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ICD-10
Boot Camp
Part 4 – Documentation
Improvement Strategies
3
Presented by Evan M. Gwilliam, DC MBA BS
CPC CCPC NCICS C...
Dr. Evan Gwilliam
• Education
• Bachelor’s of Science, Accounting - Brigham Young University
• Master’s of Business Admini...
Overview
• Part 1 - ICD-10 fundamentals and navigation
• Part 2 - Coding conventions and guidelines
• Part 3 - ICD-10 code...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
5. Review in-column instructions at the level of each
character. Pay particular attention to inclusion, Excludes1,
and Exc...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
12
Code map – page 124
13
S16.1xx_ Strain of muscle, fascia, and tendon at neck level
Common codes – page 47
14
Alphabetic Index– page 470
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
5. Review in-column instructions at the level of each
character. Pay particular attention to inclusion, Excludes1,
and Exc...
18
Tabular – pages 278 - 279
19
Tabular – page 281
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
23
Code map – page 61
24
Common codes – page 47
25
Alphabetic index – page 461
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
28
Tabular List – page 151
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
5. Review in-column instructions at the level of each
character. Pay particular attention to inclusion, Excludes1,
and Exc...
31
Tabular List – page 150
34 specialty specific
ICD-10 books
• More than 70 pages which teach
• Conventions
• Guidelines
• Implementation steps
• Do...
“Exam findings are consistent with cervical
sprain/strain and acute cephalgia. The patient was
the driver in a motor vehic...
5. Review in-column instructions at the level of each
character. Pay particular attention to inclusion, Excludes1,
and Exc...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
“Initial exam findings are consistent with whiplash sprain of the ligaments of the
cervical spine and strain of the muscle...
ICD-10 Documentation Strategy
1. Find the diagnostic statement from a recent patient note.
2. Locate the ICD-9 codes repor...
5. Review in-column instructions at the level of each
character. Pay particular attention to inclusion, Excludes1,
and Exc...
46
47
48
49
34 specialty specific
ICD-10 books
• More than 70 pages which teach
• Conventions
• Guidelines
• Implementation steps
• Do...
51
52
53
54
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ICD-10 Documentation Improvement Strategies

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In this presentation, you will figure out how to make sure your documentation for ICD-10 stand up to scrutiny when payers start auditing your records.

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ICD-10 Documentation Improvement Strategies

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  3. 3. ICD-10 Boot Camp Part 4 – Documentation Improvement Strategies 3 Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA Chief Product Officer
  4. 4. Dr. Evan Gwilliam • Education • Bachelor’s of Science, Accounting - Brigham Young University • Master’s of Business Administration - Broadview University • Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic • Certifications • Certified Professional Coder (CPC) - AAPC • Nationally Certified Insurance Coding Specialist (NCICS) - NCCT • Certified Chiropractic Professional Coder (CCPC) - AAPC • ChiroCode Certified Chiropractic Professional Coder (CCCPC) - ChiroCode • Certified Professional Coder – Instructor (CPC-I) - AAPC • Medical Compliance Specialist – Physician (MCS-P) - MCS • Certified Professional Medical Auditor (CPMA) – AAPC, NAMAS • Certified ICD-10 Trainer - AAPC 4
  5. 5. Overview • Part 1 - ICD-10 fundamentals and navigation • Part 2 - Coding conventions and guidelines • Part 3 - ICD-10 code selection strategies • Part 4 - Documentation improvement 5
  6. 6. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 6
  7. 7. 5. Review in-column instructions at the level of each character. Pay particular attention to inclusion, Excludes1, and Excludes2 notes. 6. Compare the new codes to the existing diagnostic statement. 7. Re-create the note to ensure that it supports the newly selected ICD-10 codes. 8. The next time a patient presents with that condition, document in the new way. 7 ICD-10 Documentation Strategy
  8. 8. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 8
  9. 9. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain • 339.21 Acute post-traumatic headache 9 Sample Diagnostic Statement
  10. 10. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 10
  11. 11. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain • 339.21 Acute post-traumatic headache 11 Sample Diagnostic Statement
  12. 12. 12 Code map – page 124
  13. 13. 13 S16.1xx_ Strain of muscle, fascia, and tendon at neck level Common codes – page 47
  14. 14. 14 Alphabetic Index– page 470
  15. 15. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain These methods suggest the following options: • S13.4xx_ Sprain of ligaments of the cervical spine OR • S13.8xx_ Sprain of joints and ligaments of other parts of the neck 15 Sample Diagnostic Statement
  16. 16. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 16
  17. 17. 5. Review in-column instructions at the level of each character. Pay particular attention to inclusion, Excludes1, and Excludes2 notes. 6. Compare the new codes to the existing diagnostic statement. 7. Re-create the note to ensure that it supports the newly selected ICD-10 codes. 8. The next time a patient presents with that condition, document in the new way. 17 ICD-10 Documentation Strategy
  18. 18. 18 Tabular – pages 278 - 279
  19. 19. 19 Tabular – page 281
  20. 20. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain The excludes2 note leads us to consider in addition: • S16.1xx_ Strain of muscles, fascia and tendon at neck level Note: Sprain and strain are separate codes in ICD-10. GEMs crosswalks won’t tell you about this code, you need to know how to read the instructional notes. 20 Sample Diagnostic Statement
  21. 21. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain • 339.21 Acute post-traumatic headache 21 Sample Diagnostic Statement
  22. 22. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 22
  23. 23. 23 Code map – page 61
  24. 24. 24 Common codes – page 47
  25. 25. 25 Alphabetic index – page 461
  26. 26. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 339.21 Acute post-traumatic headache These methods suggest: • G44.319 Acute post-traumatic headache, not intractable • G44.3- Headache, post-traumatic 26 Sample Diagnostic Statement
  27. 27. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 27
  28. 28. 28 Tabular List – page 151
  29. 29. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In the Tabular List, we find: G44.311 Acute post-traumatic headache, intractable 29 Sample Diagnostic Statement
  30. 30. 5. Review in-column instructions at the level of each character. Pay particular attention to inclusion, Excludes1, and Excludes2 notes. 6. Compare the new codes to the existing diagnostic statement. 7. Re-create the note to ensure that it supports the newly selected ICD-10 codes. 8. The next time a patient presents with that condition, document in the new way. 30 ICD-10 Documentation Strategy
  31. 31. 31 Tabular List – page 150
  32. 32. 34 specialty specific ICD-10 books • More than 70 pages which teach • Conventions • Guidelines • Implementation steps • Documentation strategies • Provider Documentation Guides • Specialty specific • GEMs mapping • Alpha Index • Abridged Tabular List Use “CureMD20” to save $20 at InstaCode.com
  33. 33. “Exam findings are consistent with cervical sprain/strain and acute cephalgia. The patient was the driver in a motor vehicle accident.” In ICD-9, the codes might be: • 847.0 Cervical sprain • 339.21 Acute post-traumatic headache 33 Sample Diagnostic Statement
  34. 34. 5. Review in-column instructions at the level of each character. Pay particular attention to inclusion, Excludes1, and Excludes2 notes. 6. Compare the new codes to the existing diagnostic statement. 7. Re-create the note to ensure that it supports the newly selected ICD-10 codes. 8. The next time a patient presents with that condition, document in the new way. 34 ICD-10 Documentation Strategy
  35. 35. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 35 Documentation for ICD-10
  36. 36. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 36 Documentation for ICD-10
  37. 37. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 37 Documentation for ICD-10
  38. 38. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment .” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 38 Documentation for ICD-10
  39. 39. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 39 Documentation for ICD-10
  40. 40. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 40 Documentation for ICD-10
  41. 41. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 41 Documentation for ICD-10
  42. 42. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 42 Documentation for ICD-10
  43. 43. “Initial exam findings are consistent with whiplash sprain of the ligaments of the cervical spine and strain of the muscles at the neck level. The patient also has acute post-traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with a pick up truck on the interstate and is now in active treatment.” The ICD-10 codes in this case are: • S13.4xxA Sprain of ligaments of the cervical spine, initial encounter • S16.1xxA Strain of muscles, fascia and tendon at neck level, initial encounter • G44.311 Acute post-traumatic headache, intractable • V43.53xA Car driver injured in collision with pick-up truck in traffic accident, initial encounter • Y92.411 Interstate as place of occurrence of the external cause 43 Documentation for ICD-10
  44. 44. ICD-10 Documentation Strategy 1. Find the diagnostic statement from a recent patient note. 2. Locate the ICD-9 codes reported for that service. 3. Search for the ICD-10 code using one of these three methods: a. Code mapping (i.e. GEMs tables) b. A common ICD-10 code list c. Alphabetic Index 4. Look up the code in the Tabular List and review the 4th, 5th, 6th, and/or 7th character. 44
  45. 45. 5. Review in-column instructions at the level of each character. Pay particular attention to inclusion, Excludes1, and Excludes2 notes. 6. Compare the new codes to the existing diagnostic statement. 7. Re-create the note to ensure that it supports the newly selected ICD-10 codes. 8. The next time a patient presents with that condition, document in the new way. 45 ICD-10 Documentation Strategy
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  50. 50. 34 specialty specific ICD-10 books • More than 70 pages which teach • Conventions • Guidelines • Implementation steps • Documentation strategies • Provider Documentation Guides • Specialty specific • GEMs mapping • Alpha Index • Abridged Tabular List Use “CureMD20” to save $20 at InstaCode.com
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