Overcome ICD-10-CM Documentation Challenges

By Jacqueline J. Stack, BSHA, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC

No doubt you’ve heard that moving to ICD-10-CM will give you more specific choices for coding diagnoses. This data-driven code set will enable us to code to the highest level of specificity. But our ability to do that will still rely on how well physicians and other health care practitioners document their services.

This isn’t a simple task because physicians do not typically document the way a codebook reads; they document for the care of the patient. Providers have their work cut out for them, too. Documenting for ICD-10-CM will be challenging because clinical documentation is used in many ways.
Clinical documentation is also used for:

Certified Emergency Department Coder CEDC

  • Patient care
  • Accurate and timely reimbursement
  • Reporting statistical data to aide in quality reporting
  • Assisting with financial planning and clinical data
  • Protecting the physician, the patient, and the practice in a legal situation

As such, coders and physicians do not always “speak the same language.” To break the communication barrier, and code with the increased clinical specificity ICD-10-CM provides, coders will need a comprehensive understanding of the types of disease and disease processes being documented.

Learn the Language

Example: A four-year-old girl falls off the monkey bars, causing an injury to her left arm. Based on X-rays, the physician determines the child has a buckle fracture of the left arm.

A buckle fracture (also known as a torus or incomplete fracture) is a common type of bone break in children where one side of a bone buckles upon itself without affecting the other side. With a good knowledge of fractures, the coder is able to choose a code that accurately describes the encounter based on the provider’s documentation.

Educate Physicians

In addition to brushing up on your knowledge of anatomy and physiology (A&P), now is a good time to begin educating your providers on the new documentation requirements they will need to fulfill when ICD-10-CM is implemented on Oct. 1, 2014. Changing documentation neither requires providers to change the way they practice medicine, nor does it require extensive extra work. When the provider understands what the coder needs, he or she may be able to document the information by adding just a few key words.

Laterality, for example, is expanded in ICD-10-CM; for many diagnoses there are code choices for right, left, bilateral, and unspecified. By adding one word to his or her documentation, the physician enables the coder to select the diagnosis with the highest level of specificity.

Example: A 70-year-old patient is seen for decreased hearing. After examination, the physician determines the cause was impacted cerumen.

H61.2 Impacted cerumen

H61.20 Impacted cerumen, unspecified ear

H61.21 Impacted cerumen, right ear

H61.22 Impacted cerumen, left ear

H61.23 Impacted cerumen, bilateral

Based on the documentation, the appropriate code in this case is H61.20. Had the provider added one word to specify laterality, however, you would’ve been able to code to a higher level of specificity.

Audit Documentation

To figure out where your provider’s documentation is lacking, run a frequency report. Look at the top codes your providers use. You’ll start here and work your way down the list.

Pull documentation for the most often used code. Compare that documentation to the corresponding ICD-10-CM codes. Does the current documentation allow you to select an ICD-10-CM code to the highest level of specificity? If so, move on to the next code; if not, make a point to explain to your provider(s) what sort of documentation would help you code to a higher level of specificity. When you meet with a physician, bring your code books, so he or she can see what the documentation challenges are.

If you do not feel comfortable with coding ICD-10-CM or determining where documentation needs to be changed, you can hire a consultant to do a review for you. Another option is AAPC Physician Services: They can provide low cost documentation assessments for providers. The service includes a preliminary assessment of 10 dates of service, a detailed report of findings, a half hour of webinar or telephone training based on their assessment results, and a follow-up assessment a few months later, of another 10 dates of service to measure results.

ICD-10 Documentation Requirement Examples

Consider the following common diagnoses as examples of documentation requirements you’ll find when coding from ICD-10-CM.

Diabetes Mellitus:

The codes for diabetes mellitus have been expanded in ICD-10-CM. To code for diabetes, the following information needs to be included in the documentation:

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • If type 2 diabetes, long-term insulin use

Example: Mary is being seen today for follow-up of her diabetes mellitus. She was diagnosed three years ago with type 2 diabetes mellitus, which has been well controlled with insulin.

In this example, we know that the patient is a type 2 diabetic and that she uses insulin long term to control her disease. This example would be coded:

Type 2 diabetes mellitus without

Z79.4 Long term (current) use of insulin


Documentation must include:

  • Trimester of pregnancy
  • Week of gestation

Example: Mrs. Smith presents to her OB for her monthly checkup. She is 33 weeks, four days gestation. This is her first pregnancy, and she is doing well.

In this example, Mrs. Smith is in her third trimester, at 33 weeks gestation of her first pregnancy. This example would be coded:

Z34.03 Encounter for supervision of normal first pregnancy, third trimester

Z3A.33 33 weeks gestation of pregnancy


The provider must document:

  • Site
  • Laterality
  • Type
  • Location

Example: A 30-year-old woman presents to the emergency department (ED) for an initial visit for treatment of displaced transverse fracture left tibia.

In this example the documentation tells us the site, laterality, and type of fracture. It also was the patient’s initial visit, which is necessary information to code this to the highest level of specificity. This example would be coded:

S82.222A Displaced transverse fracture of shaft of left tibia, initial encounter for closed fracture


When coding for the initial encounter of an injury, the provider must document the following to code to the highest level of specificity:

  • External cause
  • Place of occurrence
  • Activity code
  • External cause status

Example: A 30-year-old woman presents to the ED for an initial visit for treatment of displaced transverse fracture left tibia. The patient was on the balcony of her home. She was leaning against the railing, the railing broke, and the patient fell.

The documentation in this example shows us the external cause, as well as the place of occurrence. The documentation did not tell us the activity or the external cause status. This example would be coded:


W13.0XXA Fall from, out of or through balcony, initial encounter

Y92.018 Other place in single-family (private) house as the place of occurrence of the external cause


The provider should document:

  • Type
  • Mild
  • Mild intermittent
  • Mild persistent
  • Moderate persistent
  • Severe
  • With or without acute exacerbation
  • With or without status asthmaticus

Example: A 7-year-old boy is seen by his physician for asthma follow up. The patient is doing well. He only occasionally has wheezing and coughing, and has used his rescue inhaler only a few times within the last six months. The physician diagnoses the patient with mild intermittent asthma.

This example would be coded:

J45.20 Mild intermittent asthma, uncomplicated

These examples show the documentation necessary to code ICD-10-CM to the highest level of specificity. Performing a documentation readiness assessment is essential for every practice. Work with your providers now to give them time to prepare for ICD-10-CM implementation and the new concepts they will need to understand.

Jackie Stack, BSHA, CPC, CPC-I, CEMC, CFPC, CIMC, CPEDC, is ICD-10 specialist at AAPC.


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One Response to “Overcome ICD-10-CM Documentation Challenges”

  1. Erwin Duran says:

    My question is directed to Jackie Stack, what guidelines or baseline are you using to interpret the patient in the example in this article as mild intermittent?

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