Outpatient Facility Coding Alert

Question: The new ICD-10 codes have been here since October 1, 2107, and we haven't gotten around to revising our documentation templates. More than ever before, our ability to assign the correct codes depends on clinical documentation improvement (CDI). Do you have any tips on revising the documentation templates we provide for our clinical staff?

HOPD Administrator in North Carolina

Answer: Well-designed templates help providers document all the clinical information necessary for coders to assign the correct ICD-10 codes. As just one example, ICD-10 2018 contains new specificity in the N63.XX (Unspecified lump in breast) series. Providers who haven't been documenting laterality and quadrant will need to do so now for you to code breast lumps correctly.

At the recent Regional Conference of the American Academy of Professional Coders in Salt Lake City, instructor Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, shared these three template revision strategies:

1. Harness the reporting abilities of your ASC management system. Now that you have the ICD-10 2018, "one of the best things you can do is to run a report that shows you how often your practice uses the code series now," Buckholtz told conference attendees. That way, you can narrow your template revision efforts to code series that actually impact your ASC or HOPD.

2. Even though unspecified laterality is often an option in the ICD-10 code set, don't make it an option in your templates. There's often a good reason to use a code that contains the word "unspecified" in the descriptor, but not when it comes to laterality, says Buckholtz. No matter the status of diagnostic testing, providers know what side or sides the problem is on. (And it goes without saying they always know by the time surgery is involved.) If providers don't document laterality and you assign an "unspecified" ICD-10 code, the payer will almost certainly deny your claim. So don't make "unspecified" laterality an option on any template. Some coders even have their EHR vendor remove unspecified laterality codes from the ICD-10 codes available to prevent providers from accidentally choosing them.

3. Watch denial patterns carefully. You should always be tracking denials and looking out for patterns that indicate systemic problems, but you should be extra vigilant during the fourth quarter as ICD-10 changes begin affecting your claims. If you see a denial pattern, that could be a sign that you need to tweak a documentation template a bit more to help your clinicians and surgeons get it right.

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