By now you can see that ICD-10 is more finely nuanced than ICD-9, with more vocabulary, variation, and structure. It’s also far less forgiving.
ICD-10 is precise. That means your documentation must drive the ICD-10 codes you select. Haphazard, incomplete, or boilerplate documentation will force you to use non-specific or unclassified codes, creating a pattern easily flagged by claims adjusters and auditors. At best, you may be asked to supply more information. At worst, you may get audited.
Thankfully, CMS has extended a grace period. Medicare won’t reject your claim if your only mistake is an incorrect ICD-10 code. But you do have to prove you’ve tried; your diagnosis must be in the correct coding family. And include the proper “English” diagnosis in your patient’s record.
Either way, your reimbursements will be slowed, if not outright stalled. And an audit, of course, comes with the very real risk of recoupments and fines.
Not all ICD-10 diagnosis codes relate to site-specific areas, but enough of them are that it makes sense to print a cheat sheet of spinal sites/regions and post it conspicuously in areas where documentation takes place, such as treatment rooms, exam rooms, and doctors’ work areas.
Many ICD-10 codes also designate laterality. Where there is no bilateral code, you’re required to select and report both a right and a left diagnosis.
Find yourself stumped for the right ICD-10 code? The answer should be right there, in your documentation. If it still isn’t clear, it may be a sign that it’s not your coding that needs improvement, but your documentation. If you’re telling a clear story of your patient’s presentation, diagnosis, and treatment plan, the codes should reveal themselves.