Updated on: November 28, 2016

Eight Areas of Focus for Better ICD-10 Documentation

Original story posted on: December 14, 2015

If you don’t read anything else this holiday season, read this. Documentation improvement is at the heart of any successful ICD-10 coding program, and in this article I will highlight eight key areas of focus about ICD-10 and clinical documentation improvement (CDI).


1) Coding guidelines. While the majority of guidelines are unchanged in ICD-10, one in particular stands out: “a symptom(s) followed by contrasting/comparative diagnosis guideline has been deleted effective Oct. 1, 2014.”

The Centers for Medicare & Medicaid Services (CMS) does not want us reporting symptomology when the patient has a more definitive diagnosis. To be fair, Coding Clinic as well as the guidelines have been instructing us NOT to use symptoms when we had more definitive diagnoses for years; however, the overall guidelines still had this outdated rule up until the ICD-10 guidelines were published. It’s nice to see CMS finally eliminating this inconsistency. No longer does a patient who has “syncope due to either bradycardia or diabetic hypoglycemia” get reported with a principal diagnosis of “syncope.” 

2) Coding Clinic. As we move farther and farther into ICD-10, Coding Clinic will become more and more important as a tool to stay on top of the state of ICD-10 coding. Here are some of the lessons learned from recent editions that you need to know now: 

  • Diabetes and osteomyelitis are no longer an assumed relationship.
  • SIRS due to an infection (example: “SIRS due to pneumonia”) is NOT sufficient documentation for sepsis.
  • Acute cor pulmonale cannot be coded in the absence of an acute pulmonary embolism, only chronic cor pulmonale can be.
  • The Glascow coma scale CAN be captured from the EMT documentation as well as “other nonphysician documentation.”
  • Acute and sub-acute hepatic failure (Code K72.00) should be coded to add severity to patients with acute non-viral hepatitis.
  • According to CMS, it is entirely appropriate to report metabolic encephalopathy (Code G94.14) in a patient who is suffering from hypoglycemic induced confusion as a result of diabetic hypoglycemia.
  • Right sided weakness is coded right sided hemiparesis (Code I69.351) when a patient has unilateral weakness as a long term sequela of a stroke.

3) CMS add-on payments associated with new technology: A total of seven approved new technology add-on payments are at play for the coming fiscal year:

  • CardioMEMS Heart Failure Monitoring System, ICD-10 PCS Code 02HQ30Z,   Payment: $8,875. 
  • MitraClip System for cardiac valvular repair, ICD-10 PCS Code 02UG3JZ. Payment: $15,000.
  • Lutonix drug-coated balloon for PTA and PTCA, 36 Codes in total, many of which were added last-minute. How last-minute? They were released by CMS on Oct. 1. Payment: $1,035.72.
  • Argus II Retinal Prosthesis System, ICD-10 PCS Code 08H005Z and 08H105Z. Payment: $72,028.75.
  • Blincyto medication for ALL, ICD-10 PCS Code XW03351 and XW04351. Payment: $27,017.80.
  • Neuropace RNS System Neurostimulator for Epilepsy, ICD-10 PCS Codes 0NH00NZ and 00H00MZ. Payment: $18,474.
  • Kcentra Coumadin Reversal Medication, ICD-10 PCS Code 30283B1. Payment $1,587.50. 

4) What’s gone?

  • Accelerated /malignant hypertension
  • Hepatic encephalopathy
  • Diabetes uncontrolled has been replaced by diabetes, currently hyperglycemic or hypoglycemic. 
  • DRGs 237 and 238: major cardiac procedures with/without an MCC 

5) What’s changed? 

  • PVD has switched from defaulting to a venous code to an arterial code.
  • SVT has gone from being an unspecified cardiac dysrhythmia to actually capturing the correct diagnosis (also now a CC).
  • A repeat MI has changed from eight weeks to 28 days and may provide an MCC as a secondary diagnosis as long as the principal isn’t also a cardiac diagnosis.
  • Multiple significant trauma only requires two rib fractures instead of three.
  • Anemia with cancer now codes to a principal diagnosis of cancer. 
  • Ventilation hours is now broken up into 3 codes: < 24 hours, 24-96 hours and > 96 hours.

6) What’s new? 

  • Persistent Afib (CC)
  • Chronic pulmonary insufficiency following surgery (MCC)
  • Sundowning as well as delirium superimposed on a chronic dementia, which is a CC (FO5 acute infective psychosis)
  • In rare circumstances, a principal diagnosis can qualify as an MCC. Examples include traumatic cerebral edema, saddle pulmonary embolism with acute cor pulmonale, CMV pancreatitis, and candial sepsis.
  • We also have codes that qualify as a CC when listed as the principal diagnosis: diverticulosis with perforation and abscess, CMV hepatitis, and hydronephrosis with ureteral stricture.
  • Non-pressure ulcers of the thigh, calf, ankle, heel, midfoot, and lower leg may provide a CC opportunity when the wound character is described in the record (breakdown of skin, fat layer exposed, necrosis of muscle, necrosis of bone, etc.).  
  • DRGs 268 and 269: aortic and heart assist procedures except pulsation balloon with/without an MCC as well as DRGs 273 and 274: percutaneous intracardiac procedures (with and without an MCC) have been added.

7) Combo codes.

  • A COPD patient receiving antibiotics may not have pneumonia, but the combination code for COPD with acute lower respiratory tract infection is a CC. 
  • CAD with angina is now a combination code, which may include a CC component.
  • Combo codes specifying a CVA as well as the specific site of the cerebral lesion are a part of ICD-10.
  • Combo codes for an MI that reflects the site of the occlusion in an ST elevated MI. 

8) ICD-10 procedures that cause inappropriate DRG shifts (CDI has no ability to impact):

Example 1

  • ICD-9: Alcoholic cirrhosis of the liver with bleeding esophageal varices and endoscopic excision/destruction of lesion/tissue of esophagus: DRG 432: Cirrhosis & Alcoholic Hepatitis With MCC
  • ICD-10: Alcoholic cirrhosis of liver and secondary esophageal varices with bleeding and an occlusion of esophageal vein with extra-luminal device, percutaneous endoscopic approach: DRG 981 Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC. 

Example 2

  • ICD-9: Morbid obesity with laparoscopic gastric banding: DRG 619 to 621 OR Procedures for Obesity
  • ICD-10: Morbid obesity with alveolar hypoventilation and restriction of stomach with extra-luminal device, percutaneous endoscopic approach: DRG 989.  Non Extensive OR Procedure Unrelated to Principal diagnosis.

There are certainly a number of bullet points in this summation that could merit their own write-up, and several of the broad sections listed above could easily be turned into hour-long educational presentations. 2016 will be a critical year for CDI specialists to pay very close attention to Coding Clinic as well as quirks in how the documentation gets translated into DRGs and ICD-10 codes. As we move forward into the coming year, the types of queries necessary to produce quality data collection will continue to evolve.

More than any year in recent memory, both CDS and coders will need to approach each new day as an educational opportunity. If there are any CDI or coding directors out there who had been looking for an excuse to institute mandatory regular coding or CDS meetings, you now have it, especially when the quarterly coding clinics are issued.


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.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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