ICD-10 scheduled to be implemented by October 1, 2014, offers various advantages including enabling clinicians to capture laterality and others concepts in a standardized manner, which supports data exchange and increased efficiency. However this is bound to affect clinical documentation significantly, and propel physicians and billers and coders to upgrade their clinical documentation to make it ICD-10 compatible.

How will ICD-10 affect Clinical Documentation?

Though ICD-10 will not alter patient care in any manner; but it will definitely make clinical documentation very detailed, due to the increased specificity in choices for coding diagnoses. Moreover medical records will also require to be documented as much as possible by coders due to the increased specificity.

Though most of the information needed is already shared during the patient – visit, it will require accurate recording by the medical billers and coders- which will eventually help in reducing the need for follow ups on submitted claims, hence increasing saving and revenue earned. Coders would also require learning new ICD-10 codes; to ensure complete documentation and accurate selection of ICD-10 codes, an essential for patient care.

Adapting to changes with the help of Biller and Coders-

Medical billers and coders can help by working with physicians in order to improve documentation to –
  • Evaluate the current documentation system at the practice, to help find most often used codes in the practice
  • Determine if the future documentation will be specific and detailed enough to choose the best ICD-10 codes
  • Improve overall documentation of clinical services and help achieve specific, detailed clinical documentation required to assign ICD-10 codes
Are the Documentation processes ICD-10-Ready?

Billers and Coders can ensure that the documentation is ICD-10 ready by following these steps-
  • Comprehend how ICD-10 will affect the practice by reviewing the current documentation.
  • Identify the complete extent of the ICD-10 transition to help reduce the chance of overlooking any areas which require ICD-10 updates.
  • Ensure all possible gaps in the process have been worked out by testing ICD-10, right from documentation to communicating with different vendors.
  • Help find appropriate ICD-10 codes which correspond with the most often-used ICD-9 codes at the practice.
All these steps will also help in emphasizing the information which needs to be primarily looked into while documenting for ICD-10.

The initial impact of ICD-10 on physicians’ post transition will be on clinical documentation; hence the coders’ knowledge about the essential demands of clinical documentation under ICD-10; can be a crucial support to physicians. Besides demonstrating an essential level of coding capability, coders also require to be resourceful in testing.

Hence as you (medical billers and coders along with physicians) work towards meeting the challenges of the altering clinical documentation mandatory for the subsequent ICD-10 transition, Medicalbillersandcoders.com – the largest consortium of medical billers and coders across all 50 US States offers regular ICD-10 updates and training. Our unique Training Program on ICD-10 Transition – including updates, webinars, forums, and online learning materials – should help make your clinical documentation improvement job more meaningful and fulfilling.

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