HCPro, JustCoding Outpatient - 2015 Issue 48 (December)
Identify post-ICD-10 coding and documentation risks
December 23rd, 2015
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Article Overview
This article discusses post-implementation coding and documentation risk areas that CMS and third-party payers have flagged in the ICD-10 environment. It is aimed at coders, billers, compliance staff, providers, and CDI teams who need to review record authentication, documentation specificity, diagnosis consistency, chronic disease tracking, diabetes documentation, and treatment-plan support. The article also references CMS guidance and ICD-10-CM guideline topics that inform internal audits and documentation review processes.
Why This Topic Matters
These risk areas can affect claim accuracy, audit exposure, and the completeness of the medical record. The article helps readers understand which documentation and coding practices warrant closer review during ICD-10-related compliance checks.
Article Sections
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Introduction
Introduces the post-ICD-10 risk areas identified by CMS and payers and frames the article’s focus on documentation review and audit readiness.
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Signature and record authentication risks
Covers medical record authentication concerns, including handwritten, electronic, and alternate signature processes, along with related review considerations.
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Electronic health record authentication
Discusses risks tied to electronic record signing, time/date stamping, and user accountability within EHR systems.
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ICD-10-CM specificity and unspecified code use
Addresses documentation and coding review considerations related to diagnosis specificity and guideline-based use of unspecified or symptom-based coding concepts.
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Diagnosis discrepancies between the claim and the record
Reviews the risk created when billed diagnoses do not match the medical record and describes general audit and correction concerns.
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Chronic and acute condition documentation
Focuses on how chronic and acute conditions should be clearly identified and supported in the medical record for accurate coding and later care.
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Ongoing chronic condition review
Discusses annual or recurring review of chronic conditions and the need for accessible documentation that shows ongoing monitoring.
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Diabetes documentation
Covers documentation concerns related to diabetes classification, specificity, affected body systems, and related ICD-10-CM category organization.
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Monitoring, evaluation, assessment, and treatment documentation
Explains documentation expectations for treatment plans, reassessment, coordination of care, and support for billed services.
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Conclusion
Summarizes the general importance of communication, education, and compliance-focused improvement in medical records and billing workflows.
What You Will Learn
- Which post-ICD-10 documentation areas are commonly reviewed for compliance risk
- How record authentication and signature issues are evaluated at a high level
- What types of diagnosis documentation gaps can create claim and audit concerns
- Why chronic condition and diabetes documentation receive special attention
- How treatment-plan documentation supports coding and billing review processes
Who Should Read This
- Medical coders
- Medical billers
- Compliance professionals
- Clinical documentation improvement staff
- Physicians and other providers
- Practice managers
- Hospital coding and billing teams
Codes Discussed
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