Concepts that are new to ICD-10 should not be new to the clinicians
who have always used good documentation techniques. In fact ICD 10
helps paint a better picture for a patient clinical condition compared to ICD- 9.
Below are some new changes that are more prominent in in ICD- 10
Initial Encounter, Subsequent Encounter, or Sequelae
Acute or Chronic
Right or Left
Normal Healing, Delayed Healing, Nonunion, or Malunion
Majority of ICD-10 codes—more than one-third—are identical except for indicating
laterality, and the site of disorder. The advantage of ICD-10 codes is that
they enable clinicians to capture laterality and other concepts in a standardized
way that supports data exchange and interoperability for a more efficient patient care.
While ICD-10 should not require providers to change documentation practices,
reviewing documentation will help you understand how ICD-10 will affect a physician’s
practice. Understanding the scope of the ICD-10 transition will reduce the
likelihood that you will overlook areas that need updates for ICD-10. Testing ICD
10, from documentation all the way through communication with billing services, is
vital to making sure you have worked out any snags in the process before the
October 1, 2015, transition date. Physicians will encounter more inquiries from
billers who require specification for the correct coding based on guidelines.