November 2016


Time to Update ICD-10

ICD-10 launched a little over a year ago and has now undergone its first update. The October 1, 2017 update was a sizable list of changes that had accumulated during the enforced code freeze in our long transition from ICD-9 to ICD-10.

October 1, 2017 also marked the end of the CMS imposed “period of flexibility,” during which non-specific codes were accepted. Providers now must strictly avoid unspecified codes if possible. Physicians should also expect more stringent auditing of claims. Codes with unspecified laterality, for example, and other commonly known information at the time of encounter are all subject to scrutiny.

The Importance of Documenting and Reporting Laterality

Laterality is a unique concept found in ICD-10 and is an important component when documenting information in a medical record. If a diagnosis includes right or left side, for example, or proximal or distal in play, documentation should clearly state this information. Thirty-six percent of all ICD-10 codes distinguish laterality (right versus left). Physicians should always document complete and accurate information to support a specific diagnosis; this now includes specifying laterality details.

Below, are a few examples in which laterality is required. While these diagnoses are commonly found in primary care and the emergency department, they remain a good reminder for all physicians. You will note, that the laterality character is most often the fifth or sixth character of the code. You will also note, that while laterality is frequently right or left, there are several instances when laterality is simply designated by a more specific area.

Abdominal Pain

  • R10 - Abdominal and pelvic pain (category)
    • R10.0 - Acute Abdomen
      • R10.10 - Upper abdominal pain, unspecified
      • R10.11 - Right upper quadrant pain
      • R10.12 - Left upper quadrant pain
      • R10.13 - Epigastric pain
  • R10.2 - Pelvic and perineal pain
  • R10.3 - Pain localized to other parts of lower abdomen
    • R10.30 - Lower abdominal pain, unspecified
      • R10.31 - Right lower quadrant pain
      • R10.32 - Left lower quadrant pain
      • R10.33 - Periumbilical pain
  • R10.8 - Other Abdominal Pain
    • R10.81 - Abdominal tenderness
      • R10.811 - Right upper quadrant abdominal tenderness
      • R10.812 - Left upper quadrant abdominal tenderness
      • R10.813 - Right lower quadrant abdominal tenderness
      • R10.814 - Left lower quadrant abdominal tenderness
      • R10.815 - Periumbilic abdominal tenderness
      • R10.816 - Epigastric abdominal tenderness
      • R10.817 - Generalized abdominal tenderness
      • R10.819 - Abdominal tenderness unspecified site
    • R10.82 - Rebound abdominal tenderness
      • R10.821  Right upper quadrant rebound abdominal tenderness
      • R10.822  Left upper quadrant rebound abdominal tenderness
      • R10.823  Right lower quadrant rebound abdominal tenderness
      • R10.824  Left lower quadrant rebound abdominal tenderness
      • R10.825  Periumbilic rebound abdominal tenderness
      • R10.826  Epigastric rebound abdominal tenderness
      • R10.827  Generalized rebound abdominal tenderness
      • R10.829  Rebound abdominal tenderness, unspecified site
    • R10.83  Colic
      • R10.834  Generalized abdominal pain
    • R10.9.   Unspecified abdominal pain

Insect Bite

  • S40.26 - Insect bite (nonvenomous) of shoulder
    • S40.261 - Insect bite (nonvenomous) of right shoulder
    • S40.262 - Insect bite (nonvenomous) of left shoulder
    • S40.269 - Insect bite (nonvenomous) of unspecified shoulder

Otitis Media

  • H65.0 - Acute serous otitis media
    • H65.00 - Acute serous otitis media, unspecified ear
    • H65.01 - Acute serous otitis media, right ear
    • H65.02 - Acute serous otitis media, left ear
    • H65.03 - Acute serous otitis media, bilateral
    • H65.04 - Acute serous otitis media, recurrent, right ear
    • H65.05 - Acute serous otitis media, recurrent, left ear
    • H65.06 - Acute serous otitis media, recurrent, bilateral
    • H65.07 - Acute serous otitis media, recurrent, unspecified ear


  • L03 - Cellulitis and acute lymphangitis
    • L03.1 - Cellulitis and acute lymphangitis of other parts of limb
      • L03.11 - Cellulitis of other parts of limb
        • L03.111 - Cellulitis of right axilla
        • L03.112 - Cellulitis of left axilla
        • L03.113 - Cellulitis of right upper limb
        • L03.114 - Cellulitis of left upper limb
        • L03.115 - Cellulitis of right lower limb
        • L03.116 - Cellulitis of left lower limb
        • L03.119 - Cellulitis of unspecified part of limb

Sprain of Ankle

  • S93 - Dislocation and sprain of joints and ligaments at ankle, foot and toe level
    • S93.4  Sprain of ankle
      • S93.40  Sprain of unspecified ligament of ankle
        • S93.401  Sprain of unspecified ligament of right ankle
        • S93.402  Sprain of unspecified ligament of left ankle
        • S93.403  Sprain of unspecified ligament of unspecified ankle

As you can see in the examples provided, there is great importance in documenting laterality to the injury and/or treatment provided during the patient encounter to ensure proper reimbursement.

Important Coding Guideline Changes

New guidelines help define an episode of care when selecting the seventh character for injuries. The guidelines now explain that the seventh character “A” is appropriate for encounters when the patient receives active treatment for a condition to initiates the healing process.  By contrast, a seventh character “D” is used for encounters after the patient has completed active treatment of the condition, or in other words when the healing process has been established. Below is an example of how those seventh characters would be used.

A patient is evaluated in the Emergency Room and diagnosed with a Greenstick fracture of the shaft of the left radius. A splint is applied pending reduction of swelling.  Code S52.312A is assigned because the patient is receiving active management.

The same patient then goes to her family physician’s office for further treatment. Closed reduction and casting are performed. Code S52.312A is once again assigned because she is again receiving active management/treatment.  

The patient then returns for follow-up. The cast is replaced and code S52.312D is reported because the patient is now in the healing phase and active treatment has been completed.

Coding Changes To Be Aware Of

Here is a brief synopsis of some of the coding changes you should review and, if appropriate, use to update your coding systems including superbill/charge ticket (electronic and/or paper), EHR and practice management (PM)/billing system to prevent claims rejections, delays and denials.

  • New code for Zika virus;
  • Further specificity of diabetic retinopathy and the ability to capture macular edema has resolved after treatment with laterality;
  • New codes for hoarding and various obsessive-compulsive disorders;
  • Laterality reporting for carpal tunnel disorder, tarsal tunnel disorder and various lesions of specific nerves;
  • Expansion of stages of primary open angle glaucoma and code for amblyopia suspect;
  • Added hearing loss with additional information in relationship to the contralateral ear and new code for pulsatile tinnitus;
  • Updates in the circulatory chapter include addition of hypertensive urgency, emergency, or crisis; reducing specificity of nontraumatic subarachnoid hemorrhage and the communicating artery;
  • Addition of codes for numerous dental conditions;
  • New codes for preorbital cellulitis and excessive and redundant skin and subcutaneous tissue;
  • Musculoskeletal chapter added bunion, bunionette, pain in joints of the hand, more specificity to temporomandibular joints, cervical disc disorders at specific levels, atypical femoral fractures, and Periprosthetic fractures;
  • New codes for more specific urinary incontinence conditions, erectile dysfunction, ovarian cysts and conditions of the fallopian tubes;
  • Added various conditions involving ectopic pregnancy, pre-eclampsia, severe pre-eclampsia, and eclampsia complicating childbirth and puerperium;
  • Two new codes for newborn light for gestational age;
  • Addition regarding specific fractures to bones of skull and various fracture types of the foot;
  • Additions to complication types including breakdown, displacement, infection, erosion, exposure, pain, fibrosis, thrombosis, and leakage;
  • Addition of external cause code for activity of the choking game, as well as addition of code for overexertion and;
  • Z code additions for a variety of observation of newborn for carious conditions, encounter for prophylactic medications, conversion of endoscopic procedures to open, and long term use of oral hypoglycemic drugs.

Ensure you are using the most up-to-date codes to assure you are receiving the best reimbursement possible for your practice.


Mary Jean Sage is the Founding Principal and Senior Consultant of The Sage Associates. She has extensive experience as a health care management specialist and is a coding and practice management consultant.

The articles provided in Practice Management News are general. They do not constitute legal, practice management or coding advice in any particular factual situation or create at attorney-client relationship. Consult your attorney or other professional for advice in your particular situation.