Leah Posted Fri 22nd of January, 2016 17:24:22 PM
I have a question on EMR documentation and ICD-10:
Our EMR has had an issue since the ICD-10 transition. The notes are in SOAP format. The Assessment area of the office note shows the ICD-9 code and also shows what the provider chose as ICD-10 (we do not have capability to take the codes themselves off and just leave the description). Our EMR sometimes will accidentally not show the ICD-10 code conversion, so the only code showing in the Assessment section is ICD-9. We then send a note to our providers to correct this, causing them to unsign the note, fix this, and re-sign the note so the ICD-10 code shows up. The physicians would like the coding department to just interpret the ICD-9 code and bill out the correct ICD-10 codes without changing the documentation. I do not think this is a safe idea.
For charges past October 1st, would we be at risk in an audit to have ICD-9 codes listed, but not ICD-10? Is there any rule or guideline I can provide my physicians so they understand this?
SuperCoder Answered Mon 25th of January, 2016 06:21:27 AM
Yes, As per CMS all claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters.