ICD-10 CDI DIY: Documentation Tip Sheets

By Melanie Endicott

Among the most helpful tools for assisting providers through the transition to ICD-10-CM/PCS are documentation tip sheets detailing the specificity needed to assign accurate codes. Many companies are selling tip sheets, but if you are looking to save a few dollars, here’s a step-by-step method to create these tip sheets yourself:

  1. Run a report of each provider’s top 10 to 20 diagnoses
  2. Have an experienced coding or clinical documentation improvement professional (preferably an AHIMA-Approved ICD-10-CM/PCS trainer) evaluate these diagnoses to determine if there is additional or alternate documentation needed for ICD-10
  3. Create tip sheets for any diagnoses requiring more accurate documentation
  4. The tip sheets should include key words and concepts
  5. Consider adding any other important points to the tip sheets, such as definitions, clinical indicators, common manifestations, etc.
  6. Distribute the tip sheets to the providers and post them in key locations that will be seen

The tip sheets are intended to educate the providers, so they must be written in terms they use every day. The individual or team constructing the tip sheets should confer with the providers throughout the production phase to ensure that the tip sheets are written in “clinical” language, rather than “coding” language.

These tip sheets shouldn’t remain static. They will likely need to be modified over time per provider feedback and documentation gaps identified.

The tips could be printed on pocket-sized cards, laminated poster-size, or anything in between. Whatever will engage and educate the providers. Ask what would work best for them.

AHIMA has created some free ICD-10-CM/PCS Documentation Tips that might help you get started on this important project. Samples tip sheets from this document are pictured below.

Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director of HIM practice excellence, coding and CDI products development at AHIMA. She has over 15 years experience in HIM and coding, with her most recent focus being in ICD-10-CM/PCS, and has presented numerous times at the regional, state, and national levels on HIM and coding topics. She was previously a director of HIM practice excellence, focusing on coding products, resources, and education, at AHIMA. Melanie is an AHIMA-approved ICD-10-CM/PCS trainer and an ICD-10 Ambassador.

Original source:
Endicott, Melanie. "ICD-10 CDI DIY: Documentation Tip Sheets" (Journal of AHIMA), August 12, 2015.