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).