We are hearing lots about ICD-10-CM/PCS (International Classification of Diseases, 10th revisions, Clinical Modification/Procedure Coding System) documentation needs.
Yes, there is increased specificity to the code set and descriptions, but this is understandable and expected since the code set is an improvement over what we use today with ICD-9-CM (International Classification of Diseases, 9th revision, Clinical Modification).
Let’s not forget that ICD-9 is now over 30 years old, well beyond its 10-year originally planned lifespan. In addition, ICD-9 is very outdated in regards to the current medical technology and terminology code capture. It’s clear that ICD-10 truly will have very positive impact to better capturing coded data, understanding healthcare quality, and information for clinical research.
The American Health Information Management Association (AHIMA) has always been and continues to be a force driving for and obtaining quality data in order to improve healthcare. Through AHIMA’s foundational focus on clinical documentation improvement (CDI), coded data, and the management of health information, it strongly supports the adoption of ICD-10 in October 2015.
In late spring of this year, AHIMA formed a CDI workgroup made up of healthcare clinicians and HIM Professionals with a charge to develop a library of ICD-10 documentation tips for the industry. These ICD-
10 CDI tips would help physicians easily transition to the ICD-10 code set, and help CDI and coding professionals as well. Throughout this summer, the volunteer workgroup developed more and more tips. This work resulted in more than 70 ICD-10 documentation tips and they are NOW available and free to anyone, in any healthcare setting, to utilize.
The tips focus on the language, wording, and terminology that will garnish greater details and specificity in the coded data for a given diagnosis, condition, disease, and/or surgical procedure. The process the workgroup undertook was to review each chapter of ICD-10-CM identifying opportunities for a diagnosis documentation tip, and then they expanded the documentation tips to the procedure coding system (PCS).
Here are two examples from the 70-plus ICD-10 Documentation Tips (both diagnosis and procedure) developed by the workgroup:
ICD-10-CM – Chronic Kidney Disease Documentation Tips
- Document the stage of CKD
– Chronic kidney disease, stage 1
– Chronic kidney disease, stage
2 (mild)
– Chronic kidney disease, stage 3 (moderate)
– Chronic kidney disease, stage 4 (severe)
– Chronic kidney disease, stage 5
– End-stage renal disease (ESRD)
- Document any underlying cause of CKD, such as diabetes or hypertension
- Specify if the patient is dependent on dialysis
- Note that “chronic renal failure” without a documented stage will be assigned to “chronic kidney disease, unspecified”
- Always document any associated diagnoses/conditions
ICD-10-PCS – CABG Documentation Tip:
- Document the Origination/Destination of graft(s)
– Examples: aorta to RCA, LIMA to LAD (indicate if the LIMA was used as a pedicle graft)
- Specify the Type of graft(s) used
– Examples: autologous artery, autologous vein, etc.
- Document the Number of sites bypassed
– Examples: one, two, three, or four or more
- Document if Excision of autologous graft is performed
– Identify the vessel
- Examples: greater/lesser saphenous vein (left/right), radial artery (left/right)
The ICD-10 Documentation Tips include the following and is a fluid resource which will grow further in the coming months towards implementation in 2015:
| Systemic Infection/Inflammation | Hepatitis |
| Meningitis | MRSA/MSSA |
| Herpes Simplex | Neoplasms |
| Anemia | Hemolytic anemia |
| Nutritional anemia | Aplastic anemia |
| Coagulopathy | Pancytopenia |
| Purpura | Diabetes |
| Obesity | Malnutrition |
| Alcohol, Tobacco & Substance Use | Major Depressive Disorder |
| Altered Mental Status | Cerebral Palsy |
| Glaucoma | Otitis Media |
| Hearing Loss | Heart Failure |
| CVA | Myocardial Infarction |
| Cardiac Arrest | Respiratory Failure |
| Asthma | Pneumonia |
| Crohn’s/Regional Enteritis | Appendicitis |
| Hepatic Encephalopathy | Pressure Ulcers |
| Non-Pressure Ulcers | Cellulitis |
| Pathologic Fractures | Gout |
| Scoliosis | Chronic Kidney Disease |
| Acute Renal Failure | OB/Pregnancy |
| Newborn | Congenital Foot Deformities |
| Cleft Palate | Coma |
| Fractures | Gustilo Classification |
| Burns | Underdosing |
| External Cause | Encounter For |
| History (Personal and Family) | Genetic Carrier |
| Retained Foreign Body | Contact With and Exposure To |
| Reproduction Services | Socioeconomic and Psychosocial |
| Body Mass Index | Mechanical Device Complications |
| Surgical Complications | Debridement (PCS) |
| CABG (PCS) | Lymph Node Chains (PCS) |
| Omentectomy (PCS) | Lysis of Adhesions (PCS) |
| Cleft Palate Repair (PCS) | Spinal Fusion (PCS) |
| Amputations (PCS) |
CDI and coding staff as well as clinicians (e.g., CDI Physician Champions) can use these ICD-10 documentation tips now to identify documentation deficiencies in order to provide documentation improvement awareness and education and give feedback to medical providers. ICD-10-CM diagnosis documentation requirements and guidelines can be incorporated into current documentation practices to facilitate the transition to ICD-10-CM.
One should not wait until October of 2015 to start addressing documentation aspects of ICD-10—start now, and use these tips to help.
The ICD-10 documentation tip sheets will be an irreplaceable tool for learning and identifying I-10 documentation requirements. Also, these documentation tips will be an extremely beneficial tool in providing a straightforward way of educating directly the physicians by specialty as to the more specific and complete language and reporting requirements of the ICD-10-CM/PCS code set. Although often we think of the hospital inpatient setting as a primary area for clinical documentation improvement, all healthcare setting (SNF, Rehab, LTC, Ambulatory, etc.) can benefit from documentation improvement awareness and knowledge.
Collaboration between HIM, CDI, and clinicians will bring success now as well as at implementation in 2015 and even beyond. You can obtain the “AHIMA ICD-10 Documentation Tips” through the AHIMA website at: http://bok.ahima.org/PdfView?oid=300621
About the Author
Gloryanne Bryant is a nationally recognized healthcare leader. A sought-after speaker, she is the immediate past president of the California Health Information Association.
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Photo courtesy of: ICD10 Monitor
Originally published on: ICD10 Monitor
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