Diabetes continues to be a challenge for coders since the new instruction/guideline was released in AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS, First Quarter 2016. This is effective with March 18, 2016 discharges. ICD-10-CM does assume the link between diabetes and multiple common conditions.

In ICD-10-PCS two codes are required to appropriately report a carotid endarterectomy with patch graft. This is a change from ICD-9-CM procedural coding as the patch graft was included in the endarterectomy code.

The focus of this coding tip is on the excision vs. resection ICD-10-PCS coding. This can be challenging for coders when trying to determine the appropriate root operation (objective of procedure) to use. Physicians are using excision/resection interchangeably within the documentation.

If the signs and symptoms are routinely associated with a disease then it is not typically reported as an additional diagnosis. An example of an exception to this would be ascites due to cirrhosis.