(What’s Going to be Toughest to Learn – External Causes)
Remembering some of the changes that will take place as a result of the transition to ICD-10 will come quickly, but documentation requirements are a major issue for clinicians. The greater specificity of the ICD-10 codes allows for greater accuracy, but it increases clinician documentation requirements by 15 percent.
Some of the differences include codes that include place holders on documentation forms for future needs. In the current healthcare climate, payers will want to know if another entity may be responsible for paying the costs. They’re going to examine each claim closer, making it essential that clinicians are as specific as possible. It’s estimated that 65 percent of a practitioner’s notes won’t be specific enough.
One of the most difficult facets of the new codes is the way documentation is divided. There are four parts and external injury will cause the most frustration and be the hardest to remember. The external causes portion of the documentation should be a primary focus for practitioners. New documentation requirements want very exact information about the external causes of where and how an injury took place.
General Equivalency Mapping (GEM) was created by the National Center for Health Statistics to make the documentation task easier, but the system isn’t perfect. GEM is linked to all the various code alternatives for a given instance, and a single search can return as many as 2,500 responses. Other times, a compound word search will turn up nothing, while a single word will result in what the clinician wants.
GEM displays approximate matches and combinations through an alphabetic list first and then to a tabular listing from there. Practitioners will always want to wind up at the tabular section. There is always the “Not Elsewhere Classifiable” or “Not Otherwise Specified” category, but many clinicians anticipate problems with payers if either designation is used, considering the push for greater specificity.
Many payers are under the assumption that the implementation of ICD-10 codes automatically means that there’s a specific and corresponding code for every patient issue. This isn’t the case and there will be times when those two designations will be the only available options to use.
Disease classifications and categories have received some restructuring and classification of some conditions is different from what clinicians have become accustomed. Injury groups are now classified by specific locations on the body. Practitioners will find that some diseases that were lumped together now have their own separate chapters.
Clinicians should always endeavor to code at the highest level of specificity and detail, but avoid coding for a probable or suspected diagnosis. Coding should only be completed for all the symptoms that can be documented. Acute conditions should be listed before chronic issues if both exist. In some instances, a bilateral code doesn’t exist in which case clinicians will be required to do this separately.