Create a customized plan to assess documentation weaknesses for ICD-10-CM/PCS

by June Bronnert, RHIA, CCS, CCS-P

The clinical documentation in a patient’s medical record, whether paper or electronic, is the vital source for code assignment. It is so fundamental to the coding profession that both the ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting state, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.”

Coders may find that obtaining complete and accurate documentation for proper code assignment is a challenge when assigning ICD-9-CM codes. As incomplete or inconsistent documentation leads to a lack of data integrity, many organizations have started clinical documentation improvement programs. The programs typically focus on resolving incomplete or inconsistent documentation, often through physician queries.

Documentation requirements in ICD-10-CM/PCS
As the industry prepares for ICD-10-CM/PCS code assignment, complete and consistent documentation remains vital. Many organizations are asking the following questions:

  • What documentation is required to assign ICD-10-CM/PCS codes?
  • How will documentation issues change with the ICD-10-CM/PCS coding systems?

While some documentation elements will remain the same, other required documentation for accurate code assignment will change because of changes in the systems. For example, diabetes coding in ICD-9-CM requires providers to document at least the type and control status. In ICD-10-CM, however, providers will still need to document the type, but not necessarily whether it is controlled; this information is not a routine part of the ICD-10-CM code as it was in ICD-9-CM.

To specifically address how documentation should change, organizations need to include current documentation practices in their ICD-10-CM/PCS impact assessment. This will allow them to create a specific organizational plan to address the findings.

Based on these findings, identify the top 10–15 diagnoses or conditions and focus on them as you create a customized plan. Organizations that will use ICD-10-PCS codes should also identify their top 10–15 procedures.

In addition, acute care hospitals may want to identify their top 10–15 MS-DRGs. Facilities should divide MS-DRGs into medical versus surgical so they can further analyze whether the most significant documentation trouble spots fall on the diagnostic or procedure side.

Doing so will allow organizations to create a customized plan and give them an idea of their documentation strengths and weakness related to the transition to ICD-10-CM/PCS.

Review guidelines and current documentation
After identifying focus areas, review the ICD-10-CM Official Guidelines for Coding and Reporting and the ICD-10-PCS Reference Manual, which includes the PCS coding guidelines. Appendix B of the manual details the coding guidelines for ICD-10-PCS and other sections of the manual explain the meaning of root operations in ICD-10-PCS.

For example, guideline Section 1.C.9.b. atherosclerotic coronary artery disease and angina states, “A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates the angina is due to something other than the atherosclerosis.”

This guideline specifically notes the necessary documentation to assign the combination code, which illustrates one of the many guidelines that will remain unchanged in the move to ICD-10. Approximately 90% of the guidelines will remain the same, so in many cases, coders may already know what documentation they need. Other examples, however, reflect the differences necessary for proper ICD-10-CM/PCS code assignment.

For example, another guideline reflects the necessary documentation to accurately assign procedures performed on coronary arteries. In ICD-9-CM, coders report codes based on the number of vascular stents inserted and vessels treated. ICD-10-PCS Coding Guideline B4.4 indicates code assignment is not based upon the name of the artery or the number of arteries treated, but on the number of sites treated.

Organizations that identified coronary artery procedures in their top list should review a sample of the operative/procedure reports to determine whether the physicians documented the number of sites or arteries. The answer should serve to help target physician ICD-10-CM/PCS education.

Additional information needed for fractures
Another area to review is the disease process of osteoporosis and fractures. The ICD-10-CM Official Guidelines address osteoporosis when it occurs with a fracture. The guideline directs coders to assign a code from the category M80 (osteoporosis with current pathological fracture) when a patient has known osteoporosis and a fall or trauma that would not usually break a healthy bone. Physicians do not need to document this information for ICD-9-CM coding, so review this information with the medical staff can facilitate good documentation practices.

Physicians will need to include more specific documentation for all fractures, including:

  • Type of fracture
  • Specific anatomical site
  • Whether the fracture is displaced
  • Laterality
  • Routine versus delayed healing, nonunions, and malunions

For example, the physician documents a closed fracture of the tibia. In ICD-9-CM, coders would report 823.80 for an unspecified fracture of the lower leg.

In ICD-10-CM, coders would not be able to even choose the correct series of codes based on this documentation. If the patient had a stress fracture, coders would look to series M84.36-, but would still need documentation of the side and whether the encounter was initial, subsequent, or sequel. For a pathologic fracture, coders would move to M84.46- and for pathologic fracture in neoplastic disease, coders would choose from the M84.56- series.

Coding for open fractures will significantly change in ICD-10-CM. ICD-10-CM uses the Gustillo-Anderson fracture system in the code for open fractures.

Review current documentation for these injuries to identify if additional provider education is necessary to capture the additional specificity needed to code for these conditions.

Dominant vs. nondominant side
Coders will also find guidelines regarding dominant and nondominant side for injuries of the nervous system.

Currently, when it comes to hemiplegia and monoplegia in ICD-9-CM, the physician must document dominant or nondominant for coders to select the most specific code or the coders must chose an unspecified code.

In ICD-10-CM, the guideline states that when documentation is lacking and if the classification system does not indicate a default, the default should be dominant. For ambidextrous patients, the default will also be dominant.

Obstetrics coding changes
The obstetric chapter in ICD-10-CM contains changes as well. Many of the obstetric codes identify the specific pregnancy trimester through the final character of the code. Coders must determine which character to use based upon the provider documentation of the trimester or the number of weeks.

The obstetric codes identify the specific fetus if multiple are present (e.g., code O32.1xx2 [maternal care for breech presentation, fetus two]). In ICD-9-CM, the final character identifies whether the delivery occurred during the admission.

These are simply a small sample of the many examples of the greater detail of ICD-10-CM/PCS codes.

Many specific changes in documentation are necessary for proper code assignment of specific categories of codes in ICD-10-CM/PCS. The new code system will require significantly more specificity in documentation, but, the fundamental documentation requirements—complete, accurate documentation—remain the same. Organizations should keep them in mind—as well as the many changes ahead—when evaluating documentation practices.

Editor’s note: June Bronnert, RHIA, CCS, CCS-P, is the director of professional practice resources for the American Health Information Management Association in Chicago. E-mail questions to senior managing editor Michelle A. Leppert, CPC-A at

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