June 23rd, 2011

Documentation strategies for ICD-10

By Rhonda Buckholtz, CPC, CPMA, CPCI

One of the largest hurdles in all practice has always been clinical documentation and what is needed to be able to justify medical necessity. This hurdle will not disappear with the transition to ICD-10 until we fully understand what is required for code assignment in the new code set. Even physicians utilizing EMR’s will need to have a full understanding of the code set and the requirements found within ICD-10 in order to begin selection of the code in the menu boxes of the program.

Take a look at this example for acute otitis media:

  • In ICD-9-CM, we would have reported this with 381.00.
  • In ICD-10-CM we would need to know which side and if it is recurrent such as:
    • Patient has an acute onset of otitis media of the right ear, which is recurrent.  In ICD-10-CM, this is reported with H65.114 (Acute and subacute otitis media recurrent, right ear).

In order to assign a code we need to know which ear (laterality), and acute, chronic or recurring.
Or, look at this example. This is the typical level of documentation that is currently used in practices under ICD-9:

  • Impression: Cellulitis and superficial abscess index finger.
  • Plan: I am recommending debridement and irrigation of the digit today. I think the skin is dead and that she will tolerate it with anesthesia, I would like her to stay on the clindamycin and I will check back with her in 3 days to see how she is doing.

Note that left or right is not documented in this case. In ICD-10 it should not be coded without further documentation or query of the provider for further documentation. In ICD-9 this was coded as 681.00 but in ICD-10 we would need two codes:

Although the documentation above gives a good description of the patient’s problem, ICD-10 will require more information than we currently provide. ICD-10-CM takes code assignment to new levels of specificity requiring us to take a long look at our current documentation strategy now to see where we need to start beefing up.  A documentation audit is a good place to start. Follow these simple steps to begin:

  1. Run a practice management report that pulls your most frequently used diagnosis codes.
  2. Run a separate report that can pull patients with those diagnosis codes.
  3. Use this list to randomly pull charts to begin your documentation audit.
  4. Utilize the GEMS files to begin to map your current ICD-9 code to an ICD-10 code selection.
  5. Compare your documentation with the code to see if you have documented enough to assign a potential code, if not begin to work on the documentation aspects ongoing.
  6. Revisit these steps often over the next couple of years to make sure you continue to document with the specificity required.

Following these simple steps early on will help you reduce the overall burden closer to the compliance date of October 1, 2013. It is only with careful planning now that you will be able to implement ICD-10 successfully – and not have to worry too much about the lacking of documentation examples mentioned earlier.

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