ICD-10 Documentation: Tips and Tricks for Providers (Part 3 of 4)

Jim Strafford

Jim Strafford , CEDC, MCS-P


Published March 08, 2014

In Parts 1 and 2 of our series on ICD-10 implementation, we discussed differences between ICD-9 and ICD-10 coding and how both coders and providers can prepare for the upcoming change, which is scheduled to take place Oct. 1. Specifically, our research at Healthcare Administrative Partners shows a need for providers to document with increased levels of specificity and granularity so that coders to select the most appropriate ICD-10 code.

Why Preparation Is Essential

An effective way to get the attention of an ICD-10-resistant provider is to share this information with them:

  • ICD-9 Choices for finger laceration = 883.0, 883.1, 883.2
  • ICD-10 Choices = 153 and counting

A coder may be trained in how to identify the most specific finger laceration code (and they get quite specific in ICD-10), but if the ED provider is not documenting to that specificity, the coder has no choice but to assign one of the dreaded "unspecified" codes. "Unspecified" codes are more likely to raise payers' eyebrows and could delay or limit reimbursement. For these reasons, providers need to be on the same page as coders in terms of ICD-10 documentation.

In this post, we will venture into the ICD-10 "weeds" with examples based on the ED auditing and coding work done at Healthcare Administrative Partners (HAP). We will review several common ED diagnoses, compare ICD-9 and 10 codes and documentation requirements and provide quick and easy tips that physicians can begin using today to achieve ICD-10-ready documentation practices.

It should be noted, however, that these are only the tip of the iceberg. The problems surrounding this handful of codes only underscores why ICD-10 training is so important.

Special Considerations for Emergency Providers

Rapid decision-making followed by appropriate treatment are hallmarks of emergency medicine. ED physicians are taught to take histories expediently, especially in life-threatening situations. While ICD-10 in many ways creates more intuitive codes for ED visits, the specificity and granularity required sometimes go beyond the ED provider's role and training. Or, to date myself, lengthy, complex diagnostics happen on "House," not "ER."

However, ICD-10 may sometimes require ED docs to get more specific and expansive with their diagnoses. While an in-depth workup may not be practical, documenting elements like laterality or "initial encounter" will result in a more specific code.

Ear Infections





Unspecified otitis media

Otitis media, unspecified, unspecified ear

Ear infections are a common cause of ED visits, particularly in children. On its surface, the ICD-9 code (382.9) converts pretty smoothly to the equivalent ICD-10 code (H66.90). But when you look closely, a straight conversion doubles the number of "unspecified" elements. That's a lot of "unspecifieds" to present to a payer.

Under ICD-9, the code description for 382.9 includes the terms "acute" and "NOS" in its notes, so ED coding/billing entities have been able to code "acute otitis media" as long as the provider uses those terms on the chart. (While more specific ICD-9 codes are available, this code has generally been sufficient for billing and reimbursement purposes in the emergency department.)

However, in ICD-10, the description "acute otitis media" leads to "double unspecified" coding unless further documentation is provided. As with ICD-9, more specific codes, (e.g., H66.009, acute suppurative otitis media with spontaneous rupture of eardrum) can be used if more specific terminology is documented. For physicians who have relied on "acute otitis media," we strongly recommend:

  • Use of descriptors "serous" and "suppurative"
  • Note "with" or "without spontaneous rupture of eardrum"

To eliminate the second "unspecified," the provider must also document whether the infection is on the "right," "left" or "bilateral." In fact, ICD-10 requires documentation of laterality for all injuries and for illnesses involving bilateral organs (like ears).

When HAP reviewed thousand of pediatric ED charts (where otitis is rampant), we found that documentation of laterality is often lacking in the diagnosis or impression. At times, the location can be inferred from other parts of the chart. But many coders, particularly those who are hospital-based, are taught that the diagnosis, if one is documented, overrides symptoms in the HPI or ROS.

For this reason, we strongly recommend that ED providers get in the habit of identifying otitis as "right," "left" or "bilateral." We understand the position of many providers that treatment is usually the same regardless of laterality. But documentation of the specific location allows the coder to eliminate at least one "unspecified" element, which is likely to impact reimbursement.

Often fever is noted with otitis. The good news is that ICD-9 code 780.60 (fever, unspecified) converts seamlessly to ICD-10 code R50.9 (fever, unspecified). Fever is typically well documented on ED charts, so most physicians can continue using their current notation system. (We are surprised that ICD-10 does not get more granular stratifying fever codes by actual temperature. Maybe in the next edition!)

A final caveat: we at HAP understand that certain symptoms or conditions go with certain diagnoses (including otitis) and should be easily inferred by a capable coder. But remember, for compliance purposes, coders are trained to never infer. So attaining the required level of specificity is important for physicians. If you are documenting to that specificity already, good for you. If not, the next several months represent the opportunity for "spring training" before the season begins on Oct. 1 and the codes really count.

Ankle Sprains and Strains



845.00. Sprain, strain ankle

S43.409A. Sprain of unspecified ligament of unspecified ankle; first encounter


S96.919A . Strain of unspecified muscle and tendon at ankle and foot level, unspecified foot.


A weakness of ICD-9 is that it doesn't differentiate between sprain and strain. By contrast, ICD-10 provides clear descriptions for sprain (injury of a ligament) and strain (injury of a muscle or tendon).

Differentiating sprain and strain is a start. However, note that both codes above contain the dreaded "unspecified, unspecified." We can eliminate one of these by documenting whether the injury is to the left ankle, right ankle or bilateral, (e.g., S93.402A, "sprain of unspecified ligament of right ankle, initial encounter.")

For maximum specificity, we can also document the specific ligament involved (e.g., S93.421A, "sprain of deltoid ligament of right ankle, initial encounter.") Note that in order for the deltoid ligament injury to be coded, the provider must specify "deltoid ligament" in the diagnosis.

HAP's experience reviewing ED charts is that the specific ligament is seldom documented for sprains. This may not be a realistic expectation in the ED setting. But if specific documentation of an injured ligament is available (say from a radiologist's report), this should also be documented by the ED physician. (Keep in mind that coders are trained not to use x-ray findings to code a diagnosis, though this might have to be rethought under ICD-10).

You many have noticed that ICD-10 diagnoses include a seventh digit:

  • "A" for initial encounter
  • "D" for subsequent encounter
  • "S" for sequelae

Most ED visits will be "initial encounters," because they represent the first visit with the physician for a given injury. However, remember that coders are taught never to infer or assume anything about documentation. For this reasons, providers should include the term "initial encounter" in their diagnoses when appropriate, and "subsequent encounter" for follow-up visits (e.g., returning to the ED physician for cast removal).

Finger lacerations





Open wound of finger(s), unspecified, without mention of complication

Unspecified open wound of unspecified finger, without damage to nail, initial encounter

As with our above examples, the standard ICD-9 code for finger laceration become an "unspecified, unspecified" code in ICD-10. Note also that the wording between the two is significantly different. But before you decide to take early retirement or change careers, read on, since ICD-10 is a significant improvement in terms of laceration description and location.

Even the double-unspecified ICD-10 code S61.209A requires documentation that was not required for ICD-9. As a starting point, all finger laceration codes specify whether or not there is damage to the nail. We recommend that ED providers get in the habit of documenting this now.

Another improvement is that ICD-10 allows for coding of the specific finger. Our research shows that ED providers typically do a good job identifying specific finger and laterality — either narratively or graphically.

We also find that ED physicians generally document a foreign body in the wound when appropriate. But remember, coders are trained not to infer, so they can't code "without foreign body" when one isn't mentioned. Ideally, the provider should document "laceration without foreign body of left little finger, without damage to nail, initial encounter" so the coder can use the more specific code S61.216A.

However, coders can use typical chart documentation to identify mechanism of injury. The ICD-10 system contains distinct codes for "puncture" or "bite" (e.g., S61.230A, "puncture wound without foreign body, without damage to nail, initial encounter"). ICD-9 had no such codes, so external cause (E) codes were required to complete the description of the injury.

While the ICD-10 approach is more efficient, it's worth noting that it hasn't eliminated E codes. In fact, they have been expanded and can be found in the V and U chapters of the manual. Due to their specificity, these new codes have been the subject of a number of humorous articles in the New York Times and elsewhere. (Take for example V97.33A, "sucked into a jet engine, initial encounter." Would there be a subsequent encounter?)

As with other injury codes, finger laceration codes require a seventh digit (usually A for "initial encounter" in emergency department setting).

In Summary

Complete ICD-10 coding will require more specific, descriptive physician documentation in order for the coder to determine the optimum code for ED reimbursement. Now is the time for ED providers to begin documenting to ICD-10 requirements. This will require a change in provider documentation habits for some illnesses and injuries. On the bright side, ICD-10 will allow for more descriptive, intuitive coding that was not possible with ICD-9.

In Part 4, we will discuss ICD-10 implementation from an administrative point of view and provide methods of tracking its impact on ED reimbursement.

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