With the biggest change to the coding world just around the corner, dual coding in ICD-9 and ICD-10 is one task that should be at the top of everyone’s list of implementation priorities.
The role of the utilization review (UR) committee has changed as facilities transition from reporting condition code 44 for concurrent reviews to condition code W2 for post-discharge reviews.
Communication is a major portion of the documentation and coding conundrum. Creating avenues for information exchange with the physician community is essential to the success of clinical documentation improvement (CDI) and the capture of coded data. Physicians take a variety of courses (e.g., pathology, physiology, disease manifestations, etiology, and process) throughout their academic medical education. However, their education does not address the importance or the details of documenting medical terminology with specific information that corresponds to ICD-9 and ICD-10 codes. Physician profiles and scorecards have been linked to ICD-9-CM codes; physician awareness of this and future linkage to ICD-10 is necessary.
CMS has finalized changes to packaged services and E/M CPT® codes for clinic visits with the much-anticipated November 27, 2013 release of the 2014 outpatient prospective payment system (OPPS) final rule.
