1) The document discusses the importance of proper clinical documentation for selecting accurate ICD-10-CM codes beginning October 1, 2015. 2) ICD-10-CM requires more specific documentation than ICD-9-CM to capture details like laterality, severity, and complications. 3) Providers are encouraged to review their documentation practices to ensure specific details are included to support code selection and to avoid issues with reimbursement.

1. Clinical Documentation for
ICD-10-CM
ADOPTERS OR LAGGARDS – WHICH ARE YOU?

2. Pamela Marasco MEd, CPC
Adjunct Faculty, IUPUI School of Informatics and Computing
Department of BioInformatics, Human-Centered Computing, Library and Information Science
Health Information Management Program
American Academy of Professional Coders (AAPC) Approved
ICD-10-CM Trainer

3. How Do You Rate Yourself
as an Adopter of
Change?
Assess your willingness to implement
new clinical documentation for
ICD-10-CM
Improve your practices for clinical
documentation to ensure proper
selection of ICD-10-CM Coding
Guidelines
Because EVERYTHING IS
CHANGING!
From Everett Rogers "Diffusion of Innovations"
Innovator
Early Adopter
Early Majority
Late Majority
Laggards

4. Everything is Different
ICD-10-CM changes the way healthcare
providers deliver healthcare.
• Increased number of index chapters and codes
• Length of codes
• Level of specificity
• Increased number of ICD-10-CM External Cause
Codes
• Enhanced statistical gathering of health
information
• Refined levels of documentation
10-01-2015
ICD-10-CM

5. Don’t Be Like This
Version
Don’t be a provider version of a
documentation laggard for ICD-10-CM
implementation on Oct 1st 2015.
Be an active adopter of ICD-10-CM
Documentation Guidelines in your practice
for effective and quality patient care, as well
as for billing, reimbursement, research and
healthcare policy improvement.
Assess your clinical
documentation NOW!

6. Looking For Good Data
Heath care policy makers are
looking for ICD-10-CM to provide
good data to
 Evaluate disease management
 Evaluate population needs
 Eliminate waste
 Capture financial metrics
 Assist in forecasting budgets
 Provide care management
 More precisely identify and track
specific conditions
 Guide other business decisions that
affect the bottom line

7. Documentation - Capturing Data
Current ICD-10-CM revisions and
coding guidelines are intended
to capture a snapshot of
population health to
 aid in the decision making and
management of health systems
worldwide
 as well as establish medical
necessity of procedures and
services provided to patients
during an encounter

8. It’s About the Clinical Picture of
the Patient
Documenting the medical decision
making process . . . rather than just
the medical decision determines
and supports medical necessity
IDC-10-CM Documentation is All
About the Process

9. For Example
“Mrs. Rose is a 68 year old female with multiple
comorbidities. She has a moderate size aneurysm.
This does not currently require treatment but will in the
future. Bilateral lower extremity claudication is a major
problem which will require surgery. Endovascular
intervention is not a good idea because of the
aneurysm and total occlusion on the left. Open
surgery would treat both of these problems…”
Rather Than
“Bilateral claudication; surgery to be scheduled for
next week”.

10. Good Documentation is Needed
 To justify medical necessity
 To ensure accurate documentation
for equitable reimbursement and
future payment trends
 Minimize reduced or denied
payments
 Avoid audit takebacks
 Ensure quality health care

11. Documentation
Mistakes Matter
Don’t take documentation for
granted.
Providers need to review and update
practice policies for ICD-10-CM
Clinical Documentation Guidelines to
provide good and proper data.

12. Avoid EHR Documentation Shortcuts
 Don’t rely on “cut and paste”
platforms to support medical
necessity.
 Progress notes must be dedicated
to each patient encounter or
payers may question whether
services are medically necessary.
 Avoid carrying forward
documentation.
 Avoid cloned documentation.
Cloned Documentation
CMS has stated that
“Documentation is considered cloned when
each entry in the medical record for a
beneficiary is worded exactly like or similar to
the previous entries”.
“Cloning also occurs when medical
documentation is exactly the same from
beneficiary to beneficiary. It would not be
expected that every patient had the exact
same problem, symptoms, and required the
exact same treatment”

13. But Don’t Blame Your EHR
Don’t Misuse Your EHR
Just because some poor documentation
practices are possible in an EHR doesn’t
mean that EHRs in general lead to poor
or faulty documentation.
Review your practice EHR programs and
the way that you use them.

14. Don’t Rely on GEMs?
 GEM translations on computer based
systems are a helpful way to start looking for
a code when you move from ICD-9-CM to
ICD-10-CM.
 GEMs will get you to the area of search but
do not rely on them to assign a specific
code.
 GEMs are not a one-to-one match for ICD-
10-CM codes because of the increased
specificity in ICD-10-CM.
 Documentation must support crosswalk
coding and GEM mapping.
General Equivalence Mapping

15. Documentation Integrity and ICD-10-CM
The documentation of each patient encounter
should include relevant information on the
 reason for the encounter
 relevant patient history
 physical examination findings
 prior diagnostic test results
 assessment
 clinical impression
 diagnosis
 plan for care
 dated
 legible identity of the observer
Documentation integrity is based on
a flow of information that is
• Credible
• Reliable
• Patient Specific
• Avoid non-specific or irrelevant
documentation.

16. “
”
If it isn’t written down it
didn’t happen”
DOCUMENTATION - MATERIAL THAT PROVIDES OFFICIAL INFORMATION OR EVIDENCE OR
THAT SERVES AS A RECORD TO ESTABLISH MEDICAL NECESSITY.
Who hasn’t heard this old adage at some point or another. The principle
underlying this old rule of thumb is more true now than ever before.

17. • ICD-10-CM code structure
reflects the need for proper
documentation.
• In ICD-10-CM up to 7
alphanumeric characters and
placeholders are used to define
provider documentation with
greater specificity.
ICD-10-CM Code S82.221A
ICD-10-CM Restructures the
Reporting of Diagnoses
Coding’s New Zip Code

18. Place Matters
Defaults
There are specific ICD-10-CM Guidelines for
circumstances in the medical record when
the provider does not mention a modifying
condition. In this case the coder would
accept a preselected agreed upon option
choice. Examples include
 Diabetes mellitus - If the type of diabetes
is not mentioned in the medical record it
defaults to Type II
 Fractures - If the provider does not
indicate whether the fracture was open
or closed the code defaults to closed. If
the physician does not indicate whether
the fracture is displaced or
nondisplaced, the code defaults to
displaced
Position
Where X character is located matters
► X at the beginning of a code indicates a
code from ICD-10-CM Chapter 20: External
Causes of Morbidity
X78.0
 X located in the 5th and/or 6th character X is
a dummy placeholder
S03.0XXD

19. X Marks the Spot
Which answer choice is best?
1. The X serves as a placeholder for future expansion
2. The X serves as a placeholder to allow a code to
meet the specific requirement of coding to the
highest level of specificity when the code has fewer
than 6 characters and requires a 7th character
extension
3. Both 1 and 2 are correct
4. The “X” is a signal that the code is incomplete
Number3

20. ICD-10-CM Documentation
Granularity
There are nearly 5 times as many diagnostic
codes in ICD-10-CM than in ICD-9-CM.
ICD-10-CM has 70,000 codes vs14,000
codes in ICD-9-CM.
There are nearly 19 times as many
procedure codes in ICD-10-PCS than in ICD-
9-CM volume 3.
Granularity - greater specificity in identifying health conditions.
The greater level of detail in the new
ICD-10-CM code sets includes
• Laterality
• Severity
• Complexity of Disease
Conditions
.

21. ICD-10-CM Documentation Granularity Means
Greater Specificity
More Specific Codes Are Used in ICD-10-CM To Report
 Expanded “cause” codes (V-W-X-Y) to
replace E codes
 Laterality
 Episode of care – initial, subsequent, sequela
injuries, poisonings, complications of pregnancy
 Trimester of Pregnancy
 Clinical details such as acute vs. chronic
 Place of occurrence (used only once at
initial encounter)
College
Daycare center
Elementary school
High school
Kindergarten
Middle school
University
Vocational school

22. Macaws vs Parrots
ICD-10-CM Coding Specificity How to code “bitten by a bird”
Patient bitten by a macaw initial
encounter
There is a specific code for that type
of bird. (injuries –external causes –
contact with birds – parrot –macaw
etc.
W61.11XA
Macaws are a type of tropical parrot
whereas parrots are found all over
the world except Antarctica. Very
specific, indeed!
ICD-10-CM
Requires
More
Specificity

23. The Specifics of Coding a Fall While
Snow Skiing in Aspen
While skiing in Colorado, the patient fell and was
diagnosed with a fracture of the right ankle
1. identified fx as traumatic vs pathological
2. query provider as to specific location (lateral
malleolus)
4 codes needed:
S82.61XA Displaced fx, rt ankle, lateral malleolus, initial
encounter
V00.321A Snow – ski accident
Y92.39 Other specified sports and athletic area as the
place of occurrence
Y93.23 Other individual sport
Need more
documentation
If the provider does not indicate whether the fracture was
open or closed the code defaults to closed. If the
physician does not indicate whether the fracture is
displaced or nondisplaced, the code defaults to
displaced

24. ICD-10-CM Documentation
Laterality
Code descriptors include a right and
left designation that enables
documentation reflecting the
importance of which side of the body
or limb is subject to evaluation
ICD-10-CM Code S72.351C
(1 )indicates right side
(C) Indicates initial encounter for open
fracture type IIIA, IIIB, or IIIC

25. ICD-10-CM Documentation
Encounters – Episode of Care
 (A) Initial - active treatment
 (D) Subsequent - healing or recovery phase
 (S) Sequela = aftercare - residual
complications or conditions that arise as a
direct result of the injury
Initial Encounter –
Seen by multiple physicians (ED,
radiologist, neurologist) or over
an extensive period of time
(entire acute care hospital stay).
Subsequent Encounter –
Received active tx and physician is
providing routine care during the healing
or recovery phase.

26. Do not confuse initial
encounter with first visit and
subsequent encounter doesn’t
mean that ‘it happened again’.

27. ICD-10-CM Documentation for
Sequela
Sequela (ICD-9-CM Late Effect)
 The residual effect (condition
produced) after the acute phase of a
illness or injury has terminated
 You can report a sequela code at any
time after the acute phase ends
 There is no time limit on when a late
effect can occur; the residual
condition may come directly after the
disease or condition, or years later
Coding Guidelines
 When coding for sequela(e), there are typically two
codes that are required. The condition or nature of
the sequela(e)/late effect is sequenced first and the
sequela(e) (late effect) sequenced second
 Example:
 M81.8 Other osteoporosis without current
pathological fracture
 E64.8 Sequelae of other nutritional deficiencies
(calcium deficiency)
 Exceptions to this rule are if the code for the late
effect is followed by a manifestation code, identified
in the Tabular List and title or if the late effect code
has been included in the fourth, fifth, or sixth
character levels to include the manifestation(s).
Example: I69.191 Dysphagia following nontraumatic
intracerebral hemorrhage

28. Worms in the Head
Coding Sequela (Late Effects)
 Patient presents with a personal
history of parasitic worm invasion
of the brain. The worm is dead but
the patient is suffering from the
after effects (severe headaches).
 Heaches (R51) the condition or
nature of the sequela) are listed
first followed by the
Sequela(as an after effect) (B94.9) –
of other unspecified parasitic and
infectious disease
R51 – B94.9

29. ICD-10-CM Documentation
Complications of Care
 Certain intraoperative and post-
procedural complications are
reclassified to specific body system
chapters; yet others remain in
chapter 19 (chapter 17, ICD-9-CM).
 Not all conditions that occur during
or following medical care or surgery
are classified as complications.
 Must be a cause-and-effect
relationship between the care
provided and the condition, and an
indication in the documentation
that it is a complication.
 Guidelines require the presence of a
cause-and-effect relationship
 If it is anticipated, expected, and
routine for certain types of
procedures, it is not a complication
Complications
 Sequence the complication code
first followed by additional codes
to specify the nature of the
complication, when necessary:
 Examples
 Chapter 19:
 T86.43 Liver transplant infection
 B25.1 Cytomegaloviral hepatitis

30. Extend Yourself
 Coding injuries, poisonings, and certain
other conditions in ICD-10-CM will
require additional documentation in
order to capture episode of care
 As are certain complications of
pregnancy with multiple gestation to
identify which fetus(es) is(are)affected
by the condition described by the
code
 Code extenders often infer morphology
and treatment parameters
 Make sure to look at Extendor Boxes
and Chapter Guidelines for instructions
Example from category S52 .
A initial encounter for closed fracture
B initial encounter for open fracture type I or II
initial encounter for open fracture NOS
C initial encounter for open fracture type IIIA, IIIB, or IIIC
D subsequent encounter for closed fracture with routine healing
E subsequent encounter for open fracture type I or II with routine
healing
F subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
routine healing
G subsequent encounter for closed fracture with delayed healing
H subsequent encounter for open fracture type I or II with delayed
healing
J subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
delayed healing
K subsequent encounter for closed fracture with nonunion
M subsequent encounter for open fracture type I or II with nonunion
N subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
nonunion
P subsequent encounter for closed fracture with malunion
Q subsequent encounter for open fracture type I or II with malunion
R subsequent encounter for open fracture type IIIA, IIIB, or IIIC with
malunion
S sequela

31. An ICD-10 –CM Code with a
7th Character Extension
 S92.412A initial visit for a
displaced fracture of the
proximal phalanx of the
left great toe
A - Initial Encounter for closed FX
B - Initial Encounter for open FX
D - Subsequent Encounter for FX with routine healing
G – Subsequent Encounter for FX with delayed healing
K – Subsequent Encounter for FX with nonunion
P – Subsequent Encounter for FX with malunion
S – Sequela – late effect - residual complications or
conditions that arise as a direct result of the injury
The aftercare Z codes should not be used for aftercare of injuries.
For aftercare of an injury, the coder will assign the acute injury
code with the appropriate seventh character for subsequent
encounter.

32. ICD-10-CM Documentation
Terminology
Terminology and disease classification are now consistent with new
technology and current clinical practice.
In certain cases the following terms with associated clinical criterion are
needed to assign the proper ICD-10-CM code
 Frequency
 Severity
 Type
 Complications
 Contributing factors

33. ICD-10-CM Terminology Changes
First Listed
Replaces use of the term
Primary Diagnosis
Encounter Sequela
Replaces Late Effect. Also known as
lasting effects .For example after a
CVA patient may suffer additional
health problems lasting after the
event has passed
Underdosing
Taking less of a medication
that is prescribed by the
physician or manufacturer’s
instructions resulting in a
negative health
consequence
Initial –
receiving active tx even if seen
by multiple physicians (ED,
radiologist, neurologist) or over
an extensive period of time
(entire acute care hospital stay)
Subsequent –
has received active
tx and physician is providing
routine care during the healing
or recovery phase
Do not confuse initial encounter
with first visit
Rubric
A grouping of similar conditions.
In ICD-10-CM, rubric denotes
either a three-character category
or a four-character subcategory.

34. ICD-10-CM Terminology Documentation
Controlled vs Uncontrolled
 In ICD-10-CM, the diabetes
mellitus codes are no longer
classified as controlled or
uncontrolled.
 If the type of diabetes is unclear or
not mentioned in the medical
record it defaults to Type II
 If provider documentation
includes words such as
uncontrolled, out of control, or
poorly controlled, the classification
directs the coder to code the type
of diabetes with hyperglycemia.

35. ICD-10-CM Terminology Documentation
Controlled vs Uncontrolled
 ICD-10-CM does not use
controlled and uncontrolled to
describe hypertension as did ICD-
9-CM
 Coders should look in
documentation for terms such as
“transient hypertension” when a
provider records an episode of
elevated blood pressure w/o a
formal diagnosis of hypertension
 Report Code R03.0 (elevated BP
reading w/o diagnosis of
hypertension)

36. ICD-10-CM Terminology Documentation
Combination Coding
A Combination code combines documented
information in a single code. Such as
 A diagnosis with an associated secondary
process (manifestation)
 A diagnosis with an associated complication
 A diagnosis that includes condition and
symptoms or manifestations
 A diagnosis that includes location and stage
 As many combination codes as necessary can
be used to fully describe all complications or
conditions met. They should be sequenced
based on the reason for a particular encounter.
ICD-10-CM Combination Code E11.351
Type 2 diabetes with proliferative
diabetic neuropathy with macular
edema
ICD-10-CM Combination Code N41.01
Acute prostatitis with hematuria
ICD-10-CM Combination Code K50.841
Crohn’s disease of both small and large
intestine with abscess

37. Working Together
 Combination codes must fully
identify the diagnostic conditions
involved.
 If a combination code exists, and
the documentation does not
include all of the pertinent
information to assign the
combination code, the coder will
need to query the provider to
assign the most appropriate code.
 ICD-10-CM contains a number of
combination codes that identify
both the definitive diagnosis and
common symptoms of that
diagnosis
Expanded combination coding allow for
a greater level of specificity and clinical
detail

38. ICD-10-CM Terminology Documentation
Guidelines and Conventions
Excludes 1 Note
An Excludes1 note is a pure
excludes note. An
Excludes1 note indicates
that a coder should never
use the excluded code
with the code above the
Excludes1 note. The two
conditions cannot occur
together
Excludes 2 Note
Supporting
Documentation
An Excludes 2 note means
a condition is not included
in the code. An Excludes 2
note indicates that the
excluded condition is not
part of the condition the
code represents, but a
patient may have both
conditions simultaneously.
When an Excludes 2 note
appears under a code may
report both the code and
the excluded code
together when appropriate.

39. ICD-10-CM Common Coding Conventions
 Punctuation/Symbols
 Instructional notes as in “code first” and “use additional code”
 Abbreviations such as
 NEC “Not Elsewhere Classifiable”. Used when the physician provides the detail, but
no code exists to report it. An Alphabetic Index entry that directs the coder to an
“other specified” code in the Tabular List.
 NOS – “Not Otherwise Specified”. The equivalent of unspecified. NOS codes are used
when the physician does not document enough information for coders to select a
more specific code. Documentation of the condition identified by the provider is
insufficient to assign a more specific code. Even though ICD-10-CM codes include
more detail than ICD-9-CM codes, coders will still have the option to use an
unspecified code. What remains unclear is how payers will reimburse for the
unspecified codes.
 Sequencing as in etiology and manifestation

40. “
”CONVENTION - A WAY IN WHICH SOMETHING IS USUALLY DONE, AN AGREEMENT COVERING PARTICULAR MATTERS
A Word About ICD-10-CM Conventions
Do Not Ignore. Conventions provide
important information that lead you to the
proper code and require supporting
documentation

41. A Word About Guidelines
Understanding and adhering to the guidelines will ensure that you achieve
accurate and complete documentation and reporting of diagnoses and
code assignments
Guidelines are found at the beginning of the ICD-10-CM book and at the
beginning of each Chapter section.
Example of Coding Guideilnes from Coding of Injuries
 When coding injuries, assign separate codes for each injury unless a
combination code is provided, in which case the combination code is
assigned. Code T07, Unspecified multiple injuries should not be assigned
in the inpatient setting unless information for a more specific code is not
available. Traumatic injury codes (S00-T14.9) are not to be used for
normal, healing surgical wounds or to identify complications of surgical
wounds.
Guidelines are a set of rules developed to complement and accompany the official conventions provided in
ICD-10-CM

42. ICD-10-CM Terminology Documentation
Manifest Destiny
• A manifestation is a display of the
signs or symptoms or the disease
• A manifestation is an extension of the
primary illness
• A manifestation is due to the primary
illness and would not exist if not for
the primary illness
• Manifestation codes will have “in
diseases classified elsewhere” in the
code title and used in conjunction
with an underlying condition code
• Manifestation codes must be listed
following the underlying condition
etiology code
Meaning and Use of Manifestation in ICD-10-CM
 Example: Neuropathy is a manifestation of
diabetes
 CODE FIRST Diabetes

43. Who’s on First?
What’s on Second?
ICD-10-CM Code Conventions for Etiology and Manifestation
Guidelines for certain conditions that have both an
underlying etiology and multiple body system
manifestations due to the underlying etiology
• Sequence the etiology (underlying condition) FIRST
followed by the manifestation
• Look for “use additional code” note at the etiology
code
• Look for “code first” at the manifestation code
• [ ] brackets are used in the Alphabetic Index to identify
manifestation codes
Note - [ ] brackets are used in the Tabular List to include
synonyms, alternate or explanatory wording
Code
First

44. Sequencing and Pregnancy
 Codes for pregnancy, childbirth
and the puerperium (Chapter 15)
are always sequenced first
024.012 Pre-existing diabetes mellitus,
Type I (in pregnancy -2nd trimester)
Z3A.18 18 weeks gestation of
pregnancy

45. ICD-10-CM Terminology Documentation
Up in Smoke
Tobacco Terms
 You will notice as a constant recurrent
theme in ICD-10, if there's any exposure
to tobacco
 Whether it's in the cardiovascular system,
respiratory system, or during pregnancy
you're going find notes on these terms
with required documentation
 The statement “patient smokes” or
“patient smokes occasionally” or
“patient is a social smoker” is tobacco
use
 Patient “smokes 2 packs a day” or
“patient has 40 pack per year habit” is
nicotine dependence.
Tobacco Codes
 Exposure to environmental tobacco
smoke Z77.22
 History of tobacco use Z87.891
 Occupational exposure to
environmental tobacco smoke Z57.31
 Tobacco dependence F17. -
 Tobacco use Z72. 0

46. Need for Change
The updated code sets will allow, and in fact
will require, significant changes in the way
providers document and support medical
necessity resulting in the way health plans
reimburse services, and in the way coverage of
services is determined.
• ICD-10-CM has been designed to enable
significant improvements in data reporting for
care management, research, and quality
measurement
• ICD-10-CM will allow better exchange of
information with other countries who have
already adopted ICD-10 and encourage
international compatibility.

47. Coding’s Y-2-K
The Final Rule Requiring
Replacement of ICD-9-CM
with ICD-10-CM Sets the Compliance
Date for October 1, 2015.

48. • Purpose
• Scope
• Evidence
• Value
with consistent, complete, specific and accurate
documentation to justify procedures and level of service provided.
Clinical Documentation For ICD-10-CM Requires

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