Health Information Management

Coding ICD-10-PCS in an ICD-9-PCS record

HIM-HIPAA Insider, October 13, 2014

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There has been a fair amount of coverage on the documentation requirements needed to assign ICD-10-CM diagnosis codes. While changes in documentation requirements for pregnancy, coma, diabetes, fractures, and pressure ulcers are frequently cited, less information is available regarding the documentation requirements for procedures.

HIM professionals are keenly aware clinical documentation improvement (CDI) programs will be a critical tool to bridge the gap from ICD-9-CM to ICD-10-CM documentation. CDI programs in ICD-9-CM generally do not address very many procedures. A lack of published resources coupled with limited experience in procedural documentation improvement leaves HIM professionals to create their own plan to address procedural documentation requirements. Consider taking these steps to help fill in these potential documentation gaps in advance of the new ICD-10 compliance date, October 1, 2015:
  • Determine specialty-based risk
  • Don't forget to use reimbursement modeling output
  • Determine the number of records to review and who will review them
  • Create a record review tool
Continue reading "'Coding ICD-10-PCS in an ICD-9-PCS records" by Lynette Kramer, MA, RHIA, a director at Navigant Consulting, Inc., in Washington, D.C., where she leads the ICD-10 practice. Subscribers to Medical Records Briefing have free access to this article in the October issue.

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