Emergency department physicians face a broad scope of medical emergencies and quick decisions are made, impacting the patient well being. Under such circumstances, putting more burdens on physicians is unfair and unwise. The transition to ICD-10 will require added responsibility on the physicians to document diagnosis in an ICD-10 suited manner to ensure correct billing. ICD-10 implementations must utilize ICD-10 codes. These codes are essential for claim submission, while additionally serving as a crucial point for data collection processes, analysis and reporting. This can be aided with different approaches the vendor will employ to implement the ICD-10 codes in the EHR system.
A Coder codes…
In this approach, the physician enters the data in the system during emergencies. The vendor enables a system where a physician records a patient’s diagnosis via free typing, handwriting recognition, voice input, etc. That physician’s chart is then assigned an ICD-10 code by the professional coder, generally the billing support. The coder is responsible for determining the correct ICD-10 codes for the diagnosis, and all unspecified descriptions will be denoted with the unspecified codes. Currently, the impact of unspecified diagnostic codes on claims processing and reimbursement with ICD-10 is unknown. This approach is least likely to case ICD-10 code errors as the codes are entered by trained medical coders.
Natural Language Processing
Natural Language Processing (NLP) alongside auto coding in which the computer identifies physician diagnoses with the help of a transcribed report and further associated ICD-10 codes. This approach will be simpler for the physician and would not require a professional coder to translate all the diagnosis into codes. This method would require the vendor to offer auto coding capabilities which converts the transcribed physician charts to ICD-10 codes. The success of such a system depends on the physician entering all the details of the diagnosis and/or treatment to render fully specified ICD-10 code being assigned for that patient. A professional coder might be required to check the final codes prior to billing procedure.
In this approach, the vendor provides for a search tool wherein the system throws possible ICD-10 codes based on the diagnosis keywords entered by the emergency department physician. This vendor can also enable a physician to enter the details by use of voice input software which may also further simplify the process. This approach still has a wide range of shortlisted ICD-10 codes to choose from for every ailment, based on severity, location, first or subsequent visit etc. In this case, with training and experience, the physicians can enter more search terms which will further reduce the number of ICD-10 code options presented and hence reducing the chances of error.
Feedback and code generation
This is the most user-friendly means of providing a system which will enable the most efficient use of emergency physician time and also ensure accuracy of ICD-10 codes entered. In this approach, the vendor modifies their clinical content and provides a visual design for easy visibility of the clinical variables associated with any given diagnosis. In this case, the physician does not have to scroll or change screens, but merely looks at the various options and choose the appropriate one. This also does not require the physician to learn all the terminology or categorization of diagnoses in ICD-10, = taking effort away from the physician and transferring it to the vendor. The text for the selected diagnoses could be similar to the text for the description of ICD-10 codes, making it easier for coders to assign codes – or the vendor could select the ICD-10 codes based upon the physician’s selected information.
Each approach will place differing burdens upon the vendor itself, the physician, and the coders. Different approaches will be used by different vendors to generate the ICD-10 codes, but identifying a system which best suits your requirement and is essential to ensure a successful purchase and to achieve maximum reimbursement rates using these highly specific ICD-10 codes.
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