AAPC shares 6 steps for ICD-10 documentation strategy

Carl Natale
by Carl Natale

Calling clinical documentation one of the largest hurdles its constituency faces, the American Academy of Professional Coders (AAPC) this week offered up its advice on the matter. And ICD-10, at least initially, will bring its own clinical documentation challenges.

“ICD-10-CM takes code assignment to new levels of specificity requiring us to take a long look at our current documentation habits to see where we need to start making improvements,” explains Rhonda Buckholtz, AAPC's vice president of business and member development.

[Related: Top 3 understated aspects of ICD-10. See also: Is the ICD-10 deadline achievable?]

With that in mind, Buckholtz points out that a documentation audit is a good place to start, then lists 6 steps to do just that.

1 Run a practice management report that pulls your most frequently used diagnosis codes
2 Run a separate report that can pull patients with those diagnosis codes
3 Use this list to randomly pull charts to begin your documentation audit
4 Utilize the GEMS files to begin mapping your current ICD-9-CM code to an ICD-10-CM code selection. The AAPC has a Code Translator tool available for free.
5 Compare your documentation with the code to see if you have documented enough to assign a potential code; if not, begin to work on the documentation aspects moving forward
6 Over the next couple of years, revisit this process to make sure you continue to document with the specificity required
Buckholtz concludes in the article that “following these simple steps early on will help you reduce the overall burden of ICD-10 implementation as the compliance date of October 1, 2013 draws closer.”