All Entries Tagged With: "documentation"

ICD-10 guideline for urosepsis illustrates need for specific documentation

One of the most poorly documented and miscoded diagnosis is when a physician documents the term “urosepsis.” Does the physician mean that the patient has a systemic infection originating from a urinary origin, or does the patient simply have a urinary tract infection (UTI)? Currently, the default ICD-9-CM code for a UTI  is 599.0.

I had mixed feelings when I saw the following guideline in the ICD-10 Official Guidelines for Coding and Reporting (2009 version) for urosepsis:

(ii) Urosepsis
The term urosepsis is a nonspecific term. It is not to be considered synonymous with sepsis. It has no default code in the Alphabetic Index. Should a provider use this term, he/she must be queried for clarification.

The ICD-10-CM alphabetic index states:

Urosepsis – code to condition

On one hand, it will prevent (or hopefully prevent) coders from assigning a diagnosis for sepsis when the patient has only a UTI. But on the other hand, I think this will only lead to more physician queries because it is fairly common for physicians to use this term.

The implementation of ICD-10 will inherently bring with it the need for more specific documentation. With that increased need for specificity, physicians must revise their documentation for conditions such as urosepsis.

Assess documentation from an ICD-10 point of view

Can you code ICD-10 from the documentation your physicians currently provide? Look at several records for each of your physicians and ask yourself whether you could assign codes in ICD-10 based on the information the physicians provided. There is going to be a learning curve, so it’s important to take these small steps early on to assess what kind of training is necessary to prepare for ICD-10 implementation.

Identify documentation that lacks necessary details, and try to get physicians to understand the need for more specificity and expansion within their documentation. This will help ease the transition during the implementation phase.