ICD-10 is about documentation, not coding

It is no secret that physicians have a lot on their plates in 2014. Not only will doctors who are participating in the Centers for Medicare and Medicaid Services' meaningful use incentives program have to go through the steps in stage 2 this year, but they will also have to convert to the ICD-10 coding system. However, it is important that even if physicians get frustrated with everything that lies ahead this year, they do not lose sight of why these changes are important. 

For example, EHRIntelligence recently published an article by Diane Taylor, R.N.-B.C., a delivery manager at CTG Health Solutions, who explained that providers who are simply thinking of the ICD-10 switch as being all about new codes are incorrect. She explained that in reality, it is about documentation – something that doctors should consider very important, since within the medical community, "if it is not documented it was not done." With ICD-10, documentation will be more detailed than ever and all providers will get a patient's full story to help treat him or her.

Greater details of care
Taylor gave the example of a person who gets into a motor vehicle accident and is admitted into the hospital. The nurse who first sees the patient can document that she was in an accident on a busy residential street. Later on, the physical therapist working with her may discover that she got into the accident while texting following a fight with her in-laws. Under ICD-10, "MVA," "on a residential street," "texting while driving" and "fighting with in-laws" can all be coded so that the patient's full story can be told. 

Taylor stressed that this type of documentation – namely very specific documentation – will be important in coming years. 

"Real-time documentation is especially important. Care managers will need to know the documentation is present and when the patient status changes from 'Observation' to 'Inpatient'," Taylor wrote for EHRIntelligence. "They can no longer wait for the end of the shift for clinicians to document. Medical necessity must be present; if not, queries sent to physicians will likely increase. Clinical documentation improvement specialists will have to forward clarifications to physicians if information in the clinician's note does not correspond with what the physician documented. The volume of queries overall is expected to increase substantially. If documentation is not entered in real time, the longer that information remains on the coder's desk, the longer the time to attain revenue and reimbursement."

Rushing to prepare
Once providers understand the importance of ICD-10, they will hopefully start preparing for it properly. HIT Consultant recently reported that many practices across the U.S. – both large and small – have yet to begin testing for ICD-10, which is far behind recommended timeline the CMS set up for providers. The news source added that many providers seem to be under the impression that the October 2014 start date for ICD-10 will be pushed back – but that is a dangerous assumption to make. 

CMS officials have repeatedly stuck to their guns when it comes to the ICD-10 date, despite the fact that many within the health care community have called for it to be pushed back. Providers who are concerned about whether their organizations are prepared for this switch may want to start by talking to their electronic health record vendors and checking in with them on where they stand in terms of having software ready for this change. They may also want to reach out to other practices that may be further along in the testing process and can offer them help.