ICD-10 documentation, additional details from Physicians are needed
ICD-10 documentation the bad news is from the majority of current medical records reviewed, whether they are handwritten, dictated, or electronic, they do not contain the necessary documentation to support the coding specificity required to properly use the ICD-10 system. With a little effort to change the current way physicians are documenting will help coding for the future.
For the preparation, physicians need to understand the following:
- The basic changes inherent in the ICD-10 system and
- How those changes drive the need for additional documentation details.
Here is an overview of the changes
The basic ICD-10 structure is:
An ICD-10 code consists of
- Between three and seven characters
- The first character is alphabetic
- The second character is numeric
- The third character is typically numeric, but the most recent updates to ICD-10 include some alpha characters in this position. These first three characters represent the category.
- An example to explain this, diabetes mellitus falls in the E00-E89 category of ?Endocrine, nutritional and metabolic diseases.?
The fourth through seventh characters of an ICD-10 code appear after the decimal point and they may be alpha or numeric. These characters stand for etiology, anatomic site, and severity. Seventh character is an ?extension.? Most of the increases in the number of diagnostic codes under the ICD-10 coding system can be ascribed to these additional characters, as shown below:
Conjunctivitis H10,
Mucopurulent conjunctivitis H10.0
Acute follicular conjunctivitis H10.01
Acute follicular conjunctivitis, bilateral H10.013
In this example,
- The first three characters (H10) describe conjunctivitis.
- The fourth and fifth characters describe the type of infection
- The sixth character describes the bilateral nature.
- If the conjunctivitis is a result of an external cause, another code is used to identify that external cause.
It would have been easier if the purpose of the fourth, fifth, and sixth characters remained the same from category to category which is not the case. The use of these characters varies by category, as shown below:
Blindness and low vision H54
Blindness, one eye, low vision other eye H54.1
Blindness, right eye, low vision left eye H54.11
Blindness, left eye, low vision right eye H54.12
Low vision, both eyes H54.2
Blindness, one eye H54.4
Blindness, right eye, normal vision left eye H54.41
Blindness, left eye, normal vision right eye H54.42
The use of nonspecific codes are available to both of these code sets (H10 and H54).
The H10 code set has codes for:
- ?Other acute conjunctivitis? and ?unspecified acute conjunctivitis.?
- The H54 code set includes codes for ?unqualified visual loss.?
The extension, the seventh character is mostly found in two chapters of ICD-10.
In the Chapter, ?Injury, Poisoning and Other Consequences of External Causes? , it is used to describe :
- The episode of care as:
A = initial, D = subsequent, and S = sequela.
- Fractures have even more options for the seventh character depending on whether they involve the Gustilo-Anderson classifications.
- In the Chapter, ?Pregnancy, Childbirth and Puerperium?, the seventh character is used to provide information about the fetus
One fetus = 1,
Two through five fetuses =2 to 5 and
More than five fetuses = 9.
If code requires a seventh character but the base code is fewer than six characters then there is a need to fill in the empty spaces with an x (e.g., S03.4xxA).
General coding rules in ICD-10-CM:
- Common terminology is an important concept in ICD-10.
- Over the years in coding, the following concepts are frequently misapplied even in ICD-9:
- A red flag for failure of the provider to document the complications is referred to cases with ?With unspecified complications?
- The complication is specified but not contained in the ICD-10 manual, is referred to cases with ?With other specified complications?
- ?Unspecified ” is the equivalent to Not Otherwise Specified (NOS)?.
- Physicians need to be aware of the risks inherent in doing so, while it is tempting to use these nonspecific codes, perhaps including them on a superbill,
Few more common coding conventions that need to be understood:
- ?Code first? means the code is not an acceptable primary diagnosis code and another code should be in the first position,
- ?Use additional code? means certain situations require an additional diagnostic code,
- ?Includes? and ?excludes? are regarding similarly worded diagnoses that either fall within the code or are excluded from the code.
The need for better documentation:
Coding in family physicians’ offices generally takes place through one of three formats depending on the size of the practice and the use of electronic health records (EHRs).
In the first scenario, a one- or two-page superbill will not be enough to capture all the ICD-10 codes needed, so it will have to include specific documentation details to help with code selection that will likely extend beyond the superbill.
Single and small practices often rely on a so-called superbill that contains a list of the most common diagnosis codes for the physician to check.
Practices that use Electronic Health Records have an automatic billing system that translates the information from the record onto a CMS-1500 billing form. Larger practices have coders to abstract the medical record and add diagnosis codes to claim forms.
Specific documentation will be required to help either the system or the coder translate a medical record into the most specific and correct ICD-10 code for the services. This increased specificity required in documentation may want the physicians to document details that seem obvious to them but would not be obvious to those abstracting the record for coding purposes.
STEPS that can help in using the ICD-10-CM system;
- 1. Familiarizing practitioners with the basic structure of ICD-10.
- 2. Practicing documentation that includes a more complete diagnosis, including details such as site, laterality, complications, and other specific characteristics.
- 3. Developing more detailed templates to ensure that your documentation will meet coding and billing requirements.
- 4. Cross-walking your suberbill from ICD-9 codes to ICD-10 codes.
- 5. Examine your Electronic Health Record system – review the need for additional documentation elements and whether the system can accommodate both code sets.
ICD-10 is nearing and the numbers of diagnostic codes are expanding. Many of the new codes are combinations of the current ICD-9 codes. Many additional codes simply say right, left, or bilateral and many other codes are for more complex conditions that are rarely seen in primary care. By learning the basics of the ICD-10 coding system and making some adjustments to the current written or dictated documentation and ensuring that the Electronic Health Record system can handle the required increased specificity of documentation will help in being prepared when ICD-10 arrives.