ICD-10 prep: Dig into documentation

With all of the attention around the increased specificity of ICD-10-CM codes, facilities are concerned that documentation will lack sufficient detail. And as CDI specialists know, physicians don’t always provide enough information for coders to choose the most specific ICD-9-CM code.

Instead of panicking, determine which conditions the providers most often treat, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. Then evaluate the documentation to see what additional information providers will need to document with the added specificity for ICD-10-CM.