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Complete medical records: everyone’s responsibility

31 Mar 2019

Tips from HIM to avoid common ICD-10 coding mistakes

By: Kerry Scannell CCS, CPC, acute care coder III

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We know the importance of gathering correct information when documenting a final diagnosis or major treatments – but when it comes to the daily ordering of things like CBCs, urinalyses and chest X-rays, we sometimes fall a bit short. 

These tests themselves may seem less urgent, but they add dimension to the complete patient profile and can assist with anything from provider appeals to new physician training.

Why payers reject many lab tests: You may think this is small change, but it adds up to substantial lost revenue. Coders often look to the original order to support “medical necessity” when a claim is denied. If we don’t have both the written diagnosis and the ICD-10 code, our options are limited when it comes to researching coverage.

When submitting an order, both written diagnosis (working or otherwise), must be legible along with the corresponding ICD-10 diagnosis code: When the HIM department pulls the order from EPIC, often there is no written diagnosis. In this case, coders must look to the ICD-10 code, which is often incorrect. Or, we receive a partial ICD-10 diagnosis code, which tells us the ‘family’ the code belongs to. For example, an order with ‘M32.1’ tells us that the diagnosis relates to Systemic Lupus Erythematosus, but the full ICD-10 code of M32.12 gives us the complete description: Pericarditis in Systemic Lupus Erythematosus.

On the flip side, we may not have an ICD-10 code listed at all and the written diagnosis may be difficult to read. We Coders often rely on the ICD-10 code to be our clinical ‘compass’ pointing us in the right direction. If every order was submitted with both a written diagnosis and an ICD-10 code, the amount of time coders spend researching the correct diagnosis code would decrease dramatically and both accuracy and timely filing would increase. Please help us with this initiative to improve the quality of patient care and the accuracy of the medical record.