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Cutting Remarks: The Joys of ICD-10 Documentation
The new coding system requires equal parts precision and patience.
John Kelly, IV
Publish Date: December 1, 2015   |  Tags:   Opinion
icd_10 documentation Surgeons have to document why the patient was brought to the OR. "I was behind on my car payments" won't fly.

Just when I thought I had had enough, ICD-10 comes rolling in. Oy vey! What a pain in the K62.89! (That's the ICD-10 code for a disorder characterized by inflammation of the rectum.)

ICD-10 has 141,000 codes — more than 8 times the 17,000 codes in ICD-9. This coding quagmire affords entries for diseases, signs and symptoms, complaints, social circumstances, abnormal findings and external causes of injury (whew!). Thankfully, they omitted the patient's Zodiac sign and wine preferences.

The implementation of ICD-10 on Oct. 1 sent seismic waves through surgical billers nationwide. Xanax consumption has never been higher amongst staff. The basic format for coding according to the new ICD-10 guidelines requires the following: disease category, etiology, body part and severity. Since the launch of ICD-10, office note dictations have become incredibly onerous. This week I finished seeing patients at 4:30 p.m. Monday and concluded dictating at 3 p.m. Tuesday. When my coding is complete, there are more entries than the captain's log book on Noah's Ark. Let's look at the documentation necessary for fracture care (the mnemonic LEO C FAR applies):

L Location and laterality. I hope we get this right.

E Encounter (initial or subsequent). Tell the truth, Doc! Initial pays more.

O Open or closed? Duh!

C Classification. Choose your weapon.

C Category of fracture (growth plate, pathologic, stress). Aren't all fractures stressful?

C Cause (medications, age, trauma). Do in-laws apply?

F Fracture pattern (transverse, spiral, comminuted). How about "weird?"

A Alignment (displaced, non-displaced). Does "pretty good" work?

R Result (routine healing, delayed healing, non-union, etc.). Make sure no lawyer is within a 5-mile radius.

Indications for surgery
Operative notes are no picnic either. ICD-10 requires "indications for surgery" in the formal operative report. Surgeons have to document why the patient was brought to the OR. Catchphrases such as "6 months of failure of conservative therapy" may suffice. Other terminology such as "I thought he needed it" or "I was behind on my car payments" won't fly.

Exact findings at surgery must be well-annotated. Expressions such as "The rotator cuff was jacked up" will result in insurance denial — as well as a reprimand from the chief of surgery.

The transition to ICD-10 has indeed generated many growing pains. I used to receive warnings from my beloved billers that my operative notes were not signed soon enough. Now, I receive hate e-mails because I signed them too quickly before they could be reviewed. Time to audition for The Biggest Loser!

ICD-10 was created with the best of intentions: to track patient outcomes with more detail and certainty. Thankfully, I have been blessed with competent and, for the most part, patient billers. The hate mails are decreasing and I am finally learning to document "failure of conservative therapy" — even when I am taking out a bullet from a shoulder.