The Physician’s Primary Role in ICD-10: Documentation

The ICD-10 documentation requirements, along with increasing demands of regulatory and quality reporting requirements, will require physicians to fine-tune and perhaps modify their current documentation techniques.

This clinical documentation improvement process will not come without challenges. Many physicians do not fully understand the current clinical documentation standards much less are proficient in compliance. A recent study evaluating more than 3,000 medical records indicates that only 37 percent of current physician documentation would support the documentation standards required under ICD-10.

One of the biggest challenges with ICD-10 documentation is the level of specificity that physicians will have to abide by. The physician’s primary role under ICD-10 will be to provide the documentation elements needed to support ICD-10’s detailed codes. “Insurance companies will not reimburse for nonspecific codes once ICD-10 takes effect,” says Steve Arter of Complete Practice Resources in a video interview with TMA Associate Vice President Peggy Pringle.


Begin tackling this challenge by analyzing your current level of documentation skills, and identify any patterns or gaps. Share the results with staff to aid in training. Patterns of missing information may result in inaccurate coding and impact payment to the practice.

Being proactive in fine-tuning your documentation skills and knowledge will help guide your practice into the ICD-10 transition in a methodical manner as the Oct. 1, 2014, implementation deadline approaches.

TMA Can Help 

  • Bookmark to stay abreast of news and resources. Start with a live webinar on Jan. 30 from noon to 1 pm CT. Register now for ICD-10 Starts With Physicians: A Primer for Beginning the Process.
  • TMA Practice Consulting can help you assess your current documentation skills through a coding and documentation check-up or a more thorough review. For expert assistance, call (800) 523-8776 or e-mail
  • ICD-10 transition software: This easy-to-use electronic ICD-9 to ICD-10 GEMs mapping system will help you quickly and easily identify which ICD-10 codes replace the ICD-9 codes your practice uses now. It also can be a training tool for staff. Buy it by Jan. 15, and get a 25-percent discount.

Published Jan. 10, 2013 

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