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What effect will ICD-10 have on the office’s clinical documentation?

Getting ready for ICD-10-CM

A big concern about ICD-10 is how the requirements for clinical documentation will change.

The answer is that the new codes will not change the way a provider documents.

Instead, they call for more information than ICD-9 requires. Yet most of it is information doctors are already documenting.

Generally, the new required information falls into these areas:

– initial encounter

– subsequent encounter

– sequela (or after effect)

– acute

– chronic

– right

– left

– normal healing

– delayed healing

– nonunion of fractures

– malunion of fractures

– trimester of pregnancy

The government recommends that offices look at the documentation the doctors are currently producing for their most common ICD-9 codes. Compare that to what the new codes require and identify the gaps that will have to be filled.

And start filling them now.

On the positive side, the government says that more than one third of the ICD-10 codes are identical to ICD-9 except for showing laterality, or whether the right or left side of the body is affected.

Also, make it clear to the doctors that besides the money loss they will see from denied claims, ICD-10 will increase the risk of fraud and abuse, which the RACs are now pursuing aggressively.

Further, point out that it doesn’t matter whether the doctor is trying to defraud the government or the documentation is too skimpy to support the code. Inadequate documentation brings trouble.

For a good education in what the new codes require, Click Here.

This is the complete guide for using ICD-10. It is produced by the Centers for Medicare and Medicaid Services and the National Center for Health Statistics, and it covers the full picture of the new code system –the overall guides for using the codes as well as directions for the individual coding chapters.

It’s lengthy – 113 pages – but it’s a document every coder should have at hand.

Two urban legends

And here are the latest ICD-10 urban legends.


The first regards the sign/symptom and unspecified codes.

Word has been going around that offices will no longer be able to use those codes with ICD-10 and that as a result, doctors will have to perform unnecessary tests to determine an exact diagnosis.

Not true. Doctors should never perform medically unnecessary tests. And the new codes don’t call for them.

The sign/symptom and unspecified codes get used in ICD-10 just as they do in ICD-9.

The rule remains: while an encounter has to be coded to the highest level of certainty, sometimes there’s not enough information to assign a specific diagnosis. That might happen, for example, when there is a diagnosis of pneumonia but the specific type has not been determined.

In that case, a sign/symptom or unspecified code is the best information available.


The second regards the external cause codes. And the legend is that ICD-10 requires them, which means doctors will have to provide documentation that isn’t strictly necessary.

Again, not true. The external cause codes aren’t required in ICD-9, and they aren’t required in ICD-10. There may be payer-specific or state requirements to that effect, but not from the code systems themselves.

If the office is not coding external causes now, it won’t have to do so with ICD-10.

However, it is good practice to use those codes, because they provide data for research in injuries and injury prevention.









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