05/25/15 – ICD 10: Documentation is Key

Question: On October, 1 2015 we know we need to start using the new ICD-10 diagnosis codes.   Do you have any suggestions on how we can start preparing now to help with the change?

 

Answer: One way to help prepare for ICD -10 is to work on improving how you document your clinical services.

 

Remember, ICD-10 will not affect the way you provide patient care; but it will be more important to make your documentation as detailed as possible since ICD-10 gives more specific choices for coding diagnoses.

 

Below are some examples of the specific information that will be needed to accurately code the following common diagnoses:

 

Diabetes Mellitus:

  • Type of diabetes
  • Body system affected
  • Complication or manifestation
  • If type 2 diabetes, long-term insulin use
  • If gestational diabetes, diet vs insulin controlled

 

Fractures:

  • Site
  • Laterality
  • Type
  • Location
  • Encounter

 

Neoplasms:

  • Overlapping sites
  • Laterality
  • Include anemia (when applicable)
  • Include pathological fracture (when applicable)

 

Pregnancy:

  • Include specific trimester

 

Detailed documentation will also help reduce the need to follow-up on submitted claims or the coding staff emailing you for clarification.


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