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1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

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Page 1: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

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UHS, Inc.

ICD-10-CM/PCSPhysician Education

General Surgery

Page 2: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Implementation

• October 1, 2015 – Compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) – Ambulatory and physician services provided on or after

10/1/15– Inpatient discharges occurring on or after 10/1/15

• ICD-10-CM (diagnoses) will be used by all providers in every health care setting

• ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures – ICD-10-PCS will not be used on physician claims, even

those for inpatient visits2

Page 3: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

Why ICD-10Why ICD-10

Current ICD-9 Code Set is:– Outdated: 30 years old– Current code structure limits amount of

new codes that can be created– Has obsolete groupings of disease families– Lacks specificity and detail to support:

• Accurate anatomical positions• Differentiation of risk & severity• Key parameters to differentiate disease manifestations

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Page 4: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

Diagnosis Code StructureDiagnosis Code Structure

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Page 5: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10-CM Diagnosis Code FormatICD-10-CM Diagnosis Code Format

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Page 6: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

Comparison: ICD-9 to ICD-10-CMComparison: ICD-9 to ICD-10-CM

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Page 7: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

Procedure Code Structure Procedure Code Structure

Page 8: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10-PCS Code FormatICD-10-PCS Code Format

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Page 9: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Changes Everything!ICD-10 Changes Everything!

• ICD-10 is a Business Function Change, not just another code set change.

• ICD-10 Implementation will impact everyone:– Registration, Nurses, Managers, Lab, Clinical Areas,

Billing, Physicians, and Coding

• How is ICD-10 going to change what you do?

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Page 10: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

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ICD-10-CM/PCSDocumentation Tips

Page 11: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Provider ImpactICD-10 Provider Impact

• Clinical documentation is the foundation of successful ICD-10 Implementation

• Golden Rule of Documentation– If it isn’t documented by the physician, it didn’t happen– If it didn’t happen, it can’t be billed

• The purpose in documentation is to tell the story of what was performed and what is diagnosed accurately and thoroughly reflecting the condition of the patient

– what services were rendered and what is the severity of illness

• The key word is SPECIFICITY– Granularity– Laterality

• Complete and concise documentation allows for accurate coding and reimbursement

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Page 12: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

Gold Standard Documentation PracticesGold Standard Documentation Practices

1. Always document diagnoses that contributed to the reason for admission, not just the presenting symptoms

2. Document diagnoses, rather that descriptors

3. Indicate acuity/severity of all diagnoses

4. Link all diseases/diagnoses to their underlying cause

5. Indicate “suspected”, “possible”, or “likely” when treating a condition empirically

6. Use supporting documentation from the dietician / wound care to accurately document nutritional disorders and pressure ulcers

7. Clarify diagnoses that are present on admission

8. Clearly indicate what has been ruled out

9. Avoid the use of arrows and symbols

10. Clarify the significance of diagnostic tests12

Page 13: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Provider ImpactICD-10 Provider Impact

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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Page 14: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Document all acute or chronic conditions that are being:

– Clinically evaluated or

– Diagnostically tested or

– Therapeutically treated or

– Cause an increased Length of Stay (LOS) or nursing care

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Page 15: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Do not use symbols to indicate a disease.

For example “↑lipids” means that a laboratory result indicates the lipids are elevated

– or “↑BP” means that a blood pressure reading is high

These are not the same as hyperlipidemia or hypertension

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Page 16: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Site and Laterality – right versus left–bilateral body parts or paired organs

Example – cellulitis of right upper arm

Stage of disease – acute vs. chronic vs. acute on chronicExample – stage of pressure ulcer:– L89.011 Pressure ulcer of right elbow, stage 1– L89.021 Pressure ulcer of left elbow, stage 1

Episode of care – initial, subsequent, and sequelaeExample - lower leg fracture:

– A initial encounter for closed fracture– B initial encounter for open fracture type I or II– C initial encounter for open fracture type IIIA, IIIB, or IIIC– D subsequent encounter for closed fracture with routine healing– H subsequent encounter for open fracture type I or II with delayed

healing– K subsequent encounter for closed fracture with nonunion– S sequelae

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Page 17: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Cause of Injury

– Mechanism• How it happened

– Place of occurrence• Where it happened

– Activity• What was the patient doing

– External Cause• Work-related, leisure

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Page 18: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Glasgow Coma - ICD-10-CM coding will need the score from each of the assessment areas

– Eye opening – Verbal response – Motor response

» R40.211 Coma scale, eyes open never» R40.212 Coma scale, eyes open to pain» R40.213 Coma scale, eyes open to sound» R40.214 Coma scale, eyes open spontaneously

–Report the Glasgow coma scale total score» R40.241 Glasgow coma scale score 13 – 15» R40.242 Glasgow coma scale score 9 - 12» R40.243 Glasgow coma scale score 3 – 8

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Page 19: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Crohn's disease - Specify the site

• Colon• Duodenum• Ilium• Jejunum• Small intestine

Include any manifestations:

– K50.00 Crohn's disease of small intestine without complications– K50.011 Crohn's disease of small intestine with rectal bleeding– K50.012 Crohn's disease of small intestine with intestinal obstruction– K50.013 Crohn's disease of small intestine with fistula– K50.014 Crohn's disease of small intestine with abscess– K50.018 Crohn's disease of small intestine with other complication– K50.019 Crohn's disease of small intestine with unspecified complications

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Page 20: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Diabetes - include the type or cause of diabetes– Type I– Type II– Due to drugs and chemicals– Due to underlying condition– Other specified diabetes– Link any manifestations to the diabetes

• Circulatory, renal, neurological, ophthalmic, skin, other

•E08 - Diabetes mellitus due to underlying condition– E08.10 Diabetes mellitus due to underlying condition with ketoacidosis

without coma– E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with

coma

•E11 - Type 2 diabetes mellitus– E11.311 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy with

macular edema– E11.319 Type 2 diabetes mellitus w/ unspecified diabetic retinopathy without

macular edema

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Page 21: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Fractures – clearly document all aspects

– Cause – traumatic, stress, pathological

– Location – which bone, which part of the bone, laterality

– Type – displaced, non-displaced, open, closed

– Encounter – initial, subsequent, sequelae

– External cause – how the fractured occurred and the activity

• Example - Fall while skiing

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Page 22: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Open fractures - Please specify the severity using the Gustilo-Anderson Open Fracture Classification system for forearm, femur, and lower leg

–Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury).

–Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury.

–Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

–Type III fractures are further divided into

• III A: Soft tissue coverage of the fractured bone is adequate.

• III B: Disruption of the soft tissue is extensive, that local or distant flap coverage is necessary.

• III C: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

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Page 23: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Pathologic (non-traumatic) fractures:

– Exact location of fracture – • Bone, part of the bone, and laterality

– Etiology of the fracture – • osteoporosis, neoplastic disease, other specified

– Encounter type –• initial encounter, subsequent encounter with routine

healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae

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Page 24: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Neoplasm

– Location• Detailed location• Left, Right, Bilateral

– Morphology• Malignant, Benign• Primary , Secondary• In situ• Uncertain behavior, Unspecified behavior

– Histology• Identified by cytology, histology or pathology findings

– Stage / Metastatic • Different, distinct locations

– Different primaries– Metastatic sites

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Page 25: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Neoplasm continued

– Is patient being admitted for treatment of the neoplasm or an adverse reaction / complication?

• Treatment - surgery, chemotherapy, immunotherapy, radiation• Adverse reaction of treatment – neutropenic fever secondary to chemo• Complication of the disease – anemia due to malignancy

– Document if a complication is part of the disease process or an adverse effect of treatment

• Anemia due to malignancy or due to chemotherapy

– History of• Malignancies previously removed and no longer receiving active

treatment• Clearly document for follow-up and medical surveillance

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Page 26: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Drug Under-dosing is a new code in ICD-10-CM.

– It identifies situations in which a patient has taken less of a medication than prescribed by the physician.

• Intentional versus unintentional

– Documentation requirements include:• The medical condition• The patient’s reason for not taking the medication

– example – financial reason– Z91.120 – Patient’s intentional underdosing of

medication due to financial hardship

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Page 27: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Codes for postoperative complications have been expanded and a distinction made between intraoperative complications and post-procedural disorders

•The provider must clearly document the relationship between the condition and the procedure

– Example: • D78.01 –Intraoperative hemorrhage and hematoma of spleen

complicating a procedure on the spleen • D78.21 –Post-procedural hemorrhage and hematoma of spleen following

a procedure on the spleen

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Page 28: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

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Intra-operative Post-procedural

Accidental puncture / laceration Timing:•Post-procedure•Late effect

Same or different body system Classify as:•An expected post-procedural condition•An unexpected post-procedural condition, related to the patient’s underlying medical comorbidities•An unexpected post-procedural condition, unrelated to the procedure•An unexpected post-procedural condition related to surgical care (a complication of care)

Blood product

Central venous catheter

Drug:•What adverse effect•Drug name•Correctly prescribed•Properly administered

Encounter:•Initial•Subsequent•Sequelae

Page 29: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

ICD-10-PCS does not allow for unspecified procedures, clearly document:

•Body System– general physiological system / anatomic region

•Root Operation– objective of the procedure

•Body Part– specific anatomical site

•Approach– technique used to reach the site of the procedure

•Device– Devices left at the operative site

Page 30: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Example – spinal fusion

•Root Operation–Fusion

•Body Part–Thoracic vertebral joints 2 - 7

•Approach– Open (anterior/posterior) and Column (anterior/posterior)

•Device–Autologous tissue substitute

Page 31: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Root Operations for General Surgery:

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Bypass – altering the route of passage

Drainage – taking or letting out fluids &/or gases

Release – freeing a body part from an abnormal physical constraint

Resection – cutting out or off without replacement all of a body part

Detachment – cutting off all of part of the upper or lower extremity

Excision – cutting out or off without replacement a portion of a body part

Repair – restoring, to the extent possible, a body part

Restriction – partially closing an orifice or lumen of a tubular body part

Dilation – expanding an orifice or the lumen of a tubular body part

Fusion – joining together portions of an articular body, rendering it immobile

Replacement – putting in a biological or synthetic material that takes the place &/or function

Supplement – putting in a biological/ synthetic material to reinforce / augment

Division – cutting into a body part to transect the body part

Reattachment – putting back in or on all or a portion of a separate body part

Reposition – moving to its normal location

Transfer – moving, without taking out, all or a portion of a body part to another location

Page 32: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Device Types for General Surgery:

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Artificial sphincter External fixation device

Intraluminal device, plain drug-eluting or radioactive

Spinal stabilization device, facet replacement

Cardiac lead Extraluminal device Intramedullary internal fixation device

Spinal stabilization device, interspinous process device

Cardiac rhythm related device

Feeding device Liner Spinal stabilization device, pedicle-based device

Contraceptive device Hearing device, bone conduction

Monitoring device Stimulator generator

Contractility modulation device

Hearing device, cochlear prosthesis

Pacemaker, single or dual

Stimulator lead

Defibrillator Interbody fusion device

Radioactive element Tracheostomy device

Drainage device Internal fixation device

Spacer Vascular access device, reservoir or pump

Page 33: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Root Operations for Gastroenterology:

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Bypass – altering the route of passage

Drainage – taking or letting out fluids &/or gases

Repair – restoring, to the extent possible, a body part

Restriction – partially closing an orifice or lumen of a tubular body part

Control – stopping, or attempting to stop, post-procedural bleeding

Excision – cutting out or off without replacement a portion of a body part

Replacement – putting in a biological or synthetic material that takes the place &/or function

Supplement – putting in a biological/ synthetic material to reinforce / augment

Dilation – expanding an orifice or the lumen of a tubular body part

Reattachment – putting back in or on all or a portion of a separate body part

Reposition – moving to its normal location

Transfer – moving, without taking out, all or a portion of a body part to another location

Division – cutting into a body part to transect the body part

Release – freeing a body part from an abnormal physical constraint

Resection – cutting out or off without replacement all of a body part

Transplantation – putting in or on all or a portion of a living body taken from another individual or animal

Page 34: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Device Types for Gastroenterology:

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Artificial sphincter Extraluminal device

Intraluminal device, plain or radioactive

Radioactive element

Drainage device Feeding device Monitoring device

Page 35: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Root Operations for Nephrology / Urology:

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Bypass – altering the route of passage

Release – freeing a body part from an abnormal physical constraint

Resection – cutting out or off without replacement all of a body part

Dilation – expanding an orifice or the lumen of a tubular body part

Repair – restoring, to the extent possible, a body part

Restriction – partially closing an orifice or lumen of a tubular body part

Drainage – taking or letting out fluids &/or gases

Replacement – putting in a biological or synthetic material that takes the place &/or function

Supplement – putting in a biological/ synthetic material to reinforce / augment

Excision – cutting out or off without replacement a portion of a body part

Reposition – moving to its normal location

Transplantation - putting in or on all or a portion of a living body taken from another individual or animal

Page 36: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Device Types for Nephrology / Urology:

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Artificial sphincter Extraluminal device

Intraluminal device, plain, drug-eluting or radioactive

Stimulator lead

Drainage device Infusion device Monitoring device

Page 37: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Root Operations for Otorhinolaryngology:

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Control – stopping, or attempting to stop, post-procedural bleeding

Drainage – taking or letting out fluids &/or gases

Repair – restoring, to the extent possible, a body part

Restriction – partially closing an orifice or lumen of a tubular body part

Dilation – expanding an orifice or the lumen of a tubular body part

Excision – cutting out or off without replacement a portion of a body part

Replacement – putting in a biological or synthetic material that takes the place &/or function

Supplement – putting in a biological/ synthetic material to reinforce / augment

Division – cutting into a body part without draining fluids &/or gases from the body part in order to transect the body part

Release – freeing a body part from an abnormal physical constraint

Reposition – moving to its normal location

Transfer – moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of the body part

Resection – cutting out or off without replacement all of a body part

Page 38: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Device Types for Otorhinolaryngology :

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Drainage device Hearing device, bone conduction

Intraluminal device

Radioactive element

Extraluminal device

Hearing device, cochlear prosthesis

Monitoring device

Page 39: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

ICD-10 Documentation TipsICD-10 Documentation Tips

Most Common Root Operations for Ophthalmology:

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Control – stopping, or attempting to stop, post-procedural bleeding

Extirpation – taking or cutting out solid matter from a body part

Removal – taking out or off a device from a body part

Resection – cutting out or off without replacement all of a body part

Division – cutting into a body part to transect the body part

Extraction – pulling or stripping out or off all of a portion of a body part

Repair – restoring, to the extent possible, a body part

Supplement – putting in a biological/ synthetic material to reinforce / augment

Drainage – taking or letting out fluids &/or gases

Insertion – putting in a non-biological appliance that does not take the place of the body part

Replacement – putting in a biological or synthetic material that takes the place &/or function

Transfer – moving, without taking out, all or a portion of a body part to another location

Excision – cutting out or off without replacement a portion of a body part

Release – freeing a body part from an abnormal physical constraint

Reposition – moving to its normal location

Page 40: 1 UHS, Inc. ICD-10-CM/PCS Physician Education General Surgery

SummarySummary

The 7 Key Documentation Elements:

1.Acuity – acute versus chronic

2.Site – be as specific as possible

3.Laterality – right, left, bilateral for paired organs and anatomic sites

4.Etiology – causative disease or contributory drug, chemical, or non-medicinal substance

5.Manifestations – any other associated conditions

6.External Cause of Injury – circumstances of the injury or accident and the place of occurrence

7.Signs & Symptoms – clarify if related to a specific condition or disease process

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