Does your ICD-10 documentation stand up? Follow these 5 tips.

We all know that the ICD-10 CMS grace period is ending October 1st, 2016. Providers need to be very clear and concise in their choice of diagnosis codes and in their documentation to avoid denials. The tips below will help you be sure your claims can stand up to an audit.


  1. Utilize evidence-based protocols for assessing the patient’s needs. These guidelines encourage accurate documentation that will support your diagnosis choice. And quality does not equal quantity in this case. Under-documenting or over-documenting can result in overlooked or inaccurate diagnosis codes.
  2. Document to support medical necessity. Make sure to document the reason you performed the service, outline your treatment plan for each diagnosis, and as well as clinical progression.
  3. Be sure to choose the code with the greatest degree of specificity, that accurately describes the patient’s condition. If your patient has sciatic pain on the left side, be sure to choose the code that specifies sciatica, left side.
  4. Utilize peer review groups and internal auditing to stay ahead of the game. Sit down with staff and compare claims to chart notes. If there is a pattern of diagnosis related denials, this is a great opportunity to look for areas of improvement.
  5. Avoid pattern documentation and coding. Stay away from the “cloning” method of documenting, or copying and pasting from previous chart entries. The chosen ICD-10 code must correctly reflect the patient’s actual presented condition, and the documentation should support it.

Follow these tips to submit your claims cleanly the first time and beat the auditors!

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