Updated on: November 28, 2016

Surviving in an ICD-10 World

Original story posted on: January 18, 2016

The past few years we have focused closely on getting ready for ICD-10. In most cases, the transition to ICD-10 was successful. We had a few bumps in the road, but overall, things went well. What’s next? Now we need to shift the focus to improve coding and clinical documentation in order to protect revenue. Most payers, including the Centers for Medicare & Medicaid Services (CMS) have given the industry a grace period in which to code to adequate specificity in ICD-10, as long as we are coding in the correct category and laterality is reported. However, this grace period will not last forever.


We now have had a few months to become familiar with the ICD-10 codes and have been relying heavily on electronic health records to select diagnosis codes. The tools in the electronic health record are helpful, but they are just that – tools. We must rely on documentation to support the diagnosis codes and make sure that the provider is reporting to the highest level of specificity.

Time is running out to achieve compliance. Some providers are taking a break and waiting until they must report their diagnoses to proper specificity. This is a huge mistake. It will take time to change documentation and coding patterns, so the sooner you begin to work on improvement, the better for your practice or facility. Payers, including CMS, will begin auditing for specificity and appropriate documentation shortly. And yes, they will ask for money back if you cannot support medical necessity.

Have you performed an ICD-10 assessment of your coding and documentation? If you haven’t, now is the time to begin. It is imperative that we are ready before the storm of additional documentation requests happens in the next few months. Some questions managers have been asking are:

  • How do we perform an ICD-10 assessment?
  • What do I do with the information from the assessment?
  • How will an ICD-10 assessment improve coding and documentation?

How to Perform an ICD-10 Assessment

1.  Run a frequency report of the most common ICD-10 codes that have been reported from Oct. 1, 2015 to date for each individual provider in your practice, or in the facility by coder.

2.  The most frequently used diagnosis codes should be the priority. Begin by randomly sampling 10-20 patient records and audit the claims, looking at the diagnosis code selection along with ensuring that documentation is voluminous enough to support a code to the highest level of specificity.

For example, if the provider indicated that a patient has a pressure ulcer, determine whether the provider has documented the following:

  • Anatomic location
  • Laterality (right versus left)
  • Stage of ulcer
  • Whether gangrene is present.

If the provider has not documented all the elements above, the documentation is not sufficient to report the pressure ulcer to specificity.

3.  Draft a report with the result identifying the documentation and coding that is accurate versus deficient.

4.  Meet with each individual provider and share results and provide documentation and coding education during the meeting.  You should allow for an hour for each provider to answer questions and provide support.

Using the Information from the Assessment

A provider or coder whose compliance falls below 95 percent may need additional training and support.

Auditing, monitoring, and education over time should improve the percentage of coding compliance for any provider and/or coder. It is wise to base auditing and monitoring on the accuracy ratio a provider has during each assessment. For example, a provider that meets a 95 percent or above compliance ratio may not need additional training, but ongoing ICD-10 auditing should continue.

For a provider that falls below the 95 percent standard, continued education should be provided. Keep in mind that ICD-10 is still new, and providers still have a lot of questions and need assistance with coding and documentation requirements.

Remember, a provider and/or coder is struggling with coding and documentation in ICD-10, it is important that additional focused training be provided. Take a look at courses that focus on advanced ICD-10 training or clinical documentation improvement training by specialty. 

Improving Coding and Documentation Based on Results

The best way to improve coding and documentation is to provide education and training annually, at a minimum. A clinical documentation improvement program is essential to managing a successful facility or medical practice. Ongoing auditing and monitoring is critical to identify all risk areas and areas that could benefit from improvement to avoid takebacks from payers.

How often you conduct ICD-10 assessments (audit) depends on the individual provider results. A provider that meets a 95 percent standard might need an audit every six months, but the provider that falls below that ratio might need an audit more frequently. Keep in mind that the purpose of internal audits is to assist the provider to improve coding and documentation, not to penalize.

Remember that clinical documentation improvement is very important to maintain compliance with coding and billing, which:

  • Validates procedures submitted on the claim
  • Ensure accurate payment to the provider
  • Maintains quality reporting
  • Supports medical necessity

Auditing and monitoring is a vital part of compliance programs in Hospitals, medical practices, and other healthcare entities. If you don’t have the necessary staff to conduct an ICD-10 assessment (audit), hire a consultant or auditor who specializes in your specialty. 

Be proactive, and don’t wait until you get a request from a payor to start thinking about your ICD-10 coding and clinical documentation.


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.
Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner

Deborah Grider has 35 years of industry experience and is a recognized national speaker, consultant, and American Medical Association author who has been working with ICD-10 since 1990 and is the author of Preparing for ICD-10, Making the Transition Manageable, Principles of ICD-10, the ICD-10 Workbook, Medical Record Auditor, and Coding with Modifiers for the AMA. She is a senior healthcare consultant with Karen Zupko & Associates. Deborah is also the 2017 American Health Information Management Association (AHIMA) Literacy Legacy Award recipient. She is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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