Clinical documentation affects specificity for ICD-10-CM
HIM-HIPAA Insider, November 23, 2015
Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!
With the transition to ICD-10, some documentation issues have required the capture of new information while others involve updated, modified, and otherwise expanded documentation needs. As we gain experience with ICD-10 and more questions are answered, physicians, coding professionals, and other clinical staff must continue training in clinical documentation improvement (CDI) and ICD-10. Now comes the hard work: ensuring consistency and reliability of ICD-10 coded accounts and the analytics that will be the outcome of ICD-10 data.
CDI programs play a vital role in ensuring the documentation in the record reflects the true and accurate story of a patient. CDI programs with compliance oversight keep everyone accountable with proper controls in place, ongoing education, active monitoring of program outcomes, and adherence to compliance in concurrent CDI and retrospective coder queries. If you did not get it right in ICD-9, don't expect to get it right immediately with ICD-10.
This article was originally published in HIM Briefing (formerly Medical Records Briefing).
Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!
Related Products
-
Briefings on APCs
Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...
-
HIM Briefings
Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...
-
Briefings on Coding Compliance Strategies
Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...
-
Briefings on HIPAA
How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...
-
APCs Insider
This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...
Most Popular
- Articles
-
- Don't forget the three checks in medication administration
- Residency coordinators’ responsibilities
- Study: Shorter shifts reduces residents’ attentional failures
- RPA Subscriber Exclusive: February issue of Residency Program Alert now available
- Practice the six rights of medication administration
- Editor’s note
- The consequences of an incomplete medical record
- Note similarities and differences between HCPCS, CPT® codes
- Nursing responsibilities for managing pain
- Q&A: Primary, principal, and secondary diagnoses
- E-mailed
-
- White Paper: Postacute CDI: An Introduction to Long-Term Acute Care Hospitals
- Use modifiers -59, -91 to "explain" duplicate codes
- Unclear documentation fuels ongoing challenges in assigning appropriate POA indicator
- Tim Porter-O'Grady sounds off
- Skills of effective case managers
- Q: Can you clarify the reporting of dates on the plan of care for diagnosis onset and exacerbation?
- Note similarities and differences between HCPCS, CPT® codes
- ICD-10-CM coma, stroke codes require more specific documentation
- Fracture coding in ICD-10-CM requires greater specificity
- Eight tips to improve MRI throughput
- Searched