Health Information Management

Diagnose documentation shortcomings

HIM-HIPAA Insider, October 13, 2014

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The musculoskeletal system saw the largest increase in the number of new codes in ICD-10-CM, in large part because of the added specificity in the codes.
 
Consider a patient with a fracture of the navicular bone in the wrist. In ICD-9-CM, coders have two choices:
  • 814.01, closed fracture of the navicular bone
  • 814.11, open fracture of the navicular bone
In ICD-10-CM, coders will need to know the following information in addition to whether the fracture is open or closed:
  • Laterality—right or left
  • Specific part of the bone fractured—distal pole, middle third, or proximal third
  • Displaced or non-displaced
  • Episode of care—initial encounter, subsequent encounter, sequela
Continue reading "Diagnose documentation shortcomings" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the October issue.



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