Soon, your hospital or group will be expecting you to document your emergency visits in an ICD-10-CM–friendly manner. To paraphrase a famous Vice President, “ICD-10-CM is a big %%^& deal.” All emergency physicians will need to have a basic understanding of ICD-10-CM key concepts. 


ICD-10 will be impossible to ignore since it is tied to physician and hospital reimbursement as well as value-based and quality-of-care metrics. The reality of working in a busy emergency department within an electronic medical record means that ICD-10 will likely present unique challenges.

ACEP has a number of ICD-10 resources designed for the busy emergency physician that can be found at www.acep.org/administration/reimbursement/icd–10-resources/icd-10-resources.

This article presents two experts’ guidance on ICD-10.

David Chauvin, DO, FACEP, ACEP Coding & Nomenclature Advisory Committee

Vice President Reimbursement

Premier Physician Services, Inc.

Dayton, Ohio

1. How will this impact how I document?

Dr. Jeffrey Linzer: In reality, there isn’t much more required than would currently be expected for good medical documentation with the current system. The emergency physician is choosing the right term that will demonstrate why the patient was being seen and explain resource utilization. This will also help support quality metrics.

The emergency physician should consider performing a descriptive history of the present illness (HPI) instead of using checkboxes. While some electronic health records try to put this information into a “readable” format, actually dictating or free texting the HPI will provide for better details for the coder to be able to extract information. In documenting the physical exam, the emergency physician should also be clear as to the location of the problem, including laterality (left, right) and in some cases anatomic site (eg, proximal, distal, forearm, upper leg).

Dr. Pamela Bensen: The diagnosis is like a user ID, and ICD-10-CM codes are like the password—they must match to open the payment stream. ICD-10-CM will contain more than 140,000 diagnosis codes that must be selected based on the documented diagnosis. About 4,200 of the ICD-9-CM diagnosis-code pairs have a 1:1 match in ICD-10-CM (only the code numbers change, while the descriptors remain the same). However, these diagnoses match to ICD-10-CM codes that are unspecified—unspecified as to right-left, acute-chronic, type of condition, and links to etiology or manifestations. Since these codes are unspecified and represent a low severity of illness (SOI) that may not warrant medical care, many payers have decided not to pay for care related to unspecified codes. In order to get paid, emergency physicians will have to document to avoid unspecified codes by using specific words to more accurately represent the patient’s SOI.

2. Why is SOI important, and how and why should I document it?

JL: Clearly documenting SOI is important regardless of which diagnosis coding system is being used. ICD-10 will allow for better clarity in identifying the severity of the problem. For example, there are codes to identify if acute respiratory failure is associated with hypoxia or hypercapnia or if a sickle cell crisis is associated with acute chest or splenic sequestration.

For patients with pregnancy-related conditions, the emergency physician will need to document the specific trimester as this will help identify risks associated with the presenting problem. In patients with severe sepsis, documentation should reflect the presence or absence of shock.

PB: Each diagnostic code has a SOI level assigned to it. The SOI is designed to represent how sick the patient really is. By adding together the SOI for each diagnosis, you can determine how sick the patient is. The higher the SOI of each diagnosis and the more diagnoses present, the sicker the patient. It is simple arithmetic. The sicker the patient, the more we can get paid.

Payers have determined exactly what resources, including physician pay, are appropriate for each diagnosis, as adjusted for concomitant comorbid conditions that contribute to the patient’s SOI. The higher the total SOI, the more resources allocated to caring for the patient.

How to document for ICD-10-CM is only slightly more complicated. First, it is logical to include, in the assessment/diagnosis part of the record, every single diagnosis the patient has, which impacts the evaluation, treatment, or medical decision making of the current medical complaint.

Second, it is necessary to capture an accurate SOI for each of the diagnoses documented. Heart failure has 15 ICD-9-CM codes, each with its own SOI. ICD-10-CM has 23. Selection of the code depends on the words used in the documented diagnosis.

Finally, emergency physicians must include certain mandatory accessory information that the ICD-10-CM coding guidelines require for individual diagnoses (codes).

3. How do I document in ICD-10-CM for a patient with trauma and injuries?

JL: The majority of the new trauma and fracture codes are orthopedic related and should not directly affect the emergency physician. Many of these new codes are related to the healing phase of a fracture, something the emergency physician will not usually have to deal with directly. As in ICD-9, the emergency physician should identify the anatomic location of the fracture (eg, proximal, shaft, distal). ICD-10 does add greater specificity as to the type of fracture (eg, displaced, nondisplaced, greenstick). Much of this detail can be incorporated into the emergency physician’s documentation by acknowledging the radiologist’s reading of the X-ray. For those times when the emergency physician is making an independent interpretation, the documentation should include as much detail as possible. This will allow the coder to determine the correct diagnostic code.

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.

Pamela P. Bensen, MD, MS, FACEP, is president of Medical Education Programs in Buffalo Junction, Virginia.