As preparations continue for the October 1, 2014, transition to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), some physicians and practices may have concerns about how well current documentation practices will support code assignment in ICD-10-CM.

One option for implementing a documentation review and improvement project in relation to ICD-10-CM is to start with a list of the physician’s or practice’s most frequently reported International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. To focus on documentation to support specific codes, it is necessary to determine the elements that support code selection for a specific condition. For instance, ICD-9-CM code 382.9 ranked third in the top 25 diagnosis codes reported by pediatricians for encounters with children up to age 18 years for the years 2008–2010. This code represents unspecified otitis media and could be more specifically reported in ICD-9-CM if documentation provides the necessary information. (See “Top...

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