Open wounds can now be clarified as a laceration or puncture wound. The term “complicated” open wound has been omitted; the emergency physician should document, however, if the wound is infected or has a foreign body present. Lacerations involving blood vessels and muscle bundles should be identified by anatomical location (eg, popliteal artery, posterior muscle group of lower leg).

Emergency physicians have expressed concern about when to use the term “initial” or “subsequent” encounter. These terms only apply to injuries, fractures, and related external causes. The term “initial encounter” is used whenever active treatment is being provided. This includes evaluation and continuing treatment by the same or different physicians. For example, if a patient had a laceration repaired by emergency physician #1 and was seen by emergency physician #2 three days later because of concern of infection, both encounters would be considered initial for the laceration. A “subsequent encounter” occurs during the healing or recovery phase of care. If emergency physician #3 saw the same patient for suture removal, that would be considered a subsequent encounter.

Open wounds can now be clarified as a laceration or puncture wound. The term “complicated” open wound has been omitted; the emergency physician should document, however, if the wound is infected or has a foreign body present.

PB: It is true that a majority of the new codes are for “injury, poisoning, and certain other consequences of external causes”—bread and butter for most EDs. However, only 2.5 percent of the new codes are unaffected by the need for specific documentation.

Please note that I did not refer to this as new documentation. Fifty percent of the documentation required by ICD-10-CM is currently required by ICD-9-CM for the codes that are both specific and represent higher severity of illness; 40 percent of the documentation for ICD-10-CM specificity is laterality, right or left. Only 10 percent is really new.

If 50 percent of the documentation is the same as ICD-9-CM, then what’s the problem? The problem is that physicians are not taught the rules of diagnostic code selection. Each code must exactly match the terminology used in the physician diagnosis documentation. Unspecified codes are for use when information is missing from those stated diagnoses.

Most physicians do not document adequately for the higher SOI ICD-9-CM codes. So, today, many bills are submitted with unspecified codes.

Jeffrey Linzer Sr., MD, FAAP, FACEP, is professor of pediatrics and emergency medicine at Emory University in Atlanta and lead physician of the ICD-10-CM transition core leadership team at Children’s Healthcare of Atlanta.