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ICD-10 Documentation & Coding Tips

ICD-10 is a sizeable undertaking for any practice. In addition to expanding the number of codes to nearly 70,000, ICD-10 coding and documentation will require significantly more detail and specificity. PracticeMax is your partner for ICD-10 preparation, including clinical documentation requirements and tips. Here are some examples of where ICD-10-CM will require more specific documentation. […]

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ICD-10 General Concepts for Emergency Department

ICD-10-CM Emergency Department (ED) General Concepts: Signs and symptoms are still acceptable in the absence of a definitive diagnosis Example: Fever, dehydration and vomiting without nausea Location/laterality Document right, left or bilateral for paired organ structures Example: Bilateral pneumonia Location/anatomic specificity Be specific as to the exact anatomic site; see examples below Finger: Individual fingers […]

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ICD-10 Education & Resources for Providers

ACEP Now Article: ICD-10 Coding Tips to Help Emergency Physicians Navigate Documentation Changes This article from June 15, 2015 presents two experts’ guidance on ICD-10 and answers the following questions: How will this impact how I document? Why is severity of illness (SOI) important and how and why should I document it? How do I document […]

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ICD-10 Impact on Emergency Medicine Practices

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 […]

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