When HAP reviewed thousand of pediatric ED charts where otitis is rampant , we found that documentation of laterality is often lacking in the diagnosis or impression. At times, the location can be inferred from other parts of the chart.
https://dff-karlsruhe.de/wp-includes/map9.php But many coders, particularly those who are hospital-based, are taught that the diagnosis, if one is documented, overrides symptoms in the HPI or ROS. For this reason, we strongly recommend that ED providers get in the habit of identifying otitis as "right," "left" or "bilateral. But documentation of the specific location allows the coder to eliminate at least one "unspecified" element, which is likely to impact reimbursement.
Often fever is noted with otitis. The good news is that ICD-9 code Fever is typically well documented on ED charts, so most physicians can continue using their current notation system. We are surprised that ICD does not get more granular stratifying fever codes by actual temperature.
In This Article. For services on or after the deadline, you must utilize ICD Median household income quartiles for patient's ZIP Code. Percentage of U. You will receive email when new content is published. Take a minute to read and see if any of their suggestions can help you. Case 2: Level was met with the comprehensive history and high complexity medical decision-making new problem with additional workup and IV use of a controlled substance.
Maybe in the next edition! A final caveat: we at HAP understand that certain symptoms or conditions go with certain diagnoses including otitis and should be easily inferred by a capable coder.
But remember, for compliance purposes, coders are trained to never infer. So attaining the required level of specificity is important for physicians.
If you are documenting to that specificity already, good for you. If not, the next several months represent the opportunity for "spring training" before the season begins on Oct. A weakness of ICD-9 is that it doesn't differentiate between sprain and strain. By contrast, ICD provides clear descriptions for sprain injury of a ligament and strain injury of a muscle or tendon.
Differentiating sprain and strain is a start. However, note that both codes above contain the dreaded "unspecified, unspecified. For maximum specificity, we can also document the specific ligament involved e. HAP's experience reviewing ED charts is that the specific ligament is seldom documented for sprains.
This may not be a realistic expectation in the ED setting. But if specific documentation of an injured ligament is available say from a radiologist's report , this should also be documented by the ED physician. Keep in mind that coders are trained not to use x-ray findings to code a diagnosis, though this might have to be rethought under ICD Most ED visits will be "initial encounters," because they represent the first visit with the physician for a given injury.
However, remember that coders are taught never to infer or assume anything about documentation. For this reasons, providers should include the term "initial encounter" in their diagnoses when appropriate, and "subsequent encounter" for follow-up visits e. Open wound of finger s , unspecified, without mention of complication. Unspecified open wound of unspecified finger, without damage to nail, initial encounter. As with our above examples, the standard ICD-9 code for finger laceration become an "unspecified, unspecified" code in ICD These parameters were stratified by patients who presented in the emergency unit without appointment and in the scheduled outpatient clinic.
Additionally, the number of cases over the complete period was extracted and analyzed weekly. The weekly data of both periods were analyzed by using the Mann—Whitney—Wilcoxon test. In the first period before the introduction of the EHR, 17, outpatient cases were recorded. After the introduction of an EHR in the second period, the number of outpatient cases was 18,, revealing an increase of 5.
The absolute number of cases in our specialty outpatient clinics during both the periods was constant. To investigate the spread and variety of diagnoses before and after the introduction of an EHR, the number of different diagnoses per week coded at least once for every patient was evaluated.
In the first period, on average, To explore the variety of diagnoses further, we analyzed those diagnoses that were used at least 5 times a week. We found that in the paper-based documentation period, and in the digital documentation period, Four categories diabetic complications in the eye E14 , visual acuity and eye examination Z Comparing the weekly number of diagnoses during the observation periods, significant changes of the number of diagnoses per case were seen in the emergency unit and in the scheduled outpatient clinic.
The number of diagnoses rose from 1. The introduction of the EHR optimized for ophthalmology led to a significant increase in the variety and number of documented diagnoses in our outpatient cases during the observational period. We observed a significant change in the variety of coded diagnoses by the number of different diagnoses used per week As an online catalog with a full text search was available now, this option was probably used more often, leading to a more diverse coding behavior of the staff.
Before this, with the old web-based software, only a very limited number of keywords could be used. When paper charts were still used, there was no need for a doctor to be logged into a PC, although they were available at any exam room. Consequently, the web-based tool was not used. Doctors may have used memorized ICD codes. Rarer diagnoses codes may not be remembered by heart. Before the introduction of the digital recording system, the administrative staff entered the diagnoses manually by transferring the code into the HIS that was hand-written in a file by the physician.
Sometimes, a physician did not provide a diagnosis in the paper chart. Moreover, in this situation, a Z Notably, the number of diagnoses does not influence the amount of reimbursement for outpatients in Germany. As the number of diagnoses per outpatient case also went up, the previously rarely documented diagnoses such as Z Either of the two conditions including aphakia H This is probably because more diagnoses are coded for every patient, and the lens status of a patient is documented more often.
The largest increase of diagnoses categories was in coding for choroidal and retinal diagnoses. The Department for Ophthalmology of the University of Munich is a specialized center for these kinds of maladies. Another confounder might be the increase in the number of patients being treated by intravitreal injections because of diseases such as age-related macular degeneration AMD.
In addition, early onset forms of AMD occur in many older patients. Meticulous physicians might have also coded this diagnosis, even though no treatment is necessary for it yet. It also contains an automatic correction for typographical errors and offers the most suitable diagnosis in cases for which no unique ICD code for the medical condition is available. One key issue in ophthalmology is the present lack of accuracy of ICD in many ophthalmological diseases.
Considerations were made in the past to differentiate ICD coding further, but this has not been implemented as yet [ 9 ].
For clinical studies, a more detailed classification is necessary. To achieve this, the World Health Organization WHO currently proposes an ICD draft online in which professionals are asked to participate and give their input for a more precise and up-to-date classification of diseases [ 11 ]. Before the introduction of EHR, differences in diagnoses per case between scheduled patients and emergency patients were minimal 1.
Once EHR was implemented, diagnoses of emergency unit patients increased to 1. In scheduled patients, the increase was even more intense: It went up from 1. Two explanations for this finding could be: 1 the complexity of scheduled patients in an academic center and 2 the consultants now being part of the coding process to close the case. An emergency care of patients is often more straightforward. Additionally, residents often treat only emergency patients, especially in less complex situations in which a single diagnosis is usually sufficient.
A major concern raised by critics about EHR is the increase in the time needed for documentation and the consecutive reduction of patient treatment time, resulting in reduced numbers of patients treated [ 12 ]. However, the introduction of the digital system did not result in a decay of treated patients in our department; on the contrary, the overall number of treated patients increased by 5.
The general higher case numbers can cause an increase in the total number of diagnoses per period but will not alter the number of codes per case. The medical workforce in our department was not altered during the study period. One explanation for the increased patient numbers could be that, in the second period, every consultation had to be documented digitally, which is only possible, if a valid visit in the HIS on that day occurs.
At present, not all of the subspecialties covered in our department are integrated into the digital system [ 6 ]. As the EHR training of staff took place, it might have led to a bias in the results, although neither any specific education on diagnoses coding was provided for any staff group nor were the advantages of coding promoted. It might be possible that training caused more attention to proper coding. Another limitation of this study due to labor privacy laws in Germany was that we were not able to investigate the individual physician's contributions to the coding changes, which in theory could explain some of the changes in coding found in this manuscript.
In this study, we have demonstrated that a significant shift occurs in diagnoses after the introduction of an EHR. The number of diagnoses per case rise significantly in emergency department patients. In addition to the change in numbers, the diversity of diagnoses alters. For research purposes, it is advantageous to have as many precise diagnoses recorded as possible. It will greatly facilitate queries in an EHR for patients. In the future, many possibilities may arise when using EHR data for research [ 13 — 15 ].
Health Aff. We asked industry experts to provide their tips for last minute ICD prep. Take a minute to read and see if any of their suggestions can help you. View Link. ICD is likely to cause productivity loss, especially in less prepared practices. Here are ways to mitigate this issue and ward off ICDrelated emergencies. A practice that uses a paper-based clinical documentation system is at a disadvantage in preparing for ICD As with many specialties, endocrinology will see several diagnosis code expansions and changes in ICD Diabetes is just the beginning. It is important for everyone to learn how ICD may affect their role—then plan education and training accordingly.
Providers may not want to hear this, but the single biggest issue to be addressed in transitioning to ICD may be the increased need for documentation. It's time to get into the nitty gritty of ICD coding and documentation.
Your first step is to identify your top codes, and then map them to their ICD equivalents. ICDCM will allow primary care specialists to more accurately depict chronic conditions as well as other common diagnoses. Here are six key areas of note.