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Updates on ICD-10

Clinical Documentation Improvement 

Following are articles containing key information for physician documentation in the ICD-10 environment. It is important that physicians focus on the inclusion of this specific information in their documentation.

 ICD-10 Documentation Tips

Follow these ICD-10 documentation tips for valuable information you can use. Start to use this information when you document now!

Please click the titles below to view this important information. 

Documentation of Fractures

  • Laterality
  • Mechanism of injury
  • Etiology of Fracture 
    Traumatic, pathologic, osteoporosis, neoplastic disease
  • Site
    Name of the bone
    Medial, lateral, midshaft, epiphysis, etc.
  • Displaced vs. Non-displaced
  • Closed or open (use Gustillo-Anderson classification for open fractures)
  • Type of Fracture
    Comminuted, greenstick, oblique, segmental, spiral, transverse, compression, burst, etc.
  • Note Injury to Surrounding Tissue 
  • Encounter Type
    Initial encounter for fracture (type)
    Subsequent encounter for fracture with routine healing
    Subsequent encounter for fracture with delayed healing
    Subsequent encounter for fracture with nonunion
    Subsequent encounter for fracture with malunion

Example: Instead of documenting fractured R arm, you will now document “Fell while running, traumatic, acute, closed, transverse right distal radial fracture with surrounding soft tissue hematoma and swelling.”

Documentation of Anemia

Cause of Anemia:

  • Chronic anemia secondary to malignancy
  • Chronic anemia secondary to CKD
  • Acute blood loss anemia secondary to acute GI bleed
  • Acute post-operative blood loss anemia (if greater-than-expected blood loss during surgery)
  • Chronic idiopathic anemia

Type of Anemia:

  • Iron Deficiency
  • Pernicious
  • Aplastic
  • Sickle Cell
  • Blood Loss Anemia


  • Acute
  • Chronic
  • Acute on Chronic

Documentation of the CVA

  • Location, Vessel and Laterality
    Pre-cerebral: vertebral, basilar, carotid
    Cerebral: anterior, middle, posterior
    Cerebellar: right, left, anterior, posterior, middle
  • Cause
    Traumatic, non-traumatic
    Hemorrhage, embolism, thrombosis, occlusion, stenosis, infarction
  • Acuity
    Acute vs. Old 
  • Deficits- hemiplegia, exp. Aphasia
    Residuals from an old CVA?
    New deficits 
  • What is the patient’s dominant side? 
  • Was thrombolytic agent used?

Example: Instead of documenting “CVA” you will now document “acute, L middle cerebral artery occlusion with resulting R hemiplegia and expressive aphasia in a R handed patient. TPA used.”

Documentation of Sepsis

Document these key pieces of information:

  • Was the sepsis present on admission?
  • Is the sepsis with or without shock?
  • The causal agent or presence of underlying systemic infection, if known (bacterial, fungal, candida) e.g.
    Sepsis due to MRSA pneumonia or MRSA pneumonia with sepsis
    Sepsis due to a post procedural infection
    In unknown agent or source – document “sepsis, unknown source”
  • Associated organ dysfunction when documenting severe sepsis, e.g.

    Severe sepsis due to MRSA pneumonia with resulting acute respiratory failure

    If more than one organ is affected--document individually


There is no longer a code for SIRS due to an infectious process. There are two categories for SIRS of a noninfectious origin, one without acute organ dysfunction and one with acute organ dysfunction. 

Remember: In ICD-10 there is no such thing as urosepsis.

Specificity in documentation clearly defines your patient’s severity of illness and risk of mortality. Accurate documentation is the key!

Documentation of Asthma

In ICD-10, the provider will be required to grade asthma by its severity and whether it is intermittent or persistent.

There are 3 severity categories: Mild, Moderate and Severe. The “Mild” category is further classified as Mild Intermittent or Mild Persistent. 

Asthma Types

Mild Intermittent:

  • Mild Intermittent, uncomplicated
  • Mild Intermittent with acute exacerbation
  • Mild Intermittent with status asthmaticus

Mild Persistent:

  • Mild persistent, uncomplicated
  • Mild persistent with acute exacerbation
  • Mild persistent with status asthmaticus

Moderate Persistent:

  • Moderate persistent, uncomplicated
  • Moderate persistent with acute exacerbation
  • Moderate persistent with status asthmaticus

Severe Persistent:

  •  Severe persistent, uncomplicated
  •  Severe persistent with acute exacerbation
  •  Severe persistent with status asthmaticus


Documentation of a history of tobacco use, tobacco dependence, exposure to environmental tobacco smoke is also important.

    Documentation of Debridement

    It is important for providers to understand the elements necessary for the documentation of excisional vs. non-excisional debridement 

    1. Excisional debridement involves the cutting away of tissue/necrosis/slough and falls under the “Excision” definition in ICD-10.
    2. Non-excisional debridement is defined as the non-operative brushing, irrigating, scrubbing, or washing away of devitalized tissue. It falls under the “Extraction” definition in ICD-10.
      Either can be performed at the bedside, in the ER or in the OR.

    Key Documentation Concepts:

    • Location of the debridement (e.g., right ankle, left wrist)
    • Condition requiring debridement (e.g., ulcer, necrosis, abscess)
    • Instrument used (e.g., scissors, scalpel, curette, water jet, etc. If blade is used please note size)
    • Method used (e.g. ,irrigating, brushing, cutting)
    • Depth of the debridement noting the deepest layer: skin, subcutaneous, fascia, muscle, bone
    • Description of the tissue removed
    • Descriptor: incisional or excisional

    Documentation of Myocardial Infarctions

    It is important for providers to understand the elements necessary for the documentation of Myocardial Infarctions in ICD-10.

    Document the following:

    Type of MI
    • ST elevation MI (STEMI)
    • Non-ST elevation MI (NSTEMI)

    Site of MI (including wall and vessel)

    Anterior Wall

    • Left Main Coronary Artery
    • Left Anterior Descending Artery
    • Other coronary artery Anterior wall

    Inferior Wall

    • Right Coronary Artery
    • Other coronary artery of Inferior wall

    Posterior Wall MI

    • Left circumflex coronary artery
    • Right coronary artery
    • Other coronary artery of Posterior wall


    Septal Wall MI

    • Left Anterior Descending Artery
    • Other coronary artery of Septal wall

    Lateral Wall MI

    • Left anterior descending artery
    • Left circumflex artery
    • Other coronary artery of Lateral wall

    Episode of Care

    Initial - within four week timeframe (28 days)

    Subsequent - care for a subsequent, new MI, occurring within four week (28 days) timeframe of the initial MI


    List all complications related to the MI.

    Documentation of Head Trauma/Coma

    It is important for providers to understand the elements necessary for the documentation of head trauma/coma in ICD-10.

    Key Documentation Concepts

    Mechanism of Injury

    Encounter Type: Initial, Subsequent, Sequela

    Level of Consciousness

    • Document Glasgow Coma scale score (evaluation of eye opening, verbal response, motor response) AND the time the score was rendered, e.g., pre-hospital, upon arrival to the ER, on admission, or 24 hours or more after admission.
    • If loss of consciousness - document length of time patient was unconscious (if known)

    Associated Injuries

    Skull Fracture

    • Location, laterality, displaced or non-displaced

    Intracranial Injury

    • Portion of the brain involved, specific artery/vessel
    • Presence of cerebral edema

    Documentation of Pneumonia

    Important Concepts to Include in Your Documentation of Pneumonia

    Acuity - Acute or chronic

    Laterality - Left, Right, Bilateral

    Location - Upper lobe, middle lobe, lower lobe

    Cause (if known) - Community acquired, hospital acquired, aspiration, ventilator associated, chemical, bacterial, viral, associated with HIV-AIDS, etc.

    Organism (if known) - A positive sputum culture is not required for you to document the type of pneumonia you "suspect" you are treating; for example: "suspect gram neg. pneumonia."

    Document Associated Issues - Abscess, cavitation, empyeme, sepsis, respiratory failure (acute, chronic or acute on chronic hypoxic/hypercapnic)

    Remember: It is acceptable to use terms such as "Probable," "Suspected," or "Possible" in the medical record, i.e., "Suspect Pseudomonas" or "Probable gm. neg. Pneumonia." Avoid using "versus" as it posses a problem with coding.

    It is acceptable to document "rule out," but remember to document in your notes if and when you have ruled out a condition.

    Documentation of Congestive Heart Failure

    The documentation concepts necessary to describe Congestive Heart Failure in ICD-9 will note change in ICD-10.

    The two important concepts to remember when documenting Congestive Heart Failure are Acuity and Type.

    In certain cases, the type may no be known. Therefore, it is acceptable to document what you know and update your documentation as test results become available, e.g., echocardiogram results, ejection fraction.

    Acuity: Acute, chronic, acute on chronic

    Type: Systolic, Diastolic, Combined Systolic and Diastolic

    Document associated conditions such as aortic valve disease, CAD cardiomyopathy (type), mitral valve disease (stenosis, insufficiency).

    Documentation of Procedures

    To assist you in understanding the key definitions related to documenting procedures in ICD-10, enclosed is a list of terms to be used in your documentation. Please view and keep this information for reference.

    Documentation of Atrial Fibrillation and Atrial Flutter

    In ICD-10 further specificity of atrial fibrillation and atrial flutter will be required. Please use the enclosed information as a guide when documenting these conditions.

    Documentation of "Present on Admission"

    Present on Admission (POA) is defined as any diagnosis present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter - including emergency department, observation or outpatient surgery - are considered "POA." Please use the enclosed information as a guide when documenting these conditions.

    Documentation of the Diagnosis

    Signs, symptoms and ill-defined conditions are not to be used as principal diagnoses when a related definitive diagnosis has been established. Please use the enclosed information as a guide when documenting these conditions.

    Documentation of Diseases of the Genitourinary System

    Diseases of the genitourinary system are documented by their laterality, location, underlying cause or organism, and specific presence of disease, such as acute kidney or acute renal failure, chronic kidney disease and the presence of hematuria or hydonephrosis. Please use the enclosed information as a guide when documenting these conditions.

    Documentation of Inflammatory Diseases of the Female Pelvic Organs

    Inflammatory diseases of the female pelvic organs are documented by their laterality, specific conditions, including salpingitis and oophoritis, vaginitis and vulvitis and pelvic inflammatory diseases and peritonitis. In addition, these diseases are documented by the identification of an infectious agent, abscess vs. cellulitis and pelvic adhesions. Also documented are underlying diseases such as herpes, chlamydia and cancer. Please use the enclosed information as a guide when documenting these conditions.