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ICD-10: Addressing the Top Ten
Documentation Issues
Michael Powell, MD – Physician Consultant,
3M Health Information Systems
Donna M. Smith, RHIA – Senior Consultant,
3M Health Information Systems
Key Documentation Education
Opportunities
• Top 10 documentation issues related to ICD-10
– Diabetes mellitus
– Injuries
– Drug underdosing
– Cerebral infarctions
– AMI
– Neoplasms
– Musculoskeletal conditions
– Pregnancy
– Respiratory/vents
– ICD-10-PCS
Complete and Accurate Documentation
and Coding: Example: Diabetes Mellitus
ICD-9-CM
Diabetes
59 codes (249-250)
ICD-10-CM
Diabetes
200+ codes (E08-E13)
Including:
E1121 Type 2 diabetes with
diabetic nephropathy
E1122 Type 2 diabetes with
chronic kidney disease
E1129 Type 2 diabetes with
other kidney complications
E11321 Type 2 diabetes with
mild nonproliferative
retinopathy with macular
edema
E11621 Type 2 diabetes with
foot ulcer
E11649 Type 2 diabetes with
hypoglycemia without coma
 Diabetes documentation and coding will need
to include:
 Type or cause of diabetes




Type I
Type 2
Due to drugs or chemicals
Due to other cause
 Body system complications related to diabetes
 Nephropathy
 Neuropathy
 Specific complication, such as:




Chronic kidney disease
Proliferative diabetic retinopathy with macular edema
Foot ulcer
Hypoglycemia without coma
4
Complete and Accurate Documentation
and Coding: Example: Injuries
• Injuries
– Injuries have a 7th character extension to identify the encounter type, with
“A” as initial encounter and “D” for subsequent encounter
• Fractures
– Fractures have a unique 7th character extension, which indicates open or
closed fracture, initial or subsequent encounter with delayed healing,
malunion or nonunion
– Specificity – type of fracture
• Oblique
• Comminuted
• Transverse
• Displaced
– Laterality
• Lacerations/contusions (internal organs)
– Minor – length and depth
– Moderate – length and depth
– Major – length and depth
Complete and Accurate Documentation
and Coding: Example: Fractures
ICD-10-CM
ICD-9-CM
821.01 Fracture of
femur, shaft, closed
S72301A Unspecified fracture
of shaft of right femur, initial
encounter for closed fracture
S72322A Displaced
transverse fracture of shaft of
left femur, initial encounter
for closed fracture
S72326A Nondisplaced
transverse fracture of shaft of
unspecified femur, initial
encounter for closed fracture
S72301G Unspecified fracture
of shaft of right femur,
subsequent encounter for
closed fracture with delayed
healing
S72322G Displaced
transverse fracture of shaft of
left femur, subsequent
encounter for closed fracture
with delayed healing
S72326G Nondisplaced
transverse fracture of shaft of
unspecified femur, subsequent
encounter for closed fracture
with delayed healing
S72302A Unspecified fracture
of shaft of left femur, initial
encounter for closed fracture
S72323A Displaced
transverse fracture of shaft of
unspecified femur, initial
encounter for closed fracture
S72331A Displaced oblique
fracture of shaft of right femur,
initial encounter for closed
fracture
S72302G Unspecified fracture
of shaft of left femur,
subsequent encounter for
closed fracture with delayed
healing
S72323G Displaced
transverse fracture of shaft of
unspecified femur,
subsequent encounter for
closed fracture with delayed
healing
S72331G Displaced oblique
fracture of shaft of right femur,
subsequent encounter for
closed fracture with delayed
healing
S72309A Unspecified fracture
of shaft of unspecified femur,
initial encounter for closed
fracture
S72324A Nondisplaced
transverse fracture of shaft of
right femur, initial encounter
for closed fracture
S72332A Displaced oblique
fracture of shaft of left femur,
initial encounter for closed
fracture
S72309G Unspecified fracture
of shaft of unspecified femur,
subsequent encounter for
closed fracture with delayed
healing
S72324G Nondisplaced
transverse fracture of shaft of
right femur, subsequent
encounter for closed fracture
with delayed healing
S72332G Displaced oblique
fracture of shaft of left femur,
subsequent encounter for
closed fracture with delayed
healing
S72321A Displaced
transverse fracture of shaft of
right femur, initial encounter
for closed fracture
S72325A Nondisplaced
transverse fracture of shaft of
left femur, initial encounter
for closed fracture
S72333A Displaced oblique
fracture of shaft of unspecified
femur, initial encounter for
closed fracture
S72321G Displaced
transverse fracture of shaft of
right femur, subsequent
encounter for closed fracture
with delayed healing
S72325G Nondisplaced
transverse fracture of shaft of
left femur, subsequent
encounter for closed fracture
with delayed healing
S72333G Displaced oblique
fracture of shaft of unspecified
femur, subsequent encounter
for closed fracture with
delayed healing
Many possible codes
Complete and Accurate Documentation
and Coding: Example: Drug Underdosing
• Underdosing – New to ICD-10
– Combination codes exist that can identify a situation where a
patient has taken less of a medication than prescribed, as well as
the specific drug. The medical condition is sequenced first with
the underdosing code listed as a secondary diagnosis.
– Intentional vs. unintentional.
– Underdose of insulin due to an insulin pump failure – Mechanical
compilation of other specified internal and external prosthetic
devices, implants and grafts followed by underdosing conditions.
Complete and Accurate Documentation
and Coding: Example: Cerebral Infarction
• Cerebral infarction
– Specificity related to:
• Specific artery involvement
– Vertebral artery
– Carotid artery
– Cerebellar artery
• tPA (rtPA) given in a different facility within 24 hours
• Glasgow Coma Scale
• Laterality
Complete and Accurate Documentation and
Coding: Example: Myocardial Infarction
ICD-9-CM
Acute Myocardial Infarction
10 codes (410.01-410.91)
ICD-10-CM
Myocardial Infarction
9 codes for initial (I21) and 5 codes for
subsequent (I22)
Including:
I21.01 STEMI myocardial infarction
involving the anterior wall with left
main coronary artery involvement
I21.02 STEMI myocardial infarction
involving the anterior wall with left
anterior descending coronary artery
involvement
I21.09 STEMI myocardial infarction
involving other coronary artery of
anterior wall
I22.0 Subsequent STEMI of anterior
wall (within 4 weeks of initial MI)
•
Myocardial infarction documentation and
coding will need to include:
• Type of infarction
• STEMI
• NSTEMI
• Age of infarction
• If within 4 weeks coded as initial
• If older than 4 weeks coded as
“old”
• Specific site of myocardium involved
• Anterior wall
• Inferior wall
• Coronary artery involved
• Information regarding initial or
subsequent MI within 4 weeks
Complete and Accurate Documentation
and Coding: Example: Neoplasms
• Neoplasms
– Specificity related to:
• Anemia due to Neoplasms – Anemia associated with malignancy is
sequenced as a secondary diagnosis with the malignancy sequenced
as principal
• Pathological fractures due to neoplasms
• Overlapping sites
• Laterality
Complete and Accurate Documentation
and Coding: Example: Pathologic Fracture
ICD-9-CM
Pathologic Fracture
8 codes (733.13-733.19)
ICD-10-CM
Pathologic Fracture
150 + codes (M80-M84)
Including:
M8008xA Age-related
osteoporosis with current
pathological fracture, vertebra,
initial encounter for fracture
M80051A Age-related
osteoporosis with current
pathological fracture, right
humerus, initial encounter for
fracture
M8458xA Pathological fracture in
neoplastic disease, vertebra,
initial encounter for fracture
• Pathologic fracture documentation and
coding will need to include:
– Exact location of fracture
 Site
 Laterality
– Etiology of fracture
 Osteoporosis
 Neoplastic disease
– Encounter type
 Initial encounter for fracture
 Subsequent encounter for fracture
 Subsequent encounter for fracture with delayed
healing
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Complete and Accurate Documentation and
Coding: Example: Musculoskeletal conditions
• Osteoarthritis, gout, rheumatoid arthritis,
osteonecrosis, etc., all need specificity of exact
site and laterality
• Linkage to cause of disease process
– Gout due to renal impairment
– Drug-induced gout
– Post-traumatic osteoarthritis
– Primary osteoarthritis
• Specificity of other organ involvement
– Rheumatoid lung with arthritis of right wrist
Complete and Accurate Documentation
and Coding: Example: Pregnancy
• Pregnancy
– Specificity related to:
• Trimester – Pregnancy codes have a final character indicating the
trimester for the current encounter
– 1st Trimester – less than 14 weeks, 0 days
– 2nd Trimester – 14 weeks 0 days to less than 28 weeks 0 days
– 3rd Trimester – 28 weeks 9 days until delivery
• Gestational diabetes – documentation of diet controlled or insulin
controlled is required to appropriately classify this condition
– If both diet and insulin controlled, only insulin controlled will be used in
the coding process
– Only present in the second or third trimester
• Puerperal sepsis
– Causal organism should be documented
– Documentation of severe sepsis and organ dysfunction is required (if
present)
Complete and Accurate Documentation and
Coding: Example: Respiratory/Ventilators
• Respiratory/ventilators
– Specificity related to:
• Ventilators
– Less than 24 consecutive hours
– 24–96 consecutive hours
– Greater than 96 consecutive hours
• Pneumonia – Ventilator-associated pneumonia; requires
additional reporting of type of pneumonia
• Acute pulmonary insufficiency
– Following thoracic surgery (MCC)
– Following non-thoracic surgery (MCC)
– Following shock or trauma (CC)
• Respiratory insufficiency – just a symptom
Impact:
Procedure codes standardized/provide additional
specificity
Benefit:
Ability to capture new medical advances and
technology
ICD-10-PCS
Each code tells a story:
Body
System
Section
0
Root
Operation
Body
Part
Approach
B
6
8
D
Excision
Z
Transorifice
Intraluminal
Endoscopic
Med-Surg
Gastrointestinal
Device
Stomach
A character is a stable, standardized code component
Holds a fixed place in the code
Retains its meaning across a range of codes
A value is an individual unit defined for each character
Qualifier
X
Diagnostic
None
Complete and Accurate Documentation
and Coding: Example: Root Operations
• Root operation examples
– Excision: “Cutting out or off, without replacement, a
portion of a body part”
– Resection: “Cutting out or off, without replacement, all
of a body part”
– Dilation: “Expanding an orifice or the lumen of a
tubular body part”
– Extirpation: “Taking or cutting out solid matter from a
body part”
– Extraction: “Pulling or stripping out or off all or a
portion of a body part by the use of force”
ICD-10 Physician Education
• Physician education methodologies/timing
– ICD-10 improvements
– Current education
– Who to educate
– Who does the education
– Timing
– Venues
– Teaching tools
ICD-10 Physician Education
• ICD-10 improvements
– Updated medical terminology more consistent with the 21st
century:
• More specific relative to anatomy and pathophysiology
• More adaptable to IT
– Increased specificity in clinical terminology also allows for
improved medical necessity information and overall
consistency and accuracy of data collection
– Improved data allows for more accurate:
• SOI and expected mortality reflections – profiling
• Reimbursement for services provided
ICD-10 Physician Education
• Physician education methodologies/timing
– Current education
• Complete and accurate documentation
– Specificity required by ICD-10 will likely increase the volume of
queries to achieve complete documentation
• ICD-10 – raising the bar
– Requires more stringent documentation
The Need
Unable to code
Able to code
Multisystem organ failure
Liver failure, renal failure
Severe respiratory distress
Respiratory failure – acute, acute on chronic
Hemodynamically unstable
Hypotension, CHF, cardiogenic shock
Will rehydrate
Dehydration, hypovolenia
Rhythm stable today
Ventricular tachycardia
Unable to void
Urinary retention
K + 2.0, will give KCL
Hypokalemia
LLL infiltrate, will give IV ABX
LLL pneumonia
Hgb 5.2, transfuse
Acute or chronic blood loss anemia
Emaciated, total protein/albumin
Severe protein-calorie malnutrition
Low, nutrition supplements started
Secondary Diagnoses
• For reporting purposes, the definition for “other
diagnoses” is interpreted as additional
conditions that affect patient care in terms of
requiring at least one of the following:
– Clinical evaluation
– Therapeutic treatment
– Diagnostic procedures
– Extended length of hospital stay
– Increased nursing care and/or monitoring
Probable, Possible, Suspected,
Clinical, or Unable to Rule Out
• Inpatient application:
– Code these conditions as though they exist – applies to hospital
setting only
– If condition is ruled out, it may not be coded
• Outpatient application:
– Must code signs/symptoms, not the suspected condition
• Note: When ordering ancillary tests (EKG, radiology, anatomical
pathology, etc.), use signs and symptoms to indicate medical
necessity
Chest Pain Alternatives
Anxiety
MS-DRG 880
RW = 0.6191
Biliary Colic
MS-DRGs
444/445/446
RW = 1.5055
Psychogenic
Angina
Pericarditis
MS-DRGs
314/315/316
RW = 1.7589
Cardiac Cath
MS-DRGs
286/287
RW = 1.9634
GERD
Gastritis
MS-DRGs
391/392
RW = 1.0958
Anterior CP
Pleuritic CP
Chest Wall Pain
MS-DRG 204
RW = 0.6472
Costochondritis
Tietze’s Disease
MS-DRGs
205/206
RW = 1.2566
Chest Pain
MS-DRG 313
RW = 0.5404
Pleurisy
MS-DRGs
193/194/195
RW = 1.4378
Pulmonary
Embolism
MS-DRGs
175/176
RW = 1.6121
Psychogenic
Chest Pain
MS-DRG 882
RW = 0.6676
Shingles
MS-DRGs
595/596
RW = 1.7691
CAD
MS-DRGs
302/303
RW = 0.9999
Angina
MS-DRG 311
RW = 0.5128
Cardiac
Arrhythmia
MS-DRGs
308/309/310
RW = 1.2188
Specificity and Severity of Illness
Diagnosis
Acute systolic and/or diastolic heart failure
Extreme
Moderate
X
Congestive heart failure
Decubitus ulcer Stage III or IV
X
X
Decubitus ulcer (site not specified)
X
COPD with acute exacerbation
X
COPD
Acute renal failure secondary to ATN or ESRD
X
X
Acute renal insufficiency
X
Acute blood loss anemia
X
Chronic blood loss anemia
Severe protein-calorie malnutrition
Malnutrition
Minor
X
X
X
ICD-10 Physician Education
• Physician education methodologies/timing
– Who to educate
• CMO/leadership physicians/physician champion
– Qualities:
• Lends credibility and support to the program as an articulate
opinion leader who influences other physicians via
reputation or informal leadership qualities
• May be invited, may emerge, or may be a convert, but has
the courage to take a stand
• Attending physicians
• Resident physicians
• Mid-level professionals
ICD-10 Physician Education
• Physician education methodologies/timing
– Who does the education
• CDIS
• Consultant
• Physician champion
• CMO
• Department chair
• Coder
ICD-10 Physician Education
• Physician education methodologies/timing
– Timing
• Start now
• Coordinate hospital-specific strategies for implementing the
educational process
• Begin specific queries for the increased specificity with ICD-10
coding system – a graduated approach
ICD-10 Physician Education
• Physician education methodologies/timing
– Venues
• One-on-one
• Department/medical staff meetings
• Grand rounds
• Off-site meetings with physicians
ICD-10 Physician Education
• Physician education methodologies/timing
– Teaching tools
• Presentation
• Queries
• Diagnostic profiles – “pocket cards”
• Newsletters
• Documentation posters
• Encoder
• EHR
General Medical
Clinical Statement
Diagnostic Statement
(Documentation needs clarification)
(Accurate ICD-9-CM code can be assigned)
Home medications include Digoxin, Lasix, Imdur, HCTZ, etc. Chronic systolic /diastolic heart failure, CAD, atrial fib, angina,
HTN
LUL infiltrate
Pneumonia, please specify type, if known, (e.g., Klebsiella
pneumonia, aspiration pneumonia, etc.)
Hgb 5.2, will transfuse
Acute or chronic blood loss anemia
Emaciated; total protein/albumin low, nutrition supplements
started
Malnutrition (Please specify type: mild, moderate, severe)
pH = 7.25, pO2 = 58, pCO2 = 52, will treat accordingly
Acute respiratory failure; acidosis
Will rehydrate patient
Dehydration
BP 70/40, on Dopamine for support
Shock (specify type, i.e. cardiogenic, septic, hypovolemic)
Cardiac enzymes elevated, EKG positive
Acute MI, please specify site
CHF
Please specify type e.g., acute/chronic systolic and/or diastolic
heart failure
Unable to void, cathed for 600 cc
Urinary retention
Diagnoses documented solely on diagnostic reports are not “codeable.” The physician must
clinically correlate diagnoses in the body of the medical record with abnormal findings.
General Surgery
Clinical Statement
Diagnostic Statement
(Documentation needs clarification)
(Accurate ICD-9-CM code can be assigned)
Abdomen distended; NPO, NG placed
Ileus
R calf swollen, reddened and tender
Phlebitis; thrombophlebitis; DVT
Fever to 102 S/P appendectomy; patient pancultured,
IV antibiotics given
Sepsis; acute peritonitis
Dysuria, urine culture positive, will treat with
antibiotics
UTI
H&H , will transfuse
Acute or chronic blood loss anemia; expected acute
blood loss anemia
Wound red and indurated, IV antibiotics given
Cellulitis
Debrided wound
Excisional vs. non-excisional debridement and
provide a thorough description of procedure
performed
Continue home meds, Digoxin, Lasix, Imdur, HCTZ,
Dilantin
Document corresponding medical diagnosis, e.g.,
CAD, atrial fib, angina, hypertension, seizure
disorder, chronic systolic heart failure
Unable to void, will insert Foley
Urinary retention; specify cause if known (urinary
retention due to adverse effects of pain meds, etc.)
Urine output , will bolus with IV fluids
Volume depletion; dehydration
 temp,  breath sounds,  ambulation, CXR, will
begin incentive spirometry
Atelectasis
Diagnoses documented solely on diagnostic reports are not “codeable.” The physician must
clinically correlate diagnoses in the body of the medical record with abnormal findings.
Physician Documentation
Guidelines—Pneumonia
• Document type of pneumonia, if known (e.g., aspiration pneumonia,
MRSA pneumonia, pneumonia due to Klebsiella, viral pneumonia).
• Documentation of CAP, HAP, and HCAP can be further specified
with the possible/probable causative organism, if known.
• It is the physician’s responsibility, when cultures reveal the
responsible pathogen, to document the relationship between the
causative organism and the pneumonia (e.g., Klebsiella
pneumonia, pneumonia due to Klebsiella).
• Document “probable,” “suspected,” or “clinical” pneumonia if
treating pneumonia as if present but cannot be confirmed.
To reflect your patient’s true severity of illness, document all
conditions you are treating, evaluating, or monitoring.
Summary
• Transitioning to ICD-10 specificity will be
challenging and will require more complete and
accurate documentation by the physician as
well as a more thorough knowledge of anatomy
and pathophysiology by CDIS nurses and
coders.
• However, the benefits will include a more
complete capture of patient data, which will lend
support to medical necessity, more accurately
reflect severity of illness and expected mortality,
and facilitate appropriate reimbursement.
Questions?