The key thing for physicians to know about ICD-10 (International Classification of Diseases, version 10, set to transition in the U.S. on October 1,
2014) is that if they are using good clinical documentation practices, coders will do the hard work of expressing the information in ICD-10. Much of the burden of ICD-10 comes to those physicians who currently do not document the details of the patient condition.
Those that do will feel less pain from the ICD-10 transition. The number and type of new concepts required for ICD-10 are not foreign to clinicians. The focus of the documentation should really be about good patient care. Patients deserve accurate and complete documentation of their conditions.
If other industries understand the value of accurate and complete documentation of data about encounters, shouldn’t healthcare?
ICD-10 reimbursement will introduce changes based on what was done and why. Certainly any physician interested providing good care cannot argue with this? Clinicians should be leaders in the healthcare industry by providing accurate data, accurate analysis of the data and change in healthcare to continuously improve the value their patients receive. Some of the key concepts:
- Complete observation of all objective and subjective facts relevant to the patient condition
- Documentation of all of the key medical concepts relevant to patient care currently and in the future
- Coding that includes all of the key medical concepts supported by the coding standard and guidelines