1) Make a Plan, 2) Train Your Staff, 3) Update Your Processes, 4) Talk with Your Vendors and Health Plans, and 5) Test Your Systems and Processes. Today our focus is:
Step: 3 Update Your Processes
- It is crucial to update hard-copy and electronic forms (e.g., superbills, CMS 1500 forms )
- Resolve any documentation gaps identified while coding top diagnoses in ICD-10
- Make sure clinical documentation captures key new coding concepts:
- Laterality—or left versus right
- Initial or subsequent encounter for injuries
- Trimester of pregnancy
- Details about diabetes and related complications
- Types of fractures
- Create a documentation checklist for any new concepts that need to be captured for ICD-10 coding
- Remember that ICD-10 does not change the requirements for good documentation, which is always about capturing the complete clinical picture in order to provide high-quality patient care
- Review NCDs and LCDs with ICD-10 codes to ensure consistency with internal policies (e.g., coding, billing, and documentation processes)
- Outpatient and office procedure codes aren’t changing—ICD-10 does not affect the use of CPT and HCPCS coding for outpatient and office procedures
To learn more about getting ready, visit cms.gov/ICD10 for free resources including the Road to 10 tool designed especially for small and rural practices, but useful for all health care professionals.
