ICD-10 is here – and Mary Bort, Director of Coding at Surgical Notes, MDP, LP, Regent RCM coding partner, weighs in and shares four coding tips to help ASCs succeed while putting new ICD-10 codes into practice.
- Up-to-date ICD-10 templates
To safeguard against claim rejection, verify that all of your templates (EMR’s, transcription, etc.) to confirm that they meet ICD-10 standards and comply with the specificity need for ICD-10 coding. While this step should have taken place prior to ICD-10 going live, it is critical to update existing templates to me the new documentation requirements. This includes the features available in custom template designs that can better fit each health care organization’s workflow.
- Clinical documentation
The highest specificity of documentation should be used with the implementation of ICD-10. This does not mean that health care providers need to have an increased amount of documentation, but rather that the documentation is more precise including anatomical site or location, laterality and episode of care.
- Unspecified codes
As part of the ICD-10 Official Guidelines for Coding and Reporting, all HIPAA-covered entities must comply, however unspecified codes are still available when documentation does not support a higher level of specificity. The unspecified codes often have necessary and acceptable uses. For example, when sufficient clinical information is not known or available about a health condition, and the coder is unable to assign a more specific code, it is acceptable to report the appropriate “unspecified” code.
- Flexibility with family of codes
Family of codes refers to the three characters of an ICD-10 code. These are codes within the same category that are clinically related but provide differences in capturing specific information on the type of condition. For example, Crohn’s disease is in the K50 family. To include a Crohn’s disease diagnosis on a claim, a valid code must be selected. As long as the selected valid code is within the K50 family, then the audit flexibility applies.
With the challenges presented by the rapidly changing health care market, including documentation and coding challenges related to ICD-10, partners like Regent RCM can provide customized solutions and streamlined processes. Click here to contact Regent RCM and connect with an RCM expert or click here to contact Surgical Notes for coding or transcription specific information.
Ed Tschan, Regent RCM Director of Business Development, firstname.lastname@example.org
Don Callender, Surgical Notes, Central Region Sales Director, DCallender@surgicalnotes.com