Clinical Documentation
Improvement – Telling The
Patient Story Thru ICD-10
Presented by:
Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
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ICD-10 Changes Everything!
It will change the way in which we
document patient care in our medical
records both in the hospital and
in our practices.
Patient’s story will be better told through
better documentation!
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ICD-10
WHO (World Health Organization) owns &
publishes ‘ICD’ (International Classification of
Diseases).
 WHO endorsed ICD-10 in 1990; members
began using ICD-10 or modifications in 1994.
 United States is the only industrialized country
not using ICD-10 for our coding & reporting of
diseases, illnesses, and injuries. Why?

What makes us so different?
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Countries Using ICD-10
For Case Mix
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United Kingdom (1995)
Denmark, Finland, Iceland, Norway, Sweden
(1994 – 1997)
France (1997)
Australia (1998)
Belgium (1999)
Germany (2000)
Canada (2001)
United States (2015)
 (Reimbursement + Case Mix)
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What is ICD-10?
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Currently the U.S. health care industry uses ICD-9-CM
codes for identifying and reporting diagnoses and
procedures.
ICD-10 will replace the existing ICD-9 code sets (diagnosis
& procedure) effective October 1, 2015.
ICD-10-CM = Diagnosis codes
ICD-10-PCS = Inpatient hospital procedure codes only
No impact on CPT and/or HCPCS codes!
 CPT and HCPCS codes will continue to be used for
physician and outpatient services including physician
hospital visits (Observation & Inpatient) = E&M
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Why Should We Do ICD-10?

What is the benefit to the provider?
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Dramatic improvement in the assignment of costs
to procedures performed.
 ICD-10
will allow us to develop meaningful estimates
about what a disease state or a procedure costs us,
while ICD-9 is limited in what it can do in this regard.

Identify opportunities to avoid cost & improve
lives.
 Additional
information in an ICD-10 diagnosis code
includes severity and specific comorbidity, but it can
also include information about demographics and some
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of the underlying reasons for the diagnosis.
Additional Benefits…
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Share higher-quality data with other health
care providers.

ICD-10 increases the amount of “specific”
information in every diagnosis code and makes
this more valuable to other providers.
 For
example, ICD-9 has a code for laceration of an
artery.
 ICD-10 lets you know if that artery was in someone’s
finger or in their heart.
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 Reimbursements
will better align with
activity & cost.
 Payers will reimburse severe &
complex cases better and simple
cases at lower rates.
How? By the diagnosis codes!
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Here’s an Example

Imagine you had a patient who was
noncompliant with their medical therapy.
 In ICD-9, the only code we have available
is V15.81 (personal history of
noncompliance with medical treatment).
Is the patient noncompliant because of
their own personal reason? Or
something else?
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How Will it Look in ICD-10?
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Z9111 (Patient’s noncompliance with dietary regimen)
Z91120 (Patient's intentional underdosing of medication
regimen due to financial hardship)
Z91128 (Patient’s intentional underdosing of medication
regimen for other reason)
Z91130 (Patient’s unintentional underdosing of medication
regimen due to age-related debility)
Z91138 (Patient’s unintentional underdosing of medication
regimen for other reason)
Shows whether or not the patient’s noncompliance was
intentional, but also identifies if the patient needs some form
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of assistance from social services, etc.
Diagnosis Coding
(ICD-10-CM)
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ICD-10-CM
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Allows for greater “specificity & detail” which is
currently lacking in ICD-9-CM.
Moving from 14,000 ►69,000 diagnosis codes!
 25,000 (36%) of all ICD-10-CM diagnosis
codes will now distinguish ‘right’ vs. ‘left’.
 Must be documented in the medical record
for code capture.
Expanded # of characters of the ICD-10-CM
diagnosis codes will provide greater specificity to
identify: etiology, anatomical site, & severity
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Why Are There So
Many New Codes?
Main difference between ICD-9-CM and ICD10-CM codes, outside of structural changes,
is the “SPECIFICITY” of the code.
 ICD-10-CM diagnosis codes will range
anywhere from 3 to 7 characters which will
allow us to capture this greater detail.
 But it must be documented in the record!
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ICD-9-CM vs. ICD-10-CM
ICD-9-CM
3 - 5 digits or characters
1st character is numeric or
alpha (E or V codes)
◦ 2nd – 5th characters are
numeric
◦ Decimal placed after the
first 3 characters
◦ 17 Chapters and “V” & “E”
codes are ‘supplemental’
◦ 14,000 diagnosis codes
◦
◦
ICD-10-CM
3 - 7 digits or characters
1st character is alpha (all
letters used except “U”)
◦ 2nd – 7th characters can be
alpha and/or numeric
◦ Decimal placed after the
first 3 characters (the
same!)
◦ 21 Chapters and “V” & “E”
codes are ‘not’ supplemental
◦ 69,000+ diagnosis codes
◦
◦
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Level of Detail Example
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ICD-9-CM (Irregular Astigmatism) (367.22)
 Only 1 code in ICD-9-CM
ICD-10-CM (Irregular Astigmatism)
 Will have four choices:
 H52.211 (irregular astigmatism, right eye)
 H52.212 (irregular astigmatism, left eye)
 H52.213 (irregular astigmatism, bilateral)
 H52.219 (irregular astigmatism, unspecified eye)
Physicians are likely documenting “laterality” now, but
coders aren’t looking for it.
 One easy place to look for documentation improvement!
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Biggest Change in ICD-10-CM
LATERALITY
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For bilateral sites, the final character of the codes in
ICD-10-CM indicate laterality.
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Right side is always character 1 (RT)
Left side is always character 2 (LT)
Bilateral code is always character 3 (RT & LT)
But be careful! Not all codes will have a ‘bilateral’
distinction, i.e., carpal tunnel, etc.
“Unspecified” side code is also provided should the
side not be documented in the medical record.
Did we just lose our specificity?
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Diagnoses That Will
Require Laterality
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Joint pain
Joint effusion
Injuries
Fractures
Dislocations
Arthritis
Cerebral infarction
Extremity atherosclerosis
Pressure ulcers
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Cancers, neoplasms (breast, lung, bones, etc.)
Injuries
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Seventh (7th) character identifies the patient
encounter type, with “A” for the initial
encounter, “D” for the subsequent
encounter and “S” for sequela encounter.
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Initial = Patient is receiving ‘active’ treatment
 First
time being seen for the injury, i.e., ER visit,
surgery, evaluation by new physician
Subsequent = Follow-up care
 Sequela = Complication of a previous injury
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Examples of ICD-10-CM
Emergency Room
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I10
Essential (primary) hypertension
S01.02xA Laceration with foreign body of scalp, initial
encounter
S01.02xD Laceration with foreign body of scalp,
subsequent encounter
S02.2xxA Fracture of nasal bones, initial encounter for
closed fracture
H65.01
Acute serous otitis media, right ear
H65.02
Acute serous otitis media, left ear
H65.03
Acute serous otitis media, bilateral
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Procedure Coding
(ICD-10-PCS)
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ICD-10-PCS Characters
(Medical and Surgical Section)
1
2
3
4
Root
Operation
Section
5
6
Approach
Body
Body
System
Part
7
Qualifier
Device
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Dissect ICD-10-PCS Code
Endoscopic Esophageal Excision via Natural or Artificial Opening
ICD-9-CM: 45.16 Esophagogastroduodenoscopy (EGD) with Closed Biopsy
0
D
B
5
8
Z
X
Section
(Medical/Surgical)
Body System
(Gastrointestinal)
Root
Operation
(Excision)
Body Part
(Esophagus)
Approach
(Via natural or
artificial
opening
endoscopic)
Device
(No Device)
Qualifier
(Diagnostic)
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What’s New In ICD-10?
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Obstetrics
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Under ICD-10-CM diagnosis codes will be
based on the stage of pregnancy
 First
trimester
 Second trimester
 Third trimester
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Trimesters are counted from the first day of
the last menstrual period, and defined as:
First trimester: Fewer than 14 weeks
 Second trimester: Fourteen weeks
 Third trimester: Twenty-eight weeks
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Nicotine Dependence
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ICD-10-CM contains a separate category for
nicotine dependence with subcategories to identify
the specific tobacco product and nicotine-induced
disorder(s). For example:
 Cigarettes
 Chewing tobacco
 Cigar, etc.
ICD-9 has only one diagnosis code (305.1) for
tobacco use disorder or tobacco dependence.
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Underdosing
New diagnosis code in the ICD-10 world!
 Identifies situations in which a patient has
taken less of a medication than prescribed
by the physician and captures those
reason(s).
 Must be documented in the record!
Financial
Non-compliance*
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Burns and Corrosions
Burn codes identify:
 Thermal burns, except for sunburns, that
come from a heat source
 Burns resulting from electricity and/or
radiation
 Addition of the term “corrosion” is new in
ICD-10-CM:
 Corrosions are burns due to chemicals
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Physician Documentation
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Top 10 Documentation
‘Pearls’
1.
2.
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5.
6.
7.
8.
9.
10.
Laterality (left vs. right)
Stage of Care (initial or follow-up)
Specific Diagnosis (acute vs. chronic)
Specific Anatomy (specific bone in the hand)
Associated and/or Related Conditions
Cause of Injury (hit by baseball, fall)
Documentation of Additional Symptoms or Conditions
Dominant vs. Non-Dominant Side
Tobacco Exposure or Use
Gustilo-Anderson Scale
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Documentation Tips
For Specific Diagnoses
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GERD Documentation
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ICD-10-CM will include 2 codes but does not include the
abbreviation “GERD”
 K21.0 (Gastro-esophageal reflux disease with
esophagitis)
 K21.9 (Gastro-esophageal reflux disease without
esophagitis)
Barrett’s now broken down:
 With or without ulcer
 With or without dysplasia
 Staging of dysplasia
 Low grade
 High grade
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Digestive Ulcer
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Documentation needs to include the specific location:
 Gastric
 Duodenal
 Peptic
 Gastrojejunal
Further specificity needs to identify:
 Acute or chronic
 With hemorrhage
 With perforation
 With hemorrhage and perforation
 Without mention of hemorrhage or perforation
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Asthma Documentation
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Document the Severity (3 levels):
1. Mild (more than two times per week)
2. Moderate (daily and may restrict physical activity)
3. Severe (throughout the day with frequent severe attacks
limiting the ability to breathe)
Clarify whether acute, chronic, intrinsic or extrinsic
Specify exercise-induced or other forms
Specify when chronic state asthmatic bronchitis exists and
when acute exacerbation occurs
Document tobacco exposure or history of
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Congestive Heart Failure
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Documentation in ICD-10-CM needs to
identify whether the CHF is acute or
chronic and the specific ‘type’ of heart
failure:
Combined systolic & diastolic
 Diastolic
 Systolic
 Left ventricular
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Bronchitis
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Need to include specificity such as:

Acute or subacute
 Further
specify with bronchiectasis, COPD, etc.
Allergic
 Asthmatic
 Chronic
 Obstructive
 Viral
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Diabetes Mellitus
ICD-9 features 59 codes for diabetes, while
ICD-10 offers more than 200 and adds a
provision of “poorly controlled” to categories
of controlled or not controlled.
 Diabetes mellitus codes expanded to include
the classification of the diabetes AND the
manifestation.
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Needs to be clearly documented in the record!
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More on Diabetes
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Identify Type 1, Type 2, due to other secondary
cause, i.e., gestational, etc.
In Type 2 or secondary cause, identify when using
insulin long-term
Identify all body systems affected by the diabetes
(neuropathy and its manifestation, retinopathy and
proliferative or nonproliferative, nephropathy and
stage of CKD, vasculopathy, etc.)
Identify all manifestations (ulcer, coma, gangrene,
osteomyelitis, etc.)
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Hypertension & CKD
When a patient has both a diagnosis of
hypertension and CKD, there is an assumed
‘cause and effect’ relationship and will be
reported as “hypertensive chronic kidney
disease, stage I through stage IV, or
unspecified, unspecified benign or malignant”.
 If not related, provider documentation must
be stated as not due to hypertension.
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Additional documentation needs to include:
 Stage I
 Stage II (mild)
 Stage III (moderate)
 Stage IV (severe)
 Stage V
 Requiring chronic dialysis
 End-stage renal disease
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Chest Pain
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Medical record documentation must
include the specific location of the chest
pain:
Anterior wall
 Atypical
 Intercostal
 Musculoskeletal
 Non-cardiac
 Precordial
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Fracture Documentation
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Documentation will need to include the following
to accurately code a fracture in ICD-10-CM:
 Displaced or non-displaced
 Open or closed
 Laterality (left vs. right vs. bilateral)
 Specific bone and location of the bone
 Distal, proximal, mid-shaft, etc.
 Encounter
 Initial, subsequent, sequela
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Fracture “Subsequent”
Encounter
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Subsequent encounter for open and closed fractures:
 Used for encounters after active fracture
treatment has been completed and the patient is
receiving routine care during the healing or
recovery period.
 Closed Fracture 7th Character Extensions:
D
► Routine healing or aftercare
 G ► Delayed healing
 K ► Nonunion
 P ► Malunion
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What is Gustilo-Anderson Scale?
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Gustilo-Anderson classification identifies the ‘severity of soft
tissue damage’ in open fractures – may be new to coders and
physicians:
 Type I: Wound is smaller than 1 cm, clean, and generally
caused by a fracture fragment that pierces the skin (low
energy injury)
 Type II: Wound is longer than 1 cm, not contaminated, and
w/o major soft tissue damage or defect (low energy injury)
 Type III: Wound is longer than 1 cm, with significant soft
tissue disruption. The mechanism often involves highenergy trauma, resulting in a severely unstable fracture
with varying degrees of fragmentation.
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Hernias
Specify location (inguinal, femoral, umbilical,
ventral, diaphragmatic; all other abdominal
hernias default to “other”, etc.)
 Specify unilateral (which side) or bilateral
 Specify with obstruction when present
 Specify with gangrene when present
 Specify when recurrent hernia (defaults to
primary)
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Malignancy Example
Malignant Neoplasm Lung/Bronchus
 63 choices available in ICD-10-CM
 Documentation must include:
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Specific site/location:
 Hilus,
lingula, main bronchus, lower lobe, middle
lobe, upper lobe, etc.
Laterality
 Tobacco exposure or use (secondary diagnosis)
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 Example:
C34.2 (Malignant neoplasm of middle
lobe, bronchus or lung)
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Physician Practices
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ICD-10-CM diagnosis codes will impact every
physician practice large or small!
Look at all areas that will impact your practice and
identify each one that will be affected:
 Practice Management System
 Electronic Medical Record (EMR)
 Paper record
 Superbill/encounter form – Does it have
diagnosis codes on it?
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 Lab requisitions
Task Is Not As Huge
As It Appears!
Although the coding book is “huge”, many
physician practices use only a small set or #
of diagnosis codes.
 Start developing crosswalks between
ICD-9-CM & ICD-10-CM codes you use
most frequently in the office.
 Revise your superbill/encounter form if it
currently contains ICD-9-CM codes.
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That’s ICD-10!
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Contact Info:
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Certified ICD-10 Trainer
President, DiagnosisPlus, Inc.
PO Box 486
Pocatello, ID 83204
(208) 221-5486
diagnosisplus1@live.com
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