ICD-10 adoption in the US is long overdue, and adoption is necessary to ensure patient record accuracy as health care evolves. To make way for the inevitable changes that will follow that evolutionary path, the new code set is complex enough to account for future unknowns. Plus, it allows therapists and other providers to accurately report diagnoses for conditions that are part of the modern medical repertoire but do not currently exist within the ICD-9 code set. Each ICD-10 code contains up to seven characters to indicate category of diagnosis, etiology (i.e., the cause, set of causes, or manner of causation of a disease or condition), anatomic site, severity, and other vital details. And while it’s tough to argue against the many benefits of a more detailed coding system, that level of complexity also can cause even the most seasoned coding cowpoke to shake in his or her boots. Here’s how using a web-based EMR can help ease your coding fears:
Clean and Clear Documentation
If you’re working with an out-of-date dinosaur of an EMR (not that dinosaur; this dinosaur), it might be easy to overlook documentation details as you wade through your software’s cumbersome note-entry processes. When the ICD-10 era comes around, though, you won’t be able to afford taking any shortcuts—because getting paid hinges on detailed documentation. This HIMSS article stresses the importance of clean and accurate documentation in determining the correct code: “With the expansion of diagnosis codes comes a greater level of detail; therefore a greater level of detail will be required in the encounter documentation in order to assign an appropriate diagnosis code.”
Looking for an easier way to ensure clear, concise, and accurate documentation? A web-based EMR might just be the solution you seek. Web-based EMRs—the best ones, anyway—perform constant automatic updates to make sure the system always complies with the latest documentation rules and regulations. Additionally, you’ll want to make sure your system walks you through ICD-10 code conversion in a way that’s easy to understand.
Having a web-based EMR in place will certainly make documentation easier, cleaner, and more accurate. But it’s important to keep in mind that an EMR isn’t a magic eight ball. EMR systems are necessary tools, and therapists should be wary of any EMR that promises a too-good-to-be-true ICD-9 to ICD-10 conversion. Automatic, one-to-one crosswalking solutions remove a very important piece of the code translation equation: you. Don’t be fooled; no matter how much you’d like to think that there’s a magical tool that will allow you to simply close your eyes and open them to all the diagnosis answers you’ve ever dreamed of, that tool does not—and will not—exist in the real world. This article sums up the dangers of overly simplistic crosswalking: “Many EMRs plan to use the GEMs to crosswalk the existing diagnosis codes to the new ICD-10-CM codes. Although this plan sounds good in theory, the level of detail provided in the ICD-10 codes does not provide a one to one match.”
A good web-based EMR will provide a complete bank of codes and, based on your documentation, intuitively lead you to the greatest level of specificity—and thus, the best possible coding match. With a tool like that, you can trust that all the relevant codes are right at your fingertips—and that you’ll always land on the right ones.
Earlier in this post, I discussed the compliance benefits of a web-based system that performs frequent updates (ideally at no cost to you). In addition to being at the forefront of compliance, web-based EMRs have the flexibility to develop integrated enhancements—not clunky tack-on features—that allow the system to intelligently guide you to the most accurate code. No matter what system you’re using, the software should make your coding processes more streamlined and efficient, and the vendor should offer free and friendly technical support to guide you through any questions you may have.
With October 1 quickly approaching, now is the perfect time to assess whether your EMR is up to the ICD-10 challenge. And if you find that it isn’t, it might be time to implement a new system. With all that being said, here’s to ICD-10 taking health care to infinity and beyond.