Health Information Management

Tip: Update EHRs to accommodate ICD-10-CM use, abuse, and dependence codes

APCs Insider, May 30, 2014

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Recording use, abuse, and dependence for tobacco use with ICD-10-CM can be difficult if your EHR relies on "yes/no" boxes, but there are some solutions. First, start with your IT department to get information on adjusting the section of the patient record to include the new details of use, abuse, and dependence. Virtually all software programs have the ability to be updated in this manner, especially when they're connected to healthcare.
 
Second, contact the physicians. Be sure to include the questions on tobacco dependence in their detailed notes. Until you have the checkboxes in the software for use/abuse/dependence, you should be able to refer to the physician's narrative to find that information.
 
Focus on the new details. Those are details of tobacco use and whether the patient quit and when. If they're a current tobacco user, you'll need to know that in addition to type of tobacco used (cigarettes, chewing tobacco, other).
 
This tip is adapted from “This month's coding Q&A” in the May issue of Briefings on APCs.



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