Anatomical site
Histologic behavior:

• Malignant Primary
• Malignant Secondary
• In situ
• Benign
• Uncertain
• Unspecified behavior

Skin neoplasms:

• Basal cell carcinoma
• Squamous cell carcinoma
• Specified type NEC

General Documentation:

• Anatomical Site
•  Laterality (left, right)
• Histologic behavior:
  – Benign
  – Malignant, primary and secondary sites if metastatic
  – In situ
  – Uncertain
  – Unspecified behavior
• Histologic Type:
  – Carcinoma
  – Basal Cell
  – Squamous Cell
  – Adenoma
• Complications or Adverse effects of antineoplastic or immunosuppressive drugs
• Previous excision or eradication

Breast, in-situ, document:

• Lobular
• Intraductal

Leukemia, Multiple Myeloma, Malignant plasma cell neoplasms, document:

• Relapse
• Remission
• Not having achieved remission

Pathologists may need to work with their referring physician to obtain this information.
When patients have more than one malignant tumor in the same organ document the primary and metastatic disease.

Crohn’s disease and Diverticular disease, document:

• Site:
  – Small intestine
  – Large intestine
  – Both small & large intestine
• Complication (specify) or w/o complication

Ulcerative Colitis, document:

• Type:
  – Pancolitis
  – Proctitis
  – Rectosigmoiditis
  – Left sided
  – Other
•  Complication (specify) or w/o complication

Hemorrhoids, document:

• Internal
  – Specify degree, grade, state
•  External

Hernia, document:

• Site
  –  Inguinal
  –  Femoral
  –  Ventral (specify:  incisional, parastomal)
  –  Diaphragmatic
  –  Other/unspecified abdominal
• Unilateral or bilateral (applicable to inguinal & femoral)
• Recurrent or not specified as recurrent (applicable to inguinal & femoral)
• With obstruction and/or gangrene or w/o obstruction and/or gangrene

No documentation changes from ICD- 9-CM to ICD-10-CM. Column to the left are common documentation pitfalls that may have been missed while documenting I-9. Emphasizing the importance of documenting for I- 10.