Electronic Health Records

Detail and specificity: What your ICD-10 documentation should look like

In preparation for the ICD-10 transition on October 1, 2014, physicians will need to modify the way they collect patient data and document visits in their charts.  “Specificity” is the word most often associated with ICD-10 documentation, and physicians will indeed be required to collect more information in more detail in order to allow coders to select the right ICD-10 code for a symptom, disease, or provided service.

But what should that documentation actually look like?  An oft-cited example, provided by the AAPC, outlines the case of Mrs. Finley, who suffered a concussion when a cabinet fell on her head.  ICD-10 will require physicians to be specific about some new variables when documenting such a case, including the type of encounter, applied specificity (did she lose consciousness?), acute or chronic condition, relief or non-relief of symptoms, and the external cause of the accident including the activity being performed and the location where the accident took place.

Every single one of those factors is required to note in order to select the proper ICD-10 code.  If the documentation was any less specific, a coder might not be able to find the most accurate, applicable code, and the payer would likely not provide reimbursement for the consult, marking the claim as incomplete.

ICD-10 codes contain seven alpha-numeric characters, compared to 3 or 4 numbers in ICD-9.  Each character adds a degree of specificity that the 4-digit codes of ICD-9 simply couldn’t accommodate.  ICD-10 codes can precisely define the methodology and approach of procedures and add detail about the location of body parts, any device used for a procedure, and additional qualifying information to craft a complete picture of a patient’s complaint and the circumstances that led to it.

“It sounds like a lot of codes; it sounds like a lot of trouble, but the number of codes should not be the deterrent.  It’s like the phone book.  It’s a lot of numbers, and it’s a big, thick book.  But you don’t need them all.  If you did, that book is there for you to use. You’re not going to use all 144,000 codes.  It’s big because it describes specificity,” says AHIMA-certified ICD-10 trainer Pat Schmitter.

For example, while there are one-to-one mappings between ICD-9 and ICD-10 for specific diseases like Tietze’s Syndrome, the ICD-9 code for “spotting complications during pregnancy” is broken down into first, second, and third trimesters in ICD-10.  “Poisoning by hormones” in ICD-9 has sixteen specific ICD-10 counterparts, and in an extreme example, the ICD-9 code for “other disorders of bone and cartilage, non-union of fracture” has 2,530 ICD-10 codes detailing the exact location of the injury in question.  It would be absolutely impossible for a coder to pick the correct designation if that information was lacking in the physician’s notes, which means the note taker has to be very sure that he or she is capturing the right data.

Less than 3% of ICD-10 codes are as complicated as the last example, with most of the codes only adding one additional choice compared to ICD-9.  But only 24% of ICD-9 codes have a direct match in ICD-10, so physicians and coders will be facing some degree of increased choice in the majority of cases.

Practices can prepare for the changing requirements by closely examining how physicians are documenting their cases, and what needs to change.  “I think the biggest advice we can give right now is to take a very good look at your documentation procedures and infrastructure,” says M*Modal Chief Scientist Juergen Fritsch.  “How is documentation done in your hospital or practice right now?  Bring in an expert to assess that and help guide where investments need to be made in order to bring the documentation up to speed.  How is physician coding being done?  Looking at those workflows is really important.”

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