Now that ICD-10 is finally here, are you confident about your organization’s transition to the new ICD-10 coding system?
If you answered “no,” you are not alone.
Many elements of this monumental transition have dependencies on the software vendors, clearinghouses, payers and staff, but there is one thing you can control: your documentation of the information needed to support the diagnosis codes being billed. Your documentation probably does not need a major overhaul, but you will need to be more specific and detailed in certain areas.
Here are three steps1 that you can take to ease the transition to ICD-10:
- Document a more complete diagnosis, including:
- Other specific characteristics
- Create more detailed templates as a way to ensure that your documentation meets coding and billing requirements. Providers often forget to document common details for a given condition. Since coders are never present with the physicians during patient visits, it makes it impossible for coders to have a complete picture. As a result, coders are forced to go back to the physicians for further clarification, potentially leading to loss of time and revenue. Providers should try to stay away from falling into the trap of relying on non-specific codes, such as “not otherwise specified” or “other.” Although it’s easy to use these codes vs. specific details, in the long run, it might be a red flag for an audit.
- If your organization uses an EHR, ask your EHR vendor about the need for additional documentation elements. Find out whether the system can accommodate both code sets to allow for the crosswalk from ICD-9 codes to ICD-10 codes. Although there may not be a one-to-one match for each code, and such a list will have limitations, it will be helpful to have this crosswalk initially.
1 “Getting Ready for ICD-10: How It Will Affect Your Documentation,” Family Practice Management, November 2013