Providers: Are You Practicing Mismatching?

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:

—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.

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

—If the accuracy rate is below 70%:

—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.

—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.

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:

—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.

Mismatching Coding and Documentation

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

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

—Review the correct use of the Problem List.

—Medical problems resolved but have clinical importance

—Surgical 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:

—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

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:

Examples Coding Selection:

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

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.

—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


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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.