Summary of ICD-10-CM Impacts
Clinical Documentation
• ICD-10-CM has a combination code for heart disease due to hypertension.
• Document the acuity (i.e., chronic, acute, acute on chronic) and type (i.e. systolic, diastolic or
both) of heart failure, as there are discrete ICD-10-CM codes for each type.
• ICD-10-CM separates the etiology and acuity of respiratory failure so it is important to document
if respiratory failure is with hypoxia or hypercapnia, if present.
• DVT has laterality of processes for left versus right.
• Management of chronic conditions such as hypertension or heart failure should be described in
the record. When heart disease is documented “as due to” hypertension it is coded to a combination
category in ICD-10-CM.
• Pleural effusion has no laterality codes.
• Deep Vein Thrombosis (DVT) includes laterality codes to specify left vs. right.
Coding
ICD-9-CM Diagnosis Codes
995.29 Unspecified adverse effect of
other drug, medicinal and
biological substance
E934.2 Therapeutic use of medication
415.19 Acute PE
453.40 DVT
511.9 Pleural Effusion
518.81 Respiratory failure, acute
402.91 Hypertensive heart disease
428.32 LV failure, chronic, diastolic
416.8 Hypertension, pulmonary artery
ICD-10-CM Diagnosis Codes
T45.515A adverse effect of anticoagulants,
initial encounter
N/A
I26.99 Other pulmonary embolism
without acute cor pulmonale
I82.401 Acute embolism and thrombosis
of unspecified deep veins of right
lower extremity
J91.8 Pleural effusion in other
conditions classified elsewhere
J96.01 Acute respiratory failure
with hypoxia
I11.0 Hypertensive heart disease with
heart failure
I50.31 Acute diastolic (congestive)
heart failure
I27.2 Other secondary
pulmonary hypertension
Other Impacts
Note: There is nothing in the documentation that says that there was an error in the prescription for
Coumadin or that the patient took it incorrectly. If the prescription was correctly prescribed and correctly
administered/taken then it would be an adverse effect.
