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Women’s Imaging ICD-10-CMClinical Documentation Guides

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WOMEN’S IMAGING ICD-10-CMCLINICAL DOCUMENTATION GUIDES

The Interventional Radiology Guide includes topics encountered in both vascular and non-vascular interventions. Some conditions covered in the IR package include circulatory disorders of the brain, DVT, traumatic brain injury, cholelithiasis, pleural effusion, and pneumothorax.

The MRI/CT package includes a broad range of conditions generally evaluated by these modalities, such as circulatory disorders of the brain, spinal disorders, traumatic brain injury, chest pain, and pneumothorax.

The Ultrasound package includes conditions frequently seen in ultrasound studies in the hospital, physician office, and freestanding facility setting. Among the conditions included in this package are ascites, DVT, diverticular disease, abdominal pain, limb pain, and thyroid disorders.

The Women’s Imaging package includes conditions encountered in bone density studies, mammography, breast ultrasound, and other breast studies and procedures. In addition to disorders of the breast and neoplasms of the breast, this package includes a guide that focuses on definition and documentation requirements of active cancer versus history of cancer.

OTHER CLINICAL DOCUMENTATION GUIDES

MRI AND CT ICD-10-CMCLINICAL DOCUMENTATION GUIDES

ULTRASOUND ICD-10-CMCLINICAL DOCUMENTATION GUIDES

INTERVENTIONAL RADIOLOGY ICD-10-CMCLINICAL DOCUMENTATION GUIDES



Non-toxic Goiter Hypothyroidism Hyperthyroidism• Thyrotoxicosis

1. Select a condition and follow the arrows:

Physician Documentation Guide for Thyroid Disorders

Patient with Goiter, Thyroid Nodules, Hypo- & Hyperthyroidism

Diffuse• Simple

Single thyroidnodule• Colloid• Uninodular

Multinodular• Cystic

Congenital withdiffuse goiter

Congenital w/ogoiter

Other

With diffuse goiter• Exophthalmic• Graves’ Disease

With single thyroidnodule

With multinodulargoiter

From ectopic thyroid tissue

Factitia

Other

With thyrotoxicstorm or crisis

Without thyrotoxicstorm or crisis

2. Be descriptive:

How to use the ICD-10 Documentation Guides

Each documentation guide breaks down the clinical information that needs to be documented into columns and rows. Start with the first row and determine which clinical statement is appropriate for the patient. The additional information that needs to be documented for each condition continues on the following rows.

Some documentation guides are straightforward and follow a single column down the rows. This is the case with the guide for Thyroid Disorders below, once the determination is made that the patient has a non-toxic goiter, the additional information that needs to be documented is provided directly below the non-toxic goiter box.



Physician Documentation Guide for Hypertension

Patient Diagnosed with Hypertension

1. Select type and follow the arrows:

Essential(default)

Secondary Hypertensive heart and/or kidney disease

Renovascular

Other renaldisorders

Endocrinedisorders

Other

Hypertensive heart disease

Hypertensive chronic kidney disease

Hypertensive heart and kidney disease

Heart Disease

With heart failure

Without heartfailure

Chronic Kidney Disease

With stage1-4 CKD

With stage 5 or ESRD

With heart failure

Without heart failure

AND

With stage 1-4 CKD

With stage 5 or ESRD

Document the type ofheart failure

Document the stage of chronic kidney disease

Document both the type of heart failure and the stage of kidney disease

Other documentation guides will be more complex. In these cases, the information in the sub-sequent rows must be further subdivided to provide the necessary level of detail. Below is the guide for Hypertension. As you can see, more information is necessary to document patients with hypertensive heart and/or kidney disease. Once the determination is made that the pa-tient has hypertensive heart or kidney disease, both the type of heart failure and the stage of kidney disease must be documented.


Documentation Guide for Disorders of the Breast and Other Abnormal Findings

Patient with Disorders of the Breast or Other Abnormal Findings:

Abnormal Findings Disorders of Breast

Presence of:

Personal history of breast cancer

Family history of breast cancer

1. Select condition and follow the arrows:

Mammographic microcalcifications

Mammographic calcifications

Inconclusive mammogram• Dense Breasts• Inconclusive mammogramOther inconclusive andabnormal findings

Solitary cyst of breast

Diffuse cystic mastopathy• Cystic breast• Fibrocystic disease of breast

Fibroadenosis of breast

Fibrosclerosis of breast

Mammary duct ectasia

Other benign mammary dysplasias

Inflammatory disorders of breast• Abscess areola/breast• Carbuncle of breast• Infective mastitis

Hypertrophy of breast

Lump

2. Be specific: 2. Select category:

4. Provide context:

Skip Step 3

and move to Step 4

Left Right

3. Laterality:


Physician Documentation Guide for Neoplasms

Location of Neoplasm – Specify precise location of neoplasm. See Breast documentation guides for examples.

Patient Diagnosed with Neoplasm

History of Cancer – treatment has ended and no evidence of cancer:• Primary site excised or

eradicated AND• Primary site no longer being

treated AND• No evidence of remaining

malignancy

Active Cancer – diseasethat is currently causing signsand symptoms and/or is undertreatment by any modality:• Surgery• Chemotherapy• Radiation• Hormonal Therapy• Alternative Medicine

All malignancies both primary and secondary should include sitespecific details – even if no longer active.

1. Select Status and follow the steps down the column:

Previous treatments • Radiation therapy • Chemotherapy

Primary Malignancy

Secondary Malignancy

In Situ

Benign Neoplasm

2. Select Previous Treatments: 2. Select Category:

3. Specify Location:

4. Reminder:

Skip Step 3

and move to Step 4


Physician Documentation Guide for Neoplasm of Breast

Patient Diagnosed with Neoplasm of Breast

Active Cancer – disease that iscurrently causing signs andsymptoms and/or is undertreatment by any modality:• Surgery• Chemotherapy• Radiation• Hormonal Therapy• Alternative Medicine

Primary Malignancy

Secondary Malignancy

In Situ

Benign Neoplasm

2. Provide context:

Previous treatments• Radiation therapy• Chemotherapy

History of Cancer– treatmenthas ended and no evidence ofcancer:

• Primary site excised oreradicated AND

• Primary site no longer beingtreated AND

• No evidence of remainingmalignancy

1. Select status and follow the steps down the column of the same color:

3. Select Gender:

Female

Male

Right

Left

4. Select Breast:

Nipple and Areola

Central Portion

Upper-Inner Quadrant

Lower-Inner Quadrant

Upper-Outer Quadrant

Lower-Outer Quadrant

Axillary Tail

Overlapping Sites

5. Select specific location:

All malignancies both primary and secondary should include site specific details – even if no longer active.

6. Reminder:

2. Select type:


Physician Documentation Guide for Osteopenia

Patient Diagnosed with Osteopenia

Left Right

Shoulder

Upper Arm

Forearm

Hand

Thigh

Lower Leg

Ankle/Foot

Other Site

Multiple Sites

1. Select side:

2. Select location:


Physician Documentation Guide for Osteoporosis

Does the Patient have Osteoporosis with current pathologic fracture?

Yes No

1. Answer the question and follow the arrows:

Is it Age Related

OR

Other:• Drug induced (identify drug)• Idiopathic• Disuse• Post-traumatic

Right or LeftShoulderHumerusForearm/WristHandFemur/HIpLower LegAnkle/FootVertebra(e)

2. Select side and area of fracture with laterality

Initial DiagnosisSubsequent with routine healingSubsequent with delayed healingSubsequent with malunionSubsequent with non-unionSequela

3. Be descriptive:

Is it Age Related• Postmenopausal• Senile

Localized

Other• Drug induced

(identify drug)• Idiopathic• Disuse• Post-traumatic

Presence of:

Major osseous defect

Personal history of (healed) osteoporosis fracture

4. Be specific:

Skip Step 2 & 3 and move

to Step 4


Physician Documentation Guide for Episodes of Care Episodes of Care

1. Select a type and follow the arrows:

Initial Encounter (active treatment, may apply to multiple services and/or multiple dates of service)

Document as IE if:ED patient (seen in or referred from ED)

Surgical treatment including pre- & post-surgical imaging

New injury still being evaluated

2. Include the following:

Subsequent Encounter (routine care during the healing or recovery phase)

Document as SE if:Ordered as a “follow-up” or “check status” study

Presence of a cast, internal fixation device (beyond initial pre-/post- placement images)

Sequela (residual effect after the acute phase has terminated)

Document as a se-quela if the current complaint is related to prior accident/in-jury. Select from the following:

Scarring

Deformity

Post-traumatic arthritis

Pain and other conditions

Remember to include in the patient history details related to the accident/injury. e.g:

• Shoulder pain and bruising after fall from ladder

• Laceration forehead from MVA

For fractures subsequent encounters must document status as:

Routine healing

Delayed healing

Malunion

Non-union

Encounters for sequela require that the provider directly link the original injury to the identified residual effect or complication.

NOTE: Open fractures of the forearm, femur and lower leg are further defined by severity by using the Gustilo Classification. Please document class, if known.


NeoplasmDocument neoplasm

In other diseasesDocument disease

Physician Documentation Guide for Pathological Fractures

Pathological Fracture caused by/due to:

1. Select one

2. Choose the Location:

4. Encounter (Closed):

Not elsewhere classified

Initial

Subsequent routine healing

Subsequent delayed healing

Subsequent non-union

Subsequent malunion

Sequela

Shoulder

Humerus

Radius

Ulna

Hand

Pelvis

Femur

Tibia

Fibula

Ankle

Foot

Vertebra

Shoulder

Humerus

Radius

Ulna

Hand

Fingers

Pelvis

Femur

Tibia

Fibula

Ankle

Foot

Toes

Vertebra

Right Left

3. Select a side:

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