ICD-10-CM for Radiology Documentation Guidance
ICD-10-CM for Radiology Documentation Guidance
Body Area
Condition/Disease
Documentation Requirement
Documentation Details
Additional Comments
Multiple
Fractures
Traumatic or Pathological
Underlying Condition for Pathological:
There is no default
Due to neoplastic disease
Due to osteoporosis: age related
Due to osteoporosis: other cause
Due to other disease
Location
Bone
Unspecified is available
Sub Location
Laterality
Right
Unspecified is available
Left
Type (for long bones)
Bent bone
Unspecified is available
Comminuted
Galeazzi's fracture
Greenstick
Oblique
Segmental
Spiral
Transverse
Other
Displaced or Non-displaced
Displaced is default
Closed or Open
Closed is default
Episode of Care
Initial
There is not a default or an unspecified option
Subsequent
Sequela
Healing Process
Routine
Routine is default
Delayed
Nonunion
Gustilo Classification
Malunion Grade I-IIIC
"Type I and II" is default
Confidential - Internal Use Only
*This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official
Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician,
scheduling/registration)
ICD-10-CM for Radiology Documentation Guidance
Body Area
Condition/Disease
Documentation Requirement
Documentation Details
Additional Comments
Multiple
Injuries
Location
General
Unspecified is available
Sub Location
Laterality
Right
Unspecified is available
Left
Type
Abrasion
Unspecified is available
Contusion
Blisters
Foreign body
Insect bites
Laceration
Puncture Wound
Bite
Sprain
Tear
Dislocation
Strain
Laceration
Internal Injury
Crushing Injury
Amputation
Nerve Injury
Blood vessel Injury
Classification
Anterior/Inferior/Posterior
Unspecified is available
Partial or Complete
Complex/Peripheral/Bucket-Handle
Episode of Care
Initial
There is not a default or an unspecified option
Subsequent Sequela
Confidential - Internal Use Only
*This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official
Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician,
scheduling/registration)
ICD-10-CM for Radiology Documentation Guidance
Body Area
Condition/Disease
Documentation Requirement
Documentation Details
Additional Comments
Multiple
Neoplasms
Location
Sub-Location
Ascending
Unspecified is available
Descending
Anterior
Posterior
Other Locations
Laterality
Right
Unspecified is available
Left
Histologic Behavior
Malignant Primary
Unspecified is available
Malignant Secondary
Ca In Situ
Benign
Uncertain Behavior
Histologic Type
Cholangiocarcinoma
Unspecified is available
Hepatoblastoma
Melanoma
Mesothelioma
Leiomyoma
Other Histologic Types
Tobacco Status
History of Use
Document, when applicable
Dependence
Current Use
Alcohol status
Alcohol Abuse
Document, when applicable
Alcohol Dependence
Alcohol Dependence: in remission
Hepatitis Status
Hepatitis B
Document, when applicable
Hepatitis C
Related Pain
Acute
Chronic
Current v. History
Neoplasm-related
Confidential - Internal Use Only
*This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official
Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician, *The location, sub location, and laterality may also come from the clinical history depending on the study being performed. The radiologist
scheduling/registration)
could be performing a study of an area other than the primary site of malignancy to check for mets, etc., in which case, the complete
neoplasm information will come from the history.
ICD-10-CM for Radiology Documentation Guidance
Body Area
Condition/Disease Pregnancy
Documentation Requirement Number of Weeks/Trimesters Multiple Gestations Hypertension
Diabetes Mellitus
Documentation Details
Affected Fetus # of Placentas # of Amniotic Sacs Onset:
Pre-Existing Gestational Type: Essential Secondary Co-Existing Condition: Heart Disease Chronic Kidney Disease Heart and Chronic Kidney Disease Edemia Proteinuria Onset: Pre-Existing: Type 1 Pre-Existing: Type 2 Gestational: Affecting the Pregnancy Gestational: Childbirth Gestational: Puerperium Gestational: Unspecified Controlled Status: Diet Controlled Insulin Controlled Long-Term Use of Insulin
Additional Comments Unspecified is available When applicable Unspecified is available Unspecified is available When applicable
Unspecified is available
Confidential - Internal Use Only *This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician, scheduling/registration)
Body Area Head
Condition/Disease Coma Intracranial Injury
Fall Alzheimer's Disease
ICD-10-CM for Radiology Documentation Guidance
Documentation Requirement Glasgow Coma Scale Circumstances at Encounter Location
Laterality Type
Loss of Consciousness Duration
Episode of Care Current v. History Type Associated Conditions
Documentation Details
Cerebrum Cerebellum Epidural Brainstem Subdural Subarachnoid Internal Carotid Right Cerebrum Left Cerebrum Right Internal Carotid Left Internal Carotid Hemorrhage Contusion Laceration Concussion Traumatic Edema Diffuse Brain Injury Focal Brain Injury No loss of consciousness 30 minutes or less 31 to 59 minutes 1 hour to 5 hours 59 minutes 6 hours to 24 hours > 24 hours: return > 24 hours: without return Any duration with death: brain injury Any duration with death: other injury Unspecified duration Initial Subsequent Sequela Current Fall Repeated Falls History of Falling Early onset Late onset Other Alzheimer's Disease Delirium Dementia with behavioral disturbance Dementia without behavioral disturbance
Additional Comments Unconsciousness = Unspecified Coma Unspecified is available
Unspecified is available Unspecified is available
"Loss of consciousness, unspecified duration" is default. If pt did not lose consciousness, it should be documented.
There is not a default or an unspecified option
Unspecified is available When applicable
ICD-10-CM for Radiology Documentation Guidance
Body Area
Condition/Disease
Documentation Requirement
Documentation Details
Additional Comments
Cerebral Infarction
Location (Artery)
Vertebral
Unspecified is available
Basilar
Carotid
Middle Cerebral
Anterior Cerebral
Posterior Cerebral
Cerebellar
Posterior Communicating
Laterality
Right
Unspecified is available
Left
Bilateral
Type of Occlusion
Thrombosis
Unspecified is available
Embolism
Stenosis
Sequela
Congnitive deficits
When applicable
Aphasia
Dysphasia
Dysarthria
Fluency disorder
Monoplegia (Dominant or Non-dominant side)
Hemiplegia (Dominant or Non-dominant side)
Hemiparesis (Dominant or Non-dominant side)
Apraxia
Dysphagia
Facial weakness
Ataxia
Other (specify)
Confidential - Internal Use Only
*This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official
Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician,
scheduling/registration)
ICD-10-CM for Radiology Documentation Guidance
Body Area Chest
Condition/Disease Chest Pain
Documentation Requirement Location
Documentation Details Precordial Anterior Wall
Additional Comments Unspecified is available
Type
Atypical Ischemic
Musculoskeletal Non-cardiac
On breathing Pleurodynia
Respitory Conditions
Location Acute v. Chronic
Unspecified is available
Cause Infectious Agent
Tobacco Status
History of use Dependence Current Use
Document, when applicable
Pleural Effusion
Type
Malignant
Underlying Condition
Other Neoplasm Other disease
Myocardial Infarction
Type Location
STEMI NSTEMI Anterior Wall Inferior Wall Other Sites
STEMI is default Unspecified is available
Episode of Care
Initial MI Subsequent MI
Initial is default
Complication
Septal defect Rupture
When applicable
Thrombosis Hemopericardium
Current v. Old
Postinfarction angina
Old = Greater than 4 weeks old that doesn't require further care
Abnormal Findings
Method of Testing Detailed Abnormalities
Confidential - Internal Use Only *This information is intended as a summary of documentation details as described in ICD-10-CM: The Complete Official Draft Code Set and in the ICD-10-CM Draft Official Guidelines for Coding and Reporting 2014 . Please refer to these official references for complete details.
Obtained from clinical history (i.e., referring provider, technician, scheduling/registration)
Body Area Abdomen/Pelvis
Condition/Disease Abdominal Pain
Ascites Peptic Ulcers
Diverticular Disease Crohn's Disease
Ulcerative Colitis
ICD-10-CM for Radiology Documentation Guidance
Documentation Requirement Location
Type
Type Underlying Condition Location
Acute v. Chronic Complication Location Complication Location Complication
Location
Complication
Documentation Details Localized Generalized Area Quadrant Tenderness Rebound Colic Severe Malignant Other Due to Cirrhosis Due to Hepatitis Esophagus Stomach Duodenum Gastrojejunal
Hemorrhage Perforation Both Small intestine Large intestine Small & large intestine Bleeding Perforation Abscess Small intestine Large intestine Small & large intestine Rectal bleeding Intestinal obstruction Fistula Abscess Left sided colitis Rectosigmoiditis Pancolitis Proctitis Colon Rectal bleeding Intestinal obstruction Fistula Abscess
Additional Comments Unspecified is available
Other is default Unspecified is available Unspecified is available Unspecified is available When applicable Unspecified is available When applicable
When applicable
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