Guest Post: Upgrade documentation systems for ICD-10-CM now

Carl Natale
by Carl Natale

The time to start documenting for ICD-10-CM is now.

Even though the implementation deadline was recently pushed back by a year, it’s important not to lose any urgency around this issue. While HHS cannot require ICD-10 until October 2015, clinicians can and should begin documenting in such a way that supports ICD-10 now. Not all documentation systems will be prepared for the level of detail required by ICD-10, so it’s important to find the right documentation system and upgrade now.

Why begin documenting for ICD-10 now

1. ICD-10 is beneficial to patient care.

A common argument is that ICD-10 has nothing to do with patient care. I disagree (and so does the American College of Emergency Physicians among others). ICD-10-CM will provide valuable, in-depth information that can be compiled and used in a significant way after face-to-face encounters. Documenting with ICD-10 standards helps track accident prevention, justify medical necessity and more. Why delay something that can begin now, especially when it can benefit patient care?

2. ICD-10-ready systems help eliminate poor documentation.

Great documentation today supports ICD-10 coding tomorrow. The detail required to generate ICD-10 codes essentially eliminates some of the main causes of poor documentation. Many physicians are concerned about the extra work that they think will be required to document for ICD-10. However, the right system will remove the burden from the physician and seamlessly integrate the required level of specificity into their existing workflow through robust clinical content and interactive feedback on appropriate levels of documentation.

3. ICD-10 standards can help in the court of law and more.

Current documentation standards pale in comparison to ICD-10-specific documentation. It’s important to keep in mind that physicians are not the only ones who will review the patient record. Physicians can be called to testify in the court of law and by the time they take the witness stand, it has usually been months since their encounter with the patient. Highly specific documentation is critical in these circumstances. In addition, future Meaningful Use standards will give patients increasing access to their medical records, and these records will need to be complete and accurate.

Still rooting for ICD-10

From the beginning, I have been an ICD-10 optimist, as you can see in one of my previous articles: “ICD-10-CM from an optimistic coder’s perspective.” The value ICD-10 carries for providers and patients needs strong consideration and preparation. I propose that we take advantage of this extra time and begin or continue improving documentation efforts now.

Elizabeth Morgenroth, CPC, Revenue Cycle Business Analyst at T-System Inc., has 16 years of healthcare experience in the payer, provider and vendor areas of service. While with Blue Cross and Blue Shield of Kansas, she provided coding assistance to all professional specialties statewide. Morgenroth was responsible and integral to the entire revenue cycle process for a family practice in Lawrence, Kansas with four physicians and five physician assistants. While working for Clinical Coding Solutions, she performed professional and facility coding for nearly all specialties. In her current position, she is responsible for encoder tool development and ICD-10 readiness for T-System revenue cycle solutions. Morgenroth attended the American Health Information Management Association (AHIMA) Academy for ICD-10-CM and ICD-10-PCS and is an AHIMA Approved ICD-10-CM and ICD-10-PCS Trainer.