ICD-10 Documentation Requirements

How ICD-10 Affects Clinical Documentation

You've heard the warnings. You know it's coming. So how can you prepare? Although a compliance delay until October 1, 2014 is expected, one of the best ways your organization can start preparing for the looming ICD-10 deadline is by conducting efforts to improve clinical documentation now. Because the ICD-10 code set requires a much higher level of specificity than the current ICD-9 standard, it will essentially reshape clinical documentation practices that have been widely accepted for more than three decades. Thus, major clinical documentation issues are expected to result from the changeover – and documentation will drive practice coding, a cornerstone to billing revenue. Failing to prepare for ICD-10 documentation requirements can drastically impact your revenue—missing information may prevent claims from even being submitted. Taking steps now to improve documentation will be foundational in helping your practice get paid faster and experience fewer delays and denials during the changeover.

Under ICD-10, providers will need to document the following in order to be able to assign a code:

  • Laterality
  • Stages of healing
  • Trimester of pregnancy
  • Episode of care

Consider the following example of the differences in coding under ICD-9 and ICD-10:

Code Set






Patient: Betty Bea Goode

DOB: 07/04/1955


1. Patient has regional enteritis in the small and large intestine.

2. Patient has an intestinal abscess.







Patient: Betty Bea Goode

DOB: 07/04/1955


1. Crohn's disease of both the small and large intestine with abscess.

How to prepare

With the vast documentation changes required for ICD-10 compliance, healthcare organizations will need to start training physicians now. To begin, conduct an assessment of current documentation processes. Identify gaps that will need to be filled in order to ensure successful documentation under ICD-10. Next, intitiate training to educate clinicians on ICD-10 documentation requirements well in advance of the transition so that they can have ample time to adjust. Continue the process of assessing and training until optimal levels of documentation are being achieved. Use technology to aid physicians in complying with documentation requirements—select practice management systems can be configured to detect where necessary information is missing in clinical documentation and prompt the physician to include more detail.

Effects of Changes

While the increased specificity of documentation in ICD-10 will challenge the way clinical encounters are currently documented, it will ultimately promote improvements to patient care. Greater detail in clinical documentation drives more effective and efficient patient care by providing higher-quality data. The quality of patient care is enhanced by the greater detail in documentation, as it lends valuable insight and collaborative support to other practitioners the patient may encounter. The more precise, higher-quality data also promotes improved quality reporting, improved clinical decision support and increased patient safety.

The improved documentation required by ICD-10 can also result in faster and fuller reimbursement. When coders no longer have to spend time trying to interpret vague documentation or going back to the physician with questions, providers will get paid faster.

For more information on ICD-10, access a free recorded webinar on "ICD-10 Change-Over: Getting Started."