ICD-10 implementation has been delayed till October 1, 2015. But if you have not even yet begun the planning for this change, you are already behind the schedule! Every specialty, but particularly anesthesiologists, will be immensely affected by the transition from ICD-9 to ICD-10. The wide range of the diagnoses that bring patients to the surgery that translates to more impact for anesthesiologists. And how well you document for ICD-10 will decide if you will be paid or not.
This article will describe the conversion from ICD-9 to ICD-10. The article will also highlight diagnosis scenarios for some of the most common diagnoses for anesthesia in ICD-9 and then in ICD-10. This should clearly help in illustrating the differences in the coding and, more importantly for you, in the documentation. In general, a physician’s documentation for ICD-10 will also need to be more specific as well as detailed than is required for ICD-9. This may also mean capturing new information about the patient’s condition that the anesthesiologist has never documented before or updating, modifying and expanding his/her documentation. Physicians with some good documentation habits will also find the transition much easier than those who use the abbreviations or other shortcuts.
The codes will readily change in many ways, like the longer code structure, usage of laterality, combination of the codes and types of encounters. However, one thing always remains consistent. No code is ever considered valid or even complete unless it’s coded to the highest level of specificity in its very category.
A look at the musculoskeletal system’s diagnosis codes easily explains the complexity as well as the details that an anesthesiologist will really need to document. To code a fracture in ICD-10 coding for anesthesia the following will be necessary:
Let’s just take a look at an example: – An anesthesia record is presented to a coder with just the diagnosis simply written as “fracture radius shaft”. ICD-9 Coding – Without any further detailing, we can also code this as 813.21 (Fracture of radius and ulna, shaft closed, radius alone). In ICD-10, we just have to code it with the addition of the laterality, the fracture type and the episode of care. There are currently as many as 270 ICD-10 code choices for this injury. For this example, we will just choose the right side, closed and non-displaced transverse type fracture, with the initial episode of care.
To get anesthesia coding training, learn from the informative audio conferences at AudioEducator.
This article will describe the conversion from ICD-9 to ICD-10. The article will also highlight diagnosis scenarios for some of the most common diagnoses for anesthesia in ICD-9 and then in ICD-10. This should clearly help in illustrating the differences in the coding and, more importantly for you, in the documentation. In general, a physician’s documentation for ICD-10 will also need to be more specific as well as detailed than is required for ICD-9. This may also mean capturing new information about the patient’s condition that the anesthesiologist has never documented before or updating, modifying and expanding his/her documentation. Physicians with some good documentation habits will also find the transition much easier than those who use the abbreviations or other shortcuts.
The codes will readily change in many ways, like the longer code structure, usage of laterality, combination of the codes and types of encounters. However, one thing always remains consistent. No code is ever considered valid or even complete unless it’s coded to the highest level of specificity in its very category.
A look at the musculoskeletal system’s diagnosis codes easily explains the complexity as well as the details that an anesthesiologist will really need to document. To code a fracture in ICD-10 coding for anesthesia the following will be necessary:
- Anatomic site on the bone (proximal, shaft, distal)
- Then laterality (right or left)
- Fracture Type for (displaced, non-displaced, open or closed; if open there are 3 more subsets to choose from)
- Episode of care therefore (initial, subsequent, or sequela)
Let’s just take a look at an example: – An anesthesia record is presented to a coder with just the diagnosis simply written as “fracture radius shaft”. ICD-9 Coding – Without any further detailing, we can also code this as 813.21 (Fracture of radius and ulna, shaft closed, radius alone). In ICD-10, we just have to code it with the addition of the laterality, the fracture type and the episode of care. There are currently as many as 270 ICD-10 code choices for this injury. For this example, we will just choose the right side, closed and non-displaced transverse type fracture, with the initial episode of care.
To get anesthesia coding training, learn from the informative audio conferences at AudioEducator.
