Abnormal Body Fluid Analysis: Coding in ICD-10-CM

Samples usually are obtained through collection of the fluid in a container (urine, semen, etc.) or by inserting a needle into a body cavity and aspirating with a syringe a portion of the fluid (pericardial or peritoneal fluid).

Once a sample is obtained, a variety of tests may be performed, including chemistry tests, microscopic examinations, genetic tests and infectious disease tests.

For certain body fluids, including pleural, pericardial and peritoneal fluids, it is important to determine through testing whether the fluid is transudate or an exudate because doing so can help diagnose the disease or condition present.

Transudate fluid

• Caused by an imbalance between the pressure within blood vessels (which drives fluid out) and the amount of protein in blood (which keeps fluid in).
• It is a clear fluid with a low protein concentration and a limited number of white blood cells.
• Seen with conditions such as congestive heart failure and cirrhosis.

Exudate fluid

• Caused by injury and/or inflammation.
• It has a higher-than-normal protein content and may be cloudy due to increased numbers of cells.
• Seen with conditions such as infections, malignancies (metastatic cancer, lymphoma, mesothelioma, etc.) or autoimmune diseases.

(Source: American Association for Clinical Chemistry, 2012, Paragraph 5)

Sources:

American Association for Clinical Chemistry, “Body Fluid Analysis” (Jan. 6, 2012). Retrieved from http://labtestsonline.org/understanding/analytes/body-fluid/tab/glance

Lolita M. Jones Consulting Services, “ICD-10-CM Core Concepts: A Chapter-by-Chapter Review of Coding Conventions and Challenges; Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99; pp. 18-17 and 18-18).

EXERCISE:

In order to prepare you for ICD-10-CM coding of abnormal body fluid analysis, the following exercise has been prepared as an educational tool.

A 2012 ICD-10-CM code book or an electronic file of the code book contents will be needed in order to use this coding manual. To access the 2012 ICD-10-CM code book electronic files, please go online to http://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage.

Under the “Downloads” subhead, scroll down and download the folder titled “2012 Code Tables and Index [ZIP, 16.7MB] .” Once the folder is open, you will find several files, and you will need the following files when completing these exercises:

“ICD10CM_2012_Full_Tabular.pdf” – this is the 2012 ICD-10-CM Tabular List of Diseases and Injuries.

“ICD10CM_2012_Full_DIndex.pdf” – this is the 2012 ICD-10-CM Index to Diseases and Injuries.

EXERCISE:

Use the ICD-10-CM Index to Diseases and the tabular list to fill in the blanks with the appropriate ICD-10-CM codes. One row has been completed as an example. Do not code from this chart, as it is to be used for educational purposes only.

ABNORMAL FINDINGS ON EXAMINATION

ABNORMAL FINDINGS ON EXAMINATION

ANSWER KEY

EXERCISE: Use the ICD-10-CM Index to Diseases and the tabular list to fill in the blanks with the appropriate ICD-10-CM codes. The first row has been completed as an example. Do not code from this chart, as it is to be used for educational purposes only.

ABNORMAL FINDINGS ON EXAMINATION

ABNORMAL FINDINGS ON EXAMINATION