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CODING

List I-10’s documentation requirements for the office’s current I-9 codes

Getting ready for ICD-10-CM

Here’s another recommendation for the ICD-10-CM move. It comes from Medicare: make a list of the office’s most frequent ICD-9-CM codes and see where the current documentation will need to be expanded for ICD-10.

ICD-10 sets out more choices for diagnoses than does ICD-9-CM, so for many conditions, the record will have to show specific factors that currently don’t have to be documented for coding. One, for example, is laterality. For many diagnoses, the record will need to show whether the condition affects the right or left side of the body or is bilateral.

The government gives this example of what the office’s list might look like for three common diagnoses.

Diabetes Mellitus

  • type of diabetes
  • body system affected
  • complication or manifestation
  • for type 2 diabetes, long-term insulin use

Fractures

  • site
  • laterality
  • type
  • location

Injuries

  • External cause. The documentation has to show the cause of the injury. Thus, the office must ask the patient how the injury occurred.
  • Place of occurrence. Tell where the patient was when the injury occurred, perhaps at home, at work, or in a car.
  • Activity. Tell what the patient was doing at the time of the injury such as playing a sport or using a tool.
  • External cause status. Tell if the injury was related to military service, work, or other status.

Medicare points out that much of the information is already being discussed with patients and that for ICD-10 it’s simply a matter of adding it to the record so the visit can be coded properly.

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