As ICD-10 approaches, physician practices, ambulatory surgery centers and hospitals are working feverishly to meet the October 1, 2014 deadline. The majority of effort right now is focused on understanding the transition from coding in ICD-9 to ICD-10. This is imperative to be certain payers are reimbursing correctly for medical services rendered.
However, the foundation for the proper reimbursement in an “ICD-10 World” is detailed clinical documentation. Without the correct capture of clinical information by the clinician, any claim for reimbursement could be in jeopardy. Keep in mind the many different aspects that you will need in order for the medical coders to assign the correct ICD-10 codes.
These variables for ICD-10 include:
- Type of encounter (initial or subsequent)
- Applied specificity (did the patient lose consciousness?)
- Acute versus chronic
- Relief or non-relief (intractable versus non-intractable)
- External cause (what caused the accident?)
- Activity (what was the patient doing when she was injured?)
- Location (where was the patient when she was injured?)
If you have not heard of any upcoming meetings on ICD-10, make sure you contact your medical billing resource in order to find out more. You may also want to seek out education opportunities that may provide you with continuing education units. Knowing the increased documentation requirements for ICD-10 will not only help your claims get paid, it will also help you become the best practitioner you can be.