As practices prepare for the October 1, 2014, transition to ICD-10, there’s been a good deal of discussion about the many new codes ICD-10 offers and how clinical documentation will be affected. Just as with ICD-9, complete documentation is essential for patient care and accurate selection of ICD-10 codes.

ICD-10 Captures Familiar Clinical Concepts

Concepts that are new to ICD-10 are not new to clinicians, who are already documenting a patient’s chart with more clinical information than an ICD-9 code can capture about:

• Initial Encounter, Subsequent Encounter, or Sequelae
• Acute or Chronic
• Right or Left
• Normal Healing, Delayed Healing, Nonunion, or Malunion

Many ICD-10 codes—more than one-third—are identical except for indicating laterality, or whether the right or left side of the body is affected. The advantage of ICD-10 codes is that they enable clinicians to capture laterality and other concepts in a standardized way that supports data exchange and interoperability for a more efficient health care system.

Verifying Your Documentation Is ICD-10-Ready

While ICD-10 should not require providers to change documentation practices, reviewing documentation will help you understand how ICD-10 will affect your practice. Understanding the scope of the ICD-10 transition will reduce the likelihood that you will overlook areas that need updates for ICD-10. Testing ICD­ 10, from documentation all the way through communication with billing services, is vital to making sure you have worked out any snags in the process before the October 1, 2014, transition date.
Take a look at documentation for the most often-used ICD-9 codes in your practice and work with coding staff to select the appropriate corresponding ICD-10 codes. Identifying these codes will help reinforce the information to highlight when documenting patient diagnoses for ICD-10.

Keep Up to Date on ICD-10

Visit the CMS ICD-10 website for the latest news and resources to help you
prepare for the October 1, 2014, deadline.