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Physician Documentation Tips for Implementation of ICD-10-CM

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Although CMS has tentatively delayed the ICD-10-CM diagnosis code set, it is important to continue preparing for its implementation. The current diagnosis coding system ICD-9-CM has approximately 14,000 codes while the new coding system ICD-10-CM has 69,000 codes. Greater specificity will be required along with additional documentation to distinguish between the larger number of codes.

Below are some general documentation tips that you can begin using now to create a seamless transition to the new system:

Specific diagnosis

  • Document the diagnosis to the greatest level of specificity
    • Example: dysphagia, pharyngeal phase

Specific anatomy

  • Document the exact body location
    • Example: cerebral infarction due to thrombosis of the left middle cerebral artery


  • Document which side of the body- right or left
  • Note: approximately 5,000 codes have a right and left distinction
    • Example: central corneal ulcer, right eye

Combination codes for conditions and common symptoms or manifestations

  • Document any conditions that are related or causal
  • Diagnosis must be clearly documented
    • Example: central corneal ulcer, right eye
    • Example: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

Dominant verses non-dominant side

  • Document dominant verses non-dominant side for all paralytic syndrome codes such as hemiplegia, monoplegia and hemiparesis.
    • o Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

Initial verses recurrent

  • Document whether the condition is initial or recurrent
    • Example: recurrent and persistent hematuria


  • AHIMA ICD-10-CM Coder Training Manual
  • The Top 10 Documentation Tips for ICD-10-CM: The Devil is in the Details. Just Coding News: Outpatient- August 25, 2010.

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