Good Medical Records Documentation Critical for ICD-10 Success

With 140,000 ICD-10 codes – nearly ten times the number in ICD-9 – medical records documentation will be more important than ever.  But the massive volume increase isn’t just superficial.  ICD-10 was developed to provide much greater detail on patient care. 

Though getting used to the new system may seem daunting, ICD-10, when correctly utilized, can actually be beneficial for EMS providers.  The new code descriptions better describe the gravity of a patient’s condition, which can validate the use of EMS services.  

First and foremost, an EMS team’s medical documentation provides critical information for the receiving facility. Accuracy and completeness is vital for the patient’s ongoing care.  This documentation also gives coders and billers the information they need to file claims correctly and compliantly.

The need for highly-detailed medical documentation cannot be overstated.  While today, there may be only one code for a specific condition, that same condition may have numerous codes under ICD-10.  For example, an altered mental status under the current ICD 9 coding could be described with any of the following under the ICD-10:  altered mental status due to a known condition; …due to an unknown condition; alteration of mental status involving awareness; …involving cognitive functions; Glasgow Coma Scale 13-15; Glasgow Coma Scale 9-12; and Glasgow Coma Scale 3-8. The medical documentation must help the coders fully understand what happened and why during the transport.

Here is a guideline for the type of information that should be included in EMS medical documentation:

  • the narrative field is still vitally important – pull down menus cannot adequately describe the patient’s condition to include the level of detail necessary for ICD-10
  • avoid using “possible” and “rule out” without detailing the signs and symptoms that lead to these “possible” conditions – for example “possible CVA” should be accompanied with numbness, facial drooping, tingling extremities, paralysis, slurred speech, etc. to appropriately document the patient’s condition
  • be specific by documenting the patient’s actual quotes to include the onset, duration, alleviating/aggravating factors, severity, quality of the sign/symptom

Fortunately, the ICD-10 delay gives you ample time to train your staff on how to properly document medical records.  Remember; better documentation enables better coding and better coding enables better reimbursement.