Q&A: Working with physicians to improve ICD-10-CM documentation

Q: We're having some trouble in our office getting physicians to document all the necessary details required for reporting specified ICD-10-CM codes. Do you have any advice on how we can work with the physicians to improve documentation?

A:  You may consider using a medical assistant (MA) to help with securing some of the diagnosis details needed for ICD-10-CM and augmenting the physician’s efforts. Physicians can benefit from the talents of their MAs and possibly in areas other than ICD-10-CM.

MAs are typically members of the physician office team. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes.

They are one of the first clinical team members to speak with the patient, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states placing, initiating an IV, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the MA may be another option for capturing start and stop times.

Given their understanding of medical terminology, and with an orientation to ICD-10-CM code requirements, MAs can quiz the patient and capture some of the details often overlooked by physicians. MAs can save physicians time, supplement the physician’s documentation, and help the physician select a more specific code.

If we look at the ICD-10-CM injury code elements, most of the elements can be captured in whole or in part by the MA in a short interview with the patient:

• What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality, as well.
• When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or if the condition is sequela.
• Where did it happen? Knowing the patient fell at home will not get us to the most specific code.
• We need to know where in the home, and sometimes even need to ask for the type of home.
• What was the patient status and what was the patient doing when the injury happened? If the patient has been bitten by a cat, it may be attributed to a patient status of other, but if the person bitten by the cat was a vet tech when she was holding the cat for the vet to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.

This example shows us that with a little bit of prodding from the MA, we can get the additional information we need for a specified code.

Editor’s Note: This Q&A is adapted from the Practical Guide to Coding Management by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis.

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