How does documentation need to change?Start by reviewing medical record documentation, how could you have been more specific?
- Did you say “the patient has diabetes mellitus” ICD-9 250.00
- Should you have said “the patient has Type 2 diabetes mellitus with diabetic nephropathy” ICD-10 E11.21
- Did you say “The patient was bitten by a snake or spider” ICD-9 989.5
- Should you have said “the patient was bitten by a rattlesnake intentional self harm” ICD-10 T63.012
Currently there is 1 ICD-9 code to describe this encounter. In ICD-10 there will be 152.
There are approximately 70,000 ICD-10-CM codes compared to approximately 14,000 ICD-9-CM diagnosis codes. This change will affect all provider types.
In addition, ICD-10 codes are longer and use more alpha characters, which enable them to provide greater clinical detail and specificity in describing diagnoses and procedures.
Coding staff should spend time every day practicing internally using the ICD-10 codes on sample claims, such as current claims, prior to the compliance date. (Some publications are already including this information.)
For a more detailed sitemap click here.