Specificity in documentation allows the most accurate ICD-10 codes to be assigned. Correct coding allows the office to paint a more accurate picture of the patient's diagnosis.

For example: Laterality - Be sure your providers are clearly documenting laterality (left, right, bilateral) in the medical record along with clinically pertinent anatomical site(s) because over 1/3 of the ICD-10 codes contain laterality.

For example: When documenting abdominal pain, include the following: 1. Location (e.g., Generalized, right upper quadrant, periumbilical, etc.) 2. Pain or tenderness type (e.g., Colic, tenderness, rebound)
1. R10.31 Right lower quadrant pain
2. R10.32 Left lower quadrant pain
3. R10.33 Periumbilical pain

Definition Change - In ICD-10, hypertension is defined as essential (primary). The concept of "benign or malignant" as it relates to hypertension no longer exists. When documenting hypertension, include the following:
1. Type (e.g., essential, secondary, etc.)
2. Causal relationship (e.g., renal, pulmonary, etc.)
Examples include:
a. I10 Essential (primary) hypertension
b. I11.9 Hypertensive heart disease without heart failure
c. I15.0 Renovascular hypertension
Terminology Change - ICD-10 terminology used to describe asthma has been updated to reflect the current clinical classification system.

When documenting asthma, include the following:
1. Cause (e.g., exercise induced, cough variant, related to smoking, chemical or particulate cause, occupational
2. Severity: Choose one of the three options below for persistent asthma patients
a. Mild
b. Moderate
c. Severe
3. Temporal Factors: Acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation. Examples include:
a. J45.30 Mild persistent asthma, uncomplicated
b. J45.991 Cough variant asthma

Specificity Change -The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.

When documenting diabetes, include the following:
1. Type: (e.g., Type 1 or Type 2 disease, drug or chemical induced, 2. Complications: Are any other body systems are affected by the diabetes condition? (e.g., Foot ulcer related to diabetes mellitus)
3. Treatment: Is the patient on insulin? A second important change is the concept of "hypoglycemia" and "hyperglycemia." It is now possible to document and code for these conditions without using "diabetes mellitus." You can also specify if the condition is due to a procedure or other cause. The final important change is that the concept of "secondary diabetes mellitus" is no longer used; instead, there are specific secondary options. Examples include:
a. E08.65 Diabetes mellitus due to underlying condition with hyperglycemia
b. E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
c. R73.9 Transient post-procedural hyperglycemia
d. R79.9 Hyperglycemia, unspecified

Specificity Change - ICD-9 used separate "E codes" to record external causes of injury. ICD-10 incorporates these codes and expands sections on poisonings and toxins. When documenting injuries, include the following:
1. Episode of Care (e.g., initial, subsequent, sequelae
2. Injury site: Be as specific as possible
3. Etiology: How was the injury sustained (e.g., sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?
4. Place of Occurrence (e.g., School, work, etc.)
a. Intent e.g., unintentional or accidental, self-harm, etc.
b. Status e.g., Civilian, military, etc.

Examples include:
1. A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:
a. Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
b. External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
c. Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause d. Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping
2. On October 31st, Kelly was seen in the ER for shoulder pain. X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle fracture is coded as:
a. S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.

Source Medical Association of Billers -