For anesthesiologists in particular, there are a number of changes to note. For example, under ICD-9 diagnosis coding, it was enough for the anesthesia record to contain the phrase “fracture radius shaft.” The ICD-10 code requires information about the anatomic site, laterality, the type of fracture and the nature of the episode of care, whether initial or subsequent.
According to Mr. Mira, rather than attempting to master all the codes in relevant sections of the ICD-10 book, clinicians should concentrate on mastering the codes for their most common diagnoses. A total of 10 to 20 diagnoses should be adequate in most cases. The goal should be to identify gaps in documentation that would prevent a coder from choosing the right ICD-10 code for those diagnoses.
Complete and accurate documentation of the services provided is the basis for a smooth transition to ICD-10, according to the blog post.
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