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ICD-10 Documentation Requirements Are Not To Be Taken Lightly

ICD 10 coding

The long-awaited October 1, 2015 deadline for switching from ICD-9 to ICD-10 code is fast approaching. Great debate rages as to the precise impacts this transition will have on the U.S. healthcare industry, but most agree that home health agencies will be among the hardest-hit sectors when the full burden of implementing this new code becomes a reality. There are over 12,000 such agencies serving some 5 million clients nationwide, and all of these agencies must fully comply with the new coding requirements or face dire consequences.

Medicare Publications on  ICD-10 Documentation

If anyone doubts that the new ICD-10 documentation requirements will be stringently enforced, a quick look at the Medicare ICD-10 publications will remove those doubts. Medicare has issued a voluminous quantity of literature devoted to getting the whole health care industry prepared for ICD-10.

Centers for Medicare and Medicaid Services (CMS) publications and promotions on the topic include:

  • Road to 10, online tool specifically designed to help smaller practices build and implement action-plans for a successful transition
  • The CMS ICD-10 Resources Flyer, quickly summarizes the most basic information
  • The ICD-10 Introduction Fact Sheet, another “in a nut shell” presentation of the requirements
  • Three Medscape educational videos: ICD-10: Getting From Here to There, ICD-10 and Clinical Documentation, and Preparing for ICD-10: Now Is the Time
  • Official resources that target specified groups for ICD-10 transitioning, including providers, payers, and vendors
  • ICD-10 Industry Email Updates and Tweets

All Staff Must Be Ready for ICD-10

The common lesson to take from all of the above-listed CMS-related publications is that ICD-10 will affect every health care agency and every health care worker. Your entire home health organization must be prepared by October 1st, including management, nurses, physicians, therapists, aides, and medical coders. Any one weak link could cause a breakdown in the system and lead to codes being rejected and reimbursements being denied.

September 30, 2015 will be the last day that ICD-9 code will be accepted. Beginning October 1st, the old codes simply will not work. Denied or delayed claims can rapidly sink small-scale health care providers who count on a constant cash flow just to stay afloat. Thus, no home health care agency can afford to take this deadline lightly.

Meeting the new ICD-10 documentation requirements will involve a change in your current multi-faceted process. This new process must be mastered prior to the implementation deadline to avoid major disruption of your agencies’ financial affairs. Some of the most crucial aspects of the ICD-10 documentation requirements include:

  • More extensive clinical information to fill the 5 to 6 ICD-10 code-slots
  • Comprehensive medical records such as history & physicals obtained from other healthcare sources, hospitals and doctor’s offices
  • Only care actually provided at the client’s place of residence and diagnoses directly affecting that care should be encoded
  • Medical coders will need more extensive documentation available to assign the more complex code correctly and timely
  • OASIS documentation, client care plans, and all visit notes must consistently match, not contradicting one another

The Value of Outsourcing Your ICD-10 Coding

Given the difficult task of transitioning to ICD-10 and the short time remaining to prepare for that transition, many home health practices are opting to outsource their medical coding entirely. Kenyon HomeCare Consulting is a leading provider of medical coding services. Outsource coding services can either permanently relieve your agency of this task or temporarily handle it for you, while your staff transitions to the intricacies of ICD-10 coding and documentation requirements.

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