Q. How do I talk to my providers about the documentation to support specific International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes when most of them do not really know the codes, but they know the terminology?
A. Now that we are 1 year into using ICD-10-CM codes, most expect the Centers for Medicare & Medicaid Services (CMS) to lift the grace period for allowing providers to assign unspecified diagnosis codes. It is important that you are documenting to get to the highest specificity. For example, when assigning a code for a fracture, consider the following categories:
What type of fracture is this (e.g., type I, type II, greenstick, displaced, nondisplaced, open, closed)?

  • What is the anatomic location (e.g., shaft of the radius, radial styloid)?
  • What is the status of the fracture (e.g., initial encounter, subsequent encounter with routine healing)?
  • What is the laterality of the fracture (e.g., right arm, left leg)?

Once these questions are answered, you should be able to code the highest-specificity fracture code possible. Here are more examples of specifics needed for some diagnostic categories:

Neoplasms (C00-C99)

  • Type: Benign, premalignant, malignant, uncertain behavior, etc.
  • Anatomic location: Stomach, intestine, skin, etc.
  • Examples:
    • C43.31, “malignant melanoma of nose”
    • C43.__, “malignant melanoma of skin”
    •  ___.3_, “. . . unspecified parts of face”
    •  ___._1, “. . . nose”

Endocrine (E00-E99)

  • Type: type 1, type 2, gestational
  • Causes: chemical exposure, renal disease, pregnancy, etc.
  • Complications/manifestations: glaucoma, ulcers, etc.
  • Laterality: right, left, bilateral
  • Body system affected: renal, pancreas, etc.
  • Example: E11.3211, “type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macularedema, right eye”
    • E11.____, “type 2 diabetes mellitus”
    • ___.3___, “. . . with ophthalmic complications”
    • ___._2__, “. . . with mild nonproliferative diabetic retinopathy”
    • ___.__1_, “. . . with macular edema”
    • ___.___1, “. . . right eye

Diseases of the Nervous System

  • Type: pain, neuropathies, etc.
  • Laterality: right, left, bilateral
  • Example: G56.03, “carpal tunnel syndrome, bilateral upper limbs”
    • G56.__, “mononeuropathies of upper limb”
    • ___.0_, “. . . carpal tunnel syndrome”
    • ___._3, “. . . bilateral””

Diseases of the Eye and Adnexa (H00-H59)

  • Type: acute, chronic, mechanical, mucopurulent, senile, etc.
  • Laterality: right, left, bilateral
  • Example: H10.011, “acute follicular conjunctivitis, right eye”
    • H10.___, “conjunctivitis”
    • ___.0__, “. . . mucopurulent”
    • ___._1_, “. . . acute follicular”
    • ___.__1, “. . . right eye”

Diseases of the Ear and Mastoid Process (h60-H95)

  • Type: acute, chronic, externa, serous, etc.
  • Laterality: right, left, bilateral
  • Example: H65.01, “acute serous otitis media, right ear”
    • H65.__, “nonsuppurative otitis media”
    • ___.0_, “. . . acute serous”
    • ___._1, “. . . right ear”

Diseases of the Circulatory (I00-I99)

  • Associated complications/signs/symptoms: Infection, exposure to smoke, etc.
  • Type: hypertensive, ischemic, etc.
  • Site/anatomic location: heart, kidney, etc.
  • Causes: plaque, calcification
  • Stage: 1, 2, mild, severe, etc.
  • Example: I48.0, “paroxysmal atrial fibrillation
    • I48._, “atrial fibrillation and flutter”
    • ___.0, “. . . paroxysmal”

Diseases of the Digestive System (K00–K95)

  • Type: hemorrhaging, necrotizing, etc.
  • Temporal factors: bleeding, weight loss, etc.
  • Anatomic location: large intestine, small intestine, etc.
  • Stage: 1, 2, etc.
  • Laterality: right, left, bilateral
  • Example: K57.32, “diverticulitis of large intestine without perforation or abscess without bleeding”
    • K57.__, “diverticular disease of intestine”
    • ___.3_, “. . . large intestine without perforation or abscess without bleeding”

Diseases of the Musculoskeletal System and Connective Tissue (M00–M99)

  • Type: arthritis, fibromyalgia, greenstick, oblique, etc.
  • Anatomic location: ankle, wrist, etc.
  • Laterality: right, left, bilateral
  • Status: initial encounter, healing, tophi, etc.
  • Example: M13.811, “other specified arthritis, right shoulder”
    • M13.___, “other arthritis”
    • ___.8__, “. . . other specified arthritis
    • ___._1_, “. . . shoulder”
    • ___.__1, “. . . right”

Diseases of the Genitourinary System (N00-N99)

  • Type: cystitis, stone, etc.
  • Anatomic location: bladder, kidney, ovary, etc.
  • Laterality: right, left, bilateral
  • Example: N30.01, “acute cystitis with hematuria”
    • N30.__, “cystitis”
    • ___.0_, “. . . acute”
    • ___._1, “. . . with hematuria”

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00–R99)

  • Type: abnormality, pain, etc.
  • Anatomic location: abdomen, kidney, etc.
  • Laterality: right, left, bilateral
  • Example: R10.31, “right lower quadrant pain
    • R10.__, “abdominal and pelvic pain”
    • ___.3_, “pain localized to other parts of lower abdomen”
    • ___._1, “right”

Injury, Poisoning, and Certain Other Consequences of External Causes (S00–T88)

  • Type: spiral, comminuted, displaced, etc.
  • Anatomic location: radius, ulna, femur, etc.
  • Status: initial encounter, subsequent encounter, etc.
  • Laterality: right, left, bilateral
  • Causes: a fall down stairs at home, etc.
  • Complications/manifestations: malunion, infection, etc.
  • Example: S52.351A, “displaced comminuted fracture ofshaft of radius, right arm, initial encounter”
    • S52.____, “fracture of forearm”
    • ___.3___, “. . . shaft of radius”
    • ___._5__, “. . . comminuted”
    • ___.__1_, “. . . right arm”
    • ___.___A, “initial encounter”

CMS offers free guidance on ICD-10-CM documentation guidelines at https://www.cms.gov/Medicare/Coding/ICD10/ ICD-10-Coding-Resources.pdf

Note: CPT codes, descriptions, and other data only are © 2011, American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.

DAVID STERN, MD, (Practice Velocity)

How to Talk About Billing Codes to Providers Who Don’t Know Them

David Stern, MD

Chief Executive Officer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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