ICD-10 Clinical Documentation Improvement

In the coming years as we move toward the “go-live” date for ICD-10-CM of October 1, 2013, you will hear the term CDI more frequently. Clinical documentation improvement (CDI) will be vital to every practice. In last month’s article readiness assessments were discussed, which go hand in hand with CDI.

Following are a few examples of where changes may need to be made in documentation to follow the increased specificity of ICD-10-CM code assignment.

Most codes for diabetes are considered combination codes in ICD-10-CM. These codes require specific elements in the documentation to assign a code in ICD-10-CM.

Diabetes documentation requirements for ICD-10-CM include:

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • For Type II diabetes a secondary code for long term insulin use is required if patient is using insulin

Example: Codes E11.51 and Z79.4 are used for a Type II diabetes mellitus patient with diabetic peripheral angiopathy without gangrene who has used insulin for many years.

Documentation requirements for neoplasms require specificity in both the site and laterality components. Documentation for neoplasms must include:

  • Type
    • Malignant (Primary, Secondary, Ca in situ)
    • Benign
    • Uncertain
    • Unspecified behavior
  • Location(s) (site specific)
  • If malignant, any secondary sites should also be determined
  • Laterality, in some cases

Example: Malignant neoplasm of the breast has 54 choices, and requires specification of male/female breast, the site of the neoplasm on the breast, and laterality. In addition, a code for estrogen receptor status is required, if known.

Code example: C50.411 Malignant neoplasm of upper-outer quadrant of the left female breast and Z17.1 Estrogen receptor status negative status [ER-].

Asthma codes in ICD-10-CM have been expanded to include the following concepts:

  • Severity of disease
    • Mild intermittent
    • Mild persistent
    • Moderate persistent
    • Severe persistent
  • Acute exacerbation
  • Status asthmaticus
  • Other types (exercise induced, cough variant, other)

Example: J45.41 Moderate persistent asthma with (acute) exacerbation.

As you can see from examples above, the documentation requirements for ICD-10-CM will vary from ICD-9-CM documentation requirements in many cases. Working with your providers on clinical documentation improvement for ICD-10-CM through readiness assessments and education will help ease the transition. Knowledge of the coding guidelines and preparation will be essential.

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