T86.21

ICD-10-CM Official Guidelines for Coding and Reporting, quoted in full. Published by CMS and NCHS; in the public domain.

I.C.2.r Malignant neoplasm associated with transplanted organ names this code p.38

A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.

I.C.19.g.3.a Transplant complications other than kidney names this code p.86

Codes under category T86, Complications of transplanted organs and tissues, are for use for both complications and rejection of transplanted organs. A transplant complication code is only assigned if the complication affects the function of the transplanted organ. Two codes are required to fully describe a transplant complication: the appropriate code from category T86 and a secondary code that identifies the complication. Pre-existing conditions or conditions that develop after the transplant are not coded as complications unless they affect the function of the transplanted organs. See I.C.21. for transplant organ removal status See I.C.2. for malignant neoplasm associated with transplanted organ. See I.C.1.d.4. for sequencing of sepsis due to infection in transplanted organ

I.C.21.c.3 Status names this code p.93

Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is informative, because the status may affect the course of treatment and its outcome. A status code is distinct from a history code. The history code indicates that the patient no longer has the condition. A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient. For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, Chronic respiratory failure, followed by code Z99.11, Dependence on respirator [ventilator] status. The status Z codes/categories are: Z14 Genetic carrier Genetic carrier status indicates that a person carries a gene, associated with a particular disease, which may be passed to offspring who may develop that disease. The person does not have the disease and is not at risk of developing the disease. Z15 Genetic susceptibility to disease Genetic susceptibility indicates that a person has a gene that increases the risk of that person developing the disease. Codes from category Z15 should generally not be used as principal or first-listed codes. If the patient has the condition to which he/she is susceptible, and that condition is the reason for the encounter, the code for the current condition should be sequenced first. If the patient is being seen for follow-up after completed treatment for this condition, and the condition no longer exists, a follow-up code should be sequenced first, followed by the appropriate personal history and genetic susceptibility codes. If the purpose of the encounter is genetic counseling associated with procreative management, code Z31.5, Encounter for genetic counseling, should be assigned as the first-listed code, followed by a code from category Z15. Additional codes should be assigned for any applicable family or personal history. Z16 Resistance to antimicrobial drugs This category indicates that a patient has a condition that is resistant to antimicrobial drug treatment. Sequence the infection code first. Z17 Estrogen, and other hormones and factors receptor status Z18 Retained foreign body fragments Z19 Hormone sensitivity malignancy status Z21 Asymptomatic HIV infection status This code indicates that a patient has tested positive for HIV but has manifested no signs or symptoms of the disease. Z22 Carrier of infectious disease Carrier status indicates that a person harbors the specific organisms of a disease without manifest symptoms and is capable of transmitting the infection. Z28.3 Underimmunization status See Section I.B.14. for underimmunization documentation by clinicians other than the patient’s provider. Z33.1 Pregnant state, incidental This code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code from the obstetric chapter is required. Z66 Do not resuscitate This code may be used when it is documented by the provider that a patient is on do not resuscitate status at any time during the stay. Z67 Blood type Z68 Body mass index (BMI) BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity or anorexia) documented by the patient’s provider. Do not assign BMI codes during pregnancy. When the documentation reflects fluctuating BMI values during the current encounter for an associated reportable condition, assign a code for the most severe value. See Section I.B.14. for BMI documentation by clinicians other than the patient’s provider. Z74.01 Bed confinement status Z76.82 Awaiting organ transplant status Z78 Other specified health status Code Z78.1, Physical restraint status, may be used when it is documented by the provider that a patient has been put in restraints during the current encounter. Please note that this code should not be reported when it is documented by the provider that a patient is temporarily restrained during a procedure. Z79 Long-term (current) drug therapy Codes from this category indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug use, abuse, or dependence instead. Assign a code from Z79 if the patient is receiving a medication for an extended period as a prophylactic measure (such as for the prevention of deep vein thrombosis) or as treatment of a chronic condition (such as arthritis) or a disease requiring a lengthy course of treatment (such as cancer). Do not assign a code from category Z79 for medication being administered for a brief period of time to treat an acute illness or injury (such as a course of antibiotics to treat acute bronchitis). Z88 Allergy status to drugs, medicaments and biological substances Except: Z88.9, Allergy status to unspecified drugs, medicaments and biological substances status Z89 Acquired absence of limb Z90 Acquired absence of organs, not elsewhere classified Z91.0- Allergy status, other than to drugs and biological substances Z92.82 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to a current facility Assign code Z92.82, Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility, as a secondary diagnosis when a patient is received by transfer into a facility and documentation indicates they were administered tissue plasminogen activator (tPA) within the last 24 hours prior to admission to the current facility. This guideline applies even if the patient is still receiving the tPA at the time they are received into the current facility. The appropriate code for the condition for which the tPA was administered (such as cerebrovascular disease or myocardial infarction) should be assigned first. Code Z92.82 is only applicable to the receiving facility record and not to the transferring facility record. Z93 Artificial opening status Z94 Transplanted organ and tissue status Z95 Presence of cardiac and vascular implants and grafts Z96 Presence of other functional implants Z97 Presence of other devices Z98 Other postprocedural states Assign code Z98.85, Transplanted organ removal status, to indicate that a transplanted organ has been previously removed. This code should not be assigned for the encounter in which the transplanted organ is removed. The complication necessitating removal of the transplant organ should be assigned for that encounter. See section I.C.19. for information on the coding of organ transplant complications. Z99 Dependence on enabling machines and devices, not elsewhere classified Note: Categories Z89-Z90 and Z93-Z99 are for use only if there are no complications or malfunctions of the organ or tissue replaced, the amputation site or the equipment on which the patient is dependent.

II.G Complications of surgery and other medical care names this code p.109

When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

I.C.19.a Application of 7 Characters in Chapter 19 chapter guidance p.77

Most categories in chapter 19 have a 7 character requirement for each applicable code. Most categories in this chapter have three 7 character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7 character values. While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7 character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time. For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. For example, code T84.50XA, Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter, is used when active treatment is provided for the infection, even though the condition relates to the prosthetic device, implant or graft that was placed at a previous encounter. 7 character “A”, initial encounter is used for each encounter where the patient is receiving active treatment for the condition. 7 character “D” subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7 characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7 character “D” (subsequent encounter). 7 character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7 character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7 character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. See Section I.B.10. Sequelae, (Late Effects)

I.C.19.b Coding of Injuries chapter guidance p.78

When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Codes from category T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00- T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

I.C.19.b.1 Superficial injuries chapter guidance p.78

Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.

I.C.19.b.2 Primary injury with damage to nerves/blood vessels chapter guidance p.78

When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

I.C.19.b.3 Iatrogenic injuries chapter guidance p.79

Injury codes from Chapter 19 should not be assigned for injuries that occur during, or as a result of, a medical intervention. Assign the appropriate complication code(s).

I.C.19.c Coding of Traumatic Fractures chapter guidance p.79

The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the level of detail furnished by medical record content. A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced. More specific guidelines are as follows:

I.C.19.c.1 Initial vs. subsequent encounter for fractures chapter guidance p.79

Traumatic fractures are coded using the appropriate 7 character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. The appropriate 7 character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. Fractures are coded using the appropriate 7 character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7 character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R). Malunion/nonunion: The appropriate 7 character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q). A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. See Section I.C.13. Osteoporosis. The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7 character.

I.C.19.c.2 Multiple fractures sequencing chapter guidance p.80

Multiple fractures are sequenced in accordance with the severity of the fracture.

I.C.19.c.3 Physeal fractures chapter guidance p.80

For physeal fractures, assign only the code identifying the type of physeal fracture. Do not assign a separate code to identify the specific bone that is fractured.

I.C.19.d Coding of Burns and Corrosions chapter guidance p.80

The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions. Current burns (T20-T25) are classified by depth, extent and by agent (X code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.

I.C.19.d.1 Sequencing of burn and related condition codes chapter guidance p.80

Sequence first the code that reflects the highest degree of burn when more than one burn is present. a. When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. b. When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis. c. When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis.

I.C.19.d.2 Burns of the same anatomic site chapter guidance p.81

Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-).

I.C.19.d.3 Non-healing burns chapter guidance p.81

Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn.

I.C.19.d.4 Infected burn chapter guidance p.81

For any documented infected burn site, use an additional code for the infection.

I.C.19.d.5 Assign separate codes for each burn site chapter guidance p.81

When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used. Codes for burns of "multiple sites" should only be assigned when the medical record documentation does not specify the individual sites.

I.C.19.d.6 Burns and corrosions classified according to extent of body chapter guidance p.81

surface involved Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, for acute burns or corrosions when the site of the burn or corrosion is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third- degree burn involving 20 percent or more of the body surface. Codes from categories T31 and T32 should not be used for sequelae of burns or corrosions. Categories T31 and T32 are based on the classic “rule of nines” in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent. Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.

I.C.19.d.7 Encounters for treatment of sequela of burns chapter guidance p.82

Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7 character “S” for sequela.

I.C.19.d.8 Sequelae with a late effect code and current burn chapter guidance p.82

When appropriate, both a code for a current burn or corrosion with 7 character “A” or “D” and a burn or corrosion code with 7 character “S” may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Burns and corrosions do not heal at the same rate and a current healing wound may still exist with sequela of a healed burn or corrosion. See Section I.B.10. Sequela (Late Effects)

I.C.19.d.9 Use of an external cause code with burns and corrosions chapter guidance p.82

An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.

I.C.19.e Adverse Effects, Poisoning, Underdosing and Toxic Effects chapter guidance p.82

Codes in categories T36-T65 are combination codes that include the substance that was taken as well as the intent. No additional external cause code is required for poisonings, toxic effects, adverse effects and underdosing codes.

Risk adjustment

This code