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By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor
Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT).
Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse, index to no codes at all, is that we lose the ability to track conditions.
Epidemiology is defined as the science that deals with the incidence, distribution, and control of disease in a population. There is so much information that the medical community gathers from epidemiological patterns. It is how we were clued in to AIDS (i.e., Kaposi’s sarcoma in a heretofore unusual patient population) and how we discover toxic waste cancer hot spots. It can give credibility to the need for new laws, like noting how texting while driving can contribute to motor vehicle collisions (Y93.C2 Activity, hand held interactive electronic device).
Article originally published on June 5, 2018 by ICD10 Monitor.