Massachusetts Medical Society: ICD-10: Prepare Yourself by Focusing on Clinical Documentation

ICD-10: Prepare Yourself by Focusing on Clinical Documentation

From the February 2015 issue of Vital Signs

Clinical documentation is one area that physicians can focus on today in order to get ready to meet the new requirements in an ICD-10 world. The transition to the expanded code set will require physicians to capture new information in clinical documentation that reflects the associations between conditions since the ICD-10 code set contains in- creased specificity.

For example, ICD-10 code K50.814 indicates “Crohn’s disease of both small and large intestine with abscess.” The ICD-9 equivalent codes would be “555.2 — Region- al enteritis, small intestine with large intestine” and “569.5 — Abscess of intestine.” Furthermore, physicians will need to document  laterality.

For example, ICD-10 code M05.271 denotes “Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot.” The ICD-9 equivalent code would be “714.27 — Rheumatoid arthritis with visceral or systemic involvement, ankle and foot.”

The following are examples of potential problem areas that physicians should be aware of as they require an added level of specificity in clinical documentation.

  • Diabetes Mellitus: ICD-9 features 59 codes for diabetes, while ICD-10 offers more than 200 codes.

  • Injuries: ICD-10 features an expanded category for injuries.

  • Drug Underdosing: Underdosing is a new code in ICD-10. It identifies situations in which a patient has taken less of a medication than prescribed by the physician.

  • Cerebral Infarctions: Late effects of stroke are differentiated by type.

  • Acute Myocardial Infarction: Age definition for AMI has changed to four weeks rather than eight weeks.

  • Pregnancy: Documentation of trimester now required.

What can you do today to prepare for a world in ICD-10? There are a few actionable steps that you can take today to improve your clinical documentation.

Perform a clinical documentation assessment by choosing a few samples of medical records to determine whether your documentation supports the level of detail needed for ICD-10. If it does not, outline an improvement and designate someone in your practice to assist in clinical documentation education/training.

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