Most Intra-operative & Post- procedural complications are included in Chapter 17 – Injury and Poisoning.

Anemia, document:

• Nutritional, specify:
  – Iron deficiency
  – Vitamin B12 deficiency
  – Folate deficiency (dietary or drug-induced)
  – Other (protein, megaloblastic)
• Hemolytic, specify:
  – Due to enzyme disorders
  – Sickle-cell disorders
  – Other hereditary or acquired
• Aplastic
• In other chronic diseases (specify the underlying disease)

Spleen document Intra-operative & Post-procedural complications, specify:

• Intra-operative (during) or Post-procedural (following)
• Hemorrhage, hematoma, accidental puncture or accidental laceration of the spleen
• Procedure on the spleen or other procedure

Intra-operative & Post-procedural complications are also included in other chapters based on specific site/system documentation.

Diabetes: Distinguished as “Uncontrolled” or “Not stated as uncontrolled”.

Diabetes, document:

• • • • • Type 1 diabetes mellitus
        • Type 2 diabetes mellitus (default, if not specified)
        • Drug or chemically induced diabetes mellitus
        • Secondary diabetes mellitus (specify the cause)
        • Specify complication(s), when applicable
        • Specify use of insulin, when applicable

Obesity, document:

• • • • • Due to excess calories
        • Drug-induced
        • Identify body mass index

Diabetes: Distinguished as “With complications” or “Without complications”.
Gestational diabetes (in pregnancy) is reported in Chapter 15.

General Documentation:

• • • • • Specific disorder/disease
        • Laterality (right, left, bilateral)

Otitis media, document:

• • • • • Acute or chronic
        • Suppurative or nonsuppurative

Perforation tympanic membrane, document:

• • • • • Type:
          – Central
          – Attic
          – Other marginal
          – Multiple
          – Total

Hearing loss (deafness), document:

• • • • • Type:
          – Conductive
          – Sensorineural
          – Mixed
          – Other

Moved from Nervous System chapter in ICD-9-CM to its own chapter in ICD-10-CM.

Hypertension (HTN):

• • • • • Benign
        • Malignant
        • Unspecified

Coronary Artery Disease (CAD) (Atherosclerosis/Ischemia):

• • • • • Native Coronary Artery
        • Graft type
        • NonautologousAcute Myocardial Infarction (AMI) defined as duration of 8 weeks or less.

Cerebral Infarction / Cerebrovascular Accident (CVA):

• • • • • Occlusion
        • Thrombosis
        • Embolism

General Documentation:

• • • • • Site specificity, when applicable
        • Laterality (right, left, bilateral), when applicable

HTN (no distinction of status/type), document if:

• • • • • With heart involvement (and with heart failure, if applicable)
        • With kidney involvement, specify:
          – Stage 1 thru 5, or ESRD
        • Secondary

CAD, document:

• • • • • Specific artery (default is native artery)
        • With angina (specify: stable or unstable) or without angina

AMI (redefined as duration of 4 weeks {28 days} or less), document:

• • • • • Location:
          – Anterior wall (left main, left anterior descending or other coronary artery)
          – Inferior wall (right or other coronary artery)
          – Other sites (left circumflex coronary artery or other site)
        • ST elevation (STEMI) or Non-ST elevation (NSTEMI)

CVA, document:

• • • • • Location:
        • Precerebral artery
          – (vertebral, basilar, carotid)
        •  Cerebral artery
          – (right/left…middle, anterior, posterior, cerebellar)
        •  Due to:
          – Thrombosis, embolism, occlusion or stenosis

Heart Failure/CHF, document:

• • • • • Left ventricle, systolic, diastolic, combined
        • Acute, chronic, acute on chronic (decompensated)

Cardiomyopathy, document:

• Dilated
• Hypertrophic (obstructive, other)
• Endomyocardial
• Endocardial fibroelastosis• Other restrictive
• Due to: alcohol, drug or external agent

Atrial fibrillation, document:

• Paroxysmal, persistent or chronic

Atrial flutter, document:

• Typical or atypica

No distinction of HTN status/type.
CAD with or without angina inclusive in one code.
AMI redefined as duration of 4 weeks (28 days) or less.

• • • • • Severity

General Documentation:

• • • • • Document causal organism

Asthma, document:

• • • • • Severity:
          – Mild intermittent
          – Mild persistent
          – Moderate persistent
          – Severe persistent
          – Other
        • Complication:
          – With acute exacerbation o With status asthmaticus o Uncomplicated

Bronchitis, document:

• • • • • Acute, and document causal organism
        • Chronic, and document if simple, mucopurulent or mixed

Allergic rhinitis, document:

• • • • • Pollen
        • Other seasonal
        • Food
        • Animal (cat)(dog) hair and dander
        •  Other

Sinusitis, document:

• • • • • Acute (and if recurrent) or chronic
        • Site:
          – Maxillary
          – Frontal
          – Ethmoidal
        • Sphenoidal
        • Pansinusitis

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 1-10.

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.

• • • • • Site
        • Late Effect

General Documentation:

• • • • • Anatomical Site, when applicable (bone, join or muscle involved)
        •  Laterality (left, right, bilateral), when applicable
        •  Chronic, recurrent or healed musculoskeletal conditions

Fracture, document:

• • • • •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
        •  Late Effect
        •  Type of fracture:
          – Fatigue
          – Stress
          – Pathological
        •  Laterality
        •  Encounter type:
          – Initial
          – Subsequent (specify routine or delayed healing, non-union, malunion)
          – Sequela

Osteoarthritis, document:

• • • • •  Type:
          – Primary (wear and tear)
          – Secondary (caused by other condition)
          – Post-traumatic

Gout, document:

• • • • •  Acute or chronic (with or without tophus)
        •  Idiopathic
        •  Lead-induced
        •  Drug-induced
        •  Due to renal impairment (specify renal disease)
        •  Other secondary gout (specify associated condition)

Fatigue fractures and collapsed vertebra will require a 7th character:

• • • • • A – Initial encounter
        • D – Subsequent with routine healing
        • G – Subsequent with delayed healing
        • S – Sequela (complications, or conditions – i.e. scars)

Stress and Pathological fractures will require a 7th character:

• • • • • A – Initial encounter
        • D – Subsequent with routine healing
        • G – Subsequent with delayed healing
        • K – Subsequent with non-union
        • P – Subsequent with malunion
        • S – Sequela (complications, or conditions – i.e. scars)

General Documentation:

• • • • •  Conditions that have their origin in the fetal or perinatal period (defined as before birth through the 28th day following birth).
        •  Documentation of the listed maternal conditions is specified as the cause of confirmed morbidity or potential morbidity.

Conditions listed in Chapter 16 are never for use on the maternal record.
Conditions listed in Chapter 16 may be used throughout the life of the patient if the condition is still present.

• • • • • Unilateral, Bilateral
        •  Type

General Documentation:

• • • • • Laterality (right, left, unilateral, bilateral)
        •  Specify distinction between existing malformation or deformity vs. personal history.

Cleft palate, document:

• • • • •  Hard
        •  Soft
        • Hard w/soft

Cleft lip, document:

• • • • • Bilateral
        •  Median
        •  Unilateral

Hypospadias, document:

• • • • •  Site of the urethral opening:
          – Balanic
          – Penile
          – Penoscrotal
          – Perineal
          – Congenital chordae
          – Other specified

Malformation, deformation or chromosomal abnormality may be the principal / first-listed diagnosis or a secondary diagnosis.
Although present at birth malformation, deformation or chromosomal abnormality may not be identified until later in life.
Conditions listed in Chapter 17 may be used throughout the life of the patient

•Location/Site
•Injury
•Type
•Depth
•Percentage

General Documentation:

• • • • • Location/site
        •  Laterality
        •  Sequence most serious injury as determined by the provider
        •  Superficial injury/abrasions or contusions should be specified if associated with more severe injuries of the same site.
        • Injury with damage to nerve/blood vessels: document primary injury, followed by nerves and/or blood vessels. (If the primary injury is to the nerve/blood vessel code as primary.)

Fractures, document:

• • • • •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
        •  Open or Closed
        • Late Effect
        •  Type:
          – Displaced or non-displaced
        •  Laterality
        •  Gustilo classification system (specify classification) of open fractures
        •  Encounter type:
          – Initial (during active treatment)
          – Subsequent (i.e. specify routine or delayed healing, non-union, malunion)
          – Sequela

Burns, document:
Distinguish between ‘burns’ and ‘corrosions’

• • • • • If thermal burn, specify heat source (i.e. electricity or radiation)
        • Specify if due to chemicals.

Wounds, document:

• • • • • Location/site
        • Depth
        • Type:
          – Bite
          – Laceration
          – Puncture
        • With or without foreign body

Poisoning:

• • • • • Identify define Drug or Chemical
        • Specify: Adverse effect, Poisoning, Under-dosing or Toxic effects

Most codes may require a 7th
character for encounter type. Burns:

• • • • • Sequence code to highest degree of burn(s).
        • Non-healing burns coded as Acute Burn (Necrosis of non- healed burn coded as non- healed burn).
        • Infected burn site, use additional code for infection.
        • Burns are classified by degree/depth, extent and age