Health Information Management

Another reason for better documentation

HIM-HIPAA Insider, April 13, 2015

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As we continue to move closer to ICD-10 implementation (still set for October 1, 2015), I keep finding more reasons why we need better documentation. I am not trying to pick on physicians (really), but everything we do as coders depends on what the physician includes in the patient’s chart.

We know we can’t go back to a previous encounter and pick up details about a patient’s illness in ICD-9-CM. For example, the physician documents that a patient has Type 2 diabetes, is insulin-dependent, and suffers from peripheral neuropathy. On the next visit, the physician simply documents “diabetes.” We can’t look back at the previous note and add all of the additional detail.
 
The same will hold true in ICD-10-CM. No looking back in the record for information. We can only code what the physician documented for that particular encounter.
 
Why is that such a big deal in ICD-10-CM? Because of the increased specificity (obviously), but also because of the seventh character.
 
Codes in chapters 19 (Injury, Poisoning, and Certain Other Consequences of External Causes) and 20 (External Causes of Morbidity) use seventh characters to denote the encounter. In most cases, ICD-10-CM gives us three choices for that seventh character:
  • A, initial encounter
  • D, subsequent encounter
  • S, sequela
The seventh character will allow us to follow an injury through the entire course of treatment—provided the physician documents all of the information at each visit. However, if the physician leaves out details on the subsequent encounter, we may end up with a different code and not just a different seventh character.
 
Consider this scenario: Allen comes into the ED after being involved in a car accident. He suffered multiple lacerations and in some cases, glass remained in the wounds. His injuries may include:
  • S41.121A, laceration with foreign body of right upper arm, initial encounter
  • S51.021A, laceration with foreign body of right elbow, initial encounter
  • S61.521A, laceration with foreign body of right wrist, initial encounter
  • S61.011A, laceration without foreign body of right thumb without damage to nail, initial encounter
Foreign bodies remained in three of the four lacerations. Ideally when Allen comes in to see his primary care physician for a wound check, we would report the same four codes with seventh character D to indicate a subsequent encounter. (Unless Allen receives some active treatment for the injury. Then we’re back to seventh character A.)
 
The caveat is the physician has to document “with foreign body” for the subsequent encounter. Otherwise we would report codes “without foreign body.” We can’t go back to the ED record and see that glass remained in the wounds.
 
Does it really matter? Yes and no. Yes in the sense that we want to follow the injury all the way through treatment and healing mainly for data purposes. On the other hand, our payment won’t change and the treatment likely won’t change (unless some glass remains in the wound and causes problems).
 
Is it worth a query? To me, no. We already know our query rates will go up in ICD-10, both for diagnoses and procedures. As much as we would like to code every single diagnosis and procedure to the absolute highest level of specificity possible, sometimes we have to settle. With or without foreign body on a subsequent encounter is not a big enough battle to fight, in my opinion.
 
This does provide one more thing to think about when you are reviewing your physician documentation prior to implementation. Don’t look just at the initial encounters. Make sure you are also looking at those follow-up visit charts.
 
This article originally appeared on HCPro’s ICD-10 Trainer blog.



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