The document provides guidance on key documentation elements needed for ICD-10 coding of major emergency department encounters. For injuries, precise location, laterality, and circumstances are needed. Episode of care (initial, subsequent, sequelae) should also be documented. For infections, details like type, location, organism, and complications are important. For medical conditions, specifics on condition, severity, affected body system, signs/symptoms, and findings are required. Proper documentation is crucial for accurate coding and reimbursement under ICD-10.

1. Key ICD-10 Documentation
Elements for Major ED
Encounters
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2. With more number of codes and increased specificity, ICD-10 presents unique
documentation challenges for emergency department (ED) physicians. If you
have no understanding of the underlying logic and organization of new codes,
your chart documentation can become really disastrous and will drastically
affect emergency room medical billing. The absence of details will make
payers question the medical necessity of services provided and cause a delay
or decrease in reimbursement. Under ICD-10, your documentation must
clearly specify the precise mechanism and location of injury. Let’s take a
detailed look at ICD-10 documentation for three major ED encounters, which
are as follows:
Injuries and Poisonings
For injuries, poisonings, musculoskeletal and connective tissue problems,
pathologic and osteoporosis injuries, you must remember the mnemonic --
location, location, location
 Location – You have to document the precise anatomical location
 Location – Document laterality (right, left, bilateral)
 Location – Document the geographic location where the incident occurred (for
example, home), the circumstances and/or activity surrounding the injury and
how it occurred (for example, if the injury was related to military or work).

3. You should also document episode of care for treatment of injuries,
fractures, burns, poisonings, and similar conditions in the ED. Three types
of episode of care are there such as:
 Initial Encounter – This is when a patient is new to the treating ED
physician for that condition, regardless of whether or not an active
treatment is being provided. Most of the ED visits are considered as
initial.
 Subsequent Encounter – This is when additional care is provided
to a patient, who is at a healing or recovery phase from an injury,
fracture, burn, poisoning and similar condition. Such types of
encounters are not so common in the emergency setting.
 Sequelae – This type of encounter is reported when a patient is
being seen for later complications resulting from an injury, fracture,
burn, poisoning and similar condition. The management of scar at
the ED that results from a burn is an example.
For example, here are the ICD-10 codes for first degree burn on the
right hand.
 T23.101: Burn of first degree of right hand, unspecified site
 T23.101A: Burn of first degree of right hand, unspecified site, initial
encounter
 T23.101D: Burn of first degree of right hand, unspecified site,
subsequent encounter
 T23.101S: Burn of first degree of right hand, unspecified site,
sequela

4. Infectious Diseases
Consider the following components when documenting infectious diseases
such as pneumonia, cellulitis, and urinary tract infections (UTIs) at an ED
setting.
 Type of Infection – Document the exact type of infection. For example, in
the case of pneumonia, you should specify whether it is bacterial, viral,
aspiration, fungal, ventilator associated or occurred due to other reasons.
 Location of Infection – The exact anatomic location (for example, upper
lobe, middle lobe or lower lobe for pneumonia) and laterality of the
infection should be documented.
 Acuity/Temporal – Specify whether the infection is acute, chronic,
recurrent or persistent.
 Causative Organism – Specify the name of the organism that caused the
infection (in case of bacterial, fungal or viral infection).
 Clinical Manifestation – Visible symptoms or the symptoms found from
the history and examinations should be documented (For example, cough
and fever for pneumonia).
 Complications – The complications associated with the infectious disease
should be documented as well (For example, abscess, cavitation,
empyema, sepsis or respiratory failure in case of pneumonia).

5. Medical Conditions
For medical conditions such as diabetes, hypertension or angina, document
the following components:
 Medical Condition/ Type – You should specifically document the
medical condition that led to an ED visit. For example, in the case of
fever, specify whether it is drug-induced, post-procedural or post-
vaccination.
 Temporal – Specify whether the condition is acute, recurrent,
persistent or episodic.
 Stage/Severity – Document the severity of the medical condition,
whether mild, moderate or severe.
 Body System Affected – Specify which body system is affected from
that condition including the exact anatomic location and laterality (for
example, left ventricle)
 Signs and Symptoms – Clinical manifestations found during an ED
visit should be documented.
 Significant Findings – The complications associated with the medical
condition should also be documented.

6. ICD-10 allows the documentation of alcohol, tobacco and drug abuse
related to an ED visit. Do not simply state ‘rule out’, ‘suspected’ or
‘evaluate for’ during the final diagnosis without any additional descriptors.
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