# ICD 10 Documentation requirements



## m.matos@chcfl.com (Jul 1, 2015)

Hi,
My providers are arguing the documentation requirements. Because the ICD 10 code will appeal on the progress note with full description: for example: Acute suppurative otitis media, right ear, recurrent. They are arguing that they do not have to else where document in the progress note because the description of the of the diagnosis shows on the progress note and this should be enough. I strongly do not agree with this. I think it should be documented in the HPI, ROS, Exam or past medical history. Can someone please advise if I am right or wrong in my thinking? I need to be able to go back to the providers and advise that I have consulted AAPC on this.


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## erjones147 (Jul 1, 2015)

I agree with you 100%

They still have to show "medical necessity" for their dx's; for example, any details on the suppuration?

Also, ask your providers if they (or any colleague they have worked with or heard of) have NEVER - and I mean not one time ever - charted the wrong laterality by mistake

Physicians are not coders, nor are they perfect. Tell them that if they really are that good, then they can sit in on the next auditing session with CMS or whomever. Diagnoses are supposed to based on documented evidence, and "if it isn't documented, then it never happened."


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## marcieadasher@gmail.com (Jul 3, 2015)

*going through the same thing at my office*



m.matos@chcfl.com said:


> Hi,
> My providers are arguing the documentation requirements. Because the ICD 10 code will appeal on the progress note with full description: for example: Acute suppurative otitis media, right ear, recurrent. They are arguing that they do not have to else where document in the progress note because the description of the of the diagnosis shows on the progress note and this should be enough. I strongly do not agree with this. I think it should be documented in the HPI, ROS, Exam or past medical history. Can someone please advise if I am right or wrong in my thinking? I need to be able to go back to the providers and advise that I have consulted AAPC on this.



Hi. Just wanted to say. I am going through the same thing at the offices I work at. The providers have no clue about this ICD-10 and documentation guidelines. The company we work for has not provided them with any type of education what so ever. They are simply relying on the EHR system to "map"/convert the already listed ICD-9 codes that are basically generic codes and/or unspecified codes to the proper ICD-10 codes.


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## atolep (Aug 6, 2015)

*ICD-10 Documentation Education*

Where do your providers work? Are they interested in obtaining training?

The company I work for, Precyse, specializes in ICD-10 Education - you can either purchase online modules which are very comprehensive and specialty specific or obtain a live trainer.

Andy Tolep, CCS, CCDS, CPC
Precyse Consultant


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## Cynthia Hughes (Aug 6, 2015)

*ICD-10 documentation*

For an authoritative answer to your concerns, see Coding Clinic for first quarter 2012. The guidance from Coding Clinic is official under HIPAA and stated that the physician must specifically document the patient diagnosis and it is not appropriate for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. 

This is not different from ICD-9 and/or paper records in that you would question a diagnosis listed in the assessment and plan that was not supported somewhere in the rest of the note (eg, history of present illness, exam findings, counseling). 

Hope that helps.


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## Cynthia Hughes (Aug 6, 2015)

*ICD-10 documentation (more)*

I should have added the rationale that while many ICD-10-CM codes are specific including laterality, occurrence, etc., many codes still represent more than one clinical condition or lack any detail of the status of the condition. If the physician's adopt a practice of only selecting codes and not providing a specific diagnosis, medical records with these codes may lack sufficient detail to convey the physician's diagnosis. This could have implications beyond support for coding and billing.


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