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In Clinical Documentation, specificity matters

18 Sep 2016

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Beginning Oct. 1, 2016, documentation to the highest level of specificity will become paramount at Salem Health. With the implementation of ICD-10, the Center for Medicare & Medicaid Services  established a 12-month grace period during which contractors would not deny claims solely based on lack of specificity, as long as the medical code was in the right family.

This flexibility will end as of Sept. 30, 2016. After this date, failure to document without specificity will increase the risk of rejected claims.

In short, ICD-10 was implemented in part due to the higher level of specificity that it allows. Now that the grace period is coming to an end, it’s time to get serious about documenting to the highest level of specificity possible.

Read here for more information from CMS.