ICD-10 Documentation in Family Practices

by | Published on Dec 30, 2015 | Medical Coding

ICD 10 Documentation
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Family practice physicians should not only understand the basic changes with the ICD-10 to successfully prepare for ICD-10 implementation but also the additional documentation details the changes demand. The family practice medical coding process generally takes place in three formats. While small and solo practices depend upon superbill (involves the list of most common diagnosis codes), larger practices use coders to abstract the medical records and add relevant diagnosis codes in the medical claims. Practices with EHRs incorporate an automatic billing system to translate the information from the record onto claim forms. However, one- or two- page superbill cannot capture all the ICD-10 codes and a specific documentation is essential for code selection.

There are three main changes in ICD-10-CM such as definition changes, terminology differences and increased specificity. Physicians should have a thorough understanding of these changes to include additional documentation elements into their records. Specifying anatomical location and laterality (left, right, bilateral) is very important. More than 1/3 of the expanded codes in ICD-10 result from the addition of laterality. However, each condition has its own documentation requirements. Here are the ICD-10 documentation requirements for common conditions at family practices.


In ICD-10, there is no concept of ‘benign or malignant’ and hypertension is defined as essential (primary). You should include the following in your documentation.

  • Type (essential, secondary)
  • Casual relationship (Renal, pulmonary)

Examples of ICD-10 codes for hypertension are as follows:

  • I10: Essential (primary) hypertension
  • I11.9: Hypertensive heart disease without heart failure
  • I15: Secondary hypertension
  • I15.0: Renovascular hypertension


When documenting asthma, include the following:

  • Cause (Exercise induced, cough variant, related to smoking, chemical or particulate cause, occupational)
  • Severity (Mild persistent, Moderate persistent or Severe persistent)
  • Temporal Factors (Acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation)

Examples of ICD-10 codes for asthma are:

  • J45.2: Mild intermittent asthma
  • J45.21: Mild intermittent asthma with (acute) exacerbation
  • J45.22: Mild intermittent asthma with status asthmaticus
  • J45.3: Mild persistent asthma
  • J45.4: Moderate persistent asthma
  • J45.5: Severe persistent asthma
  • J45.990: Exercise induced bronchospasm


Underdosing is a new concept in ICD-10, which allows you to find out whether the patient is taking less of a medication than is prescribed. While documenting for underdosing, include the following:

  • Intentional, Unintentional or Non-compliance (to indicate whether the underdosing is deliberate owing to patient refusal or other reasons)
  • Reason why the patient not taking the medication (for example, financial hardship, age-related debility)

Examples of ICD-10 codes for underdosing are as follows:

  • Z91.11: Patient’s noncompliance with dietary regimen
  • Z91.120: Patient’s intentional underdosing of medication regimen due to financial hardship
  • Z91.130: Patient’s unintentional underdosing of medication regimen due to age-related debility
  • T36.4x6A: Underdosing of tetracyclines, initial encounter
  • T45.526D: Underdosing of antithrombotic drugs, subsequent encounter

Abdominal Pain and Tenderness

When documenting abdominal pain, include the following:

  • Location (Generalized, right upper quadrant, right lower quadrant periumbilical and more)
  • Pain or tenderness type (colic, tenderness, rebound)

Examples of ICD-10 codes for abdominal pain and tenderness are:

  • R10.811: Right upper quadrant abdominal tenderness
  • R10.815: Periumbilic abdominal tenderness
  • R10.82: Rebound abdominal tenderness
  • R10.83: Colic
  • R10.84: Generalized abdominal pain

Diabetes Mellitus, Hypoglycemia and Hyperglycemia

The codes for diabetes mellitus are combination codes, which involve the type of diabetes mellitus, the body system affected and the complications that affect the body system. While documenting for diabetes, you should include the following:

  • Type (Type 1 or Type 2, drug or chemical induced, due to underlying condition, gestational)
  • Complications (if any other body system is affected by the diabetes condition and in what way. An example is foot ulcer related to diabetes mellitus)
  • Treatment

It is now possible to document and code for hypoglycemia and hyperglycemia without using “diabetes mellitus.” You can also specify whether the condition is due to a procedure or other cause. The concept of secondary diabetes mellitus no longer exists. However, there are specific secondary options.

Some ICD-10 code examples are:

  • E08.65: Diabetes mellitus due to underlying condition with hyperglycemia
  • E09.01: Drug or chemical induced diabetes mellitus with hyperosmolarity with coma
  • R73.9: Transient post-procedural hyperglycemia
  • R79.9: Hyperglycemia, unspecified


As ICD-9 used separate ‘E codes’ for specifying external causes of injury, ICD-10 incorporate these codes better while expanding the sections on poisonings and toxins. You should include the following when documenting for injuries:

  • Episode of care (initial, subsequent, sequelae)
  • Injury site
  • Etiology (how the injury sustained (for example, vehicle crash, slip and fall))
  • Place of occurrence (School, work and more)

For initial encounters, you may need to include the following where appropriate:

  • Intent (Unintentional or accidental, self-harm)
  • Status (Civilian, military)

An ICD-10 code example for injury is as follows. Consider a right knee strain injury that occurred on a private recreational playground when a child jumped off from a swing. The codes are:

  • Injury: S86.811A, Strain of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
  • External cause: W09.1XXA, fall from playground swing, initial encounter
  • Place of occurrence: Y92.838, other recreation area as the place of occurrence of the external cause
  • Activity: Y93.3, Activities involving climbing, rappelling, and jumping off

On the whole, quality clinical documentation is crucial for communicating the intent of an encounter, confirming medical necessity, ICD-10 code selection and thereby ensuring effective family practice billing. Physicians should pay close attention to varying patient history and circumstances.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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