ICD-10 documentation requirements

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Do you know how much documentation you will need to accurately assign an ICD-10-CM code? ICD-10-CM uses three to seven alpha and numeric digits and full code titles, even though the format is very much the same as ICD-9-CM (e.g., ICD-10-CM has the same hierarchical structure as ICD-9-CM).

The changes in ICD-10-CM are in its organization and structure, code composition, and level of detail. This new ICD-10-CM structure will allow for further expansion that was previously not possible with ICD-9-CM because more positions in more chapters are left open and available for future modifications.

                ICD_10_v-9rv.jpg 
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                ICD-10-with-extrv.jpg Click on the images above for an expanded view of ICD-10 examples.


Let’s take look at acne, one of the most frequently reported conditions in a dermatology practice. In ICD-9-CM we code acne as 706.1, whereas in ICD-10-CM we need to have enough information provided in the patient medical record to define which type of acne the patient is presenting.

For example:

ICD-10-CM has eight codes for acne, as follows:
 L70 Acne
     Excludes 2 acne keloid (L73.0)
 L70.0 Acne vulgaris
 L70.1 Acne conglobata
 L70.2 Acne variolifornis
   Acne necrotica miliaris
 L70.3 Acne tropica
 L70.4 Infantile acne
 L70.5 Acn’ excorl’e des jeunes filles
   Picker’s acne
 L70.8 Other scne
 L70.9 Acne, unspecified