HCPro, JustCoding Inpatient - 2015 Issue 45 (December)
Past is present: ICD-10-CM clears some ICD-9-CM issues while others persist
December 2nd, 2015
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Article Overview
This piece discusses how ICD-10-CM changed the way certain commonly documented clinical conditions are represented compared with ICD-9-CM, while some longstanding documentation and coding challenges remain. It is aimed at coding professionals, CDI staff, and clinicians who document conditions such as sepsis, syncope, orthostatic hypotension, and hypertension. The article focuses on broad clinical and coding issues, including terminology, specificity, and how diagnosis coding frameworks handle these topics.
Why This Topic Matters
Understanding the article helps readers gauge whether they need guidance on ICD-10-CM documentation and coding for conditions where terminology, specificity, and classification still create confusion. It is especially relevant for anyone reviewing physician documentation or analyzing how older coding concepts carried forward into ICD-10-CM.
Article Sections
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SIRS
Discussion of the evolution of sepsis-related terminology and the documentation and classification issues surrounding systemic inflammatory response and infection.
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Syncope
Overview of causes of fainting or passing out and how these events are represented in coding systems, including related blood pressure changes and documentation needs.
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Hypertension
Review of hypertension-related terminology, severe blood pressure elevations, and the need for clearer documentation in certain clinical scenarios.
What You Will Learn
- How the article frames ICD-10-CM changes compared with ICD-9-CM for selected conditions
- Why documentation specificity remains important for sepsis-related reporting
- What kinds of clinical causes are discussed in relation to syncope and orthostatic hypotension
- How the article distinguishes broad hypertension terminology from more severe presentations
- Which coding and documentation issues are presented as improved versus still unresolved in ICD-10-CM
Who Should Read This
- Medical coders
- Clinical documentation improvement specialists
- Physicians and other documenters
- Coding auditors and compliance staff
Codes Discussed
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