Physician Documentation: An Essential Component to a Successful ICD-10 Transition

The transition to ICD-10-CM represents much more than just an increase in codes and field sizes. The scope and complexity of the transition are significant and should not be underestimated. Although the transition will impact many systems, processes and people, let’s focus for a moment on the impact to physicians.

When we think about how the ICD-10 transition will impact physicians, the most critical and essential aspect is documentation; specifically, the need for specificity and granularity. “It’s critical that providers are documenting with the granularity that the health plans will require,” says Robert Tennant, MGMA Government Affairs senior policy advisor. “If the coder can’t give the encounter a more specific ICD-10 code, they’ll probably code it as ‘unspecified.’ There’s no guarantee that the health plan will pay that claim.” With the notion of decreased revenue tied to insufficient documentation, how can the physician ensure his/her documentation is detailed enough?

The ICD-10 code sets have basic structural and conceptual changes. ICD-10 requires greater detail regarding risks, comorbidities, complications, severity, causation, manifestations, laterality and other key factors to accurately measure healthcare delivery. This Increased specificity of documentation for ICD-10 may appear to entail a significant amount of extra work, however in most cases; the documentation needed for ICD-10 will require just a few additional key components per condition.

So, what are a few of these “key components”?


Laterality has been added to ICD-10-CM to increase specificity. Certain conditions such as fractures, burns, neoplasms and pressure ulcers require documentation of the affected side of the body. In most cases this simply requires an additional word, i.e., “right” or “left.”

Combination Codes

ICD-10 often combines disease specificity, common sites/locations and manifestations of the disease into one code. An example would be K50.012 Crohn’s Disease of the small intestine with intestinal obstruction. The site and manifestations will need to be documented to utilize these combined codes.

Increased Specificity

Physicians will need to avoid using broad terms, such as Regional Enteritis, and begin supplying specific disease names and locations.

Each specialty is very different in the type of documentation and coding requirements. The musculoskeletal area for example accounts for over 50% of the ICD-10 codes while other areas may be represented by far fewer codes and fewer changes from the current coding pattern. Each area has its own new documentation requirements to support the new ICD-10 codes.

Is my documentation ICD-10 ready?

Although time consuming and overwhelming, a documentation assessment is essential in order to evaluate the areas within your patient population where additional documentation specificity will be required under ICD-10. A proper assessment should include:

  • Identification of the your top current diagnosis codes
  • Mapping of your current ICD-9 codes, utilizing GEMS files, to applicable ICD-10 codes
  • Chart auditing of patients with your top current diagnoses, to determine if current documentation will support the specificity of an ICD-10 code. Golden Rule: If it’s not documented, it did not happen and therefore it cannot be coded or billed.
  • Post implementation review, in order to maintain documentation compliance

Documentation evaluations identify documentation deficiencies and provide training on required specificity. A real challenge will be insufficient documentation to support the specificity required for the new ICD-10 code sets, therefore causing interruption of revenue.

CMS suggests that medical practices that do not already use a billing revenue cycle service, consider utilizing such a service to assist in the billing transition. Making the ICD-10 transition a priority will significantly reduce productivity loss and financial hardships. With careful planning and education, you can prepare for a successful transition to ICD-10.