by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Nov 21st, 2014 - Reviewed/Updated Mar 1st
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. |
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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