Health Information Management

Q&A: Improving physician documentation in preparation for ICD-10

HIM-HIPAA Insider, May 4, 2010

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Q. What should HIM staff members communicate to physicians now about the level of specificity they’ll be required to document once ICD-10 takes effect? We’re concerned about a potential swell in the number of queries if we don’t begin to address documentation requirements early on.

A. You need to first start with awareness. Make the physicians aware that this is definitely happening and get them engaged in the process.
 
Yes, there will need to be greater specificity, and the query process will need to transition to the new system that we’ll be embracing. So for now, start by making physicians aware and making sure that they’re engaged.
 
Editor’s note: Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional managing director of HIM for Northern California Revenue Cycle at Kaiser Permanente in Oakland, CA, answered this question in the May 2010 issue of Medical Records Briefing.



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