The Department of Health and Human Services recently issued a Final Rule officially resetting the ICD-10 effective date as October 1, 2015. As this revised implementation date approaches, the ability for providers to maintain comprehensive documentation will play an essential role in ensuring the proper selection of accurate diagnosis and procedure codes and, consequently, the successful billing of claims and prompt receipt of payment for those claims. To this end, below are a few quick tips that will help you improve your clinical documentation:
• Medical decision-making is the driving force behind assignment of proper E/M (Evaluation and Management) codes. Ordering and reviewing tests and summarizing old records will help support the proper selection of an E/M code.
• Legibility of documentation is very important as office staff, billers, coders and insurance companies alike must be able to read all of the documentation that is provided. The inability to read a note may cause a delay with all parties involved.
• Specificity throughout the chart is critical. With ICD-10, unspecified codes are not permitted, which is not the case with ICD-9. Accurate code selection will result in the proper payment.
• When documenting in the chart, it is helpful to know that three are more chronic conditions are necessary to complete the HPI (History of Present Illness).
The tips given above are intended to help you improve your clinical documentation in advance of the new ICD-10 implementation date. If you have questions or concerns regarding your documentation, please contact Precision at 314-565-0091 or online at www.precisionpractice.com.