Feature September 15, 2015 David Rossi

Quick tips for documentation with ICD-10-CM

ICD is the international classification of diseases for all general epidemiology, health management, and clinical usage. It is published by the World Health Organization to classify morbidity and mortality for statistics, resource allocation, reimbursement, and guidelines. On October 1st, many insurance companies will stop accepting diagnosis codes in ICD-9-CM. They will require the use of ICD-10-CM for all visits on or after October 1st, 2015. Proper planning and training will help ensure success with the transition.

To help your office prepare for the transition you should review all of the areas of your practice where diagnosis codes are involved. This could include forms, policies, contracts, administrative functions such as authorizations and referrals, and documentation.

The switch from ICD-9-CM to ICD-10-CM will increase the amount of codes by approximately 65,000. As a result, diagnosis codes are more descriptive and your documentation will require more specificity to support any selected diagnoses. The diagnosis codes will now include descriptions of laterality, anatomic location, specificity, and enhanced clinical conditions. You should decrease the usage of unspecified codes because payers are highly likely to deny unspecified codes under ICD-10-CM. With that being said, sometimes unspecified codes are the best choice to accurately reflect the visit.

You should code each visit to the level of certainty known for that encounter. If you cannot make a definitive diagnosis by the end of the visit, you can report codes for signs and symptoms. There will be times when you do not have enough information about the patient’s health status and it would be difficult to assign a more specific code. For example, a diagnosis of pneumonia has been determined but the specificity has not been as the cultures are pending. In this case the unspecified codes would most accurately reflect what is known about the patient’s condition at the time of the encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing to determine a more specific code.

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