Importance of clinical documentation for accurate icd 10 coding – medical billing and coding

Clinical Documentation ICD-10

Importance of Clinical documentation for accurate ICD-10 coding 

ICD-10 is not the coding but it’s improved Patient care which is documented

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Descriptive documentation to support accurate coding is the base of reimbursement from the insurances

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If physicians don't document their care, it can't be captured or coded

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Proper documentation has the potential to improve: 

Patient care,

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Clinical data

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Timely and appropriate claims payment

What needs to be documented?

Basic concepts such as: 

Laterality (Right, Left, Bilateral, Unilateral)

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Anatomical locations

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Trimester

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Type of diabetes

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Known complications or comorbid conditions

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Description of severity, acute or chronic or other known parameters

Major Modifications 

Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used)

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Expanded codes (e.g., injury, diabetes)

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Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used)

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Added code extensions for injuries and external causes of injuries

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Laterality – Left Versus Right

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Area specified in cases of Neoplasm

Examples 

Malignant neoplasm, of central portion of breast

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Malignant neoplasm of central portion of right female breast

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Malignant neoplasm of central portion of left female breast

Most Commonly Encountered Disease/Problems – taken as example 

DIABETES

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HEART DISEASE (CAD, A-FIB, CHF etc.)

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PAIN (BACK, LOWER BACK, LIMBS – UPPER OR LOWER)

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OSTEOARTHRITIS

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CHRONIC KIDNEY DISEASE

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PULMONARY DISEASE

Examples on the following slides…………………………………

Must/Preferable – to dictate DIABETES

HEART DISEASE (CAD, A-FIB, CHF etc.)

 Type I or Type II diabetes - Must dictate

Coronary Artery Disease (CAD):

 Onset - Preferable if dictated

Native Artery involved – Preferable if dictated

 When did it start? - Preferable if dictated

Status post bypass graft – Preferable if dictated

PAIN, OSTEOARTHRITIS, OSTEOPENIA, OSTEOPROSIS, ARTHRITIS, Anatomical location Which anatomical structure - Must dictate Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior Preferable if dictated

Laterality

Right side or left side – Must dictate

Severity

Mild, moderate or severe – Preferable if dictated

CHRONIC KIDNEY DISEASE Stage 1 to 6 (end stage) – Must dictate Dependence on Dialysis – Must dictate

Example for -PULMONARY DISEASE Temporal Factors: Must dictate Acute / Chronic / Intermittent / Persistent

Severity: Must dictate Mild / Moderate / Severe

Asthma: Must dictate Acute / Chronic / Allergic / Exacerbation

COPD: Must dictate With exacerbation

Bronchitis specific: Must dictate Simple / Mucopurulent / Mixed simple and Mucopurulent / Tracheobronchitis

To be dictated by Provider Dictated currently – ICD-9

To be dictated now – ICD-10

Condition described : DIABETES

Condition described : DIABETES

HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping

HISTORY OF PRESENT ILLNESS: The patient is an 86 years old female with history of diabetes. At last visit, we had discussed about going up on her Lantus every three days, but it seems like the patient did not do that and she is still taking Lantus 17 to 20 units and she also continued to take NovoLog Mix 70/30 in the morning and with supper. She states that her blood sugar at suppertime is staying around 188 to 200 and fasting blood sugar is 127, but she did not bring those readings with her. Her last hemoglobin A1c was checked in January and it was high at that time. She is complaining of constipation. She has been taking over-the-counter medication, but it is not helping

ASSESSMENT: 1.Uncontrolled diabetes 2.Constipation.

ASSESSMENT: 1.Uncontrolled diabetes - Type I / Type II 2.Constipation.

DX

ICD-9

ICD-10

Uncontrolled Diabetes

250.02 (Uncontrolled Diabetes Type 2 /

E11.65 (Type 2 Diabetes with

Uncontrolled Diabetes Type 1 / insulin-dependent

250.03 (Uncontrolled Diabetes Type 1 /

E10.65 (Type 1 Diabetes with

insulin dependent)

hyperglycemia)

Diabetes

250.00 (Diabetes Type 2, not stated as

E11.9 (Type 2 Diabetes without

uncontrolled)

complications)

250.01 (Diabetes Type 1 (juvenile

E10.9 (Type 1 Diabetes without

type) / insulin-dependent, not stated as uncontrolled)

complications)

Diabetes - Type 1 / Insulindependent

non‑insulin dependent)

hyperglycemia)

To be dictated by Provider Dictated currently – ICD-9 Condition described : HEART DISEASE (CAD)

To be dictated now – ICD-10 Condition described : HEART DISEASE (CAD)

ASSESSMENT AND PLAN: The patient is an individual who has CAD, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

ASSESSMENT AND PLAN: The patient is an individual who has CAD with/without - stable/unstable - other/unspecified etc angina, status post bypass graft, has dropped about 4 pounds since last time, status post multiple surgeries in the past, obesity, the patient has a history of anxiety, neuropathy, hypertension, intervertebral disk disease, hypertriglyceridemia, atrial fibrillation, GERD, and insulin-dependent diabetes mellitus.

DX

ICD-9

CAD-unspecified type of vessel, native, or graft

414.00

ICD-10 I25.10 125.110 (CAD-native artery with unstable angina) I25.111 (CAD-native artery with unstable angina with

CAD-native coronary artery

414.01

documented spasm)

I25.118 (CAD-native artery with other forms of angina pectoris) I25.119 (CAD-native artery with unspecified angina pectoris) I25.700 (Atherosclerosis of coronary artery bypass graft, unspecified, with unstable angina pectoris

CAD with bypass graft unspecified type

414.05

I25.701 (Atherosclerosis of coronary artery bypass graft, unspecified, with angina pectoris with documented spasm)

I25.708 (Atherosclerosis of coronary artery bypass graft, unspecified, with other forms of angina pectoris)

I25.709 (Atherosclerosis of coronary artery bypass graft, unspecified, with unspecified angina pectoris

To be dictated by Provider Dictated currently – ICD-9

To be dictated now – ICD-10

Condition described : PAIN

Condition described : PAIN

ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of leg

ASSESSMENT: The patient has UTI and history of kidney stones. The patient has chronic kidney disease. The patient has tobacco abuse. The patient has chronic pain of right/left – upper/lower leg

Condition described : OSTEOARTHRITIS ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis

Condition described : OSTEOARTHRITIS ASSESSMENT: This is an individual with chronic kidney disease, hypertension, insomnia, depression, chronic pain syndrome, knee pain, and gout. The patient is accompanied by her daughter. There is also underlying restless legs syndrome, COPD which is severe, degenerative joint disease, and osteoarthritis of knee right/left

DX

ICD-9

ICD-10

Pain of Leg

M79.606 (Pain in Unspecified Leg)

Pain of Right Leg

M79.604 (Pain in Right Leg)

Pain of Left Leg

M79.605 (Pain in Left Leg)

Pain of Thigh

M79.659 (Pain in Unspecified Thigh)

Pain of Right Thigh

729.5 (Pain in Limb)

M79.651 (Pain in Right Thigh)

Pain of Left Thigh

M79.652 (Pain in Left Thigh)

Pain of Lower Leg

M79.669 (Pain in Unspecified Lower Leg)

Pain of Right Lower Leg

M79.661 (Pain in Right Lower Leg)

Pain of Left Lower Leg

M79.662 (Pain in Left Lower Leg)

To be dictated by Provider Dictated currently – ICD-9

To be dictated now – ICD-10

Condition described : CHRONIC KIDNEY DISEASE

Condition described : CHRONIC KIDNEY DISEASE

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. xyz to see him for his CHF

ASSESSMENT: The patient is a 73-year-old who was recently in the hospital for volume overload, has chronic kidney disease stage 3 , etc. / end-stage / on dialysis as well as CHF, certainly does have multiple other issues including hyperlipidemia, CAD, hypertension, seasonal allergic rhinitis, is being followed by Dr. abcdef of renal. We will certainly get Dr. XYZ to see him for his CHF

DX

ICD-9

ICD-10

Chronic Kidney Disease

585.9 (CKD, stage unspecified)

N18.9 (CKD, stage unspecified)

CKD-Stage 1

585.1 (CKD, stage 1)

N18.1 (CKD, stage 1)

CKD-Stage 2

585.2 (CKD, stage 2) (mild)

N18.2 (CKD, stage 2) (mild)

CKD-Stage 3

585.3 (CKD, stage 3) (moderate)

N18.3 (CKD, stage 3) moderate)

CKD-Stage 4

585.4 (CKD, stage 4) (severe)

N18.4 (CKD, stage 4) severe)

CKD-Stage 5

585.5 (CKD, stage 5)

N18.5 (CKD, stage 5)

CKD, end stage

585.6 (End Stage Renal Disease)

N18.6 (End Stage Renal disease)

Thank You

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