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ICD-10: First Step is Improved Medical Documentation

July 21, 2015

ICD-10: First Step is Improved Medical DocumentationKnowledge is power in American healthcare, and the better caregivers are at spreading knowledge, the higher the standard of care. The new ICD-10 regulations have the potential to streamline healthcare through improved patient encounter recording, but only if hospitals and caregivers implement it properly.

ICD-10 and Patient Encounters

ICD-10 is the latest update to the UN’s International Classification of Disease system. Set to go into effect in the United States on October 1st of this year, it improves upon the ICD-9 code to better reflect the differences in patient encounters. Whereas the ICD-9 code had between 3 and 5 digits, ICD-10 has up to 7. The seventh digit indicates the type of patient encounter. The following digits represent different encounters with injured patients:

  • A– Doctor’s initial meeting with a patient
  • D– Subsequent meeting with a patient to inspect a fracture that is undergoing routine healing
  • G– A doctor’s subsequent meeting with a patient to inspect a fracture that is undergoing delayed healing
  • S– Finally, doctor’s meeting to discuss a sequela, which occurs when an acute fracture becomes a chronic condition

Besides these general changes in code structure, the ICD-10 code also requires doctors to record their patients’ conditions in greater detail. For example, whereas ICD-9 had a single code for acne, ICD-10 divides the condition into infantile acne, acne vulgaris, acne tropica, and 5 other variations. Similarly, ICD-10 has codes for 200 variations in diabetes mellitus, as opposed to ICD-9’s 59, to better reflect differences in blood sugar management.

Medical Documentation Demand will increase with ICD-10

If applied consistently, these changes in patient encounter documentation will make the healthcare system more efficient. At present, doctors and nurses do not always use the same labels or emphasize the same information in their medical reports, making it difficult for one caregiver to refer a patient to another. The new protocols will ensure that all caregivers use the same terminology to record patient encounters and include the same information. This will improve communication and raise the standard of care. Hospitals and clinics are encouraged to focus on the patient encounter protocols before moving on to other parts of ICD-10, as Medicare and Medicaid will only reimburse hospitals that record patient encounters correctly.

The Challenges of Changing Medical Documentation

Despite the many benefits of the ICD-10 protocols, many caregivers and clinics are hesitant to change the way they record patient encounters. Whereas ICD-9 had only 14,000 codes, ICD-10 has 68,000. Physicians and nurses will have to learn how to document all of these new codes. Many hospitals and clinics claim that training them to do this will disrupt ordinary healthcare operations, increasing costs and making patients wait for care. Meanwhile, many hospitals and clinics would rather focus on other improvements, such as instituting value-based reimbursement or improving physician quality ratings.

The government’s uncertainty over the ICD-10 deadline has only further exacerbated caregivers’ unwillingness to adopt the new protocols on time. Although Congress has required care providers to adopt ICD-10 by October 1st of this year, many lawmakers have considered extending the deadline. The American Medical Association and the Medical Society of the State of New York have lobbied Congress to extend the deadline to October of 2017. Although Congressional leaders have insisted that they will not change the dates, they have already made some concessions to their lobbyists. Notably, they have allowed Medicare Part B to reimburse physicians for incorrect claims during the first year after the deadline. This has convinced many doctors that the deadlines are not set in stone and that they can continue to delay patient encounter updates without consequence.

Click the link below to join our webinar to learn more about how you can implement ICD-10 action plan for your practice. Please note only first 100 registrations are free after that its $299 per participant!



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