Physician Documentation Tips for ICD-10 Implementation
December 3, 2013
On Oct. 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient
procedures will be replaced by ICD-10 codes.
The health care industry is making the transition because ICD-9 codes provide limited
data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is
30 years old, it has outdated and obsolete terms, and is inconsistent with current
medical practices.
ICD-10 codes allow for greater specificity and exactness in describing a patient’s
diagnosis and in classifying inpatient procedures. ICD-10 will also accommodate newly
developed diagnoses and procedures, innovations in technology and treatment, performance-based
payment systems, and more accurate billing.
The current ICD-9 code set has approximately 14,000 diagnosis codes while ICD-10 has
approximately 69,000 diagnosis codes.
Below are some general documentation tips that you can begin using now to create a
seamless transition to the new system of codes:
Specific diagnosis – Document the diagnosis to the greatest level of specificity (dysphagia,
pharyngeal phase).
Specific anatomy – Document the exact body location (cerebral infarction due to thrombosis
of the left middle cerebral artery).
Laterality - Document which side of the body. Approximately 5,000 codes have a right
and left distinction (central corneal, ulcer, right eye)
Combination codes for conditions and common symptoms or manifestations – Document
any conditions that are related or causal. Diagnosis must be clearly documented (atherosclerotic
heart disease of native coronary artery with unstable angina pectoris)
Dominant versus non-dominant side – Document dominant versus non-dominant side for
all paralytic syndrome codes such as hemiplegia, monoplegia and hemiparesis (previous
cerebrovascular infarction six months ago with residual left-sided hemiparesis on
his nondominant side)
Initial versus recurrent – Document whether the condition is initial or recurrent
(recurrent and persistent hematuria)
For more information, contact your Campus Billing Compliance Officer. Amarillo:
Teri Murphy, teri.murphy@ttuhsc.edu; El Paso: Gail Hayden, gail.hayden@ttuhsc.edu;
Lubbock: Corlis Norman, Corlis.norman@ttuhsc.edu; Permian Basin: Melissa Castracane,
Melissa.castracane@ttuhsc.edu.