245 As preparations continue for the October 1, 2014, transition to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), some physicians and prac- tices may have concerns about how well current documentation practices will support code assignment in ICD-10-CM. One option for implementing a documentation review and improvement project in rela- tion to ICD-10-CM is to start with a list of the physician’s or practice’s most frequently reported International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. To focus on documentation to support specific codes, it is necessary to determine the elements that support code selection for a specific condition. For instance, ICD-9-CM code 382.9 ranked third in the top 25 diagnosis codes reported by pediatricians for encounters with children up to age 18 years for the years 2008–2010. This code represents unspecified otitis media and could be more specifically reported in ICD-9-CM if documentation provides the necessary information. (See “Top 25 Pediatric Diagnoses Revisited” in the August 2013 issue of AAP Pediatric Coding Newsletter™ to learn how this code indicates a lack of specificity in documentation.) Once you have selected a condition to review, look carefully at the ICD-10-CM codes for that condition and create a list or table of the documentation elements that support code selection. The Table shows in 4 columns the documentation elements necessary to specifically identify otitis media using ICD-10-CM. A documentation element from each of the 4 columns is necessary to support specific code selection. To take this a step further, note whether there is documentation of tobacco use or exposure, as this is reported in addition to otitis media when documented. Alternatively, you can start dual coding for certain conditions now. This is a bit time con- suming because it involves assignment of ICD-9-CM and ICD-10-CM codes to current services (officially reporting only ICD-9-CM codes). However, this brings real-world ICD-10-CM coding experience to your practice prior to the date when these codes will actually be billed. This may help offset the expected October work delays related to the transition while clearly illustrating where documentation lacks information to assign specific codes. Documentation references such as the Table may be built and used as improvement tools as you find necessary during the project. Whichever method you choose, these are exercises that offer opportunity now to not only prepare for ICD-10-CM but also to report the codes that most specifically describe the conditions managed and support the necessity of services provided. Who knows? You may be pleasantly surprised that documentation for ICD-10-CM is not so different from ICD-9-CM. Appendix B-9 Documentation and Coding of Otitis Media (continued on page 246)
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