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.
Documentation is the Cornerstone to Successful Implementation – Coding Edge September 2007