ICD-10 and Nursing Documentation
I've posed this question locally to our ICD-10 super users and pretty
much got an answer that nothing will really change regarding what
information can be pulled from the chart (such as wound staging and BMI)
to support coding. What I am wondering is if there is anyone out there
who has some insight on how ICD-10 may impact nursing documentation or
how nursing documentation may impact ICD-10?
Thanks in advance.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
much got an answer that nothing will really change regarding what
information can be pulled from the chart (such as wound staging and BMI)
to support coding. What I am wondering is if there is anyone out there
who has some insight on how ICD-10 may impact nursing documentation or
how nursing documentation may impact ICD-10?
Thanks in advance.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
Comments
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
evanspx@sutterhealth.org
I have just returned from AHIMA ICD-10 training. It appears that the nursing documentation will impact ICD-10 as it does in ICD-9.
We can of course take the BMI from dietitians and wound care staging from the nursing records.
Nursing documentation may also give you an insight into a query opportunity, especially for things like the GCS.
As I learn more, I will be happy to share.
Thank you
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
804-228-6527
Angelisa.Romanello@HCAHealthcare.com
Wendy
Wendy R. Chenney RN BSN
Manager Clinical Documentation
University Hospitals Parma Medical Center
7007 Powers Boulevard
Parma, Ohio 44129
Phone 440-743-4533
Fax 440-743-4552
Pager 440-303-5929
wchenney@parmahospital.org