April 18, 2016
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.)
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
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
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.
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
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,
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.