ICD-10 CDI DIY: Documentation Tip Sheets - read online

Sep 22, 2026

ICD-10 CDI DIY: Documentation Tip Sheets provides a practical, step-by-step approach for creating documentation tip sheets that help providers transition to ICD-10-CM/PCS with accurate coding. It recommends reviewing each provider’s top diagnoses, having qualified ICD-10 evaluators identify documentation gaps, and producing diagnosis-specific tip sheets using everyday clinical language. It also emphasizes keeping materials up to date, choosing engaging formats, and distributing them widely in visible locations.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Creating ICD-10 documentation tip sheets

Step-by-step method

Writing in clinical language

Keeping tip sheets current

Distribution and format

ICD-10 CDI DIY: Documentation Tip Sheets Save to myBoK 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. [https://bokold.ahima.org/doc?oid=301426](https://bokold.ahima.org/doc?oid=301426) 1/2 12/6/24 , 5 :05 PM ICD-10 CDI DIY: Documentation Tip Sheets Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA, is senior director ofHIM practice excellence, coding and CDI products development atAHIMA. She has over 15 years experience in HIM and coding, with her most recentfocus 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 ofHIM practice excellence, focusing on coding products, resources, and education, atAHIMA. Melanie is an AHIMA-approved ICD-10-CM/PCS trainer and an ICD- 10 Ambassador. Original source : Endic ott , Melanie . "ICD-10 CDI DIY: Documentation Tip Sheets" (Journal of AHIMA) , August 12, 2015. Copyright 2022 by The American Health Information Management Association. All Rights Reserved. [https://bokold.ahima.org/doc?oid=301426](https://bokold.ahima.org/doc?oid=301426) 2/2

FAQs

How do you decide what diagnoses to include in ICD-10 tip sheets?

Run a report for each provider’s top 10 to 20 diagnoses, then evaluate those diagnoses for documentation needs in ICD-10.

Who should review the diagnoses and what should they look for?

An experienced coding or clinical documentation improvement (CDI) professional should evaluate the diagnoses to determine whether additional or alternate documentation is needed for ICD-10.

What content should be included on the tip sheets?

Tip sheets should include key words and concepts, and may add definitions, clinical indicators, common manifestations, and other important points needed for accurate documentation.

Sep 22, 2026

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