Updated on: March 14, 2016

Working with Physicians on Documentation for ICD-10: Clearing up the Chaos

Original story posted on: November 20, 2013

EDITOR’S NOTE: This is the first article from Rhonda Buckholtz, vice president of ICD-10 education and training at AAPC, who has joined the ICD10monitor editorial board.

We talk about documentation and how it needs to change under ICD-10, but really, the implementation of new codes should not be why documentation needs to change. The real issue is that we don’t have complete enough documentation now, in our current environment – ICD-10 simply is shining a spotlight on our existing problems.


The focus should always be on good patient care, which requires good documentation. Whoever picks up the patient record should have a clear, concise picture that allows them to know exactly what was done for the patient, including outcomes, orders, and other information needed to provide continuing care. Once we achieve that, everything else falls into place, including the coding.

Whenever working with clinicians, I take the codes out of the equation as much as possible. Why would I want to try to overwhelm clinicians by telling them how many codes we have, or talk about codes they will never encounter? It only serves to frustrate the clinician (and me).

Recently, AAPC released results of 20,000 assessments performed showing the percent of documentation for each specialty that is sufficient to code accurately using ICD-10. The study merits a closer look. One client reported an 87 percent transition rate; however, only seven diagnosis codes accounted for 93 percent of the organization’s revenue. That is great news, because I only need to work with them on documentation concepts for seven clinical conditions.

Instead of focusing on the codes, use documentation concepts. There are only about 21 unique documentation concepts found in ICD-10-CM. The most common among them are:

  • Laterality
  • Type
  • Cause
  • Manifestations or complications
  • Anatomical location

Let’s break each one of these down a little further. I think all of us can agree that these five concepts are important for continuing care, and if it’s important for the care of the patient then it should be documented.

Laterality: ICD-10-CM contains the concept of laterality. If there is a right side or left side, proximal or distal in play, documentation should clearly state it. Coding will capture this concept and we should veer away from the use of unspecified codes when laterality is indicated.

Type: When the condition includes variations, documentation should include which type of condition the patient has. This could impact future resources, such as services, medications, procedures, and proof of medical necessity for each patient’s clinical condition. Documentation will help other providers become better able to treat the patient when addressing underlying conditions or manifestations.

Cause: If the patient’s condition is due to another condition, then documentation should indicate the cause.

Manifestations/complications: Many conditions have complications or manifestations and all should be documented, as many require additional treatment plans or resources.

Anatomical location: The location of the condition should always be documented as precisely as possible. If it affects the colon, where? If a bone is broken, where exactly is the fracture located?

When you break down the documentation concepts, they all make clinical sense. Who really cares if there are close to 70 codes for headaches and migraines when the clinician only needs to make sure that he or she has five documentation concepts covered?

To simplify it even further, about half of 69,000 codes involve the musculoskeletal sections in ICD-10-CM, but there are only five documentation concepts for fractures. It would be overwhelming and a waste of time to work with clinicians on trying to remember all the codes and variables when all they really need to focus on is type, laterality, episode, contributing factors, and anatomical location. Simplifying it would look like this:

Factors contributing to or emerging as the cause of the fracture can be:

  • Trauma
  • Pathological
  • Stress/fatigue
  • Issue occurring placement of device, implant, graft, etc.


Next would be the type of fracture. For example, is it a:

  • Greenstick?
  • Spiral?
  • Comminuted?
  • Segmental?
  • Transverse?
  • Oblique?
  • Open?

If it is open, what is the degree of:

  • Soft tissue involvement?
  • Contamination?

For pathological fractures, the documentation also must include the underlying condition, such as:

  • Osteoporosis
  • Neoplasm
  • Osteomyelitis
  • Osteolysis
  • Osteonecrosis
  • Pagets disease
  • Osteomalacia
  • Osteogenesis imperfect
  • Cysts

The documentation must include which bone is affected or the anatomical site of the fracture. In addition to type of fracture and the anatomic site, documentation should include the site on the bone where the fracture occurred.  Sites included in ICD-10-CM include:

  • Shaft
  • Surgical neck
  • Greater tuberosity
  • Lesser tuberosity
  • Supracondylar
  • Intercondylar
  • Epicondylar
  • Medial condylar
  • Transcondylar

Localization and laterality of the fracture site also are needed in the documentation to capture the patient’s clinical condition clearly. Localization of fracture pertains to the specific location along the site on the bone, such as distal or proximal shaft. 

Any complications related to the healing of a fracture need to be documented for assignment of seventh-character specificity. Included in ICD-10-CM are the fracture complications of:

  • Malunion;
  • Nonunion; and
  • Delayed healing.

Working toward good, clear documentation helps ensure that the right codes are being provided for each patient’s clinical condition. Coding can only be as concise as the documentation allows.

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.

Rhonda Buckholtz is the vice president of practice optimization for Eye Care Leaders. She has more than 25 years of experience in healthcare, working in the management, reimbursement, billing, and coding sectors, in addition to being an instructor. She is a past co-chair for the WEDI ICD-10 Implementation Workgroup, Advanced Payment Models Workgroup and has provided testimony ongoing for ICD-10 and standardization of data for NCVHS. Rhonda spends her time on practice optimization for Eye Care Leaders by providing transformational services and revenue integrity for Ophthalmology practices. She was instrumental in developing the Certified Ophthalmology Professional Coder (COPC) exam and curriculum for the AAPC. Rhonda is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.