Preparing Your Documentation for ICD-10-CM: The Countdown is On!

  Editor’s Note: Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. Providers, suppliers, and manufacturers are responsible for case-by-case assessment, documentation, and justification of medical necessity. The author does not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader. To view “ICD-10-CM Diagnosis Coding Documentation Tips for Wound Care Infectious Diseases (A00-B99),” the first in the ICD-10-CM documentation tools series, visit https://www.todayswoundclinic.com/files/TWC_October2013_ICD-10Supplement.pdf   The arrival of ICD-10-CM is on the horizon, and it will soon be essential for all wound care practitioners to refine their documentation skills in preparation for the new coding format. To that end, there’s a lot of education to consider prior to the implementation deadline of Oct. 1, 2014. In an effort to assist our readers as they transition from ICD-9-CM, Today’s Wound Clinic will feature an assortment of ICD-10-CM documentation tools on particular disease states or conditions that have been developed to help improve one’s documentation habits, which will be vital to the success of wound clinics in the ICD-10-CM environment. The tools may also contain information on coding guidelines where appropriate. Do not delay in absorbing the materials that will be published over the course of the next year, as there will be an assortment and wealth of information to process as wound care providers move closer to the launch of ICD-10-CM. New topics will be covered in successive issues of TWC, and each topic will feature documentation tools designed as keepsakes that can be promoted/circulated to fellow staff members and colleagues. Topics have been selected by the author as key terms for review that may or may not be high-volume diagnoses in one’s respective facility, but are universal in nature.   NOTE: All efforts put into improving one’s documentation will assist the wound care center to have very granular, detailed coding under ICD-10-CM. The better the documentation and specificity of one’s codes, the better the subsequent data will be. In addition, these diagnosis codes are also used to document medical necessity for proper payments in the wound center. The data will assist with research, quality-improvement reporting, identifying trends and patterns in patient populations, and volume statistics.

Utilizing Documentation Tools

  For each documentation tool provided, the reader will need to conduct the following process for implementation:     1. Formulate a multidisciplinary team to review record documentation.     2. Run a diagnosis report to find records containing the particular documentation topic. (You may need to consult your coders/billers to assist in running the reports.)     3. Take a random sampling of the charts identified.     4. Audit the records selected for comprehensive documentation utilizing the new key terms provided in the documentation tool.     5. Identify any trends or patterns during the review (ie, all practitioners documenting incorrectly, identify most commonly used phrases for that particular diagnosis, etc.)     6. Utilize the services of a physician champion for one’s wound care program and prepare an in-service education program for practitioners who document in the outpatient record. (The documentation tool will serve as a guide of topics to cover with practitioners.)     7. Approximately 1 month after the in-service program, audit current records to see if the new documentation key terms have been retained by the learners.     8. Repeat in-services for those who are still having difficulty with the documentation key terms.     9. Celebrate successful changes in documentation habits and communicate them to the team and management (eg, expectation: 100% compliance with documentation requirements).   Refer to this introductory article in order to effectively follow the steps toward documentation change. Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She’s approved as a certified trainer on ICD-10-CM by the American Health Information Management Association and has been designated as a fellow of the American Health Information Management Association. She is also member of the Association for the Advancement of Wound Care and was named Woman of the Year in Healthcare 2012-13 by the National Association of Professional Women. She may be reached at 609-936-2265 or donna.cartwright@integralife.com.