The title of this article seems reasonable and appropriate. Unfortunately, it is patently false!

By now you are probably likely acclimated to (perhaps even enjoying!) the ‘touch once’ method of encounter documentation, in which you dictate, click and/or type through patient visit documentation. Once the patient leaves the office, you are 100% done with the documentation. Although this may not always be possible, this serves as the preferred method to complete your charting.

With the impending changes that ICD-10 will bring, you are all but assured of the requirement to re-touch a large number of your charts if you have not been properly trained in the methodology of ICD-10 billing.

What does this mean? Why is this?

As of October 1, 2014, a substantial number of differences between what your billing/coder will be looking for in your documentation once the ICD-10 set is required for reimbursement. Failure in providing that information to her/him will yield a re-review (or worse, several!) of the charting documentation for visits you believed completed. The payer rejects the claim, and more of your time is now wasted in attempting to adequately address their requirements. This need for redaction may even occur weeks later, when the patient encounter has already begun to collect dust in your memory.

No one expects you to become an expert in ICD-10. Yet, it is absolutely imperative that you have a full understanding of the differences in documentation requirements between ICD-9 and ICD-10. Examples include:

Documenting laterality (e.g. Sprained Right Ankle versus Sprained Left Ankle)
Clearly documenting whether an encounter is an Initial, Follow-up or Sequelae visit
Specificity of what led up to an injury (e.g. “Mrs. Jones obtained a concussion when a cabinet fell on top of her head.”)

These few examples represent the tip of the iceberg, but clearly allude to the need for due haste in learning the implications and changes ICD-10 will bring to your documentation. Since long term habits tend to change slowly over time, it is critical that you begin the process of learning the differences between ICD-9 and ICD-10 as soon as possible.

Thankfully, you are not without resources to achieve this. Precyse University has developed an incredibly robust ICD-10 online training program, and now you can gain access to the entire training program, for your nursing staff, medical billing staff, and yourself, and receive a 10% discount off of the entire order, by using coupon code SAVE10EHR, when visiting

Precyse University ICD-10 Online Training Program

Eric Fishman, MD
Orthopedic Surgeon &
Founder & Managing Member, EHR Scope, LLC