By Lisa Kropp, Coding and Crredentialing Manager

What to Expect in September:

  • Coding Clients: PF will continue to be a resource for questions.  Training has occurred either in person or via telephone.  If you have not received your session, you must contact PF at 716.834.1191.
  • Billing Clients: PF will expect all dates of service 10/1/2015 forward to contain ICD10 diagnosis codes on your billing sheets.

The BEST Resource at this stage:

  1. CMS’s Road to 10
    1. Clinical Documentation and ICD-10:


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 induced, due to underlying condition, gestational

  1. COMPLICATIONS: What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes
  2. 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.”
  • You 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

INJURIES….Increased Specificity

ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.

When documenting INJURIES, include the following:

  • Episode of Care:                     Initial, subsequent, sequelae (late effect)
  • Injury Site:                              Be as specific as possible
  • Etiology:                                 How was the injury sustained?
  • Place of Occurrence:               e.g. School, work, etc.

Initial Encounters may also require, where appropriate:

  • Intent:                                     e.g. Unintentional or accidental, self-harm, etc.
  • Status                                     e.g. Civilian, military, etc.


Example: A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:

  • Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
  • External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
  • Place of Occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause
  • Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping   

For additional examples, by specialty, please visit:

If you would like more information about how we can tailor our services to meet your needs, please contact Practicefirst at 716.834.1191 or<

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