For a specialty like neurology, the change to ICD-10-CM poses special challenges.
The purpose of clinical documentation is to describe the details of the services provided and the accurate diagnosis which will provide a clear idea about the patient’s condition. Concise and comprehensive documentation via EMR or by outsourcing of medical transcription is necessary to meet the specificity required under ICD-10.
What Precise Documentation Means Under ICD-10
ICD-10, as health care professional knows, has many new codes, and the medical record provides the documentation needed to determine the correct code. Specificity is the key and maintaining active and productive clinical documentation is necessary to provide a detailed and accurate description of the severity of patient illnesses. The main rules that neurologist needs to follow with regard to entering information in the patient’s electronic health record (EHR) are:
- Document symptoms as well as the diagnosis that contributed to the reason for admission
- Document diagnoses rather than descriptors (e.g. “metabolic encephalopathy” instead of “altered mental status”)
- Indicate whether the condition is acute or chronic in all diagnoses
- Link all diseases/diagnosis to their underlying cause
- Clarify the significance of diagnostic tests
- Specify ‘suspected’, ‘possible’, or ‘likely’ when treating a condition empirically
- Accurately document nutritional disorders and pressure ulcers and use supporting documents from the relevant provider for the same
- Clarify diagnoses that are present on admission
- Clearly specific conditions that have been ruled out
- Avoid use of arrows and symbols
Focus on improving clinical documentation should be a key initiative for transition to ICD-10 codes. Neurologists can make well informed decisions about patient management with accurate documentation. Collaborating with their medical transcription and coding team can lead to more detailed, accurate, and superior data which is necessary for improved patient safety, ICD-10 compliance and error-free claim submission.
Role of Medical Transcription in Enhancing Medical Documentation
Today, it is widely acknowledged that medical transcription services play a useful in enhancing clinical documentation with feeds into electronic health records (EHRs). A reliable company can provide professional and accurate transcripts of history and physicals, doctors’ notes, consultation and operative reports, imaging reports, lab reports and discharge summaries – in customized turnaround time. Service providers specialized in neurology transcription would have an expert team well-versed in subject specific terminology handling the process. This can ensure quality documentation needed for ICD-10 compliance in a neurology practice.