ICD-10-CM diagnosis codes
Documenting the specificity of ICD-10-CM
The key to successfully coding ICD-10-CM: In a nutshell
- ICD-10-CM codes have greater specificity than previous coding sets.
- Coding the highest level of specificity requires documentation that captures the necessary details identified in the code description.
- Failing to document specific information in the medical record results in reporting of unspecified diagnosis codes and increased levels of claim denials.
Documentation specificity is key
Physician documentation is the key to successful coding with ICD-10-CM. Information needed to correctly select an ICD-10-CM code often includes causality, location, or comorbidities. The physician should ensure that their documentation provides the required information.
Typically, this does not require the physician to document more information. Rather, ensure that this information is already obtained and documented in the medical record, and that it can be extracted and applied when selecting and reporting specified codes.
Recording specific information in the record will support codes with the highest specificity. This is important because insurance companies will reject codes such as “unspecified tumor location,” because there is a code that could provide more information. When you use less specific codes, insurance is likelier to deny the claim.
Look at the example below to see how an actual code can be constructed. The example concerns a basal cell carcinoma on the right upper limb.
Now consider this example of the code construction for a squamous cell carcinoma on the left ear.
Each digit added to the base code adds a greater level of specificity. In each example, the base code specifies the general condition and anatomic location, but added digits provide greater specificity as to the particular type of neoplasm and its laterality (side of the body).
You can test your knowledge of ICD-10 coding by taking a short Academy quiz, or see other coding quizzes.
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