CMS recently released guidance on how ICD-10 will impact clinical documentation.
Thorough clinical documentation is essential to the accurate selection of ICD-10 codes. Physicians already include more in their documentation than ICD-9 can capture, so the new code set's concepts will not be new to them. However, they should review ICD-10 codes to understand the scope of the transition.
ICD-10 codes are more detailed in describing:
• Initial encounter, subsequent encounter or sequelae
• Acute or chronic
• Left or right
• Normal healing, delayed healing, nonunion or malunion
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