Updated on: March 14, 2016

AHIMA Releases Helpful ICD-10-CM/PCS Documentation Tips for the Industry

Original story posted on: October 13, 2014

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 In addition, ICD-9 is very outdated in regards to the current medical technology and terminology code capture.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

References: 2014 ICD-10-CM Codebook; 2014 ICD-10-PCS Codebook; www.CMS.gov/ICD-10

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Gloryanne Bryant is an independent health information management (HIM) coding compliance consultant with more than 40 years of experience in the field. She appears on Talk Ten Tuesdays on a regular basis and is a member of the ICD10monitor editorial board.

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