Hello to everyone in ICD-10 land! In my past blogs I have focused on the specialty specific areas of coding where confusion exists, but let's face it, a large part of what we code every day is in the area of General Surgery, which poses its own set of unique challenges. So many guidelines and let’s not forget the selection of the root operation, body system, body part, device, biopsy and the list goes on. I am a big advocate of getting back to the basics so let’s start there and review some starting points.
I have been educating Provider’s on the documentation challenges and changes that are inherent in the ICD-10 coding system for the past year and it seems that many Providers are unprepared for the specificity required in medical documentation. Clinical documentation integrity begins with the Providers, and training in this area is critical to a successful ICD-10 transition, however, the impact of education regarding documentation is negated if we do not have Provider engagement. To encourage engagement, a basic understanding of the CDI and coding process is needed to facilitate ‘buy-in’ and make the documentation education and training better received.