Physician Practice

Q&A: Electronically capturing ICD-10-CM smoking details

Physician Practice Insider, May 19, 2015

Q: Our EHR system only provides for a "yes/no" choice under smoker. How can we capture the additional details necessary for an ICD-10-CM code assignment?

A: I would suggest a two-step process. First, start with your IT department to get information on adjusting the section of the patient record to include the new details of use, abuse, and dependence. Virtually all software programs can be updated in this matter, especially when they're connected to healthcare.

Second, I would contact the physicians. The questions on tobacco dependence should be included in their detailed notes. Until you have the check boxes in the software for use/abuse/dependence, you should be able to refer to the physician's narrative to find that information.

Lastly, focus on the new details: specifics of tobacco use and whether the patient quit and when. If the patient is a current tobacco user, you'll need to know that in addition to the type of tobacco used (cigarettes, chewing tobacco, other).

Editor’s note: This question was originally answered in the HCPro newsletter Briefings on APCs.

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