ICD-10 Documentation

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