Good Clinical Documentation is the key to Audit-proof ICD-10 documentation
The two key principles that support diagnosis and procedure code selection are good clinical documentation and demonstrated medical necessity. Clinical Documentation should accurately reflect the level of work for the care rendered, and support the selected diagnosis codes. Demonstrated medical necessity, CMS defines medical necessity criterion for payment of services. Quality documentation must support the medical need for performed tests and assigned diagnoses. The volume of documentation does not correlate to medical necessity (i.e. more is not always better).
Basics of Clinical Documentation:
Over- or under-documentation results in either an incorrect diagnosis code selection or unreported ICD-10 diagnosis codes. All diagnosis codes should reflect the care delivered, and every diagnosis code must have an appropriate treatment plan to be billable. Always select diagnosis codes to the highest known level of specificity at the time of the patient encounter.
Providers may fall short when documenting chronic conditions, especially now that they have more options to select from in ICD-10 (compared to ICD-9). When providers receive the right guidance, they are more likely to change this behavior and select codes that more clearly illustrate the clinical picture depicted in their documentation.
It is not necessary providers will be well versed in coding language, therefore important to communicate effectively using directives they can relate to.
Evidence-based practice guidelines are a major resource that providers can use to bolster documentation. Practice guidelines serve as the blueprint for care delivery and set medical protocol for a provider?s assessment and evaluation. When care follows these guidelines, documentation aligns with appropriate coding levels.
Practice guidelines have a valuable role in supporting documentation in each of the three key evaluation and management (E/M) components:
- History
- Physical Exam
- Medical Decision Making
- Better Documentation = Fewer Unspecified Codes
- Peer and Coding Reviews Can Strengthen Providers? Notes
- Support and Strengthen Your Provider?s Documentation:
- Documentation Should Reflect the Clinical Process
Points Providers Should Know About Clinical Documentation:
- Do not populate template-based electronic health records using copy and paste functions.
- Quantity of documentation does not equate to quality of documentation.
- Insufficient documentation may force an unspecified code.
- Many ICD-10 diagnosis codes use clinical classifications for grouping.
- Evidence-based practice guidelines promote accurate documentation.
- Proper documentation will support proper diagnosis selection.
- Appropriate coding relies on accurate documentation.
- Medical necessity is supported by precise documentation.
- Sufficient documentation minimizes unspecified code selection.
- Concise documentation is substantiated in an audit.