Reserved for future expansion (no specific ICD-9-CM direction).

General Documentation:

•  Anatomical Site of pain
•  Pain that is exclusively related to psychological disorders
• Psychological component for a patient with acute or chronic pain
•  If in remission, document based on provider’s clinical judgment and must indicate “in remission”

Psychoactive Substance, indicate:

•  “use”, “abuse” and/or “dependence”
•  If use is associated with a mental or behavioral disorder

• Type
•  Site

General Documentation:

• Type of pain:
  – Acute or chronic
  – Post-procedural (specify procedure)
  – Due to trauma
  -Neoplasm related (specify neoplasm and site)
• Site specificity, when applicable
• Laterality (right, left, bilateral), when applicable
• Dominant or Non-dominant side, when applicable

Chronic Pain:

• Central pain syndrome and Chronic pain syndrome are different than the term ‘chronic pain’ and will be coded based on your specific documentation.

Migraine, document:

• With or without aura
• Intractable or not intractable
• With or without status migrainosus

Epilepsy, document:

• Localization related or generalized
• Intractable or not intractable
• With or w/o status epilepticus

“Pain” is also included in other chapters based on specific documentation (site, not specified as acute or chronic).

Glaucoma:

• Two codes to identify type & stage.
• Identify the external cause, if applicable, of the eye condition.

General Documentation:

• Specific disorder/disease and external cause, when applicable
• Laterality (right, left, bilateral)

Cataract, document:

• Type:
  – Age-related
  – Traumatic
  – Complicated o Drug-induced o Other

Glaucoma, document:

• Type:
  – Suspect
  – Open-angle
  – Primary angle-closure
  – Secondary due to (specify: trauma, inflammation, drugs)
• Stage:
  – Mild
  – Moderate
  – Severe
  – Indeterminate (cannot be clinically determined)

Moved from Nervous System chapter in ICD-9-CM to its own chapter in ICD-10-CM.
Glaucoma type & stage combined into one code.

Anatomical site
Specimen type i.e., cyst, tag, abscess, ulcer, scar, etc.
Neoplasm skin and subcutaneous tissues see Chapter 2 guidelines.
Dermatitis, document if:

• Atopic
• Seborrheic
• Diaper
• Exfoliative
• Contact (due to…)
  – Irritant contact (due to…) & Unspecified contact (due to…)

Pressure Ulcer

General Documentation:

• Anatomical site
• Laterality

Pressure ulcer, document:

• Site
• Laterality
• Specify stage:
  – Unstageable (can’t be clinically determined)
  – Stage 1
  – Stage 2
  – Stage 3
  – Stage 4

Dermatitis, document:

• Atopic
• Seborrheic
• Diaper
• Exfoliative
• Contact
  – Allergic (specify: due to…)
  – Irritant (specify: due to….)

Non-pressure ulcer, document:

• Site
• Laterality (left or right)
• Severity:

– Limited to breakdown of skin
–  With fat layer exposed
–  With necrosis of muscle
–  With necrosis of bone

Neoplasm skin and subcutaneous tissue are included in Chapter 2.
Pressure ulcer staging is generally identified by the clinician.
As with ICD-9-CM, Pathologists may need to work with their referring physician to obtain this information.
Non-pressure ulcers are included in Chapter 19.