Clinical Documentation Clarity is Key for ICD-10-CM

CMS provides the following guidance:

A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not. In the context of the official coding guidelines, the term “provider” means a physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.


Radiologist Documentation

Additional details for specific conditions are now required to ensure accurate and specific coding in ICD-10-CM. Most changes related to radiology services are for fractures and other injuries, stroke, and neoplasms. Although ICD-10-CM provides greater specificity for many conditions, the greatest impact has been to these three categories for radiology practices. For example, the ICD-10-CM code for a tibia fracture could be as specific as “S82.255G – Nondisplaced comminuted fracture of shaft of left tibia, subsequent encounter for fracture with delayed healing.”  Previously, ICD 9 codes for fractures did not include the level of detail in regards to location, type of fracture or episode of care.

Radiologists should strive to always provide documentation of the necessary condition specifics listed below to insure the most accurate ICD-10-CM code assignment:


  • Whether the fracture Traumatic or pathological
  • The area of which bone is fractured
  • Whether the fracture is open or closed
  • Whether the fracture is displaced or nondisplaced
  • The fracture type (i.e. comminuted, spiral, torus, oblique, etc.)
  • Follow-up visits – routine or delayed healing?

  • Indicate whether current or old
  • Indicate whether vessel hemorrhagic, stenosis, thrombotic or embolic
  • Indicate the affected vessel and laterality
  • Indicate, when applicable, whether “Intraoperative” or “post procedural”: cardiac surgery or other surgery

  • Indicate whether neoplasm is current or “history of neoplasm”
  • Indicate neoplasm’s morphology
  • Indicate primary and secondary sites
  • Indicate purpose of current encounter (therapy vs evaluation)

  • Indicate whether primary, secondary, or gestational
  • Indicate whether type 1 or type 2
  • Indicate whether there are related diabetic complications
  • Indicate whether there is presence of hyper or hypoglycemia or ketoacidosis
  • Indicate if there is insulin use


The challenge process for coding a diagnostic radiology report is what to do when there is missing or inadequate information in the radiology report to assign an accurate diagnosis code. Although the problem sometimes does lie with the radiologist(s), many times it is a process issue allowing insufficient, inaccurate, or missing clinical information to exist on the patient’s order for services. The radiologist cannot dictate what he or she does not have access to, so it is imperative that all processes that impact the flow of clinical information be thoroughly reviewed to identify opportunities for improvement as ICD-10 is implemented.


Diagnostic Code Assignment

When assigning diagnosis codes, the first thing to review is the indications for the exam. Every report should provide documentation that answers the question, “Why did the treating physician order this exam?” If that information is missing or inadequate, it creates myriad potential problems. For scheduled outpatient services, there is a breakdown in the process if a patient has received a radiological exam and no one has accurately captured this key clinical information. This problem existed in the ICD-9 environment and has only been amplified in the ICD-10 environment.


The Radiologist’s Findings

Most often this will be well documented in the report impression. If the radiologist documented a confirmed diagnosis, this diagnosis should be compared with the principal reason for the exam to determine if the two are related. If the radiologist documented a confirmed diagnosis that explains the patient’s symptoms, this will be assigned as the primary diagnosis. Otherwise, the code(s) for the presenting signs and/or symptoms will be assigned according to the ICD Coding Guidelines.