The World of EMRs & Coding

EMRs have wreaked havoc with clinical documentation. When educating providers, one of the most challenging things to explain is why it is important to write out their clinical impression instead of depending on the diagnosis drop down menu. When they see the results of their audit, they are often confused as to why I have changed all of their ICD-10 CM codes and added additional ones. In our changing landscape that places greater emphasis on value-based care, it is increasingly important for providers to understand the importance of complete documentation and diagnosis specificity. Here are some of the explanations that I use to educate providers. Perhaps they will be useful to you.


1. ICD-10 CM is a billing code, the ICD-10 guidelines state “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.” Without your documentation, we cannot confirm the accuracy of the code.


2. It is important to show the full “burden of care” when treating a patient for one condition and the treatment or the condition adversely affects another condition. You have to consider that. Example: You are treating a patient for an URI with a steroid and they are DMII insulin dependent. You advise them to monitor sugar levels and adjust insulin, as needed. You are now treating the DMII during this episode of care, and it should be coded.


3. HCCs is a way to provide an accurate picture of the severity of a patients conditions using ICD-10 CM codes. HCCs are used to calculate the future cost of care. There are approximately 68,000 ICD-10 CM codes and 9,500 of those codes link to an HCC category. Without the proper code assignment, the cost of care cannot be calculated correctly. This is why it is important to select the code to the highest level of specificity and accurately capture the patient’s full burden care.


4. With healthcare reimbursement moving from Volume to Value, the ICD-10 code selection is more important than ever before. Having a certified coder in the office to assist with the proper selection of ICD-10 CM codes will become a necessity.


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