May 1, 2012

The Documentation of ICD-10

By

Submitted by Precyse

The ICD-10-CM diagnostic classification is more specific and provides a better clinical picture to support optimal quality of care and reimbursement. And by now most coding professionals know that ICD-10-CM has far greater granularity and more current healthcare information and, as a result, the language has changed to reflect more site specificity and more disease specificity.

Laterality is a good example. Site-specific laterality has been added in ICD-10-CM; conditions such as fractures, burns, and pressure ulcers will indicate right side vs. left side and in some cases, bilateral sites. So, when coding with ICD-10-CM, coding professionals will need to note the laterality of diseases or disorders that are documented in the medical record.

As with ICD-9-CM, physician documentation is the basis for all code assignment, and coding professionals in particular are aware of how essential it is to have clear documentation of each patient diagnosis and treatment. Although there is a common misconception that unreasonably detailed medical record documentation will be required for ICD-10-CM, much of the documentation specificity needed for coding is already routinely done by physicians. This includes, for example, the acuity of the disease (e.g., acute and/or chronic), the etiology (e.g., neoplasm-related pain), and the significance of related diagnostic findings (e.g., guaiac-positive stools).

When coding with ICD-10-CM, as with any code set, it is important to bear in mind that commonly used clinical terminology may have different permutations in the diagnostic nomenclature. For example, the specific terminology used in clinical documentation of pregnancy-related cases is significantly different than the current ICD-9 code terminology. Diagnosis codes in ICD-9 described the current “episode of care” in terms of whether the episode was in the antepartum or postpartum period and whether a delivery occurred during the encounter. In ICD-10-CM, the episode of care is no longer a secondary axis of classification for obstetric codes. Instead, the majority of codes have a final character identifying the trimester of pregnancy in which the condition occurred.

So when using the ICD-10-CM codes, the standard trimesters (i.e., < 14 weeks, < 28 weeks, 28 weeks until delivery) should be used to document pregnancy cases rather than the episode of care (delivered, antepartum, postpartum).

Acute myocardial infarction (AMI) is another example. Coding professionals must still review the documentation to identify the site of the AMI (e.g., anterolateral wall) as before, but it is important to note that the ICD-10-CM diagnostic classification identifies an AMI occurring within 28 days of an initial MI as a subsequent MI, while the ICD-9-CM diagnostic classification used a “stated duration of eight weeks or less.”

The implementation of the ICD-10 code sets, along with the advent of the electronic health record, make the use of standard terminology more essential than ever before. ICD-10-CM will not only provide better data about patients and the services provided to them, but will also allow coding professionals to more accurately reflect the details of physician documentation.

To comment on this article please go to