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The Challenge of Thorough Documentation: What You Need to Know and How to Cope

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dont-judge-a-book-by-its-cover-written-on-a-blackboardThe transition from ICD-9 to ICD-10 certainly appears daunting, but appearances can be deceiving. How big a challenge is it, really?

Understand the landscape

Yes, the number of codes increased from ICD-9’s 14,000 codes to the 68,000 codes of ICD-10. Despite the fact that the nearly five-fold increase also requires more specific documentation than many doctors have been accustomed to, in most cases the change is not as drastic as it seems at first glance.

For starters, the vast majority of codes require no more documentation than previously required for physicians to enter for the old codes. According to the American Health Information Management Association (AHIMA), 78 percent of ICD-9 codes map “one-to-one” with an ICD-10 code, either exactly or approximately.

From there, of the ICD-10 codes that do not have ICD-9 counterparts, almost half are related to laterality (left, right and bilateral indications), AHIMA reassures us. Additionally, another large portion of ICD-10 codes consist of external cause reporting codes, such as what caused a particular injury. And, while these have been the cause for some ridicule, the Center for Medicare & Medicaid Services does not require providers to use these codes. (Though, keep in mind that some states mandate certain ones, so be sure to know your local requirements.)

Coding varies quite a bit when it comes to specialists, according to the AHIMA. There are significant differences among specialties in terms of numbers of new codes physicians and coders have to deal with. Because of the expansion of injury and musculoskeletal codes, for example, orthopedic doctors are seeing a lot more new codes. However, endocrinologists and urologists already had very small portions of the codebook, so their changes will be less than those of primary care physicians, who use a large variety of diagnoses.

Also, many of the new codes that require documentation are those related to linked conditions such as hypertension and heart disease, as well as newer diseases like Ebola and musculoskeletal conditions such as bone fractures.

Get training

It’s never to late to hone your skills. Even though ICD-10 is in full effect, most physicians could stand to become more familiar with the coding and documentation process—especially from the perspective of their specialty and practice setting. Smaller practices will have their own unique set of concerns and issues versus doctors who are part of a health-care system with multispecialty groups.

Specialty societies offer a wealth of information on their websites; keep an eye out for physician-specific training sessions, which can be either peer-to-peer or conducted by other clinicians such as nurse practitioners.

A tremendous amount of overview materials is still out there from the initial transition—it’s never a bad idea to brush up on the fundamentals. CMS, AHIMA and the American Medical Association, among other organizations, offer many resources on their websites. AHIMA, particularly, offers some coding briefs for physicians and also provides free, downloadable tip sheets on documenting 74 different conditions for ICD-10. Other free resources are available from hospitals and physician organizations, as well as trade publications.

Additionally, some consulting firms offer peer-to-peer educational sessions, and though these might be too expensive for small practices, some third-party vendors also offer training modules and simulators at more affordable prices. Though it’s not always a good idea to rely on EHR vendors for training, many doctors are successfully collaborating with them for assistance.