This document provides guidance on ICD-10 documentation for physicians. It emphasizes the importance of specificity in documentation for accurate coding and reimbursement. Key documentation elements include acuity, site, laterality, etiology, manifestations, external causes of injury, and signs and symptoms. Common conditions like heart disease, diabetes, and strokes require documenting details like type, location, and severity. Proper documentation of procedures requires specifying the body system, root operation, body part, approach, and any devices used.
2. 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 visits
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3. Why 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– Outdated: 30 years old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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9. 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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11. ICD-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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12. Gold 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 tests
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13. ICD-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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14. ICD-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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15. ICD-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, Chronic
–Intermittent, Recurrent, Transient
–Primary, Secondary
–Stage I, II, III, IV
Example – stage of pressure ulcer:
– L89.011 Pressure ulcer of right elbow, stage 1
– L89.021 Pressure ulcer of left elbow, stage 1
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16. ICD-10 Documentation Tips
Documentation should always include:
– Patient’s BMI
– Current of past history of tobacco use or dependence
– Exposure to environmental or occupational tobacco
smoke
– History of previous MI
– Administration of tPA at a different facility within 24
hours prior to admission to current facility
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17. ICD-10 Documentation Tips
Atherosclerosis
– Specify type of vessel:
• Native artery
• CABG or Transplanted heart artery
– Specify CABG graft type:
• Autologous vein
• Autologous artery
• Non-autologous biological
• Native coronary artery or transplanted heart
– Specify CABG and transplanted heart to include:
• With and without angina pectoris
• Unstable angina
• Documented spasm
• Other forms of angina pectoris
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18. ICD-10 Documentation Tips
Heart Failure
– Specify acuity
• Acute
• Chronic
• Acute on chronic
– Identify type
• Systolic
• Diastolic
• Combined systolic and diastolic
– List relationship of hypertension to heart failure or heart
disease
– Identify underlying cause
» Example - Exacerbation of stable heart failure due to fluid overload or
due to missed dialysis
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19. ICD-10 Documentation Tips
Disorders of the Heart Valves
– Specify Site
• Mitral
• Aortic
• Tricuspid
• Pulmonary
– Specify Type
• Rheumatic
• Nonrheumatic
• Congenital
– Specify Severity – acute versus chronic
• If rheumatic, classify with or without heart involvement
– Subclassifications
• Insufficiency
• Incompetence
• Regurgitation
• Prolapse
• Stenosis
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20. ICD-10 Documentation Tips
Ischemic Heart Disease
– Specify occlusion as:
• Total, partial
– Specify the presence of:
• Angina pectoris, unstable angina, any spasm of a coronary vessel
– Identify the type and underlying cause of angina
» if not related to heart disease
– Identify ischemic heart disease as:
• Atherosclerosis
• Arteriosclerotic coronary artery disease
• Arteriosclerotic heart disease
• Coronary artery disease
• Coronary arteriosclerosis
• Coronary heart disease
• Coronary ischemia
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21. ICD-10 Documentation Tips
Type of MI along with Myocardium involved
– Specify the type – ST elevation, non ST elevation
– Specify the location/site affected
• anterior wall, anterolateral wall, interior wall
• left anterior descending coronary artery
• left main coronary artery, right coronary artery
– Timeframe
• Clearly indicate date of recent acute MIs within 28 days prior to current
admission
• History of MI (older than 28 days)
– tPA
• Was tPA administered within the last 24 hours of admission at a
different facility?
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22. ICD-10 Documentation Tips
Diabetes - include the type or cause of diabetes
– Type I
– Type II
– Due to drugs and chemicals
– Due to underlying condition
– Link any manifestations / complications to the diabetes
• Circulatory, renal, neurological, ophthalmic, skin,
other
Examples:
• 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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23. ICD-10 Documentation Tips
Strokes – dominant vs. non-dominant side
– Specify the location or source of the hemorrhage and
laterality
– Document other causes – thrombosis, embolism, occlusion,
stenosis
• Sites – precerebral or cerebral arteries
• Laterality
– Document dominant verses non-dominant side for all
paralytic syndromes such as hemiplegia, monoplegia and
hemiparesis and for residual effects
Example: previous cerebrovascular infarction 6 months ago
with residual left-sided hemiparesis on his nondominant
side.
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24. ICD-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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25. ICD-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
26. ICD-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
27. ICD-10 Documentation Tips
Most Common Root Operations:
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Bypass – altering the
route of passage
Drainage – taking or
letting out fluids &/or
gases
Insertion – putting in
a non-biological
appliance
Restriction – partially
closing
Control – stopping or
attempting to stop
bleeding
Excision – cutting out
or off
Replacement –
putting in a biological
/ synthetic material to
replace or function as
a body part
Supplement – putting
in a biological /
synthetic to reinforce
and / or augment
function
Dilation - expanding Extirpation – taking or
cutting out solid
matter
Repair – restoring to
its anatomic structure
and function
Transfer – moving a
body part to another
location
Division – cutting into
a body part to
separate or transect
Extraction – pulling or
stripping out of off
Resection – cutting
out or off
Transplantation –
putting in a living
body part from
another individual or
animal
28. ICD-10 Documentation Tips
Most Common Device Types:
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Cardiac Lead Drainage Device Monitoring
Device
Stimulator Lead
Cardiac Rhythm
Related Device
Extraluminal
Device
Pacemaker,
single or dual
Tracheostomy
Device
Contractility
Modulation
Device
Feeding Device Radioactive
Element
Vascular Access
Device,
Reservoir or
pump
Defibrillator Intraluminal
Device: Plain,
Drug-Eluting or
Radioactive
Stimulator
Generator
29. Summary
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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