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:
Type of diabetes
Body system affected
Complication or manifestation
If type 2 diabetes, long-term insulin use
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.