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Preparing for ICD-10: Performing a Baseline MR Documentation Assessment

By Michael G. Calahan, PA, MBA

No longer just a rumor, the switch-over from ICD-9-CM to ICD-10-CM is now a sure deal and the established start date remains October 1, 2013.  Providers must be an active part of the conversion process, as many of the issues to be tackled are provider-driven.  Take, for example, medical record (MR) documentation.  MR documentation represents the beginning, middle and end of the current ICD-9-CM life cycle; it is foundational to the entire process of diagnosis coding and nothing materialized to date promises to change with ICD-10.  Provider documentation will initiate the assignment of codes, will drive the assessment of medical necessity for payment of services, and will serve to validate those services upon review by oversight entities.  With recovery funds now actively worked into the front-end of the government’s budget versus being considered “found” money, the advent of ICD-10 will not slow down or alter the federal government’s plans to audit providers.

To prepare for ICD-10, performing a baseline MR documentation assessment can get the physician practices off to a good start.  This assessment will help expose areas where the providers need to strengthen their MR documentation.  Additional benefits can be realized, too.  One such benefit is the isolation of “missed opportunities” for diagnosis (ICD-9-CM) and service (CPT) coding.  These are diagnoses and services that should have been “captured” but were missed.  Likewise, services reported but under-documented enough so that the billing of them could be questioned by an outside reviewer such as an OIG, RAC or CERT auditor may be found.  The focus, however, will be on the documentation of diagnostic statements supporting the final-assigned ICD-9-CM codes, and how that documentation will likewise support the impending ICD-10-CM codes.  Case selection, i.e., determining which dates-of-service to review, should be accomplished by analyzing frequency reports generated by the billing system to assess the practice’s top 25 to 50 ICD-9-CM codes.

In preparing source documents for the MR documentation review, remember the final-reported ICD-9-CM codes for each case selected may need to be compared with information contained on the practice superbills.  This form is the source document and data facilitator for billing information, which in turn gets translated to the CMS-1500 claim forms submitted to payers.  However, errors in the translation of data from the MR to the superbill are not rare.  And, even though this is a documentation review for comparing ICD-9 to ICD-10, the claim forms for each date-of-service should also be on hand.  The CMS-1500s are important source documents for comparing what was reported to the payers versus what the MR documentation holds as the actual case data.

At a minimum then, the following source documents are needed to carry out a full MR documentation assessment:

  • Original MR documentation (e.g., office visit note)
  • Ancillary documents such as provider orders, operative reports, pathology reports, radiology reports, etc., if germane to the office visit
  • Practice superbils or encounter forms (i.e., the “charge tickets”)
  • CMS-1500 claim form copies.



To perform a comparison-and-contrast of ICD-9-CM to ICD-10-CM codes, an ICD-10 tool will be needed.  This can be a pre-2013 ICD-10-CM book, an encoder with ICD-10 mapping, or the public CMS files that include listings of the ICD-10-CM/PCS codes as well as “GEM” files (general equivalency mapping spreadsheets), tying ICD-9 and ICD-10 together.

Now select a patient date-of-service and prepare the array of MR documentation, the superbill and a copy of the CMS-1500 claim form.  Scan the progress (office visit) note for the recorded diagnostic data.  Most of the reportable ICD-9-CM codes listed on the CMS-1500 claim form and encircled on the superbill arise out of the diagnostic statement(s) noted under the “Assessment” section (if providers follow the SOAP note format), or alternatively the “Impressions” or “Diagnoses” sections.

Also scan the History section of the office visit note.  Within the History component of the typical patient office encounter, there are four distinct elements required to be documented for most evaluation and management (E/M) services:  chief complaint (CC), review of systems (ROS), past, family and social history (PFSH) and history of present illness (HPI).  Commonly, a chronic but current/ongoing diagnosis impacting current care will be listed within the elements of the History, and not carried down or re-listed in the diagnostic area found under the Assessment section.  This “bad habit” should be avoided if possible, since it often confuses coders as well as outside medical reviewers.

At this juncture let’s look at a case study to demonstrate the comparison process.  For illustration purposes we will use a patient with diabetes mellitus, type-II (DM-II), coded to ICD-9-CM code 250.00; no other ICD-9-CM codes were assigned or are listed on the CMS-1500 claim form for this particular office visit.  In this scenario, the patient’s CC is “Here for F/U of DM” and in fact, the “Impression” line states “DM-II, doing well on current regimen.”  However, the patient also has essential hypertension and is undergoing active treatment for this condition as evidenced by a note under the “Plan” section:  “Increase HCTZ to 50mg (25 mg b.i.d.).”  A quick glance under the History reveals the physician documented a correlating diagnosis in the ROS as “CV – HTN on HCTZ 25 mg q.d.”  Further, under “vitals” in the constitutional section of the progress note the annotation “Bp – 130/100 sitting x 2” is found.  Your conclusion in reviewing these notes is that the HTN did, in fact, impact the current care and therefore two diagnoses for this office visit should have been coded: DM and HTN.

In relation to the DM-II, a finger stick test (glucometery) was normal.  There was no change in the condition, and therefore the DM-II remains coded to ICD-9-CM code “250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled.”  Under ICD-9-CM coding, the main methodology of coding diabetes mellitus is to (a) ascertain the “type” (i.e., type I juvenile DM or type II adult-onset DM) and then (b) code it according to status of control, as in “not stated as uncontrolled” (250.00) or “uncontrolled” (250.02).  This methodology is anticipated to hold true under ICD-10-CM as well, but the descriptor changes somewhat.  ICD-9-CM code 250.00 maps to ICD-10-CM code “E11.9 Type 2 diabetes mellitus without complications,” or to ICD-10-CM code “E13.9 Other specified diabetes mellitus without complications.”  DM-II now stated as “uncontrolled” under ICD-9-CM code 250.02 maps to ICD-10-CM code “E11.65 Type 2 diabetes mellitus with hyperglycemia.”  The analysis:  diabetes mellitus – depending on type, status and how specific the provider has been in his/her documentation – can be coded in several ways under ICD-10-CM.  The term “hyperglycemia” appears to be key in this classification when the DM is not under control.  As with ICD-9-CM coding now, the more specific the MR documentation the more accurate the coding; this holds true in ICD-10-CM coding.

For the HTN uncovered as not being reported but was documented and impacted current care, the ICD-9-CM code in this case is 401.9.  There is no annotation or indication of concurrent hypertensive heart disease or chronic kidney disease, or any combination thereof.  Under the current ICD-9-CM coding structure, because the descriptors “benign” (ICD-9-CM code 401.1) or “malignant” (ICD-9-CM code 401.0) were not recorded in the MR documentation with the acronym “HTN,” the official coding instructions state the unspecified ICD-9-CM code 401.9 must be reported for “essential hypertension.”  Now compare this code with the anticipated requirements and information under ICD-10-CM.  The descriptors “benign” and malignant” no longer apply in ICD-10-CM coding.  The full description mapped to the current ICD-9-CM code series for essential hypertension (401.0, 401.1 and 401.9) match up to “I10 Essential (Primary) Hypertension.”  What will be required in terms of MR documentation for accurate ICD-10-CM coding?  First, establishing the hypertension as “essential” appears tantamount to getting it coded correctly; this classification should be established in the MR documentation.  Secondly, ensuring the current state of hypertension is not etiologically connected to hypertensive heart disease, chronic kidney disease or a combination of these two is vital for correct coding (these conditions map to other ICD-10-CM codes).

Performing as the “auditor” you have that the ICD-9-CM code for HTN was not reported, and you further find it was not encircled on the superbill.  The lesson buried in this for providers?  The MR documentation should be as clear, concise and explicit as possible, especially when summarizing the impressions or diagnoses.  The CC should be amended at the time of service, especially when initially recorded by ancillary staff, to reflect all of the reasons for the patient’s presentation.  A lesson herein for coders, too, is that often corroborating information is found between the History and Plan sections of the note, and both should be reviewed for possible “missed diagnosis opportunities” for ICD-9 and ICD-10 coding purposes.  Lastly, do not rely solely upon the superbills for diagnostic information.

In many instances ICD-10-CM promises to impose greater specificity on diagnosis code descriptions and assignment; therefore, a correlating level of specificity is expected to be found in the MR documentation.  Performing a baseline MR documentation assessment is often a rewarding exercise in preparation for ICD-10 conversion.



Michael G. Calahan is currently the Director of Physician Services at Kforce Healthcare, Inc., working in the Washington DC Metro area. Also on the Board of the ICD-10 Monitor, he specializes in compliance, revenue cycle management, CDI, coding, and billing in the physician and facility arenas. He may be contacted by e-mail at mcalahan@kforce.com.



  1. Yeah, I’m ready… just bring it on!!!

    I retire in six months anyway.

  2. In the midst of all this healthcare reform change, there are also ICD-10 conversions required by Oct. 2013. Are health plans ready?

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