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ICD-10: Key Changes for Primary Care

Transitioning successfully to the new ICD-10-CM code set will be particularly important for primary care physicians. ICD-10-CM will allow primary care specialists to more accurately depict chronic conditions as well as other commonly reported diagnoses.

Physicians will need to be more specific in their documentation than they likely have been in the past. Because there will be a greater number of code choices in ICD-10-CM, physicians should have to choose an unspecified code less often. The greater specificity in diagnostic coding should help improve disease management and reporting overall.

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Practices should examine their top diagnoses and compare how those codes will change once ICD-10-CM goes into effect — October 1, 2015. Here are some diagnoses to which primary care providers should pay close attention. This is certainly not an all-encompassing list, but is an example of some of the common diagnoses often reported by the PCP.

Diabetes (codes E08 – E13) has greatly expanded in ICD-10-CM. Physicians must document whether the diabetes is Type 1, Type 2, drug- or chemical-induced, or due to an underlying condition. They must document the specific underlying condition, the specific drug or toxin, as well as the use of any insulin.

ICD-10-CM requires very specific details regarding any complications or manifestation of the diabetes. For example, code E08.341 denotes diabetes mellitus due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema.

ICD-10-CM code I10 denotes essential (primary) hypertension. There are separate codes for hypertension involving vessels of the brain (codes I60 – I69) and hypertension involving vessels of the eye (code H35.0).

ICD-10-CM also includes codes for hypertensive heart disease with or without heart failure (code I11), and hypertensive chronic kidney disease (code I12). It is important to note that physicians must document the stage of the chronic kidney disease as well. Additionally, there are codes for hypertensive heart and chronic kidney disease (code I13), and secondary hypertension (code I15).

Asthma (code J45) is another diagnosis that was expanded in ICD-10-CM. Physicians must document whether the asthma is:

  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe persistent
  • Other and unspecified asthma (in ICD-9-CM, it is classified by type)

The physician must also specify whether the asthma is uncomplicated, with acute exacerbation, or with status asthmaticus.

ICD-10 instructs the physician to identify tobacco exposure as an additional code when reporting asthma. Those choices are:

  • Exposure to environmental tobacco smoke (Z77.22)
  • Exposure to tobacco smoke in the perinatal period (P96.81)
  • History of tobacco use (Z87.31)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Tobacco dependence (F17.-)
  • Tobacco use (Z72.0)

ICD-10-CM includes a variety of new codes for reporting headaches. For example, when a patient presents with a migraine (code G43), physicians must specify whether it’s common, hemiplegic, persistent, chronic, ophthalmologic, abdominal, or menstrual.

Cluster headaches and other trigeminal autonomic cephalalgias (code G44.0) are grouped into episodic, chronic, episodic paroxysmal hemicranias, chronic paroxysmal hemicranias, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing. There are also codes for vascular headaches (G44.1), tension-type headaches (G44.2), post-traumatic headaches (G44.3), drug-induced headaches (G44.4), as well as a variety of other headache syndromes.

Many of the codes in the headache section also require the following documentation:

  • With or without aura
  • Intractable vs. not intractable
  • With or without status migrainosus

ICD-10-CM includes various codes to denote specific forms of a middle ear infection. These codes are grouped in H65-H67 and distinguish between these forms of otitis media:

  • Serous
  • Allergic
  • Mucoid
  • Nonsuppurative
  • Suppurative
  • Tubotympanic suppurative
  • Atticoantral suppurative

Physicians must also document the following for many of the codes in this section:

  • Acute vs. chronic
  • Laterality (left vs. right vs. bilateral)
  • Any associated perforated tympanic membrane

Tobacco exposure should be identified as a second diagnosis, using an additional code when an ear infection is reported.

According to the Centers for Disease Control and Prevention, an estimated one in 10 adults reports depression. Depression codes have been greatly expanded in ICD-10-CM. When a patient presents with major depression (codes F32 – F33), physicians must consider and document the following:

  • Single episode vs. recurrent
  • Mild, moderate, or severe
  • With or without psychotic features
  • In partial or full remission

Chapter 21 of ICD-10-CM includes an array of codes related to factors that influence health status and contact with health services. For example, primary care physicians may be interested in codes Z55 – Z65, which pertain to health hazards related to socioeconomic and psychosocial circumstances. Codes in the Z68 category denote specific data related to body mass index (BMI). These should be reported additionally when reporting obesity (Code E66) and the BMI is known. Codes in the Z72 category denote problems related to lifestyle (e.g., tobacco use, lack of exercise, and high-risk sexual behavior).

This chapter also includes codes for preventive care, such as Z01.3 (encounter for examination of blood pressure), Z01.4 (encounter for gynecological exam), and more. Many of the codes for reporting well-visits require a selection between “with abnormal findings” or “without abnormal findings.” When abnormal findings are present, a second code is required to identify the abnormal findings.

Converting to ICD-10-CM may be a challenging transition for many practices. However, it’s likely that physicians will recognize its benefits over time. ICD-10-CM is certainly more complex than its predecessor, but in this changing world of health care economics, its increased specificity should prove beneficial to you and your practice.

>> Want Answers to Your Biggest ICD-10 Questions? Download our free ICD-10 FAQ: ICD-10 Transition: Your Biggest Questions Answered.


If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.