes of kidney disease are based on the level of kidney function and risk of loss of
function in the future. CKD tends to worsen over time; therefore, the risk of adverse outcomes
increases over time with disease severity. Staging of chronic kidney disease will facilitate
application of clinical practice guidelines, clinical performance measures and quality
improvement efforts for the evaluation of CKD, as well as management of chronic kidney
disease. Severity is based on the level of GFR because GFR is widely accepted as the best
overall measure of kidney function.
Pelvic relaxation
Pelvic relaxation is the result of laxities or weakening of the ligaments, fascia and muscles
that support the pelvic organs. Labor and delivery, obesity, aging, injury, chronic straining,
congenital malformations, increased abdominal pressure, sacral nerve disorders and connective
tissue disorders can contribute to the disorder. Pelvic relaxation may include cystocele,
rectocele, urethrocele, uterine and vaginal prolapse. 12
Cystoceles and urethroceles

The effect of labor and delivery on the female pelvis is a common cause of a cystocele or
an urethrocele. Symptoms commonly associated with a cystocele include urinary stress
incontinence, frequency or, a sensation of vaginal fullness or pressure. Symptoms are
aggravated by increased intra-abdominal pressure caused by activity such as prolonged
standing, coughing or sneezing. It is important to note that even though stress incontinence is
the most common symptom associated with a cystocele, it is not caused by the cystocele and
surgical correction of the cystocele alone will not necessarily correct the incontinence. Stress
incontinence is due to the relaxation of the surrounding pelvic support structures and the loss of
the normal urethrovesical angle.
634
A cystocele is a herniation of the bladder. When a cystocele exists alone, without any other
form of genital prolapse, it is rarely repaired surgically unless it is so large that it is the cause of
urinary retention or bladder infections. The most common method of cystocele repair is the
anterior colporrhaphy which, in CCI, is classified to the rubric 1.RS.80.^^ Repair, vagina NEC.
This repair may require that sutures, grafts or synthetic materials be used to strengthen the
vaginal walls and correct protrusion of the bladder. Colporrhaphy may be performed
concomitantly with other interventions like vaginal hysterectomy (1.RM.89.CA) when other
conditions exist.
Female stress incontinence

When stress incontinence is the main indication for the surgical intervention, repair is usually
directed toward the urethrovesical angle where urethropexy is attained. This is classified
to 1.PL.74.^^ Fixation of the bladder neck. A variety of techniques are available to elevate the
urethra and surrounding fascia and muscular support to a level that restores normal urethral
function. Any concomitant repair of any co-existent cystocele is also coded.
Rectoceles
Rectocele is a rectovaginal hernia caused by damage done to the fibrous connective tissue
between the rectum and vagina during childbirth. It may not become problematic until
after menopause. Repair of a rectocele is classified to 1.RS.80.^^ Repair, vagina.
Enteroceles
An enterocele is a small bowel herniation into the rectovaginal septum. It is commonly found in
women who have had a previous hysterectomy. The peritoneum may be in direct contact with
vaginal epithelium due to weakened or absent support structures. Repair of the defect involves
reduction of the small bowel and suturing the apex of pubocervical and rectovaginal fascia back
together. If this is the only intervention performed, then a code from the rubric 1.RS.80.^^ will
adequately capture this. However, this repair of the apical defect is sometimes followed by a
vaginal vault suspension. An additional code will then be required to capture the colpopexy or
vaginal vault suspension (1.RS.74.^^ Fixation, vagina) that restores the normal shape and
support of the vaginal vault.
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Uterine prolapse
Uterine prolapse is a condition in which the uterus drops below its normal position as a result of
damage to or weakness of the uterosacral ligaments. Childbirth, hard physical labor, aging and
lack of estrogen support may cause this damage or weakness. Uterine prolapse is often
described in degrees where
• First degree prolapse means the cervix remains within the vagina
• Second degree prolapse means the cervix protrudes beyond introitus
• Third degree prolapse (complete procidentia) means the prolapse with entire uterus
outside vulva
The surgical treatment of choice depends on whether or not a functional uterus is still desired.
In older women, a hysterectomy may be performed. In many cases, cystocele, rectocele and
enterocele are also present along with the genital prolapse and a vaginal repair (1.RS.80.^^)
may then be performed concomitantly with the hysterectomy. Younger women who desire
future pregnancies may have a uterine suspension performed. This is classified to 1.RM.74.^^
Fixation, uterus and surrounding structures.
Chapter XV — Pregnancy, childbirth and

the puerperium
Length of gestation
The duration of gestation is measured from the first day of the last normal menstrual period.
Gestational age is expressed in completed days or completed weeks (e.g., events occurring 280
to 286 completed days after the onset of the last normal menstrual period are considered to
have occurred at 40 weeks of gestation).
Gestational age is frequently a source of confusion, when calculations are based on menstrual
dates. For the purposes of calculation of gestational age from the date of the first day of the last
normal menstrual period and the date of delivery, it should be borne in mind that the first day is
day zero and not day one; days 0–6 therefore correspond to “completed week zero”; days 7–13
to “completed week one”; and the 40th week of actual gestation is synonymous with “completed
week 39.” Where the date of the last normal menstrual period is not available, gestational age
should be based on the best clinical estimate. In order to avoid misunderstanding, tabulations
should indicate both weeks and days.
Preterm
Less than 37 completed weeks (less than 259 days) of gestation.
636
Term
From 37 completed weeks to less than 41 completed weeks.
Post-dates
A pregnancy is considered post-dates at 41 completed weeks. At this point in the pregnancy,
induction may be offered.
Post-term/prolonged
A pregnancy is considered post-term (prolonged) at 42 completed weeks of gestation or 294
days from the last menstrual period (LMP) (280 days from the date of conception). At this
gestational age the risk of adverse fetal and neonatal outcome, and in particular the risk of
perinatal death, is increased.
Trimesters
For the purposes of this classification, trimesters shall be defined as follows:
• First trimester is less than and including the 13th week of gestation (≤13 weeks);
• Second trimester is the fourteenth week up to and including the twenty-sixth week
(14–26 weeks); and
• Third trimester is more than 26 weeks gestation (>26 weeks).
Chapter XVI — Certain conditions originating in

the perinatal period
Respiratory distress of newborn
“Respiratory distress syndrome (RDS), also called, hyaline membrane disease is a syndrome
caused by deficient surfactant manifested clinically by respiratory distress in the preterm infant.
RDS almost always occurs in newborns born before 37 week gestation; the more premature,
the greater the chance of developing RDS. Pulmonary surfactant, a mixture of phospholipids
and three surfactant lipoproteins, is secreted by type II pneumocytes. The air-fluid interface of
the film of water lining the alveoli exerts large forces that cause the alveoli to close if surfactant
is deficient. Lung compliance is decreased, and the work of inflating the stiff lungs is increased.
If untreated, severe hypoxemia can result in multiple organ failure and death. However, if the
newborn’s ventilation is adequately supported, surfactant production will begin and RDS will
resolve by 4 or 5 days. Recovery is hastened by treatment with pulmonary surfactant.” 13
637
“Transient tachypnea of the newborn (TTN), also called neonatal wet lung syndrome, is
respiratory distress with rapid respirations and hypoxemia caused by delayed reabsorption of
fetal lung fluid, requiring O2 supplementation. Affected newborns are often born at or close to
term. They are likely to have been delivered by Cesarean section and may have had perinatal
distress. Recovery usually occurs within 2 to 3 days.”13
Neonatal jaundice
Neonatal jaundice, also referred to as neonatal hyperbilirubinemia, is a yellow discoloration of
the skin caused by elevated levels of bilirubin in the blood (hyperbilirubinemia). Per The Merck
Manual, jaundice is diagnosed when laboratory tests show a serum bilirubin concentration of
>10 mg/dL (171 µmol/L) in preterm newborns or >18 mg/dL (257 µmol/L) in full-term newborns.
Jaundice can be classified into two main categories: physiologic and pathologic. Physiologic
jaundice occurs in almost all neonates, is usually not clinically significant and resolves within
one week. Pathologic jaundice manifests by a rapidly rising total serum bilirubin concentration
resulting in prolonged jaundice, often requiring therapy.
Phototherapy has proved to be safe and effective in treating hyperbilirubinemia with the aim of
preventing potentially toxic bilirubin levels and decreasing the need for exchange transfusion. A
maximal effect is obtained by exposing the newborn to visible light in the blue range. However,
blue lights prevent detection of cyanosis, so phototherapy using broad-spectrum white light is
often preferred.
In cases of severe neonatal jaundice, exchange transfusion is an effective form of treatment.

Severe hyperbilirubinemia, per The Merck Manual, is defined by serum bilirubin concentration of
11–14 mg/dL for preterm newborns; for full-term newborns, the definition is >20 mg/dL at 24 to
48 hours or >25 mg/dL at more than 48 hours and failure of phototherapy to result in bilirubin
decrease. In exchange transfusion, small amounts of blood are withdrawn and replaced through
an umbilical vein catheter to remove partially hemolyzed and antibody-coated red blood cells as
well as circulating immunoglobulins.
Chapter XVIII — Symptoms, signs and

abnormal clinical and laboratory findings,
Systemic inflammatory response syndrome (SIRS)
Systemic inflammatory response syndrome (SIRS) is the body’s response to an infectious or
non-infectious insult. It is identified by two or more clinical findings of elevated or reduced
temperature, rapid heart rate and respiration, and elevated or reduced white blood count.
638
The signs and symptoms associated with SIRS are indicators that a systemic reaction is
occurring in the body requiring the need for quick treatment. The signs and symptoms
associated with SIRS are the same whether the underlying cause is of an infectious or non-
infectious origin.
The following definitions may assist in understanding the interrelationships between the
concepts of bacteremia, septicemia, systemic inflammatory response syndrome, sepsis,
severe sepsis and septic shock:
• Bacteremia: The presence of bacteria in the blood with no systemic response.
• Septicemia: Systemic disease associated with the presence and persistence of pathogenic
microorganisms or their toxins in the blood. Also called sepsis. Physicians sometimes use
the terms “septicemia” and “sepsis” interchangeably.
• Systemic inflammatory response syndrome: The systemic inflammatory response due to a
severe clinical insult manifested by two or more of the following symptoms: elevated or
reduced temperature; rapid heart rate and respiration; and/or elevated or reduced white
blood count.
• Sepsis: Systemic inflammatory response syndrome when the clinical insult is infection.
• Severe sepsis: Sepsis associated with acute organ dysfunction.
• Sepsis with chronic organ failure/dysfunction (e.g., chronic kidney disease) is not
synonymous with severe sepsis.
• Septic shock: Sepsis with hypotension, despite adequate fluid resuscitation, along with the
presence of perfusion abnormalities. 14
When a patient with a known or suspected infection shows signs and symptoms of systemic
inflammatory response (SIRS), the condition is described as “sepsis.” 15
Used in the strictest sense, the term “SIRS” should be restricted to mean “SIRS of a non-infectious
origin” and the term “sepsis” should be used to mean “SIRS of an infectious origin”; however,
these terms are used interchangeably by physicians.
It is now recognized that patients with critical illnesses and injuries may trigger a systemic
inflammatory response similar to that caused by infection. These patients exhibit the same type
of reaction as sepsis patients, yet there is no evidence of generalized or systemic infection. This
reaction in non-infectious patients is what initiated the use of the term “SIRS” in clinical practice.
When a patient experiences a major insult to the body, such as massive trauma, burns, major
surgery, pancreatitis or acute coronary syndrome, a systemic inflammatory response may
occur. In summary, the following tables outline the possible SIRS scenarios and how these
scenarios are classified.
639
Classification of SIRS: Infectious origin

SIRS with specified SIRS with unspecified
SIRS acute organ failure acute organ failure SIRS with shock
Sepsis code Sepsis code Sepsis code Assign codes from either
(M), (1), (2) or MP/OP (M), (1), (2) or MP/OP (M), (1), (2) or MP/OP the second or third column,
AND AND AND when applicable
Code for underlying Acute organ failure code(s) Code for underlying AND
localized infection when (1), (2) or OP localized infection when Code for underlying
documented AND documented localized infection when
(1), (2) or MP/OP Code for underlying (1), (2) or MP/OP documented
localized infection when AND (1), (2) or MP/OP
documented AND
(1), (2) or MP/OP
Optional Optional Mandatory Mandatory

R65.0 Systemic R65.1 Systemic R65.1 Systemic R57.2 Septic shock
inflammatory response inflammatory response inflammatory response (1), (2) or OP
syndrome of infectious syndrome of infectious syndrome of infectious
origin without organ failure origin with acute origin with acute organ
(3) or OP organ failure failure
(3) or OP (1), (2) or OP
Note: R65.1 is mandatory

only when the diagnosis is
stated as “severe sepsis”
or “multi-organ dysfunction
syndrome (MODS)” or
“multiple organ failure” in
the presence of sepsis.
Rationale: SIRS is already Rationale: When the type Rationale: When acute Rationale: When septic
inherent in the sepsis of acute organ failure is organ failure is shock is documented,
code; therefore, assigning specified in the documented but not it is captured as an
R65.0 is optional. documentation, each type specified, it is mandatory additional comorbidity.
is coded separately. R65.1 to assign R65.1 to
Note: Shock in SIRS due
is optional as it does not indicate that this is a
to an infectious origin is
provide any new case of severe sepsis.
specifically septic shock.
information. The presence
of SIRS is inherent in the
sepsis code and the
progression to severe
sepsis is indicated by
the specific codes for
acute organ failure. Sepsis
code plus code(s) for
acute organ failure =
severe sepsis.
640
Classification of SIRS: Non-infectious origin

SIRS with specified SIRS with unspecified
SIRS acute organ failure acute organ failure SIRS with shock
Underlying cause code Underlying cause code Underlying cause code When shock is present in
(M), (1), (2) or MP/OP (M), (1), (2) or MP/OP (M), (1), (2) or MP/OP non-infectious SIRS, it is
AND AND AND mandatory to assign an
Acute organ failure code(s) additional code from
(1), (2) or OP category R57 Shock, not
AND elsewhere classified as a
type (1), (2) or (OP).
Note: R57.2 Septic shock

is not applicable to non-
infectious SIRS.
Mandatory Mandatory Mandatory Not applicable

R65.2 Systemic R65.3 Systemic R65.3 Systemic
inflammatory response inflammatory response inflammatory response
syndrome of noninfectious syndrome of noninfectious syndrome of noninfectious
origin without organ failure origin with acute origin with acute organ
(1), (2) or OP organ failure failure
(1), (2) or OP (1), (2) or OP
Rationale: Unlike SIRS of an infectious origin, where SIRS is already inherent in the sepsis
code, SIRS of a non-infectious origin always requires the addition of R65.2 and R65.3
(mandatory) to identify the presence of SIRS. In a non-infectious cause, SIRS is always a
significant comorbidity.
Chapter XIX — Injury, poisonings and certain

other consequences of external causes
Crush injuries
Crush injury is defined as muscle swelling and/or neurological disturbances due to compression
of extremities or other parts of the body. Typically these include injuries of the lower extremities,
upper extremities and trunk.
Crush syndrome is localized crush injury with systemic manifestations. These systemic effects
are caused by traumatic rhabdomyolysis (muscle breakdown). This muscle breakdown releases
potentially toxic muscle cell components and electrolytes into the circulatory system. Crush
syndrome can cause local tissue injury, organ dysfunction and metabolic abnormalities,
including acidosis, hyperkalemia and hypocalcemia. 16
641
Opioid overdose
Opioid overdose coding direction
Below is a brief summary of direction for coding opioid overdose cases as described in the
bulletin Opioid Overdose Coding Direction.
Coding opioid overdose cases: Summary of direction

Positive
Opioid effect from
antidote opioid
Documentation given antidote Direction
Opioid overdose May or May or may Classify the encounter as a confirmed opioid overdose since
may not not be known the documentation describes a confirmed opioid overdose.
be known
When a diagnosis of “opioid overdose” or drug overdose with
specification of the specific opioid (e.g., fentanyl) is documented,
assign the applicable codes for an opioid overdose per the
direction in the coding standard Adverse Reactions in
Therapeutic Use Versus Poisonings.
Drug overdose Yes Yes Classify the encounter as a confirmed opioid overdose
since an opioid antidote was administered and had a
positive effect.
When an opioid antidote (e.g., naloxone, [Narcan]) is

administered for a suspected overdose prior to arrival at the
facility (e.g., self-administered, administered by someone else)
or during the episode of care and there is documentation of
a positive effect (e.g., starts breathing normally and/or
regains consciousness, opens eyes), classify the
encounter as an opioid overdose.
Drug overdose Yes No Classify the encounter as unknown drug overdose.
Do not classify as an opioid overdose.
Query opioid Yes Yes Classify the encounter as a confirmed opioid overdose
overdose since an opioid antidote was administered and had a
positive effect.
When an opioid antidote (e.g., naloxone, [Narcan]) is

administered for a suspected overdose prior to arrival at the
facility (e.g., self-administered, administered by someone else)
or during the episode of care and there is documentation of a
positive effect (e.g., starts breathing normally and/or regains
consciousness, opens eyes), classify the encounter as an
opioid overdose.
642
Positive
Opioid effect from
antidote opioid
Documentation given antidote Direction
Suspected No Not Classify the encounter as a query (unconfirmed) opioid

opioid overdose. applicable overdose since an opioid antidote was not administered and
All available there is no other documentation available confirming that
documentation the drug taken was an opioid.
reviewed.
When a query/unconfirmed opioid overdose is documented
(e.g., “suspected opioid overdose,” “questionable opioid
overdose,” “rule out opioid overdose,” “possible opioid overdose”)
and an opioid antidote (e.g., naloxone, [Narcan]) is not given,
classify the encounter as a query opioid overdose and assign
prefix Q, unless other available documentation confirms that the
drug overdose was due to an opioid.
Query opioid No Not Classify the encounter as a confirmed opioid overdose since
overdose. The applicable other available documentation confirmed that the drug taken
drug taken is was an opioid.
documented as
an opioid in Use all health care provider documentation including non-
physician documentation (e.g., nurses notes, ambulance records)
other available when there is documentation of
documentation.
• A query (unconfirmed) opioid overdose; or
• A drug overdose and the specific drug is not documented by
the physician.
References
1. Beers MH, Berkow R. The Merck Manual, 17th Edition. 2000.
2. Khardori R. Type 1 diabetes mellitus. Medscape website. Accessed August 14, 2014.
3. Diabetes Canada. Diabetes. Accessed August 14, 2014.
4. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). Treatment

methods for kidney failure: Hemodialysis. Accessed June 15, 2017.
5. Birke JA, Novick A, Hawkins ES, Patout C. A review of causes of foot ulceration in patients
with diabetes mellitus. Journal of Prosthetics and Orthotics. 1991.
6. Thygesen KA, Alpert JS. The definitions of acute coronary syndrome, myocardial infarction,
and unstable angina. Current Cardiology Report. June 2001.
7. Taha Taher, et al. Aborted myocardial infarction in patients with ST-segment elevation.
Journal of the American College of Cardiology. 2004.
643
8. Popma JJ, et al. Primary coronary angioplasty in patients with acute myocardial infarction.
Texas Heart Institute Journal. 1994.
9. Letovsky E, Allen T. Initiating thrombolytic therapy for acute myocardial infarction: Whose
job is it anyway?. Canadian Medical Association Journal. 1996.
10. Goldman L, Bennett JC, eds. Cecil’s Textbook of Medicine. 2000.
11. Skinner HB, McMahon PJ. Current Diagnosis & Treatment in Orthopaedics, 5th Edition.
2005.
12. Merck Manuals. Merck Manual Professional Version. Accessed May 3, 2017.
13. Beers MH, Berkow R. The Merck Manual, 17th Edition. 2000.
14. National Centre for Classification in Health. The International Statistical Classification of Diseases
and Related Health Problems, Tenth Revision, Australian Modification, Fifth Edition. 2006.
15. Morgan BL. Identification and Management of the Patient With Sepsis. 2008.
16. American College of Emergency Physicians. Crush injury and crush syndrome. Accessed
June 19, 2017.
644
Appendix B — Y83–Y84 Inclusion List

The Y83–Y84 Inclusion List is a guide for the consistent assignment of interventions to
subcategories in Y83 and Y84. The list below includes additions up to January 2018. It is the
responsibility of each coder to keep this list up to date from responses to coding questions in the
eQuery database about interventions that are not represented on the list.
Code Use of this subcategory Includes

Y83 Surgical operation and other surgical procedures as the cause of abnormal reaction of the patient,
or of later complication, without mention of misadventure at the time of the procedure
Y83.0 Surgical This subcategory includes any • Bone marrow transplant

operation with whole or partial organ or tissue • Corneal transplant (including lamellar
transplant of whole transplant. “Transplant” is corneal transplant)
organ or tissue the keyword.
• Heart transplant
• Heart valve replacements, all natural (see
Y83.1 for artificial valves)
• Kidney transplant
• Lobes of organs
• Stem cell transplant
Y83.1 Surgical This subcategory includes all • Artificial organs

operation with interventions that employ any • Central venous catheter (CVC) that is totally
implant of artificial artificial internal device. The key implanted (e.g., Port-a-Cath) (see Y84.8 for
internal device words are “artificial,” “internal” and CVCs that are not totally implanted)
“device.” Internal means
• Heart valve replacements, artificial
completely internal.
(all artificial or combination of artificial
and natural [stented]) (see Y83.0 for all
natural valves)
• Infusion pumps (systems) (e.g.,
Baclofen, insulin)
• Joint replacement prostheses (e.g.,
TKR, THR)
• Orthopedic internal fixation devices (e.g.,
screws, pins, nails) and implants (to fill a
bony defect [e.g., cranioplasty plate]) (see
Y83.8 for external orthopedic devices)
• Other prostheses (e.g., breast implant,
ossicular prosthesis)
• Pacemakers, defibrillators and cardiac
resynchronization therapy devices (includes
leads) (see Y84.8 for temporary pacemaker)
645
Y83.1 Surgical • Shunts (shunt systems) employing artificial

operation with devices (e.g., catheters, pumps) (e.g., VP
implant of artificial shunt, Transjugular Intrahepatic
internal device Portosystemic Shunt [TIPS]) (see also Y83.2)
(cont’d)
• Slings (e.g., eyelid [silastic rods],
vaginal [TVT])
• Stents (e.g., tear [lacrimal] duct, coronary
artery [PTCA with stent], bile duct, nasal)
• Tubes (e.g., myringotomy/tympanostomy
tubes)
Other
• Dental implants
• Gastroplasty band(ing system)
• Intraocular lens
Y83.2 Surgical This subcategory includes any • Augmentation, with natural or synthetic tissue
operation with intervention involving anastomosis, (e.g., Contigen, Macroplastique, silicone) with
anastomosis, bypass bypass or graft including those that device Y83.1
or graft employ artificial or natural tissue. • Bypasses (e.g., CABG, gastric bypass,
The key words are “anastomosis,” bypass for PVD [saphenous vein graft]
“bypass” and “graft.” Excludes with [e.g., aortobifemoral, iliofemoral])
stoma formation (Y83.3).
• Grafts (autograft, homograft, xenograft)
(patch grafts, tube grafts) (flaps–local, free,
pedicled) (artificial, natural) (e.g., skin,
ligament [ACL], repair AAA, TRAM)
• Hemodialysis access (creation AV fistula
[radiocephalic–wrist; brachiocephalic or
brachiobasilic–upper arm])
• Removal organ with anastomosis (e.g.,
hemicolectomy with colocoloanastomosis,
partial gastrectomy with Billroth II,
esophagectomy with cervicogastric
anastomosis)
• Shunts without artificial devices (e.g., Sano
shunt [consists of a Gortex tube graft
between the right ventricle and the
pulmonary arteries]) (see also Y83.1)
• Surgically constructed reservoirs
(e.g., neobladder, pelvic pouch)
646
Y83.2 Surgical Other

operation with • Bladder neck fixation using fascia as a sling
anastomosis, bypass
or graft (cont’d) • Dacryocystorhinostomy
• Mesh (e.g., hernia repair with mesh)
• Trabeculectomy
Y83.3 Surgical This subcategory includes all • Anastomosis, bypass or graft with formation
operation with interventions that result in the of external stoma (e.g., neobladder
formation of formation of an external stoma. with stoma)
external stoma Complications of catheters used • Percutaneous ostomies (e.g., gastrostomy
with these stomas are included [PEG tube])
here unless the catheter has a
• Reconstructive surgery with formation of
defect or has broken (Y70-Y82).
external stoma
• Removal of organ with formation of external
stoma (e.g., Hartmann’s procedure)
• Temporary and permanent stomas
Y83.4 Other This subcategory includes • A & P repair

reconstructive surgery reconstructive, restorative and • Cleft lip and palate repair
plastic procedures that do not
• Hypospadias repair
involve implant of an artificial
internal device (Y83.1); • Lift surgery (e.g., blepharoplasty, eyebrow lift)
anastomosis, bypass or graft • Nasal septum reconstruction (e.g.,
(Y83.2); or formation of external septoplasty, SMR)
stoma (Y83.3). • Nissen fundoplication
• Reduction (size reduction) (e.g., breast
reduction, abdominoplasty)
• Repair of hernia with simple closure
(with mesh Y83.2)
Y83.5 Amputation This subcategory includes surgical • BKA

of limb(s) amputations of limbs–partial and • Amputation of finger (partial) (revision)
complete, and revisions of
• Amputation of foot
(surgical) (traumatic) amputations.
647
Y83.6 Removal of This subcategory includes removal • Excision of lesion (includes bunionectomy)
other organ (partial) of organs — partial and total — • Excisional biopsies
(total) that do not involve transplant
• Extractions (e.g., nail, tooth)
(Y83.0); implant of an artificial
internal device (Y83.1); • Procurement of tissue
anastomosis, bypass or graft • Removal of organ (partial) (total)
(Y83.2); or formation of external (e.g., appendectomy, cholecystectomy,
stoma (Y83.3). circumcision, hysterectomy, mandibulectomy,
mastoidectomy, parathyroidectomy,
pneumonectomy, tonsillectomy)
• Resection of tissue (e.g., resection brain
tumour, EMR (esophageal mucosal
resection), TURB)
Y83.8 Other surgical This subcategory includes any • Angioplasties (dilation) (see Y83.1 for with
procedures surgical intervention that does not stent placement)
involve any type of intervention • Banding (e.g., esophageal varices)
assigned to one of the specific
• Biopsies, for example, needle lung biopsy,
subcategories.
incisional biopsies (all forms except
excisional [Y83.6])
• Control of bleeding
• Debridements
• Destructions (e.g., root canal, endometrial
ablation, [YAG] laser capsulotomy)
• Dilation (e.g., hydrodilation of bladder)
(see also Angioplasties)
• Embolization (for control of bleeding
or occlusion)
• Endarterectomy (atherectomy)
(no tissue or device used) (e.g., carotid
endarterectomy, coronary artery atherectomy)
• Endoscopies with or without biopsy (e.g.,
cystoscopy, colonoscopy with biopsy) Note:
endoscopies with a therapeutic intervention
are assigned to the appropriate surgical
subcategory (e.g., endoscopic stent
placement Y83.1)
• Incision and Drainage (I & D)
• Lysis adhesions
• Orthopedic external fixation devices
(e.g., percutaneous external fixator,
halo fixation device)
648
Y83.8 Other surgical • Release procedures (e.g., plantar fasciotomy,

procedures (cont’d) carpal tunnel repair, spinal decompression)
• Repairs with simple closure (e.g., suture
laceration, repair tendon tear)
• Tubal ligation
• Vasectomy
• Vitrectomy
Y83.9 Surgical This subcategory is used when n/a

procedure, unspecified there is no documentation of the
type of surgical intervention
performed and when multiple types
of surgical interventions are
performed and none are known
to be directly attributed to the post-
intervention condition.
Y84 Other medical procedures as the cause of abnormal reaction of the patient, or of later complication,
Y84.0 Cardiac This subcategory includes • Cardiac catheterization, diagnostic
catheterization diagnostic cardiac catheterizations • Coronary angiography
only. Cardiac catheterizations with
therapeutic interventions are
assigned to the appropriate
surgical subcategory (e.g., PTCA
with stent Y83.1).
Y84.1 Kidney dialysis This subcategory includes all forms • Hemodialysis

of kidney dialysis as a procedure • Peritoneal dialysis
and the catheters employed unless
the catheter has a defect or has
broken (Y70–Y82).
Y84.2 Radiological This subcategory includes • Brachytherapy

procedure and diagnostic radiological (diagnostic • ERCP, diagnostic
radiotherapy imaging) procedures and
• Mammogram
radiotherapy only. Radiological
procedures with a therapeutic • Radiation (irradiation) (radiotherapy)
intervention are assigned to the • Retrograde pyelogram (includes cystoscopy
appropriate surgical subcategory as part of this intervention)
(e.g., ERCP with bile duct stent
placement Y83.1).
Y84.30 This subcategory includes ECT • Electroshock therapy

Electroconvulsive (of brain) only.
therapy
649
Y84.38 Other This subcategory includes all forms • Cardioversion

shock therapy of shock therapy other than ECT. • Extracorporeal shock wave therapy
• Insulin shock therapy
Y84.4 Aspiration This subcategory includes • Paracentesis

of fluid one-time aspiration of fluids for • Spinal tap/lumbar puncture
drainage or diagnostic purposes. • Thoracentesis
Y84.5 Insertion This subcategory is specific to the • Insertion of gastric or duodenal sound
of gastric or use of gastric or duodenal sounds.
duodenal sound
Y84.6 Urinary This subcategory includes urinary • Urinary catheterization (Foley insertion)
catheterization catheterization as a procedure and (indwelling catheter) (suprapubic
the catheter itself unless the catheterization Y84.8)
catheter has a defect or has
broken (Y70–Y82).
Y84.7 Blood-sampling This subcategory includes • Blood sampling

blood sampling for diagnostic
purposes only.
Y84.8 Other medical This subcategory includes all • Blood donor procedure
procedures medical interventions that do not • Blood transfusion procedure
involve any type of intervention • Casts
assigned to one of the specific
• Central venous catheters (CVC) that are not
medical or surgical subcategories.
totally implanted (e.g., permacath, PICC,
This subcategory excludes
subclavian line) (see Y83.1 for totally
adverse effects from drugs and
implanted CVC)
other products that are introduced
• Chiropractic manipulation
into the body (see Table of Drugs
• CPR
and Chemicals) and devices that
have a defect or have broken • Extracorporeal circulation (e.g.,
(Y70–Y82). extracorporeal membrane oxygenation
[ECMO], cardiopulmonary bypass [CPB])
• Hypothermia (medically induced)
• Infusion procedure
• Injection procedure
• Intubation (anesthetic)
• IUD insertion
• IVs
• Nasal packing
• Pacemaker, temporary (see Y83.1 for
permanent pacemaker)
• Reattachments
• Suprapubic catheterization
• TPN
650
Y84.8 Other medical • Transcranial magnetic stimulation

procedures (cont’d) • Tubes (e.g., chest tube, tracheal [ventilator]
tube, Hemovac drain [collection system])
• Vaccination procedure
• Ventilation therapy
Y84.9 Medical This subcategory includes cases n/a

procedure, unspecified where there is no documentation of
the type of medical intervention
performed or when two or more
medical interventions are
performed and it is unclear which
intervention is attributable to the
post-intervention condition.
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Appendix C — Table of changes —

2018 Canadian Coding Standards
The purpose of this appendix is to
1. Provide a summary of changes for easy reference; and
2. Support understanding of changes
Important: This table identifies changes that are reflected in the Canadian Coding Standards for
Version 2018 ICD-10-CA and CCI. It is not an exhaustive list of v2018 changes to ICD-10-CA
and CCI. For a complete list of new and disabled codes, see appendices A and B in ICD-10-CA
and appendices E and F in CCI.
Note: For ease of use, the coding standard title and chapter heading is a hyperlink to the
relevant standard.
Description of change Rationale
Main and Other Problem Definitions for NACRS — General coding standards for ICD-10-CA
Deleted the following statement: An invalid code cannot be entered into a CIHI
abstract; therefore, this statement is unnecessary.
“The entry must be a valid ICD-10-CA code.”
Added the word “mandatory” to the following statement: To clarify that when a condition meets the definition
of other problem, it is mandatory to assign an ICD-
“An ICD-10-CA code is assigned, mandatory, as other
10-CA code.
problem (OP) when . . .”
Added the following statement to the definition of To clarify that only those conditions/circumstances
“other problem”: that meet the definition of other problem are
mandatory; all other conditions/circumstances
“It is optional to assign a code for a condition or
are optional.
circumstance when it does not meet the above definition
for mandatory other problem (OP) assignment.”
Added the statement “CIHI recommends that any decision To incorporate CIHI’s recommendation that any
regarding optional other problem assignment . . .” decision regarding optional other problem (OP)
assignment be made at the jurisdiction or facility
level, based on data needs and in consultation with
stakeholders responsible for overseeing coding and
data quality.
Added the note “See data elements 44 and 45 in the To identify that further instructions with respect to
National Ambulatory Care Reporting System (NACRS) main problem and other problem are found in the
Abstracting Manual . . .” National Ambulatory Care Reporting System
(NACRS) Abstracting Manual.
652
Appendix C — Table of changes — 2018 Canadian Coding Standards
Added the word “optional” to the code (Q) K21.9 in the To align with direction in the standard
following example and modified the rationale: Unconfirmed Diagnosis.
“A patient presents to the emergency department with

chest pain . . .”
Coding of Main and Other Problems for NACRS — General coding standards for ICD-10-CA
Modified the second paragraph of the To clarify when these diagnoses are mandatory
introductory statement: versus when they are optional, per the definition of
other problem.
From: “Diagnoses listed only on death certificates, history
and physical or pre-operative anesthetic consults qualify
as other problems when they meet the definition of an
other problem (OP).”
To: “It is optional to assign a code as an other problem for
a diagnosis listed only on a death certificate, history and
physical or pre-operative anesthetic consult, unless that
diagnosis meets the definition for mandatory
other problem (OP) assignment.”
Deleted the code Z63.0 Problems in relationship with In the example scenario, the diagnosis is not
spouse or partner from the following example: documented by the physician/primary care provider
and cannot be inferred.
“A man who recently argued with his wife presents to the
emergency department complaining of acute dizziness . . .”
Diagnosis Typing Definitions for DAD — General coding standards for ICD-10-CA
Removed “Morphology codes (type 4)” from the list of To align with v2018 ICD-10-CA enhancements.
diagnosis types. Chapter XXII — Morphology of neoplasms was
removed from the classification; therefore, diagnosis
type (4) is no longer a valid diagnosis type.
Added the following note to the section “Determining when To clarify that performing a qualifying intervention at
a condition meets the criteria for significance”: a facility other than the reporting facility during the
current episode of care does not preclude applying a
“Treatment may include transfer to another facility (e.g.,
significant diagnosis type to the diagnosis.
another acute care inpatient facility, a day surgery unit at
another facility for an out-of-hospital [OOH] intervention) for
a diagnostic or therapeutic intervention identified as
mandatory for code assignment in the coding standards.”
Added the following note to the section “Determining when To clarify that a patient refusing treatment does
a condition meets the criteria for significance” not preclude applying a significant diagnosis type
to the diagnosis.
“Documented evidence of a diagnostic investigation or an
assessment, a confirmed diagnosis and a proposed
treatment plan that is not implemented per the patient’s
decision to refuse treatment or due to a contraindication do
not preclude assignment of a significant diagnosis type.”
653
Added the note “For details related to the intervention To provide reference to the correct section of
location code and out-of-hospital (OOH) indicator . . .” the Discharge Abstract Database (DAD)
Abstracting Manual.
Added the flowchart Assigning prefixes 5 and 6 to a DAD To assist with the proper application of prefixes 5
inpatient abstract. and 6.
Added the following statement: To incorporate CIHI’s recommendation that any

decision regarding optional diagnosis type (3)
“Direction pertaining to the assignment of diagnosis type
assignment be made at the jurisdiction or facility
(3) is found throughout the coding standards. . .”
level, based on data needs and in consultation with
stakeholders responsible for overseeing coding and
data quality.
Removed the section Diagnosis type (4) — To align with v2018 ICD-10-CA enhancements.
Morphology codes. Chapter XXII — Morphology of neoplasms was
removed from the classification; therefore, diagnosis
type (4) is no longer a valid diagnosis type.
Added two examples: To demonstrate application of the notes based on

clinically relevant cases.
• “A patient is admitted with an upper gastrointestinal
(GI) hemorrhage. On admission, the physician
documents that the hemoglobin is low. . . ”
• “A term patient with gestational diabetes presents in
labor. Resources at the facility are limited; therefore,
arrangements are made to transfer the patient to the
care of an obstetrician at another facility . . .”
Diagnosis Cluster — General coding standards for ICD-10-CA
Added the note “For more information about diagnosis To provide reference to where additional information
clusters, see Group 10, . . .” can be found in the Discharge Abstract Database
(DAD) Abstracting Manual and the National
Ambulatory Care Reporting System (NACRS)
Abstracting Manual.
Amended the following example: To comply with the requirement in the coding
standard Admission for Convalescence that an
From: “A patient has a total knee replacement in Hospital
additional code to indicate the condition for which
A and is transferred to Hospital B . . .”
convalescence is required is mandatory as a
To: “A patient with primary, bilateral osteoarthritis of the diagnosis type (3). Also to clarify that the anemia was
knee has a total knee replacement in Hospital A and is a condition that was present on transfer.
transferred to Hospital B . . .”
Added the code and diagnosis type for the osteoarthritis
and modified the rationale.
654
Underlying Symptoms or Conditions — General coding standards for ICD-10-CA
Added a purpose statement to the beginning of the To clarify that the direction in this coding standard
coding standard. applies when a patient presents for investigation of
a sign, symptom and/or abnormal finding and there
is no documentation to support that the patient
is being investigated to rule out a specific
suspected condition.
Added a rationale to the following example: To provide a rationale for code assignment in
this example.
“A patient presents to the emergency department with
a seizure . . .”
Added three examples: To demonstrate application of the directive

statements to a number of possible scenarios.
• “The patient presents with diarrhea and anemia.
A colonoscopy is performed. . .”
• “The patient presents with dyspepsia and for follow-up
of diverticulosis. An esophagogastroduodenoscopy
(EGD) and colonoscopy are performed. . .”
• “The patient presents for an EGD and colonoscopy to
investigate iron deficiency anemia. During the
colonoscopy external hemorrhoids are noted. . .”
Modified the rationale in the following example: To clarify how the direction provided in the directive
statement applies to the example.
“A patient presents to the emergency department with right
lower quadrant (RLQ) abdominal pain.”
Unconfirmed Diagnosis — General coding standards for ICD-10-CA
Added new coding standard. To facilitate reference to the direction for different
circumstances involving one or more unconfirmed
diagnoses by dividing the standard into three
sections: Unconfirmed diagnosis, Confirmed
diagnosis with unconfirmed specificity and
Sign/symptom/abnormal finding with
unconfirmed diagnosis.
To provide clear direction regarding mandatory

versus optional assignment of one or more codes,
with an accompanying prefix Q, for one or more
unconfirmed diagnoses.
Query Diagnosis (Q)/Etiology — General coding standards for ICD-10-CA
Deleted the coding standard. Direction for unconfirmed diagnoses is provided in

the new coding standard Unconfirmed Diagnosis.
655
Use Additional Code/Code Separately Instructions — General coding standards for ICD-10-CA
Modified the following exception: To clarify that it is mandatory to assign a code from
B95–B98 Bacterial, viral and other infectious agents
From: “The instruction to ‘use additional code (B95–B98)
only when the infection is due to one of the
to identify infectious agent’ is optional when it is not a drug-
mandatory drug-resistant microorganisms.
resistant infectious organism. See also the coding standard
Drug-Resistant Microorganisms.”
To: “The instruction to ‘use additional code (B95–B98) to
identify infectious agent’ is optional when it is not one of the
mandatory drug-resistant infectious organisms. See also
the coding standard Drug-Resistant Microorganisms.”
Reworded the rationale in the second example: To demonstrate that it is mandatory to assign a code
from B95–B98 Bacterial, viral and other infectious
From: “Assignment of codes from B95–B98 is optional.
agents only when the infection is due to one of the
Assignment of codes from B95–B98 is mandatory for
mandatory drug-resistant microorganisms.
infectious agents due to drug-resistant organisms only.”
To: “Assignment of a code from B95–B98 is optional,
unless the infection is due to one of the mandatory drug-
resistant microorganisms.”
Cancelled Interventions — General coding standards for ICD-10-CA
Added the note “For more information about cancelled To provide reference to where additional information
interventions, see Group 11 . . .” can be found in the Discharge Abstract Database
(DAD) Abstracting Manual and the National
Ambulatory Care Reporting System (NACRS)
Abstracting Manual.
Selection of Interventions to Code for Ambulatory Care — General coding standards for CCI
Added 1.^^.35.^^-M^ Pharmacotherapy using To incorporate the direction for the assignment of
antineoplastic and immunomodulating agents to the list chemotherapy interventions classified to 1.^^.35.^^-
Additional mandatory CCI codes for ambulatory care. M^ provided in the coding standard Admission for
Administration of Chemotherapy, Pharmacotherapy
and Radiation Therapy.
Added 1.ZZ.35.^^ Pharmacotherapy, total body — To incorporate the direction for the assignment of
mandatory only in certain circumstances; see the codes from 1.ZZ.35.^^ provided in the coding
coding standards Medical Assistance in Dying and standards Medical Assistance in Dying and
Admission for Administration of Chemotherapy, Admission for Administration of Chemotherapy,
Pharmacotherapy and Radiation Therapy to the list Pharmacotherapy and Radiation Therapy, and
Additional mandatory CCI codes for ambulatory care. to reference the appropriate coding standards
which direct when it is mandatory to assign codes
from 1.ZZ.35.^^.
Added 2.ZZ.02.PM Assessment (examination), total body To incorporate the direction for the mandatory
for assistance in dying to the list Additional mandatory CCI assignment of 2.ZZ.02.PM provided in the coding
codes for ambulatory care. standard Medical Assistance in Dying.
656
Added 5.AC.24.CK-BD Preparation by dilating cervix (for), To incorporate the direction for the mandatory
labour, using per orifice (ripening) by balloon catheter and assignment of 5.AC.24.CK-BD and 5.AC.24.CK-W6
5.AC.24.CK-W6 Preparation by dilating cervix (for), labour, provided in the coding standard Interventions
using per orifice insertion of luminaria to the list Additional Associated with Delivery.
mandatory CCI codes for ambulatory care.
Added 7.SC.08.PM Other ministration, personal care for To incorporate the direction for the mandatory
assistance in dying to the list Additional mandatory CCI assignment of 7.SC.08.PM provided in the coding
codes for ambulatory care. standard Medical Assistance in Dying.
Added the coding standard Medical Assistance in Dying to To complete the list of additional coding standards.
the list of additional standards that provide direction for
mandatory code assignment.
Selection of Interventions to Code for Acute Inpatient Care — General coding standards for CCI
Added 1.ZZ.35.^^ Pharmacotherapy, total body — To incorporate the direction for the assignment of
mandatory only in certain circumstances; see the codes from 1.ZZ.35.^^ provided in the coding
coding standards Medical Assistance in Dying and standards Medical Assistance in Dying and
Admission for Administration of Chemotherapy, Admission for Administration of Chemotherapy,
Pharmacotherapy and Radiation Therapy to the list Pharmacotherapy and Radiation Therapy, and to
Additional mandatory CCI codes for acute inpatient care. reference the appropriate coding standards
which direct when it is mandatory to assign codes
from 1.ZZ.35.^^.
Added 2.ZZ.02.PM Assessment (examination), total body To incorporate the direction for the mandatory
for assistance in dying to the list Additional mandatory CCI assignment of 2.ZZ.02.PM provided in the coding
codes for acute inpatient care. standard Medical Assistance in Dying.
Added 5.AC.24.CK-BD Preparation by dilating cervix (for), To incorporate the direction for the mandatory
labour, using per orifice (ripening) by balloon catheter and assignment of 5.AC.24.CK-BD and 5.AC.24.CK-W6
5.AC.24.CK-W6 Preparation by dilating cervix (for), labour, provided in the coding standard Interventions
using per orifice insertion of luminaria to the list Additional Associated with Delivery.
mandatory CCI codes for acute inpatient care.
Added 7.SC.08.PM Other ministration, personal care for To incorporate the direction for the mandatory
assistance in dying to the list Additional mandatory CCI assignment of 7.SC.08.PM provided in the coding
codes for acute inpatient care. standard Medical Assistance in Dying.
Added the coding standard Medical Assistance in Dying to To complete the list of additional coding standards.
the list of additional standards that provide direction for
mandatory code assignment.
Endoscopic Interventions — General coding standards for CCI
Moved the directive statements and the examples To collate all of the information about the
from the coding standards Diagnostic classification of an endoscopic intervention into
Esophagogastroduodenoscopy (EGD) and Diagnostic one coding standard.
Colonoscopic Interventions to the coding standard
Endoscopic Interventions.
657
Abandoned Interventions — General coding standards for CCI
Added the note “When an intervention meets the criteria for To clarify that it is mandatory to assign the status
‘abandoned,’ it is mandatory to assign . . .” attribute “abandoned” whenever it is available
and the intervention meets the criteria for an
abandoned intervention.
Converted Interventions — General coding standards for CCI
Added the note “When an intervention meets the criteria for To clarify that it is mandatory to assign the status
‘converted,’ it is mandatory to assign . . .” attribute “converted” whenever it is available and
the intervention meets the criteria for a
converted intervention.
Infections — Chapter I — Certain infectious and parasitic diseases
Added the following exception: To identify an exception to the directive statement

“Assignment of codes from categories B95–B98 is
“It is mandatory to assign a code from B95–B98 Bacterial,
optional; . . .” when there is a specific drug-resistant
viral and other infectious agents as a diagnosis type
microorganism infection.
(3)/other problem when the causative agent is one of the
specific drug-resistant microorganisms. See also the
coding standard Drug-Resistant Microorganisms.”
Drug-Resistant Microorganisms — Chapter I — Certain infectious and parasitic diseases
Added “carbapenem-resistant Enterobacteriaceae (CRE)” To identify the addition of carbapenem-resistant

to the introductory paragraph. Enterobacteriaceae (CRE) infection to the standard
Added “CRE” to the following directive statement: To provide direction that it is mandatory to capture
codes for drug-resistant microorganism infections
“When there is a current infection that is clearly
due to CRE.
documented by the physician/primary care provider
as being due to MRSA, CRE, ESBL producing
microorganisms or VRE, assign, mandatory,
the appropriate code combination to identify the . . .”
Removed “when it is not included in a combination code” To provide direction that it is mandatory to assign a
from the second bullet in the first directive statement. code from category B95–B98 Bacterial, viral, and
other infectious agents for all infections due to
MRSA, CRE, ESBL and VRE.
Added the code U82.20 Resistance to carbapenem to the To identify that CRE has been added to the list of
second bullet in the first directive statement. specific drug-resistant microorganisms.
Modified the code for ESBL from U82.2 Extended spectrum To align with v2018 ICD-10-CA enhancements
betalactamase (ESBL) resistance to U82.28 Resistance to whereby the code U82.2 was expanded to the
other specified extended spectrum betalactam antibiotics in fifth digit.
the third bullet in the first directive statement.
658
Added CRE to the following note: To identify that CRE has been added to the list of
specific drug-resistant microorganisms where
“Documentation by infection control staff stating that a
documentation by infection control staff may be used
patient has a current infection due to MRSA, CRE, ESBL
to meet the requirement for code assignment.
producing microorganisms or VRE . . .”
Added the statement “It is mandatory to assign the set of To demonstrate that it is mandatory to assign a code
codes that describe an infection due to a specific drug- from category B95–B98 Bacterial, viral, and other
resistant microorganism. . . ” to the rationale in the infectious agents to identify the specific infection for
following examples: a drug-resistant microorganism.
“This patient, who has primary, bilateral osteoarthritis of the

hip, is admitted . . .”
“Final diagnosis: ESBL E. coli UTI”
“The patient is admitted for treatment of infected stage II

pressure ulcers . . .”
Added the example “A patient is admitted with a diagnosis To demonstrate that it is mandatory to use a code
of pneumonia due to MRSA.” from category B95–B98 Bacterial, viral, and other
infectious agents to identify the specific infection
even when the microorganism is included in the
combination code.
Added CRE to the introductory paragraph for the To identify the addition of carbapenem-resistant
subsection Carriers of drug-resistant microorganisms. Enterobacteriaceae (CRE) carrier to the subsection
Carriers of drug-resistant microorganisms.
Septicemia/Sepsis — Chapter I — Certain infectious and parasitic diseases
Added the example “The patient is admitted for a total To demonstrate that four diagnosis codes are
colectomy with ileostomy for colon cancer. On post- required to identify the post-intervention sepsis
operative day 2, he develops post-operative (T81.4 and A41.2) and the post-intervention septic
staphylococcus sepsis . . .” shock (T81.1 and R57.2).
Added the example “The patient is admitted to the To demonstrate that four diagnosis codes are
intensive care unit with a diagnosis of central line– required to identify the central line–associated sepsis
associated E. coli sepsis . . .” (T82.701 and A41.50) and the central line–
associated septic shock (T82.8 and R57.2).
Viral Hepatitis — Chapter I — Certain infectious and parasitic diseases
Deleted the coding standard. To align with v2018 ICD-10-CA enhancements and
current terminology. The concept of being a carrier of
viral hepatitis is no longer recognized and was
removed from the classification.
659
Neoplasms of Ectopic Tissue — Chapter II — Neoplasms
Deleted the coding standard. To align with the v2018 ICD-10-CA enhancement that
neoplasms of ectopic or aberrant tissue are classified
to where they are found and not to the anatomical
site of origin. The ectopic neoplasm coding rule is
found within the classification.
Complications of Malignant Disease — Chapter II — Neoplasms
Modified the directive statement: To clarify that it is mandatory to assign a code for the
malignancy as a diagnosis type (3)/other problem in
From: “When a patient is admitted for treatment of a
this scenario.
specific complication of the malignancy, and no treatment
is directed toward the malignancy itself, assign the code
for the complication as the MRDx/main problem.
Assign the code for the malignancy as a diagnosis
type (3)/other problem.”
To: “When a patient is admitted for treatment of a specific

complication of the malignancy, and no treatment is
directed toward the malignancy itself, assign the code for
the complication as the MRDx/main problem. Assign the
code for the malignancy, mandatory, as a diagnosis type
(3)/other problem.”
Modified the directive statement: To clarify that it is mandatory to assign a code for the
malignancy as a diagnosis type (3)/other problem in
From: “When a patient is admitted for management of a
this scenario.
side effect of cancer treatment, assign a code for the side
effect as the MRDx/main problem. Assign the code for the
malignancy as a diagnosis type (3)/other problem.”
To: “When a patient is admitted for management of a side

effect of cancer treatment, assign a code for the side
effect as the MRDx/main problem. Assign the code
for the malignancy, mandatory, as a diagnosis type
(3)/other problem.”
Seizures — Chapter VI — Diseases of the nervous system
Added the note “Do not confuse intractable To clarify that the terms “intractable epilepsy” and
epilepsy (medication-resistant or refractory) with “status epilepticus” have different meanings.
status epilepticus . . .”
660
Neurologically Determined Death — Chapter VI — Diseases of the nervous system
Added new coding standard. To mandate the collection of G93.81 Neurologically

determined death in cases where there is
documentation of brain death by a designated
physician. The collection of this data makes it
possible to analyze and report on patients who
are eligible for possible organ procurement.
Thrombolytic Therapy — Chapter IX — Diseases of the circulatory system
Added the words “only when the diagnosis is ST-segment To clarify that the criteria for application of the
elevation myocardial infarction (STEMI)” to the Apply the Intervention Pre-Admit Flag to the code for
Intervention Pre-Admit Flag note. thrombolytic therapy apply only when the
thrombolytic therapy is administered prior to
admission and the diagnosis is ST-segment
elevation myocardial infarction (STEMI).
Added the note “The diagnosis is not STEMI and the To clarify that the reason the Intervention Pre-Admit
thrombolytic agent is administered after admission . . .” Flag is not applied to the code for thrombolytic
to the first and fifth examples. therapy is because the diagnosis is not STEMI.
Added the note “The diagnosis is STEMI. However, the To clarify that the reason the Intervention Pre-Admit
thrombolytic therapy is administered after admission . . .” Flag is not applied to the code for thrombolytic
to the second example. therapy is because the thrombolytic agent was not
administered prior to admission.
Revised the note “Apply Intervention Pre-Admit Flag” for To clarify that the reason the Intervention Pre-Admit
the third and fourth examples. Flag is applied to the code for thrombolytic therapy is
because the thrombolytic therapy is administered
From: “Apply Intervention Pre-Admit Flag.”
prior to admission and the diagnosis is STEMI.
To: “The diagnosis is STEMI and the thrombolytic therapy
is administered prior to admission. Therefore, the
Intervention Pre-Admit Flag does apply.”
Added the diagnosis of STEMI to the example “The patient To clarify that the reason the Intervention Pre-Admit
is brought to the emergency department at Facility A, Flag is applied to the code for thrombolytic therapy is
where he receives TNK . . .” because the diagnosis is STEMI.
Added the sentence “The Intervention Pre-Admit Flag does To clarify that the Intervention Pre-Admit Flag is not
not apply to antithrombotics or platelet aggregation applied when a code is assigned for administration of
inhibitors” to the paragraph “A patient presenting with an antithrombotic.
NSTEMI may be treated with antithrombotics (such as
heparin) to inhibit the coagulation process . . .”
661
Strokes: Hemorrhagic, Ischemic and Unspecified — Chapter IX — Diseases of the circulatory system
Renamed the coding standard To clarify that the direction within this coding
standard is specific to hemorrhagic, ischemic
From: Strokes, Cerebrovascular Accidents (CVAs) and
and unspecific strokes.
Transient Ischemic Attacks (TIAs)
To: Strokes: Hemorrhagic, Ischemic and Unspecified
Revised the wording of the introductory paragraph: To clarify what this coding standard addresses.
From: “This standard addresses the difference between

a current stroke episode and one that is considered
treatment of sequelae of stroke.”
To: “This standard addresses the classification of a stroke
in the context of
• The initial episode of care in which an acute/current
stroke is diagnosed; and
• An admission solely for rehabilitation immediately
following an acute/current stroke.”
Added a second introductory paragraph: To clarify that from an ICD-10-CA perspective, there
are only four categories to which a hemorrhagic,
“From a classification perspective, per the ICD-10-CA
ischemic or unspecified stroke is classified.
alphabetical index lookup, documentation of a stroke
(meaning acute/current stroke diagnosis) is classified to
one of four categories: I60, I61, I63 or I64. Code
assignment depends on whether the cause of the stroke is
hemorrhagic, ischemic or unknown. . .”
Added a third introductory paragraph: To ensure provinces/territories that participate in the

DAD and NACRS Stroke Strategy Performance
“It is important to note that some provinces/territories
Improvement Projects are aware of the other
monitor stroke strategy performance by collecting
conditions that are included in these projects’ criteria
additional data using the Stroke Special Projects in the
for completion.
DAD and NACRS databases. . .”
Added the following statement to the “see also” note: To direct coders to the applicable coding standards
when coding a case involving neurological deficits
“Direction related to coding neurological deficits following a
following a stroke or sequelae/late effects of a stroke.
stroke and sequelae/late effects of a stroke are found in the
coding standards Neurological Deficits Following a Stroke
and Sequelae.”
Added the term “Acute” to the subheading To clarify that “acute” equates to a “current” stroke
“Acute/current stroke.” from an ICD-10-CA code assignment perspective
versus, for example, code assignment for a history of
a stroke or sequelae/late effects of a stroke.
662
Modified the following directive statement: To clarify that it is mandatory to assign a code for an
acute/current stroke classified to I60, I61, I63 or I64,
From: “Assign the code for current stroke, classifiable to
and that this also applies to the emergency
I60, I61, I63 and I64, during the initial episode of care for
department visit in which an acute/current stroke
the stroke. This includes both the acute care hospitalization
may be diagnosed.
and any subsequent transfer to another facility for
rehabilitation to continue treating the associated
neurological deficits during the current, uninterrupted
episode of care.”
To: “Assign, mandatory, the applicable code from category

I60, I61, I63 or I64 for an acute/current stroke diagnosed
during the initial episode of care. This includes the
emergency department visit, the acute care hospitalization
and any subsequent admission to another facility for
rehabilitation to continue treating the associated
neurological deficits during the current, uninterrupted
episode of care.”
Added a new directive statement: To provide direction to assign a code for the
acute/current stroke, mandatory, as a diagnosis type
“When a patient is admitted solely for rehabilitation
(3) in this circumstance.
immediately following an acute/current stroke diagnosis, . . .”
Revised the wording of the following statement: To properly format the statement into a Note box, and
to amend the wording for clarity.
“A stroke may continue to worsen or progress for several
hours to a day or two as a steadily enlarging area of brain
tissue dies (stroke evolution). . .”
Following is the new note:
“When a hemorrhagic or ischemic stroke is described as

progressing or evolving, an additional code is not assigned.
A stroke may continue to worsen or progress for several
hours to a day or two as a steadily enlarging area of brain
tissue dies (stroke in evolution).”
Added a new note: To direct coders to the applicable coding

standard when coding an acute/current stroke
“An acute/current stroke complicating pregnancy
complicating pregnancy.
is classified per the direction in the coding
standard Complicated Pregnancy Versus
Uncomplicated Pregnancy.”
Added a new note: To direct coders to the applicable coding standard

when coding a perinatal stroke.
“The term “perinatal stroke” collectively refers to a
nontraumatic stroke that occurred before birth (fetal or
prenatal), during birth or within 28 days after birth. Refer to
the coding standard Perinatal Stroke.”
663
Added a new note: To clarify the appropriate use of Z86.78 when there is
documentation of a “history of a stroke.”
“Documentation of ‘history of a stroke’ is classified to
Z86.78 Personal history of other diseases of the circulatory
system only when there are no longer any neurological
deficits present. . .”
Added a rationale to the example “The same person is now To provide rationale for assigning I63.9 as a
transferred from acute care to rehabilitation. . .” diagnosis type (3).
Added a new example: To include an example of acute/current stroke

meeting the definition of diagnosis type (3).
“The patient presents to the emergency department after
being found to have a decreased level of consciousness
with decreased movements of her left side. . .”
Deleted the subsection Sequelae of To consolidate information and remove direction that
cerebrovascular disease. can be found in the coding standard Sequelae.
Modified the wording in the subsection Related To simplify the message and introduce the newer
interventions. treatment option for acute stroke care, endovascular
treatment (EVT).
From: “Emergency treatment of stroke from a blood clot is
aimed at dissolving the clot. Thrombolytic therapy is coded
in CCI using 1.ZZ.35.HA-1C Pharmacotherapy, total body
NEC, percutaneous approach [intramuscular, intravenous,
subcutaneous, intradermal], using thrombolytic agent. See
also the coding standard Thrombolytic Therapy. Other
aggressive treatment options include Intracranial
angioplasty 1.JW.50.^^ Dilation, intracranial vessels;
Intracranial thrombectomy 1.JW.57.^^ Extraction,
intracranial vessels; or Bypass, intracranial to intracranial
vessels 1.JW.76.^^ Bypass, intracranial vessels.”
To: “Emergency treatment of an ischemic stroke from

a blood clot is aimed at dissolving the clot using
thrombolytic therapy. See also the coding standard
Thrombolytic Therapy.
“Endovascular treatment (EVT) is a relatively new

treatment option for acute stroke care. Examples include
endovascular clot retrieval (thrombectomy) and
endovascular dilation with or without stenting of carotid
artery or intracranial vessels.”
Deleted the subsection Vascular syndromes of brain in To remove information that can be found in the ICD-
cerebrovascular diseases. 10-CA alphabetical index and tabular instructions.
664
Invasive Ventilation — Chapter X — Diseases of the respiratory system
Added the note “Use the Intervention Pre-Admit Flag To provide reference to where additional information
to indicate . . .” can be found in the Discharge Abstract Database
(DAD) Abstracting Manual.
Diagnostic Esophagogastroduodenoscopy (EGD) — Chapter XI — Diseases of the digestive system
Deleted the coding standard. To collate all of the information about the
classification of an endoscopic intervention into one
coding standard. Direction for the classification of
diagnostic esophagogastroduodenoscopic
interventions is provided in the coding standard
Endoscopic Interventions.
Diagnostic Colonoscopic Interventions — Chapter XI — Diseases of the digestive system
Deleted the coding standard. To collate all of the information about the
classification of an endoscopic intervention into one
coding standard. Direction for the classification of
colonoscopic interventions is provided in the coding
standard Endoscopic Interventions.
Cellulitis — Chapter XII — Diseases of the skin and subcutaneous tissue
Added the exception “It is mandatory to assign a code To identify an exception to the directive statement
from B95–B98 Bacterial, viral and other infectious “Assign an additional code, optional, as a diagnosis
agents as a diagnosis type (3)/other problem when the type (3) . . .”
causative agent is one of the specific drug-resistant
microorganism infections. See also the coding standard
Drug-Resistant Microorganisms.”
Pregnancy With Abortive Outcome — Chapter XV — Pregnancy, childbirth and the puerperium
Added “See Section 3: Additional Abstracting Information: To provide reference to the correct section of
Stillborn Abstracting . . .” to the third note. the Discharge Abstract Database (DAD)
Abstracting Manual.
Complicated Pregnancy Versus Uncomplicated Pregnancy — Chapter XV — Pregnancy, childbirth and

the puerperium
Added “acute myocardial infarction” to the examples of To clarify that in pregnancy an acute myocardial
cardiac disease (O99.4–) that complicate pregnancy in the infarction is always considered to complicate the
subsection Complicated pregnancy. pregnancy and O99.4– is assigned.
Added the bullet “ST segment elevation myocardial To clarify that in pregnancy STEMI or NSTEMI is
infarction (STEMI) (R94.30) . . .” to the list of conditions always considered to complicate the pregnancy and
that complicate pregnancy. when all that is documented is the working diagnosis
STEMI or NSTEMI, O99.8– is assigned.
665
Added the note “For emergency department encounters . . . To clarify that in pregnancy, when the emergency
O99.8– Other specified diseases and conditions department discharge diagnosis is documented as
complicating pregnancy, childbirth and the puerperium is the working diagnosis STEMI or NSTEMI, O99.8– is
assigned as the main problem and R94.30 or R94.31 is assigned with R94.30 or R94.31.
assigned as an other problem.”
Added the note “For inpatient and day surgery cases, To clarify that in pregnancy, for inpatient and day
O99.4– Diseases of the circulatory system complicating surgery abstracts, a diagnosis of STEMI or NSTEMI
pregnancy, childbirth and the puerperium is assigned as a is classified to O99.4–, with the appropriate code for
significant diagnosis and I21.– Acute myocardial infarction the acute myocardial infarction (I21.–, I22.– or I24.0),
or I22.– Subsequent myocardial infarction or I24.0 and per the direction in the Acute Coronary
Coronary thrombosis not resulting in myocardial infarction Syndrome coding standard, R94.30 or R94.31 is
and R94.30 or R94.31 are assigned as diagnosis type (3). assigned as a diagnosis type (3). Since STEMI or
O99.8– Other specified diseases and conditions NSTEMI is further describing the acute myocardial
complicating pregnancy, childbirth and the puerperium is infarction, O99.8– is not assigned.
not assigned.”
Added the example “A primigravida patient is admitted at To demonstrate that a code from category O99.4
37 weeks gestation for intravenous oxytocin induction of and an additional code to identify the specific
labor for gestational hypertension. . .” type of stroke are assigned for a stroke in an
obstetrical patient.
Added the directive statement “When a condition that To reinforce that when a code from category O99 is
complicates the pregnancy is classified to a code from O99 assigned, it is mandatory to assign an additional code
Other maternal diseases classifiable elsewhere but as a diagnosis type (3)/other problem, to identify the
complicating pregnancy, childbirth and the puerperium, specific condition, per the “use additional code”
assign an additional code, mandatory, as a diagnosis type instruction at category O99.
(3)/other problem, to identify the specific condition . . .”
Added the directive statement “When two or more To clarify that when more than one condition that
conditions that complicate the pregnancy are classified to complicates the pregnancy is classified to multiple
different subcategories from O99 Other maternal diseases subcategories at category O99, a code for each
classifiable elsewhere but complicating pregnancy, complication from the appropriate subcategory
childbirth and the puerperium, assign the code from the (O99.0–O99.8) is assigned separately, to permit the
appropriate subcategory (O99.0–O99.8) . . .” greatest degree of specificity.
Added the bullet to the above directive statement “Do not To clarify that O99.8– is not assigned as a flag when
assign O99.8– as a flag to identify cases with multiple there is more than one condition that complicates the
complications classifiable to O99.0–O99.7.” pregnancy, classified to multiple subcategories
(O99.0–O99.8) at category O99.
Obstructed Labor — Chapter XV — Pregnancy, childbirth and the puerperium
Amended the following example and removed the To clarify that this example is demonstrating the
intervention code from it: second directive statement, specifically the direction
to code obstructed labor “when the alphabetical index
“A female infant is delivered vaginally with significant
leads to an obstructed labor code.” Direction on
shoulder dystocia lasting for one minute . . .”
interventions (maneuvers) is provided later in the
standard and is not applicable in this example.
666
Added the words “(e.g., Rubin, Wood’s)” to the following To provide examples of what are considered “certain
directive statement: other maneuvers.”
“When an obstructing factor is resolved by version

and/or rotation . . .”
Added the following note: To clarify that maneuvers classified to rubric

5.MD.16.^^ Maternal positions for delivery
“Maternal positioning classified to rubric 5.MD.16.^^
(assistance), including McRoberts, are optional
Maternal positions for delivery (assistance) (e.g.
to capture.
McRoberts) . . .”
Added the following example: To demonstrate the directive statement and the
note regarding mandatory and optional
“Shoulder dystocia is noted during delivery . . .” maneuvers, respectively.
Postpartum Hemorrhage — Chapter XV — Pregnancy, childbirth and the puerperium
Revised the wording in the introductory paragraph: To provide clarity that blood loss occurring in the
postpartum period due to injury is not classified to
From: “Blood loss occurring in the postpartum period due
category O72 Postpartum haemorrhage.
to causes other than the aforementioned is not classified to
category O72 Postpartum haemorrhage (for example, an
injury such as a tear of the uterine artery during Cesarean
section or a sulcus tear during vaginal delivery).”
To: “Blood loss occurring in the postpartum period due to
causes other than the aforementioned, such as an injury
(e.g., tear of the uterine artery during Cesarean section,
sulcus tear during vaginal delivery), is not classified to
category O72 Postpartum haemorrhage.”
Change in direction. Revised the first criterion in the To reflect the change in direction that blood loss must
directive statement for the criteria for excessive blood loss: be greater than 500 cc/ml for vaginal delivery and
greater than 1,000 cc/ml for Cesarean delivery to
From: “Blood loss is excessive:
meet the criteria for excessive blood loss in order to
• Vaginal delivery with ≥500 cc blood loss during third assign a code from category O72 Postpartum
stage of labor, in immediate postpartum period or after haemorrhage.
24 hours following delivery.
• Cesarean delivery with ≥1,000 cc blood loss.”
To: “Blood loss is excessive:
• Vaginal delivery with >500 cc/ml blood loss during

third stage of labor, in immediate postpartum period or
after 24 hours following delivery.
• Cesarean delivery with >1,000 cc/ml blood loss.”
667
Change in direction. Revised the second criterion in the To reflect the change in direction that excessive
directive statement for the criteria for excessive blood loss: bleeding must be present with a diagnosis of
retained products to justify assignment of O72
From: “Documentation indicates uterine atony following
Postpartum haemorrhage.
delivery or bleeding in the presence of retained products,
regardless of the amount of blood loss recorded.”
To: “Documentation indicates uterine atony following

delivery, regardless of the amount of blood loss recorded.”
Modified the table Selection of the code from category To clarify that retained, trapped or adherent
O72 Postpartum haemorrhage is based on etiology and placenta with bleeding that meets the criteria for
time frame. excessive is classified to O72.0– Third-stage
haemorrhage or O72.2– Delayed and secondary
From: “Retained, trapped or adherent placenta”
postpartum haemorrhage.
To: “Retained, trapped or adherent placenta with
To clarify that uterine atony or postpartum
excessive bleeding”
hemorrhage NOS is classified to O72 Postpartum
From: “Uterine atony or unknown/not documented (that is, haemorrhage regardless of blood loss.
PPH NOS)”
To: “Uterine atony or unknown/not documented (i.e., PPH

NOS), regardless of the amount of blood loss recorded”
Added a note “Retained, trapped or adherent placenta To clarify that retained, trapped or adherent placenta
without excessive bleeding or physician documentation of with blood loss that does not meet the criteria
hemorrhage that occurs anytime during or after the third for excessive blood loss, with no physician
stage of labor is classified to O73.– Retained placenta and documentation of hemorrhage, is classified to
membranes, without haemorrhage.” O73.– Retained placenta and membranes,
without haemorrhage.
Replaced the note: To clarify that hemorrhage or excessive blood loss

that is due to an injury occurring prior to or during
From: “When the amount of blood loss recorded
the delivery of the infant is classified as an
includes blood loss from sources not associated with
intrapartum hemorrhage.
uterine atony, retained products or coagulation defects
(that is, an injury) do not assign a code from category O72
Postpartum haemorrhage.”
With: “Hemorrhage or excessive blood loss during the
delivery process or immediately following the delivery that
is secondary to an injury, including perineal lacerations, is
classified as intrapartum hemorrhage, since the injury
occurred prior to or during the delivery of the infant. It is
classified to O67.8– Other intrapartum haemorrhage.”
668
Modified the rationale in the first example: To explain the correct application of the directive.
From: “A postpartum hemorrhage occurred during the third

stage of labor due to retained placenta; therefore, O72.002
is assigned.”
To: “A postpartum hemorrhage documented as due to
retained placenta occurred during the third stage of labor;
therefore, O72.002 is assigned.”
Added “The estimated blood loss recorded is 600 cc.” to To clarify that only excessive bleeding (greater than
the third example, and updated the rationale: 500 cc/ml) due to retained portions of placenta that
does not occur during the third stage of labour is
From: “Bleeding due to retained portions of placenta not
classified to O72.202 Delayed and secondary
during the third stage of labor is classified to delayed and
postpartum haemorrhage, delivered, with mention of
secondary hemorrhage, regardless of the time frame.”
postpartum complication.
To: “Excessive bleeding due to retained portions of
placenta not occurring during the third stage of labor is
classified to delayed and secondary hemorrhage.”
Modified the code in the fourth example from O72.204 to To provide a relevant example to demonstrate that
O73.104 and updated the rationale. retained products of conception without excessive
bleeding or hemorrhage is classified to O73.1–
From: “Bleeding due to retained products of conception not
Retained portions of placenta and membranes,
during the third stage of labor is classified to delayed and
without haemorrhage.
secondary hemorrhage, regardless of the time frame.”
To: “Retained products of conception without excessive
bleeding or physician documentation of hemorrhage is
classified to O73.1– Retained portions of placenta and
membranes, without haemorrhage.”
Added a new example “The patient delivers a healthy baby To explain the correct application of the directive.
by vaginal . . .”
Interventions Associated With Delivery — Chapter XV — Pregnancy, childbirth and the puerperium
Added the directive statement “When cervical ripening is To mandate the collection of cervical ripening
performed by balloon catheter or insertion of Laminaria, performed via balloon catheter (5.AC.24.CK-BD)
assign, mandatory, . . .” and/or insertion of Laminaria (5.AC.24.CK-W6).
Added the exception note “When an intravenous (IV) To clarify that when an IV oxytocic agent is used to
oxytocic agent is used to induce labor, . . .” induce labor, any subsequent administration of an IV
oxytocic agent is a continuation of the induction and
not augmentation, even when the IV oxytocic agent is
stopped and restarted.
669
Revised the note: To identify that the pre-admit flag is applied to

capture codes for induction of labor and specific
From: “Use the Intervention Pre-Admit Flag to capture that
codes for cervical ripening when they are performed
induction of labor was performed prior to admission. See
prior to admission.
Group 11, Field 20 in the DAD Abstracting Manual for
specific instructions for applying the flag for interventions
initiated prior to admission.”
To: “Apply the Intervention Pre-Admit Flag to capture that
induction of labor (5.AC.30.^^) or cervical ripening by
balloon catheter (5.AC.24.CK-BD) and/or cervical ripening
by insertion of Laminaria (5.AC.24.CK-W6) was performed
prior to admission. See Group 11, Field 20 in the DAD
Abstracting Manual for specific instructions for applying the
flag for interventions initiated prior to admission.”
Added the example “The patient presents at 37 + To demonstrate that IV oxytocin administered to
3 weeks gestation for a planned induction of labor induce labor is classified to induction even when the
for essential hypertension. IV oxytocin is started at a IV oxytocin is stopped and restarted.
high dose, per protocol. . . .”
Introductory paragraph — Chapter XVI — Certain conditions originating in the perinatal period
Added an introduction to the beginning of Chapter XVI — To provide instruction for classifying conditions
Certain conditions originating in the perinatal period. that occur or are documented as occurring in the
perinatal period.
Low Birth Weight and/or Preterm Infant — Chapter XVI — Certain conditions originating in the
perinatal period
Modified the wording in the second bullet in the To align with information in the Discharge
second note. Abstract Database (DAD) Abstracting Manual and
to provide reference to where additional information
From: “According to the Discharge Abstract Database
can be found.
(DAD) Abstracting Manual, the gestational age recorded in
the data element for a newborn or neonate refers to the
physical assessment done to determine the newborn’s
gestational age at the time of birth, per the Algorithm for
the Estimation of Gestational Age, Canadian Perinatal
Surveillance System, 2010.”
To: “According to the Discharge Abstract Database (DAD)
Abstracting Manual, the gestational age of the newborn or
neonate is based on the physical assessment at the time of
birth, per the Algorithm for the Estimation of Gestational
Age, Canadian Perinatal Surveillance System, 2010. See
Group 18, Field 06 in the Discharge Abstract Database
(DAD) Abstracting Manual.”
670
Confirmed Sepsis and Risk of Sepsis in the Neonate — Chapter XVI — Certain conditions originating in the
perinatal period
Modified the format of the coding standard to divide To format the coding standard in such a way that the
into two subsections: direction is readily understood.
Confirmed sepsis
Ruled-out sepsis
Modified the introductory paragraph. To clarify that neonatal sepsis is divided into two
groups: early-onset (newborn) sepsis and late-onset
neonatal sepsis.
Modified the first directive statement, “When sepsis has To clarify that a code from category P36.– Bacterial
been confirmed in a neonate, assign. . .” sepsis of newborn is assigned only when sepsis
arises within the first 72 hours following birth, and to
provide direction for code assignment when sepsis
arises in a neonate more than 72 hours after birth.
Added rationale to the example “The mom has prolonged To explain the code assignment.
rupture of membranes with chorioamnionitis . . .”
Added a new example “A 20-day-old neonate is admitted To demonstrate application of the

to hospital with sepsis and acute pyelonephritis due to directive statements.
E. coli . . .”
Modified the rationale in the example “The infant is To provide clear rationale for assigning a code for
delivered vaginally at 37 weeks. The mom had premature neonatal sepsis when the physician/primary care
rupture of membranes for greater than 24 hours prior to provider has documented probable sepsis based
the delivery. . .” on clinical findings.
From: “A ‘Q’ is not placed in front of the code in this case,

as a diagnosis of “probable” in neonatal sepsis is an
indication that the diagnosis is made on the basis of clinical
findings only. Lab results may not provide confirmation in
all cases of neonatal sepsis.”
To: “A prefix ‘Q’ is not applied to the sepsis code in this
case, as the diagnosis of “probable” in neonatal sepsis is
an indication that the diagnosis was made by the
physician/primary care provider on the basis of clinical
findings only. A diagnosis of probable sepsis is classified
as confirmed sepsis. Lab results are not used to either
confirm or rule-out neonatal sepsis.”
Removed the directive statement “Ensure that a code from Removed this statement as it is self explanatory.
category P36 Bacterial sepsis of newborn is not assigned Ruled out means that the patient does not have
when sepsis is ‘ruled out.’” the condition.
671
Removed the directive statement “Do not assign Z03.8 on Removed this statement as this is redundant
the basis of risk factors alone. When any of the above information that does not apply specifically to this
codes apply on the birth admission, assign Z38.– Liveborn coding standard.
infants according to place of birth as diagnosis type (0).”
Moved the directive statement “When any of the following To provide information that clarifies the first directive
descriptors for sepsis are used on the record of a neonate . statement.
. .” to the note following the first directive statement.
Moved the directive statement “When neonatal sepsis is To align with the direction under the subheading
suspected but ruled out, classify the case as follows . . .” Ruled-out sepsis.
to below the subheading Ruled-out sepsis.
Removed the directive statement “Base code decisions on To remove redundant information as there is already
physician documentation and not on blood culture results. a similar directive in the coding standards and
Sepsis cannot be assumed or ruled out on the basis of rationale is provided in one of the examples.
blood culture results alone.”
Moved the note “The requirement to return the record to To provide direction that this is an exception to the
the physician . . .” from the second note box to the first Unconfirmed Diagnosis standard.
note box.
Modified the following note: To make the note applicable to the neonatal sepsis
standard.
From: “Z03.8 Observation for other suspected diseases
and conditions is for use in limited circumstances on
records of otherwise healthy newborns who are at risk for
an abnormal condition, that requires study, but for whom it
is determined, after examination and observation, that
there is no need for further treatment or medical care.”
To: “Z03.8 Observation for other suspected diseases and
conditions is for use in limited circumstances on records of
otherwise healthy newborns who are at risk for an
abnormal condition, such as sepsis but for whom it is
determined, after examination and observation, that there is
no need for further treatment or medical care.”
Perinatal Stroke — Chapter XVI — Certain conditions originating in the perinatal period
Added new coding standard. To provide direction for the classification of a

perinatal stroke (i.e., that originates in the perinatal
period), either hemorrhagic or ischemic.
672
Adverse Reactions in Therapeutic Use Versus Poisonings — Chapter XIX — Injury, poisonings and certain
Added the example “The patient is brought to hospital via To demonstrate that an overdose is classified as
ambulance after snorting fentanyl . . .” a poisoning; that the code is taken from the first
column of the Table of Drugs and Chemicals;
and that the external cause code is taken from
one of the poisoning columns of the Table of Drugs
and Chemicals.
Added the example “The patient is admitted to hospital for To demonstrate that an adverse effect in therapeutic
confusion due to oxycodone . . .” use is classified to the code for the manifestation
followed by an external cause code taken from the
Adverse effect in therapeutic use column of the Table
of Drugs and Chemicals.
Code Assignment for Multiple Superficial Injuries or Multiple Open Wounds — Chapter XIX — Injury,
poisonings and certain other consequences of external causes
Added the phrase “or Multiple Open Wounds” to the title of To clarify that the coding standard applies to
the standard. both multiple superficial injuries and multiple
open wounds.
Added the phrase “or multiple body regions” to the To clarify that the directive applies to multiple and/or
directive statement. bilateral superficial injuries or open wounds of both
the same body region and multiple body regions.
Added a “see also” statement and a hyperlink to the To provide ready access to another standard that
coding standard Open Wounds. includes additional information on open wounds.
Rejection/Failure of Transplanted Organs, Grafts and Flaps — Chapter XIX — Injury, poisonings and
certain other consequences of external causes
Modified the following directive statement: To clarify that it is optional to assign a code from Z94
Transplanted organ and tissue status and that, if it is
From: “When a condition is documented as affecting the
assigned, it is assigned as a diagnosis type
transplanted organ or tissue, but it cannot be classified as
(3)/other problem.
either failure or rejection, assign a code from category Z94
Transplanted organ and tissue status.”
To: “When a condition is documented as affecting the
transplanted organ or tissue, but it cannot be classified as
either failure or rejection, assign a code for the condition
and assign an additional code from category Z94
Transplanted organ and tissue status, optional, as a
diagnosis type (3)/other problem.”
673
Added the word “optional” to the Z94 codes in the To clarify that it is optional to assign a code from Z94
following examples: Transplanted organ and tissue status.
“The patient had a liver transplant due to damage from

chronic hepatitis C virus infection. . .”
“The patient develops renal cell carcinoma in a
transplanted kidney five years post-transplant.”
Admission for Observation — Chapter XXI — Factors influencing health status and contact with
health services
Added a purpose statement at the beginning of the To clarify that the direction provided in this coding
coding standard. standard is for when a patient presents for
investigation of a sign, symptom and/or abnormal
finding for which there is documentation to support
that the patient is being investigated to rule out a
specific suspected condition.
Revised the wording of the introductory paragraph: To clarify that a code from category Z03 Medical
observation and evaluation for suspected diseases
From: “Codes from Z03 are assigned as the MRDx/main
and conditions is assigned as the MRDx/main
problem when a patient is investigated for a suspected
problem only when the suspected condition is ruled
condition and is considered to have no disease/problem.
out and there is no documentation that supports
These patients will have a sign or symptom; however, after
further investigation is required.
investigation, it will have been determined that the
condition for which they are being examined has been To clarify that the reason for investigation can
ruled out and no further treatment or investigation is include an abnormal finding, such as a positive
required. When the plan is to further investigate the cause screening test.
of the sign or symptom, a code for the sign or symptom is
assigned (see also the coding standards Underlying
Symptoms or Conditions and Query Diagnosis
(Q)/Etiology). The fact that the patient may be scheduled
to return for a repeat screening test (such as a prostate-
specific antigen [PSA] test in six months or a mammogram
in one year) following observation does not limit the use of
codes from category Z03.”
To: “Codes from category Z03 Medical observation and
evaluation for suspected diseases and conditions are
assigned as the MRDx/main problem when a patient is
investigated for a suspected condition and is considered to
have no disease/problem. These patients will have a sign,
symptom and/or abnormal finding (e.g., positive screening
test); however, after investigation, it will have been
determined that the condition for which they are being
examined has been ruled out and there is no
documentation to support that further investigation is
required. See also the coding standards Screening for
Specific Diseases and Unconfirmed Diagnosis.”
674
Moved and modified the following statement in the To clarify that repeat screening does not mean the
introductory paragraph: patient is returning for further investigations. In this
case Z03 is assigned when all criteria are met.
“The fact that the patient may be scheduled to return for a
repeat screening test . . .”
to create the following new Note:
“Repeat screening is not synonymous with further
investigations required. Therefore, the fact that the patient
is scheduled to return for a repeat screening test . . .”
Revised the wording and added three criteria to the first To clarify that a code from category Z03 Medical
directive statement “Assign a code from category Z03 observation and evaluation for suspected diseases
Medical observation and evaluation for suspected diseases and conditions is assigned only when
and conditions . . .”, and added the statement “Assign an • The suspected condition is ruled out/not
additional code for the sign, symptom or abnormal finding, found; and
optional, as a diagnosis type (3)/other problem based on • There is no documentation to support that further
the facility’s data needs.” investigation is required; and
• Another underlying condition is not identified
and to provide direction for the assignment of

an additional code for the sign, symptom or
abnormal finding.
Added three directive statements: To provide direction that when the suspected
condition is found, a code for the identified underlying
“When a patient is investigated for a suspected
condition is assigned as the MRDx/main problem,
condition and the suspected condition is found, assign
and that an additional code for the sign, symptom
a code for the identified underlying condition as the
and/or abnormal finding that led to the admission
MRDx/main problem. . .”
for observation is assigned, optionally, per the
“When a patient is investigated for a suspected condition facility’s needs.
and the suspected condition is not found and there is
To provide direction that when the plan is to further
documentation to support that further investigation is
investigate the underlying cause, a code for the sign,
required, assign a code for the sign, symptom or abnormal
symptom or abnormal finding that led to admission
finding as the MRDx/main problem.”
for observation is assigned.
“When a patient is investigated for a suspected condition
To provide direction that when an underlying
and an underlying condition that is not the suspected
condition other than the suspected condition is
condition is identified, assign a code for the underlying
identified, a code for the identified underlying
condition as the MRDx/main problem.”
condition is assigned.
675
Revised the following note: To clarify that codes from category Z03 are not
assigned as a diagnosis type (3).
From: “Do not assign codes from category Z03 Medical
observation and evaluation for suspected diseases and
conditions as a diagnosis type (3)/other problem when a
diagnosis is established or when further follow-up to
investigate the cause of the sign or symptom is
recommended or planned.”
To: “Do not assign codes from category Z03 Medical
observation and evaluation for suspected diseases and
conditions as a diagnosis type (3)/other problem.”
Added the note “A fecal immunochemical test (FIT) and To clarify that fecal immunochemical tests (FITs) and
fecal occult blood test (FOBT) are screening tests for fecal occult blood tests (FOBTs) are screening tests
colorectal cancer. Therefore, a patient with a positive result for colorectal cancer. When patients are admitted for
who is admitted for an endoscopy is considered to be endoscopy to further investigate a positive FIT or
under observation for suspected colorectal cancer. There is FOBT, they are considered to be under observation
no requirement for colorectal cancer to be documented as for suspect colorectal cancer.
a suspected condition that is being ruled out.”
Amended the rationale in all the examples. To clarify that a code from Z03 is assigned when
the three criteria are met. When the three criteria
are not met, another code — depending on whether
or not another condition is found — is assigned as
the MRDx.
Added nine examples:

“The patient presents for colonoscopic examination due to a To demonstrate that the three criteria are met;
positive FIT . . .” therefore, Z03 is assigned as the MRDx.
“The patient presents for observation of obstructive sleep To demonstrate that the three criteria are met;
apnea due to increased snoring. Sleep apnea is ruled out . . .” therefore, Z03 is assigned as the MRDx.
“The patient presents for a colonoscopy due to rectal To demonstrate that the three criteria are met;
bleeding. The physician documents ‘rule out malignancy’ . . .” therefore, Z03 is assigned as the MRDx.
“The patient presents for colonoscopy due to rectal bleeding. To demonstrate that the direction in the coding
The physician notes diverticulosis in the colon during standard Admission for Observation does not apply.
examination . . .”
“The patient has been having gross hematuria. To denote the code assignment when the suspected
He presents for a biopsy of the bladder for suspected condition is found.
bladder malignancy . . .”
“The patient presents for colonoscopy to rule out malignancy To denote the code assignment when the
due to ongoing rectal bleeding, melena and weight loss . . .” documentation supports that further investigations
are required to determine the cause of the symptom.
“The patient presents for colonoscopic examination due to a To denote the code assignment when an underlying
positive FIT. During colonoscopy, a polyp is found in the condition that is not the suspected condition is identified
sigmoid colon . . .” and that the reason for the visit was a positive FIT.
676
“The patient presents for colonoscopic examination due to a To denote the code assignment when an underlying
positive FIT. The final diagnosis is recorded as ‘first-degree condition that is not the suspected condition is
bleeding internal hemorrhoids’ . . .” identified and the reason for the visit was a
positive FIT.
“The patient presents for endoscopic examination due To denote the code assignment when an
to “RUQ pain, rectal bleeding and a family history of underlying condition that is not the suspected
colorectal cancer” . . .” condition is identified.
Added the subheading Admission for observation following To provide a means to distinctly separate the
accident or alleged assault or abuse. directive statements and examples that apply to Z03
from the directive statements and examples that
apply to Z04.
Admission for Convalescence — Chapter XXI — Factors influencing health status and contact with
health services
Added “See Section 3: Additional Abstracting Information: To provide reference to the correct section of
Day Surgery Abstracting: Day Surgery Abstracting, the Discharge Abstract Database (DAD)
Patients Admitted Directly From Day Surgery to Acute Abstracting Manual.
Care . . .” to the exception note.
Screening for Specific Diseases — Chapter XXI — Factors influencing health status and contact with
health services
Added “Prostate-specific antigen (PSA) tests to detect To provide another relevant example of a
prostate cancer because of age and/or family history” to screening program.
the list of examples of screening programs.
Added the note “For direction on code assignment when To clarify that the direction on code assignment when
the episode of care is to further investigate a positive the episode of care is to further investigate a positive
screening test, see the coding standard Admission screening test can be found in the coding standard
for Observation.” Admission for Observation.
Admission for Administration of Chemotherapy, Pharmacotherapy and Radiation Therapy —

Added the bullet “Z51.0 Radiotherapy session as a To clarify the circumstances in which Z51.0
diagnosis type (1)/other problem when . . .” to the first Radiotherapy session is assigned as a diagnosis
directive statement. type (1).
Added the bullet “Z51.1 Chemotherapy session for To clarify the circumstances in which Z51.1
neoplasm as a diagnosis type (1)/other problem when . . .” Chemotherapy session for neoplasm is assigned as
to the second directive statement. a diagnosis type (1).
Added the directive statement “Assign a CCI code, To clarify that it is mandatory to assign an
mandatory, for any radiation therapy or intervention code for chemotherapy and radiation
chemotherapy interventions to treat the therapy when performed.
malignancy or neoplasm-related conditions.”
677
Added the note “Z51.0 Radiotherapy session and Z51.1 To explain that it is not correct to apply diagnosis
Chemotherapy session for neoplasm must not be assigned type (2) or diagnosis type (3) to either Z51.0 or Z51.1.
as a diagnosis type (2) or diagnosis type (3).”
Added the note “Chemotherapy and radiation therapy are To clarify that chemotherapy and radiation therapy
interventions; therefore, a CCI code is assigned . . .” are interventions, classified to a CCI code.
Added a rationale to the example “Encounter for IV To explain that Z51.1 is assigned as the most
vincristine chemotherapy session for active left main responsible diagnosis (MRDx)/main problem when
bronchus malignancy.” a patient is admitted solely for administration of
chemotherapy; that it is mandatory to assign
an additional code to identify the malignancy
as a diagnosis type (3)/other problem; and,
that it is mandatory to assign a CCI code for
the chemotherapy.
Revised the rationale for the example “A patient with To explain that Z51.1 is assigned as the most
malignant neoplasm of the breast. . .” responsible diagnosis (MRDx)/main problem when a
patient is admitted solely for administration of
chemotherapy; that it is mandatory to assign an
additional code to identify the malignancy as
a diagnosis type (3)/other problem; and, that
it is mandatory to assign a CCI code for
the chemotherapy.
Added a rationale to the example “Encounter for radiation To explain that Z51.0 is assigned as the most
therapy session. . .” responsible diagnosis (MRDx)/main problem when a
radiation therapy; that it is mandatory to assign an
additional code to identify the malignancy as a
diagnosis type (3)/other problem; and, that it
is mandatory to assign a CCI code for the
radiation therapy.
Added the example “A patient with recurrent Hodgkin’s To demonstrate that Z51.1 is not assigned because
lymphoma who previously underwent dexamethasone, the patient was not admitted solely for administration
high-dose cytarabine and cisplatin (DHAP) chemotherapy of chemotherapy, and to demonstrate that it is
for stem cell mobilization . . .” mandatory to assign a CCI code for stem cell
transfusion and a CCI code for chemotherapy
administered to treat a malignancy or neoplasm-
related condition whenever these interventions are
performed during an episode of care.
678
Added the example “A patient with acute myeloblastic To demonstrate that Z51.1 is assigned as a diagnosis
leukemia (AML) is admitted for post-remission type (1) because the patient was admitted solely for
mitoxantrone, etoposide and cytarabine (MEC) administration of chemotherapy; however, another
consolidation therapy . . .” condition arose post-admission that subsequently
met the criteria for the most responsible diagnosis
(MRDx); and to demonstrate that it is mandatory to
assign a CCI code for chemotherapy administered
to treat a malignancy or neoplasm-related condition
and for total parenteral nutrition (TPN) whenever
these interventions are performed during an episode
of care.
Modified the following directive statement: To clarify that Z51.2 is assigned when the patient is
admitted solely for administration of chemotherapy to
From: “When the patient has an encounter solely for
treat a previously diagnosed non-malignant condition.
administration of chemotherapy (pharmacotherapy) to treat
conditions other than malignant neoplasms or neoplasm
related conditions . . .”
To: “When a patient previously diagnosed with a non-
malignant condition has an encounter solely for the
administration of chemotherapy, assign . . .”
Added the bullet “Z51.2 Other chemotherapy as a To clarify the circumstances in which Z51.2 Other
diagnosis type (1)/other problem when . . .” to the directive chemotherapy is assigned as a diagnosis type (1).
statement “When a patient previously diagnosed with a
non-malignant condition . . .”
Changed the bullet “Assign an additional code to To align with the directive statements for Z51.0
identify the disease/condition, mandatory . . .” to a and Z51.1.
directive statement.
Added the directive statement “Assign a CCI code, To clarify that it is mandatory to assign a CCI code
mandatory, for any chemotherapy interventions classified for chemotherapy when the agent qualifier is “M^”.
to 1.^^.35.^^-M^ Pharmacotherapy using antineoplastic and
immunomodulating agents.”
Added the directive statement “Assign a CCI code, To clarify that it is mandatory to assign a CCI code
mandatory, for any chemotherapy interventions performed for chemotherapy performed in a clinic to be
during a clinic visit.” consistent with the direction “Assign a code from
any section in CCI for each intervention performed
during a clinic visit” provided in the coding
standard Selection of Interventions to Code for
Ambulatory Care.
Added the note “Z51.2 Other chemotherapy must not be To explain that it is not correct to apply diagnosis
assigned as a diagnosis type (2) or diagnosis type (3) . . .” type (2) or diagnosis type (3) to Z51.2.
679
Added a rationale to the sixth and seventh examples. To explain that Z51.2 is assigned as the most
responsible diagnosis (MRDx)/main problem when a
chemotherapy to treat a condition other than a
malignant neoplasm or neoplasm-related condition,
and that it is mandatory to assign an additional code
to identify the disease/condition as a diagnosis type
(3)/other problem.
Removed the statement, “Assignment of a code from To explain when Z51 Other medical care is assigned,
category Z51 Other medical care in these circumstances and to clarify that chemotherapy and radiation
is redundant. . .” and incorporated into the new note therapy are interventions, classified to a CCI code.
“When chemotherapy or radiation therapy is administered
during the episode of care in which the malignancy is
diagnosed or . . .”
Added a rationale to the eighth example. To explain that the code for the malignancy is the
most responsible diagnosis when the patient is
admitted for definitive surgery. When the patient also
receives chemotherapy during this episode of care, a
CCI code is assigned for the chemotherapy. Z51.1 is
not assigned because the patient was not admitted
solely for administration of chemotherapy.
Palliative Care — Chapter XXI — Factors influencing health status and contact with health services
Added the note “Medical assistance in dying is not the To distinguish between medical assistance in
same as palliative care. See also the coding standard dying and palliative care, and to provide a link to
Medical Assistance in Dying. the coding standard providing direction on Medical
Assistance in Dying.
Added the NACRS icon and moved the first two directive To explain that it is mandatory to assign the code
statements “Assign Z51.5 Palliative care as a significant Z51.5 Palliative care and prefix 8 when palliative care
diagnosis type . . .” and “When palliative care is is documented as a known component of the
documented as a known component . . .” to a new patient’s care prior to arrival to the hospital for both
directive box. acute inpatient care and ambulatory care visits.
Added “main or other problem” to the first directive To explain that it is mandatory to assign the code
statement “Assign Z51.5 Palliative care as a significant Z51.5 Palliative care when palliative care is
diagnosis type/main or other problem whenever there is documented as a known component of the patient’s
physician documentation of palliative care.” care prior to arrival to the hospital for both acute
inpatient care and ambulatory care visits.
Moved the note “Prefix 8 is restricted for use with Z51.5 To align with the information in the first
Palliative Care . . .” to below the first directive statement. directive statement.
680
Added the note “For more information about prefix 8, see . . .” To provide reference to the correct section of the
Discharge Abstract Database (DAD) Abstracting
Manual and the National Ambulatory Care Reporting
System (NACRS) Abstracting Manual.
Added three examples: To demonstrate that it is mandatory to assign the

code Z51.5 Palliative care and prefix 8 when
• “A patient known to be on a palliative care plan . . .”
palliative care is documented as a known component
• “A patient with advanced adenocarcinoma . . .” of the patient’s care prior to arrival to the hospital for
• “A patient with multiple myeloma . . .” ambulatory care visits.
Medical Assistance in Dying — Chapter XXI — Factors influencing health status and contact with
health services
Added new coding standard. To mandate and to provide direction on the

classification of medical assistance in dying (MAID)
to support national information needs.
Homelessness — Chapter XXI — Factors influencing health status and contact with health services
Added new coding standard. To mandate the collection of Z59.0 Homelessness

in cases where there is documentation of such
on admission. The collection of this data makes
it possible to analyze and report on this
patient population.
681
Appendix D — Mandatory attributes

in CCI
Attributes are designated as mandatory for one or more of the following reasons:
• They affect grouping.
• They provide necessary detail not present within the generic structure of the CCI code.
• They provide nationally relevant detail for CIHI data holdings and registries.
• They provide data important for health system use.
This list contains the CCI rubrics for which the status, location or extent attribute has been
activated as mandatory in Folio.
When an intervention meets the criteria for “abandoned,” “converted” or “revision,” per the
coding standards, those status attribute values, when available, are mandatory to assign, even
when the status attribute is not activated as mandatory — that is, even when the status attribute
box is not pink in Folio.
See also the coding standards Abandoned Interventions, Converted Interventions and
Revised Interventions.
For more information on attributes, see Group 11, fields 03, 04 and 05 in the Discharge Abstract
Database (DAD) Abstracting Manual and data elements 48, 49 and 50 in the National Ambulatory
Care Reporting System (NACRS) Abstracting Manual.
CCI rubric CCI rubric title Status Location Extent
1.AX.13.^^ Control of bleeding, spinal canal and meninges — — Mandatory
1.BF.59.^^ Destruction, sympathetic nerves — Mandatory —
1.CN.13.^^ Control of bleeding, retina — — Mandatory
1.ET.13.^^ Control of bleeding, nose — — Mandatory
1.FL.87.^^ Excision partial, sublingual gland — Mandatory —
1.FM.87.^^ Excision partial, parotid gland — Mandatory —
1.FN.87.^^ Excision partial, submandibular gland — Mandatory —
1.FR.13.^^ Control of bleeding, tonsils and adenoids — — Mandatory
1.FU.13.^^ Control of bleeding, thyroid gland — — Mandatory
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Appendix D — Mandatory attributes in CCI
1.FU.87.^^ Excision partial, thyroid gland — Mandatory —
1.FU.89.^ Excision total, thyroid gland — Mandatory —
1.FV.87.^^ Excision partial, parathyroid gland — Mandatory —
1.GJ.77.^^ Bypass with exteriorization, trachea Mandatory — —
1.GM.13.^^ Control of bleeding, bronchus NEC — — Mandatory
1.GR.87.^^ Excision partial, lobe of lung — Mandatory —
1.GR.89.^^ Excision total, lobe of lung — Mandatory —
1.GR.91.^^ Excision radical, lobe of lung — Mandatory —
1.GT.13.^^ Control of bleeding, lung NEC — — Mandatory
1.GT.59.^^ Destruction, lung NEC — Mandatory —
1.GT.87.^^ Excision partial, lung NEC — Mandatory —
1.GT.85.^^ Transplant, lung NEC — Mandatory —
1.GT.89.^^ Excision total, lung NEC — Mandatory —
1.GT.91.^^ Excision radical, lung NEC — Mandatory —
1.GZ.31.^^ Ventilation, respiratory system NEC — — Mandatory
1.HD.53.^^ Implantation of internal device, endocardium — — Mandatory
1.HZ.53.^^ Implantation of internal device, heart NEC — — Mandatory
1.ID.50.^^ Dilation, aorta NEC — Mandatory —
1.ID.53.^^ Implantation of internal device, aorta NEC — Mandatory —
1.ID.55.^^ Removal of device, aorta NEC — Mandatory —
1.ID.57.^^ Extraction, aorta NEC — Mandatory —
1.ID.74.^^ Fixation, aorta NEC — Mandatory —
1.ID.76.^^ Bypass, aorta NEC — Mandatory —
1.ID.79.^^ Repair by increasing size, aorta NEC — Mandatory —
1.ID.80.^^ Repair, aorta NEC — Mandatory —
1.IJ.50.^^ Dilation, coronary arteries Mandatory — Mandatory
1.IJ.55.^^ Removal of device, coronary arteries — — Mandatory
1.IJ.57.^^ Extraction, coronary arteries — — Mandatory
683
1.IJ.76.^^ Bypass, coronary arteries — — Mandatory
1.IJ.86.^^ Closure of fistula, coronary arteries — — Mandatory
1.IM.51.^^ Occlusion, pulmonary artery — — Mandatory
1.IN.51.^^ Occlusion, pulmonary vein — — Mandatory
1.IS.53.^^ Implantation of internal device, vena cava (superior — Mandatory —

and inferior)
1.JE.51.^^ Occlusion, carotid artery — — Mandatory
1.JJ.51.^^ Occlusion, brachiocephalic arteries — — Mandatory
1.JK.51.^^ Occlusion, subclavian artery — — Mandatory
1.JL.51.^^ Occlusion, internal mammary artery — — Mandatory
1.JM.51.^^ Occlusion, arteries of arm NEC — — Mandatory
1.JW.51.^^ Occlusion, intracranial vessels — — Mandatory
1.JX.51.^^ Occlusion, other vessels of head, neck and spine NEC — — Mandatory
1.JY.51.^^ Occlusion, thoracic vessels NEC — — Mandatory
1.KE.51.^^ Occlusion, abdominal arteries NEC — — Mandatory
1.KG.51.^^ Occlusion, arteries of leg NEC — — Mandatory
1.KG.82.^^ Reattachment, arteries of leg NEC — — Mandatory
1.KQ.51.^^ Occlusion, abdominal veins NEC — — Mandatory
1.KT.51.^^ Occlusion, vessels of the pelvis, perineum and — — Mandatory

gluteal region
1.MC.87.^^ Excision partial, lymph node(s), cervical — Mandatory —
1.MC.89.^^ Excision total, lymph node(s), cervical — Mandatory —
1.MC.91.^^ Excision radical, lymph node(s), cervical — Mandatory —
1.NF.13.^^ Control of bleeding, stomach — — Mandatory
1.NF.78.^^ Repair by decreasing size, stomach Mandatory — —
1.NK.87.^^ Excision partial, small intestine — Mandatory —
1.NM.87.^^ Excision partial, large intestine — Mandatory —
1.NP.13.^^ Control of bleeding, small and large intestine — — Mandatory
1.NV.89.^^ Excision total, appendix Mandatory — —
684
1.OA.13.^^ Control of bleeding, liver — — Mandatory
1.OA.87.^^ Excision partial, liver — Mandatory —
1.OB.13.^^ Control of bleeding, spleen — — Mandatory
1.PB.87.^^ Excision partial, adrenal gland — Mandatory —
1.PB.89.^^ Excision total, adrenal gland — Mandatory —
1.PC.13.^^ Control of bleeding, kidney — — Mandatory
1.PL.74.^^ Fixation, bladder neck Mandatory — —
1.PM.13.^^ Control of bleeding, bladder — — Mandatory
1.QM.89.^^ Excision total, testis — Mandatory —
1.RB.89.^^ Excision total, ovary — Mandatory —
1.RD.89.^^ Excision total, ovary with fallopian tube — Mandatory —
1.RF.51.^^ Occlusion, fallopian tube — Mandatory —
1.RF.59.^^ Destruction, fallopian tube — Mandatory —
1.RF.89.^^ Excision total, fallopian tube — Mandatory —
1.RM.13.^^ Control of bleeding, uterus and surrounding structures — — Mandatory
1.RM.87.^^ Excision partial, uterus and surrounding structures — — Mandatory
1.RS.13.^^ Control of bleeding, vagina — — Mandatory
1.RS.80.^^ Repair, vagina Mandatory Mandatory —
1.SC.54.^^ Management of internal device, spinal vertebrae — Mandatory —
1.SC.55.^^ Removal of device or appliance, spinal vertebrae — Mandatory —
1.SC.59.^^ Destruction, spinal vertebrae — Mandatory —
1.SC.74.^^ Fixation, spinal vertebrae — Mandatory —
1.SC.75.^^ Fusion, spinal vertebrae — Mandatory —
1.SC.80.^^ Repair, spinal vertebrae — Mandatory —
1.SC.87.^^ Excision partial, spinal vertebrae — Mandatory —
1.SC.89.^^ Excision total, spinal vertebrae — Mandatory —
1.SE.53.^^ Implantation of internal device, intervertebral disc — Mandatory —
1.SE.55.^^ Removal of device, intervertebral disc — Mandatory —
685
1.SE.59.^^ Destruction, intervertebral disc — Mandatory —
1.SE.87.^^ Excision partial, intervertebral disc — Mandatory —
1.SQ.53.^^ Implantation of internal device, pelvis Mandatory Mandatory —
1.SY.80.^^ Repair, muscles of the chest and abdomen Mandatory Mandatory —
1.TA.53.^^ Implantation of internal device, shoulder joint Mandatory Mandatory —
1.TA.55.^^ Removal of device, shoulder joint — Mandatory —
1.VA.53.^^ Implantation of internal device, hip joint Mandatory Mandatory Mandatory
1.VA.55.^^ Removal of device, hip joint — Mandatory —
1.VG.53.^^ Implantation of internal device, knee joint Mandatory Mandatory Mandatory
1.VG.55.^^ Removal of device, knee joint — Mandatory —
1.VP.53.^^ Implantation of internal device, patella Mandatory Mandatory —
1.VP.55.^^ Removal of device, patella — Mandatory —
1.WI.87.^^ Excision partial, first metatarsal bone and first — Mandatory —

metatarsophalangeal joint
1.WJ.87.^^ Excision partial, tarsometatarsal joints, other metatarsal — Mandatory —

bones and other metatarsophalangeal joints [forefoot]
1.WY.19.^^ Transfusion, bone marrow Mandatory — —
1.YM.59.^^ Destruction, breast — Mandatory —
1.YM.79.^^ Repair by increasing size, breast Mandatory — —
1.YM.87.^^ Excision partial, breast — Mandatory Mandatory
1.YM.88.^^ Excision partial with reconstruction, breast — Mandatory Mandatory
1.YM.89.^^ Excision total, breast — Mandatory —
1.YM.90.^^ Excision total with reconstruction, breast — Mandatory —
1.YM.91.^^ Excision radical, breast — Mandatory —
1.YM.92.^^ Excision radical with reconstruction, breast — Mandatory —
2.GT.71.^^ Biopsy, lung NEC — Mandatory —
2.MA.71.^^ Biopsy, lymph node(s), head region — — Mandatory
2.MC.71.^^ Biopsy, lymph node(s), cervical — — Mandatory
2.MD.71.^^ Biopsy, lymph node(s), axillary — — Mandatory
686
2.ME.71.^^ Biopsy, lymph node(s), mediastinal — — Mandatory
2.MF.71.^^ Biopsy, lymph node(s), intrathoracic NECC — — Mandatory
2.MG.71.^^ Biopsy, lymph node(s), intra abdominal — — Mandatory
2.MH.71.^^ Biopsy, lymph node(s), pelvic — — Mandatory
2.MJ.71.^^ Biopsy, lymph node(s), inguinal — — Mandatory
2.MK.71.^^ Biopsy, lymph node(s), extremity NEC — — Mandatory
2.YM.71.^^ Biopsy, breast — Mandatory —
2.ZZ.02.^^ Assessment (examination), total body Mandatory — —
3.IP.10.^^ Xray, heart with coronary arteries Mandatory Mandatory —
5.CA.90.^^ Selective fetal reduction — — Mandatory
5.MD.60.^^ Cesarean section delivery Mandatory — —
6.AA.02.^^ Assessment, mental health and addictions Mandatory — —
6.AA.10.^^ Counseling, mental health and addictions — — Mandatory
6.AA.30.^^ Therapy, mental health and addictions — — Mandatory
6.DA.07.^^ Facilitation, interpersonal relationships Mandatory Mandatory —
6.DA.08.^^ Test, interpersonal relationships Mandatory — Mandatory
6.DA.10.^^ Counseling, interpersonal relationships Mandatory Mandatory —
6.DA.30.^^ Therapy, interpersonal relationships Mandatory Mandatory Mandatory
6.LA.02.^^ Assessment, communication Mandatory — Mandatory
6.LA.50.^^ Training, communication Mandatory Mandatory Mandatory
6.PA.50.^^ Training, hearing — — Mandatory
6.RA.02.^^ Assessment, voice Mandatory — Mandatory
6.RA.50.^^ Training, voice — — Mandatory
6.VA.02.^^ Assessment, motor and living skills Mandatory Mandatory Mandatory
6.VA.07.^^ Facilitation, motor and living skills Mandatory Mandatory —
6.VA.08.^^ Test, motor and living skills Mandatory — Mandatory
6.VA.50.^^ Training, motor and living skills — — Mandatory
7.SC.08.^^ Other ministration, personal care — Mandatory —
687
7.SP.10.^^ Counseling, promoting health and preventing disease — — Mandatory
7.SP.59.^^ Instruction, promoting health and preventing disease — Mandatory Mandatory
7.SP.60.^^ Education, promoting health and preventing disease — Mandatory Mandatory
Note
— Optional or not activated.
688
Appendix E — Tips for Coders

This appendix consolidates all of the Tips for Coders that were released on CIHI’s Coder’s
Resource Page between 2009 and spring 2017 and that are currently relevant. The Tips for
Coders provide education and clarification on a specific topic. They have been reviewed and
updated to ensure they are compliant with version 2018 of ICD-10-CA/CCI, the Canadian
Coding Standards for Version 2018 ICD-10-CA and CCI, the Discharge Abstract Database
(DAD) Abstracting Manual and the National Ambulatory Care Reporting System (NACRS)
Abstracting Manual.

Endoscopic Retrograde Cholangiography With Sphincterotomy
Alone or Concomitant With Extraction
Endoscopic retrograde cholangiography (ERC) or endoscopic retrograde cholangiopancreatography
(ERCP) is a procedure that combines upper gastrointestinal endoscopy and X-rays to view the
bile and pancreatic ducts. With the availability of non-invasive tests such as magnetic resonance
cholangiography to investigate signs and symptoms, ERC(P) is performed primarily for cases in
which it is expected that treatment will be delivered during the procedure rather than as a diagnostic
procedure alone.
The purpose of this tip is to explain when 1.OE.50.BT.^^ Dilation, bile ducts using incisional
technique only endoscopic [retrograde] per orifice approach with incision is assigned and when
it is included in another code.
Sphincterotomy alone: Assign 1.OE.50.BT.^^ Dilation, bile ducts using incisional technique
only endoscopic [retrograde] per orifice approach with incision only when a sphincterotomy or
papillotomy is the sole intervention performed during an ERCP. A diagnosis of papillary stenosis
is an example of when a papillotomy alone may be performed to treat the stenosis.
689
Sphincterotomy concomitant with extraction: A patient with a diagnosis of biliary stones

requiring extraction may require a sphincterotomy of the bile ducts, but in this instance since the
sphincterotomy is not the only intervention performed during the ERCP, 1.OE.50.BT.^^ Dilation,
bile ducts using incisional technique only endoscopic [retrograde] per orifice approach with
incision is not assigned. Rather, we can see that extraction with sphincterotomy is included
at 1.OE.57.^^ Extraction, bile ducts.
1.OE.57.^^ Extraction, bile ducts

Includes: Choledocholithotomy
Cholelithotomy
Extraction [with or without sphincterotomy], bile duct calculus
Sphincterotomy with extraction [calculus], bile duct
Sphincterotomy with extraction [calculus], hepatic duct
Sphincterotomy with extraction [calculus], pancreatic duct
Excludes: Cholecystectomy with extraction of bile duct calculi (see 1.OD.89.^^)
Code Also: Any concomitant destruction of bile duct calculi (see 1.OE.59.^^)
Any insertion of catheter or T-tube for continuous drainage (see 1.OE.52.^^)
Any insertion of stent for continuous dilation during healing (see 1.OE.50.^^)
Note: Choledochotomy or sphincterotomy incision may be performed to enlarge bile duct

lumen in order to aid in extraction of stone(s) and usually involves subsequent
simple suture repair. Irrigation is commonly performed following extraction to
clear bile duct of calculi debris.
690
Note
Diagnostic imaging interventions (Section 3) are mandatory to capture for ambulatory care. Therefore, a code
from either 3.OE.10.^^ Xray, bile ducts or 3.OG.10.^^ Xray, biliary ducts with pancreas is also assigned for
ambulatory care cases.
Interventions: Failed/Abandoned/Change of Plans

Let’s review the operative note below. The patient was scheduled for a cystoprostatectomy with
ileal conduit.
Operative note
We entered the retroperitoneal space. We immediately encountered a hard, fixed pelvic mass.
It was very difficult to develop the space of Retzius, which appeared to be obliterated by the
patient’s cancer. The space behind the pubic bone was not accessible and was basically a rock-
hard surface with no evident tissue planes. Likewise, we were not able to develop the lateral
aspect of the space of Retzius to expose the iliac vessels. We therefore made the decision to
enter the peritoneal cavity. The peritoneum above the bladder was elevated in hemostats and
entered sharply. We opened the peritoneum from the umbilicus down to the bladder. The
urachus was taken at the umbilicus and dissected down toward the dome of the bladder.
It became evident that the sigmoid colon was quite firmly attached to the left lateral aspect of the
bladder. We spent a long time dissecting this free and were eventually able to mobilize it somewhat.
We were starting to form the impression that this was likely not a resectable bladder and
prostate, but we elected to proceed cautiously in the hope that further dissection might change
the situation. We dissected laterally on both sides in an effort to expose the iliac vessels. It
became clear that there was likely nodal metastatic disease on both sides. We were never able
to access the iliac vessels, which appeared to be involved by tumor. We did take down the
spermatic cords bilaterally, using clips and ligatures of 0-Vicryl for hemostasis. Unfortunately,
this did not really lead us into a useful plane.
Reassessing the bladder and prostate, it became clear that this was a stage T4 tumor. It was
clearly fixed, and in multiple locations laterally, anteriorly, and posteriorly. It was a very
malignant feeling, frozen pelvis and it was clear that we were not going to be able to proceed
safely. We agreed that this unfortunate gentleman had unresectable and incurable disease,
and we reluctantly elected to abort the procedure at this point.
691
This is a (select the correct option below)

A. Change of plans during an intervention
B. Abandoned intervention
C. Failed intervention
If you selected A. Change of plans during an intervention, you are correct!
The Change of Plans During an Intervention coding standard states that when an intervention is
performed that is different from the one originally intended, code only the intervention that was
actually performed. The intended therapeutic intervention has no clinical significance and must
not be recorded on the abstract. Coding of therapeutic interventions should reflect what was
actually done.
So, while the intended intervention was a radical cystoprostatectomy with ileal conduit, the
intervention actually done was lysis of extensive adhesions.
Why is this not an abandoned intervention?
The surgeon documents “We agreed that this unfortunate gentleman had unresectable and
incurable disease, and we reluctantly elected to abort the procedure at this point.”
The patient was scheduled to have a cystoprostatectomy. Why wouldn’t we assign 1.PM.91.^^
Excision radical, bladder with the status attribute A — abandoned after onset?
The Abandoned Interventions coding standard defines an abandoned intervention as follows:

“. . . a situation in which a planned intervention classifiable to Section 1 or Section 5 is begun
but, due to usually unanticipated circumstances, cannot be completed beyond an incision,
inspection, biopsy or anesthetization.”
More than an incision, inspection, biopsy or anesthetization was completed; therefore, this is not
an abandoned intervention.
Why is this not a failed intervention?
The Failed Interventions coding standard defines a failed intervention as follows:

“. . . on termination of the procedure, the expected outcome is either poor or not achieved
entirely. Classify a failed intervention in the same manner as one that is successful.”
The cystoprostatectomy was not performed because the tumor was fixed in multiple locations
and proceeding with the surgery was not deemed to be safe. This describes a change of plans.
692
See also the coding standards Abandoned Interventions, Failed Interventions, Change of Plans
During an Intervention and Cancelled Interventions.
Apheresis
Apheresis is a procedure in which blood is withdrawn and passed through a machine that
separates out one particular component and returns the remaining components back to
the person.
The procedure
Apheresis is an extracorporeal therapy, meaning that blood is taken from the patient to have a
process applied to it before it is returned to the patient. During the procedure, whole blood is
removed from the body through an intravenous line and enters a cell separator machine
adjusted to separate out a selected blood component. The selected layer is removed and
retained and the remaining unused components are returned into the patient through a different
intravenous line. Additional fluids such as saline or plasma may be given to replace/correct the
intravascular volume. The procedure takes about two hours.
Apheresis is named for the component that is selectively separated and retained from the donor
as indicated in the following table:
Apheresis Selective removal of
Erythrocytapheresis Red blood cells
Leukapheresis Leukocytes (white blood cells)
Lymphocytapheresis Lymphocytes
Plasmapheresis Blood plasma
Plateletpheresis (also called thrombapheresis, Platelets

thrombocytapheresis)
Stem cell apheresis or harvesting Circulating bone marrow cells
There are two purposes for performing apheresis; classification depends upon the intent of
the procedure:
Donation apheresis
Apheresis is a method of procuring healthy blood components from a donor for later transfusion
into another person (homologous transfusion) or for storage and later transfusion back into the
donor (autologous transfusion).
693
In CCI, donation apheresis is classified to 1.LZ.58.^^ Procurement, circulatory system NEC.

The later transfusion into another person or into the donor is classified to 1.LZ.19.^^
Transfusion, circulatory system NEC.
Therapeutic apheresis
Therapeutic apheresis is performed on a sick person to remove the component of the blood
that is contributing to his or her diseased state. Therapeutic apheresis is classified to 1.LZ.20.^^
Apheresis, circulatory system NEC.
Note
Mandatory to capture for ambulatory care:
1.LZ.20.^^ Apheresis, circulatory system NEC
1.LZ.19.HH-U7-^ Transfusion, circulatory system NEC, of stem cells
1.LZ.19.HH-U8-^ Transfusion, circulatory system NEC, of cord blood stem cells
Mandatory to capture for acute inpatient care:
1.LZ.19.HH-U7-^ Transfusion, circulatory system NEC of stem cells
1.LZ.19.HH-U8-^ Transfusion, circulatory system NEC of cord blood stem cells
See also the lists Additional mandatory CCI codes for ambulatory care and Additional
mandatory CCI codes for acute inpatient care.
Spinal Decompression
Hierarchy of interventions
In alignment with the CCI principle of reducing the need for multiple code assignment to
describe complex health interventions, a hierarchy of surgical interventions performed on the
spinal vertebrae or intervertebral discs for decompression was established.
Lowest to highest:
1.SC.80.^^ Repair, spinal vertebrae — includes laminectomy, facetectomy and foraminotomy

when performed alone (without discectomy).
1.SE.87.^^ Excision, partial, intervertebral disc — includes discectomy with any single-level
fusion (two vertebrae being fused together), facetectomy, laminectomy or foraminotomy (without
fixation/instrumentation).
694
1.SC.74.^^ Fixation, spinal vertebrae — includes instrumentation with any discectomy,

facetectomy, laminectomy or foraminotomy (without grafting).
1.SC.75.^^ Fusion, spinal vertebrae — includes grafting with any instrumentation, discectomy,
facetectomy, laminectomy or foraminotomy (without vertebrectomy).
1.SC.89.^^ Excision total, spinal vertebrae — includes vertebrectomy with any grafting,
instrumentation, discectomy, facetectomy, laminectomy or foraminotomy.
Vertebrectomy takes precedence over discectomy.
Key point
Most often spinal decompression is achieved by surgical interventions performed on the spinal vertebrae
or intervertebral discs without ever touching the dura. When there is no mention of damage to the dura,
it means decompression was successful without further resorting to a spinal cord/nerve root release
(1.AW.72.^^). The ultimate goal is to not damage the dura. Surgeons may state that the spinal cord is
“completely free” or “bouncing free” or that the nerve root is “moving well” and “totally exposed.”
Code also 1.AW.72.^^ Release, spinal cord?

A spinal cord release (1.AW.72.^^) describes surgery that involves some sort of repaired
damage to the spinal cord/nerve root. It represents the most invasive form of decompression.
Clues to justify assigning 1.AW.72.^^ Release, spinal cord:

• Compression is so bad that the nerve root or cord is damaged or must be damaged by the
surgeon to effect the release.
• Bone fragment or spicule is lodged in the dura or nerve root and must be plucked out.
• Ligamentum flavum is so calcified/hypertrophied that it is adherent to the dura or nerve root
and can only be removed with damage to the neural structures.
• Posterior longitudinal ligament (PLL) is ossified so badly that it abuts the dura, attenuating it
to such thinness that dissecting the PLL away from it results in tearing the dura.
Caution
Physicians will use the term “decompression” to describe spinal cord decompression achieved by surgical
interventions performed on the spinal vertebrae or intervertebral discs.
Use the following alphabetical index search only when there is documentation of damage to the dura:
Decompression (see also Release, by site)

– spinal
– – cord (nerve root) with dural breach 1.AW.72.^^
695
Whenever the cord does actually require extra or intradural release, 1.AW.72.^^ is the principal
procedure followed by any concomitant intervention on the vertebrae or intervertebral discs.
Damaged dura
Is the dura damaged because of the compression of vertebral structures on it or because it is
impossible to decompress without deliberately incising? When documentation indicates that
damage to the dura to achieve complete spinal decompression was “deliberate,” do not assign
T81.2 Accidental puncture and laceration during a procedure, not elsewhere classified.
Whereas, when the documentation indicates that an “accidental damage/tear” or “unintended
tear/damage” of the dura occurred, T81.2 is appropriated assigned. Mention of a dural tear
means the spinal cord dura has been compromised and regardless if the dural tear was
deliberate or accidental, this is the circumstance in which you assign 1.AW.72.^^ Release,
spinal cord.
696

parasitic diseases
Infections: Interpretation of This Versus That
Purpose: Some discrepancies have been found with the coding of infections. It is important to
determine whether
• An infection has been confirmed or ruled out;
• An infection is present on admission or acquired following admission; and
• A patient has an active infection or is a carrier of an infective organism.
Assignment of the correct ICD-10-CA codes and accurate diagnosis typing are crucial to
providing quality data that will be used for improving outcomes for patients. The health
information management professional must have a thorough knowledge of the coding standards
and always apply that knowledge to each and every case. Failure to do so results in unreliable
data. The following table provides some assistance in discerning some common situations
surrounding the coding of infections whereby interpretation of this versus that will result in
different code selections and diagnosis typing.
Coding of infections: Interpretation and considerations

This That Considerations
Methicillin-resistant Methicillin-sensitive With an MRSA infection, treatment with

Staphylococcus aureus Staphylococcus aureus methicillin will not be effective since the
(MRSA) infection (MSSA) infection bacteria is resistant to methicillin. For an
MRSA infection, it is mandatory to assign
ICD-10-CA codes to identify (a) the site
of infection, (b) the infectious microorganism
and (c) the specific drug resistance (in
this case, U82.1 Resistance to methicillin),
and to always apply the diagnosis cluster to
link the codes.
With an MSSA infection, treatment with

methicillin will be effective since the bacteria
is sensitive to methicillin. For an MSSA
infection, U82.1 Resistance to methicillin is
not assigned.
697
Confirmed Ruled out There must be documentation of a confirmed

infection by the physician/primary care
The infection has been verified The infection has been excluded
provider in order to assign a code. When
based on various factors such based on various factors such
symptoms present, patients are often put on
as physical examination, as physical examination,
established infection control protocols prior to
laboratory testing, diagnostic laboratory testing, diagnostic
confirmation of an infection, such as when a
imaging and clinical input. imaging and clinical input.
patient has diarrhea and a Clostridium difficile
(C. difficile) infection is suspected. This is a
precaution to ensure that the potential
infection is contained in the event that the
patient tests positive for the infection.
If the infection is ruled out on initial testing,

a code is not assigned for the infection.
The patient does/did not have the infection.
Further information is available in a

Public Health Agency of Canada fact sheet
on C. difficile.
Infection Carrier Care must be taken to ensure that

documentation of any microorganism —
A microorganism is present on A microorganism is present
and in particular any drug-resistant
or in the body causing illness. on or in the body without
microorganism (DRMO) — is classified
causing illness.
appropriately either as a confirmed infection
or as carrier status. Remember that
documentation by the physician, nursing staff
or infection control staff may be used for
mandatory code assignment of a carrier of a
drug-resistant microorganism. However, there
must be confirmation by the physician/primary
care provider in order to assign a code for an
active infection.
698
Pre-admit comorbidity Post-admit comorbidity The timeline of a condition must be

considered when applying the correct
A significant condition A significant condition that
diagnosis type to any comorbidity. For
that is present prior to develops after admission.
infections, the presentation of symptoms
or on admission.
and the timing of the testing are important
considerations. For example, when a patient
presents with symptoms of an infection and
blood cultures that were taken in the
emergency room or on day 1 of admission
are positive, this is indicative of a pre-admit
comorbidity even if the infection is not
documented until later (sometimes days later)
by the physician/ primary care provider.
Conversely, if the patient starts to deteriorate
or to show signs of a new condition after
admission, it is reasonable to consider this a
post-admit comorbidity. Each case must be
looked at individually and steps taken
to carefully review the documentation to
ensure the correct diagnosis typing.
Post-intervention condition Not a post-intervention condition When determining whether a condition is a

post-intervention condition, the documentation
A condition or symptom that is A condition or symptom
must be carefully reviewed in order to ensure
not attributable to another occurring in the post-intervention
that the condition was not present prior to the
cause that arises during an period of 30 days that is
intervention or that the condition was not
uninterrupted, continuous attributable to another cause,
attributable to another cause.
episode of care within 30 days including
following an intervention Here’s an example: The patient suffers
• A condition that represents
(including transfers from one a gastrointestinal (GI) bleed due to
a worsening of the very
facility to another) or a condition an antral ulcer on day 1 following an
condition being treated;
where a cause/effect intervention. The GI bleed is attributable
relationship is documented, • An exacerbation of a pre- to another cause and is not a post-
regardless of timeline. existing condition; and intervention condition.
• A condition that is due to
another cause.
699
Remember that laboratory results are not used for code assignment. A positive blood
culture does not always mean that an infection is present. The diagnosis must be documented
(as stated in the table above).
The following resources are also available to assist the health information
management professional:
• CIHI’s education products

• eQuery Tool
• CIHI’s website (cihi.ca)
See also the coding standards Infections and Drug-Resistant Microorganisms.
Urosepsis
The term “urosepsis” may be classified 2 ways, depending on whether the health care provider
means that the patient has:
1. A urinary tract infection (UTI) that has progressed to generalized sepsis (i.e., the organism
causing the UTI has entered the blood stream and become generalized sepsis); or
2. A localized infection of the urinary tract (without progression to generalized sepsis).
In order to determine the meaning of the term “urosepsis” for a specific case, as described
above, review all pertinent source documentation to see whether or not there is evidence that
the patient’s UTI has progressed to generalized sepsis. If a review of all the pertinent source
documentation does not help you determine the intended meaning of “urosepsis,” seek
clarification from the physician.
When the diagnosis “urosepsis” means that the UTI has progressed to generalized sepsis,
search the alphabetical index using the lead term “Sepsis” and assign
• A41.9 Sepsis, unspecified (or the more specific code for generalized sepsis, as
applicable); and
• N39.0 Urinary tract infection for the localized UTI.
When the diagnosis “urosepsis” means a localized UTI without progression to generalized
sepsis, search the alphabetical index using the lead term “Urosepsis” and assign
• N39.0 Urinary tract infection.
See also the coding standards Septicemia/Sepsis and Systemic Inflammatory Response
Syndrome (SIRS).
700

Capture a code for thrombolytic therapy on the first inpatient encounter of a current, uninterrupted
episode of care whenever it is administered, regardless of the diagnosis, mandatory.
Don’t let the terminology confuse you . . .

A thrombolytic agent actively breaks down a clot and is also known as a “clot buster,” while
an antithrombotic acts to reduce the risk of clot formation by preventing or interfering with
clot formation.
Let the classification be your guide . . .

Common thrombolytic agents include anistreplase, alteplase, reteplase, streptokinase,
tenecteplase, TNKase (TNK), tissue plasminogen activator (TPA) and urokinase.
The CCI Section 1 agent qualifier for a thrombolytic is 1C — using thrombolytic agent.
Common antithrombotic agents include warfarin, heparin, enoxaparin, dipyridamole and

glycoprotein IIb/IIIa receptor inhibitors (GPIs) (e.g., ReoPro [abciximab], Aggrastat and Integrilin
[eptifibatide]). The CCI Section 1 agent qualifier for an antithrombotic is C1 — using
antithrombotic agent.
Intervention Pre-Admit Flag: Yes or no?
The Intervention Pre-Admit Flag identifies that the intervention was initiated prior to, and in
some cases continued into, the acute care inpatient admission. Its application is restricted to
interventions listed in the Discharge Abstract Database (DAD) Abstracting Manual Group 11,
Field 20 — Intervention Pre-Admit Flag.
Thrombolytic therapy is listed as an intervention that qualifies for application of the Intervention
Pre-Admit Flag. However, the Intervention Pre-Admit Flag is Y (yes) only when the thrombolytic
therapy was administered prior to admission, during an encounter of the current, uninterrupted
episode of care, when the patient’s diagnosis is ST segment elevation myocardial infarction
(STEMI) and the intervention is classified to one of the following CCI codes:
1.ZZ.35.HA-1C Pharmacotherapy, total body, percutaneous approach [intramuscular,
intravenous, subcutaneous, intradermal], blood and blood forming organ agents, using
thrombolytic agent
1.IL.35.HA-1C Pharmacotherapy (local), vessels of heart percutaneous injection approach, of
thrombolytic agent
701
1.IL.35.HH-1C Pharmacotherapy (local), vessels of heart percutaneous infusion approach, of

thrombolytic agent
Knowledge check
1. The patient was diagnosed with an ischemic stroke. He was given tissue plasminogen activator
(TPA) in the emergency department and then admitted to an acute care inpatient bed.
i. It is mandatory to assign an intervention code for administration of the TPA.
a. True
b. False
ii. The Intervention Pre-Admit Flag is Y (yes).

a. True
b. False
2. The patient was diagnosed with an ST segment elevation myocardial infarction (STEMI). She
was given streptokinase in the emergency department of Facility A. She was then transferred
and admitted to an acute care inpatient bed at Facility B.
i. It is mandatory to assign an intervention code for administration of the streptokinase.
a. True
b. False
ii. The Intervention Pre-Admit Flag is Y (yes).

a. True
b. False
Correct answers
1. i. a. True: TPA is a thrombolytic agent. It is mandatory to assign a code for administration of a

thrombolytic agent on the first inpatient encounter of a current uninterrupted episode of care,
regardless of the diagnosis.
1. ii. b. False: The diagnosis was not ST segment elevation myocardial infarction (STEMI).
2. i. a. True: Streptokinase is a thrombolytic agent. It is mandatory to assign a code for administration of a

thrombolytic agent on the first inpatient encounter of a current uninterrupted episode of care, regardless
of the diagnosis.
2. ii. a. True: The diagnosis was ST segment elevation myocardial infarction (STEMI).
702
See also the coding standard Thrombolytic Therapy.
Cardiac Arrest
A code for cardiac arrest is assigned when terminology such as “asystole,” “cardiac arrest,”
“cardiorespiratory arrest,” “circulatory arrest” or “cardiac standstill” is documented by the
physician and a resuscitative intervention is undertaken, regardless of the outcome.
An intervention code is assigned for resuscitative interventions that are initiated prior to and that
continue following admission, or those that are performed during the episode of care. An intervention
code is not assigned for resuscitative interventions that stopped prior to admission.
Knowledge checks
(Use the information above and refer to the coding standard Cardiac Arrest to answer the
following true or false questions.)
1. The patient had a documented “cardiac arrest.” The paramedics initiated cardiocerebral
resuscitation (CCR) at the scene. The patient reverted to normal sinus rhythm in the
ambulance en route to the hospital. CCR was discontinued prior to arrival at the emergency
department. A code for CCR is assigned.
a. True
b. False
2. The patient suffered a documented “cardiac standstill.” The paramedics initiated

cardiopulmonary resuscitation (CPR). The patient was intubated and ventilated via a bag–
valve mask. The emergency department physician assessed the patient and wrote an order
for admission. The patient was admitted to the coronary care unit intubated and ventilated.
i) I46.0 Cardiac arrest with successful resuscitation is assigned as a diagnosis type (1) on
the acute care inpatient abstract.
a. True
b. False
ii) 1.GZ.31.CA-EP Ventilation, respiratory system NEC, Invasive per orifice approach by
endotracheal intubation, manual hand assisted (e.g. ambu bag) is assigned on the acute
care inpatient abstract.
a. True
b. False
703
3. A bystander witnessed the patient fall. The patient was not breathing and the bystander
was unable to find a pulse. The bystander initiated cardiopulmonary resuscitation (CPR).
The paramedics took over and continued CPR until arrival at the emergency department,
where the patient was pronounced dead. The physician documented the final diagnosis as
“vital signs absent.”
A code for “cardiac arrest” is assigned.

a. True
b. False
Correct answers
1. b) False. The resuscitative intervention was discontinued prior to arrival at the hospital. It was not in
progress at the time of admission.
2. i. a) True. Cardiac standstill was documented; intubation and ventilation were initiated prior to and
continued into the admission. I46.0 Cardiac arrest with successful resuscitation meets the criteria for
significance per the coding standard Diagnosis Typing Definitions for DAD.
Ii. a) True. The intubation and ventilation were initiated prior to and continued into the admission.
A code from rubric 1.GZ.31.^^ Ventilation, respiratory system NEC is mandatory per the coding
standard Invasive Ventilation.
3. b) False. Cardiac arrest was not documented. The documented diagnosis “vital signs absent” is classified
to R99 Other ill-defined and unspecified causes of mortality.
See also the coding standards Cardiac Arrest and Vital Signs Absent (VSA).
I21 Acute Myocardial Infarction: Diagnosis Typing

Given the direction in the coding standard Acute Coronary Syndrome (ACS), it is expected that
codes from category I21.– would rarely be assigned a diagnosis type (3).
Instruction: Review the coding standard Acute Coronary Syndrome (ACS) and then complete
the following exercise by selecting “True” or “False” for each of the statements.
Question: A code from category I21 Acute myocardial infarction is assigned as a diagnosis type
(3) on a DAD abstract, when
A. It is part of a post-intervention condition as an additional code to provide specificity
(i.e., a sandwich code). True/False?
B. A patient is admitted for a condition not related to the AMI (i.e., admission is within 28 days
of the AMI) and the AMI is not treated during this episode of care. True/False?
704
C. A patient has recently suffered an AMI (i.e., admission is within 28 days of the AMI) and is
admitted electively for treatment of coronary artery disease (CAD) with percutaneous
coronary intervention (PCI). True/False?
D. The patient is admitted for continuing observation following treatment of the AMI at another
facility. The AMI occurred 30 days ago. True/False?
E. A patient has a subsequent AMI classified to a code from category I22 Subsequent
myocardial infarction on the abstract and the original AMI is also coded. True/False?
Correct answers
A. False. An acute myocardial infarction (AMI) that meets the definition of a post-intervention condition is
never assigned as an additional (sandwich) code. The AMI code (I21) is the primary code for the post-
intervention condition. A myocardial infarction within the acute phase is always assigned a significant
diagnosis type.
B. False. A myocardial infarction within the acute phase is always assigned a significant diagnosis type.
C. False. In this case, the code for the coronary artery disease is the most responsible diagnosis and the AMI
code (I21) is a significant diagnosis type per the coding standard Acute Coronary Syndrome (ACS).
D. False. Since the patient is still receiving care (i.e., observation) for the myocardial infarction, the
myocardial infarction is classified to category I21. The same criteria noted in B above apply since the AMI
is still considered acute, albeit more than 28 days old. For a myocardial infarction to be classified to I25.2
Old myocardial infarction both listed criteria must apply.
E. True. A subsequent MI is one that occurs within 28 days of a previous MI (i.e., the original MI is still
within the acute phase). In such a case, a code from category I22 Subsequent myocardial infarction is
assigned as a significant diagnosis type. A code from category I21 may be assigned, optionally, as a
diagnosis type (3), as per the coding standard Acute Coronary Syndrome (ACS).
Data quality check
Selection criteria: Records with a code from category I21 Acute myocardial infarction as a diagnosis type (3)
without an additional code of I22 Subsequent myocardial infarction assigned as a significant diagnosis type
(M, 1, 2, W, X, Y). Review the chart documentation for appropriate correction.
See also the coding standard Acute Coronary Syndrome (ACS).
705

Bariatric Surgery and Diagnosis Code Mismatch
Purpose: As a rule, the intervention code 1.NF.78.^^ Repair by decreasing size, stomach is
assigned only to identify a patient receiving gastric bypass surgery for the purpose of weight
reduction. Data analysis identified cases of 1.NF.78.^^ being assigned with a diagnosis code for
cancer of the stomach and other stomach diseases.
1.NF.78.^^ Repair by decreasing size, stomach is assigned only for weight reduction surgery.
The error in the data is due to either the diagnosis code assignment or the intervention
code assignment.
1. Potentially incorrect diagnosis code assignment
Suspect data is identified when reviewing cases with an intervention assigned from
1.NF.78.^^ (excluding cases with status attribute “R” — revised) and without a diagnosis
of E66.– Obesity assigned on the abstract.
Suspect data includes cases with the diagnosis codes listed below on the same abstract
as 1.NF.78.^^:
C16.– Malignant neoplasm of stomach

C25.– Malignant neoplasm of pancreas
D37.– Neoplasm of uncertain or unknown behaviour of oral cavity and digestive organs
K21.– Gastroesophageal reflux disease
K25.– Gastric ulcer
K31.– Other disease of stomach and duodenum
K44.– Diaphragmatic hernia
2. Potentially incorrect intervention code assignment

Suspect data is identified when reviewing cases with E66.– assigned as the most
responsible diagnosis (MRDx) and 1 of the following intervention codes:
1.NF.76.^^ Bypass, stomach
1.NF.80.^^ Repair, stomach
1.NF.87.^^ Excision partial, stomach
1.NF.89.^^ Excision total, stomach
1.NF.91.^^ Excision radical, stomach
706
Cases with E66.– as the MRDx and any of the above-listed interventions will group to CMG 910
Unrelated Interventions.
Data quality check
1. Identify cases with intervention code 1.NF.78.^^ (excluding cases with status attribute “R” assigned)
and without E66.– as a significant diagnosis type on the abstract.
2. Identify cases with an intervention code from 1.NF.76.^^, 1.NF.80.^^, 1.NF.87.^^, 1.NF.89.^^ or
1.NF.91.^^ and with E66.– assigned as the MRDx.
3. Identify cases grouped to CMG 910 Unrelated Interventions, make corrections and send the corrected
data to CIHI before year-end database closure.
707
Chapter XIII — Diseases of the musculoskeletal

system and connective tissue
Where Do Soft-Tissue Injuries Fit in the Classification?
The purpose of this tip is to provide assistance with code selection when the documentation
indicates soft-tissue injury. As there is no index look-up for this term, emergency visit coders
will benefit from the 4 relevant examples provided in this tip.
The most common soft tissues injured are muscles, tendons and ligaments. These injuries often
occur during sports and exercise activities, but sometimes simple everyday activities can cause
an injury.
Soft-tissue injuries (STIs) fall into 2 basic categories: acute injuries and overuse injuries.
• Acute injuries are caused by a sudden trauma, such as a fall, twist or blow to the body.
Examples of acute injuries include sprains, strains and contusions.
• Overuse injuries occur gradually over time, when an athletic or other activity is repeated so
often that areas of the body do not have enough time to heal between occurrences.
Tendinitis and bursitis are common soft-tissue overuse injuries.
As soft-tissue injuries can occur anywhere in the body, the first axis for classification purposes is
the site of the injury. After that, the choice of code is case specific.
Case 1: A patient presents to the emergency department (ED) with a bruised ankle. The
patient dropped a 10 lb weight on the ankle. The physician confirms no broken bones
and documents STI.
The highest level of specificity in this case is a bruise.
S90.0 Contusion of ankle
Case 2: A patient presents to the ED with a swollen ankle. The patient states that he twisted
his ankle and fell down 3 stairs. The physician confirms no broken bones and
documents “STI — ankle sprain.” The patient has to be non-weight-bearing with a
soft or hard cast, and he needs to rest and use ice, compression, elevation and anti-
inflammatory medications.
The highest level of specificity here is ankle sprain.
S93.49 Sprain and strain of ankle, unspecified
708
Case 3: A patient presents to the ED with a painful ankle; she is unable to walk after a sports
injury. There is severe edema, bruising and disabling pain. The physician confirms no
broken bones; after the imaging tests are done, the STI is determined to be a
significant tendon rupture. The patient is immobilized with a cast.
S96.90 Laceration of unspecified muscle and tendon at ankle and foot level
Case 4: The only documentation is “Fall down stairs, STI ankle.”

You have an anatomic site; the code could be from one of the categories listed below:
S90.– Superficial injury of ankle and foot;
S93.– Dislocation, sprain and strain of joints and ligaments at ankle and foot level; or
S96.– Injury of muscle or tendon at ankle and foot level.
Select the unspecified code of the least-severe injury in the options available:
S90.9 Superficial injury of ankle and foot, unspecified
See also the coding standard Excision (of Lesion) of Bone, Soft Tissue and Skin.
709
Chapter XV — Pregnancy, childbirth and

the puerperium
Fetal Heart Rate Anomaly
Purpose: To ensure that ICD-10-CA codes for fetal stress [distress] are not being assigned
when there is no true fetal heart rate (FHR) anomaly occurring.
These codes (O68.001 and O68.201) are assigned for the delivery episode of care when
there is evidence of an FHR anomaly or non-reassuring FHR. Not every change in FHR is
“non-reassuring.” A normal baseline FHR is 110 to 160 beats per minute. During labor, when
contractions occur, certain changes in the FHR are expected and normal. It is when these
changes in FHR are abnormal or persistent that there is a need for concern. The following table
serves to promote a better understanding of FHR patterns and the terminology typically seen in
the chart. It is not intended to help coders interpret monitor strips or FHR patterns.
Documentation of . . . . . . means this

Accelerations — periodic Normal: This is the fetus responding to increased activity during labor. Accelerations
increases in the FHR are actually reassuring as they confirm that the fetus is not hypoxic.
Variability in FHR Normal: As long as no atypical features are present, this is reassuring.
Early decelerations Normal: This is a transient decrease in heart rate with the onset of a contraction.
It is a normal response during a contraction.
Tachycardia Abnormal: This may be a sign of fetal hypoxia and is concerning.
Bradycardia Abnormal: This may be a sign of fetal hypoxia and is concerning.
Late decelerations Occasional decelerations may be normal. Decelerations that are persistent and/or
repetitive are very concerning, and require that the care provider take action.
Variable decelerations Although variability and occasional decelerations are not concerning, the presence
with atypical features of atypical features or persistent variable decelerations may be a cause for concern.
710
The documentation of occasional FHR variability, accelerations or early decelerations does not
indicate a non-reassuring FHR; these occurrences are therefore not classified to a code from
category O68 Labour and delivery complicated by fetal stress [distress].
The codes O68.001 and O68.201 include documentation of fetal bradycardia, fetal tachycardia,
fetal heart rate irregularity (note: this is not the same as “variability”) and non-reassuring fetal
heart rate (NRFHR). When these conditions are documented or when abnormal fetal heart rate
(fetal heart rate anomaly) is a reason for intervention (e.g., instrumented or operative delivery),
then a code from this category is assigned as a significant diagnosis type.
Section 5 Intervention Codes Applicable to Stillbirths, Missed

Abortion and Termination of Pregnancy
Purpose
Coders have indicated that they would like information on the obstetrical intervention codes that
are valid for use in various obstetrical circumstances.
This Tip for Coders covers 3 separate topics: stillbirths, missed abortion and termination
of pregnancy:
1. Section 5 intervention codes applicable to delivery of a stillbirth
2. Section 5 intervention codes applicable to missed abortion
3. Section 5 intervention codes applicable to termination of pregnancy
Overview
The selection of intervention codes related to intrauterine death depends on the time of death
of the fetus. Intrauterine death at or after 20 weeks equates to a delivery (see Section 5
intervention codes applicable to delivery of a stillbirth). Intrauterine death before 20 weeks
equates to an abortion (see Section 5 intervention codes applicable to missed abortion).
In contrast, interventions to end a pregnancy where the fetus is alive equate to termination;
thus a different selection of intervention codes is required (see Section 5 intervention codes
applicable to termination of pregnancy).
This tip covers the selection of Section 5 CCI codes that are valid for use for the expulsion,
extraction and facilitation of removal of a stillbirth, missed abortion and termination of pregnancy.
Interventions following stillbirth, missed abortion and termination of pregnancy are also covered.
711
1. Section 5 intervention codes applicable to delivery of a stillbirth

Definitions
Stillbirth
Death that occurs in utero at or after 20 completed weeks of gestation (also known as late
intrauterine fetal death)
Interventions to expel, extract or facilitate removal of a stillbirth equate to a delivery.
Code selection
1. For interventions to initiate labor, select a code(s) from

5.AC.^^.^^ Antepartum Therapeutic Interventions
2. For interventions during labor, select a code(s) from

5.LC.^^.^^ Interventions during Latent Labour or
5.LD.^^.^^ Interventions during Active Labour
3. For interventions to facilitate delivery, select a code(s) from

5.MD.11.^^ to 5.MD.47.^^
4. For interventions to accomplish delivery, select 1 code* from

5.MD.50.^^ to 5.MD.60.^^
5. For interventions following delivery, select a code(s) from

5.PC.^^.^^ Postpartum Therapeutic Interventions
* A minimum of 1 intervention code (the delivery code, 5.MD.50.^^ to 5.MD.60.^^) is required

for stillbirths.
Example
Intrauterine demise occurs at approximately 24 weeks. The patient is admitted for intravenous
(IV) oxytocic induction of labor, which is followed by spontaneous vaginal delivery.
5.MD.50.AA Manually assisted vaginal delivery (vertex) without episiotomy
5.AC.30.HA-I2 Induction of labour using percutaneous injection of oxytocic agent
712
Exclusion
Fetal death that occurs before 20 completed weeks is a missed abortion (not a stillbirth), even
when expulsion of the fetus takes place after 20 weeks. See the topic Section 5 intervention
codes applicable to missed abortion.
See also the topic Section 5 intervention codes applicable to termination of pregnancy.
2. Section 5 intervention codes applicable to missed abortion

Definitions
Missed abortion
Death that occurs in utero before 20 completed weeks of gestation with retention of the fetus,
even when expulsion of the fetus takes place after 20 weeks (also known as early intrauterine
fetal death)
Interventions to expel, extract or facilitate removal of a missed abortion equate to a naturally

occurring abortion.
Code selection
1. For interventions to induce/facilitate expulsion, select a code(s) from

5.AC.^^.^^ Antepartum Therapeutic Interventions
2. For interventions to accomplish (complete) removal, select a code from

5.PC.91.^^ Interventions to uterus (following delivery or abortion)
3. For interventions following removal, select a code(s) from

Note that there is no minimum number of intervention codes for a missed abortion.
Examples
Example 1: Intrauterine demise occurs at 16 weeks. The patient is admitted for administration of
misoprostol, which is followed by spontaneous expulsion.
5.AC.30.CK-A2 Induction of labour, using per orifice (intra vaginal) administration of antacids
[e.g. misoprostol]
713
Example 2: Missed abortion is diagnosed at 18 weeks. The patient is admitted 2 weeks later for
dilatation and curettage (D & C). At the time of the D & C, there is bleeding of the cervix from
trauma related to application of the tenaculum, which is controlled by sutures.
5.PC.91.GA Interventions to uterus (following delivery or abortion) dilation and curettage
5.PC.80.JJ Surgical repair, postpartum of current obstetric laceration of cervix occurring at

vaginal delivery
Exclusion
Fetal death that occurs at or after 20 weeks is a stillbirth (not a missed abortion). See the topic
Section 5 intervention codes applicable to delivery of a stillbirth.
See also the topic Section 5 intervention codes applicable to termination of pregnancy.
3. Section 5 intervention codes applicable to termination of pregnancy

Definitions
Termination of pregnancy
The intentional medical or surgical cessation of a pregnancy where the fetus is alive at the
initiation of the intervention, regardless of the outcome of the fetus (products of conception,
stillbirth, livebirth)
Interventions to expel, extract or facilitate removal of a live fetus equate to termination (an
induced abortion).
Code selection
1. For interventions to facilitate and/or accomplish termination, select a code(s) from

5.CA.^^.^^ Termination of Pregnancy
2. For interventions following termination, select a code(s) from

Note that a minimum of 1 intervention code (to accomplish termination) is required for
termination of pregnancy.
Example
The patient is admitted at 26 weeks for termination due to severe cardiac anomalies in the
fetus. Labor is induced via means of intravenous oxytocin. The fetus is expelled and lives for
approximately 2 hours.
714
5.CA.88.HA-I2 Pharmacological termination of pregnancy, percutaneous approach

[e.g. intravenous, injection into intraamniotic or extraamniotic sac], oxytocin
Exclusions
Interventions when the fetus is already dead. See the topics Section 5 intervention codes applicable
to delivery of a stillbirth and Section 5 intervention codes applicable to missed abortion.
See the coding standards Pregnancy With Abortive Outcome and Continuing Pregnancy After
Abortion/Selective Fetal Reduction in Multiple Gestation.
Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare obstetric occurrence, yet it is one of the leading causes
of maternal mortality in developed countries. In Canada, from 1997 to 2000, AFE ranked third
behind cerebrovascular and hypertensive disorders and ahead of postpartum hemorrhage and
other pulmonary embolisms as a direct cause of maternal deaths. AFE is believed to arise from
simultaneous tears in the fetal membranes and the uterine vessels, thus permitting amniotic
fluid to enter the uterine vein and hence the maternal pulmonary arterial circulation. It is
characterized by sudden dyspnea, cardiopulmonary collapse and intravascular coagulation.
A study on AFE attempted to reduce false-positive diagnoses in CIHI’s data. A confirmed case
required the presence of at least one of the following conditions or procedures: cardiac arrest,
shock or severe hypertension, respiratory distress, coma, seizure, coagulation disorder or
mechanical ventilation. A total of 292 AFE cases were identified in Discharge Abstract Database
(DAD) data, of which only 120 (40%) were confirmed; 33 of the confirmed cases were fatal. 1
AFE remains a rare but serious obstetric outcome, with major implications for maternal, fetal
and neonatal health; therefore, it is important to classify cases correctly and to not confuse AFE
with other diagnoses of obstetric embolism from category O88 Obstetric embolism. AFE is
classified to O88.1– Amniotic fluid embolism.
715
Data quality check

As there should be very few cases of AFE, a data quality check on all DAD abstracts with a diagnosis of O88.1–
Amniotic fluid embolism as any diagnosis type should be performed to help reduce false-positive cases of AFE
in the DAD. The abstract should be reviewed for other diagnoses and/or intervention codes that would be
expected with a true diagnosis of AFE:
• Cardiac arrest
• Shock or severe hypertension
• Respiratory distress
• Coma
• Seizure
• Coagulation disorder
• Mechanical ventilation
If none of these are identified on the abstract, the chart should be reviewed to confirm the diagnosis of AFE.
Assisted Reproductive Technology (ART)

ART includes any technology that manipulates ovulation, fertilization and conception. The type
of technology used is dependent on the underlying cause of the infertility.
Categories Z37 and Z38

Categories Z37 Outcome of delivery and Z38 Liveborn infants according to place of birth include
a sixth digit so that pregnancies occurring as the result of ART can be distinguished from those
that are the result of completely unassisted and spontaneous ovulation and conception.
A sixth digit of 0 indicates that pregnancy was achieved or baby was a product of natural and
spontaneous ovulation and conception. A sixth digit of 1 indicates that some type of manipulation
of sperm and/or ovum was required to achieve pregnancy.
What is included in ART?

For the purposes of code selection from Z37 and Z38, ART includes any technology that
manipulates ovulation, fertilization and conception, including artificial insemination. Specifically,
these include:
• In-vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) or in-vitro
(egg) maturation (IVM);
• Embryo transfer; fresh or frozen
716
• Ovarian stimulation/ovulation induction which include the use of drugs such as clomiphene
citrate (brand names Clomid, Milophene, Serophene), human menopausal gonadotropins
(hMG) either urinary or recombinant, follicle-stimulating hormone (FSH) products either
urinary or recombinant or luteinizing (LH) agonists; and
• Artificial insemination
What is not included in ART?

ART does not include surgical procedures to rectify anatomical reproductive problems in either
the male or the female such as repair of damaged/blocked fallopian tubes or repair of male
varicocele. It also does not include surrogacy. Finally, it does not include medication taken to
increase sperm motility.
The coder is not expected to go back to previous patient visits to determine if the current
pregnancy was a result of ART. If there is no documentation on the current admission to support
ART, then select the sixth digit of 0.
Data quality check
Ensure that the Z37 Outcome of delivery code on the mom’s abstract matches the Z38 Liveborn infants
according to place of birth on the baby’s abstract. Both should have the same sixth digit of either 0 or 1
that indicates the pregnancy/baby was a product of either spontaneous ovulation and conception or
ART respectively.
717
Chapter XVI — Certain conditions originating in

the perinatal period
Spot the Error: Use of Codes From Chapter XVI — Certain
conditions originating in the perinatal period (P00–P96)
The following is from an abstract submitted to the Discharge Abstract Database (DAD). Can you
spot the error?
ICD-10-CA diagnosis code ICD-10-CA code description

O42.021 Premature rupture of membranes, onset of labour within 24 hours, full term,
O70.001 First degree perineal laceration during delivery, delivered, with or without
P08.1 Other heavy for gestational age infants
Z37.000 Single live birth, pregnancy resulting from both spontaneous ovulation
and conception
CCI intervention code CCI intervention code description
5.MD.50.AA Manually assisted vaginal delivery (vertex) without episiotomy
Note
For obstetrical cases, remember the general rule: O– codes are for the mother, P– codes are for the baby.
Codes from Chapter XVI describe conditions originating in the perinatal period. Conceivably, an
adult could continue to have a disorder that originated in the perinatal period. As such, there are
no CIHI edits in place to restrict the use of P– codes on any abstract submitted to the DAD.
Data quality check

For adult abstracts (age group 19 to 44) with any diagnosis code beginning with P, review the chart
documentation and the abstract to ensure that the correct diagnosis code has been assigned.
718
Sixth Digit at Z37 and Z38

Z37.0 Single live birth
Z37.000 (Canadian enhancement) Single live birth, pregnancy resulting from both spontaneous
Z37.001 (Canadian enhancement) Single live birth, pregnancy resulting from assisted
reproductive technology (ART)
What is wrong with this picture?

Mother’s abstract: Z37.001 Single live birth, pregnancy resulting from assisted reproductive
technology (ART)
Newborn’s abstract: Z38.000 Singleton, born in hospital, delivered vaginally, product of both
Data quality check

Selection criteria: Records where the sixth digit for the Outcome of delivery code (e.g., Z37.000) on
the mother’s abstract does not match the sixth digit for the Liveborn according to place of birth code
(e.g., Z38.001) on the newborn’s abstract.
Error explanation: The sixth digit for the Outcome of delivery code (e.g., Z37.000) does not match the sixth
digit for the Liveborn according to place of birth code (Z38.001). The sixth digits for the Outcome of delivery
code and Liveborn according to place of birth code must match. Review the mother and newborn charts to
determine which abstract requires correction.
See also the coding standard Selection of the Sixth Digit in Obstetrical Coding.
719
Chapter XIX — Injury, poisonings and certain

Selecting the Primary Code for a Post-Intervention Condition
Purpose
A review of Discharge Abstract Database (DAD) abstracts reveals that the set of codes for a
post-intervention condition is sometimes missing the required T-code or PP-code as the primary
code. This Tip for Coders is a refresher of the rules for assigning the primary code for a post-
intervention condition. These rules were created to ensure that coders in Canada maintain
consistency with both the international (ICD-10) and national (ICD-10-CA) disease
classifications in order to support reliable comparison and reporting of data.
Selecting the primary code for a post-intervention condition: Refresher of

the rules
The minimum set of codes for a post-intervention condition consists of a primary code and an
external cause code. The primary code can be a T-code (T80–T88), a PP-code (from the
postprocedural disorders category at the end of most body system chapters) or a regular code
(all other codes) in the classification. The basis for selecting the primary code is the alphabetical
index lookup using the PIC steps. An abbreviated form of these steps is displayed below. For
full details, see the section Searching the alphabetical index for the primary code for a post-
intervention condition in the coding standard Post-Intervention Conditions.
Step 3
If there is no postprocedural
Step 1 Step 2 subterm, assign the regular code
Locate the lead term for Look for a subterm denoting or a code specific to one of the
the condition. “postprocedural.” select interventions.
Notes Notes Notes
a) Go to lead term Misadventure a) If there is no postprocedural a) Go to lead term Complication,
for misadventures. subterm, go to Step 3. complications (from) (of) for
b) Go to lead term Complication, b) If there is only 1 postprocedural conditions associated with the
complications (from) (of) for subterm, select the code per outcome of
conditions associated with the classification. i) Amputation;
i) Artificial fertilization; c) If there are 2 or more ii) Device/implant/graft;
ii) Immunization (includes postprocedural subterms — iii) Lumbar puncture;
vaccination); and one specific to the interventions iv) Mastoidectomy;
iii) Infusion, transfusion and listed in Step 3, the other to v) Reattached extremity/body
therapeutic injection T81 — assign the code specific part; and
(includes dialysis, to the interventions listed in vi) Stoma.
extracorporeal circulation Step 3 if the condition is b) For all others, assign the regular
and perfusion). associated with the outcome of code per the classification.
that intervention; otherwise,
assign the code from T81.
720
Selecting the primary code for a post-intervention condition: Putting the

rules into practice
Instructions: Use the alphabetical index lookup and the PIC steps above to determine whether
the primary codes for the post-intervention conditions listed below are T-codes, PP-codes or
regular codes in the classification. After locating the correct primary code, circle the correct code
on the right-hand side of the table.
Number Post-intervention condition Primary code
1 Acute renal failure following N99.0 Postprocedural renal failure N17.9 Acute renal failure,
coronary artery bypass graft unspecified
2 Myocardial infarction following I97.8 Other postprocedural I21.9 Acute myocardial

hemicolectomy disorders of circulatory system, infarction, unspecified
3 Sepsis following total T81.4 Infection following a A41.9 Sepsis, unspecified

hip replacement procedure, not elsewhere classified
4 Accidental laceration of ureter T81.2 Accidental puncture and S37.111 Laceration of ureter
during subtotal cystectomy laceration during a procedure, with open wound into cavity
5 Cerebral infarction following repair T81.88 Other complications of I63.9 Cerebral infarction,
of aortic aneurysm procedures, not elsewhere classified unspecified
6 Septic shock following T81.1 Shock during or resulting R57.2 Septic shock
subtotal pancreatectomy from a procedure, not
7 Abdominal abscess following T81.4 Infection following a K65.0 Acute peritonitis

diversionary colocolostomy procedure, not elsewhere classified
8 Acute peritonitis associated T80.2 Infections following infusion, K65.0 Acute peritonitis
with continuous ambulatory transfusion and therapeutic injection
peritoneal dialysis
9 Severe hyperkalemia E89.8 Other postprocedural E87.5 Hyperkalaemia

post adrenalectomy endocrine and metabolic disorders
10 Aortic valve stenosis post aortic T82.8 Other specified complications I35.0 Aortic (valve) stenosis
valve replacement of cardiac and vascular prosthetic
devices, implants and grafts
721
Correct answers
Number Post-intervention condition Primary code
1 Acute renal failure following coronary artery N99.0 Postprocedural renal failure
bypass graft
2 Myocardial infarction following hemicolectomy I21.9 Acute myocardial infarction, unspecified
3 Sepsis following total hip replacement T81.4 Infection following a procedure, not
4 Accidental laceration of ureter during T81.2 Accidental puncture and laceration during a
subtotal cystectomy procedure, not elsewhere classified
5 Cerebral infarction following repair of aortic I63.9 Cerebral infarction, unspecified

aneurysm
6 Septic shock following subtotal pancreatectomy T81.1 Shock during or resulting from a procedure,
7 Abdominal abscess following T81.4 Infection following a procedure,

diversionary colocolostomy not elsewhere classified
8 Acute peritonitis associated with continuous T80.2 Infections following infusion, transfusion and
ambulatory peritoneal dialysis therapeutic injection
9 Severe hyperkalemia post adrenalectomy E87.5 Hyperkalaemia
10 Aortic valve stenosis post aortic valve replacement T82.8 Other specified complications of cardiac and
vascular prosthetic devices, implants and grafts
Ventilator-Associated Pneumonia Versus

Postoperative Pneumonia
Purpose: To ensure that the coding standard Post-Intervention Conditions is being applied
consistently in the circumstances involving a diagnosis of ventilator-associated pneumonia or
postoperative pneumonia. Ventilator-associated pneumonia and postoperative pneumonia are
patient safety concerns in hospitals across the country. Furthermore, data quality is crucial for
accurate reporting.
Ventilator-associated pneumonia (VAP) is specifically indexed and classified to a residual (.8)

code. It is found in the alphabetical index as follows:
Pneumonia
A “use additional code” instruction is present at J95.88 Other postprocedural respiratory disorders
reminding the coder to assign a “sandwich code” to identify the specific type of pneumonia.
722
The external cause code applicable to a diagnosis of ventilator-associated pneumonia is Y84.8

Other medical procedures as the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time of the procedure.
Correct classification of ventilator-associated pneumonia

J95.88 [A] Other postprocedural respiratory disorders
J18.9 [A] Pneumonia, unspecified (Note: If specific type of pneumonia is known, assign applicable
code instead of J18.9.)
Y84.8 [A] Other medical procedures as the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time of the procedure
Postoperative pneumonia is classified to the “regular” code, per the direction in the coding
standard Post-Intervention Conditions under the heading Searching the alphabetical index for
the primary code for a post-intervention condition.
Correct classification of postoperative pneumonia

J18.9 [A] Pneumonia, unspecified (Note: If specific type of pneumonia is known, assign
applicable code instead of J18.9.)
Y83-Y84 [A] Surgical and other medical procedures as the cause of abnormal reaction of the
patient, or of later complication, without mention of misadventure at the time of the procedure.
(Note: The applicable external cause code will depend on the circumstances of the case.)
Data quality check
Facilities are encouraged to review their open-year data using the following parameters:
1. Ventilator-associated pneumonia — Abstracts with intervention code 1.GZ.31.^^ Ventilation, respiratory

system NEC and J95.88 in a diagnosis cluster without external cause code Y84.8.
Note: This code combination is suspect for a case of ventilator-associated pneumonia that has been classified
using the wrong external cause code. Chart review is necessary to confirm.
2. Postoperative pneumonia — Abstracts without 1.GZ.31.^^ Ventilation, respiratory system NEC but with
J95.88 and an external cause code from Y83.0–Y83.9 in a diagnosis cluster on the same abstract.
Note: This code combination is suspect for a case of postoperative pneumonia that has been classified
incorrectly to the primary code J95.88. Chart review is necessary to confirm.
See also the coding standard Post-Intervention Conditions as well as Appendix B — Y83–Y84
Inclusion List.
723
Post-Intervention Conditions — Residual Codes

Analysis of previous years’ data has identified an unexpectedly high volume of abstracts in the
Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS)
with one or more residual codes related to post-intervention conditions.
Which post-intervention conditions are assigned to a residual code?

A residual code is assigned as the primary code for a post-intervention condition when
1. A post-intervention condition is specifically indexed to a residual code; or
Example: Ventilator-associated pneumonia
Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved) J18.9
2. There is no index entry for a particular post-intervention condition and direction is provided
in the eQuery tool to assign a residual code for the condition.
Example: Slipped Nissen fundoplication
K91.8 Other postprocedural disorders of digestive system, not elsewhere classified
Apply the PIC steps to look up the following post-intervention

conditions. Is the residual code the correct or incorrect primary code?
Example 1: Irradiation stricture of rectum
K91.8 [Cluster A] Other postprocedural disorders of digestive system, not elsewhere classified
K62.4 (3) [Cluster A] Stenosis of anus and rectum
Y84.2 (9) [Cluster A] Radiological procedure and radiotherapy as the cause of abnormal
reaction of the patient, or of later complication, without mention of misadventure at the time of
the procedure
Example 2: Pneumonia following hepatic resection

J95.88 [Cluster A] Other postprocedural respiratory disorders
J18.9 (3) [Cluster A] Pneumonia, unspecified
Y83.6 (9) [Cluster A] Removal of other organ (partial) (total) as the cause of abnormal reaction of the
patient, or of later complication, without mention of misadventure at the time of the procedure
Example 3: Intraoperative (CABG) hypotension

I97.8 [Cluster A] Other postprocedural disorders of circulatory system, not elsewhere classified
I95.9 (3) [Cluster A] Hypotension, unspecified
724
Y83.2 (9) [Cluster A] Surgical operation with anastomosis, bypass or graft as the cause of
abnormal reaction of the patient, or of later complication, without mention of misadventure at
Correct answers
Example 1: Irradiation stricture of rectum
K91.8 [Cluster A] Other postprocedural disorders of digestive system, not elsewhere classified
K62.4 (3) [Cluster A] Stenosis of anus and rectum
Y84.2 (9) [Cluster A] Radiological procedure and radiotherapy as the cause of abnormal reaction of the
patient, or of later complication, without mention of misadventure at the time of the procedure
Correct use of residual code: The index leads you to a residual code for stricture of rectum when it is a post-
intervention condition. An additional code is assigned for specificity, because K91.8 does not fully describe
the condition, a code is available and use of that code is not contraindicated.
Example 2: Pneumonia following hepatic resection
Y83.6 (9) [Cluster A] Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient,
or of later complication, without mention of misadventure at the time of the procedure
Incorrect use of residual code: There is no subterm denoting “post-procedural” for pneumonia that is relevant
to these circumstances. The regular code is assigned as the primary code, and is linked with the external
cause code by the diagnosis cluster. The residual code J95.88 Other postprocedural respiratory disorders is
not assigned.
Example 3: Intraoperative (CABG) hypotension
Y83.2 (9) [Cluster A] Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of
the patient, or of later complication, without mention of misadventure at the time of the procedure
Incorrect use of residual code: There is no subterm denoting “post-procedural” for hypotension that is
relevant to these circumstances. The regular code is assigned as the primary code, and it is linked with the
external cause code by the diagnosis cluster. The residual code I97.8 Other postprocedural disorders of
circulatory system, not elsewhere classified is not assigned.
725
The “Ifs” and “Thens” of Broken Devices

A variety of circumstances can arise involving broken devices that affect code assignment.
The different circumstances and their related code assignment are described below using “if” and
“then” statements — if the situation is such-and-such, then the code assignment is this-and-that.
Keep in mind that diagnosis typing definitions apply for all codes.
If an in situ device breaks by means of intrinsic force, then the code assignment is T82–T85
and Y70–Y82.
Example: Patient presents with fractured hip prosthesis. There is no history of trauma.
T84.033 [Cluster A] Mechanical complication of hip prosthesis, breakage and dissociation
Y79.2 [Cluster A] Orthopaedic devices associated with adverse incidents, prosthetic and
other implants, materials and accessory devices
Rationale: A device that is intended to be (remain) in the body that breaks while in place is
classified as a mechanical complication. When a broken (or malfunctioning) device is not
associated with extrinsic force, the external cause code is selected from Y70–Y82.
If an in situ device breaks by means of extrinsic force, then the code assignment is T82–T85
and V01–X59.
Example: Patient presents with fractured hip prosthesis. Patient had fallen off a chair at home.
T84.033 Mechanical complication of hip prosthesis, breakage and dissociation
W07 Fall involving chair
U98.0 Place of occurrence, home
Rationale: A device that is intended to be (remain) in the body that breaks while in place is
classified as a mechanical complication. When a broken (or malfunctioning) device is
associated with extrinsic force, the external cause code is selected from V01–X59. This
circumstance is classified as an accident and not a post-intervention condition.
If a device breaks on insertion or removal or during use by medical personnel and a fragment
(piece) is retained, then the code assignment is T81.5– and Y70–Y82.
“Retained” means that the fragment (piece) was not retrieved (was deliberately left, or attempts
to retrieve it were unsuccessful) or that retrieval of the retained fragment (piece) required a
separate or special intervention.
726
Example 1: On removal of PEG tube, the stem broke off. The residual part required
endoscopic removal.
T81.57 [Cluster A] Foreign body accidentally left in body cavity or operation wound following
a procedure, without mention of any complication
Y73.1 [Cluster A] Gastroenterology and urology devices associated with adverse incidents,
therapeutic (nonsurgical) and rehabilitative devices
Rationale: The stem of the PEG tube is a foreign body, as the residual part is not intended to
remain in the body and is not serving a function. When a broken (or malfunctioning) device is
not associated with extrinsic force, the external cause code is selected from Y70–Y82. Routine
removal, insertion and use by medical personnel are not considered an extrinsic force, nor is
this circumstance considered a misadventure, as there is no documentation of an adverse event
(i.e., it is assumed that the removal of the PEG tube was performed properly).
Example 2: A drill bit broke during revision of a total hip replacement and could not be retrieved.
T81.57 [Cluster A] Foreign body accidentally left in body cavity or operation wound following
a procedure, without mention of any complication
Y79.3 [Cluster A] Orthopaedic devices associated with adverse incidents, surgical

instruments, materials and devices (including sutures)
Rationale: The retained piece of the drill bit is considered a foreign body, as it is not intended to
remain in the body. When a broken (or malfunctioning) device is not associated with extrinsic
force, the external cause code is selected from Y70–Y82. Routine removal, insertion and use by
medical personnel are not considered an external force, nor is this circumstance considered a
misadventure, as there is no documentation of an adverse event (i.e., it is assumed that the use
of the drill bit was proper).
If a device breaks due to extrinsic force and a fragment (piece) is retained, then the code
assignment is T81.5– and V01–X59.
Example: Patient cuts his or her Jackson Pratt drain; the intra-abdominal portion was retained
and required a laparotomy for removal.
T81.57 Foreign body accidentally left in body cavity or operation wound following a
procedure, without mention of any complication
W49 Exposure to other and unspecified inanimate mechanical forces
U98.20 Place of occurrence, hospital
727
Rationale: The retained piece of the drain is a foreign body, as the residual part is not intended
to remain in the body and is not serving a function. When a broken (or malfunctioning) device is
associated with extrinsic force, the external cause code is selected from V01–X59. This
circumstance is classified as an accident and not a post-intervention condition.
If a device breaks on insertion or removal or during use and a fragment (piece) is readily
retrieved, then there is no code assignment.
Example: On removal of guidewire used for central line insertion, a piece of the guidewire broke
off. The broken piece was immediately retrieved with no difficulty.
No code assignment.
Rationale: There is no retained fragment (piece) of a device for which to assign codes.
See also the coding standard Complications of Devices, Implants or Grafts.
728
Chapter XXI — Factors influencing health status

and contact with health services
Admissions “Solely for a Specific Purpose . . .”
This Tip for Coders provides direction on the correct use of the “admission for . . .” codes. Let’s
take a closer look at these codes.
Notes in ICD-10-CA
The note at the block Persons encountering health services for specific procedures and health
care (Z40–Z54) outlines the circumstances under which a code from the block Z40–Z54 is
assigned, as follows:
“Categories (Z40–Z54) are intended for use to indicate a reason for care. They may be used for
patients who have already been treated for a disease or injury, but who are receiving follow-up
or prophylactic care, convalescent care, or care to consolidate the treatment, to deal with
residual states, to ensure that the condition has not recurred, or to prevent recurrence.”
Directive statements from the Canadian Coding Standards for ICD-10-CA

and CCI
The directive statements from the coding standard Admission for Administration of Chemotherapy,
Pharmacotherapy and Radiation Therapy are clear when an “admission for . . .” code is the most
responsible diagnosis (MRDx)/main problem:
• When a patient previously diagnosed with a malignancy has an encounter solely for
the administration of radiation therapy, assign Z51.0 Radiotherapy session as the
MRDx/main problem.
• When a patient previously diagnosed with a malignancy has an encounter solely for the
administration of chemotherapy to treat the malignancy or neoplasm-related conditions,
assign Z51.1 Chemotherapy session for neoplasm as the MRDx/main problem.
However, what about other diagnosis types for an “admission for . . .” code?
729
Direction on diagnosis typing
An “admission for . . .” code is
• The MRDx when a patient previously diagnosed with a condition has an encounter solely for a specific
purpose (e.g., admission for administration of chemotherapy, admission for insertion of vascular access
device, admission for dialysis).
• A diagnosis type (1) only when a patient previously diagnosed with a condition has an encounter solely for a
specific purpose (e.g., admission for administration of chemotherapy, admission for insertion of vascular
access device, admission for dialysis) and, during that encounter, another condition (e.g., chemotherapy-
induced febrile neutropenia) meets the criteria for MRDx.
• Never a diagnosis type (2).
• Never a diagnosis type (3).
Knowledge check
Can you identify the discrepancies?
1. C18.9 (M) Malignant neoplasm colon, unspecified and Z51.1 (1) Chemotherapy session
for neoplasm
2. D70.0 (M) Neutropenia, D70.0 (2) Neutropenia, Y43.3 (9) Other antineoplastic drugs, causing
adverse effects in therapeutic use and Z51.1 (1) Chemotherapy session for neoplasm
3. C34.99 (M) Malignant neoplasm bronchus or lung, unspecified, unspecified side, C79.3 (1)
Secondary malignant neoplasm of brain and cerebral meninges, C78.7 (1) Secondary
malignant neoplasm of liver and intrahepatic bile duct and Z51.1 (1) Chemotherapy session
for neoplasm
4. Z51.5 (M) Palliative care, Z51.1 (1) Chemotherapy session for neoplasm and C85.9 (3) Non-
Hodgkin lymphoma, unspecified
730
Correct answers
While it isn’t always possible to identify an error in a data set unless you have access to the source document,
1 and 3 potentially have errors. It appears that these patients were diagnosed with a malignant neoplasm and
received chemotherapy during the same episode of care. Z51.1 is assigned when the encounter is solely for
the administration of chemotherapy to treat the malignancy and not to identify that chemotherapy was
administered during an episode of care. Administration of chemotherapy is captured with a CCI
(intervention) code.
For 2, it is possible that this patient was admitted solely for the administration of chemotherapy and
that during the episode of care he developed neutropenia (which then met the criteria for the most
responsible diagnosis).
For 4, it is possible that this patient was admitted solely for the administration of chemotherapy but was then
deemed palliative care.
Data quality check
Identify cases when ICD-10-CA codes Z51.0, Z51.1 and Z51.2 are assigned as a diagnosis type other than the
MRDx. Review the assigned codes to determine whether or not there are potential errors.
See also the coding standard Admission for Administration of Chemotherapy, Pharmacotherapy
and Radiation Therapy.
Reference
1. Kramer MS, Rouleau J, Liu S, Bartholomew S, Joseph KS. Amniotic fluid embolism:
Incidence, risk factors, and impact on perinatal outcome. BJOG: An International Journal of
Obstetrics and Gynaecology. 2012.
731
Appendix F1 — References to
mandatory diagnosis type (3)/other
problem in directive statements
This appendix is intended to be a quick reference that summarizes all directive statements
giving instruction to assign a code as diagnosis type (3)/other problem, mandatory. It is
important to always refer to the applicable coding standard to ensure the directive statement
is interpreted within the correct context.
Important: This appendix is not a list of mandatory capture of chronic diseases. This list
represents ICD-10-CA codes that are mandatory to provide additional detail that in themselves
do not represent a condition meeting the criteria for significance.
Notes
• Diabetes mellitus is a chronic condition that is always mandatory to code, when documented,
regardless of whether or not it meets the criteria for significance. See the coding standard
Diabetes Mellitus.
• Chronic kidney disease is mandatory to code when it occurs with acute kidney injury and a
code for the acute kidney injury is assigned. See the coding standard Acute on Chronic
Kidney Disease.
• The “use additional code” instruction in the classification, when associated with certain
conditions, requires the mandatory capture of a chronic condition even when the chronic
condition does not meet the criteria for significance. See the coding standard Use Additional
Code/Code Separately Instructions.
Standard Directive statement Rationale
Dagger/Asterisk Assign diagnosis type (6) or As this is an ICD convention, both codes
Convention diagnosis type (3) to asterisk codes are required. Asterisk codes contain
in accordance with the diagnosis information about both an underlying
typing definitions. generalized disease and a manifestation in
a particular organ or site which is a clinical
problem in its own right.
732
Appendix F1 — References to mandatory diagnosis type (3)/other problem in directive statements
Cancelled When a scheduled or planned intervention It identifies another circumstance for the
Interventions is cancelled due to a contraindication and patient that is important from a national
the patient is treated for the planning and research perspective.
contraindication, assign
• The contraindication as the
MRDx/main problem; and
• Z53.0 Procedure not carried out
because of contradiction as
a diagnosis type (3)/other
problem, mandatory.
Drug-Resistant When there is a current infection that is The code for the infectious organism
Microorganisms clearly documented by the physician/ (B95–B98) is supplemental information
primary care provider as being due to that is required to identify the organism
MRSA, CRE, ESBL producing resistant to the drug.
microorganisms or VRE, assign,
mandatory, the appropriate code
combination to identify the
• Site of the infection, as a significant
diagnosis type/main problem or
other problem;
• Infectious microorganisms from
categories B95–B98 Bacterial, viral
and other infectious agents as a
diagnosis type (3)/other problem; and
• Specific drug-resistance, as a
comorbid diagnosis type (1) or type
(2)/other problem:
− U82.1 Resistance to methicillin; or
− U82.20 Resistance to
carbapenem; or
− U82.28 Resistance to other
specified extended spectrum
betalactam antibiotics; or
− U83.0 Resistance to vancomycin.
733
Drug-Resistant Assign Z22.30– Carrier of drug-resistant It identifies another circumstance for the
Microorganisms microorganism, mandatory, as a diagnosis patient that is important from a national
type (3)/other problem when there is planning and research perspective.
documentation that the patient is a carrier
of a specific drug-resistant microorganism.
Septicemia/Sepsis When septicemia/sepsis is classified to It identifies another condition in the patient

one of the following that is important from a national planning
and research perspective.
O03–O05 Pregnancy with abortive
outcome (with a fourth character .0 or .5)
O07.3 Failed attempted abortion,
complicated
O08.0– Genital tract and pelvic infection
following abortion and ectopic and molar
pregnancy
O75.3– Other infection during labour
O85.– Puerperal sepsis
O98.– Maternal infectious and parasitic
diseases complicating pregnancy,
childbirth and the puerperium (with a
fourth character of .2, .5 or .8)
T80.2 Infections following infusion,
transfusions and therapeutic injection
T81.4 Infection following a procedure, not
T88.0 Infection following immunization
T82–T85 Infections and inflammatory
reaction due to prosthetic devices,
implants and grafts
• Assign the appropriate code from the
list above as a significant diagnosis
type/main or other problem; and
• Assign an additional code,
mandatory, to identify the type of
sepsis as a diagnosis type (3)/other
problem.
734
Human When patients are admitted and It identifies another condition in the patient
Immunodeficiency discharged on the same day for primary that is important from a national planning
Virus (HIV) Disease prophylactic chemotherapy for HIV and research perspective.
infection, select Z29.2 Other prophylactic
chemotherapy as the MRDx/main problem
along with Z21 Asymptomatic human
immunodeficiency virus [HIV] infection
status, mandatory, as an additional
Primary and Secondary When a patient is diagnosed with a It identifies another condition in the patient
Neoplasms secondary neoplasm, assign an additional that is important from a national planning
code, mandatory, to identify the primary and research perspective.
site: a code from either
• Chapter II — Neoplasms; or
• Category Z85 Personal history of
malignant neoplasm when the
malignancy has been completely
eradicated or excised and there is no
further treatment (including adjuvant
therapy) being directed to the
primary site.
Acquired Absence of When a patient has a history of total It identifies another circumstance for the
Breast and Lung Due mastectomy for the treatment of primary patient that is important from a national
to Primary Malignancy malignancy and is now undergoing partial planning and research perspective.
or total excision of the contralateral breast
(with/without reconstruction) for a new
primary breast malignancy, assign two
additional codes, mandatory:
• Z90.1– Acquired absence of breast(s)
as a diagnosis type (3)/other problem;
and
• Z85.3– Personal history of malignant
neoplasm of breast as a diagnosis
735
Acquired Absence of When a patient has a history of lobectomy It identifies another circumstance for the
Breast and Lung Due or pneumonectomy for the treatment of patient that is important from a national
to Primary Malignancy primary malignancy and is now planning and research perspective.
undergoing partial or total excision of
either lung for a new primary lung
malignancy, assign two additional
codes, mandatory:
• Z90.2– Acquired absence of lung [part
of] as a diagnosis type (3)/other
problem; and
• Z85.11– Personal history of malignant
neoplasm bronchus and lung as a
Complications of When a patient is admitted for treatment It identifies another condition in the patient
Malignant Disease of a specific complication of the that is important from a national planning
malignancy, and no treatment is directed and research perspective.
towards the malignancy itself, assign the
code for the complication as the
MRDx/main problem.
• Assign the code for the malignancy,
mandatory, as a diagnosis
Complications of When a patient is admitted for It identifies another condition in the patient
Malignant Disease management of a side effect of cancer that is important from a national planning
treatment, assign a code for the side and research perspective.
effect as the MRDx/main problem.
• Assign the code for the malignancy,
mandatory, as a diagnosis type
(3)/other problem.
Recurrent Assign a code from categories C00–C75 It identifies another condition in the patient
Malignancies when a primary malignancy, eradicated that is important from a national planning
from the same organ or tissue, and research perspective.
has recurred.
• Assign an additional code, mandatory,
from category Z85 Personal history of
malignant neoplasm as a diagnosis
type (3)/other problem to identify the
primary site.
736
Diabetes Mellitus When multiple complications of diabetes This is supplemental information that is
mellitus affect separate body systems and important from a national planning and
none meet the criteria for significance, research perspective.
assign the one code E1–.78 Type ~
diabetes mellitus with multiple
other complications.
Neurologically Assign G93.81 Neurologically determined This is supplemental information that is

Determined Death death as a diagnosis type (3)/other important from a national planning and
problem, mandatory, when there is research perspective.
documentation of brain death by a
designated physician.
Chapter IX — Diseases of circulatory system
Acute Coronary When any code from category I21 Acute This is supplemental information that is
Syndrome (ACS) myocardial infarction or I22 Subsequent important from a national planning and
myocardial infarction or the code I24.0 research perspective.
Coronary thrombosis not resulting in
myocardial infarction is assigned, assign an
additional code from subcategory R94.3–
Abnormal results of cardiovascular function
studies, mandatory, as diagnosis type
(3)/other problem.
Acute Coronary When a code from category I22 This is supplemental information that is
Syndrome (ACS) Subsequent myocardial infarction is important from a national planning and
assigned, assign an additional code from research perspective.
subcategory R94.3- Abnormal results
of cardiovascular function studies,
(3)/other problem.
Strokes: Hemorrhagic, When a patient is admitted solely for This is supplemental information that is
Ischemic and rehabilitation immediately following an important from a national planning and
Unspecified acute/current stroke diagnosis, assign a research perspective.
code from category Z50.– Care involving
use of rehabilitation procedures as
the MRDx.
• Assign an additional code as a

diagnosis type (3), mandatory,
to identify the specific type of
acute/current stroke (i.e., I60, I61,
I63, I64).
737
Fractures — When a combination category is not It identifies another condition in the patient
Pathological fractures available or when a dagger/asterisk that is important from a national planning
convention is not applicable, assign and research perspective.
separate codes for the pathological
fracture and the underlying disease
that precipitated the fracture.
• Sequence the code for the
pathological fracture first, followed
by the code for the underlying disease
as a mandatory diagnosis type
(3)/other problem.
Continuous Assign an additional code from category This identifies another condition in the
Ambulatory Peritoneal K65 Peritonitis, mandatory, as a diagnosis patient that is important from a national
Dialysis (CAPD) type (3)/other problem, to specify planning and research perspective.
Peritonitis the infection.
Pregnancy With When a medical abortion is performed at It identifies another condition in the patient
Abortive Outcome — or after 20 weeks gestation and it results that is important from a national planning
Medical abortion at in a stillborn, assign P96.4 Termination of and research perspective.
or after 20 weeks pregnancy, affecting fetus and newborn
resulting in a stillborn as the MRDx/main problem on the
stillborn abstract.
• When applicable, assign an additional
code(s), mandatory, as a diagnosis
type (3)/other problem to describe any
associated congenital anomaly.
Pregnancy With When a medical abortion performed at or This is supplemental information that is
Abortive Outcome — after 20 weeks gestation results in a important from a national planning and
Medical abortion liveborn, assign: research perspective.
resulting in a liveborn
On the mother’s abstract, a code from
• Category O04 Medical abortion, as the
• Category Z37 Outcome of delivery as
a diagnosis type (3)/other problem to
indicate that the abortion resulted in
a liveborn.
738
Delivery in a Assign a code from category Z37 This is supplemental information that is
Normal Case Outcome of delivery, mandatory, for important from a national planning and
all deliveries. research perspective.
• When any other code from Chapter XV
— Pregnancy, childbirth and the
puerperium applies to the case, assign
the appropriate code from category
Z37, mandatory, as a diagnosis
type (3).
Complicated When a condition that complicates As this is an ICD convention, the “use
Pregnancy Versus the pregnancy is classified to a code from additional code” instruction provides
Uncomplicated O99 Other maternal diseases classifiable direction to assign an additional code to
Pregnancy elsewhere but complicating pregnancy, identify the specific condition.
childbirth and the puerperium, assign an
additional code, mandatory, as a
diagnosis type (3)/other problem, to
identify the specific condition, per the
“use additional code” instruction.
Complicated When a code from Chapter XV is not This is supplemental information that is
Pregnancy Versus assigned during the antepartum episode important from a national planning and
Uncomplicated of care, assign Z33 Pregnant state, research perspective.
Pregnancy incidental, mandatory, as a diagnosis
type (3).
Post-Intervention When a post-intervention condition is This is supplemental information that is
Conditions classified to a code that does not fully important from a national planning and
describe the condition, assign an research perspective.
additional code (when available),
mandatory, as a diagnosis type (3)/other
problem to provide more detail regarding
the nature of the condition.
Pre-Treatment When a significant condition diagnosed This is supplemental information that is

Assessment during the pre-treatment assessment important from a national planning and
requires further treatment or investigation, research perspective.
assign a code for the significant condition
• Assign Z01.8 Other specified special
examination, mandatory, as a
739
Admission for Follow- When the examination reveals that the This is supplemental information that is
Up Examination original condition has recurred or identifies important from a national planning and
another related condition, assign research perspective.
• A code for the condition as the
• An additional code from Z08 or Z09,
(3)/other problem
Admission for When a patient is transferred from one This is supplemental information that is
Convalescence hospital to another or admitted from day important from a national planning and
surgery to inpatient care solely for the research perspective.
purpose of receiving care in the recovery
phase following treatment of an illness or
injury or following a surgical intervention,
assign a code from category Z54
Convalescence as the MRDx.
• Assign an additional code, mandatory,
as a diagnosis type (3) to indicate
the condition for which convalescence
is required.
Screening for When the condition or a sign of the This is supplemental information that is
Specific Diseases condition for which the patient is screened important from a national planning and
is found, assign a code research perspective.
• For the condition or sign as the
• From Z11, Z12 or Z13, mandatory,
as a diagnosis type (3)/other problem.
Admission for When a patient previously diagnosed It identifies another condition in the patient
Administration of with a malignancy has an encounter that is important from a national planning
Chemotherapy/ solely for the administration of radiation and research perspective.
Pharmacotherapy and therapy, assign
Radiation Therapy • Z51.0 Radiotherapy session as the
MRDx/main problem; or
• Z51.0 Radiotherapy session as a
diagnosis type (1)/other problem
when a post-admit condition arises
during the episode of care and that
condition meets the criteria for
MRDx/main problem.
740
Admission for When a patient previously diagnosed with

Administration of a malignancy has an encounter solely for
Chemotherapy/ the administration of chemotherapy to
Pharmacotherapy and treat the malignancy or neoplasm-related
Radiation Therapy conditions, assign
(cont’d)
• Z51.1 Chemotherapy session for
neoplasm as the MRDx/main
problem; or
• Z51.1 Chemotherapy session for
neoplasm as a diagnosis type (1)/other
problem when a post-admit condition
arises during the episode of care and
that condition meets the criteria for
MRDx/main problem.
Assign an additional code to identify the
malignant condition, mandatory, as a
diagnosis type (3)/other problem for
radiation therapy visits and
chemotherapy visits.
Admission for When a patient previously diagnosed with It identifies another condition in the patient
Administration of a non-malignant condition has an that is important from a national planning
Chemotherapy/ encounter solely for the administration of and research perspective.
Pharmacotherapy and chemotherapy, assign
Radiation Therapy
• Z51.2 Other chemotherapy as the
MRDx/main problem; or
• Z51.2 Other chemotherapy as a
when a post-admit condition arises
during the episode of care and meets
the criteria for MRDx/main problem.

disease/condition, mandatory, as a
741
Admission for When a patient is admitted solely for It identifies another condition in the patient
Insertion of a Vascular insertion of a vascular access device (VAD) that is important from a national planning
Access Device (VAD) for treatment of an existing condition, and research perspective.
assign Z51.4 Preparatory care for
subsequent treatment, not elsewhere
classified as the MRDx/main problem.
Classify any encounter that is solely for

adjustment or removal (without
replacement) of an implanted VAD to
Z45.2 Adjustment and management of
vascular access device as the
MRDx/main problem.

disease/condition, mandatory, as a
Personal History of Assign a code from Z85.11– Personal It identifies another circumstance for the
Primary Malignant history of malignant neoplasm of bronchus patient that is important from a national
Neoplasms of Breast, and lung or Z85.3– Personal history of planning and research perspective.
Lung and Prostate malignant neoplasm of breast or Z85.4
Personal history of malignant neoplasm of
genital organs, mandatory, as a diagnosis
type (3)/other problem when all of the
following criteria are met:
• There is a history of primary
malignancy of the breast, lung or
prostate; and
• The previous malignancy has been
completely excised or eradicated; and
• There is no further treatment (including
adjuvant therapy) directed to the
primary site; and
• The current episode of care relates
to a follow-up examination,
prophylactic organ removal or
Homelessness Assign Z59.0 Homelessness as a It identifies another circumstance for the

diagnosis type (3)/other problem, patient that is important from a national
mandatory, for patients who are planning and research perspective.
homeless on admission.
742
Appendix F2 — References to optional diagnosis type (3)/other problem in directive statements
Appendix F2 — References to
optional diagnosis type (3)/other
problem in directive statements
The purpose of this appendix is to provide a summary of all directive statements giving
instruction to assign a code as diagnosis type (3)/other problem as optional or not specified
as mandatory. It is important to always refer to the applicable coding standard to ensure the
directive statement is interpreted within the correct context.
Important: This appendix is not a list of optional capture of chronic diseases. This list
represents ICD-10-CA codes that are optional to provide detail that in themselves do not
represent a condition meeting the criteria for significance.

Acute and Chronic When a condition is described as being This is supplemental information that is
Conditions both acute (or subacute) and chronic, and useful for local data retrieval.
ICD-10-CA provides separate categories
or subcategories for each but not for the
combination, assign a code for the
acute condition.
• Assign a code for the chronic
condition, optional, as a diagnosis
Underlying Symptoms When a patient presents with a symptom This is supplemental information that is
or Conditions or condition and, during that episode of useful for local data retrieval.
care, the underlying disease or disorder is
identified, assign the underlying disease or
disorder as the MRDx/main problem.
• Assign an additional code for the
symptom or condition, optional, as a
743
Unconfirmed Diagnosis When two (or more) unconfirmed This is supplemental information that is
diagnoses are recorded as the final useful for local data retrieval.
diagnosis and there is no further
information or clarification, assign the
first-listed unconfirmed diagnosis as the
MRDx/main problem. Assignment of a
code for the additional unconfirmed
diagnosis is optional. If assigned, it is a
• Apply the prefix Q in

such circumstances.
Unconfirmed Diagnosis When a sign, symptom or abnormal This is supplemental information that is
finding and an unconfirmed diagnosis useful for local data retrieval.
are recorded as the final diagnosis and
there is no further information or
clarification, assign the code representing
the sign, symptom or abnormal finding.
Assignment of a code for the unconfirmed
diagnosis is optional. If assigned, it is a
diagnosis type (3)/other problem and
prefix Q is mandatory to apply.
Sequelae When a patient presents with a sequela of This is supplemental information that is
a previously treated condition, assign a useful for local data retrieval.
code for the current condition under
investigation or treatment as a significant
diagnosis type.
• Assign codes from categories titled
“Sequelae of…” (B90–B94, E64, E68,
G09, I69, O94, O97, T90–T98),
optional, as a diagnosis type (3)/other
problem to identify the current problem
as sequelae.
744
Infections When the causative organism is known, This is supplemental information that is
classify the case in one of the following useful for local data retrieval.
three ways, as indicated by the
classification:
• Use the dual classification
(dagger/asterisk) with a code
specifying the infectious organism
followed by the manifestation. Both
codes must be used together
to identify the infectious disease.
• Use a combination code.
• Use two codes, the first identifying the
locally manifesting disease and the
second identifying the infectious
organism. The infectious agent is
classified to categories B95–B98.
Assignment of codes from categories
B95–B98 is optional; if coded, they
must be assigned diagnosis type (3)/
other problem.
Exception: It is mandatory to assign a
code from B95–B98 Bacterial, viral and
other infectious agents as a diagnosis type
(3)/other problem when the causative
agent is one of the specific drug-resistant
microorganisms. See also the coding
standard Drug-Resistant Microorganisms.

Acute Coronary Assign I25.2 Old myocardial infarction It identifies another condition in the
Syndrome (ACS) (i.e., “history of MI”) optional, as a patient that is useful for local
diagnosis type (3) only when both of the data retrieval.
following criteria apply:
• The previous myocardial infarction
occurred more than 4 weeks (28 days)
ago; and
• The patient is not currently receiving
observation, evaluation or treatment
for the previous myocardial infarction.
745
Chapter XII — Diseases of the skin and subcutaneous tissue
Cellulitis When the course of treatment involves This is supplemental information that is
intravenous antibiotics, sequence useful for local data retrieval.
cellulitis as the MRDx/main problem and
record the soft tissue injury as an
additional diagnosis/other problem.
When the course of treatment involves

only oral antibiotics, sequence the soft
tissue injury as the MRDx/main problem
and the cellulitis as a comorbid
condition/other problem.
Assign an additional code, optional, as a

diagnosis type (3)/other problem from the
range B95–B98 Bacterial, viral and other
infectious agents when a causative agent
is identified.
Exception: It is mandatory to assign a

code from B95–B98 Bacterial, viral and
other infectious agents as a diagnosis type
(3)/other problem when the causative
agent is one of the specific drug-resistant
microorganism infections. See also the
coding standard Drug-Resistant
Microorganisms.
Streptococcal Group B Assign O23.90– Other and unspecified It identifies another circumstance in
Infection/Carrier in genitourinary tract infection in pregnancy the patient that is useful for local
Pregnancy only when there is documented evidence data retrieval.
of an active infection.
• When there is active infection, assign
B95.1 Streptococcus, Group B, as the
cause of diseases classified to other
chapters, optional, as a diagnosis type
(3) to identify the organism.
Assign Z22.38 Carrier of other specified

bacterial diseases, optional, as a
diagnosis type (3) to identify GBS
carrier state.
When antibiotics are given for prophylaxis in

a GBS carrier patient, assign Z29.2 Other
prophylactic chemotherapy, optional, as a
diagnosis type (3).
746
Congenital Anomaly When a patient is diagnosed with This is supplemental information that is
Syndromes and Specific multiple congenital anomalies described useful for local data retrieval.
Manifestations as a syndrome that cannot be classified
to a more specific code (see flowchart
below), assign Q87.8 Other specified
congenital malformation syndromes, not
elsewhere classified.
• Assign additional codes from
Q00–Q85.9 or other appropriate
chapter to provide further specificity,
− Mandatory, when the anomalies
meet the criteria for significance; or
− Optional, when the anomalies
do not meet the criteria
for significance.
Congenital Anomaly When a patient presents solely for This is supplemental information that is
Syndromes and Specific management of a specific manifestation of useful for local data retrieval.
Manifestations a congenital anomaly syndrome, assign a
code for the manifestation as the MRDx/
main problem.
• Assign an additional code, optional, as

describe the syndrome.
Systemic Inflammatory When SIRS of an infectious origin is This is supplemental information that is
Response Syndrome present without organ failure, assign useful for local data retrieval.
(SIRS) • A code identifying the type of
sepsis; and
• R65.0 Systemic inflammatory
response syndrome of infectious origin
without organ failure, optional, as a
Adverse Reactions in Classify conditions resulting from It identifies another circumstance in
Therapeutic Use noncompliance with therapy to a code the patient that is useful for local
Versus Poisonings describing the manifestation followed data retrieval.
by Z91.1 Personal history of
noncompliance with medical treatment
and regimen, optional, as a diagnosis
747
Current Versus Old When a patient presents with a condition This is supplemental information that is
Injuries that is a sequela/late effect resulting from useful for local data retrieval.
a previous injury, assign a code for the
current condition under investigation
or treatment.
• Assign a code from T90–T98 Sequelae
of injuries, of poisoning and of other
consequences of external causes,
optional, as a diagnosis type (3)/other
problem to identify the current
condition as a sequela of an injury.
Crush Injuries Assign all significant injuries associated This is supplemental information that is
with a crush injury as comorbid conditions useful for local data retrieval.
or a main/other problem.
a diagnosis type (3)/other problem, to
identify the crush injury. When multiple
body regions are involved in a crush
injury, select the crush injury code from
the category T04 Crushing injuries
involving multiple body regions.
Burns and Corrosions When a patient presents for change of This is supplemental information that is
burn dressings, assign as the MRDx/main useful for local data retrieval.
problem Z48.0 Attention to surgical
dressings and sutures.
identify the burn itself.
Burns of Multiple When documentation of specific sites of This is supplemental information that is
Body Regions burns is provided, assign separate codes useful for local data retrieval.
for each burn site.
Assign T29.– Burns and corrosions of

multiple body regions, optional, as a
diagnosis type (3)/other problem, to
facilitate data retrieval.
Rejection/Failure of When a condition is documented as This is supplemental information that is

Transplanted Organs, affecting the transplanted organ or tissue useful for local data retrieval.
Grafts and Flaps but it cannot be classified as either failure
or rejection, assign a code for the
condition and assign an additional code
from category Z94 Transplanted organ
and tissue status, optional, as a diagnosis
748
Pre-Treatment Assign Z01.8 Other specified special It identifies another condition in

Assessment examination to describe an encounter for a the patient that is useful for local data
pre-treatment assessment. retrieval.
Assign an additional code to describe

the underlying reason for the
assessment, optional, as a diagnosis
Admission for Assign a code from category Z03 Medical It identifies another condition in
Observation observation and evaluation for suspected the patient that is useful for local
diseases and conditions as the MRDx/main data retrieval.
problem when a patient with a sign,
symptom and/or abnormal finding is
investigated for a suspected condition and
all of the following criteria are met:
• The suspected condition is ruled
out/not found; and
• There is no documentation to
support that further investigation
is required; and
• Another underlying condition is
not identified.
Assign an additional code for the sign,

symptom or abnormal finding, optional, as
a diagnosis type (3)/other problem based
on the facility’s data needs.
Admission for When a patient is investigated for a It identifies another condition in

Observation suspected condition and the suspected the patient that is useful for local
condition is found, assign a code for the data retrieval.
identified underlying condition as the
MRDx/main problem.
Assign an additional code for the sign,

symptom or abnormal finding, optional, as
a diagnosis type (3)/other problem based
on the facility’s data needs.
749
Admission for Follow-Up When the purpose of the examination is to It identifies another condition in
Examination assess the status of a previously treated the patient that is useful for local
condition or injury (a personal history data retrieval.
classifiable to categories Z85–Z88) and
the outcome indicates no need for
further treatment, select the appropriate
code from one of the following as the
MRDx/main problem:
• Z08 Follow-up examination after
treatment for malignant neoplasm; or
• Z09 Follow-up examination after
treatment for conditions other than
malignant neoplasms.
− In either case, assign an additional
code indicating a personal history
of the condition, optional, as a
diagnosis type (3)/other problem,
unless identified as mandatory
elsewhere in the coding standards.
Admission for Follow-Up When the sole purpose of the encounter It identifies another condition in
Examination is to receive a specific intervention or the patient that is useful for local
service, select the appropriate code data retrieval.
from one of the following as the MRDx/
main problem:
Z39.2 Routine postpartum follow-up

Z42 Follow-up care involving
plastic surgery
Z47 Other orthopaedic follow-up care
Z48 Other surgical follow-up care
describe the underlying disease or
injury for which specific follow-up care
is required.
750
Screening for When a patient undergoes a screening It identifies another condition in

Specific Diseases examination and no sign of disease is the patient that is useful for local
found, assign a code from category Z11, data retrieval.
Z12 or Z13 as the MRDx/
main problem.
Assign an additional code, optional, as

identify any circumstances indicating the
reason for the screening test (such as
family history).
Assign an additional code, optional, as

identify any incidental findings noted at
the time of the exam.
Coding of NACRS Visits Assign a code from category Z50 Care It identifies another condition in
for Rehabilitative involving use of rehabilitation procedures the patient that is useful for local
Services as the main problem when rehabilitation is data retrieval.
a reason for the NACRS visit.
When a person is referred solely for

physical therapy (care involving use of
rehabilitation procedures), assign Z50.1
Other physical therapy as the
main problem.
Assign an additional code, optional,

as an other problem to identify the
underlying disorder.
Admission for Blood When a patient is admitted solely for It identifies another condition in
Transfusion the purpose of a blood transfusion the patient that is useful for local
session, assign data retrieval.
• Z51.3 Blood transfusion (without
reported diagnosis) as the MRDx/
main problem; and
• An additional code to identify the
disease/condition, optional, as a
Personal and Family Assign a code from Z80 Family history It identifies another condition in
History of Malignant of malignant neoplasm, optional, as the patient that is useful for local data
Neoplasms diagnosis type (3)/other problem to retrieval.
denote a reason for an examination or
prophylactic surgery.
751
Appendix G — Text alternative

for images
Text alternative for flowchart in coding standard Diagnosis Typing Definitions for DAD,
Assigning prefixes 5 and 6 to a DAD inpatient abstract, page 30
This flowchart describes the time frame from the post-admit comorbidity (diagnosis type 2) to
the first qualifying intervention episode.
Is this a DAD acute care inpatient abstract?

If no, prefixes 5 and 6 do not apply.
If yes, is there at least one post-admit comorbidity (diagnosis type 2) on the abstract (excludes
OBS codes O00 to O99)?
If yes, is there at least one qualifying intervention on the abstract (intervention performed in
main operating room [location 01] or cardiac catheterization room [location 08] or an out-of-
hospital [OOH] intervention from 3.IP.10, 1.IJ.50 or 1.IJ.57)?
If yes, for each post-admit comorbidity (diagnosis type 2) on the abstract, establish whether this
condition arose before or after the first qualifying intervention episode (the qualifying
intervention episode with the earliest start date) and assign prefix 5 or 6 accordingly.
If the post-admit comorbidity arose before the first qualifying intervention episode,
assign prefix 5.
If the post-admit comorbidity arose during or after the first qualifying intervention,
assign prefix 6.
Text alternative for flowchart in coding standard Hierarchy for Classification of

Intracranial Lesion Resection, page 217
When an intracranial resection overlaps regions of the brain and involves the cranium or skull
base, classify the excision to rubric 1.EA.92.^^ Excision radical with reconstruction, cranium.
When an intracranial resection that overlaps regions of the brain is described as a posterior
fossa resection and involves the brain stem, classify the excision to rubric 1.AP.87.^^ Excision
partial, brain stem.
752
Appendix G — Text alternative for images
fossa resection and involves the ventricles of the brain, classify the excision to rubric 1.AC.87.^^
Excision partial, ventricles of brain.
fossa resection and involves the cerebellopontine angle, classify the excision to rubric
1.AK.87.^^ Excision partial, cerebellopontine angle.
fossa resection and involves the cerebellum, classify the excision to rubric 1.AJ.87.^^ Excision
partial, cerebellum.
When an intracranial resection overlaps regions of the brain and involves one or more lobes of
the brain, classify the excision to rubric 1.AN.87.^^ Excision partial, brain.
When an intracranial resection overlaps regions of the brain and primarily involves the pituitary
region, classify the excision to rubric 1.AF.87.^^ Excision partial, pituitary region.
When an intracranial resection overlaps regions of the brain and primarily involves the pineal
gland, classify the excision to rubric 1.AG.87.^^ Excision partial, pineal gland.
When an intracranial resection overlaps regions of the brain and involves only the meninges or
dura mater of the brain, classify the excision to rubric 1.AA.87.^^ Excision partial, meninges and
dura mater of brain.
Text alternative for flowchart in coding standard Seizures, Correct index search for
seizure(s) and seizure disorder, page 221
When the diagnosis is recorded as seizures(s) or seizure disorder and the seizure is due to
alcohol or psychoactive drug withdrawal, search the ICD-10-CA alphabetical index on the lead
term “withdrawal” and the subterm “state.” This search leads to the block F10 to F19.
When the seizure is due to high fever or documented as a febrile seizure, search the ICD-10-CA
alphabetical index on the lead term “seizure” and the subterm “febrile.” This search leads to
sub-category R56.0–.
When an acute medical illness provokes a seizure, assign a code for the acute illness and
assign R56.88 Other and unspecified convulsions, optionally.
When the diagnosis is a single, isolated or first seizure, search the ICD-10-CA alphabetical index
on the lead term “seizure.” This search leads to R56.88 Other and unspecified convulsions.
When the diagnosis is seizure with a history of previous seizure(s) or recurrent seizures, search
the ICD-10-CA alphabetical index on the lead term “epilepsy.” This search leads to category
G40.– Epilepsy.
When the diagnosis is recorded as seizure(s) or seizure disorder and there is nothing
documented about a history of previous seizure(s) or recurrent seizures, search the ICD-10-CA
753
alphabetical index on the lead term “disorder” and subterm “seizure.” This search leads to
R56.80 Seizure disorder, so described.
Text alternative for flowchart in coding standard Selection of Status Attribute for
Percutaneous Coronary Intervention (PCI), page 247
When an elective percutaneous coronary intervention (PCI) is performed, apply status attribute
“P” — elective PCI to the code from rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI is performed and there is not a current acute coronary syndrome
(ACS) diagnosis, apply status attribute “OP” — other PCI to the code from rubric 1.IJ.50.^^
Dilation, coronary arteries.
When a non-elective PCI is a second stage of a staged PCI performed for a current ACS
diagnosis of ST-segment elevation myocardial infarction (STEMI), classified to R94.30, apply
status attribute “OP” — other PCI to the code from rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI that is not a second stage of a staged PCI is performed and there is a
current ACS diagnosis of STEMI, classified to R94.30, and the patient received thrombolytic
therapy prior to the PCI, apply status attribute “D1” — other PCI for STEMI to the code from
rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI that is not a second stage of a staged PCI is performed within 12 hours
of presentation at the first hospital, and there is a current ACS diagnosis of STEMI, classified to
R94.30, and the patient did not receive thrombolytic therapy prior to the PCI, apply status attribute
“N” — primary PCI for STEMI to the code from rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI that is not a second stage of a staged PCI is not performed within 12 hours
of presentation at the first hospital and there is a current ACS diagnosis of STEMI, classified to
R94.30, and the patient did not receive thrombolytic therapy prior to the PCI, apply status attribute
“D1” — other PCI for STEMI to the code from rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI is performed and the current ACS diagnosis is I24.9 Acute ischaemic
heart disease, unspecified (i.e., the diagnosis is not STEMI, classified to R94.30; or is not non-
ST-segment elevation myocardial infarction [NSTEMI], classified to R94.31; or is not unstable
angina, classified to I20.0), apply status attribute “UN” — unknown to the code from rubric
1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI is a second stage of a staged PCI performed for a current ACS
diagnosis of NSTEMI, classified to R94.31, or unstable angina, classified to I20.0, apply status
attribute “OP” — other PCI to the code from rubric 1.IJ.50.^^ Dilation, coronary arteries.
When a non-elective PCI that is not a second stage of a staged PCI is performed for a current
ACS diagnosis of NSTEMI, classified to R94.31, or unstable angina, classified to I20.0, apply
status attribute “UR” — urgent PCI for NSTEMI or UA (unstable angina) to the code from rubric
1.IJ.50.^^ Dilation, coronary arteries.
754
Note: Ensure that status attribute N — primary PCI for STEMI or D1 — other PCI for STEMI is
selected only with a diagnosis of STEMI (i.e., R94.30 must be assigned on the abstract).
Text alternative for flowchart in coding standard Resection of Space-Occupying Lesions

(Polyps) of Nose, page 291
When a resection of a space-occupying lesion (polyp) of the nose extends into the nasopharynx,
classify the excision to a code from rubric 1.FA.87.^^ Excision partial, nasopharynx.
When a resection of a space-occupying lesion (polyp) of the nose extends into the nasopharynx
and involves a radical nasopharyngectomy, classify the excision to a code from rubric
1.FA.91.^^ Excision radical, nasopharynx.
When a resection of a space-occupying lesion (polyp) of the nose extends into multiple sinuses
but not as far as the nasopharynx, classify the excision to a code from rubric 1.EY.87.^^
Excision partial, paranasal sinuses.
When a resection of a space-occupying lesion (polyp) of the nose extends into multiple sinuses
but not as far as the nasopharynx and involves a radical pansinusectomy, classify the excision
to a code from rubric 1.EY.91.^^ Excision radical, paranasal sinuses.
When a resection of a space-occupying lesion (polyp) of the nose extends into the ethmoid sinus
only, classify the excision to a code from rubric 1.EU.87.^^ Excision partial, ethmoidal sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the ethmoid
sinus only and involves a total exenteration, classify the excision to a code from rubric
1.EU.89.^^ Excision total, ethmoidal sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the sphenoid sinus
only, classify the excision to a code from rubric 1.EV.87.^^ Excision partial, sphenoidal sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the frontal sinus
only, classify the excision to a code from rubric 1.EX.87.^^ Excision partial, frontal sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the maxillary sinus
only, classify the excision to a code from rubric 1.EW.87.^^ Excision partial, maxillary sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the maxillary
sinus only and involves a radical antrectomy, classify the excision to a code from rubric
1.EW.91.^^ Excision radical, maxillary sinus.
When a resection of a space-occupying lesion (polyp) of the nose extends into the nasal cavity —
middle meatus only, classify the excision to a code from rubric 1.ET.87.^^ Excision partial, nose.
755
Text alternative for flowchart in coding standard Septoplasty for Deviated Nasal Septum,
page 293
When a septoplasty is performed to correct a deviated nasal septum and it is included as part of
an intervention involving reshaping of the nasal bone or bones, classify the intervention to a
code from rubric 1.ET.80.^^ Repair, nose. This rubric includes septoplasty (repositioning or
realignment of nasal cartilage [septum]) with nasal tip/bone reshaping (e.g., rasping, osteotomy,
bone fracturing), with or without turbinectomy.
When a septoplasty is performed to correct a deviated nasal septum and it involves resection
of the septum with (cartilage) graft, classify the intervention to a code from rubric 1.ES.80.^^
Repair, nasal cartilage. This may involve some resection of bones that articulate with the
septum (e.g., ethmoid, vomer, maxillary crest), with or without turbinectomy.
When a septoplasty is performed to correct a deviated nasal septum and it involves resection of
the septum without (cartilage) graft, classify the intervention to 1.ES.87.LA Excision partial,
nasal cartilage, using open approach with simple apposition (suturing) for closure. This includes
a simple septoplasty involving trimming of the septum with a swing to midline; it may also
involve some resection of bones that articulate with the septum (e.g., ethmoid, vomer, maxillary
crest), with or without turbinectomy. An example is a submucous resection of the septum.
When a septoplasty is performed to correct a deviated nasal septum and it involves manual
reduction of the nasal structures without resection or graft, classify the intervention to a code
from rubric 1.ET.73.^^ Reduction, nose. This involves reduction of the nasal structures into
proper alignment; it may also involve reducing the turbinates.
Text alternative for flowchart in coding standard Arthrectomy and Arthroplasty, page 314
When an arthrectomy is concomitant with a joint replacement or joint resurfacing, either using an
antibiotic cement spacer or a joint prosthesis, classify the intervention to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, generic intervention 53 Implantation, joint, by site.
When an arthrectomy is concomitant with a joint release, loose body extraction, ligament repair,
excision or other arthroplasty, classify the intervention to CCI Section 1 — Physical/Physiological
Therapeutic Interventions, generic intervention 80 Repair, joint, by site.
An arthrectomy alone, without any concomitant interventions, is classified to CCI Section 1 —

Physical/Physiological Therapeutic Interventions, generic intervention 87 Excision partial, joint,
by site.
Text alternative for flowchart in coding standard Fractures, page 319
When the fracture is the result of a birth injury, classify it to a code from category P13 Birth
injury to skeleton.
When the fracture is a periprosthetic fracture, classify it to a code from subcategory M96.6
Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate.
756
When the fracture is the result of iatrogenic trauma while inserting an orthopedic prosthetic
implant or a fixation device, or during another intervention, classify it to T81.88 Other
complications of procedures, not elsewhere classified, along with a code for the fracture, by site
from Chapter XIX — Injury, poisoning and certain other consequences of external causes.
When the fracture is the result of trauma, classify it to a code from Chapter XIX — Injury,
poisoning and certain other consequences of external causes, for the fracture, by site.
When the fracture is a pathological fracture of a vertebra and the underlying disease process is
a neoplasm (classified to a code from the range C00 to D48), classify it to M49.5 Collapsed
vertebra in diseases classified elsewhere. M49.5 is an asterisk code or manifestation code, so
an additional code (a dagger code) to denote the etiology or underlying disease is also required.
When the fracture is a pathological fracture of a bone other than a vertebra and the underlying
disease process is a neoplasm (classified to a code from the range C00 to D48), classify it to
M90.7 Fracture of bone in neoplastic disease. M90.7 is an asterisk code or manifestation code, so
an additional code (a dagger code) to denote the etiology or underlying disease is also required.
When the fracture is a pathological fracture and the underlying disease process is osteoporosis,
classify it to a code from category M80 Osteoporosis with pathological fracture.
When the fracture is a pathological fracture not elsewhere classified, classify it to M84.4
Pathological fracture, not elsewhere classified.
When a vertebral fracture is described as a stress fracture or as being due to overexertion

alone, classify it to a code from subcategory M48.4 Fatigue fracture of vertebra.
When the fracture of a bone other than a vertebra is described as a stress fracture or as being
due to overexertion alone, classify it to a code from subcategory M84.3 Stress fracture, not
elsewhere classified.
Text alternative for flowchart in coding standard Joint Fracture Reduction, Fixation and
Fusion, page 320
When a joint only is reduced into place, whether it is a closed or an open reduction, classify the
intervention to CCI Section 1 — Physical/Physiological Therapeutic Interventions, generic
intervention 73 Reduction, joint, by site.
When a fixation device is inserted into the joint, with or without concomitant joint reduction,
classify the intervention to CCI Section 1 — Physical/Physiological Therapeutic Interventions,
generic intervention 74 Fixation, joint, by site.
When a fixation device is inserted into the joint, with or without concomitant joint reduction, to
fuse the joint — which often involves a bone graft — classify the intervention to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, generic intervention 75 Fusion, joint, by site.
757
When a fracture through a joint is repaired without a fixation device, classify the intervention to
CCI Section 1 — Physical/Physiological Therapeutic Interventions, generic intervention 80
Repair, joint, by site.
Text alternative for flowchart in coding standard Excision (of Lesion) of Bone, Soft
Tissue and Skin, page 322
When excision of a lesion includes bone with other soft tissue, classify the excision to CCI
Section 1 — Physical/Physiological Therapeutic Interventions, generic intervention 91 Excision
radical, bone by site, to one of the following rubrics:
1.TK.91.^^ Excision radical, humerus
1.TV.91.^^ Excision radical, radius and ulna
1.SQ.91.^^ Excision radical, pelvis
1.VC.91.^^ Excision radical, femur
1.VQ.91.^^ Excision radical, tibia and fibula
When excision of a lesion of the cranium includes bone with other soft tissue, classify the
excision to CCI Section 1 — Physical/Physiological Therapeutic Interventions, generic
intervention 92 Excision radical with reconstruction, cranium, to the following rubric:
1.EA.92.^^ Excision radical with reconstruction, cranium
When excision of a lesion includes bone alone, classify the excision to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, generic intervention 87 Excision partial, bone
by site, to one of the following rubrics:
1.EA.87.^^ Excision partial, cranium
1.EB.87.^^ Excision partial, zygoma
1.ED.87.^^ Excision partial, maxilla
1.EE.87.^^ Excision partial, mandible
1.SF.87.^^ Excision partial, sacrum and coccyx
1.SL.87.^^ Excision partial, ribs
1.SM.87.^^ Excision partial, clavicle
1.SN.87.^^ Excision partial, scapula
1.SQ.87.^^ Excision partial, pelvis
1.SW.87.^^ Excision partial, pubis
1.TK.87.^^ Excision partial, humerus
1.TV.87.^^ Excision partial, radius and ulna
1.UC.87.^^ Excision partial, distal radioulnar joint and carpal joints and bones
1.UF.87.^^ Excision partial, other metacarpal bones
1.UJ.87.^^ Excision partial, other phalanx of hand
758
1.VC.87.^^ Excision partial, femur

1.VQ.87.^^ Excision partial, tibia and fibula
1.WE.87.^^ Excision partial, tarsal bones and intertarsal joints [hindfoot, midfoot]
1.WJ.87.^^ Excision partial, tarsometatarsal joints, other metatarsal bones and other
metatarsophalangeal joints [forefoot]
1.WL.87.^^ Excision partial, other phalanx of foot
When excision of a lesion is a minor debridement only that involves soft tissues (e.g., muscle,
tendon) with or without skin, classify the excision to CCI Section 1 — Physical/Physiological
Therapeutic Interventions, generic intervention 59 Destruction, soft tissue by site, to one of the
following rubrics:
1.TX.59.^^ Destruction, soft tissue of arm NEC
1.UY.59.^^ Destruction, soft tissue of the wrist and hand
1.VX.59.^^ Destruction, soft tissue of leg
1.WV.59.^^ Destruction, soft tissue of the foot and ankle
When excision of a lesion is a non-viable (necrotic) muscle flap that involves soft tissues (e.g.,
muscle, tendon) with or without skin, classify the excision to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, generic intervention 87 Excision partial,
muscle by site, to one of the following rubrics:
1.EP.87.^^ Excision partial, muscles of head and neck
1.SG.87.^^ Excision partial, muscles of the back
1.SY.87.^^ Excision partial, muscles of the chest and abdomen
1.TQ.87.^^ Excision partial, muscles of the forearm [around elbow]
1.VD.87.^^ Excision partial, muscles of hip and thigh
When excision of a lesion involves soft tissues (e.g., muscle, tendon) with or without skin,
classify the excision to CCI Section 1 — Physical/Physiological Therapeutic Interventions,
generic intervention 87 Excision partial, soft tissue by site, to one of the following rubrics:
1.EQ.87.^^ Excision partial, soft tissue of head and neck

1.SH.87.^^ Excision partial, soft tissue of the back
1.SZ.87.^^ Excision partial, soft tissue of the chest and abdomen
1.TX.87.^^ Excision partial, soft tissue of arm NEC
1.UY.87.^^ Excision partial, soft tissue of the wrist and hand
1.VX.87.^^ Excision partial, soft tissue of leg
1.WV.87.^^ Excision partial, soft tissue of the foot and ankle
759
When excision of a lesion involves only skin, is a minor debridement only and is followed by a
skin graft or flap, classify the excision to CCI Section 1 — Physical/Physiological Therapeutic
Interventions, generic intervention 80 Repair, skin by site, to one of the following rubrics:
1.CX.80.^^ Repair, eyelid NEC
1.YA.80.^^ Repair, scalp
1.YB.80.^^ Repair, skin of forehead
1.YC.80.^^ Repair, skin of ear
1.YD.80.^^ Repair, skin of nose
1.YE.80.^^ Repair, lip
1.YF.80.^^ Repair, skin of face
1.YG.80.^^ Repair, skin of neck
1.YR.80.^^ Repair, skin of axillary region
1.YS.80.^^ Repair, skin of abdomen and trunk
1.YT.80.^^ Repair, skin of arm
1.YU.80.^^ Repair, skin of hand
1.YV.80.^^ Repair, skin of leg
1.YZ.80.^^ Repair, skin NEC
When excision of a lesion involves only skin, is a minor debridement only and is followed by
temporary skin coverage (e.g., Dermagraft, cadaver allograft, xenograft), classify the excision to
CCI Section 1 — Physical/Physiological Therapeutic Interventions, generic intervention 14
Dressing, skin by site, to one of the following rubrics:
1.CX.14.^^ Dressing, eyelid NEC
1.YA.14.^^ Dressing, scalp
1.YB.14.^^ Dressing, skin of forehead
1.YC.14.^^ Dressing, skin of ear
1.YD.14.^^ Dressing, skin of nose
1.YE.14.^^ Dressing, lip
1.YF.14.^^ Dressing, skin of face
1.YG.14.^^ Dressing, skin of neck
1.YR.14.^^ Dressing, skin of axillary region
1.YS.14.^^ Dressing, skin of abdomen and trunk
1.YT.14.^^ Dressing, skin of arm
1.YU.14.^^ Dressing, skin of hand
760
1.YV.14.^^ Dressing, skin of leg

1.YZ.14.^^ Dressing, skin NEC
When excision of a lesion involves only skin and is a minor debridement only, classify the
excision to CCI Section 1 — Physical/Physiological Therapeutic Interventions, generic
intervention 59 Destruction, skin by site, to one of the following rubrics:
1.CX.59.^^ Destruction, eyelid NEC
1.YA.59.^^ Destruction, scalp
1.YB.59.^^ Destruction, skin of forehead
1.YC.59.^^ Destruction, skin of ear
1.YD.59.^^ Destruction, skin of nose
1.YE.59.^^ Destruction, lip
1.YF.59.^^ Destruction, skin of face
1.YG.59.^^ Destruction, skin of neck
1.YR.59.^^ Destruction, skin of axillary region
1.YS.59.^^ Destruction, skin of abdomen and trunk
1.YT.59.^^ Destruction, skin of arm
1.YU.59.^^ Destruction, skin of hand
1.YV.59.^^ Destruction, skin of leg
1.YZ.59.^^ Destruction, skin NEC
When excision of a lesion involves only skin, classify the excision to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, generic intervention 87 Excision partial, skin
by site, to one of the following rubrics:
1.CX.87.^^ Excision partial, eyelid NEC
1.YA.87.^^ Excision partial, scalp
1.YB.87.^^ Excision partial, skin of forehead
1.YC.87.^^ Excision partial, skin of ear
1.YD.87.^^ Excision partial, skin of nose
1.YE.87.^^ Excision partial, lip
1.YF.87.^^ Excision partial, skin of face
1.YG.87.^^ Excision partial, skin of neck
1.YR.87.^^ Excision partial, skin of axillary region
1.YS.87.^^ Excision partial, skin of abdomen and trunk
1.YT.87.^^ Excision partial, skin of arm
1.YU.87.^^ Excision partial, skin of hand
761
1.YV.87.^^ Excision partial, skin of leg

1.YZ.87.^^ Excision partial, skin NEC
Text alternative for flowchart in coding standard Dilation and Curettage, page 404
When the intent of a dilatation and curettage (D and C) is to terminate a pregnancy and the fetus
is alive at the initiation of the intervention, classify it to CCI Section 5 — Obstetrical and Fetal
Interventions, rubric 5.CA.89.^^ Surgical termination of pregnancy, regardless of the outcome.
When the intent is to perform a D and C of the uterus following a delivery or an abortion, classify
it to CCI Section 5 — Obstetrical and Fetal Interventions, rubric 5.PC.91.^^ Interventions to
uterus (following delivery or abortion).
When the intent is to perform a D and C of a non-gravid uterus, classify it to CCI Section 1 —
Physical/Physiological Therapeutic Interventions, rubric 1.RM.87.^^ Excision partial, uterus and
surrounding structures
Text alternative for flowchart in coding standard Congenital Anomaly Syndromes and
Specific Manifestations, Primary code selection for ICD-10-CA classification of multiple
congenital anomalies, page 424
When there are multiple anomalies described as a syndrome and there is an ICD-10-CA code
for that specific syndrome or for alternate or synonymous terms, assign the code from Q00 to
Q99 or the other appropriate chapter, per the alphabetical index lookup.
When there are multiple anomalies not described as a syndrome and each anomaly is
specifically identified, assign an ICD-10-CA code for each anomaly.
When there are multiple anomalies not described as a syndrome and each anomaly is not
specifically identified, assign Q89.7 Multiple congenital malformations, not elsewhere classified.
When multiple anomalies are described as a syndrome and are specified as chromosomal,
classify the anomalies to a code from the range Q90 to Q99 Chromosomal abnormalities, not
elsewhere classified. Assign also additional codes from the range Q00 to Q85.9 or other
chapters to add specificity.
When multiple anomalies are described as a syndrome and are specified as being due to an
exogenous cause, classify the anomalies to a code from category Q86 Congenital malformation
syndromes due to known exogenous causes, not elsewhere classified. Assign also additional
codes from the range Q00 to Q85.9 or other chapters to add specificity.
When multiple anomalies are described as a syndrome and they affect a single body system,
classify the anomalies to a code from the range Q00 to Q85.9. Assign also additional codes
from the range Q00 to Q85.9 or other chapters to add specificity.
When multiple anomalies are described as a syndrome that affects multiple specific body
systems and the syndrome predominantly involves skeletal changes classifiable to a code
from category Other specified congenital malformation syndromes affecting multiple systems,
762
specifically to a code from the range Q87.0 to Q87.5, classify the anomalies to a code from the
range Q87.0 to Q87.5. Assign also additional codes from the range Q00 to Q85.9 or other
chapters to add specificity.
When multiple anomalies are described as a syndrome that affects multiple specific body
systems and the syndrome does not predominantly involves skeletal changes classifiable to the
range Q87.0 to Q87.5, classify the anomalies to Q87.8 Other specified congenital malformation
syndromes, not elsewhere classified. Assign also additional codes from the range Q00 to Q85.9
or other chapters to add specificity.
When multiple anomalies are described as a syndrome with no further details, classify the
anomalies to Q89.9 Congenital malformation, unspecified.
Text alternative for image in Appendix A, Acute coronary syndrome (ACS) and related
interventions, page 619
Typical flow of diagnostic and treatment events for patients presenting with symptoms of acute
coronary syndrome:
When a patient presents with chest pain or other symptoms of acute coronary syndrome an
electrocardiogram (ECG) is performed and the clinician establishes a working diagnosis or
impression based on his or her interpretation of the ECG results.
When the clinician determines that the chest pain or other symptoms are nonischemic in nature,
classify the condition accordingly.
When the clinician establishes a working diagnosis of ST-segment elevation myocardial infarction
(STEMI), the typical treatment protocol is administration of thrombolytic therapy and/or a primary or
direct percutaneous coronary intervention (PCI).
When the clinician establishes a working diagnosis of non-ST-segment elevation myocardial

infarction (NSTEMI) the typical treatment protocol is administration of antithrombotic therapy;
administration of other medications such as an angiotensin-converting-enzyme (ACE) inhibitor,
platelet aggregation inhibitor, acetylsalicylic acid (ASA) or beta blocker; and/or PCI.
Cardiac biomarkers such as troponin or creatine kinase-MB (CK-MB) are also used by clinicians
to confirm a diagnosis within the acute coronary syndrome spectrum, to assess prognosis and
the risk of progression to an acute myocardial infarction; and, to establish a treatment plan
based on the clinical assessment.
When the clinician establishes a working diagnosis of STEMI, a diagnosis of acute myocardial
infarction is virtually inevitable. Prompt treatment based on the working diagnosis can alter the
final diagnosis or outcome or the type of acute myocardial infarction that occurs, resulting in one
of the following three possible outcomes:
1. Evolution to a Q-wave [transmural] myocardial infarction, classified to I21.0 Acute transmural

myocardial infarction of anterior wall or I21.1 Acute transmural myocardial infarction of
763
inferior wall or I21.2 Acute transmural myocardial infarction of other sites or I21.3 Acute
transmural myocardial infarction of unspecified site with R94.30 Electrocardiogram
suggestive of ST segment elevation myocardial infarction [STEMI] as a diagnosis type (3).
2. Evolution to a non-Q-wave [subendocardial] myocardial infarction, classified to I21.4 Acute
subendocardial myocardial infarction with R94.30 Electrocardiogram suggestive of ST
segment elevation myocardial infarction [STEMI] as a diagnosis type (3).
3. An aborted or averted myocardial infarction, classified to I24.0 Coronary thrombosis not
resulting in myocardial infarction with R94.30 Electrocardiogram suggestive of ST segment
elevation myocardial infarction [STEMI] as a diagnosis type (3).
When the clinician establishes a working diagnosis of NSTEMI, while Q-waves can develop, the
final diagnosis may be one of the following two possible outcomes:
1. Evolution to a less-damaging non-Q-wave [subendocardial] myocardial infarction, classified

to I21.4 Acute subendocardial myocardial infarction with R94.31 Abnormal cardiovascular
function studies (biomarkers or ECG) suggestive of non ST segment elevation myocardial
infarction [NSTEMI] as a diagnosis type (3).
2. A final diagnosis of unstable angina or non-ST-elevation acute coronary syndrome
(NonSTEACS or NSTEACS) classified to I20.0 Unstable angina.
Note that when the final diagnosis is NonSTEACS or NSTEACS it must be further confirmed
whether the patient had an NSTEMI or unstable angina.
Text alternative for image in Appendix E: Tips for Coders, Endoscopic Retrograde
Cholangiography With Sphincterotomy Alone or Concomitant With Extraction, page 690
The Canadian Classification of Health Interventions (CCI) 2018 code 1.OE.50.^^ Dilation, bile
ducts includes choledochotomy with dilation, dilation of sphincter of Oddi,
hepaticocholedochotomy with dilation, insertion of stent, bile duct, recanalization of bile duct
[following stricture or other mechanical blockage] and release [stricture], bile duct.
1.OE.50.^^ Dilation, bile ducts excludes correction of [congenital] biliary atresia (see 1.OE.84.^^) and
insertion of indwelling T-tube, catheter or endoprosthesis (for drainage), bile duct (see 1.OE.52.^^).
764
A table containing the complete list of codes from rubric 1.OE.50.^^ Dilation, bile ducts is
provided with additional instruction.
endoscopic
[retrograde] per
orifice approach
endoscopic [retrograde] per [ERC] with incision percutaneous
1.OE.50.^^ orifice approach [ERC] (This column includes [transhepatic]
Dilation, bile (This column does not include sphincterotomy/ transluminal
ducts sphincterotomy/papillotomy) papillotomy) open approach approach
using Not applicable 1.OE.50.BT Not applicable Not applicable

incisional
technique
only
using balloon 1.OE.50.BA-BD 1.OE.50.BT-BD 1.OE.50.LA-BD 1.OE.50.HA-BD

dilator (with
or without
stent)
using laser 1.OE.50.BA-AG 1.OE.50.BT-AG 1.OE.50.LA-AG 1.OE.50.HA-AG
(with or
without
stent)
using rigid 1.OE.50.BA-NR 1.OE.50.BT-NR 1.OE.50.LA-NR 1.OE.50.HA-NR
dilator [e.g.
stent]
Text alternative for image in Appendix E: Tips for Coders, Fetal Heart Rate Anomaly,
page 710
O68 Labour and delivery complicated by fetal stress [distress]
O68 Labour and delivery complicated by fetal Delivered, with or without mention of antepartum
stress [distress] condition
O68.0 Labour and delivery complicated by fetal heart O68.001 (Canadian enhancement)
rate anomaly ++
O68.2 Labour and delivery complicated by fetal heart O68.201 (Canadian enhancement)
rate anomaly with meconium in amniotic fluid
765
Text alternative for image in Appendix E: Tips for Coders, Sixth Digit at Z37 and Z38,
page 719
Z38.0 Singleton, born in hospital
Note: Assisted reproductive technology includes ovulation induction, intracytoplasmic sperm

injection (ICSI), embryo transfer, and in vitro fertilization (IVF).
Z38.0 Singleton, born in hospital Product of both spontaneous Product of assisted reproductive
(NOS) ovulation and conception technology (ART)
Z38.00 delivered vaginally Z38.000 (Canadian enhancement) Z38.001 (Canadian enhancement)
766
help@cihi.ca
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ICD-10-CA | CCI

Canadian Coding Standards

All rights reserved.

The contents of this publication may be reproduced unaltered, in whole or in part

For permission or information, please contact CIHI:

Canadian Institute for Health Information

ISBN 978-1-77109-675-1 (PDF)

© 2018 Canadian Institute for Health Information

How to cite this document:

Procurement or Harvesting of Tissue for Closure, Repair or Reconstruction ....................117

Chapter IV — Endocrine, nutritional and metabolic diseases ..................................................196

Chapter XI — Diseases of the digestive system ......................................................................300

Chapter XII — Diseases of the skin and subcutaneous tissue.................................................308

Premature Rupture of Membranes ...................................................................................381

Admission for Insertion of a Vascular Access Device (VAD) ............................................570

Appendix A — Resources .......................................................................................................603

Length of gestation ...................................................................................................636

Appendix B — Y83–Y84 Inclusion List ....................................................................................645

Chapter XV — Pregnancy, childbirth and the puerperium ................................................710

Format of the coding standards

Each standard contains

The icons used are

DN DAD and NACRS

(M) Most responsible diagnosis

A hyperlink to Appendix C — Table of changes — 2018 Canadian Coding Standards also

1. Deficiencies in the documentation

Source documents recommended to support quality

Medical • Discharge/case summary (final diagnoses must be recorded)

Type of case Documentation requirements

Death • Discharge/case summary (final diagnoses must be recorded)

Obstetrical • Prenatal record

Newborn • Mother’s record or copy of delivery record

ED/outpatient visits • Emergency/outpatient record (final diagnoses must be recorded)

Day surgery • Outpatient record (final diagnoses must be recorded)

Using the PDF version of the coding standards

You can search the PDF using the following methods:

History of the coding standards

The basic structure and classification principles

2. World Health Organization. International Statistical Classification of Diseases and Related

General coding standards for ICD-10-CA

Jurisdiction-wide or facility-mandated direction ensures consistent capture of optional other

Code NACRS Code title

J18.9 MP Pneumonia, unspecified

E11.52 OP Type 2 diabetes mellitus with certain circulatory complications

Rationale: E11.52 is assigned as an other problem because the coding standard

Code NACRS Code title

Z51.1 MP Chemotherapy session for neoplasm

C34.01 OP Malignant neoplasm of left main bronchus

Rationale: It is mandatory to assign an additional code for the malignant neoplasm as

Code NACRS Code title

R07.4 MP Chest pain, unspecified

(Q) K21.9 OP Gastro-oesophageal reflux disease without oesophagitis (optional)

Rationale: Codes for suspected diagnoses may be assigned, optionally, as other

Coding of Main and Other Problems for NACRS

Diagnoses must be supported by physician or primary care provider documentation to be

Conditions documented in nurses’ notes, pathology reports, medication profiles, radiological

NACRS-only directive statements

• The definitive (formulated) diagnostic statement;

N Always code to the greatest degree of specificity supported by the documentation.