Health Information Management

Discover and correct common documentation insufficiencies before ICD-10 implementation

HIM-HIPAA Insider, November 18, 2013

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How well could you code in ICD-10 using your current physician documentation? Do your physicians document the specificity and detail coders need to select the correct ICD-10-PCS code? Do your physicians document laterality, which coders will need for many ICD-10-CM codes?

One way to reduce the anticipated decline in coder productivity is to improve physician documentation. Complete and ­accurate documentation reduces the need for coder and CDI queries and allows coders to complete a chart sooner.

ICD-10-CM retains many of the coding guidelines and conventions from ICD-9-CM, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of coding and HIM at HCPro, Inc., in Danvers, Mass. The major difference between the two systems is the level of detail required to correctly assign ICD-10-CM codes, McCall says. For example, many ICD-10-CM codes include laterality. Odds are physicians are documenting laterality now; coders just aren't looking for it.

The transition to ICD-10-PCS for inpatient coders may be more challenging because ICD-10-PCS is a completely different system. "People are scared about ICD-10-PCS," says Mark N. Dominesey, MBA, RN, CCDS, CDIP, HIT Pro-CP, director of auditing and clinical documentation improvement services for TrustHCS in Springfield, Mo. "ICD-10-PCS really isn't scary. Most often the information coders need is already in the chart."

Editor’s note: Continue reading "Discover and correct common documentation insufficiencies before ICD-10 implementation" on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the November issue.

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