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).
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.
The intent of quality and safety programs is evaluating and monitoring performance and improving results. Organizations develop annual quality and safety plans with measurable objectives that departments adopt and include as integral to their performance improvement plans.
The July quarterly I/OCE update from CMS brought few new APCs or edit updates, but did deliver new modifier -L1. Hospitals will use the new modifier to submit outpatient laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) in certain circumstances to claim separate payment.
"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.
