Module 1 - AAPCstatic.aapc.com/3f227f64-019f-488a-b5a2-e864a522ee71/9eef5bf1-89a4... ·...

Anatomy and Pathophysiology

for ICD-10

Module 1

ii Anatomy and Pathophysiology for ICD-10 © 2013 AAPC. All rights reserved. 111213

DisclaimerThis course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accu-racy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpre-tation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course.

AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within.

ICD-10 ExpertsRhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education

Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training

Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training

Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training

Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and Training

Illustration copyright © OptumInsight. All rights reserved.

©2013 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, www.aapc.com

Revised 111213. All rights reserved.

CPC®, CPC-H®, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

© 2013 AAPC. All rights reserved. www.aapc.com iii111213

Content

Module 1 Blood and Lymphatic Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1i

Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Blood Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Lymphatic System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Diseases and Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Infectious Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

© 2013 AAPC. All rights reserved. www.aapc.com 1111213

Module1

Blood and Lymphatic Systems

TerminologyAntibodies—Substances produced by the body in response to bacteria, viruses, or other foreign substances.

Ascites—Accumulation of fluid in the peritoneal cavity containing large amounts of protein and electrocytes.

Coagulation—A complex process in which blood forms clots.

Erythremia—Abnormal increase in the number of red blood cells.

Fibrin—Stringy, insoluble protein that is the substance of a blood clot.

Globulin—A plasma protein made in the liver.

Hemostasis—Termination of bleeding by mechanical or chemical means.

Immunity—Resistance of an organism to infection or disease.

Pathogens—Disease-producing microorganisms.

Phagocytosis—The process of a cell engulfing and destroying bacteria.

Platelet—A clotting cell.

Splenomegaly—An abnormal enlargement of the spleen.

Thrombus—A clot.

IntroductionThe hemic (blood) system is the system that passes nutrients (such as amino acids, electrolytes, and lymph), gases, hormones, blood cells, etc. to and from cells in the body to help fight diseases and help stabilize body temperature and pH to maintain homeostasis. It is made up of blood containing vessels such as arteries, capillaries, and veins that carry the blood through the body. The two main functions of the blood are

to transport oxygen and nutrients to the cells and to remove carbon dioxide and other waste products from the cells for elimination. Blood accounts for approxi-mately 8 percent of the body’s total weight.

Blood CellsBlood cells are the formed elements of blood and are generally classified as follows:

• Erythrocytes• Leukocytes• Thrombocytes

Source: AAPC

2 Anatomy and Pathophysiology for ICD-10 © 2013 AAPC. All rights reserved. 111213

Blood and Lymphatic Systems Module 1

ErythrocytesErythrocytes are red blood cells (RBCs). Erythrocytes are the most common type of blood cell and an organism’s principal means of delivering oxygen to the body tissues via the blood flow through the circu-latory system. They take up oxygen in the lungs and release it while squeezing through the body’s capillaries. The cells’ cytoplasm is rich in hemoglobin, which is responsible for the blood’s red color.

Mature erythrocytes are flexible biconcave disks that lack a cell nucleus and most organelles. The interior of the cell is composed of cytoplasm, lipids, proteins, and hemoglobin. Around 2.4 million new erythrocytes are produced per second through a process called eryth-ropoiesis. Erythropoiesis is the development process in which new erythrocytes are produced, through which each cell matures in about seven days. Through this process erythrocytes are continuously produced in the red bone marrow of large bones at a rate of about 2 million per second in a healthy adult. (In the embryo, the liver is the main site of red blood cell production.) The production can be stimulated by the hormone erythropoietin (EPO), synthesized by the kidney. Just before and after leaving the bone marrow, the devel-oping cells are known as reticulocytes; these comprise about 1 percent of circulating red blood cells.

Before birth, erythrocytes are formed in the bone marrow, liver, spleen, and lymph glands. After birth, they develop solely in the bone marrow. They circu-late for about 100–120 days in the body before their components are recycled by macrophages. Each cycle of circulation takes about 20 seconds to complete. Approxi-mately 25 percent of the cells in the human body are red blood cells.

LeukocytesLeukocytes are white blood cells (WBCs). Leukocytes are cells of the immune system involved in defending the body against both infectious disease and foreign materials. Leukocytes are found throughout the body, including the blood and lymphatic system. Leukocytes make up approximately 1 percent of blood in adults. An increase in the normal number of leukocytes is called leukocytosis, while a decrease in the normal number is called leukopenia.

Five different and diverse types of leukocytes exist, but they are all produced and derived from the hematopoi-etic stem cell in the bone marrow. They all have many things in common, but are all distinct in form and func-tion. A major distinguishing feature of some leukocytes is the presence of granules; white blood cells are often characterized as granulocytes or agranulocytes:

• Granulocytes (polymorphonuclear leukocytes): granulocytes are leukocytes characterized by the presence of differently staining granules in their cytoplasm when viewed under light microscopy. These granules are membrane-bound enzymes which primarily act in the digestion of endocytosed particles. There are three types of granulocytes: neutrophils, basophils, and eosinophils, which are named according to their staining properties.

Neutrophils are filled with neutrally-staining granules and are the most common type of white blood cell, comprising about 50–70 percent of all white blood cells. The mature neutrophil has a segmented nucleus (a seg or poly) while the immature neutrophil has a band-shaped nucleus (band). They are phagocytic, are the first to arrive at the site of infection, and have a short lifespan (about three days). Before ingesting invasive bacteria, neutrophils can release a net of fibers called a neutrophil extracellular trap (NET), which serves to trap and kill microbes outside of the cell. When neutrophils ingest microbes, they release a number of proteins in primary, secondary, and tertiary granules that help kill the bacteria. They also release superoxide, which becomes converted into hypochlorous acid, or chlorine bleach.

Basophils got their names because these cells take dyes and stains very readily, turning a vivid purple when stained. They are chiefly responsible for allergic and antigen response, as they secrete a biologically active chemical, histamine, causing inflammation. Each basophil has a two-lobed nucleus, surrounded by the tiny granules it carries. Basophils originate in the bone marrow where they are created continually by stem cells. They circulate throughout the body in the blood stream, with the ability to pass into various tissues as needed. When an infectious agent is detected by the immune system, basophils respond, along with numerous other types of white blood cells.


Module 1 Blood and Lymphatic Systems

Eosinophils are white blood cells that are one of the immune system components responsible for combating multicellular parasites and certain infections. These cells are eosinophilic or ‘acid-loving’ as shown by their affinity to coal and tar dyes. Along with mast cells, they also control mechanisms associated with allergy and asthma. They are granulocytes that develop during hematopoiesis in the bone marrow before migrating into blood. Eosinophils persist in the circulation for 8–12 hours, and can survive in tissue for an additional 8–12 days in the absence of stimulation.

• Agranulocytes (mononuclear leucocytes): agranulocytes are leukocytes characterized by the apparent absence of granules in their cytoplasm. Although the name implies a lack of granules these cells do contain non-specific azurophilic granules, which are lysosomes. The cells include lymphocytes and monocytes.

Lymphocytes are much more common in the lymphatic system. Lymphocytes are distinguished by having a deeply staining nucleus which may be eccentric in loca-tion, and a relatively small amount of cytoplasm. The blood has three types of lymphocytes:

• B cells: B cells make antibodies that bind to pathogens to enable their destruction. (B cells not only make antibodies that bind to pathogens, but after an attack, some B cells will retain the ability to produce an antibody to serve as a ‘memory’ system.)

• T cells: º CD4+ (helper) T cells co-ordinate the immune

response and are important in the defense against intracellular bacteria. In acute HIV infection, these T cells are the main index to identify the individual’s immune system activity. Research has shown that CD8+ cells are also another index to identify human’s immune activity.

º CD8+ cytotoxic T cells are able to kill virus-infected and tumor cells.

º γδ T cells possess an alternative T cell receptor as opposed to CD4+ and CD8+ αβ T cells and share characteristics of helper T cells, cytotoxic T cells and natural killer cells.

• Natural killer cells (NKC): Natural killer cells are able to kill cells of the body displaying a signal to kill them, as they have been infected by a virus or have become cancerous.

Monocytes share phagocytic function of neutrophils, but are much longer lived (they spread through the body in one to three days) as they have an additional role: they present pieces of pathogens to T cells so that the pathogens may be recognized again and killed or so an antibody response may be mounted. Monocytes eventually leave the bloodstream to become tissue macrophages which remove dead cell debris as well as attacking microorganisms. Neither of these can be dealt with effectively by the neutrophils. They have the kidney shaped nucleus and are typically agranulated. They also possess abundant cytoplasm.

Monocytes are made in the bone marrow and can develop into either dendrites or macrophages. Dendritic cells are antigen presenting cells; they acquire antigens and show them to T cells so that the T cells learn to recognize dangerous antigens. Dendritic cells present antigens to T cells before they are fully developed, so that the T cell can respond appropriately after it has been shown an antigen.

Macrophages are cells which ingest foreign mate-rial. They attack infectious microorganisms, such as a bacteria or virus, consuming it so it cannot hurt the body and preserving an antigen so that the body will be able to recognize the foreign material in the future. Macrophages can also eat cells in the body which have been infected by a pathogen to curb the spread of the pathogen and keep the body healthy. Blood monocytes migrate into the tissues of the body and there differen-tiate into macrophages.

ThrombocytesThrombocytes (platelets) are small, regularly-shaped clear cell fragments originating from fragmentation of precursor megakaryocytes found in the bone marrow. The average lifespan of a platelet is normally just five to nine days. Platelets play a fundamental role in hemo-stasis, important for normal blood clotting, and are a natural source of growth factors.

Platelets release a multitude of growth factors, including platelet-derived growth factor and TGF beta. PGDF is one of the many growth factors and plays a significant role in angiogenesis (blood vessel formation), the growth of blood vessels from already-existing blood vessel tissue. TGF beta is a protein that controls proliferation,



cellular differentiation, and stimulates the deposition of extracellular matrix. Both of these growth factors have been shown to play a significant role in the repair and regeneration of connective tissues. Other healing-associated growth factors produced by platelets include basic fibroblast growth factor, insulin-like growth factor 1, platelet-derived epidermal growth factor, and vascular endothelial growth factor. Local application of these factors in increased concentrations through platelet-rich plasma (PRP) has been used as an adjunct to wound healing for several decades.

Lymphatic SystemThe lymphatic system is part of the immune system. The immune system is made up of a network of conduits that carry a clear fluid called lymph. The conduits, also known as lymphatic vessels, compose a one-way system in which lymph flows only toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated with the digestive system such as the tonsils. The system also includes all the structures dedicated to the circulation and production of lymphocytes, which includes the spleen, thymus, bone marrow, and the lymphoid tissue associated with the digestive system.

Source: AAPC

The lymphatic system has three primary functions:

• Defend against invading microorganisms and disease• Return excess interstitial fluid to the blood• Absorb fats and fat-soluble vitamins from the

digestive system and transport them as chyle to the venous circulation

The first and probably most well known function of the lymphatic system is defense against disease and invading microorganisms. Lymph nodes and other lymphatic organs filter the lymph to remove microorganisms and other foreign particles. Lymphatic organs contain lymphocytes that destroy invading organisms.

A second function of the lymphatic system is it returns excess interstitial fluid to the blood. Of the fluid that leaves the capillary, about 90 percent is returned. The 10 percent that does not return becomes part of the interstitial fluid that surrounds the tissue cells. Small protein molecules may “leak” through the capillary wall and increase the osmotic pressure of the interstitial fluid. This further inhibits the return of fluid into the capillaries, and fluid tends to accumulate in the tissue spaces. If this continues, blood volume and blood pres-sure decrease significantly and the volume of tissue fluid increases, which results in edema (swelling). Lymph capillaries pick up the excess interstitial fluid and proteins and return them to the venous blood. After the fluid enters the lymph capillaries, it is called lymph.

The third function of the lymphatic system is the absorption of fats and fat-soluble vitamins from the digestive system and the subsequent transport of these substances to the venous circulation. The mucosa that lines the small intestine is covered with fingerlike projections called villi. There are blood capillaries and special lymph capillaries, called lacteals, in the center of each villus. The blood capillaries absorb most nutrients, but the fats and fat-soluble vitamins are absorbed by the lacteals. The lymph in the lacteals has a milky appear-ance due to its high fat content and is called chyle.



Blood vesselsHilum

Afferent vessels (in)

Efferent vessel (out)

Submental

Submandibular

Superficialparotid

Occipital

Jugulodigastric

Jugulomyohyoid

Anterior cervicalLymphatic drainage of the

head, neck, and face

Schematicof lymph node

Copyright OptumInsight. All rights reserved

The lymphatic system consists of a fluid (lymph), lymphatic vessels that transport the lymph, and organs that contain lymphoid tissue.

Lymph is considered part of the interstitial fluid. Interstitial fluid lies in the interstices (space that inter-venes between things) of all body tissues. Interstitial fluid becomes lymph when it enters a lymph capillary. The lymph travels to at least one lymph node before emptying into either the right or left subclavian vein. It then mixes back with blood. Lymph returns protein and excess interstitial fluid for circulation, picks up bacteria and brings them to lymph nodes to be destroyed, and transports fats from the digestive system.

Lymphatic vessels are thin walled, valved structures that carry lymph. They are complementary to the cardio-vascular system. Lymph vessels are lined by endothelial cells, have a thin layer of smooth muscle, and adventitia that bind the vessel to its surroundings. Lymph vessels are devoted to propulsion of lymph from the lymph capillaries. Lymph capillaries are a little bigger than capillaries of the vascular system. There are two types of lymphatic vessels: afferent lymph vessels and efferent lymph vessels. Afferent lymph vessels carry lymph to a lymph node and efferent lymph vessels carry lymph from a lymph node.

Lymphatic organs are organs characterized by clusters of lymphocytes and other cells, such as macrophages, enmeshed in a framework of short, branching connec-tive tissue fibers. The four types of lymphatic organs are lymph nodes, tonsils, thymus, and spleen.

• Lymph nodes are small, bean-shaped organs distributed throughout the body and linked by lymph vessels. Lymph nodes act as filters for foreign particles. Lymph nodes are usually less than 2.5 cm in length, are surrounded by a connective tissue capsule, and divided into compartments called lymph nodules, which are dense masses of lymphocytes and macrophages. They are separated by lymph sinuses. Afferent vessels carry lymph to move through the lymph sinuses and enters an efferent vessel that carries the lymph away from the node. The efferent vessel leaves the node at an indented region named the hilum. They are clinically significant as inflammation of the lymph nodes indicate many conditions.

• Tonsils are clusters of lymphatic tissue just under the mucous membranes that line the nose, mouth, and throat. There are three groups of tonsils: pharyngeal (also called the adenoids), located near the opening of the nasal cavity into the pharynx; palatine, located near the opening of the oral cavity into the pharynx; and lingual, located on the posterior surface of the tongue near the opening of the oral cavity into the pharynx.

• The thymus sits in the middle of the pleural cavity and aids in developing the immune system. The only known function of the thymus is the production and “education” of T-lymphocytes (T cells), which are critical cells of the adaptive immune system. The thymus is composed of two identical lobes and is located anatomically in the anterior superior mediastinum, in front of the heart and behind the sternum.The thymus is divided into a central medulla and a peripheral cortex which is surrounded by an outer capsule. Cells in the thymus can be divided into thymic stromal cells and cells of hematopoietic origin. Developing T-cells are referred to as thymo-cytes and are of hematopoietic origin. Stromal cells include thymic cortical epithelial cells, thymic medullary epithelial cells, and dendritic cells.

The thymus continues to grow between birth and puberty, as it is largest and most active during the neonatal and pre-adolescent periods. The thymus is of a pinkish-gray color, soft, and lobulated on its surfaces in children. By the early teens, the thymus



begins to atrophy due to high levels of circulating hormones and because thymic stroma is replaced by adipose tissue. The thymus of older people is scarcely distinguishable from surrounding fatty tissue. As one ages the thymus slowly shrinks and becomes yellow in color, eventually degenerating into tiny islands of fatty tissue. Nevertheless, residual T lymphopoiesis continues throughout adult life.

• The spleen is located in the upper left abdominal cavity, just beneath the diaphragm posterior to the stomach. It is purple/grey in color and is similar to a lymph node in shape and structure, but much larger (11 cm in length, weighing 150–200 grams). In fact, it is the largest lymphatic organ in the body. The spleen is surrounded by a connective tissue capsule, which extends inward to divide the organ into lobules. There are two types of splenic tissue, white pulp and red pulp. The white pulp is lymphatic tissue consisting mainly of lymphocytes around arteries. The red pulp consists of venous sinuses filled with blood and cords of lymphatic cells, such as lymphocytes and macrophages. Blood enters the spleen through the splenic artery, moves through the sinuses where it is filtered, then leaves through the splenic vein. The spleen filters blood much in the same way that the lymph node filters lymph. It removes old red blood cells and the splenic sinuses hold a reserve of blood in case of hemorrhagic shock. The spleen also recycles iron. It synthesizes antibodies in its white pulp and removes antibody-coated bacteria along with antibody-coated blood cells by way of blood and lymph node circulation. The spleen only possesses efferent lymphatic vessels.

Diseases and DisordersHypertensionHypertension is when the systemic arterial blood pres-sure is elevated. Blood pressure readings are measured in millimeters of mercury (mm Hg) and usually given as two numbers. For example, 120 over 80 (written as 120/80 mm Hg). The top number is the systolic pres-sure which indicates the pressure created when the heart beats. The bottom number is the diastolic pres-sure which indicates the pressure inside the blood vessels when the heart is at rest. Either one or both of

the numbers may be too high. Pre-hypertension is when your systolic blood pressure is between 120 and 139 or your diastolic blood pressure is between 80 and 89 on multiple readings. If you have pre-hypertension, you are more likely to develop high blood pressure.

Persistent hypertension is one of the risk factors for other conditions, such as:

• Heart disease. Hypertensive heart disease is coronary artery disease (CAD), heart failure, and enlargement of the heart that occurs due to hypertension. The high blood pressure increases the pressure in the blood vessels, which makes it work harder over time. This causes the heart muscle to thicken and the left ventricle to become enlarged. Then cardiac output decreases and may develop into congestive heart failure. Hypertensive heart disease is the leading cause of illness and death due to hypertension.

• Chronic kidney disease. Hypertension is a major cause of kidney disease and kidney failure. The high blood pressure causes damage to the blood vessels and filters in the kidney. This makes removal of waste from the body difficult.

Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.

Following is a table showing the classifications and stages for hypertension.

ClassificationSystolic Pressure Diastolic Pressure

mm Hg mm Hg

Normal 90–119 60–79Prehyperten-sion

120–139 80–89

Stage 1 140–159 90–99Stage 2 ≥160 ≥100Isolated Systolic Hypertension

≥140 <90

Source: American Heart Association (2003).



Hypertension has several sub-classifications including, hypertension stage I, hypertension stage II, and isolated systolic hypertension. Isolated systolic hyper-tension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly. They are demonstrated in the table above. These classifica-tions are made after averaging a patient’s resting blood pressure readings taken on two or more office visits. Hypertension is diagnosed if a patient has a blood pressure readings consistently of at least 140 mm Hg systolic or 90 mm Hg diastolic.

Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it’s treated differently to essential hypertension, by treating the underlying cause of the elevated blood pressure. Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the hormone-regulating endocrine system, that regu-late blood plasma volume and heart function. Many conditions cause hypertension, some are common and well recognized secondary causes, such as Cushing’s Syndrome, which is a condition where the adrenal glands overproduce the hormone cortisol. In addition, hypertension is caused by other conditions that cause hormone changes such as hyperthyroidism and certain tumors of the adrenal medulla (eg, pheochromocy-toma). Other common causes of secondary hyperten-sion include kidney disease, obesity/metabolic disorder, pre-eclampsia during pregnancy, the congenital defect known as coarctation of the aorta, and certain prescrip-tion and illegal drugs.

The ICD-10-CM code range for hypertension is I10–I15.9. To code hypertension in ICD-10-CM the following is necessary:

• Essential or Secondary• Causal relationship of other conditions• Elevated blood pressure versus hypertension

Following are the ICD-10-CM codes for hypertension.

Essential hypertension I10

Hypertensive heart disease with heart failure I11.0

Hypertensive heart disease without heart failure

I11.9

Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I12.0

Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I12.9

Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.0

Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.10

Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.11

Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I13.2

Renovascular hypertension I15.0

Hypertension secondary to other renal disorders

I15.1

Hypertension secondary to endocrine disorders

I15.2

Other secondary hypertension I15.8

Secondary hypertension, unspecified I15.9

According to the ICD-10-CM guidelines, controlled hypertension and uncontrolled hypertension are both



coded to I10 Essential hypertension. In some cases a causal relationship between hypertension and other diseases is made. For example, with hypertensive heart disease, a causal relationship must be stated (due to hypertension) or implied (hypertensive) To use the code category I11. An additional code from category I50 Heart failure, should also be used to identify the type of heart failure. But for hypertensive chronic kidney disease, a causal relationship is always presumed. An additional code from category N18 Chronic kidney disease should also be used to indicate the stage of disease.

Transient hypertension is an elevated blood pressure reading without a diagnosis of hypertension. In these cases, ICD-10-CM code R03.0 Elevated blood pressure reading without a diagnosis of hypertension should be assigned.

Lymphadenitis/LymphangitisLymphadenitis is swelling of the lymph nodes. Usually it occurs in the neck, armpits, or groin. It is relatively common and most likely indicates the presence of a bacterial, viral, fungal, or parasitic infection. Less commonly, it may be a result of cancerous cells invading the node. The lymph nodes may feel hardened and painful to the touch. The skin covering the lymph node may be hot or slightly red.

A more serious form of lymphadenitis is lymphangitis, which is swelling of the lymph vessels. It almost always indicates the presence of bacterial infection. Its symp-toms include high fever, red streaks around the swollen lymph node, throbbing pain in the lymph nodes, and flulike symptoms like lack of appetite, fatigue, and aching muscles. Lymphangitis is most associated with strep and staph bacterial infections. Cellulitis, infection of the blood, is a quite common cause.

The ICD-10-CM codes for lymphadenitis and lymphan-gitis are spread throughout various chapters. To code lymphadenitis/lymphangitis in ICD-10-CM the following is necessary:

• Lymphadenitis or lymphangitis• Site of swelling• Acute or chronic• Cause

Following are some examples of ICD-10-CM codes for lymphadenitis and lymphangitis:

Acute lymphadenitis of face, head, and neck L04.0

Acute lymphadenitis of trunk L04.1

Acute lymphadenitis of upper limb L04.2

Acute lymphadenitis of lower limb L04.3

Acute lympadenitis of other sites L04.8

Acute lymphadenitis, unspecified L04.9

Nonspecific mesenteric lymphadenitis I88.0

Tuberculous peripheral lymphadenopathy A18.2

Acute lymphangitis of right axilla L03.121

Acute lymphangitis of left axilla L03.122

Acute lymphangitis of right upper limb L03.123

Acute lymphangitis of left upper limb L03.124

Lymphangitis (chronic, NOS) I89.1

Acute lymphangitis of abdominal wall L03.321

Acute lymphangitis of chest wall L03.323

Acute lymphangitis of groin L03.324

Infectious DiseaseInfectious diseases (also called communicable diseases or transmissible diseases) are usually a clinically evident illness that results from the transmission and presence of pathogenic biological agents. Infectious pathogens include some viruses, bacteria, fungi, protozoa, multicel-lular parasites, and aberrant proteins known as prions. These pathogens are the cause of disease epidemics, in the sense that without the pathogen, no infectious epidemic occurs. A parasitic disease is an infectious disease caused



or transmitted by a parasite. Many parasites do not cause diseases. Parasitic diseases can affect practically all living organisms, including plants and mammals.

Among the almost infinite varieties of microorganisms, relatively few cause disease in otherwise healthy indi-viduals. Transmission of an infectious disease can occur in one or multiple ways, including physical contact, contaminated food, body fluids, objects, airborne inhalation, or through vector organisms. Transmis-sible diseases resulting through contact with an ill person or their secretions or objects touched by them are especially infective and are sometimes referred to as contagious diseases. Infectious disease results from the interplay between those few pathogens and the defenses of the hosts they infect. The appearance and severity of disease resulting from any pathogen depends upon the ability of that pathogen to damage the host as well as the ability of the host to resist the pathogen. Infec-tious microorganisms, or microbes, are classified as either primary pathogens or as opportunistic pathogens according to the status of host defenses.

Primary pathogens cause disease as a result of their presence or activity within the normal, healthy host, and their intrinsic virulence is, in part, a necessary conse-quence of their need to reproduce and spread. Many of the most common primary pathogens of humans only infect humans; however many serious diseases are caused by organisms acquired from the environment or which infect non-human hosts.

Opportunistic pathogens are organisms which cause an infectious disease in a host with depressed resistance. Opportunistic disease may be caused by microbes that are ordinarily in contact with the host, such as pathogenic bacteria or fungi in the gastrointestinal or the upper respiratory tract, and they may also result from microbes acquired from other hosts (as in Clostridium difficile colitis) or from the environment as a result of traumatic introduction (eg, surgical wound infections or compound fractures). An opportunistic disease requires impairment of host defenses, which may occur as a result of genetic defects, exposure to antimicrobial drugs or immunosuppressive chemicals, exposure to ionizing radiation, or as a result of an infectious disease with immunosuppressive activity. Primary pathogens may also cause more severe disease in a host with depressed resistance than would normally occur in an immunosufficient host.

A parasitic disease is an infectious disease caused or transmitted by a parasite. Many parasites do not cause diseases. Parasitic diseases can affect practically all living organisms, including plants and mammals. Some parasites like Toxoplasma gondii can cause disease directly, but other organisms can cause disease by the toxins that they produce.

Although organisms such as bacteria function as para-sites, the usage of the term “parasitic disease” is usually more restricted. Parasites are classified based on their interactions with their hosts and their life cycles: ecto-parasites and endoparasites. Ectoparasites are parasites that live on the surface of the host, as seen in mites. Endoparasites are parasites that live inside the host, as seen in parasitic worms. Endoparasites are further broken down into two forms: intercellular, which inhabit spaces in the host’s body, and intracellular, which inhabit cells in the host’s body.

There are many different infectious and parasitic diseases. In this portion we will be discussing specific diseases found in chapter 1, Certain Infectious and Parasitic Diseases, in the ICD-10-CM manual.

Staphylococcus AureusStaphylococcus is a group of bacteria that can cause a multitude of diseases as a result of infection of various tissues of the body. Staph-related illness can range from mild and requiring no treatment to severe and potentially fatal. Over 30 different types of Staphylococci can infect humans, but most infections are caused by Staphylococcus aureus.

Staphylococcus aureus (S. aureus) is an anaerobic, Gram-positive coccus and is the most common cause of staph infections. It can be found as part of the skin flora found in the nose and on skin of 25-30 percent of healthy adults. It is one of the five most common causes of nosocomial infections, often causing postsurgical wound infections.

Methicillin-resistant Staphylococcus aureus, known as MRSA, is a type of Staphylococcus aureus that is resistant to the antibiotic methicillin and other drugs in the same class, including penicillin, amoxicillin, and oxacillin. MRSA is one example of a so-called “superbug,” a term used to describe a strain of bacteria that has become resistant to the antibiotics usually used



to treat it. MRSA first appeared in patients in hospitals and other health facilities, especially among the elderly, the very sick, and those with an open wound (such as a bedsore), or catheter in the body. In these settings, MRSA is referred to as health-care-associated MRSA (HA-MRSA). There are also cases of community-asso-ciated MRSA (CA-MRSA) when found in the commu-nity outside of the hospital. MRSA in the community is associated with recent antibiotic use, sharing contami-nated items, having active skin diseases or injuries, poor hygiene, and living in crowded settings.

MRSA infections are usually mild superficial infections of the skin that can be treated successfully with proper skin care and antibiotics. MRSA, however, can be diffi-cult to treat and can progress to life-threatening blood or bone infections because there are fewer effective anti-biotics available for treatment.

Another strain of Staphylococcus aureus has been iden-tified that are resistant to the antibiotic vancomycin, which is normally effective in treating Staph infections. These bacteria are referred to as vancomycin-inter-mediate resistance Staphylococcus aureus (VISA) and vancomycin-resistant Staphylococcus aureus (VRSA).

Most ICD-10-CM codes for Staphylococcus aureus are found in chapter one. To code Staphylococcus aureus in ICD-10-CM the following is necessary:

• Type of Staphylococcus• Condition

Following are the ICD-10-CM codes for Staphylococcus:

Foodborne staphylococcal intoxication A05.0

Sepsis due to Methicillin susceptible Staphylococcus aureus A41.01

Sepsis due to Methicillin resistant Staphylococcus aureus A41.02

Sepsis due to other specified Staphylococcus A41.1

Sepsis due to unspecified Staphylococcus A41.2

Staphylococcal infection, unspecified site A49.0

Following are some other ICD-10-CM codes for staphylococcal conditions that are not first listed codes:

Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere B95.61

Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere B95.62

Other Staphylococcus as the cause of diseases classified elsewhere B95.7

Unspecified Staphylococcus as the cause of diseases classified elsewhere B95.8

These are used for conditions like abscesses, furuncles, and carbuncles. For example, a cutaneous abscess of the face caused by Staphylococcus aureus the codes would be L02.01, B95.6.

Following are some ICD-10-CM codes for staphylo-coccal conditions that are not located in chapter one:

Staphylococcal scalded skin syndrome L00

Pneumonia due to Staphylococcus, unspecified J15.20

Pneumonia due to Methicillin susceptible Staphylococcus aureus J15.211

Pneumonia due to Methicillin resistant Staphylococcus aureus J15.212

Pneumonia due to other Staphylococcus J15.29

Clostridium DifficileClostridium difficile (C. diff) is a species of Gram-positive bacteria of the genus Clostridium that causes diarrhea and other intestinal disease when competing bacteria are wiped out by antibiotics.

Clostridia are anaerobic, spore-forming rods (bacilli). It is a bacterium that is related to the bacterium that causes tetanus and botulism. The C. difficile bacterium has two



forms, an active, infectious form that cannot survive in the environment for prolonged periods, and a nonactive form called a spore, that can survive in the environment for prolonged periods. Although spores cannot cause infection directly, when they are ingested they transform into the active, infectious form.

C. difficile is the most serious cause of antibiotic-associ-ated diarrhea (AAD) and can lead to pseudomembranous colitis, a severe infection of the colon, often resulting from eradication of the normal flora by antibiotics. The C. difficile bacteria, which naturally reside in the body, become overpopulated: The overpopulation is harmful because the bacterium releases toxins that can cause bloating and diarrhea with abdominal pain, which may become severe. Often, it can be cured by discontinuing the antibiotics responsible. In more serious cases, oral administration of medications (metronidazole or vanco-mycin) is the treatment of choice.

Most ICD-10-CM codes for clostridium difficile are found in chapter one.

Enterocolitis due to Clostridium difficile A04.7

Other specified bacterial foodborne intoxications A05.8

Sepsis due to anaerobes A41.4

Gas gangrene A48.0

Other specified bacterial agents as the cause of diseases classified elsewhere B96.89

Human Immunodeficiency Virus/Acquired Immune Deficiency SyndromeHuman immunodeficiency virus (HIV) is a lentivirus, a member of the retrovirus family. a condition in which the immune system begins to fail, leading to life-threat-ening opportunistic infections. Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate, or breast milk. Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells. The four major routes of transmission are unprotected sex, contaminated needles, breast milk, and perinatal transmission. Screening of

blood products for HIV has largely eliminated transmis-sion through blood transfusions or infected blood prod-ucts in the developed world. HIV infection is considered a pandemic by the World Health Organization (WHO).

HIV infects primarily vital cells in the human immune system such as helper T cells (to be specific, CD4+ T cells), macrophages, and dendritic cells. HIV infection leads to low levels of CD4+ T cells through three main mechanisms: First, direct viral killing of infected cells; second, increased rates of apoptosis in infected cells; and third, killing of infected CD4+ T cells by CD8 cytotoxic lymphocytes that recognize infected cells. When CD4+ T cell numbers decline below a critical level, cell-medi-ated immunity is lost, and the body becomes progres-sively more susceptible to opportunistic infections.

HIV is most commonly spread in the following manners:

• Contact with infected blood• Accidental exposure• Sexual contact with an infected person• Accidental needle stick from contaminated needles

by health care workers• Drug users sharing needles or syringes• Accidental body fluid exposure

HIV progresses to AIDS at a variable rate affected by viral, host, and environmental factors; many will prog-ress to AIDS within 10 years of HIV infection. Some of those infected will have progressed much sooner, and some will take much longer. Treatment with anti-retro-virals increases the life expectancy of people infected with HIV. Even after HIV has progressed to diagnos-able AIDS, the average survival time with antiretroviral therapy has increased greatly over the years.

The initial infection with HIV generally occurs after transfer of body fluids from an infected person to an uninfected one. The first stage of infection, the primary, or acute infection, is a period of rapid viral replication that immediately follows the individual’s exposure to HIV leading to an abundance of virus in the peripheral blood with levels of HIV commonly approaching several million viruses per mL.

This response is accompanied by a marked drop in the numbers of circulating CD4+ T cells. This acute



viremia is associated in virtually all patients with the activation of CD8+ T cells, which kill HIV-infected cells and subsequently with antibody production, or sero-conversion. The CD8+ T cell response is thought to be important in controlling virus levels, which peak and then decline as the CD4+ T cell counts rebound. A good CD8+ T cell response has been linked to slower disease progression and a better prognosis, though it does not eliminate the virus.

During this period (usually 2–4 weeks post-exposure) most individuals (80 to 90 percent) develop an influenza or mononucleosis-like illness called acute HIV infec-tion, the most common symptoms of which may include fever, lymphadenopathy, pharyngitis, rash, myalgia, malaise,and mouth and esophageal sores; and, symp-toms may also include, but less commonly, headache, nausea and vomiting, enlarged liver/spleen, weight loss, thrush, and neurological symptoms. Infected indi-viduals may experience all, some, or none of these symp-toms. The duration of symptoms varies, averaging 28 days and usually lasting at least a week.

A strong immune defense reduces the number of viral particles in the blood stream, marking the start of secondary or chronic HIV infection. The secondary stage of HIV infection can vary between two weeks and 20 years. During this phase of infection, HIV is active within lymph nodes, which typically become persis-tently swollen in response to large amounts of virus that becomes trapped in the follicular dendritic cells (FDC) network. The surrounding tissues that are rich in CD4+ T cells may also become infected, and viral particles accumulate both in infected cells and as free virus. Indi-viduals who are in this phase are still infectious. During this time, CD4+ CD45RO+ T cells carry most of the proviral load.

During this stage of infection early initiation of anti-retroviral therapy significantly improves survival, as compared with deferred therapy.

AIDS (acquired immune deficiency syndrome) is the final and most serious stage of HIV disease, which causes severe damage to the immune system. Over 25 million people worldwide have died from this infec-tion since the start of the epidemic. AIDS begins with HIV infection. People infected with HIV may have no symptoms for 10 years or longer, but they can still

transmit the infection to others during this symptom-free period. Meanwhile, if the infection is not detected and treated, the immune system gradually weakens and AIDS develops.

Acute HIV infection progresses over time to asymptom-atic HIV infection and then to early symptomatic HIV infection. Later, it progresses to AIDS (advanced HIV infection with CD4 T-cell count below 200 cells/mm3).

Almost all people infected with HIV, if not treated, will develop AIDS. There is a small group of patients who develop AIDS very slowly, or never at all. These patients are called nonprogressors.

The ICD-10-CM codes for HIV are found in multiple chapters due to the stage and relationship. To code HIV in ICD-10-CM the following is necessary:

• Symptomatic or asymptomatic• Reason for encounter

Following are the ICD-10-CM codes for HIV:

Human immunodeficiency virus disease B20

Inconclusive laboratory evidence of human immunodeficiency virus R75

Encounter for screening for human immuno-deficiency virus Z11.4

Asymptomatic human immunodeficiency virus infection status Z21

Human immunodeficiency virus counseling Z71.7

Following are the ICD-10-CM codes for HIV when complicating pregnancy. These codes always take prece-dence over all other codes. A code from above would be used as a secondary code to these listed below.

HIV disease complicating pregnancy, first trimester O98.711

HIV disease complicating pregnancy, second trimester O98.712



HIV disease complicating pregnancy, third trimester O98.713

HIV disease complicating pregnancy, unspecified trimester O98.719

HIV disease complicating childbirth O98.72

HIV disease complicating the peurperium O98.73

According to the ICD-10-CM guidelines, only confirmed cases of HIV infections should be coded with confirma-tion meaning the provider has made a diagnostic state-ment in the patient’s medical record indicating they are HIV positive or has an HIV-related illness.

Sequencing of these codes is dependent upon the reason for the encounter. The guidelines state that if a patient

is admitted for an HIV-related condition, then the first listed code should be B20, followed by additional codes for all reported HIV-related conditions. If the patient is admitted for an unrelated condition, the code for the unrelated condition should be the first listed code, and other diagnoses would be the HIV appropriate code, followed by additional diagnosis codes for all reported HIV-related conditions.

Another important guideline discusses proper use of B20. Patients with any known prior diagnosis of an HIV-related illness should be coded to B20. Once a patient has developed an HIV-related illness, the patient should always be assigned code B20 on every subsequent admis-sion/encounter. There is an Excludes2 note that indicates patients previously diagnosed with any HIV illness should never be assigned to R75 (inconclusive HIV) or Z21 (asymptomatic HIV).

SourcesComprehensive Medical Terminology (Fourth Edition) by Betty Davis Jones.

Stedman’s Medical Dictionary, 28th edition

Bates’ Pocket Guide to Physical Examination and History Taking, Third Edition (Lynn S. Bickley-Lippincott)

Date post:	22-Aug-2019
Category:	Documents
Upload:	dokiet
View:	216 times
Download:	0 times

Module 1 - AAPCstatic.aapc.com/3f227f64-019f-488a-b5a2-e864a522ee71/9eef5bf1-89a4... ·...

Documents