The new documentation requirements for ICD-10 have a focus on the specifics. Payers want as many in-depth details as possible for each claim so they can decide if they’ll make the reimbursement or if the financial responsibility can be shifted elsewhere. Clinical documentation is a critical element for clinician reimbursement.
The American Academy of Professional Coders (AAPC) estimates that only 37 percent of current clinician documentation provides enough detail to meet the stringent reporting requirements of ICD-10. Documentation will require more detailed information on topics that include the what, when, where and why of injuries, diseases and conditions.
Typical information about the client’s height, weight and vital signs will remain, but the details of an injury and surrounding circumstances are much more specific. In the previous example of the woman who suffered shoulder pain and headaches after an accident on a cruise ship, the following information will be required under ICD-10 coding.
- All external causes that led up to or contributed to the injury;
- The exact location of the injury on the patient’s body;
- The patient’s actions and activities at the time of the injury and after;
- Injury codes require a character extender to identify the type of encounter and if the patient sought medical attention;
- Data will be required to identify where the client sought medical treatment, any tests that were conducted and referrals that were made;
- The patient’s location when the injury took place or when the symptoms appeared is essential and ICD-10 provides data that narrows the location to a specific room, environment or mode of public transportation, including cruise ships;
- Applied specificity is required for any number of accidents and injuries to document the immediate symptoms experienced by the patient at the time of the incident, as well as ongoing symptoms, severity and frequency;
- Clinicians must indicate any methods the patient has used for pain relief or to alleviate the problem, from over the counter medications to hot and cold therapies;
- Documentation must identify if the pain or symptoms from the injury are chronic or acute;
- Any related complications encountered;
- The result of hands-on examination and any tests ordered;
- A detailed account of the treatment plan, including the symptoms that will be addressed and how.
Complete and detailed documentation is essential for reimbursements and Medicare requires clinicians to maintain records on all of a patient’s health and medical history both past and present. A number of variables must be documented that were not required under ICD-9 code sets.
Clinicians will need to exercise caution to ensure each item is thoroughly documented with the corresponding code. The new documentation requirements have a focus on the immediate complaint and no suspected diagnosis must enter the equation, only what can be clearly determined from the available information.