Key ICD-10 Documentation Elements for Major ED Encounters

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Key ICD-10 Documentation Elements for Major ED Encounters

With more number of codes and increased specificity, ICD-10 presents unique documentation challenges for emergency department (ED) physicians. If you have no understanding of the underlying logic and organization of new codes, your chart documentation can become really disastrous and will drastically affect emergency room medical billing. The absence of details will make payers question the medical necessity of services provided and cause a delay or decrease in reimbursement. Under ICD-10, your documentation must clearly specify the precise mechanism and location of injury. Let’s take a detailed look at ICD-10 documentation for three major ED encounters, which are as follows:

Injuries and Poisonings For injuries, poisonings, musculoskeletal and connective tissue problems, pathologic and osteoporosis injuries, you must remember the mnemonic -location, location, location 

Location – You have to document the precise anatomical location



Location – Document laterality (right, left, bilateral)



Location – Document the geographic location where the incident occurred (for example, home), the circumstances and/or activity surrounding the injury and how it occurred (for example, if the injury was related to military or work).

You should also document episode of care for treatment of injuries, fractures, burns, poisonings, and similar conditions in the ED. Three types of episode of care are there such as:

 Initial Encounter – This is when a patient is new to the treating ED physician for that condition, regardless of whether or not an active treatment is being provided. Most of the ED visits are considered as initial.

 Subsequent Encounter – This is when additional care is provided to a patient, who is at a healing or recovery phase from an injury, fracture, burn, poisoning and similar condition. Such types of encounters are not so common in the emergency setting.

 Sequelae – This type of encounter is reported when a patient is being seen for later complications resulting from an injury, fracture, burn, poisoning and similar condition. The management of scar at the ED that results from a burn is an example.

For example, here are the ICD-10 codes for first degree burn on the right hand.

 T23.101: Burn of first degree of right hand, unspecified site  T23.101A: Burn of first degree of right hand, unspecified site, initial encounter

 T23.101D: Burn of first degree of right hand, unspecified site, subsequent encounter

 T23.101S: Burn of first degree of right hand, unspecified site, sequela

Infectious Diseases Consider the following components when documenting infectious diseases such as pneumonia, cellulitis, and urinary tract infections (UTIs) at an ED setting.  Type of Infection – Document the exact type of infection. For example, in the case of pneumonia, you should specify whether it is bacterial, viral, aspiration, fungal, ventilator associated or occurred due to other reasons.  Location of Infection – The exact anatomic location (for example, upper lobe, middle lobe or lower lobe for pneumonia) and laterality of the infection should be documented.  Acuity/Temporal – Specify whether the infection is acute, chronic, recurrent or persistent.  Causative Organism – Specify the name of the organism that caused the infection (in case of bacterial, fungal or viral infection).  Clinical Manifestation – Visible symptoms or the symptoms found from the history and examinations should be documented (For example, cough and fever for pneumonia).  Complications – The complications associated with the infectious disease should

be

documented

as

well

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example,

abscess,

empyema, sepsis or respiratory failure in case of pneumonia).

cavitation,

Medical Conditions For medical conditions such as diabetes, hypertension or angina, document the following components:

 Medical Condition/ Type – You should specifically document the medical condition that led to an ED visit. For example, in the case of fever, specify whether it is drug-induced, post-procedural or postvaccination.

 Temporal – Specify whether the condition is acute, recurrent, persistent or episodic.

 Stage/Severity – Document the severity of the medical condition, whether mild, moderate or severe.

 Body System Affected – Specify which body system is affected from that condition including the exact anatomic location and laterality (for example, left ventricle)

 Signs and Symptoms – Clinical manifestations found during an ED visit should be documented.

 Significant Findings – The complications associated with the medical condition should also be documented.

ICD-10 allows the documentation of alcohol, tobacco and drug abuse related to an ED visit. Do not simply state ‘rule out’, ‘suspected’ or ‘evaluate for’ during the final diagnosis without any additional descriptors.

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