Noncompliance in ICD-10 Clinical Documentation


So, now let’s see how much we’ve learned.  During clinical documentation for ICD-10 training, we have urged our physicians and healthcare clinicians to provide as much specificity as possible.   Our teaching strategies included advice such as “make sure you explain severity and frequency, using terms such as acute, chronic acute on chronic… make sure you clearly define complications and comorbidities….use terms like due to, and secondary to…..”

We looked at the data for one of the largest EHRs for week one and what they reported were the most frequently used ICD-10 codes on their platform for the first week.  Ready for what we found?  The top ICD-10 codes were essential (primary) hypertension (I10), type 2 diabetes mellitus without complications (E11.9), hyperlipidemia, unspecified (E78.5), low back pain (M54.5), and anxiety disorder, unspecified (F41.9).

It’s incredible, we still haven’t learned the lesson.  Is this truly the most robust documentation we could provide?  Type 2 diabetes mellitus without complications?  Is that the right diagnosis or did the documentation fail to mention complications.  Lower back pain?  What happened to laterality?  Right?  Left?  Musculoskeletal?  Due to?  And finally unspecified anxiety disorder.  For goodness sakes, what will it take for our providers to begin documenting with greater specificity and less generality?

It’s as simple as this…if we’re not capturing comorbidities and complications, we will have a problem with the case mix index.  If we’re not capturing the data correctly to the greatest specificity, you will not be fairly reimbursed, your risk scores will be impacted and your institution will suffer for it.

I wonder if we would continue using an accountant who was not up-to-date with the documentation requirements in finance.  Would we use an IT team who were unfamiliar with the new technologies?  If not, why do we use physicians and providers who are unfamiliar with the technology, terminology and requirements?  If you are unpaid for your claims this month, can you use “unspecified” as to the reason why you haven’t paid your rent, payroll, mortgage, etc.  Medicine is an art, but it is also a business and until we understand this, we will always struggle to pay for healthcare.

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