The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
ICD-10 Requires Communication with Staff
As I write this, the transition to the new International Classification of Diseases, 10th Edition, Diagnosis and Procedure Codes (ICD-10) implementation is set to begin October 1. As a consultant and educator, my life has been consumed as of late working to help physicians and practices get ready. Following is one final piece of advice prior to the transition.
Talk to your staff. Starting today and through the transition period, communicate with your staff. The interaction is invaluable for both the physician and the staff as you enter this new era of coding. Everything about successful ICD-10 coding begins with proper documentation. Your staff knows what to do with the documentation, which is essential in ensuring complete and accurate coding. What you “write” in a patient’s record is crucial to selecting the specificity that ICD-10 requires. This information, mostly all clinical, can only come from you and it must be present. It is in your head. As the physician, you have the knowledge to treat the patient, you need to be sure to communicate the necessary information to others for the purpose of maximizing your compensation.
A successful transition to ICD-10 coding is in your hands. The information you document about a patient’s condition is what will in the end ensure proper reimbursement for the services you provide.