Because the ICD-10 codes sets have approximately five times more codes than ICD-9-CM, many presume this equates to the need for five times more clinical documentation. A close look at the changes in the ICD-10 code sets shows how inaccurate this assumption is. For instance the addition of laterality (left and right) to ICD-10-CM codes (where applicable) had an exponential effect on the number of codes in the code set, yet left and right is commonly documented in health records today. In general, the underlying rationale for modifications to ICD, when creating the 10^th version, were done to update the code set to reflect current medical practice. So in many instances we can expect that the ICD-10 codes will more closely reflect terminology that physicians use today. Diabetes mellitus is a good example of this. Coding Guidelines for diabetes are extensive. Numerous AHA Coding Clinic articles have been published addressing questions on the appropriate assignment of diabetes codes, all in an attempt to provide clarity and consistency in using ICD-9-CM codes that are based on antiquated terminology. We’ve found that assigning codes for diabetes is actually much easier in ICD-10-CM than in ICD-9-CM.

Still, no one doubts that more specific clinical documentation will be needed in many instances to take advantage of the specificity provided in the ICD-10 code sets. On this issue however, more is not always better. The focus should be on quality not quantity. That’s why it’s important to identify your ICD-10 documentation gaps, determine pragmatic tactics to capture the desired specificity, and prioritize your documentation improvement efforts.

The best way to identify your ICD-10 documentation gaps is to perform ICD-10-CM/PCS coding on a representative sampling of inpatient records and capture details on the specificity of clinical documentation currently available. You should look at records that reflect the intersection of where the most changes were made in the code set and the most common cases in your hospital. The specific details you capture on the missing elements required for correct code assignment will help you identify focus areas for clinical documentation improvement efforts.

According to AHIMA, identifying your ICD-10 documentation gaps is something you should be doing now. The AHIMA Top 10 list for Phase 2 of ICD10 implementation specifically lists evaluation of “the detail and quality of medical record documentation” and “implementing/monitoring of documentation improvement strategies” as a priority right now (starting in 2011). This makes good sense because it’s difficult to change clinician documentation habits.  Documentation improvement requires lead time to achieve measurable success. This is something you can do now to take proactive steps to better prepare. After all, if documentation is insufficient for ICD-10, more physician queries will be needed, which will significantly impede coding operations on and around Oct 1, 2013.

Mary H. Stanfill - Vice President of Health Management Services

November 21, 2011