ICD-10 News: Improving Clinical Documentation

Simple Steps to Improve Clinical Documentation

On October 1, 2014, your practice and the clearinghouses, payers, and billing companies that you work with will need to use ICD-10 codes. One way to help your practice prepare for ICD-10 is to work on improving how you document your clinical services. This will help you and your coding staff become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.

Take a look at documentation for the most often used codes in your practice, and work with your coding staff to determine if the documentation would be specific and detailed enough to select the best ICD-10 codes. For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information on which side of the body is affected (i.e., right, left, or bilateral).

Below are additional examples of the specific information 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

Fractures:

• Site
• Laterality
• Type
• Location

Injuries:

• External cause – Provide the cause of the injury; when meeting with patients, ask and document “how” the injury happened.
• Place of occurrence – Document where the patient was when the injury occurred; for example, include if the patient was at home, at work, in the car, etc.
• Activity code – Describe what the patient was doing at the time of the injury; for example, was he or she playing a sport or using a tool?  
• External cause status – Indicate if the injury was related to military, work, or other.

Remember, ICD-10 will not affect the way you provide patient care. It will just be important to make your documentation as detailed as possible since ICD-10 gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during your visit—it’s just a matter of recording it for your coding staff. Good documentation will also help reduce the need to follow-up on submitted claims—saving you time and money.