Posted in ICD-10 & Coding

ICD-10 complaints often really about documentation

Carl Natale
by Carl Natale
ICD-10 complaints often really about documentation

When physicians complain about ICD-10 coding, they're often complaining about the documentation and/or electronic health records (EHRs).

If medical practices tackle the complaints as a documentation problem, then ICD-10 burdens will be much more manageable.

Clinical documentation will have an immediate impact on factors such as:

  • Medical necessity
  • Denials
  • Quality indicators
  • Mortality risk
  • Accountable care

Like ICD-10 implementation, documentation isn't free. Especially if productivity is calculated. But medical practices can find quite a bit of revenue in being able to bill for every code that was previously missed.

Reimbursement is driven by medical necessity — which is shown by documenting the diagnoses that support the procedure. Medical practices can increase revenue by documenting everything their physicians diagnose. Otherwise healthcare payers can keep money that medical practices can earn with thorough medical claims.

This does not mean fraud or upcoding. This is about understanding what a medical practice is legally owed and submitting the actual medical codes for reimbursement. To know what diagnoses are available and to prove it isn't fraud, clinical documentation needs to reflect what is being billed.

Even if medical practices are not looking improve revenue through capturing more medical codes, they need proper clinical documentation to mitigate denials and suspended claims with requests for more information.

It's also worth remembering that improving clinical documentation is better for the patient. It captures diagnoses and treatments that will be referenced later. Not understanding what has been done in the past will have a direct impact on patient care.

Once these concerns are addressed, finding the proper ICD-10 codes for medical claims becomes much easier. ICD-10 compliance becomes a much smaller problem after clinical documentation improvement.