Increased Documentation Requirements and ICD-10: What You Need To Know

By Sebastian Mitchell for Medical Practice Trends

There are many daily chores to being a good physician. Patient care, nursing staff issues, medical decision making, patient paper work and referrals, constant prescription refills requests; the list goes on and on. This list goes on even longer if you run your own private practice, to which you would add all of the countless headaches of practice management.

Patient charting is one of those crucial daily tasks, which cannot be overlooked, and which you must complete to the best of your ability, all the while seeing other patients, and dealing with all of your other responsibilities in the office. Come October 1, 2013, this specific responsibility will become even more problematic.

On October 1, 2013, the International Classification of Diseases system (ICD, currently in its 9th revision) will be updated to the most current system, ICD-10. While this is mainly a problem for medical billers and coders, it will also affect the way you perform as a doctor. The ICD-9 system is the set of codes that the entire medical industry uses to indicate patient diagnosis, condition, or other reason for a visit to the doctor or healthcare facility. Although some of the codes are updated every year, the entire ICD-9 system has not been completely redesigned for at least a decade.

This has led to the development of the newest revision of ICD codes, the 10th edition, which is already in use throughout Europe. This new edition contains thousands more new codes than ICD-9, and allows for some of the most precise diagnoses to be indicated with a specific set of numbers and letters. Again, assigning these codes and sending them to insurance will be the job of medical billers and coders, but as a physician, you will be required to change the way you document that majority of your patient charts.

ICD-10 is implementing new documentation requirements, in order to support the specificity needed for the new codes. The type of additional documentation needed will depend on the types of patient visit, so you will not have to write a two-page patient visit note for each and every patient visit.

For example, if your patient comes into the office with a sore throat and you do a simple exam, palpate the throat, have the nursing staff perform a strep swab, which turns out positive, and diagnose the patient with strep throat, your regular documentation will suffice. This is because there are not many more specific details needed in order to determine that the patient actually has strep throat.

If the patient visit is more complex, your documentation will also have to be much more complex, containing details that the medical coders will need in order to assign the correct diagnosis code per ICD-10. For example, your patient is a middle-aged woman who was cooking in her kitchen, when a cabinet fell off the wall and hit her in the head, causing a concussion and intractable headaches. Because of the many variables in this scenario, your documentation must be as specific as possible, keeping in mind the many different aspects that you will need in order for the medical coders to assign the correct ICD-10 codes.

These variables include:

  • Type of encounter (initial or subsequent)
  • Applied specificity (did the patient lose consciousness?)
  • Acute versus chronic
  • Relief or non-relief (intractable versus non-intractable)
  • External cause (what caused the accident?)
  • Activity (what was the patient doing when she was injured?)
  • Location (where was the patient when she was injured?)

Believe it or not, all of these factors must be documented in order to accurately code the entire claim. These are not all of the necessary factors, however, and different patient visits will require different types of documentation. What this does mean is that if your documentation does not include all of the different necessary aspects, your claims will not be going out correctly, which will end up affecting the bottom line for your practice.

Whether or not you own your own practice, work for a facility, or work as a locums doctor, you will have to know all of the increased documentation requirements when ICD-10 is implemented on October 1, 2013. This may seem like a long time away, but if you don’t begin now, there will be a very steep learning curve by the time October 2013 rolls around.

Your practice, office, or facility should already be making preparations for the transition to ICD-10, as some other requirements are already taking effect. This includes provider education. If you have not heard of any upcoming meetings on the topic, make sure you contact your medical billing or coding department in order to find out more. You may also want to seek out education opportunities that may provide you with continuing education units. Knowing the increased documentation requirements will not only help your claims get paid, it will also help you become the best practitioner you can be.

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