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46 days to ICD-10
Documentation - the cure for ICD-10
Etiology is just as important as manifestation

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Each member of the team has a role to play. The role of the clinician is to document as accurately as possible the nature of the patient conditions and services done to maintain or improve those conditions. This documentation then becomes what is coded by your coding professional for billing.
  
Today's Tip: Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. Be sure to document the underlying condition as well as the manifestation. 
 
Example: Diabetes mellitus with foot ulcer*, left foot, plantar midfoot and/or heel
*Coding for nonpressure chronic ulcers and pressure ulcers may be based on medical record documentation from other clinicians.  The associated diagnosis must be documented by the patient's provider, however. 
  
Location! Location! Location! And Laterality!
Document where, you're half-way there

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Location and laterality are literally 50% of ICD-10. Approximately 50% of all codes are related to the musculoskeletal system, and 36% of all ICD-10 codes distinguish left from right. With the amount of specific information contained in each ICD-10 code, new diseases and technologies can be tracked with greater accuracy, data on new technologies and procedures is more accessible, and ambiguity in diagnosis and co-morbidity is reduced.
  
Today's Tip: Specify whether the condition occurs on the left, right or is bilateral whenever appropriate. Also document the specific anatomical site.
 
Example: Cutaneous abscess, trunk. Also include abdominal wall OR back OR buttock OR chest wall OR groin OR perineum OR umbilicus.
Cutaneous abscess of limb, axilla OR upper limb OR lower limb AND right OR left
  
Residual conditions, complications, and side effects
Document all as sequelae

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Instead of using the term "late effects," ICD-10 uses the term sequela (singular) or sequelae (plural). 
A sequela is a chronic or residual condition that is a complication of an acute condition that occurs after the acute phase of an illness, injury or disease. It can also be caused indirectly by the treatment. There is no time limit on when a late effect can occur; the residual condition may come directly after the disease or condition, or years later.
 
Today's Tip: Specify if a condition or disease is the result of, or a complication of, an earlier illness, injury or disease when documenting.
 
Examples:
  • Chronic pain due to trauma; unspecified injury of muscle, fascia and tendon of lower back, sequela.
  • Fatigue fracture of vertebra, cervicothoracic region, sequela of fracture
  • Late effect of nontraumatic intracerebral hemorrhage
  • Sequela of pregnancy, childbirth, and the puerperium
  • Dysarthria following other cerebrovascular disease

 
"Initial" is a subtle concept in ICD-10. Subsequent Is Simple.
Is this the initial visit or a subsequent visit for the complaint?

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The ICD-10 definition of "initial" is more complicated than the usual understanding. The initial encounter for the injury or condition is while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.
  
If the visit is a patient's initial encounter for active treatment of the injury, it's always an initial encounter. If the patient previously received active treatment for this condition it may be a subsequent encounter-with exceptions.
 
Today's Tip: Documentation must answer the basic question, "Has the patient previously received active treatment for this condition in any setting or by any provider?"
  
Example: The patient is evaluated in the ER for a displaced transverse fracture of the left ulna. The ER applies immobilization and ice and instructs the patient to follow up with orthopedics. This is an initial encounter for closed fracture. When the orthopedist rechecks the patient and reduces the fracture, the patient is receiving initial active treatment for this fracture as this is the point at which the patient receives definitive care (the ER was able to apply comfort care only). In ICD-10, this visit is an initial encounter for closed fracture.
  
How to be ready for October 1, 2015
Step One: find your top 20

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The February 16 edition of the EPCMS newsletter mapped out a month-by-month guide to get ready for ICD-10.
 
Step One is to find out the top 20 codes you use and convert them to ICD-10 codes.  Lists of the most common codes by specialty and their ICD-10 equivalents are found here