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Coding Corner: Clinical documentation improvement

February 01, 2015
Area(s) of Interest: Hospitals and Health Facilities Practice Management 


CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Stilley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.   


As implementation of the ICD-10 code set approaches on October 1, 2015, physicians should examine their current clinical documentation. An efficient way to accomplish this is to perform documentation assessments.


Generate a frequency report based on ICD-9 codes reported for the practice or the physician over the most recent two to three months. Next, gather a set number of records associated with these diagnosis codes and review the current documentation to determine compliance with the new code set. In this way, the practice can identify where documentation is complete and compliant, and where documentation may need to be improved.


Documentation is an official record of the medical care or treatment provided to a patient, and a means of demonstrating medical necessity for encounters, diagnostic services and surgical procedures. Relevant details of any patient encounter include risk factors, chronic conditions managed and how the patient is responding to any current treatment. The information must be recorded in a complete, accurate and timely manner.


Specificity in the medical record—such as anatomic location, time parameter (acute, chronic, recurrent), and laterality (left, right, unilateral)—will improve clinical documentation. These concepts can easily be added to the documentation template, whether the physician uses an electronic health record or a paper template. Clinical documentation improvement (CDI) is an ongoing process, not a one-time assessment. CDI will require follow-up assessments to verify that clinical concepts are being captured in documentation.


Example A: A 7-year-old boy was brought in with symptoms of cough, sore throat, fever of 102Ëš and runny nose. A rapid antigen test was positive for influenza A.


ICD-10 coding: J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations


In this example, the patient is diagnosed with Influenza A. This is one of the three subcategories in ICD-10, broken down by the type of virus and respiratory manifestations (cough, sore throat, fever, runny nose).


Example B: Patient presents with a fracture of the right humeral shaft. Fracture was reduced and cast placed.


ICD-10 coding: S42.301A Unspecified fracture of shaft of humerus, right arm, initial encounter for closed fracture


In ICD-10, clinical concepts for fractures require documentation of:



  • Location of the fracture

  • Type of fracture

  • Laterality

  • Open or closed

  • Displaced or non-displaced

  • Episode of care


In Example B, the right humeral fracture (location, laterality) is documented but does not identify the type of fracture, which results in the use of an “unspecified” code. In Example C below, the type of fracture is documented and a specific code can be assigned.


Example C: Patient presents with oblique fracture of the right humeral shaft. Fracture was reduced and cast placed.


ICD-10 coding: S42.331A Displaced oblique fracture of shaft of humerus, right arm, initial encounter for closed fracture


ICD-10 implementation is manageable, if started early and done systematically. Don’t try to address all documentation deficiencies at once, or the task may seem daunting. Start with concepts that are used frequently and can be easily addressed; for instance, laterality or anatomic location. ICD-10 implementation will be a team effort and should involve all members of the practice staff. 

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