In less than four months, Carolinas HealthCare System will implement ICD-10, the new classification system that has been expanded to capture a higher degree of specificity.
As a physician, here are the top-10 things you need to know about ICD-10:
Physicians do not need to learn how to code.
Physicians have many resources available at Carolinas HealthCare System, no matter the practice setting. These include the Documentation Excellence team, the Clinical Documentation Improvement team, Coding Support and more. You can also contact them via email.
The bulk of the expanded codes have been created to capture laterality, so if there is a left or a right, be sure to specify.
ICD-10 is not about more documentation; it is about better documentation.
Accurate physician profiles depend on the most accurate codes – which depend on the most accurate documentation.
CPT codes and their use do not change.
In many instances, one word – such as “acute” – can vastly change the interpretation of the severity of illness.
Timing is everything! Carefully noting minutes or hours for loss of consciousness; weeks for trimesters; days for previous MIs and injury; and episode of care (initial, subsequent or sequelae) makes a significant difference.
Tell me where it hurts. Be very specific as to site. Where are the adhesions? What exact site in the bowel, etc.
If you can think of it, there’s a code for that! This site will give you an idea of the scope of codes available.
Visit the ICD-10 webpage on PhysicianConnect for more information. Please note you must be logged into the CHS System to access this intranet site.