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Volume 24 Bulletin 1/2014

AMERICAN MEDICAL ASSOCIATION

BULLETIN 2014

Clinical Documentation Assessment: Looking at the Patterns Between the ICD-9-CM and ICD-10-CM Coding Systems

Clinical documentation specificity is one of the most important characteristics of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding system. Additional details in clinical documentation provides more information, suggestions, guidance, and checklists—all of which will be used by coding professionals to select the appropriate codes that most accurately describe the procedure(s)/service(s) provided.

One aspect of performing a clinical document assessment to test an organization’s ICD-10-CM readiness is to assess the quality of its current medical record documentation. In order to do so, it is necessary to be able to identify proper clinical documentation for the ICD-10-CM code set and understand the similarities and differences between the clinical concepts of the ICD-9-CM and ICD-10-CM coding systems. This article provides an overview of conducting a clinical documentation assessment to prepare for the

ICD-10-CM transition, and looks at the similarities and differences between the clinical concepts of ICD-9-CM and ICD-10-CM.

Conducting a Clinical Documentation AssessmentConducting a clinical documentation assessment is a step toward preparing for the transition to the ICD-10-CM code set that does not first require updates to the practice man-agement system (PMS) or electronic health record (EHR). It is important to note that although a clinical documenta-tion assessment can be done without updating either the PMS or EHR right away, updates to these systems may be necessary depending on the results of the assessment. Clinical practices may perform clinical documentation assessments by using current patient charts as samples to code patient scenarios with the ICD-10-CM code set. The

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CPT® Assistant Bulletin / Volume 24 Issue 1 • 2014

charts selected as samples should include a variety of patient conditions, including the most common diagnoses seen in the practice, as well as some conditions that are less com-monly seen. In addition, when conducting a documentation assessment, it is important to identify the information that is considered necessary to complete the coding process but is missing or insufficient in current documentation.

Although current clinical documentation practices may be sufficient for ICD-10-CM coding, it is anticipated that some changes in documentation may be necessary to better describe patients’ clinical scenarios. Due to the increased specificity of the ICD-10-CM diagnosis codes, clinical documentation should be detailed enough to allow coding professionals to identify the most accurate code from the ICD-10-CM code set.

The American Academy of Professional Coders (AAPC) has conducted thousands of documentation assessments. And, based on these assessments, they have concluded that only 63%1 of current documentation is detailed enough to use with the ICD-10-CM code set, which means 4 out of 10 claims could be rejected as insufficient due to a lack of detailed documentation. (Note: This average is mistakenly

listed as 37% on the AAPC’s Web site, which is incorrect.) In addition, if an imprecise ICD-10-CM code is reported—one that does not exactly support a patient’s diagnosis—the claim may not be rejected, but such low accuracy in code selection may result in improper payment or a request by the third-party payer for additional information.

Comparing the Clinical Concepts in ICD-9-CM and ICD-10-CMMany of the clinical concepts found in the ICD-10-CM coding system are already included in the ICD-9-CM code set. However, a clear understanding of the clinical concepts new in ICD-10-CM will allow for documentation specific enough to support accurate coding practices, even if not all of the new ICD-10-CM features apply to all special-ties and not all physicians would need to use them for coding purposes. See Table 1 for a snapshot of the features and examples of the clinical concepts of the ICD-10-CM coding system that are already included in the ICD-9-CM coding system.

Table 1. ICD-10-CM Clinical Concepts From ICD-9-CM: Features and Examples

Features Examples

Coding Concept Description of Coding Concept

Code Number

Code Descriptor

Type Describes a condition that is typically considered a type of a condition, eg, malignant neoplasm, pathological fracture, etc

I26.01

C18.6

N85.01

H35.031

Septic pulmonary embolism with acute cor pulmonale

Malignant neoplasm of descending colon

Benign endometrial hyperplasia

Hypertensive retinopathy, right eye

Temporal factors Relates a condition to a particular time parameter, eg, acute, chronic, recurrent, etc

J01.01

K25.7

J45.21

I48.2

Acute recurrent maxillary sinusitis

Chronic gastric ulcer without hemorrhage or perforation

Mild intermittent asthma with (acute) exacerbation

Chronic atrial fibrillation

Note: Underlined words indicate information in the code descriptor that meets the coding concept.



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Features Examples


Code Number

Code Descriptor

Caused by/Contributing factors

Describes any contributing factors to the current condition, eg, history of tobacco use, allergy, infection, trauma, etc

O99.331

L55.1

T80.221A

G89.11

Smoking (tobacco), complicating pregnancy, first trimester

Sunburn of second degree

Bloodstream infection due to central venous catheter, initial encounter

Acute pain due to trauma

Symptoms/Findings/Manifestations

Describes symptoms the patient is having as a result of the condition, eg, tenderness, insomnia, vomiting, etc

R05

E86.0

K92.1

M54.5

Cough

Dehydration

Melena

Low back pain

Anatomy Identifies the anatomical location related to the condition, eg, maxillary, femur, knee, ulna, etc

C56.1

K57.11

M23.52

H52.12

Malignant neoplasm of right ovary

Diverticulosis of small intestine without perforation or abscess with bleeding

Chronic instability of knee, left knee

Myopia, left eye

External cause Identifies how the injury or condition occurred

W21.03XD

V49.40XA

W55.01XA

V92.09

Struck by baseball, subsequent encounter

Driver injured in collision with unspecified motor vehicle in traffic, initial encounter

Bitten by cat, initial encounter

Drown due to fall off unspecified watercraft

Number of gestations Specific for coding of pregnancy O30.011 Twin pregnancy, monochorionic/monoamniotic, first trimester


Table 1. ICD-10-CM Clinical Concepts From ICD-9-CM: Features and Examples (Continued)


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Features Examples


Code Number

Code Descriptor

Outcome of delivery Specific for coding of a delivery of a baby

O80 Encounter for full-term uncomplicated delivery

Remission status Identifies that a condition is in remission and no longer active

C92.31

F17.210

F31.71

Myeloid leukemia, in remission

Nicotine dependence, cigarettes, in remission

Bipolar disorder, in partial remission, most recent episode hypomanic

History of Identifies that the patient has a history of the condition

Z85.841

Z87.312

Z87.891

Personal history of malignant neoplasm of brain

Personal history of (healed) stress fracture

Personal history of nicotine dependence

Substance Identifies the substance related to the injury or condition

L23.0

L24.0

Allergic contact dermatitis due to metals

Irritant contact dermatitis due to detergents

Activity Describes the activity that was being done at the time the injury or condition occurred

Y93.02

Y93.82

Activity, running

Activity, spectator at an event

Place of occurrence Identifies the location of the patient at the time of the injury or condition occurred

Y92.010

Y92.321

Y92.61

Kitchen of single-family (private) house as place

Football field as place

Building under construction as place


Table 1. ICD-10-CM Clinical Concepts From ICD-9-CM: Features and Examples (Continued)

See Table 2, for some examples and features of the clinical concepts that are new in ICD-10-CM.



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Table 2. New ICD-10-CM Clinical Concepts: Features and Examples

Features Examples

Coding Concept

Description of Coding Concept Code Number

Code Descriptor

Localization/Laterality

Relates to the location of the body, eg, right, left, bilateral, upper quadrant, lower lobe, etc

R10.11

T16.1xxA

G56.02

S52.531B

Right upper quadrant pain

Foreign body in right ear, initial encounter

Carpal tunnel syndrome, left upper limb

Colles’ fracture of right radius, initial encounter for open fracture type I or II

Loss of consciousness

Specific for coding when a loss of consciousness has occurred

S06.1X1A Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter

Complicated by Identifies any factors that have complicated the condition

O77.0

B05.2

Labor and delivery complicated by meconium in amniotic fluid

Measles complicated by pneumonia

Associated with Identifies any other conditions associated with the current condition of focus

O91.112

C80.2

Abscess of breast associated with pregnancy, second trimester

Malignant neoplasm associated with transplanted organ

Episode Indicates which episode of care is involved in the treatment for the condition, eg, initial encounter, subsequent encounter, or sequela

S93.401A

T18.120D

Sprain of unspecified ligament of right ankle, initial encounter

Food in esophagus causing compression of trachea, subsequent encounter

BMI Specific for coding body mass index (BMI)

Z68.32

Z68.52

Body mass index (BMI) 32.0-32.9, adult

Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age



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Benefits of Improved DocumentationSome of the benefits of improved clinical documentation include, but are not limited to, the following:

• More efficient diagnosis coding. Fewer follow-up queries about patient visits means the coding professional and the physician save time.

• Shorter response time to payer requests for additional information. If a payer requests for additional infor-mation about a patient’s condition to support a claim, providing detailed documentation would result in a shorter review period by the payer.

• Better support for audits. More complete documenta-tion makes post-payment reviews and audits easier.

Conducting a clinical documentation assessment is an important step toward preparing for the transition to the ICD-10-CM code set, and the goal of this assess-ment is to minimize the negative effect of ICD-10-CM implementation on the organization’s billing and revenue cycle. Knowing the clinical documentation requirements of the ICD-10-CM coding system and understanding the similarities and differences between the clinical concepts of ICD-9-CM and ICD-10-CM are important steps to highlight and improve the deficiencies of your organiza-tion’s clinical documentation, in order to avoid denied or unbillable claims and reduce lost or interrupted revenues.

Reference1. AAPC. ICD-10 Assessment: Clinical Documentation Evalu-

ation. www.aapc.com/icd-10/assessment-readiness.aspx. Accessed June 5, 2014.

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The transition to ICD-10-CM will impact all physician practices. With an increased number of codes, along with enhanced code speci� city, the transition will require a signi� cant amount of planning and training. The third editions of Principles of ICD-10-CM Coding and Principles of ICD-10-CM Coding Workbookwill give you what you need to smoothly and successfully make the move.

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