HM16 Session Analysis: ICD-10 Coding Tips

Presenter: Aziz Ansari, DO, FHM

Summary: With the implementation of ICD-10, correct and specific documentation to ensure proper patient diagnosis categorization has become increasingly important. Hospitalists are urged to understand the impact CDI has on quality and reimbursement.

Quality Impact: Documentation has a direct impact on quality reporting for mortality and complication rates, risk of mortality, as well as severity of illness. Documenting present on admission (POA) also directly impacts the hospital-acquired condition (HAC) classifications.

Reimbursement Impact: Documentation has a direct impact on expected length of stay, case mix index (CMI), cost reporting, and appropriate hospital reimbursement.

HM Takeaways:

  • Be clear and specific.
  • Document principle diagnosis and secondary diagnoses, and their associated interactions, are critically important.
  • Ensure all diagnoses are a part of the discharge summary.
  • Avoid saying “History of.”
  • It’s OK to document “possible,” “probably,” “likely,” or “suspected.”
  • Document “why” the patient has the diagnosis.
  • List all differentials, and identify if ruled in or ruled out.
  • Indicate acuity, even if obvious.

This presenter also reviewed common CDI opportunities in hospital medicine.

Note: This discussion was specific to the needs of the hospital patient diagnosis and billing, and not related to physician billing and CPT codes.

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