ICD-10: Artificial Openings
By Melody W. Mulaik, MSHS, CRA, RCC, PCS, FCS, CPC, CPC-H
Like ICD-9-CM, ICD-10-CM contains a
variety of codes for encounters that involve
an artificial opening like a gastrostomy or
nephrostomy. The code selection will
depend on the purpose of the encounter.
When the purpose of the encounter is
routine maintenance of the opening or
tube, the primary diagnosis is an aftercare
code from category Z43 (Encounter for
attention to artificial openings). Examples
of routine maintenance include:
• Encounter for routine diagnostic imag-
ing exam (“tube check”) without men-
tion of any problems related to the tube
or the artificial opening
• Encounter for tube change
• Encounter for tube removal (when sepa-
Codes for routine maintenance are
indexed under “Attention (to).” Table 1
shows the Z43 codes that are most commonly used in radiology coding.
In addition to the Z43 code, a secondary
code should be assigned to describe the
diagnosis for which the artificial opening
was created. For example, a patient who has
indwelling nephrostomy tubes for bilateral
hydronephrosis presents for a tube change.
The primary diagnosis is Z43.6 for the
nephrostomy tube change, followed by
N13.30 (Unspecified hydronephrosis).
TABLE 1. Commonly Used Z43 Codes
Encounter for attention to tracheostomy
. . . gastrostomy
. . . ileostomy
. . . colostomy
. . . other artificial openings of digestive tract
. . . cystostomy
. . . other artificial openings of urinary tract
diagnosis, such as hydronephrosis, should
also be coded.
When a patient has an artificial opening, but the reason for the encounter is
unrelated to the artificial opening, a status
code from category Z93 (Artificial opening status) can be assigned as a secondary
diagnosis for informational purposes.
These codes are listed in the Index under
the main term “Status.” The first-listed
diagnosis code should represent the reason for the encounter.
For example, a nursing home patient
undergoes a CT scan due to left lower
quadrant abdominal pain. The scan reveals
no cause for the pain. The radiologist notes
that the patient’s gastrostomy tube appears
to be in good position. The primary diagnosis for this encounter is R10.32 (Left
lower quadrant pain), followed by Z93.1
(Gastrostomy status). Note that a status
code should never be reported with a
complication code for the same artificial
The most important factor in ensuring
correct ICD-10-CM code assignment for
artificial openings is good documentation
of the reason for the encounter. This
information should always be clearly and
explicitly stated in the radiology report.
Additionally, every report should stand on
its own. Even if the patient is well known
to the department and has had many
prior encounters, the radiologist should
still document enough clinical history to
ensure that a payor auditor will be able to
tell why the procedure was performed.
Melody W. Mulaik is president and co-founder of
Coding Strategies, Inc. She is a nationally recognized
speaker and has delivered numerous presentations at
AHRA annual meetings and conferences. Melody is a
member of AHRA, has published extensively, and may
be contacted at firstname.lastname@example.org.