Thursday July 19th 2018

New ICD-10 coding

Documentation to provide better care, support more accurate billing

By Denesecia Green, Office of E-Health Standards and Services, Centers for Medicare and Medicaid Services

Editors note: The ICD-10 implementation has been postponed until Oct. 1, 2015.

Most people would agree: Good clinical documentation is part of good patient care. The ICD-10 code set, which will go into use on Oct. 1, allows for greater specificity than the current set, ICD-9. Good documentation will be more important than ever for accurate coding, and nurses have a key role to play.

Documentation essentials can be boiled down to a three-step process:

• Complete observation of all facts relevant to the patient’s condition.

• Documentation of all the key clinical concepts relevant to the patient’s care now and in the future.

• Coding, based on accurate documentation, that includes all of the key clinical concepts captured during observation and documentation and supported by the coding standard and guidelines.

ICD-10 coding standards: Improving patient care and public health

The Oct. 1 transition to ICD-10 marks an important step in supporting the standardized capture of clinical concepts. By using standardized codes to describe all important clinical concepts related to a patient’s condition, we can improve our nation’s health by facilitating the sharing of information across the continuum of care, and capturing data that can be analyzed to improve public health nationally and globally.

ICD-10 diagnosis codes and inpatient procedure codes must be used for health care services provided in all states and U.S. territories on or after Oct. 1. This mandate applies to every organization and individual classified as a “covered entity” under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA covers health care providers, hospitals and payers, whether or not they participate in Medicare, Medicaid or both programs.

Recurring clinical concepts in ICD-10 diagnosis codes

ICD-10 allows for better capture of key clinical concepts than the current U.S. coding standard, ICD-9. Recurring concepts that are new to ICD-10-CM (diagnosis) codes are:

• Initial encounter

• Subsequent encounter

• Sequela

• Right (laterality)

• Left (laterality)

• Routine healing

• Delayed healing

• Nonunion (fracture)

• Malunion (fracture)

• 1st, 2nd or 3rd trimester (pregnancy)

• Assault

• Self-harm

• Accidental

Many health care providers already capture much of this detail in their documentation, but the addition of these clinical concepts in ICD-10 will better translate the details about a patient’s clinical condition. The goal is to provide better care and support more accurate billing.

Tip: To prepare for the transition, take a look at recent documentation for the top three to five diagnoses for your patient population. Is the documentation comprehensive, and does it include all the clinical concepts needed to select an ICD-10 code?

If not, think about what you can change in your patient intake, assessment and follow-up protocols to support thorough documentation for accurate coding and optimal patient care.

The number of diagnosis codes for diabetes jumps from 69 in ICD-9 to 239 in ICD-10. With an understanding of the clinical concepts driving the increased number of codes for diabetes and other diagnoses, you can fine tune your processes to ensure that you have all the documentation needed for ICD-10 coding.

Visit the CMS ICD-10 website  at to learn how you can improve your documentation and prepare for the Oct. 1 compliance date. You can also sign up for CMS ICD-10 Industry Email Updates at and follow us on Twitter at for news and resources.

Clinical concept example: ICD-10 clinical concepts for diabetes mellitus

Let’s use diabetes as an example to see how ICD-10 will help support good patient care. In the following list, concepts that are included in ICD-10, but not in ICD-9, are italicized. While current documentation should already include the details in the list below, reviewing this list can help you understand how ICD-10 is changing coding. These concepts are representative of the detail required for all ICD-10 codes:

Type of diabetes: type 1 diabetes, type 2 diabetes, underlying condition, drug or chemical induced, pre-existing, gestational, poisoning by insulin and oral hypoglycemic, adverse effect of insulin and oral hypoglycemic, underdosing of insulin and oral hypoglycemic, neonatal, secondary

Pregnancy: first trimester, second trimester, third trimester, childbirth, puerperium, antepartum, postpartum

Neurological complications: neurological complication, neuropathy, mononeuropathy, polyneuropathy, autonomic (poly)neuropathy, amyotrophy, coma

Lab findings: ketoacidosis, hyperosmolarity, hypoglycemia, hyperglycemia

Renal complication: nephropathy, chronic kidney disease, kidney complication

Ophthalmologic complications: retinopathy, macular edema, cataract, ophthalmic complication, mild nonproliferative retinopathy, moderate nonproliferative retinopathy, severe nonproliferative retinopathy, proliferative retinopathy, background neuropathy

Vascular complications: circulatory complications, peripheral angiopathy, gangrene

Skin complications: dermatitis, foot ulcer, skin complications, skin ulcer

Joint complications: neuropathic arthropathy, arthropathy

Oral complications: oral complications, periodontal disease

Diabetic control: diet controlled, insulin controlled, uncontrolled, controlled

Encounter: initial encounter, subsequent encounter, sequel

Other concepts: complications, right, left, accidental, intentional self-harm, assault, family history, personal history, screening

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