ICD-101: Focus ICD-10 training on documenting details

Carl Natale
by Carl Natale

Clinical documentation improvement will be an important part of your ICD-10 transition. That means physicians and staff will need to be more specific in describing diagnoses and procedures.

Laura Legg has some advice on how to document clinical encounters for ICD-10 codes. Specifically, she covers diabetes, pathological fractures and pregnancy. Generally, laterality often will be needed.

Here are a couple examples of how specific ICD-10-CM codes will get:

This is a weekly feature that I use to highlight practical tips on how to use and understand ICD-10-CM/PCS codes. Please let me know of any other sources that I can include.