ICD-10 coding goes into effect on Thursday, October 1. This much heralded, often delayed, new and more extensive set of documenting codes, is long overdue. Still, it is a huge change in the medical world. Write down an improper code and the office/hospital may not only not be paid, but there could potentially be a penalty levied by the government.
There is a great article posted in The American Nurse publication, produced by the American Nurses Association (ANA), which offers information and tips on how to adjust quickly to the new coding. If your office has an electronic medical records system that will automatically reconcile to ICD-10 you are certainly fortunate. If not, you will have to be more fastidious in being thorough and correct in diagnosis code entry.
Here are four of the top tips extracted from the ANA publication:
- Tip #1: Complete observation of all facts relevant to the patient’s condition. We’ll take it one step further. Observe the facts and write them down or enter them into your tablet/electronic system right away.
- Tip #2: Document all key clinical concepts regarding each patient’s care now and recommendations for the future.
- Tip #3: Use the information gathered in steps 1 and 2 to enter the correct code, based on all of your observations and information gathered. Refer to the coding guidelines if you have any questions; avoid assuming or guessing that you have the right code.
- Tip #4: If you haven’t already, look at the top five diagnoses for your patient population. Is your past documentation thorough and does it include all clinical concepts required for a correct ICD-10 code? If not research what changes must be made starting now to make this comprehensive.
ICD-10 offers many benefits, including the ability to more accurately review patient health and create wellness plans for greater health outcomes. The more extensive documentation also lends itself to population health management, whereby certain patient populations – say, senior citizens with A1C levels greater than 7 – can be closely monitored and cared for to avoid even greater health issues.
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