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Clinical documentation is key
e-Reports, May 18, 2015
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Now is the time to assess your clinical documentation. Run a report of your top 25 diagnosis codes and evaluate the content of your documentation. You may need to hire an ICD-10-CM auditor to provide these services, if you don’t already have an internal staff auditor.

Review at least 10 records from each physician to assess the documentation deficiencies. Don’t get caught up with other issues. Focus on the content of the record as it relates to the complaint that brought the patient to see you, and other conditions as applicable.

Ask yourself if the requirements of documentation to determine the appropriate ICD-10 code were met. Will the documentation support the ICD-10-CM code(s)?

Once the audit results are in, you will need to correct any deficiencies in the medical record and monitor for accuracy.

The ISMA is here to answer all your ICD-10-CM questions. For more information on ICD-10, see the education section on the ISMA website, www.ismanet.org/education. Visit this page often for specialty education and all the ICD-10 news.

End-to-end testing in July?
Medicare has extended the deadline for applications to participate in July’s end-to-end testing; additional July volunteers are being accepted until May 22, 2015. If you participated in January and April end-to-end testing, you can test again in July without re-applying. Also, the testing is available to physicians who submit claims directly to Medicare, and a clearinghouse may apply to conduct testing.

Learn more about testing on the CMS website and the WPS website.

Copyright: Information written and displayed on www.ismanet.org is the property of ISMA and may not be reproduced without expressed written permission of the Indiana State Medical Association.

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