Q&A: Tips for improving documentation to transition to ICD-11

Q: I’ve heard some facilities are beginning to incorporate ICD-11, even though it is not yet implemented in the United States. How can coders help their providers transition to ICD-11?

Response #1: I would recommend starting now. Back when we were preparing for the transition from ICD-9 to ICD-10, the original plan was to make the change in 2012. However, we ended up not doing so until 2015. So, between 2012 and 2015, we could really get the providers to start providing additional documentation that we knew we were going to need when the U.S. finally implemented ICD-10.

It’s important to utilize the resources that are out there today and familiarize yourself with the reporting system. Start asking your providers questions. Query your providers now. If there is additional detail that is not covered in their documentation per ICD-10 today and you know there is going to be more, start easing them in with some of those concepts sooner rather than later.

For example, if a patient had type 2 diabetes mellitus with a diabetic cataract of the left eye, this case would be reported as follows in ICD-9, ICD-10-CM, and ICD-11:

ICD-9:

• 250.50, Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
• 366.41, Diabetic cataract

ICD-10-CM:

• E11.36, Type 2 diabetes mellitus with diabetic cataract

ICD-11:

• 9B10.21, Diabetic cataract
• XK8G, Left
• 5A11, Type 2 diabetes mellitus

Response #2: My number one recommendation is education—getting the providers educated, as well as the coders, CDI professionals, management, and operations department. Education really is key. It’s almost like learning a new language. If we just decide one day to switch from English to Spanish, there’s going to be some uptake there, so just getting familiar with the content and having a good plan for education and awareness for relevant parties is really important.

Editor’s note: This article originally appeared in JustCoding. This question was answered by Kaycie LeSage, MSHCM, RHIA, CCS, CDIP, CPC, a domestic clinical nosology manager at 3M Health Information Systems, and Michelle Badore, a global clinical and nosology content manager at 3M Health Information Systems, during the HCPro webinar, “ICD-11: Prepare for Change.”