doctor working on computerPractice administrators are focused on a variety of tasks for ICD-10 readiness. Systems updates and testing, communication with vendors, coding software research, staff training and development – the list goes on.

One big ticket item that could cause issues during the transition is clinical documentation that is not up to par. Clinical documentation will need to support the new ICD-10 codes used and be specific enough to get claims paid. 

An example of a documentation challenge is laterality, which is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information on which side of the body is affected (i.e., right, left, or bilateral). Below are additional examples of the specific information needed to accurately code in ICD-10 for the following common diagnoses:

Diabetes Mellitus:

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • If type 2 diabetes, long-term insulin use


  • Site
  • Laterality
  • Type
  • Location


  • External cause – Provide the cause of the injury; when meeting with patients, ask and document “how” the injury happened.
  • Place of occurrence – Document where the patient was when the injury occurred; for example, include if the patient was at home, at work, in the car, etc.
  • Activity code – Describe what the patient was doing at the time of the injury; for example, was he or she playing a sport or using a tool?
  • External cause status – Indicate if the injury was related to military, work, or other.

One of the first steps is to have a documentation assessment completed internally or by hiring a professional consultant. The assessment can provide needed insight into where your documentation is at and what is needed to meet the needs of ICD-10. You can conduct an internal audit of the existing medical records for the required documentation to see if it is already a part of protocol or if it will need to be added.

Another first step is to create a comprehensive list of top codes and prioritize them by usage and reimbursement. Most practice management or EMR/EHR systems can generate a simple report of this detail. Next, divide the code list into manageable groups of up to 10 a month. Schedule a meeting each month to cross-walk a new group of codes. Review the codes with the physicians and coding staff and identify what the new documentation requirements will be for ICD-10.

For providers using an electronic medical records system many documentation requirements can be built into templates. Having a strong grasp of what actually needs to be included in documentation for ICD-10 is necessary before adding lots of steps that may add extra time for physicians.

While “unspecified” will still be an option in ICD-10, it should only be used when no other available options exist. This will be less likely with the increased specificity of ICD-10. The EMR can be built to ask the questions that get the code to the highest level of specificity and the associated documentation required, but this takes time and testing. ICD-10 codes will require the type, manifestation, and complications requiring providers to understand and document the difference.

Another key aspect to consider with documentation and ICD-10 is a tested communication and feedback loop for your coding staff and billing company. Documentation challenges will arise, especially if your physicians are not doing the coding themselves, and a strong workflow that promotes efficient and timely communication on documentation needs is important. Again, many EMRs offer noting and messaging functions. EMRs with workflow queues that can show a physician what needs their attention are a great way to manage these types of challenges. Lastly, a system that can provide broader feedback on global changes, for example, coding changes for a common procedure with a specific payer is something to consider. Everyone needs to use the system consistently in order for these features to work properly. Monitoring these feedback loops will help identify physicians that may need additional assistance getting prepared.

Another great tool is internet based coding search applications and websites. There are many on the market and some are even integrated with EMRs to be accessible within the system. These tools can quickly identify coding options and some provide noting assistance. Getting detailed documentation that specifically applies to the code will help physicians focus on what is needed to substantiate the use of the code. Moreover, if the search is conducted efficiently shortly after the time of the visit the increased information is typically available from the patient themselves and just needs to be included in the record.

Good documentation can reduce the amount of follow-up on submitted claims. Good documentation can decrease the turn-around time and increase your cash flow. Having a strong understanding of what the changes will be for each person in your clinic and having training to meet their needs is crucial for success. Change is always a challenge and getting people engaged early on and getting buy-in will make a big difference in your ICD-10 transition.

Outsource Receivables has created an assessment to get the process started at

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