Improving Documentation

1314902_medical_doctorThe purpose of ICD-10 is to provide more detailed information on the care being provided. There are many steps that need to be taken in order for a practice to prepare for the ICD-10 conversion that is coming October 1, 2014. One of the key changes that will need to be made by some, if not most, physicians is what type of information is being documented in a patient’s medical records and determining whether that information is enough.

Looking at how diagnosis information is being documented will help physicians and coding staff be better prepared for the ICD-10 switch.

Here is a suggested process on how you can better prepare your documentation for ICD-10.

Pull a handful of medical records on some of your more commonly used diagnoses. Review those records with your coding staff, and have them determine if your current documentation provides enough information to associate the appropriate ICD-10 code. If it doesn’t, then you’ll know improving documentation is a necessary change for your practice.

But what kind of information are you supposed to include in your documentation to be able to code for ICD-10???

The best way to think of what the differences are between ICD-10 and ICD-9 is to think of ICD-10 as “expanded”. Most diagnoses in ICD-10 are expanded to include things like body locations, types, causes etc. Laterality is an example of what is expanded in ICD-10. So, documentation for diagnoses needs to include information on which side of the body is affected (right, left, or bilateral). Below are a few other examples of how ICD-10 is expanding on a particular diagnosis and the documentation that will need to be in the medical records.

Fractures –

  • Site
  • Laterality
  • Type
  • Location

Injuries –

  • External Cause – You will need to provide “how” the injury occurred.
  • Place of occurrence – Where did the injury take place?
  • Activity code – What was the patient doing that caused the injury?
  • External cause status – Indicate if the injury was related to another source (military, work, etc.)

Diabetes Mellitus –

  • Type of Diabetes
  • Complication or manifestation
  • Body system affected
  • If type 2 diabetes, long-term insulin use

Making your documentation as detailed as possible will help your coding staff assign the appropriate codes and help reduce the potential for rejected claims. ICD-10 shouldn’t affect patient care. All it is doing is requiring more detailed information. Most of the information is likely already being provided to you during the patient’s visit. It is just making sure you’re recording everything your coding staff will need to chose the correct code.

Improving documentation will improve coding staff turnaround time on billings and in turn reduce the amount of rejected claims for coding issues and so will help you to maintain a consistent revenue stream.