ICD-10 Documentation: What EDs Should Be Doing Today to Prepare (Part 2 of 4)

Jim Strafford

Jim Strafford , CEDC, MCS-P


Published February 26, 2014

In his previous post, Jim Strafford of Healthcare Administrative Partners (HAP) introduced his series on how EDs can prepare to implement ICD-10 coding standards. In today's post, he talks about where EDs should be today in their progress toward implementation and shares some practical suggestions for getting started.

Parallel Coding

At this point your coding entity should, at minimum, be "sampling" ICD-10 coding. This means the coders should be coding both ICD-9 and ICD-10 for 5 percent of your charts at minimum. Parallel coding should be in place whether or not a given payer is ready to accept the ICD-10 codes.

Parallel coding has many benefits:

  • Abstracting ICD-10 codes based on current ED chart documentation will help coders familiarize themselves with coming changes. Training and documentation are important, but coding is best learned by coding repetitively.
  • Parallel coding allows coders to pinpoint existing documentation limitations on providers' ED charts that result in "unspecified" codes under ICD-10 so that steps can be taken now to correct documentation practices. ("Unspecified" items are the most likely to pose payment/denial challenges after Oct. 1.)
  • Parallel coding allows administrators to track coder productivity. Every country that has implemented ICD-10 so far has seen an impact on production. In the United States, medical documentation/coding experts predict a 20­–40 percent decrease in productivity effective Oct. 1. Parallel coding will not eliminate production issues, but it should lessen the impact and provide management with projected production data prior to implementation.

A Major Caveat

Coding is a technical task, but it is also a production task. Coding entities, whether in-house or an outside company, typically measure production in charts coded per hour. These entities have already experienced a slowdown in production with the implementation of EMRs. Outside companies in particular must code a minimum number of charts per hour in order to remain profitable.

Paralleling ICD-9 to ICD-10 coding certainly presents production challenges for these entities. The additional work of parallel coding just 5 percent of ED charts will have an impact. But our view is that in terms of production, your coding entity will pay now or pay more later. In addition to boosting production down the road, parallel coding will improve ICD-10 coding quality.

Ongoing Provider Feedback

If you are a provider that uses an external coding/billing service, start working with that service now to prepare for a smooth ICD-10 implementation. Areas to address include parallel coding, IT changes and payer testing.

In addition to keeping you informed of their ICD-10 preparations, your coding/billing entity should be providing you with specific feedback about your documentation. Feedback should be reported to physicians and reviewed with them on a regular basis. (HAP and other revenue cycle companies have invested a great deal in ICD-10 documentation and training for their clients.)

Parallel coding can provide a framework for these conversations. For example, the same documentation that would result in a code of 382.9, "otitis media" under ICD-9 would result in a code of H66.90, "unspecified otitis media, unspecified ear" under ICD-10. At minimum, going forward, the provider should be documenting right, left or bilateral infection for greater coding specificity.)

In the case of mental illnesses presenting in the ED, ICD-10 documentation codes require physicians to specify the severity of the symptoms (e.g., mild, moderate) and whether psychotic features are present. It is not unreasonable for the ED physician to take the position that this level of specificity is more appropriately the realm of psychiatry. But with the enormous number of psychiatric cases presenting in the ED, a change in documentation mindset to allow for the most specific ICD-10 code will be required to prevent revenue decreases and interruptions after Oct. 1.

Provider feedback should also pinpoint documentation that might result in an acceptable ICD-9 code, but that cannot be coded at all in ICD-10. Returned charts have always been a challenge to coding/billing entities in terms of tracking and reconciliation. Unfortunately, it is likely that these entities will receive charts that lack sufficient documentation for ICD-10 coding. Identifying and correcting these scenarios now will hopefully minimize yet another process that slows down cash flow.

A simple example is ICD-9 883.0, "laceration, finger." All of the ICD-10 codes for finger laceration require documentation as to whether or not nail damage occurred. Now is the time to get in the habit of documenting either "with" or "without" nail damage.

In Part 3, we will discuss some more common ED ICD-10 coding scenarios that providers should be aware of.

More ICD-10 Documentation Tips

A combination of ICD-10 documentation training and "live case" feedback should allow ED providers to develop the documentation granularity and specificity required for Best ICD-10 Coding Practices. Some additional steps providers can take include:

  • Get in the habit of documenting "first encounter" as prescribed by ICD-10. While ED visits are often by their nature first encounters, coders will be looking for this terminology.
  • With lacerations, get in the habit of documenting laterality, specific finger and wound type (puncture, bite, etc.).
  • For head injures with loss of consciousness, get in the habit of documenting how long the patient was unconscious in the following increments: 30 minutes or less, 31 to 59 minutes, 1 hour to 5 hours 59 minutes, etc.
  • Differentiate a sprained ligament from a strained muscle. If possible, document the specific ligament sprained. This is not always reasonable in the ED. But if, for example, the orthopedist has provided more specific information like "sprain of deltoid," there is a more specific code: S93.421A, "sprain deltoid, right ankle, initial encounter." And remember, laterality, laterality, laterality.

Caveat 2

Completely eliminating unspecified documentation will be useless if your EMR is not supporting the level of granularity required for ICD-10. As of this writing, ICD-10 codes and descriptions should be a feature of your EMR. And by now, you should have received (at minimum) an orientation from the vendor and your IT/HIM personnel. If that is not the case, the clock is running.


In Part 2, we have reviewed where ED providers and coder/biller entities should be in terms of ICD-10 preparation at this point in time. We realize that documenting to ICD-10 specificity will require a change in mindset and approach by ED providers. And this can only be accomplished with constant feedback and support from the coding/billing community.

We have not discussed at length another key stakeholder in ICD-10, the technology space. This would include EMRs, coding software, revenue cycle software and so on. Your EMR vendor should be ICD-10 ready as of this writing.

In Part 3, we will review several ED cases in detail in terms of ICD-9- vs. ICD-10-compliant documentation.

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