Complete clinical documentation can boost ICD-10 productivity

Carl Natale
by Carl Natale
Complete clinical documentation can boost ICD-10 productivity

Complete clinical documentation is going to save physicians time in the long run. It cuts down on the need for queries and readily supports diagnoses if there are any questions from healthcare payers or audits.

Susan Dooley lists the elements of proper clinical documentation:

  • "Condition"
  • "Onset"
  • "Etiology"
  • "Laterality"
  • Severity
  • Environment
  • Timing
  • "Healing status"

Here's a round up of recent articles and posts on how to code diagnoses and procedures in ICD-10:

This is a weekly feature that I use to highlight practical tips on how to use and understand ICD-10-CM/PCS codes. Please let me know of any other sources that I can include.