Updated on: March 14, 2016

The Challenges of Helping Physicians Document with ICD-10

Original story posted on: February 21, 2014

As we move toward the ICD-10 deadline of Oct. 1, 2014, educating physicians and non-physician practitioners regarding documentation requirements is an important step. Right now I and many of my colleagues in the industry have begun training physicians how to document with ICD-10.


All physicians, non-physician practitioners, and other clinical staff will benefit from documentation training. Most practitioners will use their \electronic health record (EHR) or other methods to code in ICD-10. But documentation, as we all know, will be a significant issue. The current state of documentation may not be sufficient for ICD-10. It is important to break down the documentation training by specialty.

The other key issue to address is how electronic health records will look under ICD-10. Will EHRs have the capability to build a logic tree to drill down to more specific diagnoses? Or will the practitioners have a “pick list” when selecting a diagnosis code? From polling numerous physicians and practitioners of various specialties, we know that if they are burdened with a pick list, they will select the initial diagnosis and generally will not search for a more specific diagnosis. For practitioners whose medical records are still on paper, how will they be able to use a superbill with so many diagnosis codes? The key, before even beginning physician documentation training, is to determine how the practitioner will select his or her diagnosis using ICD-10 and to build training to help them achieve compliance based on the practice’s unique circumstances. Before beginning training, it is imperative that the trainer has these key questions answered in order to tailor effective training to the practice.

Sounds simple, right? Training physicians to document with ICD-10 should be a simple process; all it takes is identifying their top diagnoses currently reported and showing them how the documentation should look with ICD-10. Training physicians is not so easy. Physicians and non-physician practitioners have a great deal of questions concerning their evaluation and management service levels as they relate to their diagnoses and management of patient care. It is important to ensure that practitioners understand that medical necessity drives each patient encounter, whether it is an office or hospital visit or a surgical or diagnostic procedure. I am finding that physicians are willing to do whatever they must to achieve compliance as long as it is stressed to them that without the appropriate and specific diagnosis codes submitted for payment, they are subject to takebacks from insurance carriers for not meeting medical necessity criteria. If you don’t stress that point, practitioners are less likely to take ICD-10 seriously. One suggestion is to take a very simple approach of training practitioners on their top 25-30 diagnoses, then identifying what additional diagnosis is required for documentation.

You will discover in some cases that no additional documentation is required, whereas some diagnoses do require more extensive detail in the documentation. It is beneficial to show practitioners which diagnoses require additional documentation and which do not. It is also helpful to show them chart notes side-by-side, comparing ICD-9 and ICD-10 documentation requirements. I always suggest that they take a step-by-step approach. Instead of trying to meet ICD-10 documentation requirements for all of their top diagnoses, all at once, ask practitioners to take one diagnosis a week and begin documenting with ICD-10 requirements. The next week, expand their documentation scope for the next diagnosis, and so forth. By the time ICD-10 is fully implemented, documenting using the new code set will be second nature to them and compliance will be realized.

To ensure successful physician training, the professional training the physician(s) must have a high level of expertise working with physicians on documentation issues, including their office and hospital visits, RVUs, levels of service, and surgical procedures, when applicable. Employing an ICD-10-certified trainer without an in-depth working knowledge of how a medical practice operates or how practitioners are paid could end result in ineffective training with no benefit. The trainer also must be able to answer all practitioner questions without hesitation. Some of the questions that may be asked include:

  • How does this affect my RVUs?
  • Why must we document more?
  • What’s in this for me?
  • I don’t get paid based on a diagnosis, so why should I care?
  • Do I need to document all the diagnoses, or just the conditions I am managing?
  • How many diagnoses do I need to get to a level 3 or 4 visit?
  • Do we have to document the same when I see a patient in the hospital?

These are just a few questions I have been asked by practitioners of all specialties.

One last word of advice: make certain you provide practitioners with a high-level overview of why we must transition to ICD-10 in addition to offering documentation training. Most practitioners need to know the importance of the “why” and “how” of ICD-10. Again, whoever provides your training should be able to achieve success if he or she possesses a working knowledge of how a medical practice operates. Successful transition depends on a solid working training plan, training tailored to each specialty, and an experienced physician trainer.

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.