Tune in to this monthly online coding column to learn from AHIMA’s coding experts about challenging areas and documentation opportunities for ICD-10-CM/PCS.
With only six months until the implementation of ICD-10-CM/PCS, now is the time to ensure that your practice is ready for the transition. Here are some ways to prepare for the transition that don’t involve countless hours of mundane training.
Convert Your Superbill
Take a look at your current superbill and focus on the ICD-9-CM diagnosis codes that are listed. Ask yourself the following questions:
- Are all of the diagnoses listed necessary for my practice?
- Are there key diagnoses missing?
- Why am I still using a paper superbill?
- Can this process of selecting diagnoses be integrated into the electronic health record (EHR) system that I am already or will soon be using?
After reviewing your superbill, select a stellar coding professional in your office to convert the ICD-9-CM codes to ICD-10-CM codes. If none of your coding staff have been trained on ICD-10-CM yet, now is the time to send one, some, or all of them to “countless hours of mundane training.” There are a multitude of ICD-10 trainings being offered in various modalities, including online courses, workshops, and textbooks. Appropriate training for your coding staff will ensure a smooth transition.
The AHIMA website also offers two examples of superbills converted to ICD-10 at this link.
Use the Electronic Health Record (EHR)
Most EHRs have a coding feature built in, as well as electronic templates that can assist with the documentation nuances that ICD-10-CM has to offer. Make sure you check in with your EHR software vendor to guarantee that they are ready for ICD-10. They may even offer training for you and your staff on these new features.
Deep Dive into Documentation
One way to determine if your documentation is ready for ICD-10 is to have one of your stellar coders (preferably one who has attended that mundane ICD-10-CM training) begin coding a few charts each day in ICD-10-CM. This practice will quickly reveal any documentation gaps. Since ICD-10-CM consists of several new features that are not found in ICD-9-CM (such as laterality and episode of care), it is likely that some gaps in documentation will be identified. Doing this analysis months in advance of implementation will allow for plenty of time to fill in those gaps and become documentation superstars!
AHIMA has created ICD-10-CM/PCS Documentation Tips as a tool to assist providers in transitioning their documentation to ICD-10.
Communication is the key to success for any project. As you are planning out your implementation plan for the transition to ICD-10, be sure that all physician office staff is aware of the transition timeline for the next six months and what is expected of each individual along the way. You can communicate this plan, as well as throw in a little training, by creating posters, newsletters, tip sheets, documentation pocket cards for physicians, and e-mail updates.