ICD-10 Documentation Tips for Oncology Practices Medical Transcription Service
The ICD-10 diagnosis code changes in oncology will lead to more accurate clinical research for preparing comprehensive documentation that would ensure improved patient outcomes. The anatomical specificity, laterality and disease process must be reflected in the oncologist’s documentation. Your documentation through accurate oncology transcription should cover the initial situation, the changes occurring throughout the stay and a clear summary that bring all these together. Let’s take a detailed look into the ICD-10 documentation for common conditions treated in oncology practices. Neoplasms Identify the exact site and document it. For example, if you are documenting breast, specify whether it is the quadrant of the breast. State the morphology such as malignant, benign or in situ. You should document uncertain and unspecific behavior, if any. It is also required to indicate the stage (primary and secondary, if malignant) and metastatic sites. Any related exposure to smoke (secondhand smoke) should be documented as well. If the patient is presented for treatment for neoplasm, you should document the details of the treatment. Lymphoma Document the following for lymphoma:
Type: Hodgkins, follicular, non-follicular, and T/NK-cell among others
Histology: Nodular sclerosis, mixed cellularity, lymphocyte-rich and so on
Anatomic site: Intra-thoracic lymph nodes, spleen, intrapelvic etc.
Anemia The following elements should be included in your documentation for anemia:
Acuity: Acute, Chronic
Type: Nutritional Anemia, Hemolytic Anemia, Aplastic Anemia
www.medicaltranscriptionservicecompany.com
1-800-670-2809
Etiology: Post hemorrhagic, Drug induced (autoimmune or non-autoimmune), Chemotherapy/Immunotherapy/Radiation, Malignancy, Manifestation of an adverse effect or poisoning
Sickle Cell Anemia Specify the type such as Hb-SS disease, Sickle-cell/Hb-C disease, Sickle-cell trait, Sickle-cell thalassemia, or other Sickle-cell disorders. Clarify whether the patient is in crisis. If so, document the type - acute chest syndrome or splenic sequestration. Associated fever, if present should be documented. Leukemia While documenting leukemia, include the following details:
Acuity: Acute, Chronic
Type: Acute lymphoblastic, Chronic lymphocytic, Hairy cell, Adult T cell
Status: Not having achieved remission, In remission, In relapse
For pancytopenia, clarify the cause and effect such as related to neoplasm, related to antineoplastic therapy, bone marrow failure and bone marrow infiltrations. Best Documentation Practices By following these practices, you can improve the accuracy of your documentation and ensure the right selection of ICD-10 codes.
Instead of specifying only the present symptoms, document the diagnosis (es) that have contributed to the reason for admission.
It is important to document the diagnoses rather than descriptors.
Specify the acuity or severity of all diagnoses (acute, chronic, acute on chronic or exacerbation).
www.medicaltranscriptionservicecompany.com
1-800-670-2809
Associate all diseases/diagnoses to their underlying causes, if they are known. Use the word ‘due to’ to link the cause and effect relationship.
While treating for a condition empirically (for example, gram negative pneumonia), indicate ‘suspected’, ‘possible’ or ‘likely.’
Add supporting documentation from dietician and wound care specialists to report nutritional disorders and pressure ulcers accurately.
You should clarify what is present on admission and clearly specify what has been ruled out.
Avoid use of temporal indicators, if they are not pertinent and are intended to describe complications rather than expected events.
If systemic inflammatory response syndrome (SIRS) is found to be present in trauma, burns and pancreatitis cases, consider documenting it provided VS and labs support this.
Don’t use arrows or symbols.
Revise your EHR templates to reflect additional documentation details and consider obtaining medical transcription services, if necessary.
www.medicaltranscriptionservicecompany.com
1-800-670-2809