Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

July 2017

Careful Documentation Paves the Way for Accurate Coding Capture

It all begins with you and your patients – this fact did not change with the transition to ICD-10. However, with ICD-10, a higher level of specificity in your documentation is necessary in many instances, including documenting laterality to support proper assignment of ICD-10-CM/PCS codes. To help ensure claims are properly billed and appropriate benefits are applied, your documentation must paint a clear and complete picture of each patient’s condition with details to support subsequent diagnoses and treatment.

Quality of Care, Provider Profiles and Reimbursement
Careful documentation cannot be understated. It is important for auditing purposes because a patient’s health record helps demonstrate adherence to quality of care measures. Also, medical record data is used to help develop provider report cards and to demonstrate meaningful use of electronic health records. Provider profiles can be made public through online transparency or comparison tools, and potential patients may use this information when they choose where to go for care. Additionally, accurately capturing the severity of illness may ultimately affect case management index weighting and different forms of reimbursement.

Documentation Tools and Services
Clinical documentation improvement (CDI) tools and services are widely available. As part of the transition to ICD-10 coding, many providers implemented CDI programs. Regardless of whether your organization or office has implemented a specific program, there are some basic CDI principles you can use to support accurate ICD-10 coding:

  1. Lay the groundwork by outlining a complete history
  2. Go below the surface by highlighting potential red flags and risk factors
  3. Include progress notes to illustrate how the patient was monitored and evaluated
  4. Put the pieces together with details on why decisions were made
  5. Focus on teamwork between medical, coding and billing staff

This material is for educational purposes only and is not intended to be a definitive source for what codes should be used for submitting claims. Health care providers are instructed to submit claims using the most appropriate codes based upon the medical record documentation and coding guidelines and reference materials.