Clinical documentation needs of ICD-10

Clinical documentation is an integral part of health Information Management. The clinical documentation needs doesn’t end with diagnosis and treatment of patients. It is also needed for efficient medical claims processing. Clinical documentation remains the source for the coders to assign the exact diagnosis and procedure codes. Let’s explore more about the dependency on clinical documentation with ICD-10.

  • ICD-10 is an organized coding system that contains more than 150,000 specific ‘diagnosis and procedure codes’ for diseases. In ICD-10, due to its ‘specificity’, coding is much dependant on clinical documentation for medical billing reimbursements. So, the clinical documentation should capture all possible observations including even minute variations in procedure done for patients, which will be captured in coding through specific ICD-10 codes and the claims will get paid for the allotted amount for that procedure. Which means ‘better the clinical documentation; better will be coding and thus reimbursements’.
  • It’s essential to evaluate the current clinical documentation procedure of ICD-9 and explore the clinical documentation needs for ICD-10. This GAP analysis will enable better focus to clinical documentation. Claims that are sent on/after Oct01, 2013 will strongly depend on specificity of clinical documentation.
  • It is necessary to identify the introduction of new terminologies in clinical documentation and get the coders acquainted with the terminologies to get along with ICD-10 in a faster pace.
  • Consulting a ‘clinical documentation specialist’ or recruiting them can help a lot when you start with ICD-10.
  • When you work with clinical documentation, it is essential to decide on the point of communication – whom you will contact in case there are discrepancies in clinical documentation.
  • Improper documentation will not only lead to denials or low reimbursements, but also increase documentation queries and reworks resulting in increase of the medical billing cycle.
  • Consulting a ‘clinical documentation specialist’ or recruiting them can help a lot when you start with ICD-10.

Therefore, when implementing ICD-10, clinical documentation should also be given necessary attention so that it will not be a last minute surprise for you.