ICD-10 Assessment

Documentation Readiness Evaluation

Documentation will become critical with ICD-10

One of the largest problems following the October 1, 2014 implementation date for ICD-10 will be documentation insufficient to support the specificity required for the new ICD-10 code sets. For many organizations, this has been forgotten among the other education, training, and implementation objectives. A recent study evaluating the assessments of more than 3,000 medical records across the country revealed that on average, only 37% of the current physician documentation would support the newer standards that will be required by ICD-10.

If your office is fully prepared for ICD-10, but clinical documentation has not been improved, accurate coding and proper payment will not be possible. A behavioral change in documentation habits for most providers will be necessary – and now is the time to start preparing.

A clinical documentation ICD-10 assessments will:

  • Validate sufficient ICD-10 documentation
  • Identify ICD-10 clinical documentation deficiencies
  • Identify ICD-10 training specific to your needs
  • Avoid an increase in denied or unbillable claims
  • Prevent an interruption in revenue

ICD-10 Documentation Example

The following case highlights the increased specificity required to code for ID-10-CM. Mouse over the highlighted text to see further explaination.

S: Mrs. Finley presents today after having a new cabinet fall on her last week, suffering a concussion, as well as some cervicalgia. She was cooking dinner at the home she shares with her husband. She did not seek treatment at that time. She states that the people that put the cabinet in her kitchen missed the stud by about two inches. Her husband, who was home with her at the time told her she was "out cold" for about two minutes. The patient continues to have cephalgias since it happened, primarily occipital, extending up into the bilateral occipital and parietal regions. The headaches come on suddenly, last for long periods of time, and occur every day. They are not relieved by Advil. She denies any vision changes, any taste changes, any smell changes. The patient has a marked amount of tenderness across the superior trapezius.

Q: Her weight is 188 which is up 5 pounds from last time, blood pressure is 144/82, pulse rate 70, respirations are 18. She has full strength in her upper exremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart rate is regular and lungs are clear.


  • Status post concussion with acute persistant headaches
  • Cervicalgia
  • Cervical somatic dysfunction

P: The plan at this time is to send her for physical therapy, three times a week for four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We'll recheck her in one month, sooner if needed.

  ICD-10-CM Coding:
S06.0x1A Concussion with loss of consciousness of 30 minutes or less, initial encounter
G44.311 Acute post traumatic headache, intractable
M54.2 Cervicalgia
M99.01 Segmental and somatic dysfunction of cervical region
W20.8xxA Struck by falling object (accidentally), initial encounter
Y93.g3 Activity, cooking and baking
Y92.010 Place of occurance, house, single family, kitchen

Identify your opportunities for documentation improvement.
Contact us for an ICD-10 Documentation Evaluation today.