Importance of Clinical documentation for accrate ICD-10

1. Clinical Documentation ICD-10

2. Importance of Clinical documentation for accurate ICD-10 coding • ICD-10 is not the coding but it’s improved Patient care which is documented • Descriptive documentation to support accurate coding is the base of reimbursement from the insurances • If physicians don't document their care, it can't be captured or coded • Proper documentation has the potential to improve: • Patient care, • Clinical data • Timely and appropriate claims payment

3. What needs to be documented? Basic concepts such as: • Laterality (Right, Left, Bilateral, Unilateral) • Anatomical locations • Trimester • Type of diabetes • Known complications or comorbid conditions • Description of severity, acute or chronic or other known parameters

4. Major Modifications • Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used) • Expanded codes (e.g., injury, diabetes) • Added trimesters to obstetrical codes (5th digits from ICD-9-CM will not be used) • Added code extensions for injuries and external causes of injuries • Laterality – Left Versus Right • Area specified in cases of Neoplasm Examples • Malignant neoplasm, of central portion of breast • Malignant neoplasm of central portion of right female breast • Malignant neoplasm of central portion of left female breast

5. Most Commonly Encountered Disease/Problems – taken as example • DIABETES • HEART DISEASE (CAD, A-FIB, CHF etc.) • PAIN (BACK, LOWER BACK, LIMBS – UPPER OR LOWER) • OSTEOARTHRITIS • CHRONIC KIDNEY DISEASE • PULMONARY DISEASE Examples on the following slides…………………………………

6. Must/Preferable – to dictate

7. Example for -PULMONARY DISEASE

8. To be dictated by Provider

10. To be dictated by Provider

12. To be dictated by Provider

14. To be dictated by Provider

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