Documentation in the patient’s record will be integral to
accurate coding with the new system. As surgeons, we must
ensure that our documentation covers laterality, severity of
disease, time of onset, and so on to provide the necessary
details for accurate coding within the ICD- 10 code set.
was to reflect these intricacies.
New devices and advanced
procedures are now included and
can be accurately coded in the
health record. The transition aids
in data collection to accurately
reflect the condition that is
being treated, as well as the
outcomes for that treatment.
For example, similar injuries
on opposite limbs cannot be
accounted for in ICD- 9. With
ICD- 10, different injuries or
different severities of medical
conditions now can be coded.
documentation leads to
accurate coding, and accurate
coding leads to appropriate
and timely claims payments
for hospitals and physicians.
Most importantly, accurate
documentation can lead to
better, more effective patient
care. It can provide more
detailed information to
other health care providers
performing subsequent care
or services on patients.
Documentation in the patient’s
record will be integral to accurate
coding with the new system.
As surgeons, we must ensure
that our documentation covers
laterality, severity of disease, time
of onset, and so on to provide
the necessary details for accurate
coding within the ICD- 10 code set.
Quality and safety measures
Many of our quality and safety
measures are risk-stratified.
Thorough documentation with
the appropriate coding of the
problem list will accurately reflect
the overall state of the patient.
The quality and safety measures
affect payments directed to
hospitals. As requirements for
surgeon-specific data increase,
clear documentation with ICD- 10
could affect potential future pay-
for-performance programs. If
certain conditions were present
on admission or certain co-
morbid conditions exist and
are not documented, it could
affect the observed-to-expected
death ratio for morbidity and
mortality. If a surgeon under-
codes a case, then the observed
ratio may fall below the expected
average of his or her colleagues.
If your practice has not yet
started the transition, now is the
time to get ready for ICD- 10. As
surgeons, we must enhance our
clinical documentation to reflect
the more detailed changes with
ICD- 10. For more information,
visit the ACS ICD- 10 resource
website at www.facs.org/advocacy/