Munson Health
 
ICD-10 Documentation Tips

Documentation Tips are brief, one-page, informative examples of ICD-10 compliant documentation compared to the current documentation required in ICD-9 for various specialty areas. These tips are intended for physicians, clinicians, documentation specialists, coders and others who generate or use clinical documentation in their job function. 

Tips will be posted through August 2015.

Read the TipsSample Documentation Tip

Tip 1 - Mark the Date!
Tip 2 - Why Change?
Tip 3 - Positive Effects on Healthcare
Tip 4 - Myocardial Infarction
Tip 5 - Traumatic Fracture
Tip 6a - Cerebral Artery Occlusion with Infarction
Tip 6b - Cerebral Artery Occlusion without Infarction
Tip 7a - Precerebral Artery Stenosis with Infarction
Tip 7b - Precerebral Artery Stenosis without Infarction
Tip 8a - Intracerebral Hemorrage - Non-Traumatic 
Tip 8b - Intracranial Hemorrage - Non-Traumatic
Tip 9 - Diabetes Mellitus
Tip 10 - Appendicitis

Tip 11 - What is ICD-10-PCS?
Tip 12 - What is ICD-10-CM?
Tip 13 - Respiratory Failure
Tip 14a - Pressure Ulcer
Tip 14b - Chronic Skin Ulcer - Non-Pressure 
Tip 15 - Glaucoma
Tip 16 - Drug Induced Neutropenia
Tip 17 - Sepsis
Tip 18a - Poor Fetal Growth - Maternal Record
Tip 18b - Poor Fetal Growth - Perinatal Record
Tip 19 - Alzheimer's Disease
Tip 20 - Edema

Tip 21 - Arteriosclerosis of Extremities
Tip 22 - Gout
Tip 23 - Feeding Problems of Newborn
Tip 24 - Obesity
Tip 25 - Regional Enteritis - Crohn's Disease
Tip 26a - Dysrhythmia - Fibrillation/Flutter
Tip 26b - Dysrhythmia - Tachycardia/Bradycardia
Tip 27 - Documentation of Joint Prosthesis Explantation and Aftercare
Tip 28 - Dermatitis
Tip 29 - Scoliosis
Tip 30 - Angina Pectoris

Tip 31 - Abnormality of Gait and Mobility
Tip 32 - Bronchitis and Bronchiolitis
Tip 33 - Heart Valve Disorders
Tip 34 - Asthma
Tip 35 - Pneumonia
Tip 36 - Influenza
Tip 37 - Urinary Incontinence
Tip 38 - Choleithiasis
Tip 39 - Bundle Branch Blocks
Tip 40 - Cirrhosis/Fibrosis of the Liver - Non-Alcoholic

Tip 41 - Tobacco Use
Tip 42 - Varicose Veins - Lower Extremities
Tip 43 - Vitamin B12 Deficiency or Anemia
Tip 44 - Malignant Melanoma
Tip 45 - Acoustic Nerve Disorders
Tip 46a - Gastroenteritis - Infectious
Tip 46b - Gastroenteritis -Non-Infectious
Tip 47 - Lumbago-Sciatica
Tip 48a - Otitis Externa
Tip 48b - Otitis Media