In this article, I will bring some things to your attention that you should be aware of.

There are some things that you may need to change in regard to your documentation.

Are you documenting laterality?

 There are some diagnoses that will require documentation as to whether you are working on the left or right. Breast, Lung and Ovarian cancers will require the specificity of laterality. Pain will also need that information. Tinnitus and Otitis Media must specify left or right ear or both. A Meniscal Tear will require the information documented of whether it is a left or right knee. Back pain will require documentation stating the specific site and laterality e.g. Pain of the left lumbar spine.

Are you documenting the Encounter type?

Is this an initial visit, a subsequent visit or a sequela visit?

Although we may be able to tell from the documentation as to the encounter type, if the documentation does not tell us, we cannot presume. It is being recommended that you include this information in your initial documentation so you do not see a request to addend your dictation to include this information.

You can use phrases such as “ The patient is being seen for the first time” or “ follow-up x-ray for a fractured left wrist” or “patient being seen for an MRI for pain in the left knee due to an old meniscus tear”. This gives us the information that we need to determine the encounter type and assign the correct seventh character.

Are you documenting the Fracture Healing Status?

Some of the new ICD-10 CM codes require a seventh-digit character for subsequent (follow-up) visits. One of the following healing categories MUST be documented for all follow-up fracture exams: routine healing, delayed healing, nonunion and malunion.


Some of the new ICD-10 CM codes have very specific anatomic descriptions. Be as specific as possible when documenting anatomy. Below are some of the requirements of the kind of specificity that will be required when documenting for ICD-10:

If the patient is being seen for a cerebral infarction, are you documenting the affected artery? Was it the pre-cerebral, cerebral, anterior cerebral, posterial cerebral or the cerebellar artery?

If the patient is being seen for lung cancer, are you assigning designation between the main bronchus versus the upper, middle or lower lobes? Is there more than one site or over-lapping sites and which lung is affected – left, right or both?

If the patient is being seen for an ankle fracture, are you documenting whether it is medial or lateral, bimalleolar or trimalleolar? If this is not documented, it cannot be coded to the specificity required. You may get a denial on your claim or a denial resulting in late payment or a denial of payment.

If the patient is seen for a sprain, the documentation must state whether the sprain is calcaneofibular, deltoid or the tibiofibular ligament.

If you are conducting contrast studies, in ICD-10 CM, it is required that you state in your documentation whether you used high or low molecular contrast. We have not needed this information with any of the classification of international disease until ICD-10. Be sure to have all of this information specified in your report so that you do not get inundated with requests for addendums.

Start now and the transition to ICD-10 will be a breeze.

I am pleased to announce that we participated in ICD 10 testing week and our test was a success. We have applied to participate in the end-to-end testing being conducted July  21st –2th however, only 32 participants from our MAC jurisdiction will be selected to provide a representation of DMEPOS supplier types, claim types and submitter types. The volunteers will be notified by April 14th if they have been selected for the testing effort.  Please see here for more information on Medicare’s testing.