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.

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