ICD-10 Clinical Documentation Improvement – Injuries
One of the major changes for medical practices and hospitals with ICD-10 approaching is clinical documentation improvement.
Providers will need to improve documentation so diagnoses and procedures can be coded to the highest level of specificity. A more complete and accurate patient’s medical record will help ensure patient quality of care and support medical necessity of the procedures submitted for reimbursement.
ICD-10 will include an expanded injury category. Documentation for an injury must include the following elements: specificity, laterality, acute vs. chronic, external cause, activity, location and relief vs. no relief. In addition, the code set will have a seventh character extension to identify the encounter.
The character extensions are:
- A – initial encounter
- D – subsequent encounter
- G – subsequent encounter with delayed healing
- S – sequela
Provider documentation reviews should start to take place now to ensure you’ll meet all the requirements before October 1, 2014.