13 Documentation Requirements to Note in ICD-10

13 Documentation Requirements to Note in ICD-10

It’s been almost a year since our last ICD-10 discussion—back when you were breathing a sigh of relief at ICD-10’s latest delay. Well, now it’s here. And surprisingly enough,

new ICD-10 requirements won’t impact coders exclusively.

CDI specialists, who act as go-betweens connecting medical staff and coders, will need to be educated about new specificity and documentation requirements, as the burden of accuracy will fall largely to them.

Take a look at the information below and consider this your laundry list of things to keep in mind while you and your team brush up on ICD-10 training and readiness. No more stays of execution!

Laterality: There is heightened emphasis on laterality when documenting the factors contributing to treatment; this will improve communication between all who contribute care to the patient case.

Disease Pathophysiology: Documentation of ongoing changes in a disease state will need to be more detailed and explain the highest known level of disease physiology; this will assist CDI specialists in properly identifying disease severity.

Encounter Timing: This will require documentation of treatments provided for specific conditions (e.g. injuries, symptoms, external causes of morbidity) as well as current stage of care for each.

Combination Codes: These codes merge two diagnoses that are usually related to each other; this means some codes will now have as many as six options, where they once had only one or two.

Increased Disease Specificity: Several disease code descriptions have been considerably expanded to help connect all complications and manifestations to specific conditions.

Trimester Identification & Pregnancy: New descriptions have been introduced requiring obstetric clinicians to document the current trimester with each episode of care. In addition, documentation must identify whether conditions are preexisting or developed during pregnancy.

Expanded Injury Codes: When treating injury, clinicians will now be required to document the precise injury site and type of injury. In addition, ICD-10 injury codes now distinguish between burn types (e.g. heat, electricity, radiation) and splits out abrasions, contusions, lacerations and puncture wounds.

Open Wound Coding: ICD-10 will require clinicians to document laterality distinctions and type of open wound, whether laceration or puncture wound (with or without foreign body), open bite or other unspecific wound type.

Fracture Codes: New specificity requirements for fractures will require physicians to identify whether fractures are displaced or not, open or closed, its laterality and whether treatment is active, subsequent or a sequela.

Traumatic Fractures: OMS documentation and coding requires specification of whether a fracture is traumatic or pathologic; traumatic fractures will need to specify the encounter type, while pathologic (non-traumatic) fractures will need to specify encounter type, site and laterality of the fracture and etiology of the fracture (e.g. osteoporosis, neoplastic disease, etc.).

Post-Procedural Disorders: Physicians will now have to clearly document if and when a new disorder or injury is triggered by or follows an in-facility procedure.
Alcohol & Drug Abuse: New documentation requirements for drug and alcohol abuse will clear up confusion related to patient conditions and underlying causes and includes effects, aspects and manifestations of drug and alcohol abuse.

Other Things to Remember: The proper sequencing of codes will require documentation of whether a condition is “due to” or “associated with” another condition in order to be properly coded. When using combination codes, clinicians may be required to note the reason for admission or treatment. All documented conditions should be identified as acute, chronic or recurrent acute.

Questions about a gap analysis?

Contact Jocelyn Gaddie, VP of Business Development, for a simple evaluation of where you stand in the transition and how to prepare for ICD-10 at 913-617-5088.

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