ICD-10-CM/PCS Documentation Tips
ICD-10-CM/PCS Documentation Tips
ICD-10-CM/PCS Documentation Tips
ICD-10-CM/PCS
Documentation Tips
MX11442
Clinical Documentation Improvement
Chapter 18
Coma
Introduction
The AHIMA CDI Workgroup has responded to the needs of ICD-10 implementation
by creating a large library of CDI ICD-10 documentation tips that are now available
for the healthcare industry. These tips focus on the language and/or wording that
will garnish greater details and specificity of the coded data for a given diagnosis,
condition, disease and/or surgical procedure.
Systemic Infection/Inflammation
Meningitis
Viral Meningitis
• Documentation of “Viral Meningitis” should include the specific viral
organism if known (i.e., adenovirus, enterovirus, chickenpox, measles,
etc.).
• Document any associated diagnoses/conditions
Bacterial Meningitis
• Documentation of “Bacterial meningitis” should include the specific
bacterial organism (i.e., Escherichia coli, bacillus, gram-negative,
Klebsiella, staph, strep, etc.) if known.
• Document if the meningitis is due to “other causes,” which can include
“nonpyogenic meningitis,” “chronic meningitis,” “Benign recurrent
meningitis.”
• Document any associated diagnoses/conditions
Hepatitis
• Document acuity:
-- Acute
-- Chronic
• Document etiology:
-- Alcoholic
-- Drug (specify)
-- Viral (Type A, B, C, or E)
• Document also:
-- With hepatic coma
-- Without hepatic coma
-- With delta agent
-- Without delta agent
• Document any associated diagnoses/conditions
MRSA/MSSA
Herpes Simplex
Neoplasms
• Behavior:
-- Malignant (primary, secondary, in-situ)
°°Document any secondary sites
-- Benign
-- Unspecified behavior
-- Of uncertain histological behavior
• Laterality (specify right/left)
• Anatomical site (topography)
• Other condition(s) associated with malignancy (dehydration, anemia,
etc.)
• Complication(s) associated with neoplasm
• Include estrogen receptor status (if applicable)
• History of:
-- Has the malignancy been excised or eradicated?
-- Is there still treatment being provided for the primary and/or
metastatic site?
-- Is there evidence of remaining malignancy at the primary site?
• Document any associated diagnoses/conditions
Anemia
Hemolytic Anemia
Nutritional Anemia
Aplastic Anemia
Pancytopenia
• Specify if:
-- Antineoplastic chemotherapy induced pancytopenia
-- Other drug-induced pancytopenia
°°Specify drug
-- Other pancytopenia
• Specify the etiology of pancytopenia (if known), such as:
-- Myelodysplastic Syndrome
-- Leukemia
-- HIV
-- Other (specify)
• Document any associated diagnoses/conditions
Coagulopathy
• Specify type:
-- Disseminated intravascular coagulation
-- Hereditary factor VIII deficiency
-- Hereditary factor IX deficiency
-- Von Willebrand’s disease
-- Hereditary factor XI deficiency
-- Hereditary deficiency of other clotting factors
-- Acquired coagulation factor deficiency
-- Primary thrombophilia
°°Activated protein C resistance
°°Prothrombin gene mutation
°°Other primary thrombophilia
-- Other thrombophilia
°°Antiphospholipid syndrome
°°Lupus anticoagulant syndrome
-- Other Specified coagulation defects
• Document any associated diagnoses/conditions
• Hemorrhagic disorder due to circulating anticoagulants
-- Due to intrinsic circulating anticoagulants, antibodies, or inhibitors
°°Acquired hemophilia
°°Antiphospholipid antibody with hemorrhagic disorder
°°Other hemorrhagic disorder due to intrinsic circulating
anticoagulants, antibodies, or inhibitors
-- Hemorrhagic disorder due to extrinsic circulating anticoagulants
°°Document specific drug, if drug-induced
Purpura
Diabetes
• Type:
-- Type 1
-- Type 2
-- Drug/chemical induced
-- Due to underlying condition
-- Other specified type
• Control:
-- Inadequate control
-- Out of control
-- Poorly Controlled
-- Hypoglycemia
-- Hyperglycemia
• Insulin use
• Document any associated diagnoses/conditions
• Manifestation/Complication (document link to diabetes)
-- Circulatory complications
-- Hyperosmolarity
-- With or without coma
-- Hypoglycemia
-- Ketoacidosis
-- With or without coma
-- Kidney complications
-- Neurological complications
-- Ophthalmic complications
-- Oral complications
-- Skin complications
-- Arthropathy
-- Other (specify)
Obesity
• Obesity
-- Morbid (severe)
°°Due to excess calories
°°With alveolar hypoventilation (Pickwickian syndrome)
-- Drug Induced
°°Document drug
-- Other
°°Due to excess calories, familial, endocrine
• Overweight
• Body Mass Index (BMI)
• Document any associated diagnoses/conditions
Malnutrition
• Severity:
-- Mild (first degree)
-- Moderate (second degree)
-- Severe (third degree)
• Avoid documenting a range of severity, such as “moderate to severe”
• Form:
-- Kwashiorkor (rarely seen in the U.S.)
-- Marasmus
-- Marasmic kwashiorkor
-- Other
• Document any associated diagnoses/conditions
• Document episode:
-- Single
-- Recurrent
• Document severity:
-- Mild
-- Moderate
-- Severe
°°With psychotic features
°°Without psychotic features
• In partial or full remission (if applicable)
• Document any associated diagnoses/conditions
Cerebral Palsy
Glaucoma
Otitis Media
• Incidence:
-- Acute/subacute
-- Acute recurrent
-- Chronic
• Laterality:
-- Right ear
-- Left ear
-- Bilateral
• Types:
• Serous
• Suppurative or Nonsuppurative
• Tubotympanic
• Atticoantral
• Allergic
• Mucoid
• Document if associated with:
-- Spontaneous rupture of tympanic membrane
-- Without spontaneous rupture of tympanic membrane
-- Infectious or other external agent
-- Exposure to environmental tobacco smoke
• Document any other associated diagnoses/conditions
Hearing Loss
• Laterality:
-- Bilateral
-- Unilateral
• Extent of hearing loss:
-- Left/right ear with unrestricted hearing on the contralateral side
• Types:
-- Conductive
-- Sensorineural
-- Mixed
-- Other (specify)
• Document any associated diagnoses/conditions
Heart Failure
• Document acuity
-- Acute
-- Chronic
-- Acute on Chronic
• Document type
-- Diastolic
-- Systolic
-- Combined systolic and diastolic
• Due to or associated with
-- Cardiac or other surgery
-- Hypertension
-- Valvular disease
-- Rheumatic heart disease
°°Endocarditis (valvitis)
°°Pericarditis
°°Myocarditis
-- Other (specify)
CVA
• Due to Hemorrhage
-- Location or source of hemorrhage
°°Subarachnoid (specify artery, if known)
°°Intracerebral (specify location, if known)
°°Intracranial
»» Subdural
* Acute, Subacute, Chronic
»» Extradural
-- Laterality
-- Document any associated diagnoses/conditions
• Due to causes other than hemorrhage
-- Cause
°°Thrombosis
°°Embolism
°°Other (specify)
°°Unspecified Occlusion or stenosis
-- Site
°°Precerebral Arteries (specify artery, if known)
°°Cerebral Arteries (specify artery, if known)
-- Laterality
-- Document any associated diagnoses/conditions
Myocardial Infarction
Cardiac Arrest
Respiratory Failure
• Document acuity:
-- Acute
-- Chronic
-- Acute on chronic
• Document inclusion of:
-- Hypoxia
-- Hypercapnia
• Document tobacco:
-- Use
-- Abuse
-- History of
• Document any associated diagnoses/conditions
Pneumonia
Asthma
• With
-- Acute lower respiratory infection
-- COPD
-- Chronic obstructive bronchitis
-- Exacerbation
-- Status asthmaticus
• Severity
-- Mild intermittent
-- Mild persistent
-- Moderate persistent
-- Severe persistent
• Form or Type
-- Cough variant
-- Childhood
-- Exercise induced bronchospasm
-- Extrinsic allergic
-- Idiosyncratic
-- Intrinsic nonallergic
-- Late-onset
-- Mixed
-- Other (specify)
• Document any associated diagnoses/conditions
• With Complication
-- Abscess
-- Fistula
-- Intestinal obstruction
-- Rectal bleeding
-- Other (specify)
• Site
-- Small intestine
-- Large intestine
-- Both small and large intestines
• Document any associated diagnoses/conditions
Appendicitis
• Severity
-- Acute
-- Chronic
-- Recurrent
-- Subacute
• With
-- Perforated or ruptured appendix
-- Peritoneal abscess
-- Peritonitis
°°Generalized
°°Localized
-- Other (specify)
Hepatic Encephalopathy
• Etiology
-- Due to alcohol
-- Due to drugs
-- Post-procedural
• Acuity
-- Acute
-- Subacute
-- Chronic
• Severity
-- With coma
-- Without coma
• Document any associated diagnoses/conditions
Pressure Ulcers
Non-Pressure Ulcers
• Site:
-- Back
-- Buttock
-- Lower limb
°°Laterality
»» Right
»» Left
°°Specific site/area
»» Ankle
»» Calf
»» Heel/midfoot
* Plantar surface
»» Thigh
»» Other part of lower leg
-- Other (specify)
• Ulcer depth:
-- Limited to skin breakdown
-- With fat layer exposed
-- With muscle necrosis
-- With bone necrosis
• Cause of lower limb ulcers:
-- Atherosclerosis of lower extremity
-- Chronic venous hypertension
-- Diabetic ulcer
-- Postphlebitic syndrome
-- Postthrombotic syndrome
-- Varicose ulcer
-- Other (specify)
• With gangrene
• Document any associated diagnoses/conditions
Cellulitis
Pathologic Fractures
• Document location:
-- Bone (distal, proximal, shaft, etc.)
-- Laterality
• Document etiology:
-- Osteoporosis
°°Disuse
°°Drug-induced
°°Postmenopausal
°°Idiopathic
°°Postsurgical malabsorption
°°Other (specify)
-- Neoplastic disease
-- Other (specify)
• Document encounter type:
-- Initial encounter
-- Subsequent encounter
°°Routine healing
°°Delayed healing
°°Nonunion
°°Malunion
-- Sequela
• Document any associated diagnoses/conditions
Scoliosis
• Specify type:
-- Infantile idiopathic
°°Progressive
°°Resolving
• Juvenile idiopathic
• Adolescent
• Other idiopathic
• Thoracogenic
• Neuromuscular
• Other secondary
• Other (specify)
• Specify site:
-- Cervical
-- Cervicothoracic
-- Thoracic
-- Thoracolumbar
-- Lumbar
-- Lumbosacral
-- Sacral
-- Sacrococcygeal
• Document any associated diagnoses/conditions
• Laterality
-- Left, right, bilateral
• Specificity of Location
-- Ex: foot and/or hand
-- Upper or lower limb
• Status
-- Acute
-- Chronic
-- Intermittent
-- Recurrent
• Specificity
-- Rigid or flexible
-- Type of neuroma, if applicable
-- Bone vs. joint
• Cause
-- Traumatic
-- Primary or secondary
-- Post traumatic
-- Other disease (OA, RA, Gout)
°°Generalized or particular joint(s)
Tendon Disorders
• Laterality
-- Left, right, bilateral
• Specificity of Location
-- Ex: meniscus, flexor tendons, extensor tendons
• Status
-- Acute
-- Chronic
-- Intermittent
-- Recurrent
• Cause
-- Traumatic
-- Non-traumatic: use or overuse, pressure
-- Past trauma
-- Other disease
• General
-- Episode of care for 7th character placement:
°°Initial–active treatment
°°Subsequent–follow up by this provider
°°Sequela–residual condition from injury or other disease
Pain in Joint
• Laterality
-- Left, right, bilateral
• Specificity of Location
-- Ex: hip, knee, shoulder, fingers (joints)
• Status
-- Acute
-- Chronic
-- Intermittent
-- Recurrent
• Type of pain
-- Chronic
-- Acute
-- Related to neoplasm
-- Chronic Pain syndrome
• Cause
-- Traumatic
-- Primary or secondary
-- Post traumatic
-- Other disease
-- Dysplasia
-- Other disease (OA, RA)
• General
-- Episode of care for 7th character placement:
°°Initial–active treatment
°°Subsequent–follow up by this provider
°°Sequela–residual condition from injury or other disease
Gout
OB/Pregnancy
• Specify trimester
-- First (less than 14 weeks, 0 days)
-- Second (14 weeks, 0 days to less than 28 weeks, 0 days)
-- Third (28 weeks until delivery)
• Specify preterm labor/delivery
• Gestational Diabetes needs documentation specification of diet
controlled or insulin controlled
• Document any associated diagnoses/conditions
Newborn
• Birth:
-- In hospital
°°Specify delivery type
-- Outside hospital
• Document any maternal conditions affecting the newborn
• Specify gestational age and weight of newborn
• Specify congenital vs. acquired conditions
• Document any associated diagnoses/ conditions
Cleft Palate
Coma
• Document:
-- Somnolence, drowsiness
-- Stupor, catatonic stupor, or semicoma
-- Coma, unconsciousness
-- Include any associated skull fracture or intracranial injury if present
• Document the Glasgow (coma scale) score
-- (Typically reported as a total score 0–15)
-- Higher the score = higher functioning
• Also document each assessment area:
-- Eye opening
-- Verbal response
-- Motor response
Gustilo Classification
• Specificity for open fractures of the forearm, femur, and lower leg
will require provider documentation to specify Gustilo Type l through
Type lllC:
-- TYPE l: The wound is smaller than 1 cm, clean, and generally caused by
a fracture fragment that pierces the skin.
-- TYPE II: The wound is longer than 1 cm, not contaminated, and without
major soft tissue damage or defect. This is also a low energy injury.
-- TYPE III: The wound is longer than 1 cm., with significant soft tissue
disruption. The mechanism often involves high-energy trauma, resulting
in a severely unstable fracture with varying degrees of fragmentation.
-- IIIA: The wound has sufficient soft tissue to cover the bone without the
need for local or distant flap coverage.
-- IIIB: Disruption of the soft tissue is extensive, such that local or distant
flap coverage is necessary to cover the bone. The wound may be
contaminated, and serial irrigation and debridement procedures are
necessary to ensure a clean surgical wound.
-- IIIC: Any open fracture associated with an arterial injury that requires
repair is considered IIIC. Involvement of a vascular surgeon is generally
required.
• NOTE: Even though the fracture may be described using the terminology
found in the Gustilo classification the provider must document the type
of Gustilo fracture present; coder CANNOT code based on the fracture
description.
Fractures
• Cause:
-- Traumatic
-- Stress
-- Pathologic
• Location:
-- Which bone?
-- Which part of the bone?
-- Laterality (right, left, or bilateral)
• Type:
-- Non-displaced
-- Displaced
-- Open (Gustilo classification where applicable)
-- Closed (Greenstick, spiral, etc.)
-- Salter-Harris (specify type)
• Encounter:
-- Initial
-- Subsequent
°°For routine healing
°°For delayed healing
°°For non-union
°°For malunion
-- Sequela (such as bone shortening)
• Include the external cause of the fracture, such as fall while skiing, motor
vehicle accident, tackle in sports, etc.
• Document any associated diagnoses/conditions
Burns
• Type:
-- Corrosion
-- Thermal
• Site:
-- Specify body part
-- Include laterality
• Degree:
-- First
-- Second
-- Third
• Document total body surface area (TBSA) burned (percentage)
• Specify the percentage of third degree burns
• Include the external cause of the burn, such as house fire, stove, acid, etc.
• Document any associated diagnoses/conditions
Underdosing
Dislocations
• Laterality
-- Left, right, bilateral
• Underlying cause
-- Past trauma
-- Other disease
• Status
-- Acute
-- Chronic
-- Intermittent
-- Recurrent
• General
-- Detailed location
-- Episode of care for 7th character placement:
°°Initial–active treatment
°°Subsequent–follow up by this provider
°°Sequela–residual condition from injury or other disease
• Cause of Injury (only for the initial episode of care)
-- Mechanism–how it happened
-- Place of occurrence–where did it happen
-- Activity–what were they doing
-- External cause status–Military, civilian, work-related, leisure
Lacerations
• Laterality
-- Left, right, bilateral
• With or without foreign body
• General
-- Detailed location with dimensions
-- Episode of care for 7th character placement:
°°Initial–active treatment
°°Subsequent–follow up by this provider
°°Sequela–residual condition from injury or other disease
• Cause of Injury (only for the initial episode of care)
-- Mechanism–How it happened
°°Intention
»» Accident
»» Assault
»» Self-inflicted
»» Undetermined
-- Place of occurrence–where did it happen
-- Activity–what were they doing
-- External cause status–Military, civilian, work-related, leisure
• Laterality
-- Left, right, bilateral
• Specificity of Location
-- Ex: muscle of the upper right arm, flexor tendons, extensor tendons
• Cartilage tear
-- Incomplete
-- Complete
-- Bucket-handle
-- Peripheral
-- Complex
-- Other
• Cause
-- Traumatic
-- Non-traumatic: use or overuse, pressure
• General
-- Episode of care for 7th character placement:
°°Initial–active treatment
°°Subsequent–follow up by this provider
°°Sequela–residual condition from injury or other disease
• Cause of Injury (only for the initial episode of care)
-- Mechanism–how it happened
°°Intention
»» Accident
»» Assault
»» Self-inflicted
»» Undetermined
°°Place of occurrence–where did it happen
°°Activity- what were they doing
°°External cause status–military, civilian, work-related, leisure
External Cause
Encounter For
Genetic Carrier/Susceptibility
• Specify what the patient came into contact with, such as:
-- AIDS virus
-- Anthrax
-- Varicella
-- Mold
-- Second-hand tobacco smoke
-- Other (specify)
Reproductive Services
• Body system
• Type of device
• Specific complication
-- Breakdown
-- Displacement
-- Leakage
-- Infection
-- Hemorrhage
-- Pain
-- Embolism
-- Fibrosis
-- Other _________________________
• Episode of care
-- Initial encounter
-- Subsequent encounter
-- Sequela
• Document any associated
diagnoses/conditions
Surgical Complications
ICD-10-PCS: Omentectomy
ICD-10-PCS: CABG
• Origination/Destination of graft(s)
-- Examples: aorta to RCA, LIMA to LAD (indicate if the LIMA was
used as a pedicle graft)
• Type of graft(s) used
-- Examples: autologous artery, autologous vein, etc.
• Number of sites bypassed
-- Examples: one, two, three, or four, or more
• Excision of autologous graft
-- Identify the vessel
°°Examples: greater/lesser saphenous vein (left/right), radial artery
(left/right)
• Column fused
-- Anterior (rounded, smooth portion of spine)
-- Posterior (pedicle, lamina, facet, transverse process of spine)
• Approach
-- Anterior
-- Lateral
-- Posterolateral
-- Posterior
-- Lateral transverse
• Type of device(s) used
-- Interbody fusion device
-- Autologous bone graft
-- Nonautologous bone graft
-- Etc.
• Number of joints fused
-- L1–L3
-- L5–S1
-- Etc.
ICD-10-PCS: Amputations
ICD-10-PCS: Debridement
• Depth:
-- Skin
-- Subcutaneous tissue/fascia
-- Muscle
-- Joint
-- Bone
• Type:
-- Excisional
-- Non-excisional
• Specify the type of instrument used