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ICD-10 CM Clinical Examples for Documentation


The providers need to be specifying the anatomical location and laterality in the documentation to select the appropriate most specific ICD codes. 

There are a few examples of clinical documentation updated below and how the physicians and clinicians communicate and what they pay attention to it is a matter of ensuring the information is captured in your documentation.

In ICD-10-CM, there are three main categories of changes,

  • Definition Changes
  • Terminology Differences
  • Increased Specificity

The expansion of ICD-10 codes is due to the addition of laterality (left, right, bilateral). Physicians and other clinicians likely already note the side when evaluating the clinically pertinent anatomical site(s).


When documenting an AMI, include the following,

Time-frame an AMI is now considered “acute” for 4 weeks from the time of the incident.

The episode of care ICD-10 does not capture an episode of care (e.g. initial, subsequent, sequelae).

Subsequent AMI ICD-10 allows coding of a new MI that occurs during the 4 weeks “acute period” of the original AMI.

  • I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
  • I21.4 Non-ST elevation (NSTEMI) myocardial infarction
  • I22.1 Subsequent ST elevation (STEMI) myocardial infarction

Clinical Examples:2 - HYPERTENSION

In ICD-10, hypertension is defined as essential (primary). The concept of “benign or malignant” as it relates to hypertension no longer exists.

When documenting hypertension, include the following,

Types Hypertension - HTN, e.g. essential, secondary, etc.

Causal relationship e.g. Renal, pulmonary, etc.

  • I10 Essential (primary) hypertension
  • I11.9 Hypertensive heart disease without heart failure
  • I15.0 Reno-vascular hypertension

Clinical Examples:3 - ASTHMA

ICD-10 terminology used to describe asthma has been updated to reflect the current clinical classification system.

When documenting asthma, include the following,

Cause Exercise-induced, cough variant, related to smoking, chemical or particulate cause, occupational.

Severity Choose one of the three options below for persistent asthma patients
  • Mild persistent
  • Moderate persistent
  • Severe persistent
Temporal Factors Acute, chronic, intermittent, persistent, status asthmatics,  acute exacerbation,

  • J45.30 Mild persistent asthma, uncomplicated
  • J45.991 Cough variant asthma

Clinical Examples:4 - UNDER-DOSING

Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed.

When documenting underdosing, include the following,

Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal).

Reason Why is the patient not taking the medication? ( hardship, age-related debility).

  • Z91.120 Patient’s intentional underdosing of medication regimen due to  financial hardship
  • T36.4x6A Underdosing of tetracyclines, initial encounter
  • T45.526D Underdosing of antithrombotic drugs, subsequent encounter


The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. When documenting diabetes, include the following,

Type e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational.

Complications What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus.

Treatment Is the patient on insulin?.

A second important change is the concept of “hypoglycemia” and “hyperglycemia.” It is now possible to document and code for these conditions without using “diabetes mellitus.”  The provider can also specify if the condition is due to a procedure or other cause.

The final important change is that the concept of “secondary diabetes Mellitus” is no longer used; instead, there are specific secondary options.

  • E08.65 Diabetes Mellitus due to underlying condition with hyperglycemia
  • E09.01 Drug or chemical induced diabetes Mellitus with  hyperosmolarity with coma
  • R73.9 Transient post-procedural hyperglycemia
  • R79.9 Hyperglycemia, unspecified


When documenting abdominal pain, including the following,

Location e.g. Generalized, Right upper quadrant, periumbilical, etc.

Pain or tenderness type e.g. Colic, tenderness, rebound

  • R10.31 Right lower quadrant pain
  • R10.32 Left lower quadrant pain
  • R10.33 Periumbilical pain

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