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Understanding ICD-10 Documentation Requirements

June 5, 2013

Understanding ICD-10 Documentation RequirementsHow ICD-10 Affects Clinical Documentation

October 2014 is the deadline for implementation of ICD-10 coding standards. Preparing for the transition will be much easier when you take immediate action to improve your clinical documentation. The specificity level for the new code is much greater than that of ICD-10 and filling in the missing information will be a challenge. Major implementation issues will arise during changeover. Coding is a primary requirement of billing revenue. Being unprepared for ICD-10 documentation requirements can substantially impact your bottom line. Claims that are incomplete may preclude payment.

Under ICD-10 to assign a code: the following information will be required for code assignment.

  • Laterality – Which side is related to the procedure or event
  • Stages of healing – Includes whether healing progress is being made
  • Trimester of pregnancy – First, second or third
  • Episode of care – used to evaluate physician efficiency

How to prepare

Substantial changes in documentation are required to meet ICD-10 requirements. It’s imperative that documentation gaps be filled starting immediately. In addition physicians, coders and other relevant staff members must start training now if they haven’t begun already. Assessing the nature of missing documentation is essential. Assessment and training should be cyclic and ongoing processes.

Current documentation processes should also be assessed. Identify gaps that will need to be filled in order to ensure successful documentation under ICD-10. Next, initiate training to educate clinicians on ICD-10 documentation requirements a substantial amount of time prior to the transition so that they can have adequate time to prepare. Continue the process of assessing and training until documentation gaps are filled. Technological aids will help physicians comply with documentation requirements— Practice management systems can be configured to identify critical information missing from documentation and alert physicians to include additional detail.

Effects of Changes

Increased specificity of documentation for ICD-10 may entail significantly extra work, while challenging the way current clinical visits are documented, but it will ultimately promote patient care improvement. Collaborative insight and support for advanced research will result from ICD-10 implementation. More detailed, accurate and higher-quality data will lead to improved quality reporting, better clinical decision support and patient safety improvement.

Reimbursement for patient care will be faster with ICD-10. It will also be easier for medical coders to select the appropriate diagnostic codes because of the higher level of specificity. With greater detail fewer questions will be asked and payment difficulties will be reduced.

Documentation on Getting Ready lists resources that can help on getting ready for ICD-10; providers are encouraged to take advantage of them. One such resource can be found at Centers for Medicare & Medicaid Services (CMS) ICD-10 website. It provides a comprehensive overview and includes free papers to help in implementation. There are also official codes and guideline for both small and large practices. You can use these to walk users through the process.


The American Association of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA) offer formal training for coders. Train the trainer programs are also available.



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