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 ICD-10
ICD-9 Name ICD-10 Name Documentation tips
Code Code

Autistic disorder, 299.0 F84.0 Autistic disorder Refer to 7 key impact of ICD-10
current or active Documentation
state
Brachial plexus 353.0 G54.0 Brachial plexus disorders
lesions
Delayed milestones 783.42 R62.0 Delayed milestone in childhood
Developmental 315.4 F82 Specific developmental disorder of motor
coordination function
disorder
Disturbance of skin 782.0 R20.0 Anesthesia of skin Disturbance of Skin Sensation
sensation R20.1 Hypoesthesia of skin • Identify the skin sensation
disturbance:
R20.2 Paresthesia of skin o Anesthesia of skin
R20.3 Hyperesthesia o Hypoesthesia of skin
o Paresthesia of skin
R20.8 Other disturbances of skin sensation
o Hyperesthesia
R20.9 Unspecified disturbances of skin o Other and unspecified
sensation disturbances of skin sensation

Edema 782.3 R60.0 Localized edema Refer to 7 key impact of ICD-10

R60.1 Generalized edema Documentation

R60.9 Edema, unspecified

Feeding difficulties 783.3 R63.3 Feeding difficulties
and mismanagement

1
 ICD-9 ICD-10
ICD-9 Name ICD-10 Name Documentation tips
Code Code

Hemiplegia, 342.90 G81.90 Hemiplegia, unspecified affecting Paresis

unspecified, affecting unspecified side • Specify the site or type (e.g.,
unspecified side G81.91 Hemiplegia, unspecified affecting right congenital, psychogenic, bladder,
dominant side bowel, eye, etc.).
• State the laterality when applicable
G81.92 Hemiplegia, unspecified affecting left (i.e., right, left, or bilateral).
dominant side • Identify dominant versus non-
G81.93 Hemiplegia, unspecified affecting right dominant side when applicable.
nondominant side • Differentiate between flaccid and
spastic hemiplegia.
G81.94 Hemiplegia, unspecified affecting left
• Report the underlying cause (e.g.,
nondominant side
status post-stroke).
Paraplegia 344.1 G82.20 Paraplegia unspecified • Detail paraplegia and quadriplegia
as being incomplete or complete
Infantile cerebral 343.9 G80.9 Cerebral palsy, unspecified Refer to 7 key impact of ICD-10
palsy, unspecified Documentation
Lack of coordination 781.3 R27.0 Ataxia, unspecified
R27.8 Other lack of coordination
R27.9 Unspecified lack of coordination
Lack of normal 783.40 R62.50 Unspecified lack of expected normal
physiological physiological development in childhood
development, R62.59 Other lack of expected normal
unspecified physiological development in childhood
Mixed development 315.5 F82 Specific developmental disorder of motor
disorder function
Muscle weakness 728.87 M62.81 Muscle weakness (generalized)
(generalized)
Other joint 718.84 M24.841 Other specific joint derangements of
derangement, not right hand, not elsewhere classified
elsewhere classified, M24.842 Other specific joint derangements of left
involving hand 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
Other specified delays 315.8 F88 Other disorders of psychological
in development development
Stiffness of joint, not 719.50 M25.60 Stiffness of unspecified joint, not
elsewhere classified, elsewhere classified
involving unspecified
site
Unspecified delay in 315.9 F81.9 Developmental disorder of scholastic
development 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 ICD10@choa.org.

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