June 10, 2011

NPPs and ICD-10: Performing a Baseline Medical Record Documentation Assessment


EDITOR’S NOTE: This is a continuation of an article from Michael G. Calahan appearing in last month’s edition of ICD-10monitor e-news entitled, “It’s Time to Get to Work!”

Last month we provided an introduction into how practice NPPs (physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, nurse midwives) can assist in the ICD-10 conversion process preliminarily without the benefit of having gone through ICD-10-CM classes and without access to special ICD-10 software. This preliminary preparation step involves the performance of a baseline medical record (MR) documentation assessment. The practice NPP is perfectly suited to perform or assist with this endeavor.

The baseline assessment will help expose areas where a practice’s various providers might need to shore up their MR documentation so practical conversion from ICD-9 to ICD-10 will be more efficient. Various additional benefits can be realized as well: as you perform the MR documentation assessment you may come across missed opportunities (that is, services that should have been “captured” but were missed) as well as services reported but under-documented enough so that the billing for these services could be questioned by an outside reviewer such as an OIG, RAC or CERT auditor. The focus, however, will be on the documentation of diagnostic statements supporting the final assigned ICD-9-CM codes and how well that documentation would support the ICD-10-CM codes. Case selection, or determining what dates of service to review (as stated in last month’s article) should be accomplished by analyzing frequency reports generated by a billing software system to assess, at a minimum, the top 25 ICD-9-CM codes reported to payers during the last year.

Source Documents

In preparing source documents for the MR documentation review, remember that the final reported ICD-9-CM codes for each selected case may need to be compared with information contained in the practice superbills or encounter forms (also known as “charge tickets”), since physician practices often utilize this type of form as a charge-capture tool.

This form is typically the source document and data facilitator for billing information, which in turn gets translated to the CMS-1500 claim forms submitted to payers for reimbursement. However, errors in the translation of data from the MR documentation to the superbill are not rare. And even though this is a documentation review for ICD-9-to-ICD-10 comparison purposes, the CMS-1500 claim forms for each date of service also should be on hand.

The CMS-1500 claim forms are important source documents that can be used for comparing what was reported to the payers versus what the MR documentation states as actual case data. The true crux of an audit is ultimately a comparison of the MR documentation against the CMS-1500 claim forms.

At a minimum then, you will require the following source documents to carry out a full MR documentation assessment for diagnosis comparison purposes:

- Original MR documentation (i.e. an office visit note)
- Ancillary documents such as provider orders, operative reports, pathology reports, radiology reports, etc., if germane to the office visit
- Practice superbills or encounter forms (i.e. the “charge tickets”)
- CMS-1500 claim form copies.

To perform a comparison and contrast of ICD-9-CM-to-ICD-10-CM codes, an ICD-10 tool also will be needed. This can be a pre-2013 ICD-10-CM book, an encoder with ICD-10 mapping or the public CMS files that include listings of the ICD-10-CM/PCS codes as well as “GEM” files (general equivalency mapping spreadsheets) that tie ICD-9 and ICD-10 together.

Review Process

It’s time to begin the review. Select a patient date of service, arranging in front of you the original MR documentation, ancillary documents, the superbill and a copy of the CMS-1500 claim form. Scan the progress (office visit) note for the recorded diagnostic data. Most of the current reportable ICD-9-CM codes found on the CMS-1500 claim form and encircled on the practice superbill will arise out of the diagnostic statement(s) listed under the “assessment” section (if providers follow the SOAP note format), or alternatively this section can be labeled “impressions” or “diagnoses.” There should be uniformity in terms of provider note organization and final documentation of patient data.


Also scan the ”history” section of the office visit note. Within the history component of the typical patient office encounter you will find four distinct elements required to be documented for most evaluation and management (E/M) services: chief complaint (CC); review of systems (ROS); past, family and social history (PFSH); and history of present illness (HPI). A chronic but current/ongoing diagnosis impacting current care also commonly will be listed within the elements of the history, but not carried down or relisted in the diagnostic area found under the assessment section.  This practice should be avoided as it is often confusing for coders as well as outside medical reviewers. Chronic but ongoing (and therefore reportable) diagnoses frequently are missed when they are buried in the history component of an E/M service file and not relisted under the assessment.

At this juncture let’s look at a case study to demonstrate the comparison process. For illustration purposes we will use a patient with essential hypertension (HTN) coded to ICD-9-CM code 401.9; consider that no other ICD-9-CM codes were assigned or are listed on the CMS-1500 claim form for this particular office visit. In this scenario the patient’s CC is “Here for F/U of HTN,” and in fact the “impression” line states “HTN, doing well on current meds.” However, the patient also has generalized osteoarthritis and is undergoing active treatment for this condition, as evidenced by a note under the “plan” section reading “Increase Celebrex to 100mg b.i.d.” A quick glance at the history reveals the physician had documented a correlating diagnosis in the ROS as “Musculoskeletal - gen OA w/noctural multi-jt. pain.” Your conclusion in reviewing these notes is that the OA did in fact impact the current date of service, and therefore two diagnoses for this office visit should have been coded: the HTN and the OA.

In relation to the hypertension, there is no annotation or indication of concurrent hypertensive heart disease or chronic kidney disease (or any combination thereof): it is strictly noted as “HTN.” Under the current ICD-9-CM coding structure, because the descriptor “benign” (ICD-9-CM code 401.1) or “malignant” (ICD-9-CM code 401.0) was not recorded in the MR documentation along with the acronym “HTN,” the official coding guidelines and instructions state that the unspecified ICD-9-CM code 401.9 must be reported for “essential hypertension.” Now compare this code with the anticipated requirements and information under ICD-10-CM. Utilize your ICD-10 tool to locate the code for essential hypertension and you find a small surprise: in ICD-10-CM the descriptors “benign” and malignant” no longer apply. The full description mapped to the current ICD-9-CM essential hypertension code series (401.0, 401.1 and 401.9) match up to “I10 Essential (Primary) Hypertension” (see table). What will be required in this case in terms of MR documentation for accurate ICD-10-CM coding of the recorded information? First, establishing the hypertension as “essential” appears tantamount to getting it coded correctly.

This baseline classification should be established in the MR documentation in a highly visible area at some point even if it is not repeated each and every time the hypertension is recorded. Secondly, ensuring that the current state of hypertension is not connected etiologically to hypertensive heart disease, chronic kidney disease or a combination of these two is vital for correct coding (these conditions map to other ICD-10-CM codes).


ICD-9-CM Code

Current Descriptor

ICD-10-CM Code

I-10 Descriptor




Essential hypertension: malignant, benign, unspecified



Essential (primary) hypertension


For the generalized osteoarthritis (OA) that you have uncovered as not being reported but clearly documented and impacting current care, the ICD-9-CM code based on the MR documentation should be “715.00 Generalized osteoarthrosis, unspecified site.” (Note: if the adjective “generalized” was not noted in the MR documentation, then ICD-9-CM code “715.90 Osteoarthrosis, unspecified whether generalized or localized, unspecified site” would be assigned in this case.) Each of these descriptions for OA (715.00 and 715.90) maps to ICD-10-CM code M15.9 Polyosteoarthritis, unspecified.


However, it should be noted ICD-9-CM code 715.90 dually maps to ICD-10-CM code “M19.90 Unspecified osteoarthritis, unspecified site” as well. This particular ICD-10-CM code encompasses numerous other, more specific ICD-9-CM codes for various joints afflicted with OA, whether localized or not specified as “generalized or localized” (see table below). The analysis reveals that osteoarthritis, depending on how specific the provider has been in his or her documentation, can be coded in several ways under ICD-10-CM. As with ICD-9-CM coding now, the more specific the MR documentation, the more accurate the coding – and this holds true in ICD-10-CM coding.


ICD-9-CM Code

Current Descriptor

ICD-10-CM Code

I-10 Descriptor


Generalized OA, unspecified site


Polyosteoarthritis, unspecified


OA, unspecified whether localized or generalized, unspecified site


Polyosteoarthritis, unspecified

715.30, 715.31, 715.32, 715.33, 715.37, 715.38, 715.90, 715.91, 715.92, 715.93, 715.97, 715.98,

(715.3x series) Localized OA not specified whether primary or secondary, unspecified site,  -shoulder region, -upper arm, -forearm, -ankle and foot, -other specified sites;     (715.9x series) OA, unspecified whether generalized or localized, unspecified site, -shoulder region, -upper arm, -forearm, -ankle and foot, -other specified sites


Unspecified osteoarthritis, unspecified site


Your Findings

As the NPP “auditor,” you have found upon comparison of the MR documentation to the CMS-1500 claim form that the ICD-9-CM code for OA was not reported at all, and you further find that it was not even encircled on the practice superbill. The lesson buried in this for providers? The MR documentation should be as clear, concise and explicit as possible, especially when summarizing impressions or diagnoses. The lesson herein for coders is that there often is corroborating information between the history and plan sections of the note, and both should be reviewed for possible “missed diagnosis opportunities” for ICD-9 and ICD-10 coding purposes. Lastly, do not rely solely on the superbills for diagnostic information.

Delineating between old (past or no longer under treatment) and current (new or ongoing conditions that impact care) diagnoses is important so that practice coders can benefit from nicely detailed and organized MR documentation. The common denominator in deciding if a diagnosis should be coded for the current encounter is if it impacts care in some way; the condition must be demonstrated in the note to have been evaluated, assessed, managed and/or treated to some extent. This can be accomplished by straightforward statements such as “no change in hypertension; current regimen to be continued,” or it can be made clear by more unassuming statements such as that outlined in the above scenario: “Increase Celebrex to 100mg b.i.d.”


If unconfirmed diagnostic statements are made, such as “ruled out,” “probable,” or “suspected,” then the patient’s signs and symptoms should be demarcated clearly in the notes so the practice coders can assign appropriate ICD-9-CM codes (and, in the future, ICD-10-CM codes) to represent fully the signs and symptoms prompting the patient’s office visit.

General documentation standards should be reviewed while assessing the status of the MR documentation. These standards include legibility, provider signature/authentication, identification/credentials of annotations made by non-provider staff and adequate patient identifiers, including patient name, MR number (if used), date of service, time (if timed services such as prolonged care are being provided), etc.

In many instances ICD-10-CM promises to demand greater specificity on diagnosis code descriptions and assignment, therefore a correlating level of specificity is expected to be found in the MR documentation. Performing a baseline audit and having the practice NPP perform or assist with this audit is often a rewarding exercise.  We will explore more complex “greater specificity” ICD-10-CM coding scenarios in upcoming articles.

About the Author

Michael G. Calahan, PA, MBA, is the director of physician services at KForce Healthcare, Inc. Michael has more than 25 years of experience in health care, beginning as a physician assistant with the USN. He has served as an administrator for several physician practices and has enjoyed a varied career in healthcare consulting, being affiliated with Ingenix, CGI, Navigant, PWC and Parente-Randolph. He has authored numerous industry publications and articles in physician, IP/OP/ASC, DMEPOS, ESRD, HHA, ambulance, HIPAA and in Medicare Parts C & D for Medicare Advantage.

Contact the Author

Read 389 times Updated on September 23, 2013
Michael Calahan, PA, MBA

Michael G. Calahan, PA, MBA, is the vice president of hospital and physician compliance for HealthCare Consulting Solutions (HCS). Michael lives and works in the Washington, D.C. metro area, specializing in compliance, revenue cycle management, CDI, and coding/billing in the facility inpatient/outpatient and physician arenas.