Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Documentation and billing for observation stays has come under increased scrutiny from the OIG, though many hospitals have struggled with changing regulations and frequently updated guidance.
The ICD-10 implementation deadline is just around the corner, so hospitals must carefully assess their systems and processes to ensure things go smoothly on and after October 1.
The road to ICD-10 has been a long one, and we still have many miles ahead of us. Organizations have invested a significant amount of time and money into this venture, and even though October 1 is rapidly approaching, there’s still work to be done before and after implementation.
The U.S. healthcare system is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation.
Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.
