In medical billing, the ICD-10 transition wheel has many cogs and nothing is more important than prepping the physician who provides the documentation that gets the coding ball rolling. After all, you can’t code anything unless you have a medical record from which to gather information. That’s why helping docs understand their role — as ambassadors of detail — in the ICD-10 transition is so very important.

Here are some things you can do to help the physicians get ready:

  • Review existing medical records to see how they would meet ICD-10 documentation requirements. This activity will helps you evaluate whether the level of specificity in the current medical record documentation is sufficient (or lacking) for the ICD-10 requirements.

  • Make a list of the kind of documentation that’s insufficiently specific (and therefore doesn’t meet ICD-10 reporting requirements) and show the physician what steps he needs to take to close the information gap. Possible documentation lapses include clarification as to whether a condition is acute or chronic, for example — info that’s needed to choose the correct code.

In general, documenting a generalized condition such as pneumonia no longer suffices. Physicians need to indicate whether the illness is viral (what virus is suspected or identified) or bacterial (identify the bacterial strain), whether this is the first known infection, and where the infection has settled (in what part of the lung, for example).