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.
Follow these ICD-10 documentation tips for valuable information you can use. Start to use this information when you document now!
Documentation of Fractures
- Mechanism of injury
- Etiology of Fracture
Traumatic, pathologic, osteoporosis, neoplastic disease
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
- Sickle Cell
- Blood Loss Anemia
- 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
Hemorrhage, embolism, thrombosis, occlusion, stenosis, infarction
Acute vs. Old
- Deficits- hemiplegia, exp. Aphasia
Residuals from an old CVA?
- 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.
- Mild Intermittent, uncomplicated
- Mild Intermittent with acute exacerbation
- Mild Intermittent with status asthmaticus
- Mild persistent, uncomplicated
- Mild persistent with acute exacerbation
- Mild persistent with status asthmaticus
- Moderate persistent, uncomplicated
- Moderate persistent with acute exacerbation
- Moderate persistent with status asthmaticus
- 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
- Excisional debridement involves the cutting away of tissue/necrosis/slough and falls under the “Excision” definition in ICD-10.
- 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)
- Left Main Coronary Artery
- Left Anterior Descending Artery
- Other coronary artery Anterior 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)
- Location, laterality, displaced or non-displaced
- 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
Documentation of Atrial Fibrillation and Atrial Flutter
Documentation of "Present on Admission"
Documentation of the Diagnosis
Documentation of Diseases of the Genitourinary System
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.