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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

ICD-10-CM Documentation Improvement

May 2nd, 2013

Beginning on October 1, 2014, ICD-10-CM will replace the current ICD-9-CM diagnostic coding system. ICD-10 will bring an increased level of specificity including changes in terminology, reassignment of codes, expanded concepts for injuries, ability to identify laterality, and ability to identify the level of encounter. Many OMSs will have to significantly change the way they document within patient charts to convey this information to those who are assigning codes from the ICD-10-CM code set. The following examples are only a sampling of how documentation will affect ICD-10-CM code selections.

OMSs must use detailed descriptions for some diagnoses such as edentulism and dental impactions. For example, ICD-10-CM coding requires the more specific mention of whether the caries is limited to the enamel, dentin, or pulp and requires the more specific mention of the patient's class of edentulism pertaining to a specific cause (loss of teeth due to trauma, class I-IV). Also, is will be necessary for the OMS' documentation to specify if a fracture is of "Traumatic" or "Pathologic" nature. Traumatic fracture documentation and coding will need to include:

  • Encounter type: initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae

Pathologic (non-traumatic) fracture documentation and coding will need to include:

  • Exact location of fracture-site and laterality
  • Etiology of the fracture-osteoporosis, neoplastic disease, other specified
  • Encounter type: initial encounter, subsequent encounter with routine healing, subsequent encounter with delayed healing, malunion, nonunion, or sequelae

Open wound coding is another example of an area that will require detailed documentation due to the changes within the ICD-10-CM coding system. ICD-10-CM provides a laterality distinction to be made and the type of open wound including:

  • Laceration, with or without foreign body
  • Puncture wound with or without foreign body
  • Open bite
  • Unspecified open wound

Improved documentation is important for both reimbursement and patient care. Medical claims are often rejected and/or down-coded due to lack of documentation provided by the surgeon to support the diagnosis code reported. Also, complete and accurate medical records are needed to ensure proper treatment to patients. AAOMS recommends all members and their staff to be educated in ICD-10's complexity in order to ensure proper coding, reduced claim denials, and quality patient care.

For more information on the ICD-10-CM code set and all the changes it will bring, visit the ICD-10 page of both the AAOMS website and the CMS website.