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ICD-10 Information

Referring Provider Clinical History Needs for ICD-10

We provide a reference sheet for common imaging indications related to ICD-10 to help referring physicians provide our radiologists with the clinical history needed to make the most accurate evaluations and interpretations.

PLEASE NOTE: Specify clinical indication/symptoms: Cannot accept “evaluate for “as the only reason for imaging.

Head:

  • Headache:
    • Chronic
    • Migraine- with or w/o Aura
    • Tension
    • Acute- post traumatic
  • Dizziness, visual change

Neck:

  • Pain: specify location and laterality
  • Swelling or lump: specify location and laterality medial/lateral, anterior/posterior
  • Difficulty swallowing

Chest:

  • Cough, Shortness of Breath
  • Pain: specify location and laterality

Abdominal/Pelvic/Flank:

  • Pain: specify location (quadrant):
    • RUQ, LUQ, RLQ, LLQ, RT, LT, Bilateral, Generalized
  • Diabetes Type:
    • Complication (retinopathy, nephropathy, neuropathy)
  • Kidney Disease:
    • Chronic
    • Stage: 1 2 3 4 5
    • ESRD (end stage with chronic dialysis)
    • Dialysis: Y/N

Hypertension (HTN):

  • Is it related to heart disease or chronic kidney disease?

Pregnancy:

  • Reason for visit (routine, complaint)
  • Pt. complication/condition i.e bleeding, small for dates, large for dates, pain, etc.
  • Trimester/weeks of pregnancy

Back Pain/Lumbar Pain:

  • Specify location: (level and laterality of spine)
    • Low Back Pain RT/LT
    • Low Back with Sciatica RT/LT
    • Radiculopathy Lumbar
    • Radiculopathy Lumbosacral Region
    • Radiculopathy Leg RT/LT
    • Sciatica RT/LT, Bilateral
  • Specify other known spinal disease or complication

Venous US Lower Extremity:

  • Pain, swelling, ulcer: specify location and laterality

Neoplasm:

  • Current cancer or history of cancer
  • Define: Primary, Secondary, CA in Situ, Benign, Unspecified
  • Secondary Cancer:
    • Define primary with secondary
  • Current treatment or completed treatment:
    • Type: Chemo or Rad. Therapy MM/YY

History of CA: Previously excised or eradicated and no further treatment is directed to that site and no evidence of any existing primary malignancy Type and year

Injury: How? When? Symptom?

  • Work Comp or Auto accident
  • Pain, injury, swelling
  • Specify location and laterality: Proximal/distal, medial/ lateral, anterior/posterior

Fracture status:

  • Initial visit for evaluation or encounter for active treatment of a fracture
  • Subsequent treatment (follow up fracture - NO active treatment)
  • Fracture location:
    • Laterality: proximal/distal, medial/lateral
    • Define type of fracture
    • Open or closed
  • Pathologic FX:
    • Due to neoplasm or other chronic disease

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