Manage ICD-10 implementation by focusing on productivity and accuracy
ICD-10-CM/PCS requires increased specificity in the clinical documentation to support that specificity in coding, says Bonnie S. Cassidy, MPA, FAHIMA, FHIMSS, RHIA, AHIMA-approved ICD-10 trainer, senior director of HIM innovation at Nuance Communications headquartered in Massachusetts.
"Providers don't need to provide 'more' clinical documentation, they need to provide clinical documentation that is required for ICD-10 coding," she says, such as laterality, specificity, and anatomic sites.
"Physicians need to understand that this more specific information needs to be included in their documentation, that the system is depending on their documentation," says Reid Conant, MD, FACEP, board-certified emergency physician and CMIO at Tri-City Emergency Medical Group in Oceanside, California. "It's not something the coder can add later."
CDI staff should be prepared to review some of the following known weaknesses in documentation, says Cassidy:
- Acute myocardial infarctions
- Asthma
- Cerebrovascular disease
- Comas
- Diabetes
- Fractures
- Orthopedics
- Pregnancy
- Pressure ulcers
- Respiratory failure