Physician Documentation Tips for Implementation of ICD-10-CM
Physicians will need to provide more comprehensive documentation so that coders can select the correct diagnosis code(s). Be aware that relying on unspecified codes is not acceptable and payment may not be made if a more specific code exists.
A few tips to remember when documenting:
Specific diagnosis: Document the diagnosis to the greatest level of specificity
Example: dysphagia, pharyngeal phase
Specific anatomy: Document the exact body location
Example: cerebral infarction due to thrombosis of the left middle cerebral artery
Laterality: Document which side of the body- right or left
Note: approximately 5,000 codes have a right and left distinction
Example: central corneal ulcer, right eye
Combination codes for conditions and common symptoms or manifestations: Document any conditions that are related or causal.Diagnosis must be clearly documented
Example: central corneal ulcer, right eye
Example: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
Dominant verses non-dominant side: Document dominant verses non-dominant side for all paralytic syndrome codes such as hemiplegia, monoplegia and hemiparesis.
Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.
Initial verses recurrent: Document whether the condition is initial or recurrent
Example: recurrent and persistent hematuria
[i] AHIMA ICD-10 Coder Training Manual
[i][i]The Top 10 Documentation Tips for ICD-10-CM: The Devil is in the Details. Just Coding News: Outpatient August 25, 2010