ICD 10 Training: Steps to Improve Clinical Documentation

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<span class="Apple-style-span" style="font-size: large;">Simple Steps to Improve Clinical Documentation</span></div>
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On October 1, 2014, your practice and the clearinghouses, payers, and billing companies that you work with will need to use <span class="Apple-style-span" style="font-weight: bold;">ICD-10 codes.</span> 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.</div>
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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).</div>
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Below are additional examples of the specific information needed to accurately code the following common diagnoses:</div>
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<span class="Apple-style-span" style="font-weight: bold;">Diabetes Mellitus:</span></div>
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<li style="text-align: justify;">Type of diabetes</li>
<li style="text-align: justify;">Body system affected</li>
<li style="text-align: justify;">Complication or manifestation</li>
<li style="text-align: justify;">If type 2 diabetes, long-term insulin use</li>
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<span class="Apple-style-span" style="font-weight: bold;">Fractures:</span></div>
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<li style="text-align: justify;">Site</li>
<li style="text-align: justify;">Laterality</li>
<li style="text-align: justify;">Type</li>
<li style="text-align: justify;">Location</li>
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<span class="Apple-style-span" style="font-weight: bold;">Injuries:</span></div>
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<li style="text-align: justify;"><span class="Apple-style-span" style="font-weight: bold;">External cause</span> – Provide the cause of the injury; when meeting with patients, ask and document “how” the injury happened.</li>
<li style="text-align: justify;"><span class="Apple-style-span" style="font-weight: bold;">Place of occurrence</span> – Document where the patient was when the injury occurred; for example, include if the patient was at home, at work, in the car, etc.</li>
<li style="text-align: justify;"><span class="Apple-style-span" style="font-weight: bold;">Activity cod</span>e – 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?  </li>
<li style="text-align: justify;"><span class="Apple-style-span" style="font-weight: bold;">External cause status</span> – Indicate if the injury was related to military, work, or other.</li>
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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.</div>
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Simple Steps to Improve Clinical Documentation On October 1, 2014, your practice and the clearinghouses, payers, and billing companie...