Texas Tech University Health Sciences Center
Physician Documentation Tips for ICD-10 Implementation

Physician Documentation Tips for ICD-10 Implementation

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 ICD-9 is 30 years old, it has outdated and obsolete terms, and is inconsistent with current medical practices.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.