The current diagnosis coding system ICD-9 has approximately 14,000 codes while the new coding system ICD-10 has 69,000 codes. Greater specificity will be required along with additional documentation to distinguish between the larger number of codes. Below are some general documentation tips that you can begin using now to create a seamless transition to the new system:

Specific Diagnosis:
Document the diagnosis to the greatest level of specificity
Example: dysphagia, pharyngeal phase

Specific Anatomy:
Document the exact body location
Example: cerebral infarction due to thrombosis of the left middle cerebral artery

Laterality:
Document which side of the body- right or left
Note: approximately 5,000 codes have a right and left distinction
Example: central corneal ulcer, right eye

Combination Codes for Conditions and Common Symptoms or Manifestations:

Document any conditions that are related or causal
Diagnosis must be clearly documented
Example: central corneal ulcer, right eye
Example: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

Dominant vs Non-Dominant Side:
Document dominant verses non-dominant side for all paralytic syndrome codes such as hemiplegia, monoplegia and hemiparesis.
Example: previous cerebrovascular infarction 6 months ago with residual left-sided hemiparesis on his nondominant side.

Initial vs Recurrent:
Document whether the condition is initial or recurrent
Example: recurrent and persistent hematuria

Here are a few examples of where documentation changes will likely be needed:

Diabetes documentation must include:

Type of diabetes
Body system affected
Complication or manifestation
If a patient with type 2 diabetes is using insulin, a secondary code for long term insulin use is required

Neoplasms documentation must include:

Type: malignant (primary, secondary, ca in situ), benign, uncertain, unspecified behavior
Location(s) (site specific)
If malignant, any secondary sites should also be determined
Laterality, in some cases

Asthma documentation must include:

Severity of disease: mild intermittent, mild persistent, moderate persistent, severe persistent
Acute exacerbation
Status asthmatics
Other types (exercise induced, cough variant, other)

These are only a few examples of the more specific documentation requirements.