Document Like This, Not That—Coders’ Perspective

By Wil Lo, MD, CDIP, CCA


Coders play an important role in navigating through the chart, abstracting the proper diagnoses and procedures, assigning the proper codes, and sequencing the codes. Although the passage of H.R. 4302 effectively delayed ICD-10-CM/PCS implementation until October 1, 2015, the ICD-10-CM/PCS code set will eventually replace the ICD-9-CM code set. It’s time to get ready.

The ICD-10-CM/PCS code set will present additional challenges in documentation. Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, an AHIMA approved ICD-10 trainer and director of coding education at YES HIM Consulting, confirms that ICD-10-CM and ICD-10-PCS codes are much more specific than ICD-9-CM in many areas.

“For instance, the specific type and site of fracture must be documented on not only the initial visit, but also on follow-up visits,” Endicott says. “Another big change is the classification of a myocardial infarction being coded as acute for eight weeks in ICD-9-CM to only four weeks in ICD-10-CM.” This specificity will call for more accurate and complete documentation in the health record.

With respect to ICD-10-PCS, Endicott states that ICD-10-PCS requires very specific documentation in the operative report so that the coder is able to clearly understand the objective of the procedure in order to select the correct root operation. An example of a possible documentation improvement opportunity is in the coding of amputations. In ICD-10-PCS, the coder must know the specific level (i.e., high, mid, or low femur) to correctly assign the code, Endicott says.

Dictation is a challenge to the documentation needs of ICD-10-PCS as well. “In PCS there is a real disconnect in communication between PCS and the way things are dictated,” says Garry Huff, MD, CCS, CCDS, an AHIMA approved ICD-10 trainer and president of Huff DRG Review. “Part of this is the physician does not understand the impact of their words and the ICD-10-PCS is inconsistent.”

For example, the physician in an operative report for rotator cuff procedure will describe release of CA (coracoacromial) ligament, Huff says. Based on this documentation, a coder would code ‘release CA ligament.’ “However, the physician is actually not releasing the ligament, but is releasing a tendon by the cutting the ligament. Also a physician will describe a repair of the shoulder labrum with wire sutures; however, this is a re-attachment,” Huff notes.

To prepare for ICD-10, both the physicians and coders must be prepared, Endicott says. The physicians need detailed documentation, and the coders need to understand the Official Coding Guidelines for both ICD-10-CM and ICD-10-PCS, as well as have in-depth knowledge of anatomy and physiology.

Many feel that physicians, CDI specialists, and coders will need to become familiar with ICD-10-CM/PCS. It has been established that the physicians and CDI specialists must be on the same page if they want to improve documentation practices. However, it is ultimately the coders’ responsibility to navigate through the patients’ charts and link the documentation with the coding guidelines and conventions so that codes can be properly assigned and sequenced. This is a formidable task.

Maggie Foley, PhD, RHIA, CCS, an AHIMA approved ICD-10 trainer and associate professor in the HIM department at Temple University says improving the beginner-level and intermediate-level coders’ ability to navigate through a record and interpret what is being documented is certainly necessary. “However, I would argue given the constant advances in clinical medicine, this is also an ongoing need for advanced coders and CDI staff as well,” she says. “Also, I don’t know that the responsibility of this training rests solely with the CDI staff. A good coding manager is probably already providing this type of training to the coding staff.

“I think any type of clinical updates from the medical staff is worthwhile for a new or intermediate-level coder. With the switch to ICD-10-PCS, an emphasis on understanding operative report documentation is certainly a priority,” Foley says.

Foley addresses the documentation challenges for physicians with the ICD-10-CM/PCS code sets. ”I think the challenges for physicians as we move to the ICD-10-CM and ICD-10-PCS code sets can be mitigated with awareness training regarding new documentation requirements,” she says. “Much of what is being requested in terms of greater specificity (i.e., laterality or type of atrial fibrillation, if clinically relevant) will be seen as reasonable requests from physicians and the needed changes in documentation practices fairly easy to implement. I do think it is important for coders and CDI specialists to work with physicians as early as possible about increased documentation needs so that the transition to ICD-10 can be as smooth as possible.“

Huff says one of the challenges of translating clinical vocabularies into coding vocabularies is that practicing physicians are not actively involved in the development of the code book. Also, the terminology used is not what is used clinically.

“The code book parses conditions differently than clinicians. For example, physicians classify pneumonias based on demographics and not organism,” Huff says. “The demographics do dictate the antibiotic selection because certain organisms tend to cause pneumonias in different venues.

“There is no code for healthcare-associated pneumonia. However, this is a common clinical diagnosis,” Huff says.

In an immune-compromised host with healthcare-associated pneumonia, one has to cover for pseudomonas, MRSA, and anaerobes, Huff says. “The only way you can capture the complexity of the pneumonia is for the physician to document what he is covering for. However, many physicians do not want to use suspected diagnoses. Thus, these patients get incorrectly assigned to patient groups that are less complex.”

From a diagnostic standpoint, most of the same documentation issues present in ICD-9-CM will exist in ICD-10-CM, Huff says. ICD-10 will not solve physician documentation issues. “It will, in many ways, create problems,” he says.

Diana Karff, RHIA, CCS, CPC, an AHIMA approved ICD-10 trainer and ambassador and lead instructor at the American Coding School, offers additional insight about placing the burden of clinical documentation on the coder, not the physician or the CDI specialist.

“The bridges we build with a CDI team cannot be complete without coding staff members who understand basic clinical pathways and anticipated medical and procedural interventions,” Karff says. “Established clinical pathways provide the context for the documentation framework constructed by physicians. Physicians are predominantly communicating with one another in the medical record, in my humble opinion.

“Until we, as coders, accept this statement, we will experience conflict with CDI team members and physicians.”

All coders need systems-based coding training, Karff says. This training respects the accepted clinical pathways needed to comprehend documentation while strengthening coding rules. “If taught together, the coder becomes a stronger, better educated team member,” she says.


Wil Lo, MD, CDIP, CCA ( is a CDI physician consultant.


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