With the onset of ICD-10, CMS and AMA agreed on a 12-month delay in documentation specificity enforcement. It was determined that “where both parties agreed in part for 12 months after ICD-10 implementation, Medicare review contractors would not deny physician or other practitioner claims billed under the Part B physician fee schedule, through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code, as long as the physician/ practitioner used a valid code from the right family of codes.”
With the 12-month delay in possible reimbursement ramifications for utilizing unspecified ICD-10 diagnosis codes quickly coming to an end, it is not too late for physicians to become more familiar with and begin documenting and utilizing the enhanced specificity ICD-10 diagnosis codes when clinically warranted. If we logically think about why ICD-10 was introduced and rolled out in the first place, the rationale for converting to the ICD-10 classification system becomes even more palatable and understanding.
ICD-10 allows for increased opportunities to track disease progression over time, facilitating understanding and identification of best practices in clinical management that result in optimal quality focused most on cost effective treatment parameters. Today’s current focus in the US is that healthcare consumes a greater [unsustainable] amount of the Gross Domestic Product. The cost-effective, evidence-based practice of clinical medicine is becoming more ingrained in physician’s incentive-based reimbursement mechanisms that are being devised, introduced and rolled out in most third party payment contracts (including Medicare), with the pending replacement of the Sustainable Growth Rate formula (SGR) with the Merit-based Incentive Payment System (MIPS).
A physician’s best approach to increasing their knowledge of clinical specificity principles of ICD-10 is simply to remain true to the roots of medicine, culminating in an assessment and plan of care arrived at through: (a) employment of experience, training and clinical judgment, (b) documentation of medical decision making and (c) communication of analytical/problem solving skills. A best approach to becoming even more fluent and comfortable with the ICD-10 classification system is to focus upon achieving effective documentation and communication of the clinical information, clinical facts and content - culminating in arrival of diagnoses with appropriate and accurate clinical specificity unique to the patient encounter.
Many of the diagnostic specificities afforded by the ICD-10 classification system are intuitive to the practice of medicine including laterality and clinical description. Examples in laterality of injury such as: (a) Fracture of the shaft of the left femur, or (b) Stage IV pressure ulcer of the left heel or diabetic ulcer of the buttock down to the fascia. The old adage of “call it what it is” applies to best principles and strategies in the communication of degree or severity of illness which will support the medical necessity for patient care provided.
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