Get Ready! Improve your Clinical Documentation!

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
November 21st, 2014

It is time to start improving your clinical documentation to prepare your practice for ICD-10.

Select the codes most often used in your practice. Now, you need to determine if your current documentation is sufficient to support ICD-10. It would be best to assume it is not, since ICD-9 was not as specific as ICD-10. For example, you did not need to include laterality, now you must include which side of the body is affected (i.e. right, left, or bilateral).

Keep in mind a few of the examples below, and prepare your clinical notes to include the specific information needed to accurately code some common diagnoses:

Diabetes Mellitus:

Type of diabetes

Body system affected

Complication or manifestation

If type 2 diabetes, long-term insulin use

Fractures:

Site

Laterality

Type

Location

Injuries:

External cause –

Provide the cause of the injury; when meeting with patients, ask and document “how” the injury happened.

Place of occurrence –

Document where the patient was when the injury occurred; for example, include if the patient was at home, at work, in the car, etc.

Activity code –

Describe what the patient was doing at the time of the injury; for example, was he or she playing a sport or using a tool?

External cause status –

Indicate if the injury was related to military, work, or other.

Get Ready! Improve your Clinical Documentation!. (2014, November 21). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/get-ready-get-set-improve-your-clinical-documentation-2396.html

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