As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes.
Most Important CDI Documentation
During the next few months, make a concerted effort to remind physicians and CDI specialists of the importance of the following:
- Patient demographics
- Date of procedure
- Pre- and post op diagnoses
- Title of procedure(s) performed
- Surgeon/co-surgeon
- Surgical assistants/residents
- Type of anesthesia
- Anesthesiologists
- History of present illness or indications for the procedure
- Findings
- Any complications
- Any specimen(s) sent to pathology
- Estimated blood loss
Essentials For Coding In ICD-10-CM/PCS
In addition to the above components, ensure that all documentation includes the following:
- Detailed anatomical location of the operative field, including laterality, specific vessels, organs, and body part on which the procedure is performed.
- Description of the objective of the procedure and any secondary procedures accomplished during the operative episode.
- Description of the approach.
- Detailed description of any devices that remain after the procedure is completed, including grafts/prostheses, implants, simple/mechanical appliances, and electronic appliances.
- Detailed description of any potential qualifier-associated items, such as a biopsy, the specific vessel bypassed from (for CABG procedures), and the type of donor tissue in transplants (i.e. allogeneic, syngeneic, zooplastic).
Reminding physicians and CDI specialists of these important documentation elements doesn’t need to be a lengthy or time-consuming endeavor. Consider weekly documentation tips/emails or posters/signs. Any small reminders are helpful and will go a long way in terms of coding compliance once ICD-10 takes effect.
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