Clinical documentation tips for ICD-10

Now is the best time to consider the clinical documentation initiatives you need to implement in 2013. The preparation for ICD-10 has documentation needs first and foremost on everyone’s mind. Start now and you have time for an effective and well planned set of initiatives.

Let’s look at some of the diagnosis specific initiatives.

Diabetes documentation and coding will need to include the type or cause of diabetes:

• Type I
• Type II
• Due to drugs and chemicals
• Due to underlying condition
• Other specified diabetes.

Pathologic (non-traumatic) fracture documentation and coding will need to include:

• Exact location of fracture-site and laterality
•  Etiology of the fracture-osteoporosis, neoplastic disease, other specified
•  Encounter type-initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae

Note these OB and pregnancy coding requirements:

• Documentation of conditions/complications of pregnancy will need to specify the trimester in which the condition occurred. Some obstetric chapter codes specify trimester but not all.
• If the condition develops prior to admission, assign the trimester at the time of admission.
• If the patient is hospitalized during one trimester and a condition/complication develops during the same hospitalization but in a subsequent trimester, assign the code for the trimester in which the complication developed.
• The provider’s documentation of “weeks” may be used to assign appropriate codes for trimester.
• ICD-10-CM definitions of trimesters:

First trimester=less than 14 weeks, 0 days

Second trimester=14 weeks, 0 days to less than 28 weeks, 0 days

Third trimester=28 weeks until delivery

• Gestational diabetes needs specification of diet controlled or insulin controlled. If both, assign the code for insulin controlled.

Incorporate the following scales into documentation templates or queries.

• National Heart, Lung and Blood Institute asthma severity classification scale of intermittent, mild persistent, moderate persistent, and severe persistent.
• Glasgow Coma Scale will need a score from each of the three assessment areas: eye opening, verbal response and motor response
• Gustilo Open Fracture Classification-I, II, III, IIIB, or IIIC

Additional documentation tips:

• Anticipate needing queries for approach, laterality, and root operation for procedure coding.
• Clarify the relationship between chronic obstructive pulmonary disease, bronchitis, and asthma. ICD-10-CM distinguishes between uncomplicated cases and those in exacerbation. An acute exacerbation is a worsening or decompensating of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition. An additional code can be used regarding exposure to or use of tobacco.
• Physicians will need to document side of dominance: left, right, or ambidextrous.
• Codes in ICD-10-CM include laterality for paired organs or structures.
• General and focal seizures have different codes and general seizures require specific type and identify intractable seizures.
• Provider must identify the substance related to adverse effect, poisoning, or toxic effect.

As we learn more about ICD-10 in the coming months, more clinical documentation issues will be brought forward. Be prepared. I’ve heard it said often in 2012 that the key to successful ICD-10 implementation is improving our clinical documentation to meet the specificity requirements. Propel your ICD-10 preparation by beginning now.