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Reading Between The Lines Of Medicare ICD 10 Coding. Are You Missing Something Or Are Your Ducks In A Row?

ducks in a row

In the home health industry, everyone knows the importance of ICD 10 coding today. So, most agencies invest in certified coders on staff or the service is outsourced. However, today we need to hone in on making sure your documentation gets the reimbursement you deserve on the Medicare patients you see. Let’s look at what the coders need and what are their issues in making sure they have the clear picture of your patient’s scenario.

What The ICD 10 Coders Say: 

Well, the truth is that if the documentation in the clinical record and supporting documentation is present, it makes the job of an ICD 10 coder much easier. However, with the clinical groupings of PDGM and co-morbidity factors, one missing piece can throw off a primary diagnosis or negate the ability to have reimbursement for a co-morbidity. Here are some clear cut items that paint your clinical picture for the coder.

  • Write A Clear Narrative: The coder needs an clear understanding regarding the focus of care and how that relates to clinical diagnosis. Most narratives do not contain enough relevant clinical information to answer those questions. If your nurses use a narrative, then make a standard statement: The focus of care is____ and it relates to the clinical diagnosis by  ____. If you don’t use a narrative, then it is time to start.
  • Get A Strong Referral: Strong documentation begins with a strong referral. Agencies may have plenty of documentation from the referral source, but it misses info related to potential co-morbidity adjustments.
  • Strong Past Medical History Statements: Clear past medical history statements cue the coder into whether or not there is further documentation to dig for in the mix. We know how easy it is to become bogged down in medical records from other sources and our own. It can be missed, so make sure that your past medical history is easy for the coder to see.

Ok, So What Now?

Take an objective look at your documentation. If you have multiple branches, compare the documentation for uniformity in process.  Is every bit of documentation in the assessment? If so, then are are the elements needed to paint a clear picture in the same place for the coders to review. If agencies do not use a clinical note narrative, then often times relevant data is scattered throughout the assessment and it is not uniform between clinicians. This leads to errors or things that could be missed. Make sure the process makes sense and clearly communicates relevant admission information.

Utilize your coding company. These guys work with agencies across the United States. So, they see what works well and what doesn’t. If you want them to provide education to your people, then they will help. It makes their lives much easier as well. Whether you are working with a few clinicians or many across multiple branches, it is worth the time and has the ability to save you money and earn revenue in the process.

Let Kenyon Homecare Consulting Be You ICD-10 Coding HQ:

At Kenyon Homecare Consulting, we work with agencies to provide the best quality in-home care to patients. We can be your ICD 10 coding, Oasis, and documentation solution if you are struggling to make a difference in your bottom line in a PDGM world. Call us at 206-721-5091 or contact us online to see how we can help you. We will provide 10 free re-codes to serve as a check and balance for your current coding and documentation system. Call today and see if we can make a difference for your agency.

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