General Surgery Coding Alert - 2017 Issue 11
You Be the Coder: 3 Tips for Revising Documentation Templates Quickly
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Article Overview
This article focuses on how CDI-oriented documentation templates can be updated to support more accurate ICD-10 coding in outpatient surgical environments. It is aimed at coding and administrative professionals who want to understand broad template-revision strategies, documentation completeness issues, and denial monitoring considerations tied to ICD-10 implementation.
Why This Topic Matters
Template design affects whether clinicians capture the documentation needed for accurate code selection and claim processing. The article is relevant for organizations reviewing workflow, documentation quality, and denial trends in response to ICD-10 specificity requirements.
Article Sections
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Question
Introduces the need to revise documentation templates in response to ICD-10-era coding and documentation requirements.
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Answer
Summarizes the overall purpose of well-designed templates and introduces an example involving greater documentation specificity in a breast-related code family.
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Template revision strategies
Presents three broad approaches for improving documentation templates, including using reporting tools, avoiding vague template choices, and monitoring denial trends.
What You Will Learn
- How documentation templates support ICD-10-oriented CDI efforts
- Why specificity in clinical documentation affects outpatient coding workflows
- How reporting and denial monitoring can inform template revision priorities
- General considerations for template design in ambulatory surgery and hospital outpatient settings
Who Should Read This
- Coders
- CDI professionals
- HOPD administrators
- ASC administrators
- Revenue cycle staff
- Physician practice administrators
Codes Discussed
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