ICD-10 DOCUMENTATION FOR PALLIATIVE CARE With ICD-10, a more comprehensive and specific documentation is required for palliative care.
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Palliative care improves the quality of life of patients with life-threatening problems by ensuring early identification and providing impeccable assessment and treatment. Complete and accurate clinical documentation is essential to enhance care provision, communication and teamwork in a palliative care unit. As the ICD-10 implementation date is fast approaching, it is very important to make the necessary changes to your documentation to accommodate new codes and definitions as quickly as possible. This will not only increase your reimbursement, but also improve the quality of palliative care.
The ICD-10 documentation for palliative care requires higher level of specificity and more comprehensiveness. The key impacts to ICD-10 documentation are as follows:
Disease or disorder site
Acuity and/or encounter status of treatment
Etiology, causative agent, or disease type and injury/poisoning cause, intent, activity at the time of the event and place event occurred
Manifestation
Complications or adverse events
Supporting information such as lab values or socioeconomic key impacts to ICD10 documentation
Let’s take a detailed look into the ICD-10 documentation for commonly found and critical diagnoses in palliative care unit.
Leukemia While documenting leukemia, you should specify the type (Acute lymphoblastic, Acute Myeloid, Acute Myelomonocytic, Acute Promyelocytic or Acute Myeloblastic). You should also identify the disease status as being ‘In remission’, ‘Not having achieved remission’ or ‘In relapse’.
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Malignant Neoplasm The documentation of malignant neoplasm must include the following:
Identify the site (pelvic bones, brain stem or parietal lobe)
State the morphology as malignant or primary/secondary
Specify the stage and any metastatic site
Indicate any related exposure to smoke (second hand smoke)
Details when the patient is presented for treatment related to neoplasm (for example, chemotherapy)
How EHR Enhances Your ICD-10 Documentation Electronic health record systems or EHRs have the following the qualities that facilitate ICD-10 transition.
Templates – Documentation templates within the EHR system help physicians to incorporate all important details about the patient for proper ICD-10 documentation in a clear, organized and structured manner. The templates can also be used to remind physicians to ask their patients specific questions for comprehensive documentation.
Ability to Access Previous Visits – The ability to access the patient’s previous visits can supply more information to the physicians such as pertinent medical history and test results to perform the correct diagnosis.
Integrated Order System for Ancillary Services – Most EHR systems are capable of integrating orders for lab, radiology and pharmacy services into the patient’s current visit and this will provide a complete record of that patient’s encounter for that date.
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These facilities will help physicians to document the details for each patient encounter with high precision to incorporate laterality, co-morbidity, anatomic location and other specific details. However, errors from frequent copy pasting and limitations to narrative description are the major challenges with regard to EHR documentation. EHR transcription is an effective way to eliminate these drawbacks. In this approach, skilled and experienced transcriptionists transcribe the physician’s dictations and the transcribed data is populated into corresponding fields. This option is also useful to reduce the speech recognition errors with speech-enabled EHRs.
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