• Abbott Northwestern Hospital Hyperbaric Oxygen Therapy Clinic
  • Volume 07 - Issue 1


Continuing our series of interviews featuring outstanding hyperbaric and wound care centers around the world, we spotlight in this issue the Abbott Northwestern Hospital Hyperbaric Oxygen Therapy Clinic in Minneapolis, Minnesota.

What are the most common indications treated at your clinic?

  • Diabetic foot ulcer

  • Radiation-related soft tissue injury including radiation cystitis

  • Osteoradionecrosis

  • Chronic refractory bone infection

  • Failed flap or graft

  • Deep soft tissue infection

What is the most memorable treatment success story that has come out of your clinic?

A young man with type 1 diabetes presented with spontaneous deep foot ulcer that was complicated with deep soft tissue and bone infection. Initially, amputation was considered. Using hyperbaric oxygen treatment (HBOT) in conjunction with debridement, wound care and antibiotics, however, he healed completely.

A 66-year-old female with a history of rheumatoid arthritis and Felty’s syndrome presented with a nonhealing ulcer on her left leg caused by a trauma. She failed multiple treatment options including debridement, different wound dressings, antibiotics, anti-inflammatories and vein-closure procedure. She finally healed with skin graft following HBOT that prepared the wound bed before the procedure.

Do you work with a management company?

We do not work with a management company.

If you had to pick two things to attribute your clinic's success to, what would it be?

  • We use a multidisciplinary approach with experienced staff involving vascular medicine, vascular surgery, general surgery, plastic surgery, infectious disease, and internal medicine.

  • We monitor our outcome and use data for better patient care.

Are there any additional questions you'd like to answer, or any other information about your clinic you'd like to showcase?

  • We published our HBOT outcome data in Annals of Vascular Surgery (Ann Vasc Surg. 2015 Feb; 29(2): 206-14).

  • We published another peer-review paper related to the indications of HBOT (J Wound Care. 2014 Oct; 23(10 Suppl):S18-22).

  • We have provided excellent service to the metropolitan and suburban areas with very memorable success stories.
Clinic Name: Abbott Northwestern Hospital Hyperbaric Oxygen Therapy Clinic
Location: 800 East 28th Street, Suite W4300, Minneapolis, MN 55407
Website: Northwestern-Hospital/Services/Hyperbaric- oxygen-therapy
Phone: 612-863-9774
How long in business: 7 years
How many chambers: 3
Chamber types: Sechrist 3200
How many physicians/nurses/CHTs: 11 physicians, 3 nurses, 2 CHTs, 3 hyperbaric assistants
Medical director: Dr. Nedaa Skeik, MD, vascular medicine


Offloading Diabetic Foot Ulcers Q&A

  • Jayesh B. Shah, MD, CWSP, UHM
  • Volume 07 - Issue 1

In anticipation of the publication and current presales of the Wound Care Certification Study Guide, Second Edition, we offer a sneak peek of several questions and answers from“Chapter 20: Offloading Diabetic Foot Ulcers – Orthotics” by Elias R. Cheleuitte, DPM, FACFAS.


1. Which is a common etiology of diabetic foot ulcerations?

         a.) repetitive microtrauma

         b.) peripheral neuropathy

         c.) areas of high pressure

         d.) all of the above

2. Which modality is best suited for forefoot plantar diabetic ulceration?

         a.) healing sandal

         b.) cam walker

         c.) integrated prosthetic and orthotic system (IPOS)

         d.) PO shoe

3. Which is the highest risk factor for diabetic foot ulceration?

         a.) poor glycemic control

         b.) increased plantar pressure

         c.) loss of plantar sensation

         d.) PVD

4. Which modality is considered the gold standard in offloading diabetic foot ulcerations?

         a.) total contact cast

         b.) healing sandal

         c.) CROW device

         d.) PO shoe

5. All of the following factors require consideration before choosing an offloading modality except:

         a.) location of ulceration

         b.) patient functional capabilities

         c.) patient insulin dependency

         d.) vascular studies


  1. d) A common etiology of diabetic foot ulcerations is usually repetitive microtrauma at areas of high pressure in patients with peripheral neuropathy.
  2. c) An integrated prosthetic and orthotic system (IPOS) is best suited to offload diabetic forefoot ulceration. The healing sandal and cam walker are also used to offload diabetic ulcers; however, IPOS is best suited for offloading diabetic forefoot ulcers. The PO shoe is not able to offload forefoot ulcers.
  3. c) Loss of protective sensation in the plantar foot (neuropathy) is the highest risk factor for the diabetic foot ulcer.
  4. a) Total contact casting (TCC) is considered the gold standard for offloading diabetic foot ulcers.
  5. c) Before choosing an offloading device, it is important to look at the location of the ulcer, the functional capabilities of the patient, and the patient’s vascular status. Insulin dependency is not a factor in the choice of an offloading device. 


  1. Bosker GW, La Fontaine J. Orthotics and prosthetics in wound care. Sheffield PJ, Fife CE, editors. Wound Care Practice. 2nd ed. North Palm Beach, Fla.: Best Publishing Company; 2007:901-20.
  2. Armstrong DG, Lavery LA. Elevated peak plantar pressures in patients who have Charcot arthropathy. J Bone Joint Surg Am. 1998 Mar; 80(3):365-9.
  3. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL. Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care. 1996; 19(8):818-21.
  4. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999; 22(1):157-62.
  5. Bauman JH, Girling Brand Plantar pressures and trophic ulceration: an evaluation of J Bone Joint Surg. 1963;45B(4):652-73.
  6. Cavanagh PR, Bus SA. Offloading the diabetic footfor ulcer prevention and healing. J Am Podiatr Med Assoc. 2010;52(3Suppl):37S-43S.
  7. Landsman AS, Meaney Cargill RS, et al. Highstrain rate tissue deformation: a theory on the mechanical etiology of diabetic foot ulcerations. J Am Podiatr Med Assoc. 1995;85(10):519-27.
  8. Zou Mueller Lott Effect of peak pressureand pressure gradient on subsurface shear stresses in the neuropathic foot. J Biomech. 2007;40(4):883-90.
  9. Pound N, Chipchase S, Treece K, et al. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med. 2005; 22(10):1306-9.
  10. Snyder Kirsner RS, RA, et al. Consensus recommendations of advancing the standard of care for treating neuropathic foot ulcers in patients withdiabetes. Ostomy Wound Manage. 2010;56(4Suppl):S1-24.
  11. Van Deursen R. Footwear for the neuropathic patient: offloading and stability. Diabetes Metab Res Rev. 2008; 24(Suppl1):S96-100.
  12. Armstrong DG, Lavery LA, Kimbriel HR, Nixon Boulton Activity patterns of patients with diabetic foot ulceration. Patients with active ulcerations may not adhere to a standard pressure offloading regiment. Diabetes Care. 2003;26(9):2595-97.
  13. Searle A, Campbell R, Fitzgerald A, K. A qualitative approach to understanding the experience of ulceration and healing in the diabetic foot: patient and podiatrist perspective. Wounds. 2005;17(1):16-26.
  14. Crews Armstrong DG, Boulton A method for assessing offloading compliance. JAPMA. 2009; 99(1):100-3.
  15. Wunderlich RP. Off-loading diabetic foot wounds/ orthotics. Shah JB, Sheffield PJ, Fife CE, eds. Wound Care Certification Study Guide. North Palm Beach, Fla.: Best Publishing Company; 2007:163-7.
  16. Snyder Frykberg RG, Rogers LC, Applewhite Bell Bohn G, Fife CE, Jensen Wilcox,management of diabetic foot ulcers through optimal off-loading; building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014; 104(6):555-67.
  17. Elias C, DPM. Offloading diabetic foot wounds/ orthotics. Shah JB, Sheffield PJ, Fife CE, eds, Wound Care Certification Study Guide, North Palm Beach, Fla: Best Publishing Company; 2016.

About the Author


JAYESH B. SHAH, MD, CWSP, UHM, is president of South Texas Wound Associates, PA, and of TIMEO2 Healing Concepts, LLC, both in San Antonio, Texas. His degrees include an MBBS (bachelor of medicine and surgery) from Maharaja Sayajirao University in Baroda, India, and an MD in internal medicine from St. Luke’s Roosevelt Hospital, Columbia University, New York. He is board certified in internal medicine and in undersea and hyperbaric medicine and certified in wound management and in hyperbaric medicine.

Shah has more than 18 years’ experience in wound care and hyperbaric medicine practice and more than 12 years’ experience as program director for continuing medical education courses. He currently serves as the medical director for the Northeast Baptist Wound Healing Center. An adjunct professor in the Department of Family and Community Medicine at the University of Texas Health Science Center, Shah is coeditor of the Wound Care Certification Study Guide, First Edition (published by Best Publishing Company). He created the WoundDoctor app for smartphones and authored 19 chapters on various wound topics in four books in addition to more than 30 scientific articles on wound care and hyperbaric medicine.



The Benefits of UHMS Membership

  • Enoch Huang, MD
  • Volume 07 - Issue 1

The Undersea and Hyperbaric Medical Society (UHMS) is the oldest and most prominent scientific organization dedicated to the field of undersea and hyperbaric medicine (UHM). We represent physicians, nurses, allied health professionals and basic science researchers in the advancement of scientific and clinical knowledge in the specialty. Founded in 1967, we are celebrating our 50th anniversary next year.underseahyperbaricmedicalsociety

The mission of the UHMS has evolved over time. While we were once a purely scientific society focused on research and academic pursuits, we have broadened our scope to address the more pressing concerns of our membership: the mechanics and politics of the practice of UHM. We are shouldering the burden of defending practice patterns to agencies that seek to reduce the reimbursement of our services, while also educating a new workforce that has had less formal training in the field. With the support of UHMS staff, a tireless cadre of volunteer clinicians has tackled the intricacies of these new responsibilities while balancing these extracurricular duties with their day jobs. We have found, however, that with each new mission-driven initiative comes a concomitant need for increased infrastructure and administrative time.

With multiple demands on medical professionals’ attention and finances, one must ask what the benefit is of joining yet another professional medical society. The underlying question — “What’s in it for me?” — can often be a difficult exercise when calculating the return on investment of another annual membership fee. In considering the field of UHM, not every physician is as invested in the field as another. Many practitioners are new to the field and have only a limited familiarity with regulatory, safety and reimbursement concerns. Others practice UHM only part- time and rely on the effort of more vested members of the field to lay the groundwork and do the heavy lifting with regard to protecting their interests.

A recent survey of nearly 2,000 physicians who billed for supervision of hyperbaric oxygen therapy revealed that only 16% were members of the UHMS. It also revealed that nearly 60% of UHMS members were older than 55 years of age. Even more surprising is that only 30% of practitioners who had been in the field for five years or less were UHMS members. This poses the question: “Why have our newer colleagues not joined the society?” The answers can only be that they are either unaware of our existence, unaware of the benefits of being a member, or feel that the efforts of the society are not worthy of their support.

One might argue the value of the UHMS is the greatest for those who are newest to the field because of the tangible benefits to its members. We provide the following tools for the practitioner to gain additional knowledge and expertise:

  • access to the MEDFAQs program, a compendium of more than 50 of the most commonly asked clinical-, safety- and reimbursement-related questions, answered by leading experts in the field
  • discounted registration for live courses throughout the year, taught by leading educators and experts in diving medicine, clinical hyperbaric medicine and wound care
  • discounted rates on more than 50 hours of online hyperbaric-related educational content to meet continuing medical education (CME) and maintenance of certification (MOC) requirements

The UHMS has many publications that are essential components of any hyperbaric practitioner’s library:

  • the 13th edition of the Hyperbaric Oxygen Therapy Indications Manual, which details all the literature related to the UHMS-approved indications for hyperbaric oxygen therapy
  • the 2nd edition of the Guidelines for Hyperbaric Facility Operations
  • the bimonthly scientific journal Undersea and Hyperbaric Medicine, which now offer members free PDF downloads of all of its articles
  • the Society’s newsletter, Pressure, which updates members on developments in the field

There are many intangible benefits of being a member of the UHMS, however, that are just as important — including, but not limited to, educational initiatives focused on preserving our payment system for hyperbaric medicine, raising funds for research and public policy initiatives, networking, and establishing best practices in safety and operational procedures.

The UHMS is constantly working behind the scenes to advance and protect the field of UHM. Our accreditation program is designed to ensure the highest standards of practice on a facility level, and our new Certification of Added Qualification program is intended to fill a gap between the 40-hour introduction to hyperbaric medicine course and the gold standard of American Board of Medical Specialties (ABMS) certification in UHM. We are developing clinical practice guidelines to define best practices in UHM, and we have created reportable quality measures to allow clinicians to submit their outcomes to CMS.

I encourage you to consider supporting the organization that is working on your behalf by joining or renewing your membership. It is only through the financial support of our members and the hard work of our leaders that the UHMS is able to accomplish these tasks.

The UHMS has several regional chapters in the United States, and these are a great forum to introduce yourself to colleagues and peers in your region. You can choose to become involved in one of the 19 committees that the UHMS relies on to carry out its mission, submit an abstract to be presented at the Annual Scientific Meeting every June, or even seek election to the UHMS board of directors. Whatever your interests are, we welcome your engagement in the betterment of our Society and the field of undersea and hyperbaric medicine. Find out more at

About the Author


An active UHM reviewer, former chair of the UHMS Clinical Practice Guidelines Oversight Committee, and current chair of the Graduate Medical Education Committee, ENOCH HUANG is the incoming president of the UHMS at the close of the 2016 Annual Scientific Meeting.


Providers: Are You Practicing Mismatching?

  • Gretchen Dixon, MBA, RN, CCS, AHIMA ICD-10-CM/PCS Trainer, CPCO; and Johanna Legaspi, MBA, CPC, CPMA, AHIMA ICD-10-CM/PCS Trainer
  • Volume 07 - Issue 1

Many people have been congratulating each other on how well the transition to the ICD-10 coding system has proceeded with little adjustments. From a compliance viewpoint, however, there is concern over the quality of clinical documentation supporting billed ICD-10-CM codes. Questions to ponder are: What is the true realization from post-October 1, 2015, if an external audit is conducted? Are you absolutely comfortable your clinical documentation (key source supporting medical necessity of provided services) supports the ICD-10-CM code you selected? Guess what we discovered? Overall, only 43% of clinical documentation actually supported billed/reported ICD-10 codes.

Mismatching Issue

We conducted a retrospective review of more than 200 providers who select their own ICD-10 codes reported on claims. The review included more than 1,500 claims with more than 3,800 ICD-10-CM diagnoses codes covering a multitude of provider specialties and subspecialties from small to large practices. In our process, clinical documentation details were compared with billed/reported ICD-10 codes.

Initially, we assessed the overview of providers’ ICD-10-CM documentation education, noting all of the providers during the implementation and transition phase had attended or participated in some type of formal and informal ICD-10 documentation and coding education based on general information followed with a specialty-focused education. Education continued through specialty physician champions as well as clinical documentation specialists and/or coding liaisons during medical staff meetings or during patient rounds. The self-learning education methods were tracked to ensure 100% participation for all practices.

As this audit project began, we had some questions about the educational content for coding in general and then specifically related to ICD-10-CM as follows:

  1. Did the providers receive any overall information regarding Official Guidelines for Coding and Reporting?
  2. Did the providers understand how to apply the ICD-10- CM Official Guidelines for Coding and Reporting?
  3. Do the providers understand clinical documentation for ICD-10-CM requires additional details to support accurate code selection?
  4. Do the providers understand the specificity available with ICD-10-CM codes and how each ICD-10-CM code supports a patient’s level of acuity, intensity of services, and complexity of care for each encounter?
  5. Why do providers continue to code medical conditions that no longer exist as if the condition is an acute or ongoing condition?

Our answers to each question were more negative than positive. For demonstration purposes only, the chart below notes some of the common specialties we found to have an accuracy rate below 50%. Where does your specialty fall in the accuracy rate? Do you know? Maybe not.

Table.1 General overview of specialties with accuracy rates below 50%
Ophthalmology 8%
Vascular Surgery 10%
Plastic Surgery 22%
Cardiothoracic Surgery 24%
Endoscopy 30%
Radiation Oncology 30%
Orthopedics 30%
Psychiatry 38%
ED Pediatrics 39%
Pulmonary Medicine 43%
Neurology 48%

Where Do We Begin To Fix the Mismatching?

CMS has given providers a year from October 1, 2015, as somewhat of a grace period to fine-tune coding skills as noted in their Clarifying Question and Answer Document (Reference 2) on how ICD-10 codes need to be selected.

Careful reading of this document will provide the provider/ coder a resource to understand the necessity to select an ICD-10-CM code using all of the required characters to provide the highest level of specificity for the medical condition.

CMS and the healthcare industry use the accuracy rate of 95% as a guideline for any person performing coding and/or billing activities. Therefore, this is the goal everyone needs to be aiming toward. With accuracy rates below 50%, however, start with the following steps:

  • Focus on your specialty’s most common specific ICD-10- CM selected codes.

—Select the top five diagnoses.

—Educate/discuss the specific elements within the five diagnoses that need to be clinically documented.

—Develop documentation hint tools to improve the clinical information allowing for an improved ICD-10- CM code selection.

  • Conduct a prebilling review by your coder comparing each provider's clinical documentation with selected ICD-10-CM codes.

—Benchmark with an initial review of 5-10 claims/encounters per provider.

  • Use the findings for documentation improvement as starting points.
  • Set goal to increase the accuracy of each ICD-10 code selection supported by clinical documentation.
  • Continue with internal reviews focusing on clinical documentation and accuracy of ICD-10-CM code selection improvement.

—If the accuracy rate is below 70%:

  • Identify the top three issues with coding and/or clinical documentation.
  • Provide specific specialty education.
  • Develop clinical documentation education for the provider.

—If the determined accuracy goal rates are not improving toward at least 85% then the focus may need to be specific to the group of providers or to a specific provider.

  • Collaboration with a physician champion and coder liaison may be necessary to ensure specific documentation/coding weaknesses are addressed in a timely manner and corrected.

—Establishing a timeline for ongoing monitoring with education flexibility is a must to ensure competency of ICD-10-CM code selection is supported by clinical documentation.

  • Select diagnoses from the Problem List that often are not the reason for the encounter.
  • Ensure all providers authenticate/append a signature including date for every encounter whether through the electronic health record or handwritten.

Challenge to Diminish Compliance Risk

Accurate code selection and clinical documentation compliance is a challenge in all healthcare settings, while inaccuracy can place the organization at risk from all directions, especially with external auditing organizations. No organization wants to suffer regulatory fines or civil and criminal penalties along with a damaging reputation. Therefore, focus on your coding accuracy to achieve documentation and coding compliance and anticipate financial benefits. The benefits really have not changed in years and include the following:

  • Overcoding creates a compliance risk with the possibility of fraudulent submission of claims.

—Per the OIG: Civil Monetary Penalties (CMP) consist of treble damage per claim amount plus from $5,000 up to $10,000 per claim to begin.

  • Undercoding creates a financial risk of losing money when documentation supports a more accurate code for the provided service.
  • Decrease the amount of time and effort of reworking rejected claims or having to write-off costs of service.

Mismatching Coding and Documentation

It is our recommendation to conduct proactive activities to possibly mitigate high-compliance risk liabilities:

  • Validate that each encounter has been authenticated by the provider.

—Handwritten clinical documentation must include a legible signature and credentials and be dated.

  • If the signature is not legible, a sample of the provider’s signature needs to be entered into a logbook with the provider’s printed name, credentials, and date of entry.
  • Refer to the CMS issued Transmittal 327 on March 16, 2010, titled “Signature Guidelines for Medical Review Reporting.” This transmittal reference is located in the Resources section at the end of this article with the specific website.
  • Establish policies and procedures for routine audits to ensure ICD-10-CM codes are supported with detailed clinical documentation.

—Review the correct use of the Problem List.

  • Add new problems.
  • Update problem list at each visit as necessary, and move to the inactive/past medical history resolved problems such as:

—Medical problems resolved but have clinical importance

—Surgical procedures

  • Signs and symptoms are only temporary and should be replaced with a refined diagnosis when workups are completed.
  • Minor complaints do not belong on the problem list.
  • Nonproblems do not belong on the problem list.
  • Develop a process to evaluate and identify the accuracy rate for overall clinic, office, and department and accuracy rate for overall clinic, office, and department and accuracy rate per provider.
  • Develop clinical documentation education to be given to providers based on findings from each review period as designated by the reviewer. The goal is to ensure that the accuracy rate of selecting ICD-10-CM coding improves toward the goal of 95%.
  • Maintain reports documenting compliance with the Policies and Procedures.


The following are examples from a few provider specialty services with mismatching ICD-10 codes and clinical documentation.

Radiotherapy side effects/complication code selection

Radiotherapy ICD-10-CM code selection involves a convoluted path through the ICD-10-CM coding manual, beginning with a “must” understanding of each code’s description and directions for selecting the most accurate code. Understanding Official Guidelines for Coding and Reporting is imperative to selecting the most accurate ICD-10-CM code.

At issue is the crosswalk of ICD-9-CM 990: effects of radiation, unspecified, which takes the coder to ICD-10- CM code T66.XXXA — radiation sickness, unspecified, initial encounter. Since this in an inappropriate ICD-10-CM code selection, there is no need to provide detail to the 7th character. Below is how ICD-10-CM code T66 (requiring a 7th character) appears in the coding manual:

T66 Radiation sickness, unspecified (7th character required)1

Excludes 1 specific adverse effects of radiation, such as:

Burns — go to category T20-T31

Leukemia — go to category C91-C95

Radiation gastroenteritis and colitis — go to category K52.0

Radiation pneumonitis — go to category J70.0

Radiation-related disorders of the skin and subcutaneous tissue — go to the category L55-L59 [L59 will be the family code to select]

Radiation sunburn — go to category L55.7

The appropriate 7th character is to be added to code T66:

A     Initial encounter

D    Subsequent encounter

S    Sequela

According to the excerpt from 2016 Official Guidelines for Coding and Reporting2

Section 1 — Conventions, General Coding Guidelines and Chapter Specific Guidelines, Subsection: 12.a. notes the below directions for a coder to follow and understand:

12. Excludes Notes

The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use, but they are all similar in that they indicate that codes excluded from each other are independent of each other.

    a. Excludes1: A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Therefore, the coder interpreting this directional needs to reference the ICD-10-CM code family of L55-L59. The correct ICD-10-CM family would be L59. Other disorders of skin and subcutaneous tissue related to radiation with two choices to select from are:

L59.8: Other specified disorders of the skin and subcutaneous tissue related to radiation or

L59.9: Disorder of the skin and subcutaneous tissue related to radiation, unspecified (this may be the only option based on a third-party payer’s unique policies and procedures for billing).

Surgical Care of various specialties was audited as noted in the above chart. The following is a sample of clinical documentation and code selection weaknesses:

  • Plastic Surgery —Scenario: Female patient has right breast cancer and is requesting a consultation premastectomy regarding a right breast mastectomy with reconstruction. The provider ICD-10-CM billed the following codes without supporting clinical documentation evidence:

—N64.89: Other specified disorders of breast

—Z85.3: Personal history of malignant neoplasm of breast

—Z90.11: Acquired absence of the right breast and nipple

Not Coded: C50.911: Malignant neoplasm of unspecified site of the right female breast is supported by clinical documentation

  • Pediatric Surgery —Scenario: History of cervical lymphadenitis, resolved with treatment using antibiotic and steroid regime. Presents for follow-up noted ”without any evidence of lymphadenitis.” Return to office as needed.

The provider billed the following ICD-10-CM code without supporting clinical documentation evidence the lymph nodes were still enlarged:

—R59.0: Localized enlarged lymph nodes

Missed Code Z09: Encounter for FU examination after completed treatment for conditions other than malignant neoplasm

Orthopedics clinical documentation in ICD-10-CM requires several elements to be documented. The majority of code selections identified were for unspecific ICD-10-CM codes, thus missing these specific elements. The following ICD-10- CM elements for selection of follows were missing on the majority of claims reviewed:

  • Acuity (Acute, Chronic)
  • Anatomical specific location
  • Etiology
  • Laterality— Right, Left, Bilateral
  • Episode of care is the same as the type of encounter (initial, subsequent, sequela)

Examples Coding Selection:

  • M41.9: Scoliosis, unspecified (missing type, age related and anatomical location)

Correct code M41.124: Adolescent idiopathic scoliosis, thoracic region is based on detailed documentation

  • M25.519: Pain in unspecified shoulder (laterality)

Correct code M25.511: Pain in right shoulder based on documentation

Radiation Oncology ICD-10-CM clinical documentation needs to include specific details related to the neoplasm  under treatment or post-treatment monitoring. The following ICD-10 example may provide you with the level of clinical documentation that is necessary to support ICD-10 codes.

  • A female had invasive lobular carcinoma of the upper- outer quadrant of the right breast, which was removed with a right mastectomy. Also, the patient had completed the chemotherapy regime and was now ready to begin radiotherapy. The condition is still under active treatment and requires an active condition code.

—The billed ICD-10 code was C50.919: Malignant neoplasm of unspecified site of unspecified female breast

Missed ICD-10-CM code C50.411: Malignant neoplasm of upper-outer quadrant of right female breast

Missed ICD-10-CM code Z92.21: Personal history of antineoplastic chemotherapy

Missed ICD-10-CM code Z90.11: Acquired absence of right breast and nipple

Proactiveness Begins Now

Be proactive now, and get out of the mismatching process by recognizing and understanding the nuances of ICD- 10CM diagnosis code selection. Augment in detail your clinical documentation to support your selected ICD-10- CM diagnosis code to its highest level of specificity. Your coding data will then accurately support your patient’s level of acuity and intensity of services with complexity of care reported on claims to your insurers, accurately reflect patient care, professional profiles, etc.

NOTE: It is imperative to understand clinical documentation and ICD-10-CM code selections are under the microscope from many different levels. CMS and some third-party payers have already identified ICD-10 coding and documentation risks at this early stage after the transition. Although claims are being paid, the challenge is to ensure each provider’s clinical documentation is accurate and complete, thus supporting each ICD-10-CM code selected for reporting (billing and data use).


  1. Take action by performing oversight prebilling review of ICD-10-CM codes selected by providers, and determine if their clinical documentation supports the ICD-10-CM code selection.
  2. Understanding the clinical documentation details required for the top 10 diagnoses to obtain the highest level of specificity for each ICD-10-CM code.
  3. Engage ICD-10-CM subject matter experts (coders, CDIS, ICD-10 trainers) for support of coding questions.
  4. Institute an incremental goal toward reaching the industry’s coding accuracy of 95% consistently.


¹Optum 360, ICD-10-CM Professional for Hospitals 2016 Coding Manual, pg. 1129 ICD-10 code T66

²Optum 360, ICD-10-CM Professional for Hospitals 2016 Coding Manual, Official Guidelines for Coding and Reporting pg. 3 Subsection 12.a.



  1. Department of Health and Services. CM/PCS The Next Generation of Coding; 2015 at: ICD10/downloads/ICD-10Overview.pdf

  2. CMS Questions and Answers Related to the 6, 2015 CMS/AMA Announcement and Guidance Regarding ICD-10 Flexibilities. Refer to the specific questions 3, 4, 6, 7. at: Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint- Announcement.pdf

  3. CMS 327. Signature Guidelines for Medical Review Purposes; 2010 16. at: https:// Trandmittals/downloads/r327pi.pdf

  4. Optum 2016 ICD-10-CM Professional Coding Manual

  5. CMS ICD-10-CM 2016 Official Guidelines for Coding and Reporting website at: Guidelines.pdf

  6. OIG–A Road for New Physicians: Fraud and Abuse Laws. Available at: education/01laws.asp


Free Mini-Course: The Business of Wound Care and Hyperbaric Medicine

Join us for this free 4-part mini-course and jump start your clinic business today! 
  • Are you a clinic manager or medical director who wants to increase patient load and referrals but has no money for marketing?
  • Could you be losing money due to incorrect billing and coding?
  • Do you want to become a profit center for the hospital but inefficient business operations are holding your clinic back?

If you don't know where to start, how to start, or what you need to know to take your clinic to the next level, this free 4-part mini-course is for you.

This mini-course is taught by Dr. Michael White, MD, MMM, CWS, UHM and course director for the live two-day workshop, The Business of Wound Care and Hyperbaric Medicine.

You Will Learn:

Lesson 1: [Video] How to create a strong (or stronger) foundation for your clinic business

  • How to identify where your patient referrals are coming from (or should be coming from).
  • How to create an action plan for effective, efficient marketing.
  • How to become a profit center for the hospital.

Lesson 2: [Video] The explosion of chronic wounds in the U.S. and the opportunity for wound care and hyperbaric medicine clinics to serve more patients.

Lesson 3: 4 Easy steps to market your clinic.

Lesson 4: How key are front office operations to the wound clinic business?

  • Learn the two key considerations for creating efficient front office operations that contribute to the achievement of your clinic's overall financial goals.
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About the Authors

GRETCHEN DIXON, MBA, RN, CCS, is the owner of Professional Compliance Strategies (PCS), LLC, and consults on outpatient departments and physician services. She has provided revenue- cycle compliance audits of services with a focus on wound care department operations for more than 10 years. She holds several credentials including an MBA in healthcare management, an RN with a practicing license in New York, and 23 multistate licensure from Virginia, AHIMA Certified Coding Specialist (CCS), AHIMA ICD-10-CM/PCS Approved Trainer, and is an AAPC Certified Professional (Healthcare) Compliance Officer. A longtime internal healthcare auditor, Dixon identifies issues through audits of D, C, B (documentation, coding and billing) of provided services. The outcome of each audit determines the topics of education to be provided to the staff and physicians, as she proactively believes education is the key to having complete, accurate, and consistent documentation supporting reimbursement for billed services. If you are interested in her services, contact Dixon at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-615-210-7476.

JOHANNA S. LEGASPI MBA, CPC, CPMA, is a senior consultant at Hayes Management Consulting with more than 10 years of healthcare auditing experience. She holds credentials from AAPC as a certified professional coder and a certified professional medical auditor, is certified in EpicCare Ambulatory, and has been trained using MDAudit Professional Program. Legaspi performs ICD-10 clinical documentation readiness by analyzing clinical diagnosis based on documentation. She has developed and documented project team procedures for implementing system changes and other tasks. She has developed relationships with providers and staff to ensure a smooth transition into their EMR operations.


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