As I stated in the email on 06/12/2015, we would be addressing different topics every 2 weeks as we head towards our October 1, 2015 effective date for ICD-10.
The topic this week is: Chart Documentation and What You Can Begin Doing Now
A major hurdle in the transition to ICD-10 is making sure that the documentation of the providers is supportive of the new coding criteria that will need to be met. It is not only the codes that are transitioning, but also the documentation to meet it. Here are some areas of particular interest in documentation:
- Specificity - this is one of the main reasons for the transition to ICD-10. Increased specificity will enable conditions to be clearly indicated. Specificity issues include laterality, time parameters, site, and expansion of certain conditions under ICD-10.
- Laterality - the addition of laterality is one of the reasons for the increased number of codes in the transition to ICD-10. For example, in ICD-9, you had codes such as otitis media that were reported, but in ICD-10 it is expected that you will report right ear, left ear or in some cases, bilateral. Your documentation is expected to match what you bill.
- Time Parameters - the use of acute, chronic, acute on chronic, and recurrent are important time parameter documentation factors. The difference between a specific and an unspecified code may be this time parameter indication.
- Site - the site expansion into the code set is another reason for the increase in the number of codes from ICD-9 to ICD-10. This is especially prevalent in the “fracture” and “wound” type codes. For example, the use of distal radial fracture might have been good enough in ICD-9, but in ICD-10 this is still an unspecified code. They would expect to see “radial styloid fracture”, etc. to disseminate more site specifics in ICD-10.
These are only a portion of the changes when it comes to documentation. In our training sessions, we will also discuss how some common conditions have other requirements. These other requirements may include Type (primary, secondary), Associated Complications, Severity (mild, moderate, severe), Manifestations, Temporal Factors, Contributing Factors.
If you have not already begun making changes to the way that you document, please consider that easing into this process will make it much easier on you rather than waiting until the deadline.