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Factor Better Documentation into ICD-10 Coding

Vague documentation will lead to questions, errors, and ultimately claim denials.

By Patricia A. Smith, RHIT, CPC

Implementation of ICD-10 is inevitable. The delay to October 1, 2015 should not deter education and training. ICD-10 code sets are far more specific than those in ICD-9-CM, making comprehensive documentation necessary to capture correct diagnoses.

Documentation describes why an individual seeks care and how the care was provided, and may be called on as evidence in malpractice cases, as clarification of rendered services, for communication between physicians, etc. Documentation is reviewed on a case-by-case basis. Every diagnosis addressed during a visit should be identified, evaluated, and have a treatment plan. And every bit of that must be documented.

In years past, reimbursement was based solely on submitted CPT® codes, and reviews focused on whether the procedure codes were supported within the documentation. With the implementation of ICD-10, diagnoses will become a factor for reimbursement decisions, as well. Per the Social Security Act, “clear and concise medical record documentation is required in order for physicians to receive accurate and timely payment for services.” Payers (reasonably) want a detailed explanation to justify payment, and have the right to review documentation before paying claims.

Identify Weaknesses in Documentation

Every date of service should be self-supporting. The documentation must address the problem, show an examination, and tie everything together in the assessment and plan. Because coders and auditors are trained to assume nothing, vague documentation may result in many questions or cause incorrect diagnosis codes to be submitted. If a reviewer is unable to understand how the diagnoses are assessed and treated, the claim will be denied.

Insurers and health information vendors have been reviewing and auditing documentation to identify missing elements. The health information vendor HRS has been working specifically with hospitals to prepare them for expected changes regarding ICD-10 and documentation specificity. According to AHIMA’s Bird’s Eye View of ICD-10 Documentation Gaps, HRS identified seven basic elements (listed as most popular first) that current documentation often lacks to properly assign an ICD-10 diagnosis code:

1.Disease type is not indicated.

2.Exact details pertaining to disease are not mentioned.

3.Documentation is missing entirely.

4.Specific location (if relevant) is not identified.

5.Stages of diseases are missing in documentation.

6.Right/Left sides are not properly identified.

7.Documentation for combination codes is improperly documented to code accurately.

These seven elements are not all-inclusive, but are an excellent guide for improving documentation.

Target and Fix Skimpy Areas

Improving documentation takes initiative. Focus your efforts on fixing the seven missing elements in your documentation. Ask questions, such as: Is the documentation easy to follow? Does it contain the necessary information to accurately portray the diagnoses and procedures represented in the claim submission? To give you an idea of good vs. bad documentation, consider the following examples.

Example 1

A 13-year-old boy comes in complaining of arm pain. Swelling is apparent. An X-ray is ordered, which shows a fractured radius.

With the specificity changes found in ICD-10, the example above cannot be coded. It lacks detailed information required for ICD-10. To code this example appropriately, the documentation must specify:

  • Laterality (i.e., which arm was fractured)
  • Location on bone (e.g., head, neck, shaft, upper end, etc.)
  • Type of fracture (e.g., green stick, spiral, fissured, etc.)
  • Episode of care (i.e., initial, subsequent, sequela)

The example below contains the necessary information to assign an ICD-10 code accurately:

Example 2

A 13-year-old boy comes in for an initial evaluation after falling off his skateboard. He is complaining of pain in his left arm. Swelling is obvious. An X-ray is ordered, which shows a spiral fracture of the left radial shaft.

The proper ICD-10 code for this encounter is S52.342A Displaced spiral fracture of shaft of radius, left arm, initial encounter for closed fracture.

Denial rates due to weak documentation and using unspecified codes will increase with ICD-10. You are required to code to the highest specificity, per ICD guidelines. Although unspecified codes may still be listed in ICD-10, their use is discouraged. Physicians must take time to document the specifics to ensure accurate code selection.

Physicians may grumble at the time it takes to document so specifically. Remind them of the extra time that will be required to correct incomplete documentation. Amending the medical record is not as simple as just adding the missing information; it needs to be done in a certain way, following specific regulations. Amendment dates are scrutinized closely. They must be dated and signed by the physician. In some cases, if a claim was denied due to insufficient documentation, the physician may not be able to amend it.

Identify Diseases Clearly for Billers

Another common factor affecting accurate code selection is failure to identify specifically the type of disease. A fellow clinician may be able to read a documented note and ascertain a specific type of disease due to their training and experience, but an auditor or reviewer may not.

Example 3

Documentation may specify, “Robbie comes into the office today for a recheck on his atrial fibrillation.” When looking up the ICD-10 code for atrial fibrillation you are faced with five different types of atrial fibrillation: Paroxysmal, Persistent, Chronic (permanent), Typical (type I), and Atypical (type II). If the documentation had specified, “Robbie comes into the office today for a recheck on his paroxysmal atrial fibrillation,” the type of atrial fibrillation is no longer in question and ICD-10 I48.0 Paroxysmal atrial fibrillation may quickly be assigned.

When applicable, documentation also must clearly identify the stage of a disease.

Example 4

Documentation may state, “Billy is back in the office for his CKD [chronic kidney disease]. He has a history of CKD. He will continue his current medication regime and follow up in three months.” This documentation supports only N18.9 Chronic kidney disease; unspecified. Documentation that is more complete would specify, for instance, CKD stage 3, which allows reporting of N18.3 Chronic kidney disease, stage 3 (moderate).

There’s another problem with the above example: According to ICD-10 guidelines, “history of” means the condition no longer exists, and no active treatment is being received, but the condition can reoccur. Providers sometimes use “history of” to indicate the patient has had the condition for a long time. This causes confusion for coders, auditors, and other providers.

Connect the Right Diagnosis to the Plan of Care

One major problem auditors encounter in documentation reviews is the connection between the diagnosis and the plan of care. The number of diagnoses, medications, and treatment options are extensive, which makes it difficult to know how a specific condition is treated. Encourage physicians to be clear in the overall plan for each specified condition. For example, the physician might document in the medication log, “Tricor 145 mg taken for hypertriglyceridemia.” Or within the history of present illness, she might note, “Patient takes Tricor to lower her triglycerides.” The medication information should also connect to the plan of care; for example, “Hypertriglyceridemia – refilled Tricor 145 mg, one tab every evening. Patient will follow up with a routine lipid panel in three months.”

These examples show how documentation can help ensure the correct diagnosis is attached to the correct plan of care. If a patient is on several medications, it’s the physician’s responsibility to indentify a clear connection for each medication. A coder or auditor should never assume a refill of a specific medication is for a specific condition. An assumption or unclear verbiage may result in diagnosing a patient with a condition they do not have.

Educate Physicians and Staff

A solid understanding of ICD-10 guidelines will aid in teaching physicians and staff the specifics required in using this code set to its utmost. The guidelines are broken down into several conventions and chapters, with detailed explanations of the basic coding rules and examples.

Take the time now to code from both ICD-9-CM and ICD-10-CM using current documentation as examples. Show physicians examples of what is preventing accurate code selection. Explain that documentation does not have to be lengthy, but it does have to be specific enough to identify and support the diagnoses, and explain how the patient was treated.

Last, but not least, conduct internal audits. Review documentation with an open mind. Are the diagnoses, exam, and plan of care easy to follow? Write down questions that prevent code selection. Present those questions to physicians and staff as an educational tool for improvement.

Medicine has expanded beyond the scope of ICD-9-CM. Healthcare continues to advance, and so must coders, physicians, and staff. Use the extra year to prepare.

Patricia A. Smith, RHIT, CPC, is a contracted auditor for Arrow Strategies on behalf of Blue Cross Blue Shield of Michigan. She earned an Associate Degree of Applied Science from Baker College of Clinton Township, Mich. Smith is acting secretary for the Macomb Township Michigan local chapter, and has spoken at several chapter meetings on ICD-10.

October 1st, 2014

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AAPC Committed to Ethical Standards

Members can rely on AAPC’s Ethics Committee to uphold honesty and excellence.

By Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO

To help members remain ethical throughout their career, AAPC has established an Ethics Committee as a standalone entity responsible for evaluating alleged violations of the AAPC Code of Ethics and, when necessary, determining appropriate sanctions. AAPC’s Ethics Committee is comprised of eight members: Four from the Legal Advisory Board, two from the National Advisory Board, and two from the AAPC Chapter Association board. Ethics Committee members are selected by their respective boards.

Ethics Committee Working for You

When a complaint is submitted to the committee, a Legal Advisory Board member is appointed to investigate the complaint, gather information, and when necessary, refer the case to the other committee members for a determination. After the investigating member refers a case, the remaining members review the submitted information, which includes the complaint, any response from the member involved, and other investigatory information. The remaining seven members of the committee then vote as to whether a violation of the AAPC Code of Ethics occurred and, if so, determine the appropriate sanction to impose.

Cases Show What Crosses the Line of Ethics

To provide you with a better understanding of the Ethics Committee’s role in serving you, here are actual cases the committee has evaluated. They do not represent all cases, but will show you the types of cases we address. The cases have been stripped of identifying factors to protect members from embarrassment. To deter members from ethical misconduct, use these cases to educate yourself and other members of the type of conduct that’s contrary to the AAPC Code of Ethics.

Case No. 1

A test proctor inappropriately opened an extra examination booklet and was not completely forthcoming to the committee when responding to the Notice of Complaint.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. The sanction was a letter of reprimand and permanent preclusion from serving as a test proctor.

Mitigating factors: No prior ethics related issues, expression of remorse and embarrassment, and no evidence that exam information was further disclosed.

Case No. 2

A member falsely represented possession of both AAPC and non-AAPC credentials.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials.

Mitigating factors: No prior ethics related issues.

Aggravating factors: Member did not respond to the committee and took no action to correct the misrepresentations, once notified.

Case No. 3

A member falsely represented possession of a Certified Professional Coder (CPC®) credential in the signature block of email correspondence, falsified credential verification results from the AAPC website, and made multiple false statements to employer indicating possession of the CPC® credential.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was a 12-month suspension of membership and credentials.

Mitigating factors: No prior ethics related issues, and member sat for and passed the CPC® exam (having already passed a specialty examination) within weeks of misconduct.

Case No. 4

An AAPC curriculum instructor improperly obtained copies of the CPC® examination while serving as proctor, and created a study guide containing actual exam questions and answers. The instructor provided the study guide to students, allowing students to compete unfairly on the CPC® examination.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials and loss of license to provide AAPC-approved curriculum instruction.


Mitigating factors:No prior ethics related issues and member was forthcoming to committee in response to Notice of Complaint.

Aggravating factors: The violation was considered especially egregious because the instructor was in a position to influence future members regarding ethical obligations as professional coders. The member’s actions compromised the integrity of the CPC® examination and devalued the CPC® credential by causing potentially unqualified individuals to obtain the CPC® credential, thereby justifying the imposed sanction.

Case No. 5

A coding instructor improperly obtained copies of CPC® and specialty examinations while serving as proctor. Copies of the examinations were allegedly provided to students, who then sat for the exams, completed them, and passed their respective CPC® and/or specialty examination in approximately three hours.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was permanent revocation of membership and credentials.

Mitigating factors: No prior ethics related issues.

Aggravating factors: Member was not forthcoming in the response to the Notice of Complaint submitted to the Ethics Committee. Member also interfered with the investigation by responding on behalf of the students. The violation was considered especially egregious because the instructor was in a position to influence future members regarding ethical obligations as professional coders. The member’s actions compromised the integrity of the CPC® and specialty examinations and devalued AAPC credentials by causing potentially unqualified individuals to obtain the CPC® or specialty credential, justifying the imposed sanction.

Case No. 6

A member misrepresented possessing a number of specialty certifications, as well as falsely having status as an “AAPC Approved Online Education Provider” on a publicly accessible development Web page.

Determination: The committee concluded a violation of the AAPC Code of Ethics occurred. Sanction was a letter of reprimand and instruction to remove inaccurate statements from the development page on the website.

Mitigating factors: No prior ethics related issues, forthright response, and committee determined there was no intent to deceive the public.

Considering the size of our membership, the incidence of improper conduct is extremely small. This suggests the vast majority of AAPC members are committed to upholding the ethical standards of our profession. Of the cases reported, the most common cases pertain to misrepresentation of credentials or experience needed to obtain removal of apprentice status; however, the recent cases involving improper conduct by instructors (and potentially students) involving AAPC examinations are the most disturbing. Those who are tempted to accept dishonest help should consider that cheating on an exam may get you a credential, but it doesn’t mean you have the skills needed to perform the job.

Instructors and proctors must understand that obtaining an exam and providing it to students doesn’t help the students. It may result in a high pass rate, but it does not mean the person is a good instructor.

Speak Up! Your Reputation Is on the Line

The AAPC Code of Ethics imposes a duty to report unethical conduct by another member. Silent acquiescence enables such conduct, and diminishes the credibility of all who have earned AAPC credentials.

If you want to file a complaint, but are concerned about retribution, know that the committee takes great pains to keep the identity of the complainant anonymous, when anonymity is requested. If you are aware of ethical misconduct, report it to the Ethics Committee via email at:

The Ethics Committee needs the help of all members in upholding the ethical standards of our profession by not tolerating unethical conduct.

Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, serves on AAPC’s National Advisory Board, Legal Advisory Board, and is chair of the AAPC Ethics Committee. He has over 20 years of experience in healthcare coding and over 16 years as a compliance expert, forensic coding expert, and consultant. Miscoe has provided expert analysis and testimony on a wide range of coding and compliance issues in civil and criminal cases and his law practice concentrates exclusively on representation of healthcare providers in post-payment audits as well as with responding to HIPAA OCR issues. He speaks and is published on the national level, addressing a variety of coding, compliance, and health law topics. Miscoe is a member of the Johnstown, Pa., local chapter.

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Debunking ICD-10 Myths

In an age of urban legends and conspiracy theories, it’s no surprise that some have popped up about ICD-10, prompting the Centers for Medicare & Medicaid Services (CMS) to post Medicare Learning Network (MLN) pages on “ICD-10-CM/PCS Myths and Facts.

Sadly, none are as intriguing as the urban myths we usually hear, but CMS feels too many people believe them at a time when ICD-10 is close to implementation.  CMS uses the document to quash misinformation that’s making the transition more difficult for providers, facilities, and coders.  Some of the information CMS wants you to know includes the following:

  • ICD-10-CM and PCS will be implemented on October 1, 2015.
  • State Medicaid programs will be required to use ICD-10.
  • ICD-10 was developed with significant clinical input.
  • ICD-10-CM and ICD-10-PCS books will be available after implementation.
  • ICD-10 is current, having been updated several times since introduction.
  • ICD-10 won’t require unnecessary documentation when implemented as most of the necessary information is already the medical record.

There are plenty other truths in the MLN document that will help calm nerves and make the ICD-10 implementation a little easier to swallow.

September 29th, 2014

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ICD-10 Monitor: Talk Ten Tuesday

In the most recent episode of the Talk Ten Tuesdays podcast, Betty Hovey, CPC, CPMA, CPC-I, CCS-P, CPC-H, CPCD reported on the 2nd Code-a-Thon held sept 15th.  The event was hosted by CMS and AAPC in an effort to ensure health care providers and other industry professionals are preparing for the transition to ICD-10.

“AAPC’s ICD-10 expert coders including myself, Peggy Stilley, [Jacqueline] Stack, and—of course—Rhonda [Buckholtz], answered ICD-10 coding questions for three hours by live stream.” said Betty Hovey. “We looked at more than 600 questions on ICD-10-CM and PCS…a lot of good information was shared with the attendees.”

The September 2014 Code-a-Thon transcripts are available for download.

September 26th, 2014

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2014 CMS-AAPC Code-a-Thon Recap

On Monday, September 15, 2014  CMS collaborated with AAPC to host live three-hour Q&A “Code-a-Thon”. ICD-10 trainers from AAPC made themselves available to help industry leaders and providers prepare for the ICD-10 code set compliance date of October 1, 2015.

Materials from the webinar are available below:

[Code-a-Thon Q&A transcript]

[Code-a-Thon audio transcript]

September 25th, 2014


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