What you'll need to provide for specific and detailed ICD-10 coding

One practical way to prepare for the ICD-10 transition is to look at areas in which you can improve how you document your clinical services. Such an approach, according to the Centers for Medicare & Medicaid Services (CMS), will help you and your coding staff become familiar with the specific and detailed clinical documentation needed to assign ICD-10 codes.

In a Dec. 27 electronic update, CMS suggested that you take a close look at documentation for the most commonly used codes in your practice. Subsequently you can work with your coding staff to determine whether the documentation would be specific and detailed enough to enable you to select the best ICD-10 codes. One prominent example is laterality, which is expanded in ICD-10-CM. As such, CMS explained, clinical documentation for diagnoses should include information on which side of the body is affected (i.e.,  right, left or bilateral).

The following examples, supplied by CMS, show the specific information needed to accurately code common diagnoses:

Diabetes mellitus

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • If Type 2 diabetes, long-term insulin use


  • Site
  • Laterality
  • Type
  • Location


  • External cause – Provide the cause of the injury; when meeting with patients, ask and document "how" the injury happened.
  • Place of occurrence – Document where the patient was when the injury happened (e.g., include if the patient was at home, at work, in a car, etc.).
  • Activity code – Describe what the patient was doing at the time of the injury (e.g., playing a sport or using a tool).
  • External cause status – Indicate whether the injury was related to military, work or other activity.

CMS noted that ICD-10 will not affect the way you provide patient care. "It will just be important to make your documentation as detailed as possible since ICD-10 gives more specific choices for coding diagnoses," the update stated. "This information is likely already being shared by the patient during your visit -- it’s just a matter of recording it for your coding staff. Good documentation will also help reduce the need to follow-up on submitted claims -- saving you time and money."

Click here to visit CMS' ICD-10 website.