1. Clinical Documentation Requirements for Physician Transition to I-10
Kathy Fennick, RHIA, CCS

2. Objectives
Gain an understanding of the International Classification of Diseases, Tenth Edition Clinical Modification (ICD-10-CM)
Identify impacts by specialty
Understand the key documentation impacts and changes to provider workflows

3. ICD-10 Overview
ICD-10: WHO’s International Classification of Diseases, 10th Rev.
U.S. version: Modified for the US healthcare system by CMS and the National Center for Health Statistics (NCHS)
ICD-10-CM : Diagnosis coding
ICD 10-PCS : Procedure coding
ICD-10-CM/PCS will not replace
Evaluation & Management (e.g. visit service 99213)
Outpatient procedure coding

4. What’s Changing & What’s Not
Professional Billing
Hospital Billing
Diagnoses
Outpatient
ICD-10-CM
Inpatient
Evaluation & Management
CPT
n/a
Procedures
ED/Observation
(Surgical & Bedside)
ICD-10-PCS
ASC & OSC

5. Moving from ICD-9 to ICD-10-CM Example
S72.301G
Fracture, femur closed, shaft, right, with delayed healing, subsequent encounter
821.01
Fracture of femur, shaft, closed

6. Moving from ICD-9 to ICD-10-CM Example
Many more possible codes
S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture
S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture
S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture
S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
821.01
Fracture of femur, shaft, closed

7. What If We Entered Charges on Paper?
Converted Orthopedics Superbill
49-Pages
Original Orthopedics Superbill
2-Pages

8. Impact varies by Specialty
Features of the ICD-10 coding system will impact providers differently based on your specialty and clinical practice:
Injuries grouped anatomically rather than by type of injury
Laterality (e.g. fractures)
Combination codes for common comorbidities
Encounter specificity (Initial, Subsequent etc.)
New and reclassified diseases/definitions
Specialties with highest expected impact
Neurosurgery
Orthopedics
Cardiothoracic Surgery
General Surgery
Emergency Medicine
Primary Care

9. Documentation Concept Examples
Hypothyroidism
Type (congenital, acquired)
With manifestations
If the condition is drug induced there is an instructional note that states to first list the drug or substance.

10. Documentation Concept Examples
Ischemic heart disease
Vessel affected
Native coronary etc…
With/without angina
Heart failure type as well as systolic, diastolic, combination

11. Documentation Concept Examples
Acute Myocardial Infarction (AMI)
Age definition for AMI has changed to four weeks rather than eight weeks.
New categories for subsequent AMI and for complications within 28 days of AMI.
Different terminology is used and laterality is included (e.g., I21.02 designates “ST segment elevation myocardial infarction [STEMI] involving left anterior descending coronary artery”).

12. Documentation Concept Examples
Cerebrovascular disease
Type
cerebral infarction, occlusion, hemorrhage
Site/location
cerebral, subarachnoid, carotid
Cause
due to embolism, occlusion, and thrombosis.

13. Documentation Concept Examples
Fractures
Location of fracture
Type of fracture
Stage of healing
Laterality

14. Documentation Concept Examples
Drug Under-dosing
Under-dosing is a new code in ICD-10-CM. It identifies situations in which a patient has taken less of a medication than prescribed by the physician.
The medical condition is sequenced first.
The under-dosing code is listed as a secondary diagnosis.
The additional code explains why the patient is not taking the medication (e.g., financial reasons).
Since this is new, many physicians will not be in the habit of documenting a patient’s reasons for under-dosing in the record.

15. Documentation Concept Examples
Pregnancy
Documentation of trimester now required.
Counted from first day of last menstrual period.
Must document number of weeks.
Episodes of care have been deleted.
For example, ICD-10-CM code of O15.03 designates “eclampsia in pregnancy, third trimester.”
Obstructed labor codes incorporate reason for the obstruction and code extensions are used to identify specific fetus (1-5) affected by obstetric condition (e.g., ICD- 10-CM code O64.1xx2 designates “obstructed labor due to breech presentation, fetus 2”).

16. Unspecified Codes Use of unspecified codes Will NEVER be covered?
Does not guarantee payment?
We will pay you less for continued use?
How do I prepare and identify high frequency codes?
Analyze historical data
Translate ICD-9 codes to ICD-10 codes for comparison
Develop report to monitor cases with unspecified codes
Develop report templates and smart text tools for EHRs

17. Knowledge Retention

18. Clinical Documentation Requirements Summary
Laterality
A renewed emphasis on laterality within documentation under ICD-10 is intended to enhance communication between providers and improve patient safety.
Disease pathophysiology
Disease pathophysiology, or the study of ongoing changes in the disease state, is much more detailed in the ICD-10 disease descriptions.
Combination codes:
Combination codes have been created to merge two diagnoses that typically are related to one another. In ICD-10, this means some codes now have six options, whereas they had one or two options previously under ICD-9.
Encounter timing:
ICD-10-CM requires documentation of the type of treatment that is rendered for specific conditions, such as injuries, signs and symptoms, and external causes of morbidity. Stage of care is also a critical element of this documentation.
Identification of trimester in ICD-10:
For obstetrics clinicians, new definitions of trimesters have been introduced. In addition, each episode of care must be reported along with the patient’s trimester.

19. Clinical Documentation Requirements Summary
Increased disease specificity:
ICD-10-CM has expanded many code descriptions to connect complications and manifestations with conditions.
Alcohol and drug abuse
ICD-10 has clarified the way alcohol and drug abuse and dependence should be documented to mitigate confusion when attempting to accurately represent the patient’s condition. This will include effects, aspects, and manifestations of substance abuse.
Expansion of injury codes
Documentation of the sites and types of injuries will be required in ICD-10.
Post-procedural disorders
ICD-10-CM requires documentation to indicate if a condition or disorder is caused by or follows a procedure. Every physician needs to clearly state if a procedure caused a negative impact to a patient’s condition.

20. Preparing Providers for ICD-10-CM
What can be done NOW to prepare physicians/providers for the changes that will occur when ICD-10-CM is implemented?
Perform Clinical Documentation Assessments. This can involve evaluating samples of various types of medical records to determine whether the documentation supports the level of detail found in ICD-10-CM.
Documentation improvement strategies can be implemented to address areas where documentation is found to be lacking.
Designate a physician/provider champion to assist in clinical documentation education and promote the positive aspects of moving to ICD-10-CM.
Develop physician query templates for coding and clinical documentation improvement

21. Physician Query Example
DOCUMENTATION CLARIFICATION
Malnutrition
Patient Name:
Discharge Date:
The medical record has physician documentation of "Malnutrition" needing clarification Please clarify the acuity and the condition you are treating, such as:
Mild/first degree malnutrition
Moderate/second degree malnutrition
Resulting from gastrointestinal surgery
Retarded development following protein calorie malnutrition
Severe/third degree malnutrition
Severe malnutrition with marasmus
Other (please specify)_____________
Unable to determine
Unknown

22. Questions? Kathy Fennick, RHIA, CCS kfennick@gmail.com 724-674-9168