ICD-10 Documentation and Quality Reporting Changes

April 3, 2015

Make sure your practice is ready for changes in documentation analysis and quality reporting tied to the ICD-10 coding transition.

In the physician practice, it cannot be stressed enough that only ICD-10 will be utilized come Oct. 1, 2015. The first thing that needs to be understood is what exactly is changing in regard to the diagnosis codes in ICD-10.


ICD-10 has gone from 17 chapters to 21 chapters. While this might sound like the cause of all the additional codes, it really is not. In ICD-9, there were the V-codes and E-codes that were not classified as "chapters." That accounts for two of the four new chapters. The other two are the result of diseases of the eye and ear each being promoted out of the nervous system chapter. There are also some codes that have been reclassified into more appropriate categories based on current medical knowledge.

In contrasting the two code sets, ICD-10 has changed how injuries are classified. They are now grouped by the body site injured and then by the type of injury, whereas ICD-9 only classified injuries by type. To allow for future expansion, ICD-10 codes can be as small as the three-character category code and as information rich as a seven-character code that includes laterality, severity, and episode of care. Additionally, ICD-10 has switched over to alphanumeric versus the straight numeric ICD-9.


Documentation has been touted as one of the biggest challenges with ICD-10, which is understandable considering the need for more specificity in order to obtain the most accurate code to describe the patient's condition. The more precise the description of a patient's condition, the more detailed the code choice can be. This leads to better data for outcomes reporting, research, and public health statistics, just to name a few benefits. The goal of documentation improvement is not to increase the amount a provider charts on a patient. The goal is to give an accurate depiction of the symptoms that lead to diagnosis, and the treatment course chosen to most effectively care for the patient. When looking at the groups of quality measures in the Physician Quality Reporting System (PQRS), ICD-10 offers the physician a greater number of combination codes to more succinctly report the more common etiologic and manifestation relationships.


In ICD-10, there was a significant change in the diabetes mellitus codes. In ICD-9, there was only the 250 category. With ICD-10, there are five categories, but the most significant change is the combination codes that were created. As mentioned earlier, there have been a number of additional codes added to ICD-10, and diabetes is one of the places where that occurred. These added combination codes actually reduce the number of codes to report. Rather than using two codes to describe a single condition, the diabetes combination codes describe both the etiology (diabetes) and the manifestation (such as, glaucoma) all in one code. A perfect example of this is type 2 diabetic retinopathy with macular degeneration. In ICD-9, it would have taken three codes to capture every detail of this condition. In ICD-10, it only takes one code. So if there is type 2 diabetic retinopathy with macular degeneration, then there is also a type 1 diabetic retinopathy with macular degeneration. Sufficed to say, the same would be true for each of the other three categories of diabetes mellitus. It is for this reason that, when looking in the 2015 PQRS Measures Group Specifications Manual, there is going to be a longer list of possible codes the diabetes group. The number of reportable diabetes codes for Jan. 1, 2015, through Sept. 30, 2015, is 54. Beginning Oct. 1, 2015, there are a total of 92 reportable diabetes codes. Again, these codes provide more granularity, and therefore improved data.

While some providers may be alarmed at the increased availability of these more definitive code descriptions, there is a change with ICD-10 many will be pleased about. No longer will they be inundated with queries asking if the diabetes is controlled or uncontrolled. This classification is removed from ICD-10. However, if the terms "inadequately controlled," "out of control," or "poorly controlled" are used in documentation, coders will be guided by the ICD-10 index to use the type of diabetes with hyperglycemia.


Another reportable diagnosis in the PQRS Measures Group is asthma. While the number of reportable diagnoses for asthma has also increased when comparing ICD-9 to ICD-10, the number of codes is significantly lower. There is only an increase of four additional codes in the list of reportable asthma diagnoses. This change is attributable to the addition of terms that more appropriately reflect the current clinical classification of asthma. The terms that have been added are "mild intermittent," "mild persistent," "moderate persistent," and "severe persistent." Providers that see a high number of asthma patients should be aware of these classifications and utilize an appropriate source to make consistent diagnosis and treatment decisions based on the chosen source.


On Dec. 10, 2014, a joint presentation was done by CMS and the American Health Information Management Association (AHIMA). The following list was provided as documentation focus areas:

• Disease type

• Disease acuity

• Disease stage

• Site specificity

• Laterality

• Missing combination code detail

• Changes in timeframes associated with familiar codes

By reviewing the 2015 PQRS Measures Group Specifications Manual and focusing on this list of areas for documentation improvement, any physician practice can improve not only their documentation, but also demonstrate improved quality of care by providing a clear picture of the patient throughout the care continuum.

Now that some of the groundwork has been laid, it is time to build on the foundation of strong documentation. Every ounce of clarity noted in the provider documentation builds a complete picture of the patient's health, history, treatment, and quality care. Additional steps for preparation are easily accomplished when these building blocks are in place.


• AHIMA. ICD-10-CM/PCS Implementation Toolkit: http://www.ahima.org/topics/icd10

• AHIMA. ICD-10 for Physicians and Clinicians: http://www.ahima.org/topics/icd10/physicians

• AMA ICD10 Resources: www.ama-assn.org/go/ICD-10

• CMS Provider Resources - Road to 10: http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

Maria N. Ward, M.Ed, RHIT, CCS-P, is a director of health information management practice excellence at AHIMA. She can be reached at maria.ward@ahima.org.

© 2015 American Health Information Management Association (AHIMA). Reprinted by permission.