Co-Author: Laura Gold
As many of you know, while ICD-10 was created by the World Health Organization (WHO) in 1994, the United States is one of the last countries to adopt this coding standard. In part, ICD-10 was created to provide an updated medical terminology and disease classification, which aids in the ability to improve healthcare services and metrics. While all past implementation dates have been pushed, the current go-live date is October 1st, 2015. Majority of healthcare organizations spent the past year preparing their systems to accept and use ICD-10 coding standards.
Organizations should be in the process of educating their providers, clinicians, end users and billing/coding staff on the new ICD-10 coding complexities. Choosing the correct ICD-10 code alone will be meaningless without the required supporting elements to substantiate the clinical note.
For instance, it is common everyday practice throughout the healthcare community to document otitis media w/ spontaneous rupture of ear drum with an ICD-9 code of 382.01. ICD-10 coding requires a much higher level of specificity not currently supported or required for ICD-9. Moving forward when documenting a patient with otitis media, it will be imperative to be precise in code selection as well as in recording the patient’s visit via the office note. This will include Type, Infectious Agent, Temporal factors, Side, Tympanic membrane rupture status, and Secondary causes e.g. tobacco smoke usage or exposure.
Otitis Media: ICD-9 vs. ICD-10
Documentation Differences at a Glance (*ICD-10 Changes Appear In BOLD)
Preparing your staff with the tools to be able to select the correct ICD-10 code is only the first step. The second step is to have the visit documentation mirror the ICD-10 code. Even providers who have been doing a stellar job documenting and coding their patient care for ICD-9 are more than likely going to need guidance and assistance navigating through the intricacies of ICD-10 and its documentation needs. Clinicians, therefore will need help capturing the new information or expanding on old required documentation standards.
How to prepare - The new ICD-10 guidelines will increase the time a provider spends accurately documenting a patient visit, but it doesn’t have to. Creating ICD-10 Compliant and Provider Friendly forms will remove this time consuming annoyance and help ease the transition to ICD-10.
What can be done - As healthcare organizations navigate the new ICD-10 coding requirements, a Clinical Documentation Improvement (CDI) assessment of internal notes should be performed. A review of your existing forms and practices by a Clinical Documentation specialist will greatly ensure all the required supporting elements are available in a provider friendly format.
Who is going to do the work – Ideally, this CDI project would include a note specialist who is familiar with your notes and documenting practices as they are today, an ICD-10 certified coder, and clinical documentation specialist.
When do you start – Regardless of the number of note forms and templates you use today, reviewing them can be a laborious process. If your organization has not already started reviewing your clinical documentation practices for ICD-10, start NOW! Don’t let the implementation date catch you off guard!
Galen has a team of skilled ICD-10 clinical document improvement analysts available to guide your organization through this process, and has already contracted with several clients at various levels to assist in their efforts. For additional information, please contact us at firstname.lastname@example.org.