Why ICD-10 is not Just About the Codes

“Why ICD-10 is not just a coding project” is an article over at EHR Intelligence that makes a good point about how the transition to ICD-10 is not just about the new coding system, it’s more about being able to properly document encounters…

Excerpt:

“If you think ICD-10 is all about new codes, you are dead wrong. ICD-10 is really about “documentation” ─ we clinicians have learned from day one that, “If it’s not documented, it wasn’t done.” This situation is even truer in the ICD-10 world, where the coder must build the ICD-10 code based on the presenting story of that patient’s visit from admissions to discharge. With all the new code options, you never know what code will be built.

Case in point: The ED physician sees and diagnoses the patient with head and chest contusions and a fractured femur caused by a motor vehicle accident (MVA). The hospital admits the patient. The nurse, who documents the patient history assessment, discovers the patient hit the vehicle in front of her on a busy residential street. The therapist teaching the patient how to crutch walk discovers new information that the patient was driving home after a fight with her in-laws and was texting when the accident occurred. The entire story is now documented fully and ready for coding to add to the claim’s reimbursement.”

Diane discusses how real-time documentation will be an important aspect of ICD-10 and I couldn’t agree more. Having the documentation consistently updated will give all care givers dealing with a patient access to the real-time information about that patient, making their care more understandable and manageable at any time during the stay.

Authored by: Diane Taylor, RN-BC on EHR Intelligence

Read the full original article