Health Information Management

Respiratory coding updates and guidance

HIM-HIPAA Insider, December 8, 2014

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Coding and documentation should tell a patient's complete story. With the greater specificity in ICD-10-CM, organizations should be better able to capture these stories, and the respiratory codes, listed in Chapter 10: Diseases of the Respiratory System (J00–J99), are no exception.
As the industry moves toward ICD-10-CM implementation, organizations should focus on updating their query forms to meet ICD-10-CM documentation requirements. For respiratory coding, the forms should ask providers whether the condition is acute, chronic, or recurrent, since this information is needed for coding in ICD-10-CM, said Tara L. Bell, RN, MSN, CCM, AHIMA-approved ICD-10-CM/PCS trainer and assistant manager of clinical documentation improvement services at UASI in Cincinnati. Bell spoke about changes to respiratory coding and documentation during HCPro's webcast "Transition to ICD-10-CM Respiratory Coding: Anatomy, Documentation, and Guidelines."
"The major hitters are the new indications for asthma and pneumonia," Bell said. One way to help coders on the back end is to ensure query forms address the key points needed for thorough documentation so that information can be included in the medical record, she said.
Continue reading "Respiratory coding updates and guidance" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the December issue.

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