tracelogoRB Staying Ahead of the Curve


Documenting for ICD-10 image



Just as with ICD-9, thorough and accurate documentation is essential for optimal patient care and accurate selection of ICD-10 codes.


CMS reminds physicians that "ICD-10 will not affect the way you provide patient care.  It will just be important to make your documentation as detailed as possible since ICD-10 gives more specific choices for coding diagnoses."


While ICD-10 codes involve greater specificity and clinical detail, in most cases, clinical documentation for ICD-10 will require just a few more words per condition documented.  The good news is that physicians already know this information as part of the clinical story based on their encounters with the patient - all they need to do is make sure they actually document this information.  And physicians may already be aware of the new terminology required due to changes in clinical practice.


Concepts that are new to ICD-10 are not new to physicians, who are already documenting in a patient's chart more clinical information than an ICD-9 code can capture, such as:


  • Initial Encounter, Subsequent Encounter, or Sequela*

  • Acute or Chronic

  • Right or Left

  • Normal Healing, Delayed Healing


Many ICD-10 codes - more than one-third - are identical except for indicating laterality (whether the right or left side of the body is affected).  The advantage of ICD-10 codes is that they enable physicians to capture laterality and other concepts in a standardized way that supports data exchange and interoperability for a more efficient health care system.


Verify Your Documentation is ICD-10 Ready


While ICD-10 should not require providers to drastically change documentation practices, assessing your current documentation is essential to ensuring your documentation practices are consistent with the greater degree of specificity and detail required by ICD-10.


To help ensure appropriate documentation in the health care records, the HNS Documentation Policies have been updated to reflect the greater degree of specificity required by ICD-10.


HNS recommends the use of the HNS Self-Assessment Documentation Form to assess your current documentation practices to ensure they support the use of the ICD-10 codes you will be reporting.


*Sequela in ICD-10 

A late effect, termed 'sequela' in ICD-10-CM, is a chronic or residual condition that is a complication of an acute condition that occurs after the acute phase of a disease, illness or injury.  It can also be caused indirectly by the treatment for the disease or condition.  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.


In the ICD-10-CM code set, instead of using 'late effects' (as in ICD-9-CM in code descriptions), the term sequel (singular) or sequelae (plural) is used in describing these diseases or conditions.