ICD-10-CM⾃自學網站

http://icd10data.com/ http://quizlet.com/7731541/icd-10-cm-flash-cards/

時間 + 空間(解剖位置)

What’s New in ICD 10 ?

Format & Structure

The ICD-10-CM Tabular List contains categories, subcategories and codes.

Tabular List (表格式)

Alphabetic Index (按⼦子⺟母)

Code Structure:

Basic categories:

⼀一個英⽂文字⺟母後接⼆二個阿拉伯數字 例: A00

⼩小數點之後爲 subcategory 和 subclassfication

例: A00.01

Sections: (group of three-character categories)

L00-L08 infection of skin and subcutaneous tissue

Categories (three-character code numbers)

L02, Cutaneous abscess, furuncle and carboncle

Subcategories (four-character code numbers)

L02.2, Cutaneous abscess, furuncle and carboncle of trunk

5.6.7 subclassifications

L02.211 , Cutaneous abscess of abdominal wall

http://www.icd10data.com/ICD10CM/Codes/L00-L99/L00-L08/L02-/L02.211

Section Categorie

Sections: (group of three-character categories)

L00-L08 infection of skin and subcutaneous tissue

Categories (three-character code numbers)

L02, Cutaneous abscess, furuncle and carboncle

Subcategories (four-character code numbers)

L02.2, Cutaneous abscess, furuncle and carboncle of trunk

5.6.7 subclassifications

L02.211 , Cutaneous abscess of abdominal wall

http://www.icd10data.com/ICD10CM/Codes/L00-L99/L00-L08/L02-

Subcategories(L02.2)

subclassifications

K29 Gastritis and duodenitis (category)

K29.0 acute gastritis (subcategory)

K29.00 acute gastritis without bleedings (code)

http://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K29-

Use of codes for reporting purposes

For reporting purposes only codes are permissible, not categories or

subcategories, and any applicable 7th

character is required.

Placeholder character

The ICD-10-CM utilizes a placeholder character "X". The "X" s used as a

placeholder at certain codes to allow for future expansion.

T16 Foreign body in ear Includes foreign body in auditory canal

T16.1 Foreign body in right ear

T16.2 Foreign body in left ear

T16.9 Foreign body in ear, unspecified ear

A Initial encounter

D subsequent encounter

S sequela

有一個小孩到急診, 主訴有一顆綠豆塞在右耳裏頭

T16.1 ?

T16.1XXA

7th Character

Certain ICD-10-CM categories have applicable 7th characters.

Includes Notes

This note appears immediately under a three character code title to further define or give examples of, the

content of the category.

有⼀一個病⼈人因為左側腦幹中⾵風住院, 經檢查發現, 左側腦幹有急性中⾵風,並且左側基底動脈完全堵塞,因此我們的診斷如下:

left side brain stem stroke

left vertebral artery occlusion

brain stem stroke syndrome

有⼀一個病⼈人因為頭暈, 做頸動脈檢查發現 “左側基底動脈完全堵塞”, Brain MRI 沒有看到中⾵風, 因此我們的診斷如下:

left vertebral artery occlusion

Excludes 1

A type 1 Exclude note is a pure exclude note. It means "NOT CODED HERE!" An Exclude 1 note indicates that the code excluded should never be used at the same

time as the code above the Exclude 1 note.

NOT CODED HERE !

Excludes 2

A type 2 excludes note represents "Not included

here". An excludes 2 note indicates that the condition

excluded is not part of the condition represented by the code but a patient may have both conditions at the same time. It is acceptable to use both the code and the excluded code together, when appropriate.

NEC vs NOS

NEC :

"Not elsewhere classifiable" This abbreviation

represents "other specified". When a specific code is not available for a condition.

!

NOS :

"Not otherwise specified" This abbreviation is the equivalent of unspecified.

[ ] Brackets

Brackets are used in the Tabular List to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the Alphabetic

Index to identify manifestation codes.

( ) Parentheses

Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it assigned. The terms within the

parentheses are referred to as nonessential modifiers.

: Colons

Colons are used in the Tabular List after an

incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category.

“and"

When the term "and" is used in a narrative statement it represents and/or.

"Other"

Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist.

"Unspecified"

Codes titled "unspecified" are for use when the information in the medical record is insufficient to

assign a more specific code.

“With"

The word "with" should be interpreted to mean

"associated with" or "due to" when it appears in

a code title, the Alphabetic Index, or and

instructional not in the Tabular List.

Syndromes

Follow the Alphabetic Index guidance when

coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the

syndromes.

Ramsay Hunt syndrome

Ramsay-Hunt disease or syndrome

Signs and symptoms

Codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for

reporting purposes when a related

definitive diagnosis has not been

established (confirmed) by the provider.

Multiple coding

For a single conditionIn addition to the etiology/manifestation convention that

requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also

require more than one code.

Malignant carcinoid tumor of the sigmoid colon & rectum

C7A.025 & C7A.026

這麼複雜, 誰記得住 ?

時代不一樣了,只要會查即可!

Paradigm shift 典範轉移

Ask Google !!!

優點:

放棄背, 直接查

從查詢中快速學習 ICD 10 編碼原則

更清楚依照病人事實編碼

缺點:

似乎有點耗時

大量倚靠 ”網路”

ICD 10 直接查詢 Google + site:icd10data.com

ICD 10 直接查詢 Google + site:icd10data.com

搜尋方法:

於搜尋窗內: keyword site:icd10data.com

通常第一個就是 ! 點進去 (next slide)

可瀏覽樹狀圖

提供常用醫學名詞 供搜尋比對

提供US DRG 作參考

此碼的定義

瀏覽C16 樹狀圖

其他可能的診斷 點C7A.092(next slide)

ICD 10 直接查詢 Google + site:icd10data.com

點選C16 可看到完整編碼樹狀圖

想知道 C7A.092 是什麼? 為什麼不和其他Gastric tumor擺在一起?

可瀏覽樹狀圖, 點選可得知C7A之樹狀圖

ICD 10 直接查詢 Google + site:icd10data.com

真的很慢嗎? 可以用同法查詢以下診斷

Carpal tunnel syndrome(G56.01), aortic dissection (I71)

Hyponatremia(E87.1), renal artery stenosis(I70.1 or Q27.1)

ESRD, COPD, CKD, AMI, STEMI, STEMI+LAD(I21.02)

traumatic SAH (S06) vs nontraumatic SAH(I60)

tibial fracture (S82)

Right MCA embolic infarction (I63.412)

ICD 10 直接查詢 Google + site:icd10data.com

http://www.icd10data.com/ICD10CM/Table_Of_Neoplasms

http://www.icd10data.com/ICD10CM/Table_Of_Drugs