Clinical Documentation Improvement and ICD-10: Are You Ready?

on Monday, 23 February 2015. All News Items | Documentation | Coding

2015 Could Finally be the Year that ICD-10-CM/PCS is Implemented

The Energy and Commerce Committee’s Subcommittee on Health held a hearing on February 11th, 2015 Examining ICD-10 Implementation. Committee members heard from several stakeholders as the latest implementation date is set for October 1, 2015. According to their website “The committee has been working with the Centers for Medicare and Medicaid Services for several months to ensure this deadline is successfully met.” And Subcommittee chair Rep. Joe Pitts (R-PA) indicated in the hearing notice that “This hearing is an important opportunity to hear about the state of preparedness of all those involved and ensure that we are continuing to move forward in health care technology.”

At the close of this hearing Rep. Pitts ended by saying that there had been “excellent testimony, very informative, very important” and I believe that the October 1, 2015 implementation date might just happen. Though as we all know here in the south, predicting that this might happen is like our weathermen telling us to prepare for snow.

Not to stress out those of you that have been thankful for the past delays but the Center for Disease Control and Prevention (CDC) ICD-10-CM/PCS Transition page has posted a countdown and while writing this article it is only 224 days, 19 hours, 24 minutes and 56 seconds until implementation. So, are you ready?

For the Clinical Documentation Improvement Professional I want to provide you with a list of “did you know” changes occurring in ICD-10 to assist in your preparation and Physician education.


ICD-10-CM/PCS: What is Needed to Accurately Code a Diagnosis

Myocardial Infarction Timing: Acute episode now ≤ 4 weeks
Type and Location: STEMI of anterior wall, inferior wall, other sites
Type and Location: NSTEMI – nontransmural, subendocardial, non Q-wave
Cardiomyopathy Type: e.g. dilated/congestive, obstructive/nonobstructive hypertrophic, etc.
Location: Endocarditis, right ventricle, etc.
Cause: e.g. congenital, alcohol, etc.
Arrhythmias Location: e.g. atrial, ventricular, supraventricular, etc.
Rhythm name: e.g. Flutter, fibrillation, type 1 atrial flutter, Sick Sinus Syndrome, etc.
Acuity: Acute, chronic, etc.
Cause: e.g. hyperkalemia, HTN, Alcohol consumption, etc.
Hypertension Essential, Malignant & Benign HTN will ALL code to the 1-10 code I10:Essential HTN
Diabetes documentation Type: e.g., Type 1 or Type 2, drug induced, gestational, etc.
Complications: Link to the diabetes e.g. diabetic foot ulcer, diabetic gastroparesis, etc.
Note: Unlike ICD-9, a 4th Quarter 2013 Coding Clinic indicates that “No, ICD-10-CM does not presume a linkage between diabetes and osteomyelitis.
Treatment: Is the patient on Insulin? e.g. Type 2, long-term insulin use
Fractures Location of fracture: site AND laterality
Type: e.g. open, closed, pathological, neoplastic disease, etc.
Pattern: e.g. comminuted, oblique, segmental, spiral, transverse
Encounter of care: initial, subsequent
If is a subsequent encounter: note the healing status: normal, delayed, nonunion, malunion
Pregnancy: Documentation of Trimester is Required First Trimester defined as <14 weeks, 0 days
Second Trimester defined as 14 weeks, 0 days through 27 weeks and 6 days
Third Trimester defined as 28 weeks through delivery

By no means is this table meant to be all inclusive of the changes coming. My hope is that this information will serve to “jump start” those that have been anticipating a perpetual delay to the implementation of ICD-10-CM/PCS.


Link to the Examining ICD-10 Implementation Hearing:

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-three years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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