ICD-10 Emergency Medicine Concept Reminder: Location!

To capture the best clinical diagnosis, providers must document the following aspects of Location:

  • Be very specific as to the anatomic locations
    • Finger: Phalanges, phalanxes (Proximal, middle and distal phalanx)
    • Toe: Individual toes and specific joints
    • Hand: Carpal, metacarpals, trapezium, trapezoid etc.
    • Foot: Tarsal, metatarsals, joints, intertarsal etc.
  • The documentation of laterality is key to accurate code assignment
    • Document right, left or bilateral for paired organ structures
      • Example: Bilateral pneumonia
    • Indicate the geographic location
      • Home, work, amusement park, grocery store etc.
    • Describe the activity
      • Job related, playing football, jumping jacks, Frisbee etc.
  • Think of the board game Clue to help you remember the appropriate documentation of location
    • Abrasion of the right ear that occurred at home while bathing the dog in the bathroom of the patient’s mobile home.
      • Abrasion of the right ear, initial encounter (S00.411A)
      • Struck by the dog, initial encounter (W54.1XXA)
      • Bathroom in the patient’s mobile home as placeof occurence (Y92.O22)
      • Activity, grooming or shearing an animal (Y93.K3)

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