• E-mail
• Print
• RSS

Discover and correct common documentation insufficiencies before ICD-10 implementation

HIM-HIPAA Insider, November 18, 2013

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?

One way to reduce the anticipated decline in coder productivity is to improve physician documentation. Complete and ­accurate documentation reduces the need for coder and CDI queries and allows coders to complete a chart sooner.

ICD-10-CM retains many of the coding guidelines and conventions from ICD-9-CM, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, Mass. The major difference between the two systems is the level of detail required to correctly assign ICD-10-CM codes, McCall says. For example, many ICD-10-CM codes include laterality. Odds are physicians are documenting laterality now; coders just aren't looking for it.

The transition to ICD-10-PCS for inpatient coders may be more challenging because ICD-10-PCS is a completely different system. "People are scared about ICD-10-PCS," says Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, director of auditing and clinical documentation improvement services for TrustHCS in Springfield, Mo. "ICD-10-PCS really isn't scary. Most often the information coders need is already in the chart."

Editor’s note: Continue reading "Discover and correct common documentation insufficiencies before ICD-10 implementation" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the November issue.

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

• E-mail to a Colleague
• Print
• RSS
• Archive