Documenting ICD-10-CM: What's new?

Because of the increased granularity of the new ICD-10-CM codes, which are scheduled to be implemented on Oct. 1, 2015, physicians will need to provide more specific information in their clinical documentation. That specificity will be critical for efficient claims processing, and learning what is needed may require some time and practice.

For instance, physicians will need to note cause of injury and date of onset, which are not details always documented before.

Note the following patient scenario.

An 81-year-old man presents for preoperative evaluation before transurethral resection of the prostate, which is scheduled to take place in 5 days. His surgeon has requested evaluation for hypertension and cardiac clearance. The patient had an inferior-wall myocardial infarction (MI) 1 year ago, for which he received thrombolytic therapy with complete resolution of symptoms. His last ejection fraction measurement, 1 month ago, was 50%. The patient's regular physical activity includes walking and swimming. He reports no shortness of breath on exertion. He does not have cerebrovascular disease, diabetes mellitus, congestive heart failure, renal failure, or angina. He has a history of essential hypertension and was prescribed metoprolol succinate once daily but is not taking the drug because he can't afford it.

The patient is in no acute distress on physical exam, and his height and weight are appropriate for his age. His blood pressure is elevated at 157/92 mm Hg. His chest is clear, and he has no pedal edema. An electrocardiogram shows nonspecific T-wave changes. Laboratory values include a creatinine concentration of 1.5 mg/dL, a slight increase from the patient's baseline that could indicate early renal insufficiency.

The physician plans to monitor blood urea nitrogen and creatinine levels for renal function and nephrology referral if necessary. He notes that the patient's hypertension is probably due to nonadherence to metoprolol succinate, and indicates that he will communicate this to the surgeon, who may not be aware of the patient's financial situation. The physician changes the patient's medication regimen to oral propranolol, two 20-mg tablets daily, with the first dose administered in the office. A 30-day supply of free samples is provided. The physician plans to reevaluate the patient's hypertension in 3 days and will clear him for surgery if it is improving.

When documenting this encounter, the physician should note why the encounter is taking place, since there are different ICD-10-CM codes for a routine visit, a surgery clearance, and an initial visit.

If known, it is important to document whether patients are adherent with their medications. “Underdosing” is a new concept in ICD-10-CM and can be captured along with the diagnoses. When an issue with underdosing is noted, it should be documented whether the matter is new or has been recurrent. The ICD-10-CM terms provide new detail compared to the previous ICD-9-CM code V15.81, “history of past noncompliance.”

The physician in this case documented that the patient's lab results showed a slight increase in creatinine from baseline, which may indicate early renal insufficiency. Guidelines allow the reporting of an additional diagnosis to support the abnormal test result. (The accompanying Table compares the codes for the sample scenario in ICD-9-CM versus ICD-10-CM. Note the codes 794.4 and R94.4 for abnormal test results.)

In ICD-10-CM, coders are provided a “Use Additional Code” note for hypertensive diseases (I10-I15). If known, it should be documented whether hypertensive patients have any of the following: exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and/or tobacco use. This patient had none of these.

While there are some new things to include in ICD-10-CM documentation for billing and coding purposes, some of these elements may already be in use for purposes of clinical care. Documentation requirements for some conditions may be easier or more difficult for physicians, depending on how they are accustomed to documenting now. Eventually, it is anticipated that the new elements in ICD-10-CM will become second nature, just as ICD-9-CM is now.

A good way to prepare for the switch to ICD-10-CM is to conduct a self-audit similar to the above exercise for the more common conditions seen in your practice. It may also be helpful to begin requesting a testing plan schedule from your vendor. Conduct internal testing within your clinical practice as well as external testing with payers and other external business partners after you have completed the planning stages.

More ICD-10 resources are available online. Also, the Centers for Medicare and Medicaid Services maintains an ICD-10 website that has the latest news and resources to help prepare.