The transition from ICD-9 coding to ICD-10 coding has many physicians wondering if their CCHIT certified electronic health record (EHR) software or electronic medical record (EMR) software is ICD-10 compliant. Fortunately, many vendors are prepared to offer EHR solutions that are compatible with the high degree of specificity required by the ICD-10 coding system. Here are a few tips to help you to determine if your EHR solution is ICD-10 compliant:
EHR and ICD-10
Mandatory use of ICD-10 will be required by October 2014. The new coding system demands a more robust system that can handle complex documentation. Selecting electronic health records (EHRs) and electronic medical records (EMR) to address the problem ensures that data can be manipulated easily without limitation.
Is EHR Able to Handle Comprehensive Documentation?
ICD-10 codes are more detailed and descriptive for more accurate billing and forecasting. Experts predict this will help physicians capture better data to provide a more comprehensive view of healthcare on a local and global scale. Since not all EHR applications are created equal, it is essential to assess the ability of the EHR to capture and manage complex data structures.
Here are some essential components of EHR:
Most EHRs can handle complex data definitions. Robust database solutions are required to maintain and retrieve data definitions.
The discharge summary should provide a complete view of the patient’s condition at the beginning of treatment. Data from tests, procedures and examinations must be captured and stored. The discharge summary is a part of a comprehensive solution.
EHRs should have the capability to capture data related to procedures during a hospital stay including: diagnosis prior to the procedure, procedure performed, description of the procedure and the name of the attending physician or assistant.
History and Physical (H&P)
This two-part medical report provides documentation of the patient’s past history. This is just one component of comprehensive data collection. The information gathered can be used to determine the patient’s initial treatment plan.
The consultation report is another type of data that should be captured and stored in EHRs. The tool must capture information about the patient’s medical record and also any recommendations from the consultant.
If More Documentation Needed Then is Transcription Still Relevant?
Transcription has evolved and does not resemble transcription of the past. Transcription continues to be relevant, but the method of transcription has changed. Voice recognition technology allows physicians to create narrative reports with three different options for document editing. These options consist of: medical editor modification using speech recognition, schedule self-editing and physician real-time self-editing.
Transcription has evolved to include the “once-and-done” approach. Physicians capture the data once at the point of care to make the process more streamline. In the midst of the transition, many physicians are using the blended approach which is a mix of text transcription and voice recognition transcription. The blended approach aids in the transition to ICD-10 codes.
In the meantime, physicians must ensure that their new ICD-10 software is compliant and supports voice recognition software. The new process can only streamline processes and make processes more efficient. New technologies incorporate the use of dictation templates to facilitate efficient reporting.
Some physicians are resistant to change and are avoiding the transition from ICD-9 to ICD-10. They are confused about the benefits of the ICD-10 as this article is correctly highlighting- http://www.fortherecordmag.com/archives/061812p29.shtml. The lack of knowledge leads to inferior EHR systems that deliver imperfect health information. Physicians can ease the ICD-10 implementation with an efficient EHR that will help providers select the best code to describe the patient’s medical condition.
Maintaining Compliance is Essential to Success
Physicians must ensure they are in compliance with the electronic discovery rule and maintain guidelines for EHR documentation. Maintaining compliance makes audits easier and more efficient. EHRs must be evaluated to select software that is both compliant and comprehensive.