ICD-10 Documentation & Coding Tips

ICD-10 is a sizeable undertaking for any practice. In addition to expanding the number of codes to nearly 70,000, ICD-10 coding and documentation will require significantly more detail and specificity. PracticeMax is your partner for ICD-10 preparation, including clinical documentation requirements and tips. Here are some examples of where ICD-10-CM will require more specific documentation.

ICD-10-CM Documentation & Coding Tips


  • Providers must document:
    • Whether asthma is intermittent or persistent and whether it is mild, moderate or severe
    • Indicate status (uncomplicated, acute exacerbation, status asthmaticus)
  • Be sure to clarify the relationship between COPD, bronchitis and asthma
    • ICD-10-CM distinguishes between uncomplicated cases and those in exacerbation
      • Acute exacerbation is a worsening or decompensation of a chronic condition
      • An acute exacerbation is not equivalent to an infection superimposed on a chronic condition
  • An additional code can be used to denote exposure to or use of tobacco


  • Providers must document:
    • Acuity (i.e. acute, chronic or subacute)
    • Causal organism (e.g. RSV, metapneumoviris)
  • If the cause is unknown, which is typically the case for patients with initial presentation, it may be adequate to report an unspecified code
  • An additional code can be used to denote exposure to or use of tobacco


Diabetes documentation and coding will need to include:

  • Provider must document:
    • Type or cause of diabetes
      • Type 1
      • Type 2 (if type is not indicated, Type 2 is the default)
      • Due to drugs or chemicals
      • Due to underlying condition
      • Other specified diabetes
    • Indicate if patient uses insulin or is pregnancy related
  • Report body system complications related to diabetes such as:
    • Kidney or neurological complications
    • Chronic kidney disease
    • Foot ulcer
    • Hypoglycemia without coma


ICD-10-CM codes are categorized by anatomical site.

  • Provider must document:
    • Specific anatomical injury site, including laterality
    • Type of injury (laceration, fracture, burn etc.)
    • Injury site
    • Episode of care (initial or active treatment, subsequent or follow up treatment, or sequela)
  • Report external cause codes to explain how the injury occurred
    • External cause (how the injury was sustained)
    • Place of occurrence (where the injury happened)
    • Activity (what the patient was doing when they were injured)
    • External cause status (i.e. leisure activity)

Otitis Media

In ICD-10-CM, it is no longer enough to document just otitis media.

  • Provider must document:
    • Type (e.g. serous, sangiunous, suppurative, allergic or mucoid)
    • Severity (i.e. acute, chronic, subacute or recurrent)
    • Laterality
  • Additional codes are used to:
    • Denote the presence of any associated perforated tympanic membrane
    • Indicate environmental factors like smoking, tobacco dependence or history of tobacco use


  • New concept in ICD-10-CM
  • Helps identify occurrences where a patient takes less of a medication that what was prescribed
  • Providers must specify:
    • Intentional: Indicate if due to financial issues or inability to pay for medication
    • Unintentional: Document if due to age related debility or another reason

To learn more about PracticeMax ICD-10-CM resources and training or to talk to someone about ICD-10-CM general concepts and documentation, feel free to contact us.

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