The transition to ICD-10 will change the way emergency medicine physicians document the ED patient encounter. ICD-10 requires significantly more detail than ICD-9 to help support medical necessity. In this regard, ICD-10 requires more effort on part of the provider to document the exact type of patient diagnosis. Not providing the required additional detail and specificity in documentation can lead to delays in claims processing and decreased reimbursement. Overemployment of “other” or “unspecified” codes will also lead to delays and decreased payments, especially if an alternative code(s) is available.
The following is a brief overview of some of the key concepts of ICD-10 coding and documentation:
Severity of Illness
This term describes the patient’s level of sickness and disease complications. It is also an indication of resource utilization and how expensive it is to treat the patient. ICD-10 codes provide better support for documentation of severity of illness (SOI).
Signs and Symptoms/Unspecified
ICD-10 understands that there are occasions when a provider must list an “unspecified” diagnosis. Therefore, ICD-10 does not require a “definitive final diagnosis”. It is acceptable to use signs and symptoms (e.g. chest pain, vomiting) as the first diagnosis.
Episodes of Care for Injuries and Poisonings
- Initial encounter is defined as when the patient is receiving active care for injuries, fractures, burns and poisonings in the ED. Initial encounters account for the majority of ED encounters.
- Subsequent encounters occur when the patient is receiving additional or routine care while still recovering from an injury, fracture, burn, poisoning or similar condition. An example of a subsequent encounter in the ED is a cast change, change in medication or removal of sutures.
- Sequale encounter is only used when the patient is being seen for a complication that arises from an injury, fracture, burn, poisoning or similar condition. This is similar to the late effect codes in ICD-9.
Enhanced Anatomic Specificity
The ICD-10 code set allows for a very specific anatomic description of the condition or injury (e.g. laterality)
Sprains and Strains
Unlike ICD-9, ICD-10 differentiates between a strain and a sprain, and also provides the opportunity to specify the exact tendon, ligament or muscle.
External Cause of Injury
In ICD-10, you must document the how, the physical location and the circumstance (mechanism) in which the injury occurred.