ICD-10 Implementation: Can Current Clinical Documentation Support the New Codes?

ICD-10 implementation is set to take effect on October 1, 2014. The increase to approximately 70,000 diagnosis codes reflects the growing need for more detail in clinical documentation.  Physicians, who are already struggling to comply with new federal regulations, must now turn their focus to ensure that their documentation supports the increased specificity of the new code set.  Since it will take time to get accustomed to the new requirements, provider education must begin soon.
To facilitate identification of potentially deficient areas, providers should consider a medical chart review.  During the review, a certified coder will assess a sampling of patient charts and compare frequently used ICD-9 codes to the new ICD-10 codes.  After the review, it will be easier to identify where the clinician may need to adjust his notes to incorporate all the necessary elements for ICD-10 implementation.  For example, new concepts addressed in this code set include causes and manifestations of diabetes, episode of care for injuries, and laterality—indicating the left or right side.
With this implementation, physicians will need to comply with the new guidelines or risk not fully identifying the patient’s condition on the medical claim.  Some insurance carriers have indicated that they may either deny these unspecified diagnosis codes or require a potentially time-consuming medical review before paying these claims.   Early planning can ensure that clinical information is sufficient to support specific ICD-10 codes and diminish these denials.  Preparation to confirm documentation is compliant now will help to mitigate disruptions to the revenue cycle during the upcoming transition.

Nancy Clark is a Manager in the Health Care Services Group. Her expertise focuses on coding and documentation audits, which includes chart review and report compilation.

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