User documentation, education and governance remain the top three issues threatening ICD-10 readiness. But another, equally disturbing practice is emerging. Many hospitals and practices have opted to let coding staff select ICD-10 codes based upon physician documentation, placing key decisions in the hands of the coders instead of clinicians. In a recent Healthcare Informatics article, Dr. John Elion noted that certain ICD-10 PCS (procedure coding system) codes require a great degree of detail and granularity. The physician must explicitly detail a procedure and the circumstances associated with the event so that there is no ambiguity as to the correct code. The real concern is not missing information, it is that the physician’s description is not formatted to meet the requirements of ICD-10. When this happens, then it is up to the coder, or clinical documentation improvement (CDI) specialist, to either […]
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