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. |
Quick, Current, Complete - www.findacode.com