Does Your Documentation Have To Change For ICD-10?

The answer to this question really lies in how you have been documenting up until now. The rule to code to the highest specificity has not changed. The rule that your documentation must support the specificity of the code and justify the code has not changed either. ICD-10 gives us the ability to (and in some cases the requirement to) indicate the etiology, anatomic site, laterality, severity and progression of a pathology with our coding in instances when this was not always possible with ICD-9. Going through some examples is a good way to illustrate this.

If we have an initial encounter with a patient for a closed, non-displaced left second toe proximal phalanx fracture, the appropriate ICD-9 code would be 826.0, which reads “closed fracture of phalanx of foot.” For billing purposes, your note must contain the words “closed fracture” and “phalanx” to support the diagnosis code. The ICD-10 code would be S92.515A, which reads “nondisplaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture.” Therefore, when billing this code, your documentation should contain the words “non-displaced,” “left,” “second toe” and “proximal phalanx” as well as the fact that this was the initial visit for this problem.

For purposes of excellent documentation, continuity of care and risk management, some may argue that whether or not the fracture is displaced, which toe is fractured, which phalanx is fractured, and laterality should all be part of the documentation anyway. What has changed as of October 1, 2015 is that this content is not only appropriate for the reasons listed above, it is now required to satisfy the diagnosis code.
Shortening the code so you do not have to document as much is not an option. You should code to the highest specificity. If a code can be seven characters long to be as specific as possible, it is required to take the code out to its seventh character. One of the areas where this comes in to play is coding for fracture care. Among the seventh character options for a subsequent encounter for a fracture are:

• D (subsequent encounter for normal healing fracture)
• G (subsequent encounter for delayed healing fracture)
• K (subsequent encounter for fracture with non-union)
• P (subsequent encounter for fracture with malunion)

For a subsequent encounter, you must choose one of these, include it in the code and document the terminology to support the code. If you use a fracture diagnosis with a seventh character of “D,” your note must state that the fracture is healing normally. You may have included that in your documentation in the past because you considered it important or good documentation, but now you are required to do so to support the diagnosis code you have chosen.

Key Differences Between ICD-9 And ICD-10 In Coding For DFUs
When coding for a diabetic foot ulcer, you may find that your documentation had to change starting October 1, 2015. For a patient with type 2 diabetes taking daily insulin, if you saw that patient for a chronic left lateral midfoot ulcer with necrosis of muscle, the ICD-9 codes you used would have been 707.14 (ulcer of midfoot, chronic) and 250.80 (type 2 diabetes with specified manifestations). Your documentation would need to support these codes by containing the proper terminology.

When coding this encounter with ICD-10, you would start with L97.423 (non-pressure chronic ulcer of left midfoot with necrosis of muscle) and see that the L97-codes require you to “Code first any associated underlying condition, such as diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622).” “Code first” indicates that an additional code is required and you should list this first. In this scenario, L97.423 mandates that you code first E11.621 (type 2 diabetes mellitus with foot ulcer).

We are still not finished because under E11.621, we see the direction to “Use additional code to identify any insulin use (Z79.4)” so we must also code Z79.4. If we use Z79.4, we must also support its use in our documentation. The documentation necessary to support 707.14 and 250.80 is different than what is necessary to support E11.621, L97.423 and Z79.4. The documentation we need to support the ICD-10 codes that we would not have needed to support the ICD-9 codes in this scenario include laterality, the fact that there is necrosis of muscle, the patient’s insulin use and that this is a non-pressure ulcer. These are points of documentation that some may not have been including under ICD-9 guidelines.

What You Should Know About Sequela Coding
When coding a condition that developed as the result of an underlying illness or injury, ICD-10 may mandate a code indicating what the underlying problem was in the form of a “sequela” code. This is another example of added documentation that may be necessary with ICD-10. An example is a patient with chronic left ankle instability following a Grade III sprain of the calcaneofibular ligament that happened two years prior to her visit with you. The ICD–9 code for this would be 728.4 (ligamentous laxity, ankle) with only three words needed to support the code.  

The ICD-10 code for ligamentous laxity of the left ankle is M24.272 (disorder of ligament, left ankle). This code carries with it a note that states, “Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.” In this case, we think the prior ankle sprain is the cause of the patient’s ligamentous laxity so you must code the ankle sprain as well. The appropriate ICD-10 code is S93.412S (sprain of calcaneofibular ligament of the left ankle, sequela). The additional documentation needed to support the ICD-10 codes above what would be needed to support the ICD-9 code in this example includes laterality and that the laxity is a sequela of a calcaneofibular ligament sprain.

In Conclusion
The best way to prepare for ICD-10 is by first taking a close look at how you are currently documenting, identifying any deficiencies and planning what changes will be needed. The use of electronic health records in many cases allows for the use of templates and building the additional documentation that is required with ICD-10 into those templates may prove useful. You can run a report to identify the most commonly used diagnoses in your practice and a good place to start is by looking at the templates currently in place for those diagnoses and comparing them to the ICD-10 descriptions and terms that will be necessary.

Most clinicians had to change the way they document starting October 1, 2015. Ensure that you are coding to the highest specificity and that your documentation supports the ICD-10 code you are using. Prepare by identifying the most commonly used diagnoses in your practice, evaluating your current level of documentation for those diagnoses and taking a close look at the changes you need in switching to ICD-10.

Dr. Lehrman is on the American Podiatric Medical Association Coding Committee, is an expert panelist on Codingline.com and is a Fellow of the American Academy of Podiatric Practice Management.

Reference

1. APMA Coding Resource Center. Available at https://www.apmacodingrc.org .