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Factor Better Documentation into ICD-10 Coding

Vague documentation will lead to questions, errors, and ultimately claim denials.
By Patricia A. Smith, RHIT, CPC
Implementation of ICD-10 is inevitable. The delay to October 1, 2015 should not deter education and training. ICD-10 code sets are far more specific than those in ICD-9-CM, making comprehensive documentation necessary to capture correct diagnoses.
Documentation describes why an individual seeks care and how the care was provided, and may be called on as evidence in malpractice cases, as clarification of rendered services, for communication between physicians, etc. Documentation is reviewed on a case-by-case basis. Every diagnosis addressed during a visit should be identified, evaluated, and have a treatment plan. And every bit of that must be documented.
In years past, reimbursement was based solely on submitted CPT® codes, and reviews focused on whether the procedure codes were supported within the documentation. With the implementation of ICD-10, diagnoses will become a factor for reimbursement decisions, as well. Per the Social Security Act, “clear and concise medical record documentation is required in order for physicians to receive accurate and timely payment for services.” Payers (reasonably) want a detailed explanation to justify payment, and have the right to review documentation before paying claims.

Identify Weaknesses in Documentation

Every date of service should be self-supporting. The documentation must address the problem, show an examination, and tie everything together in the assessment and plan. Because coders and auditors are trained to assume nothing, vague documentation may result in many questions or cause incorrect diagnosis codes to be submitted. If a reviewer is unable to understand how the diagnoses are assessed and treated, the claim will be denied.
Insurers and health information vendors have been reviewing and auditing documentation to identify missing elements. The health information vendor HRS has been working specifically with hospitals to prepare them for expected changes regarding ICD-10 and documentation specificity. According to AHIMA’s Bird’s Eye View of ICD-10 Documentation Gaps, HRS identified seven basic elements (listed as most popular first) that current documentation often lacks to properly assign an ICD-10 diagnosis code:
1.Disease type is not indicated.
2.Exact details pertaining to disease are not mentioned.
3.Documentation is missing entirely.
4.Specific location (if relevant) is not identified.
5.Stages of diseases are missing in documentation.
6.Right/Left sides are not properly identified.
7.Documentation for combination codes is improperly documented to code accurately.
These seven elements are not all-inclusive, but are an excellent guide for improving documentation.

Target and Fix Skimpy Areas

Improving documentation takes initiative. Focus your efforts on fixing the seven missing elements in your documentation. Ask questions, such as: Is the documentation easy to follow? Does it contain the necessary information to accurately portray the diagnoses and procedures represented in the claim submission? To give you an idea of good vs. bad documentation, consider the following examples.
Example 1
A 13-year-old boy comes in complaining of arm pain. Swelling is apparent. An X-ray is ordered, which shows a fractured radius.
With the specificity changes found in ICD-10, the example above cannot be coded. It lacks detailed information required for ICD-10. To code this example appropriately, the documentation must specify:

  • Laterality (i.e., which arm was fractured)
  • Location on bone (e.g., head, neck, shaft, upper end, etc.)
  • Type of fracture (e.g., green stick, spiral, fissured, etc.)
  • Episode of care (i.e., initial, subsequent, sequela)

The example below contains the necessary information to assign an ICD-10 code accurately:
Example 2
A 13-year-old boy comes in for an initial evaluation after falling off his skateboard. He is complaining of pain in his left arm. Swelling is obvious. An X-ray is ordered, which shows a spiral fracture of the left radial shaft.
The proper ICD-10 code for this encounter is S52.342A Displaced spiral fracture of shaft of radius, left arm, initial encounter for closed fracture.
Denial rates due to weak documentation and using unspecified codes will increase with ICD-10. You are required to code to the highest specificity, per ICD guidelines. Although unspecified codes may still be listed in ICD-10, their use is discouraged. Physicians must take time to document the specifics to ensure accurate code selection.
Physicians may grumble at the time it takes to document so specifically. Remind them of the extra time that will be required to correct incomplete documentation. Amending the medical record is not as simple as just adding the missing information; it needs to be done in a certain way, following specific regulations. Amendment dates are scrutinized closely. They must be dated and signed by the physician. In some cases, if a claim was denied due to insufficient documentation, the physician may not be able to amend it.

Identify Diseases Clearly for Billers

Another common factor affecting accurate code selection is failure to identify specifically the type of disease. A fellow clinician may be able to read a documented note and ascertain a specific type of disease due to their training and experience, but an auditor or reviewer may not.
Example 3
Documentation may specify, “Robbie comes into the office today for a recheck on his atrial fibrillation.” When looking up the ICD-10 code for atrial fibrillation you are faced with five different types of atrial fibrillation: Paroxysmal, Persistent, Chronic (permanent), Typical (type I), and Atypical (type II). If the documentation had specified, “Robbie comes into the office today for a recheck on his paroxysmal atrial fibrillation,” the type of atrial fibrillation is no longer in question and ICD-10 I48.0 Paroxysmal atrial fibrillation may quickly be assigned.
When applicable, documentation also must clearly identify the stage of a disease.
Example 4
Documentation may state, “Billy is back in the office for his CKD [chronic kidney disease]. He has a history of CKD. He will continue his current medication regime and follow up in three months.” This documentation supports only N18.9 Chronic kidney disease; unspecified. Documentation that is more complete would specify, for instance, CKD stage 3, which allows reporting of N18.3 Chronic kidney disease, stage 3 (moderate).
There’s another problem with the above example: According to ICD-10 guidelines, “history of” means the condition no longer exists, and no active treatment is being received, but the condition can reoccur. Providers sometimes use “history of” to indicate the patient has had the condition for a long time. This causes confusion for coders, auditors, and other providers.

Connect the Right Diagnosis to the Plan of Care

One major problem auditors encounter in documentation reviews is the connection between the diagnosis and the plan of care. The number of diagnoses, medications, and treatment options are extensive, which makes it difficult to know how a specific condition is treated. Encourage physicians to be clear in the overall plan for each specified condition. For example, the physician might document in the medication log, “Tricor 145 mg taken for hypertriglyceridemia.” Or within the history of present illness, she might note, “Patient takes Tricor to lower her triglycerides.” The medication information should also connect to the plan of care; for example, “Hypertriglyceridemia – refilled Tricor 145 mg, one tab every evening. Patient will follow up with a routine lipid panel in three months.”
These examples show how documentation can help ensure the correct diagnosis is attached to the correct plan of care. If a patient is on several medications, it’s the physician’s responsibility to indentify a clear connection for each medication. A coder or auditor should never assume a refill of a specific medication is for a specific condition. An assumption or unclear verbiage may result in diagnosing a patient with a condition they do not have.

Educate Physicians and Staff

A solid understanding of ICD-10 guidelines will aid in teaching physicians and staff the specifics required in using this code set to its utmost. The guidelines are broken down into several conventions and chapters, with detailed explanations of the basic coding rules and examples.
Take the time now to code from both ICD-9-CM and ICD-10-CM using current documentation as examples. Show physicians examples of what is preventing accurate code selection. Explain that documentation does not have to be lengthy, but it does have to be specific enough to identify and support the diagnoses, and explain how the patient was treated.
Last, but not least, conduct internal audits. Review documentation with an open mind. Are the diagnoses, exam, and plan of care easy to follow? Write down questions that prevent code selection. Present those questions to physicians and staff as an educational tool for improvement.
Medicine has expanded beyond the scope of ICD-9-CM. Healthcare continues to advance, and so must coders, physicians, and staff. Use the extra year to prepare.
Patricia A. Smith, RHIT, CPC, is a contracted auditor for Arrow Strategies on behalf of Blue Cross Blue Shield of Michigan. She earned an Associate Degree of Applied Science from Baker College of Clinton Township, Mich. Smith is acting secretary for the Macomb Township Michigan local chapter, and has spoken at several chapter meetings on ICD-10.


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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

No Responses to “Factor Better Documentation into ICD-10 Coding”

  1. jitendra says:

    need to have specific documentation to code specific icd10 code..because of more specific icd10 code documentation should be more clear……nice share