In today’s health care world, words like quality, efficiency and better outcomes are becoming attached to virtually every aspect of the clinical delivery of health care. I think we should also begin applying them to the clinician’s approach to documentation which is the foundation for medical coding.
The transition from ICD-9 to ICD-10 coding requirements that went into effect in October was significant for the medical coding community. Just to give you an idea of the breadth of change for the coders, there are approximately 70,000 codes in the new system, almost five times as many as ICD-9. Not only is this a significant increase in number, it’s a significant change in required clinical documentation to transition smoothly.
For hospital revenue streams, the need for accuracy in medical coding is critical. A recent Healthcare Finance story about the ICD-10 transition noted that the true impact may not be felt early in the transition due to “the initial leeway granted by CMS and private payers.” While the percentage of claims being rejected due to coding issues remains small for now, it’s only a matter of time before coding errors or omissions lead to delays, denials and the potential for millions in lost revenue.
This is where those three words I noted earlier should be applied. The “efficiency” and “quality” of clinical documentation directly impact “outcomes.”
Your role as a clinician in ICD-10
Documentation is one thing, detailed documentation is something else.
With the changes in the ICD-10 requirements, there is a great deal more specificity needed when coding a procedure or diagnosis. As an example, in ICD-9 there was a single code for a total hip replacement. The coding in ICD-10 is much more specific. The coder must specify: a right or left total hip; define the product used, for example: ceramic on poly, metal on poly or metal on metal; and describe whether it is cemented or non-cemented.
I have found that documenting as the product is labeled by the manufacturer on the product packaging is good practice. It is the most accurate and I recommend it be considered as the standard utilized by the clinical staff.
Detailed documentation delivers other benefits as well. Consider for a moment if the patient needs to have a revision or additional procedure in the future. Having all of the specific information makes it much easier for those planning the care for the patient. Having an understanding of what is needed by the coder will assist others in health care positions to document in such a way that it will provide what is needed for the coding of diagnosis, services provided and implanted products utilized.
Clearly, I’ve only scratched the surface of the ICD-10 conversation, but the work that is done by the clinician in the OR allows the medical coder to more easily do their job, which in turn leads to efficient, quality coding and ultimately better revenue outcome. I’m asking you to remember that the medical coder is on the same patient care team you are. Even though they may not give direct care and do not work beside you in the hospital, what you do in regards to your documentation, however, has a downstream impact including your organization’s bottom line.
