Documentation is the Cornerstone to Successful Implementation

Remember that ICD-10-CM implementation is only a few years away. Think about the specificity in ICD-10-CM and ask yourself the question, “Will the practitioner’s documentation be ‘up to snuff?’”

Since I audit medical records within the scope of my responsibilities, I can tell you that most current documentation practices will not support the higher levels of specificity for ICD-10-CM. Now is the time, if you have not done so already, to perform a baseline ICD-10-CM readiness audit. Why is this so important as the first step? To prepare, it is important to identify current documentation deficiencies when reporting diagnoses in the medical record.

Full article:
Documentation is the Cornerstone to Successful Implementation – Coding Edge September 2007