ICD-10 is finally here and what most of us do not realize is that, it is just not enough that we are able to code in ICD-10 and get the claims billed out, we need to ensure that the documentation is specific and supportive of the ICD-10 diagnoses billed.
We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.
For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).
Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,
Clinical Documentation Parameters:
Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:
Diabetes Mellitus:
It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.
We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.
For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).
Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,
Clinical Documentation Parameters:
- Onset - when did it start
- Manifestation - Paralysis, Loss of Consciousness
- Comorbidities
- Etiology/Causation - Infectious agent, Physical agent, Internal failure, Congenital
- External Causes - Motor vehicle, Injury, Assault, Accidental, Work related, Intentional Self harm
- Complication
- Detailed Anatomical Location - Proximal, Distal, Medial, Lateral, Central, Peripheral, Superior, Inferior, Anterior, Posterior
- Functional Impairment
- Biological & Chemical Agents
- Phase/Stage
- Lateralization /Localization - Rt side, Lt side, Bilateral or Unilateral
- Severity - Mild, Moderate or Severe
- Time Parameters - Intermittent, Recurring, Postoperative, Postdelivery
- Encounter type - Initial, Subsequent
- Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c
Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:
Diabetes Mellitus:
- Type of diabetes
- Body system affected
- Complication or manifestation
- Long-term insulin use
- Site
- Laterality
- Type - open, closed
- Encounter type - Initial, Subsequent
- Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c
- Place of occurrence
- External cause - Cause of injury, how the injury happened
- Activity code - what the patient was doing at the time of the injury ?
- External cause status - Injury related to military, work or others
It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.
