ICD-10 coding is only as good as the documentation

ICD-10 coding is only as good as the documentation

It's worth emphasizing that healthcare providers cannot code what has not been documented in the clinical notes or reports. Even when it means leaving money on the table.

Dave Pearson cites a study in the Journal of the American College of Radiology that found incorrectly coded ultrasounds were being reimbursed at a lower rate than they should have been.

The problem came from missing information in radiology reports from complete abdominal ultrasound exams. Because the information was missing, the exams were coded as limited.

But when custom report templates were created that prompted clinicians to document completely, reimbursements went back up.

This is not upcoding. This is coding that captures what is allowable and due the healthcare providers.

The study authors, Kristine Pysarenko, MD, Michael Recht, MD, and Danny Kim, MD, noted that "ICD-10 has made it harder than ever to ensure correct and accurate coding."

Perhaps some ICD-10 compliant electronic health records (EHRs) have made it harder to ensure complete documentation.