Updated on: March 16, 2016

Clinical Documentation Improvement by Service – The Introduction

Original story posted on: June 23, 2014

EDITOR’S NOTE: This article marks the beginning of a series of articles on clinical documentation improvement by clinical service.

Changes associated with switching from ICD-9-CM to ICD-10-CM/PCS typically are reviewed in total and discussed service by service. When reviewing by individual services, the variances between the two classification systems will not be so daunting.


The services that will be covered will include:

  • Cardiology/Cardiovascular Surgery
  • Pulmonology
  • Musculoskeletal
  • Pregnancy
  • Pediatrics
  • Oncology/Hematology         
  • Emergency Medicine
  • Infectious Diseases
  • Behavioral Medicine
  • Gastroenterology
  • Ear, Nose, and Throat (ENT) Conditions
  • Dermatology
  • Urology

In general, ICD-10-CM/PCS is more specific than ICD-9-CM. ICD-10-CM/PCS clinical documentation should indicate acute versus chronic, laterality, condition severity (i.e. stages), devices that are implanted, procedure approaches, etc. The documentation rules for ICD-10-CM/PCS are also appropriate for ICD-9-CM, but the classification systems reflect the information differently. ICD-10-CM/PCS can reflect additional specificity.

According to the October 2013 issue of Becker’s Hospital Review, septicemia is the most expensive diagnosis to treat, generating annual costs of $20.3 billion in the U.S. How do documentation requirements for septicemia vary between ICD-9-CM and ICD-10-CM? In ICD-9-CM, the coder would review the medical record for an organism causing the infection, the presence of systemic inflammatory response syndrome (SIRS), and associated acute organ dysfunction.

In ICD-10-CM, the process remains the same. The only difference between the two classification systems is the lack of a specific code for septic shock (ICD-10-CM combines septic shock with SIRS, R65.21). SIRS also has moved from the chapter on complications to Chapter 18 (Signs, Symptoms, and Ill-Defined Conditions).   

Another frequently encountered infectious disease is acquired immunodeficiency syndrome (AIDS).  There continues to be similarity between ICD-9-CM and ICD-10 in documenting this. The provider should be very clear regarding the status of this disease. The coder will assign a human immunodeficiency virus (HIV) code only if the diagnosis is confirmed. If the patient is only HIV-positive, he or she would be coded as Z21 (in ICD-9-CM, V08). A patient that has progressed to AIDS is coded as B20 (in ICD-9-CM, 042). Once a patient becomes symptomatic, he or she will always be coded as having AIDS.

The key to HIV documentation is the clear indication as to whether the patient is asymptomatic or symptomatic. The documentation challenge is the same in ICD-9-CM.

Infections may be documented with an instructional note, which can be used to add an additional code to specify the organism. Such notes are used in ICD-9-CM as well as ICD-10-CM. For example, documentation of a urinary tract infection (N39.0) can have the instructional note of “use additional code (B95-B97) to identify infectious agent.” This same instruction appears in ICD-9-CM as “use additional code to identify the organism.” The provider should indicate the significance of the organism in the clinical documentation. There is a difference in coding drug-resistant infections, however. ICD-9-CM incorporates drug resistance into the organism. ICD-10-CM has a category (Z16) that indicates drug resistance to a drug category. Drug resistance will require two codes in ICD-10-CM. There is an instructional note to code the infection first, yet the difference in the coding process will not impact the type of clinical documentation.

It is evident in the exploration of infectious diseases that clinical documentation requirements have not changed significantly between ICD-9-CM and ICD-10-CM/PCS. Will we continue to see this trend as we explore other services?

The next article will discuss cardiology and cardiovascular surgery.

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.
Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.

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