Preparing for ICD-10 includes more than just codes!

With ICD-10, coders may need to probe deeper into the patient’s medical record and/or query the physician more often to obtain the level of specificity required by the ICD-10-CM codes. As a result, coders will need to fully understand anatomy and physiology (not only the structure and location of organs and body parts, but also how they function), medical terminology, disease process, surgical procedures, and drugs and pharmaceuticals.
ICD-10-CM includes many combination codes that require the underlying condition, as well as one or more manifestations, complications, or associated conditions. Often one will need to first identify the diseases and disorders in the medical record documentation, and then find the ICD-10-CM code that best represents the patient’s documented condition.
For example, ICD-10-CM defines a ‘minor contusion of the kidney’ (S37.01-) as being less than 2 centimeters. A different category will be used if the contusion is more than 2 centimeters and therefore considered a ‘major contusion of the kidney’ (S37.02-). Physician documentation must include this information, and the coder should be able to differentiate between the clinical conditions to assign the proper code.