MRA Thought of the Day – Avoid an ICD-10 Transition Roadblock: Assess Clinical Documentation Now


Lynn Salois, RHIT, CCS, CDIP, Director of Coding Lynn Salois, RHIT, CCS, CDIP, Director of Coding

Let’s begin with two very important ICD-10 readiness true or false questions:

Question 1: True or false -Today’s coding professionals will be ready for the ICD-10 transition?

Question 2: True or false –Physician documentation will include the necessary detail for accurate and specific ICD-10 code assignment?

Response: True -Coding professionals will be ready for the ICD-10 transition on October 1, 2014.

Response: False -Physician documentation will not include all the necessary detail for accurate and specific ICD-10 code assignment.

Here are my thoughts…

Clinical documentation is the foundation of every code assignment. Coding professionals understand that ICD-10 will bring about a new level of required documentation specificity. However, are the physicians aware of this vital fact? Most likely they are unaware they will need to document the severity level of asthma – mild, moderate or severe intermittent, document pregnancy in terms of trimesters, document fracture in terms of laterality, initial or subsequent episode of care, open vs. closed, routine vs. delayed healing, non-union vs. malunion. HIM managers take note – reduced coder productivity won’t be the only item negatively impacting the DNFB, you will see a dramatic increase in the number of queries.

Of course, unspecified codes may be assigned when the documentation does not support specific code assignment. However, selecting unspecified codes as the norm will negatively impact reimbursement, quality reporting, and coding compliance. Healthcare organizations and physician practices will also encounter increased claim denials as unspecified codes typically do not support medical necessity.

To avoid clinical documentation roadblocks, ICD-10 clinical documentation assessments should already be underway. Focus on the top 15 diagnoses, procedures and DRGs and apply the ICD-10 code set utilizing current medical record documentation to identify documentation gaps. The results will provide the necessary baseline data to begin modifying queries for ICD-10 documentation requirements. In addition, the results will identify focus areas for physician and CDS ICD-10 documentation training.

What are your thoughts?

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