ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

INTRODUCTION

Introduction

Documentation is one of the central elements that underlie patient care, coding and billing for patient care, and an effective compliance plan. Many diseases, disorders, injuries, other conditions and even signs and symptoms require specific documentation to be compliant with the code structure and provide diagnosis coding to the highest level of specificity for accurate reporting and reimbursement. An ongoing review of documentation practices will help to determine if corrective changes are needed. The ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity is designed to address this need.

Documentation and Coding

In this book, three aspects of ICD-10-CM coding and documentation are addressed. The first relates to documentation requirements. Before actual medical record documentation can be analyzed, physicians and coders must understand the ICD-10-CM requirements for commonly reported signs, symptoms, diseases, and other medical conditions. Frequently, codes capture specific information about the condition itself. For example, strep infections of the throat and tonsils must be specifically identified as strep throat or strep tonsillitis; and for patients with strep tonsillitis, the condition must be specified as acute or acute recurrent.

Codes may also capture a disease and related conditions. For example, there are combination codes that capture the type of diabetes and specific manifestations or complications, such as Type 2 diabetes with hypoglycemia, which must also be specified as with or without coma. Some codes capture a condition and common symptoms, such as intervertebral disc disorders with radiculopathy. ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity covers many commonly reported diagnoses and reviews the necessary documentation elements so that providers and coders have a good understanding of what documentation is required based on the available codes for the condition.

The next aspect of coding and documentation that is addressed is the analysis component. Each condition covered in the book includes a bulleted list of coding and documentation elements. This list is designed to be used for actual documentation analysis. A documentation and coding example is provided with bolding of the portion of the documentation that captures the information required for ICD-10-CM code assignment. Coders will need to remember that physicians do not always document using exactly the same terminology in the code descriptor. However, that does not mean that a specific code cannot be identified.

The physician may use an alternate term that describes the same condition with the necessary level of specificity. So coders will need to rely on and enhance their knowledge of medical terminology and synonymous terms. In addition, coders will need to rely on coding instructions in the Alphabetic Index and Tabular List as well as the ICD-10-CM Official Guidelines for Coding and Reporting to determine whether the most specific code can be assigned from the documentation provided or whether the physician will need to be queried.

The last aspect of coding and documentation addressed is documentation improvement. Several documentation checklists are provided in Appendix B for physician feedback related to specific conditions. These checklists can be used to identify any missing documentation elements required to assign the most specific code. Information contained in the checklists can be compiled for each physician and any documentation deficiencies identified. Documentation and coding checklists for conditions not addressed in this book can also be created for other conditions using the formats of the checklists provided. There are a few different formats and styles of checklists so users can determine which style works best for their practice and then create additional checklists using that format and style.

In addition to the coding and documentation checklists there are clinical documentation improvement bulleted lists for three conditions that are often lacking sufficient documentation in the inpatient setting. The information in these lists identifies common indicators of the condition so that the physician can be queried to determine if the condition should be included as a diagnosis in the medical record or can be coded to a more specific diagnosis.

Documentation and Compliance

Complete and accurate provider documentation is a continuous concern for physicians and hospitals alike. In addition to supporting quality patient care and serving as a legal document to verify the services provided, provider documentation is also needed to support correct coding initiatives, coding and documentation audits, and Medicare oversight reviews.

The Social Security Act and the Centers for Medicare & Medicaid Services (CMS) regulations require that services be medically necessary, have documentation to support the claims, and be ordered by physicians. Consistent, current and complete documentation in the treatment record is an essential component of quality patient care according to the National Committee for Quality Assurance. Specific documentation criteria are required for inpatient medical records by the Joint Commission on Accreditation of Healthcare Organizations and the federal Conditions of Participation. In addition to accreditation standards and federal regulations, medical record documentation must also comply with state licensure regulations and payer policies, as well as professional practice standards. Compliance and accurate reimbursement depend on the correct application of codes, which is based on provider documentation. In addition to the reimbursement implications, provider documentation is also used in quality improvement initiatives.

The codes reported on health insurance claims must be supported by the documentation in the medical record. Most payers require reasonable documentation that services are consistent with the insurance coverage provided. In one year, for example, the Office of Inspector General (OIG) found that 43.7 percent of errors were due to insufficient documentation, posing a significant compliance risk. Recovery Audit Contractors and Medicare Administrative Contractors reviews continue to identify numerous erroneously paid claims due to a high incidence of “insufficient documentation.”

Medicare specifically requires that any services billed be supported by documentation that justifies payment. The Centers for Medicare & Medicaid Services (CMS) has implemented numerous corrective actions to reduce improper payments along with efforts to educate providers about the importance of thorough documentation to support the medical necessity of services and items. CMS review contractors identify and recover improper payments made due to insufficient documentation—the review determines that the documentation is not sufficient to support the provided service or that it was medically necessary. For example, a pilot study estimated that additional documentation would have reduced the amount of improper payments identified in 2010 by approximately $956 million.

Medical record documentation must comply with all legal/regulatory requirements applicable to Medicare claims. Documentation guidelines identify the minimal expectations of documentation by providers for payment of services to the Medicare program. Additional documentation is often required by state or local laws, professional guidelines, and the policies of a practice or facility. In general, medical record documentation that specifically justifies the medical necessity of services is necessary to support approval when those services are reviewed. Services are considered medically necessary if the documentation indicates they meet the specific requirements for medical necessity.

The key to ensuring appropriate documentation hinges on understanding how much depends on the quality and completeness of provider documentation in the medical record. Providers typically do not know the specific type of documentation needed to code various diseases and disorders accurately, so education is also a key factor. Prior to conducting provider education, it is important to know the extent and type of documentation in the medical record. Conducting a provider documentation assessment of medical records will identify key areas of risk and focus education efforts.

Documentation is central to patient care, billing for patient care, and an effective compliance plan. Accurate patient record documentation is a key component of the compliance plan, as it provides the justification necessary to support claims payment. Increased scrutiny of provider documentation by auditors has added even greater emphasis to the importance of identifying documentation deficiencies, correcting them, and ensuring proper documentation for every case. One of the key components of an effective compliance program for physician practices is the implementation of a system to audit and monitor an organization’s practices.

Overview of ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity

The ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity is designed around ICD-10-CM with a documentation and coding chapter for each ICD-10-CM chapter.

Chapter Introduction

Introductory information for each chapter covers general information about the chapter. A table is provided showing the chapter coding blocks, which are the ranges of 3-character categories that cover related diagnoses within the chapter. Review of this table provides coders and physicians with information about the organization of that specific chapter.

The introduction also covers chapter level instructional notes, including includes and excludes notes. Chapter level includes notes further define or give examples of the content of the chapter. Excludes notes indicate that certain diseases, injuries or other conditions are excluded from or not coded in the chapter. There are two types of excludes notes in ICD-10-CM designated as Excludes1 and Excludes2, which are defined as follows:

•Excludes1 – A type 1 excludes note is a pure excludes note. In general, it means “NOT CODED HERE”. An Excludes1 note indicates that the code excluded should rarely be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. There are a few exceptions when both conditions may be coded such as a sequela from a prior CVA and a new CVA or chondromalacia of the patella as well as the femur.

•Excludes2 – A type 2 excludes note represents “NOT INCLUDED HERE”. An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Chapter Guidelines

Following the introduction, the ICD-10-CM Official Guidelines for Coding and Reporting for the chapter are reviewed. The chapter guidelines provide information on assigning codes from the chapter which often includes information related to documentation. Many coders think of the guidelines primarily as instructions on assignment and sequencing of codes, but there are many references to information that must be included in the documentation to allow assignment of specific codes. In addition, the coding guidelines often indicate when the physician should be queried for additional information related to the diagnosis. So, the chapter-specific guidelines are an important tool that must be used to ensure that the documentation supports assignment of a specific code.

General Documentation Requirements

For each chapter, general documentation requirements are covered. Many chapters in ICD-10-CM have documentation requirements that relate to the entire chapter or to many code categories in the chapter. Examples of the types of information covered in the general documentation requirements include:

•Site specificity, such as proximal or distal, or upper/middle/lower lobe

•Laterality (right, left, bilateral)

•Combination codes that capture:

–Etiology and manifestation

–Related conditions

–Disease, injury or other medical condition and complications

–Diseases or other medical conditions and common signs or symptoms

•Identification of the fetus affected by certain complications of pregnancy, childbirth and puerperium in multiple gestation pregnancies

•Identification of the trimester for complications occurring during pregnancy

•Increased specificity related to histologic behavior of certain neoplasms

•Episode of care (initial, subsequent, sequela) for injuries, poisoning, external causes and other conditions

•Increased specificity related to type of injury

•Use of fracture classification systems (Gustilo, Salter-Harris, Neer)

•Intraoperative and postprocedural complications

•Reclassification of codes into different categories or chapters

•Revised terminology

Chapter-Specific Documentation Requirements

In this section, code categories, subcategories, and subclassifications for some of the more frequently reported diseases, disorders, or other conditions in each ICD-10-CM chapter are reviewed. Specific documentation requirements are identified. The focus is on conditions with specific clinical documentation requirements. Although not all codes with significant documentation requirements are discussed, this section provides a representative sample of the type of documentation needed for diseases, disorders, or other conditions coded in the chapter. The section is organized alphabetically by the ICD-10-CM code category, subcategory, or subclassification depending on whether the documentation affects only a single code or an entire subcategory or category.

The condition reported by the category, subcategory, or code is discussed, followed by a bulleted list identifying the specific elements that must be captured to allow assignment of the most specific code. A scenario provides an example of the documentation required to capture the most specific code and the scenario is also coded. Coding notes are provided that discuss any guidelines, includes/excludes notes and other information that affected the code assignment for the scenario.

Quiz

A self-assessment quiz is provided at the end of the chapter. The quiz covers general and chapter specific guidelines, documentation requirements, and code assignment for the conditions discussed in the chapter. Answers and rationales are listed on the pages following the quiz in each chapter.

Appendixes

There are three appendixes. Appendix A provides checklists for common diagnoses and other conditions to be used for documentation review of current records to help identify documentation deficiencies. Appendix B provides bulleted lists that can be used for clinical documentation improvement. Appendix C provides a glossary of medical terminology encountered in the book.

Other Recommended Resources

The ICD-10-CM Documentation: Essential Charting Guidance to Support Medical Necessity may be used alone; however, the most benefit will be derived when the book is used with other coding resources. It is recommended that the book be used in conjunction with the most recent ICD-10-CM Code Set and ICD-10-CM Official Guidelines for Coding and Reporting. A comprehensive medical dictionary is also recommended.

Summary

Patient care, documentation, coding and compliance go hand-in-hand. It is not possible to assign the most specific and most appropriate diagnosis code without complete, detailed documentation related to the patient’s disease, injury, or other reason for the encounter/visit. Documentation must also support the medical necessity of any services provided or procedures performed. Detailed, consistent, complete documentation in the medical record is one of the cornerstones of compliance. In addition, the effect of documentation on reimbursement cannot be overemphasized. Failure to support the medical necessity of the services or procedures provided or performed can result in loss of reimbursement, financial penalties, and other sanctions. Because of the specificity of ICD-10-CM codes and requirements by health plans to support the services billed, current documentation must be reviewed, documentation deficiencies identified, and a corrective action plan initiated. This book is designed to help coders, physician practices, and other health care providers understand the documentation requirements and prepare for improved documentation to support the services billed and the severity of the patient’s condition.