Click her to see a replay and/or download the handouts from the Solve the Documentation Puzzle for ICD-10-CM and PCS webinar. View this webinar to learn how to respond to the statement “Just tell me what to document.” We’ve cover the types of documentation necessary to assign a diagnostic statement to a specific ICD-10-CM code or to correctly assign an ICD-10-PCS code. You’ll receive clear and concise guidance on the types of documentation required for the new systems and see how documentation can affect codes and MS-DRG assignment under ICD-10.
Objectives:Discuss how documentation impacts the ICD-10-CM and PCS code assignmentLearn the basics of the ICD-10-CM and PCS documentation requirementsHighlight how documentation could affect MS-DRG assignment
*Note* - Replays are NOT eligible for CEU credits
Questions & Answers:
Question: Are you saying on slide 16 all these options can affect reimbursement?
Answer: Some of the codes listed may affect reimbursement but some may not. The intent of the slide was to show the types of documentation that is required to assign one of those codes.
Question: Has Medicare published any documentation guidelines for ICD-10?
Answer: The documentation guidelines for ICD-10-CM are available on the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/index.html and these are available in the Coding Suites in the Code Book folders.
Question: Can we take any documentation from nursing in order to code transfusion procedures?
Answer: This could be a controversial issue. My opinion is that you can take nursing documentation for the transfusion procedure. We do now in ICD-9 procedures. The nurse is performing a facility-based procedure based on a physician order. If the order and the treatment are both documented, then the procedure can be coded. The physician wouldn't specify the location of the transfusion. That is a nursing decision and would be included in the transfusion record.
Question: if a patient has chronic pain from a previous fracture is there now only one code to report?
Answer: You'd assign the codes based on the documentation. If they have chronic pain, you'd assign the code for that condition. If a previous fracture is the cause of the chronic pain, you'd code the fracture and assign the 7th character of "S" because the chronic pain is a long term result of the fracture. The exact code decisions would be made based on the documentation details.
Question: Sounds like this coding system is A LOT larger than ICD 9..is there going to be a hard copy versions (books) or is this only going to be available via computer software?
Answer: The coding systems are larger. There are printed books from the current publishers of code books. There are also electronic versions available on the CMS website and the enhanced electronic code books found in the Coding Suites.
Question: Do you anticipate any additions or changes to Root Operation terms? Also, are the definitions of Root Operations defined in the ICD-10-PCS guidelines? Thank you.
Answer: There haven't been any additions or changes to root operation definitions in the last few years. I can't be sure of their plans regarding this, but I doubt we'd see any additions during the code freeze period. In the future, additions or changes would probably depend upon new technology advances. See Definition of Root Operations in the PCS CodeBook.