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Coding and Documentation Problems Spinning Out Of Control?

This is the final article in our series discussing coding and documentation issues now occurring due to ICD-10. If your organization is to survive, be successful and receive payment for services rendered, changes must be made now before your world spins out of control!coding and documentation

Struggling With Coding and Documentation Issues?

Are there days when you feel your world is spinning out of control? If so, you have lots of company! The industry is struggling with ICD-10 coding and documentation problems occurring due to sequencing, severity coding and incomplete, inaccurate clinical charting, as discussed in our current series of articles. But we are also contending with face to face changes – hopefully for the better, value based purchasing and now the threat of requiring preauthorization for Medicare admits. Add to this, implementation of the universal assessment form across all health care settings and oh yes – let’s not forget – ICD-11. This article will focus on summarizing the top three coding and documentation issues CMS and the intermediaries are taking action on which are the biggest current threats to your survival.

Coding and Documentation Responsibilities

I remember the good old days when diagnosis codes only required three or four digits. Anyone could code as long as they had the current coding book. When we went to 5 digit codes, I knew it was time to find someone who loved coding enough to become certified and take the helm. Now with seven digits necessary for ICD-10, much more explicit documentation details are needed and much more is at risk. There are now 70,000 choices of diagnosis codes instead of a mere 16,000 choices available to describe a condition, illness, injury, or symptom under ICD-9. The diagnosis sequencing must match that of other providers – hospital, nursing home and/or physician. If an additional diagnosis is identified and addressed during the episode of care, the clinician must have written confirmation from the physician that the diagnosis is valid and approved for that plan of care.

To meet these additional demands, we MUST have certified experienced coders available to code.  Certified coders will identify OASIS errors through review and document those clinicians failing to accurately complete the OASIS. Managers must be responsible to:

  • Communicate with clinicians
  • Monitor OASIS integrity and documentation
  • Educate and train clinicians making errors
  • Assure clinical documentation supports the codes
  • Verify that documentation is explicit and shows services provided are appropriate

Coding and Documentation Habits

As the saying goes – old habits are hard to break. Clinical staff, nurses in particular, are used to addressing all health concerns and doing very basic high overview charting. This does not work under the stringent requirements of ICD-10. First, only the diagnoses coded and included in the care plan during the current episode are to be addressed. Then documentation must support the primary and secondary codes and must be comprehensive and specific. To be sure clinical notes meet coding requirements, all staff must be trained to documentation adequately and correctly. Ongoing documentation monitoring by managers will identify retraining needs and prevent decreased, delayed or denied reimbursements. Quickly it becomes apparent that your managers don’t have enough time to mentor, supervise, review documentation, complete OASIS review, retrain and do ICD-10 coding.

Kenyon HomeCare Consulting recognizes industry trends and that you feel your world is spinning out of control. Therefore we offer both outsourced ICD-10 coding and an education division. Our coders are tenured, certified, and experienced. Our qualified QI team is available to train and educate your staff to ensure your coding and documentation meets the requirements preventing reimbursement denials.

If you feel your agency is spinning out of control and may be at risk, schedule an appointment, call 206-721-5091 ext. 100 or e-mail We are here to help!


Category: ICD Coding

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