ICD-10-CM is full speed ahead. The Senate approved the Medicare Sustainable Growth Rate (SGR) bill which did not include a reference to an ICD-10 delay. The implementation date remains just a few short months away (Oct. 1, 2015), increasing the urgency for those still preparing.

ICD-10-CM has 21 chapters and over 61,000 new codes. It is imperative that providers’ documentation be clear, detailed and concise. This will take education and working with referring physicians to obtain as much information as possible in order for the pathologist to document to the highest specificity as possible. Each chapter has its own guidelines in either the front of the manual or in the tabular section.

ICD-10 documentation requirements

  • Laterality (right, left or bilateral)
  • Site specificity
  • Identification of the fetus affected by certain complications of pregnancy, childbirth and puerperium in multiple gestation pregnancies
  • Identification of the trimester for complications occurring during pregnancy
  • Episode of care (initial, subsequent, sequela) for injuries, poisoning, external causes and other conditions
  • Combination codes (etiology and manifestations) (related conditions) (disease, injury or other medical condition and complications) (diseases or other medical conditions and common signs or symptoms)
  • Current codes moved to new categories or chapters – Example is fractures (see example below)

 ATC Pathology ICD-10 Documentation

In ICD-9, if the fracture was documented traumatic or pathological per guidelines, the coder was to assign the first listed. ICD-10 eliminates this guideline. Thus, the provider will need to clearly document the fracture as traumatic or pathologic in order for an ICD-10 code to be assigned.  ICD-10 guidelines I/C13.b states “If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider”.1


  • 2014 ICD-9-CM Professional Manual (AMA)  page 121
  • 2015 Draft ICD 10-CM Manual (AMA)  page 143, 144

1 2015 Draft ICD 10-CM Manual (AMA), ICD-10 Draft Official Guidelines for Coding and Reporting 2014, page 14.

Author - Female

About the author

Kimberly West, CPC is National Pathology Auditing & Coding Manager of web2pro Business Performance Services.