ICD-10 Success Step 4: Documentation Improvement

Kareo ICD-10 Resource CenterProviders may not want to hear this, but the single biggest issue to be addressed in transitioning may be the increased need for documentation. After October 1, 2015, the old order for documentation standards will no longer suffice. The new order requires greater detail. CMS believes this increased specificity will make it easier to assign codes correctly, which should result in fewer errors, fewer unpaid claims and therefore fewer requests to resubmit claims with supporting documentation. Time alone will show if this assumption comes to pass... let’s hope so.

Unfortunately, many providers do not document for a high level of specificity today. In fact many providers undercode or overcode, both of which can be a compliance risk. Undercoding also means you are not getting paid all that you are owed. ICD-10 may help providers code more accurately and therefore get paid more accurately as well.

ICD-10 doesn't require providers to change the way they document—using templates, dictating, free text, etc.—but it does require more specific elements.
Many ICD-10 codes include laterality or identification of left and right. Some also include a requirement for cause of the injury or condition. Each specialty has it's own unique changes as well. Here are several examples of ICD-10 specialty changes with links to more detailed articles: Tweet this Kareo story
  1. Primary Care: There are a lot of new codes for primary care providers. Each practice will need to complete mapping of top codes to make sure that they focus on the ones that impact them the most. Common conditions such as headaches, asthma, depression, ear infections, hypertension, and diabetes have many more codes in ICD-10.
  2. Pediatrics: Many of the most common conditions that pediatricians see like otitis media, bronchitis, and asthma require much more detail that often includes laterality, causation, and type. For example, documentation of ‘asthma’ is not sufficient. Instead, pediatricians must specify the type of asthma (i.e., mild intermittent, mild persistent, moderate persistent, severe persistent, or other) as well as whether the asthma is uncomplicated, with exacerbation, or with status asthmaticus.
  3. OB/GYN: Many of the codes in Chapter 15 of the ICD-10-CM Manual require coders to report the specific trimester of the patient’s pregnancy. Other changes with regard to pregnancy include documenting the reason for fetus viability scans and more detail around impact of maternal age on pregnancy. There are also changes that add more specificity for pelvic pain, migraines, and annual exams.
  4. Mental Health: In ICD-10 mental and behavioral disorders due to psychoactive substance use are not only expanded but there is a distinction now between abuse and dependence. There are also more codes for conditions that commonly affect children like ADHD and anorexia. Mental health providers should review all of ICD-10-CM Chapter 5 (mental, behavioral, and neurodevelopmental disorders) to ensure compliant coding.
  5. General Surgery: General surgeons must describe the condition for which they’re performing surgery with as much precision as possible. This includes documenting manifestations and the presence of any complications so coders can assign the correct code.
  6. Rheumatology: Many of the diagnoses relevant to rheumatology include laterality, anatomical specificity, and causation. When possible, rheumatologists should document the relationship between two conditions using language such as ‘due to,’ ‘exacerbated by,’ ‘with,’ or ‘in.’ This helps demonstrate patient severity, and it also allows coders to assign the most specific code. Payers may automatically deny codes that are unspecified. Codes for commonly treated conditions like gout and rheumatoid arthritis have been greatly exapanded to accommodate the added detail.
  7. Orthopedics: Site specificity is a common theme in ICD-10, and many of the orthopedic diagnoses will require this information. Laterality, place of occurrence, and type of encounter are also commonly used in orthopedics. Orthopedists should expect to have a significant increase in the number of codes so getting started with code mapping and documentation improvement early on will be critical.
From this broad overview it is easy to see that all providers will face unique challenges with ICD-10. So it important to identify top codes, complete code mapping (which we reviewed in our last post), and then look at what documentation changes need to be made to meet the requirements for those new codes. The sooner providers start to work on these changes, the easier—and more accurate—documentation will be come October 1, 2015.

To help with documentation improvement, now is the time to implement an EHR if you haven't already. The templates help ensure more accurate detailed documentation and the electronic superbill should have tools to help code for ICD-10.

Another option is to hire a clinical documentation improvement (CDI) specialist or a consulting company to formally audit your documentation. A CDI specialist is someone—often a nurse or certified coder with a clinical background—who helps physicians improve their documentation so it accurately reflects patient severity of illness and meets regulatory requirements. Although ICD-10 won’t require physicians to change the way they document, it does require you to be more mindful of specificity. Accountable care organizations (ACOs) are already engaging CDI specialists to ensure that the physicians in their affiliated practices are documenting appropriately —you can hire these specialists, too!

For more ICD-10 tools and resources, visit the Kareo ICD-10 Resource Center.

About the Author

Lea writes educational articles to help medical practices improve their businesses. In addition to Kareo, Lea has written for Medical Manager Health Systems, WebMD...

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