Continue the process of assessing and training until documentation gaps are filled.
Next, initiate training to educate clinicians on ICD-10 documentation requirements a substantial amount of time prior to the transition so that they can have adequate time to prepare. Identify gaps that will need to be filled in order to ensure successful documentation under ICD-10. Assessment and training should be cyclic and ongoing processes.Ĭurrent documentation processes should also be assessed. Assessing the nature of missing documentation is essential. In addition physicians, coders and other relevant staff members must start training now if they haven’t begun already. It’s imperative that documentation gaps be filled starting immediately. Substantial changes in documentation are required to meet ICD-10 requirements. Episode of care – used to evaluate physician efficiency.Trimester of pregnancy – First, second or third.Stages of healing – Includes whether healing progress is being made.Laterality – Which side is related to the procedure or event.
Under ICD-10 to assign a code: the following information will be required for code assignment. Claims that are incomplete may preclude payment. Being unprepared for ICD-10 documentation requirements can substantially impact your bottom line. Coding is a primary requirement of billing revenue. Major implementation issues will arise during changeover. The specificity level for the new code is much greater than that of ICD-10 and filling in the missing information will be a challenge.
Preparing for the transition will be much easier when you take immediate action to improve your clinical documentation. October 2014 is the deadline for implementation of ICD-10 coding standards. How ICD-10 Affects Clinical Documentation