ICD-10 RESOURCE GUIDE DIAGNOSIS DOCUMENTATION PRINCIPLES FOR ANESTHESIOLOGY

-->August 25, 2015Billing & Compliance Alerts

     

    Presented by the Medac Compliance Department

     

    INTRODUCTION

    With the advent of a new diagnosis coding regime, set to descend upon America this coming October, providers of medical services have become increasingly concerned about the potential impact to their bottom line.  How will ICD-10 affect my reimbursement?  What percentage increase in denials will I encounter over the course of the next year?  Will coders and payors be up to speed when October 1 rolls around?

     

    Medac cannot answer all these questions; in fact, no one can.  However, Medac has taken steps to ensure that potential problems—at least on our end—will be kept at a minimum during the transition from ICD-9 to ICD-10.  We have spent more than a year in intensive research, testing, internal training and system improvement.  In addition, we have made available training modules for all our clients, so that each provider is introduced to the principles of ICD-10 documentation.  To supplement that training, Medac is now presenting this ICD-10 Resource Guide that will (a) give you an even greater appreciation of payor expectations relative to your diagnostic descriptions, and (b) demonstrate what we have already found to be deficiencies in anesthesiologists’ documentation of diagnoses—from an ICD-10 perspective.  Bottom line:  we believe this Guide will give you an added edge in avoiding the potential pitfalls of inadequate ICD-10 documentation.

     

    BACKGROUND METHODOLGY

    During the last few months, Medac’s Coding Department has undertaken the task of “dual coding.”  That is, while submitting all claims under the current ICD-9 regime, our coders are simultaneously coding a portion of those cases using ICD-10 coding standards, as well.  The purpose of this ongoing exercise is to determine how current provider documentation falls short of the ICD-10 thresholds.  We have categorized the documentation deficiencies uncovered thus far according to case type, and the findings have been enlightening.

    In the attached document, we will present a summary of the primary documentation deficiencies, per case type, that we have encountered during the dual coding exercise.  The overall goal is to illustrate for you the diagnosis documentation elements that must not be omitted, per case type, so that your chances of getting paid are improved.

     

    CASE TYPES

    The data presented will be categorized as to “case type.”  In other words, each section will be based on an anatomical region or other unifying factor, such as “OB/GYN” or “Neoplasms.”  Again, the findings and recommendations are based strictly on superimposing ICD-10 documentation criteria onto current provider documentation.

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    The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author’s presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.