•  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 intractabl
• With or w/o status epilepticus

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

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

• 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)

•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