Careful Documentation Paves the Way for Accurate Coding Capture

It all begins with you and your patient . This fact did not change with the transition to ICD-10. However, with ICD-10, a higher level of specificity in your documentation is necessary in many instances – such as documenting laterality – to support proper assignment of ICD-10-CM/PCS codes. To help ensure that claims are properly billed and appropriate benefits are applied, your documentation must paint a clear and complete picture of each patient's condition with details to support subsequent diagnoses and treatment.

Careful documentation is also important for auditing purposes, as the patient's health record helps demonstrate adherence to quality of care measures. Medical record data is used to help develop provider report cards and to demonstrate meaningful use in electronic health records. Provider profiles may be made publicly available through online transparency or comparison tools, and potential patients may use this information when they are choosing where to go for care. Additionally, accurately capturing the severity of illness may ultimately affect case management index weighting and different forms of reimbursement.

Clinical documentation improvement tools and services are widely available. As part of the transition to ICD-10 coding, many providers have implemented clinical documentation improvement (CDI) programs. Regardless of whether your organization or office has implemented a specific program, there are some basic CDI principles you can use to help support accurate ICD-10 coding on your claims:

1. Lay the groundwork by outlining a complete history
2. Go below the surface by highlighting potential red flags and risk factors
3. Include progress notes to illustrate how the patient was monitored and evaluated
4. Put the pieces together with details on why decisions were made
5. Focus on teamwork between medical, coding and billing staff

For a quick overview of the importance of documentation and coding capture, we invite you to view our short video  which also includes a link to helpful information on our Provider website.

This material is for educational purposes only and is not intended to be a definitive source for what codes should be used for submitting claims. Health care providers are instructed to submit claims using the most appropriate codes based upon the medical record documentation and coding guidelines and reference materials.