In 2008, only 11% of respondents to an Association of Clinical Documentation Improvement Specialists (ACDIS) poll indicated their clinical documentation improvement (CDI) programs either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient areas (8% and 3% respectively).
The April 1 confirmation of the delay in implementing the ICD-10 code set certainly took the wind out of many healthcare organizations' sails. Those organizations spent countless hours and dollars preparing for the go-live date that was six months away.
Numerous community groups are working to help people stay healthy. Programs that help individuals pay for expensive medications, free health clinics, and support services for chronic illnesses are just a few examples. However, the problem is that the people who need these services often don't know they're available.
The Center for Connected Health at Partners HealthCare System in Boston is putting technology to use to track patient health in the home setting. The center uses the latest technologies, from text messaging and social media to remote monitoring and patients downloading their medical records to help them take control of chronic conditions.
"Sometimes the questions are complicated and the answers are simple." ?Dr. Seuss
This quote seemed an appropriate way to begin a discussion about outpatient encounters and ICD-10-PCS.
You see, outpatient procedures will still be coded using CPT®/HCPCS?the HIPAA-approved code set for reporting hospital outpatient procedures?regardless of when ICD-10 is implemented.
Coders have only two options for reporting fractures of the patella in ICD-9-CM, closed (822.0) and open (822.1). In ICD-10-CM, that number will jump to more than 400.
Many of these options are the result of separate codes to denote laterality (right or left) in ICD-10-CM. However, the code set also includes options for specific types of fractures, increasing the importance of clear and accurate provider documentation.
