Let’s talk about documentation for ICD-10 CM. Did you know that if there is an external cause, you must document the activity, location, relief or no relief treatment has provided, if there is an acute or chronic condition and if there is a concussion, you must specify whether the patient lost consciousness?

ICD-10 requires you to document the external cause and description. What was the patient doing when the accident happened? Is this the initial treatment for the patient or have they been seen before? Where was the patient when the accident occurred? Did any treatments give the patient relief? Is this an acute or chronic condition? Did the patient lose consciousness for any period of time?

Lets look a little deeper.

Jane is in her home that she occupies with her fiancé, Tom. They recently had new carpets installed. Jane has tripped over the edge of the rug in her living room while vacuuming. The fall was witnessed by Tom who was present at the time. Both Jane and Tom tell us today that the carpets were incorrectly installed and have become loose throughout the home. Tom states that Jane lost consciousness for a full three minutes. Jane is now complaining of neck pain and headaches. She has tried over the counter relief for the pain and is also feeling nauseous and suffering from visual disturbances. Her headaches are constant and nothing offers her any relief. Her neck pain radiates from the left side, through her shoulders and into her mid back.

Only documentation that offers this level of acuity will allow ICD-10 coding to the highest degree of specificity. Does your documentation have the required information to pass ICD-10 guidelines or will you be one of the many who will be queried by your coder for an addendum, which in turn will cause a delay in payment?