Updated on: March 14, 2016

Top 10 Physician Documentation Improvement Targets for ICD-10-CM

Original story posted on: January 10, 2014

Physician documentation is of the utmost importance in the healthcare industry, both today and once ICD-10-CM/PCS goes into effect on Oct. 1, 2014. Insufficient physician documentation will continue to be problematic under ICD-10-CM/PCS unless hospitals address the problem now.


Approximately 15-20 percent of all ICD-10-CM diagnosis codes require more documentation specificity. To maximize the effectiveness of your clinical documentation improvement (CDI) efforts in 2014, one best practice is to select certain areas for focused physician awareness, education, and training.

Hospitals should consider their most frequently reported diagnoses alongside known areas of documentation concern. Here are 10 top physician documentation targets for ICD-10 CDI efforts.

Diabetes mellitus

Diabetes documentation must include the type or cause of the diabetes (i.e. type 1, type 2, due to drugs or chemicals, or due to another cause), the body system affected (i.e. nephropathy or neuropathy), and the specific complication (chronic kidney disease, proliferative diabetic retinopathy with macular edema, foot ulcer, hypoglycemia without coma, etc.). Start asking physicians for this information now. 


Documentation of all injuries must include a seventh character extension to identify the encounter type, with “A” listed for all initial encounters and “D” for subsequent encounters. For fractures, physicians must document whether each is open or closed as well as specify an initial or subsequent encounter with delayed healing, malunion, or nonunion. Fracture documentation also must specify type (i.e., oblique, comminuted, transverse, or displaced) as well as laterality. For lacerations/contusions affecting internal organs, physicians must specify the length and depth (minor, moderate, or major). If physicians don’t currently provide this information, ask them to do so going forward.


The concept of underdosing — when a patient takes less of a medication than what is prescribed — is new for ICD-10-CM. Coders will sequence the medical condition first, followed by an underdosing code as a secondary diagnosis. When an underdose occurs due to an insulin pump failure, coders will sequence a mechanical complication of other specified internal and external prosthetic devices, implants, and grafts first, followed by an underdosing code as a secondary diagnosis. Physicians must specify intentional vs. unintentional as well as the specific drug involved in the underdosing.

Cerebral infarction

Documentation of a cerebral infarction must include the specific artery (i.e., precerebral, vertebral, carotid, or cerebellar), laterality, score from the Glasgow Coma Scale when applicable, and whether tPA (rtPA) was rendered in a different facility within 24 hours. Review documentation to ensure that these details are present in the record.

Myocardial infarction

Documentation of myocardial infarction must include the type (i.e., STEMI vs. NSTEMI), age (“initial,” within 4 weeks, or “old,” older than 4 weeks), specific site (anterior wall or inferior wall), coronary artery involvement, and information regarding whether the condition is initial or subsequent. Ensure that physicians provide this information.


Documentation of neoplasms must include anemia due to the neoplasm (when applicable), pathological fracture due to the neoplasm (when applicable), any overlapping sites, and laterality. Anemia associated with malignancy is sequenced as a secondary diagnosis, with the malignancy sequenced as principal.

Pathologic fracture

Documentation of pathologic fractures must include the exact location (site and laterality), etiology (osteoporosis or neoplastic disease), and the type of encounter (initial, subsequent, or subsequent with delayed healing). Ensure that physicians begin to provide this information if they don’t already do so.

Musculoskeletal conditions

Diagnoses such as osteoarthritis, gout, rheumatoid arthritis, and osteonecrosis each require specificity regarding the exact site and laterality. Physicians also must document linkage to cause of disease process, such as gout due to renal impairment, drug-induced gout, post-traumatic osteoarthritis, or primary osteoarthritis. Documentation also must include specificity of other organ involvement, such as rheumatoid lung with arthritis of right wrist.



Documentation of pregnancy must include the specific trimester. Pregnancy codes include a final character that indicates the trimester for the current encounter. These characters include:

  • 1st Trimester – less than 14 weeks, 0 days
  • 2nd Trimester – 14 weeks, 0 days to less than 28 weeks, 0 days
  • 3rd Trimester – 28 weeks, 9 days until delivery

For gestational diabetes, physicians must document diet-controlled vs. insulin-controlled. If the condition is both diet- and insulin-controlled, only the insulin-controlled gestational diabetes will be used for coding purposes. Gestational diabetes is only present in the second or third trimester. For puerperal sepsis, physicians must document the causal organism as well as severe sepsis and organ dysfunction, when present.


Physician documentation must include the following:

  • For ventilators: Specify fewer than 24 consecutive hours, 24-96 consecutive hours, or greater than 96 consecutive hours.
  • For pneumonia: Specify the type of pneumonia for ventilator-associated pneumonia.
  • For acute pulmonary insufficiency: Specify whether it follows thoracic surgery, non-thoracic surgery, or shock/trauma.
  • For respiratory insufficiency: Specify an underlying diagnosis, if possible.

About the Author

Kim Carr is the clinical documentation director for HRS. She brings nearly 30 years of HIM experience to HRS. Kim’s background includes revenue cycle improvement, coding and compliance, coding and CDI education, and denials management in a variety of provider environments and consultant settings.

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.
Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.