Wiki Documentation Audit: Prep for I-10

[Summer]

Good afternoon everyone:

Does anyone have a good tool to use to Audit your physician's documentation for ICD-10 - I'm looking for something specific to Cardiology.

Thank you,
Summer

 

[mjb5019]

audit

Pull some notes and code them with the ICD-10. Make notes of what additional info needs to be there. It may not be much.

 

[mitchellde]

It may be more than you think also, look carefully at the ICD-10 Cm codes and guidelines. For example osteoarthritis, must be documented as primary or secondary or you will need to use an unspecified code. In ICD-9 we can chose the code that states not specified as primary or secondary, ICD-10 Cm does not contain this choice, and to use the more desirable left side or right side codes it must be specified as primary or secondary.
Also for injuries the use of the 7th character has been throwing coders and providers off. In addition the cause of the injury must be coded on each encounter using 7th characters as well, many times this documentation is no where in the note.
All O codes require a Z3A.?? for weeks of gestation.
You will need to code several representative samples following the guidelines and paying attention to coding conventions in the book as well.