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Medical Coding and Documentation Relationship

Approximately 65% of today’s medical documentation is complete for ICD-10 coding. Insufficient documentation to support the specificity required for the new ICD-10 code sets will be one of the largest problems. If an office is fully prepared for ICD-10, but clinical documentation has not improved, accurate coding and proper payment will not be feasible. M-Scribe believes that for most providers, a behavioral change in documentation habits will be crucial — now is the time to start preparing.

With the transition to ICD-10, some documentation subjects will require physicians and providers to capture new information while others may be involved in updating, modifying and expanding documentation needs.

For instance, ICD-10 contains multiple combination codes — the documentation must reflect the association between conditions. For example, ICD-10 code K50.814 designates “Crohn’s disease of both small and large intestine with abscess.” The ICD-9 equivalent code would be “555.2, regional enteritis, small intestine with large intestine” and “569.5, Abscess of intestine.” In addition, laterality necessitates documentation.

Another example, ICD-10 code M05.271 designates “Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot.” The ICD-9 equivalent code would be “714.27 – Rheumatoid arthritis with visceral or systemic involvement, ankle and foot.”

The following conditions are potential problem areas related to insufficient documentation. Physicians and providers should be conscientious of necessary specificity levels, enabling clinical documentation to be better understood:

Injuries: ICD-10 features an expanded category for injuries. A seventh character extension identifies the encounter type:

  • “A” signifies the initial encounter.
  • “D” represents the subsequent encounter for fracture with routine healing.
  • “G” denotes subsequent encounter for fracture with delayed healing.
  • “S” refers to sequela of fracture.

Coding professionals will be required to code the size and depth of the injury, which may not be captured in physician documentation. In addition to coding the type of injury, the cause of the injury should be documented and coded as well.

Drug Under-dosing: A new code for under-dosing has been added to the ICD-10 coding categories. It identifies situations in which a patient has taken less of a medication than prescribed by the physician.

  • The medical condition is sequenced first.
  • The under-dosing code is listed as a secondary diagnosis.
  • The additional code explains why the patient is not taking the medication (e.g., financial reasons). Since this is a new code, many physicians will not be accustomed to documenting in the patient record why the patient was under-dosing.

Cerebral Infarctions

  • Late effects of stroke are differentiated by type of stroke.
  • Combination codes for common etiologies/manifestations are included (e.g., ICD-10 code I63.012 designates “cerebral infarction due to thrombosis of left vertebral artery”).

Acute Myocardial Infarction (AMI)

  • The age classification for AMI has reduced from eight weeks to four weeks.
  • New categories have been added for subsequent AMI and for complications within 28 days of AMI.
  • Different terminology is used and is now laterality included (e.g., I21.02 designates “ST segment elevation myocardial infarction [STEMI] involving left anterior descending coronary artery”).

Musculoskeletal Conditions

ICD-10 contains additional diagnosis codes related to musculoskeletal conditions. For example, there are eight codes for pathologic fractures in ICD-9 but more than 150 codes in ICD-10.


Some codes require time frame documentation. For example, respiratory/ventilator codes are acknowledged based on the amount of time a patient has been on a ventilator. They are divided into three segments: less than 24 consecutive hours, 24-96 consecutive hours, or greater than 96 hours.

How will M-Scribe help prepare physicians/providers when changes for ICD-10 are implemented?

  • We perform Clinical Documentation Assessments. This can involve evaluating samples of various types of medical records to determine if the documentation supports the level of detail found in ICD-10.
  • Improvement strategies can be implemented to address areas where documentation is deficient.
  • Assign an ICD-10 specialist to guide your practice to implement clinical documentation strategies


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