Occupational Therapy
ICD-10 documentation
Seven key impacts to ICD-10 documentation
1. Disease or disorder site
4. Underlying and associated conditions
2. Acuity and/or encounter status of treatment
5. Manifestations
3. Etiology, causative agent, or disease type and injury/
6. Complications or adverse events
poisoning cause, intent, activity at the time of the event
7. Supporting info such as lab values or socioeconomic key
and place event occurred
impacts to ICD-10 documentation
Most commonly used diagnoses
ICD-9
Code
ICD-10
Code
Autistic disorder,
current or active
state
299.0
F84.0
Autistic disorder
Brachial plexus
lesions
353.0
G54.0
Brachial plexus disorders
Delayed milestones
783.42
R62.0
Delayed milestone in childhood
Developmental
coordination
disorder
315.4
F82
Disturbance of skin
sensation
782.0
R20.0
Anesthesia of skin
R20.1
Hypoesthesia of skin
R20.2
Paresthesia of skin
R20.3
Hyperesthesia
R20.8
Other disturbances of skin sensation
R20.9
Unspecified disturbances of skin
sensation
R60.0
Localized edema
R60.1
Generalized edema
R60.9
Edema, unspecified
R63.3
Feeding difficulties
ICD-9 Name
Edema
Feeding difficulties
and mismanagement
782.3
783.3
ICD-10 Name
Documentation tips
Refer to 7 key impact of ICD-10
Documentation
Specific developmental disorder of motor
function
Disturbance of Skin Sensation
• Identify the skin sensation
disturbance:
o Anesthesia of skin
o Hypoesthesia of skin
o Paresthesia of skin
o Hyperesthesia
o Other and unspecified
disturbances of skin sensation
Refer to 7 key impact of ICD-10
Documentation
1
ICD-9 Name
Hemiplegia,
unspecified, affecting
unspecified side
ICD-9
Code
ICD-10
Code
342.90
G81.90
Hemiplegia, unspecified affecting
unspecified side
G81.91
Hemiplegia, unspecified affecting right
dominant side
G81.92
Hemiplegia, unspecified affecting left
dominant side
G81.93
Hemiplegia, unspecified affecting right
nondominant side
G81.94
Hemiplegia, unspecified affecting left
nondominant side
ICD-10 Name
Paraplegia
344.1
G82.20
Paraplegia unspecified
Infantile cerebral
palsy, unspecified
343.9
G80.9
Cerebral palsy, unspecified
Lack of coordination
781.3
R27.0
Ataxia, unspecified
R27.8
Other lack of coordination
R27.9
Unspecified lack of coordination
R62.50
Unspecified lack of expected normal
physiological development in childhood
R62.59
Other lack of expected normal
physiological development in childhood
Lack of normal
physiological
development,
unspecified
783.40
Mixed development
disorder
315.5
F82
Muscle weakness
(generalized)
728.87
M62.81
Muscle weakness (generalized)
Other joint
derangement, not
elsewhere classified,
involving hand
718.84
M24.841
Other specific joint derangements of
right hand, not elsewhere classified
M24.842
Other specific joint derangements of left
hand, not elsewhere classified
M24.849
Other specific joint derangements of
unspecified hand, not elsewhere classified
M25.241
Flail joint, right hand
M25.242
Flail joint, left hand
M25.249
Flail joint, unspecified hand
M25.341
Other instability, right hand
M25.342
Other instability, left hand
M25.349
Other instability, unspecified hand
Documentation tips
Paresis
• Specify the site or type (e.g.,
congenital, psychogenic, bladder,
bowel, eye, etc.).
• State the laterality when applicable
(i.e., right, left, or bilateral).
• Identify dominant versus nondominant side when applicable.
• Differentiate between flaccid and
spastic hemiplegia.
• Report the underlying cause (e.g.,
status post-stroke).
• Detail paraplegia and quadriplegia
as being incomplete or complete
Refer to 7 key impact of ICD-10
Documentation
Specific developmental disorder of motor
function
Other specified delays
in development
315.8
F88
Other disorders of psychological
development
Stiffness of joint, not
elsewhere classified,
involving unspecified
site
719.50
M25.60
Stiffness of unspecified joint, not
elsewhere classified
Unspecified delay in
development
315.9
F81.9
Developmental disorder of scholastic
skills, unspecified
F89
Unspecified disorder of psychological
development
The ICD-10 Provider Specialty Tool Kit is meant to assist providers with documentation best practices necessary for the transition from ICD-9-CM to ICD-10-CM. This tool
kit includes the most commonly used diagnoses for a specialty using 2012 claims data for top encounters and top number of dollars per diagnosis. The tool kit can be
used as a quick reference guide for providers and can also be shared with Practice Managers. This tool kit is not meant to be a coding cross walk and therefore should
not be used as such. Questions regarding this tool kit and/or ICD-10 should be submitted via email to [email protected].
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