ICD-10 General Concepts for Emergency Department

ICD-10-CM Emergency Department (ED) General Concepts:

Signs and symptoms are still acceptable in the absence of a definitive diagnosis

  • Example: Fever, dehydration and vomiting without nausea


  • Document right, left or bilateral for paired organ structures
  • Example: Bilateral pneumonia

Location/anatomic specificity

      • Be specific as to the exact anatomic site; see examples below
        • Finger: Individual fingers and phalanxes
        • Toe: Individual toes and specific joints
        • Hand: Individual metacarpals
        • Foot: Individual metatarsals
        • Phalanges: Document whether proximal, mid or distal
        • Face: Upper or lower eyelids and lips
        • Portion of bone: Proximal, distal, shaft, base, upper
        • Abscess/cellulitis: Document the precise anatomic location
      • Example: Nondisplaced fracture of proximal phalanx of right index finger, initial encounter for closed fracture

Trimester for OB patients – include 1st, 2nd or 3rd trimester

      • Example: Pregnancy related exhaustion and fatigue, first trimester

Episode of care for injuries and poisonings

  • Initial treatment (Active treatment)
  • Subsequent
  • Sequela (Complications/late effects)
  • Example: Severe, persistent asthma with (acute) exacerbation

Severity of illness

  • Mild, moderate, sever
  • Burn degrees
  • Gustilo classification for open fractures


  • Acute, chronic, ulcer staging
  • Example: Acute serous otitis media, right ear

External cause of injury

  • Documentation for injuries should include the how, where (geographic location) and mechanism of the injury being documented
  • Describe the activity: job-related, playing football, jumping jacks, Frisbee etc.
  • Indicate the geographic location: home, work, amusement park, grocery store etc.
  • Describe the external cause of injury: fall, assault, procedure complication etc.
  • Example: Fall while playing basketball at the park

For more information about PracticeMax ICD-10 resources and training, or to talk to someone about ICD-10-CM general concepts and documentation please contact us.