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Take a deep breath – we now have the implementation of ICD-10 delayed one more year from Oct. 1, 2014. Will you be ready when Oct. 1, 2015 arrives? Take the time now to learn what you need to be documenting in your specialty by adding details of granularity. If your documentation provides specific details, the level of acuity and intensity with complexity of care provided should support the services. Make time to conduct reviews of your information recorded. Does your documentation support your selection of diagnosis codes, as well as the medical necessity for all aspects of care provided?

Benefits of improved documentation, now and in the future, include:

  1. Improved level of acuity and intensity, with complexity of services reported

  2. Improved provider profiles for patient care

  3. Improved timely reimbursement

  4. Decreases in the number of claims in adjudication (held claims/denied claims)

  5. Decreases in the amount of re-work for the billing/coding staff

With the healthcare industry in flux due to the change from the outdated system of ICD-9 codes to the complexity of ICD-10 coding system, we need to continue on this path. Why? It’s simple.

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