Proper application of ICD-10 codes on claims submitted to payers is crucial for healthcare providers to receive maximum reimbursement for services rendered. ICD-10 codes provide detail on a patient’s diagnosis and are used by payers to determine appropriate payment based on the provider’s contract. According to the good folk over at Find-A-Code.com, using unspecified, vague, or outdated ICD-10 codes can lead to rejected claims or lower reimbursement. Providers should therefore ensure their coders are well-trained in the latest coding guidelines.
Improving Documentation for Coding Specificity
A key prerequisite for specific ICD-10 code assignment is detailed, clear documentation in the medical record from physicians and nurses on the patient’s symptoms, medical conditions, and treatment. Providers should implement robust documentation improvement initiatives focusing on problem-oriented charting. For instance, documentation should go beyond merely stating “pneumonia”, but also indicate the specific type of pneumonia, laterality and severity based on clinical indicators. With rich documentation, coders can select more precise codes to better reflect complexity.
Utilizing Laterality for Increased Reimbursement
Certain diagnoses, like fractures, pneumonia and joint disorders have different ICD-10 codes depending on the laterality of the condition (i.e., right vs left body part affected). Training physicians and coders to document and code laterality means two separate diagnoses can be listed instead of one unspecified diagnosis, which increases reimbursable conditions. Pay attention to CC (complication or comorbidity) and MCC (major complication or comorbidity) designations, as two CCs with laterality may result in higher payment than one MCC.
Reviewing Code Options for Optimal Choice
Coders should develop strong analytical skills for code selection, rather than automatically going with familiar or convenient codes. For example, with disorders involving injuries, poisoning, or complications, review possible coding combinations to identify whether: a) two diagnoses together make up a CC or MCC; or b) another alternative, specific diagnosis code better reflects the clinical presentation and appropriate reimbursement.
Querying Physicians for Clarification
Encourage coders to maintain continuous, open dialogue with physicians when documentation lacks sufficient detail. Querying physicians for clarification on unclear terms, missing laterality, patient risk factors and overall clinical significance means coders can obtain needed details to assign optimal codes.
Implementing CDI Program with Collaboration
Consider launching a rigorous Clinical Documentation Improvement (CDI) initiative centered on collaboration between coders and physicians to improve documentation and diagnosis capture. Set meetings for coders to present physicians with usage trends, problematic diagnoses with documentation gaps, and queries requiring clarification. Enable dialogue on optimizing problem lists, H&P formats, discharge workflows and templates to standardize proper coding terminology.
Using Encoder Program for Code Selection Support
Invest in a quality software program to assist coders in identifying accurate diagnosis codes and code combinations to yield better reimbursement. Software programs contain HCC and risk adjustment data, fast Medicare code edits and QPP details needed for optimal claims submissions and revenue cycle performance. Many programs also integrate with EHRs to match codes with clinical indicators from charted patient data for greater precision.
Attending Continuing Education on ICD-10 Updates
Medical coding evolves rapidly, with frequent code changes, guideline adjustments and payer instruction updates. Prioritize ongoing education for coders through AHIMA, AAPC, or specialty coursework to reinforce skills. Lots of courses also prepare coders for advanced specialty credentials to master reimbursement nuances in settings like cardiology, OBGYN, and orthopedics. Savvy coding translates to sizable financial returns.
Conclusion
Precise application of updated diagnosis codes reflecting documented clinical detail is imperative for providers to capture optimal reimbursement from payers and thrive amid healthcare regulatory shifts. Harnessing quality documentation, coder training, external resources and cross-departmental collaboration lays the foundation for accurate claims submissions and revenue integrity. Payers reward providers demonstrating coding precision across encounters.
